Archives For August 2012

Acute Renal Success!!

rpaicu —  August 30, 2012 — Leave a comment

On Thu, Aug 30, 2012 at 3:22 PM, Mark Lucey <marklucey> wrote:

I think these are 2 really great articles explaining not only the patho-physiological mechanisms of AKI, especially “pre-renal” dysfunction and ATN, but also the interesting relationship between cardiac output, circulating volume, blood pressure, renal blood flow and glomerular filtration. Acute Renal Success is a concept that has been around for a long time, as you can see from Boylan’s article, but I never really thought about this beofre I came across the article a number of years ago. For me, it deals with what I call “physiological” oliguria! Our great challenge in this area, I think, is to recognise when “physiological” oliguria becomes pathological.

(Mark L)

Mechanisms of Acute Renal Failure.pdf

Acute Renal Success – the unexpected logic of oliguria in acute renal failure.pdf

Bye Bye Balloon?

expensivecare —  August 30, 2012 — Leave a comment

Early release 300 patient RCT in the NEJM from a study presented at the European Society of Cardiology this week.  No benefit with IABP in patients with cardiogenic shock undergoing/about to undergo revascularisation.

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock

So it seems the groin may not be as dirty as we thought…a meta-analysis from the prolific Paul Marik (see previous post on fluid resuscitation) shows that the femoral route for CVC insertion may not be associated with a higher rate of catheter related bloodstream infection (CRBSI) than the jugular or subclavian routes.

Femoral CVC not so bad for CRBSI Marik CCM 12

See also Scott Weingart’s blog on this, and listen to the podcast – an interview with Paul Marik in which he explains the results of his meta-analysis.

 

Nobody better than the NEJM to produce a good review from a clinical scenario.
NEJMct1206321.pdf

Joe Bloggs is a 90 year old gentleman admitted from Casualty with chest pain. He is noted to look unwell. He is an ex-smoker and tells you he has mild emphysema and high blood pressure. He is clammy, tachypnoeic and hypotensive. He tells the ED intern looking after him that he was gardening when he started to feel a heaviness in his chest. He says he has been having this heaviness on-and-off for the past 6 months, particularly when climbing the stairs. He had seen his GP who thought he might have angina and he had been commenced on metoprolol 25mg BD and aspirin. His GP referred him to a Cardiologist, but he missed his appointment.

He was treated with morphine and cautious fluids in ED, but his chest pain did not subside. His ECG was reviewed by the Registrar on duty who spotted inferolateral ST segment elevation. She quickly rang the Cardiologist on call who arranged an urgent angiogram. The results are urgently faxed to the CICU floor (see angio.pdf below).

An urgent theatre slot was made and the patient underwent emergency on-pump CABG. A Swan-Ganz catheter and 4-lumen CVC were inserted. Anaesthesia was complicated by runs of atrial fibrillation and non-sustained VT. Sternotomy was performed. Cardiopulmonary bypass was established with bicaval cannulation and cardioplegia. Four grafts were carried out, LIMA to LAD, SVG to LCx, RCA and PDA.
The surgeon commented frequently that the surgical field was complicated by bleeding and by small calibre friable vein grafts, leading to a CPB time of 128 minutes. He also complained of ineffective cardioplegia (myocardial contraction was noted during bypass).

On rewarming the patient, the intraoperative TOE shows a severely dilated, poorly contracting RV, TAPSE 0.5cm, poor radial function with moderate TR. PA pressures were noted to be 70/48mmHg. The left ventricle was only mildly impaired with mild-moderate MR. A loading dose of milrinone was given and the IABP recommenced. He remained unstable coming off bypass requiring high doses of milrinone, adrenaline and vasopressin to maintain BP.

He is hastily brought round to CICU, where a tired Anaesthetist hands the patient over to you. Shortly afterward, you review the patient. The nursing staff have given a fluid challenge and have documented their observations. (See numbers.pdf below).

How should we manage these patients? Comments please!

Next week I will post a useful paper on RV failure and a presentation on the use of vasoactive drugs in CICU.
angio.pdf
numbers.pdf

We are soon to take delivery of a Storz video laryngoscope. This will help with difficult airways but also be great for teaching purposes. It also performs well in clinical trials – some researchers from Melbourne have shown that it blows its nearest competitor out of the water…

C Mac beats McGrath BJA 12

See it in action below – yes, this is footage of some mad anaesthetist performing self-laryngoscopy. Please don’t try this at home…

Mark L has sent us these excellent review articles from August’s Current Opinion in Critical Care. From how to look after those tricky septic and post-op surgical patients to pragmatic advice on the treatment of acute AF and heart failure, and much more besides…

Periop morbidity – lessons from recent trials Thiele COCC 12

Less invasive approaches to periop optimisation Geisen COCC 12

Enhanced recovery to reduce surgical morbidity Grocott COCC 12

IV fluids in surgical ICU patients Raghunathan COCC 12

Postop Delerium – etiology and management McDaniel COCC 12

Emergency management of sepsis Puskarich COCC 12

Management of AF in the acute setting Chenoweth COCC 12

Early management of Acute Heart Failure Summers COCC 12

Risk stratification and treatment of PE Penazola COCC 12

Anaphylaxis De Bisschop COCC 12