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GENERAL CRITICAL CARE
General Critical Care
Current Insights in ICU Nutrition
Nutrition support plays a crucial role in the care of critically ill patients. This review aims to shed light on the latest findings regarding critical care nutrition, with a particular emphasis on the complex relationship between critical illness, the gastrointestinal tract, and nutrition support. The review also examines the available evidence concerning the optimal administration route, type, dosage, and timing of nutrition in this patient population. By exploring these key aspects, we can gain a better understanding of how to effectively provide nutrition support in critical care settings. While indirect calorimetry is the recommended method for measuring energy expenditure, predictive equations are commonly used in practice. However, these equations have limitations as they often lack accuracy when applied to individual patients. Current evidence supports the early initiation of enteral nutrition (EN) in most patients, with a gradual increase in the daily dose during the first week of critical illness. Patients with severe shock may benefit from delayed EN. Recent trials suggest that parenteral nutrition is comparable to EN in terms of effectiveness and may be considered if adequate EN is not achieved within the first week. Although a higher protein dose is recommended, the optimal timing for its administration remains uncertain. Routine use of immuno-nutrition in critically ill patients is not recommended. Patients receiving artificial nutrition should be closely monitored for metabolic abnormalities. Further well-designed studies with sufficient sample sizes are needed to address many remaining unanswered questions in this field. Dr. Abouchala joined UAB as an Assistant Professor of Medicine in Pulmonary and Critical Care Medicine in July 2021. He has also currently held the position of Associate Professor of Medicine at the University of North Dakota, School of Medicine & Health Sciences, since October 2019, where he previously held the position of the Medical Director of the Medical & Surgical ICU, and Program Director of the Critical Care Fellowship. Before his time at UAB, Dr. Abouchala worked as Assistant Professor of Medicine at the University of Tennessee in Memphis, where he also completed his residency and fellowship training in pulmonary and critical care medicine. Dr. Abouchala completed his initial medical training at Aleppo Medical School in 1983.
Nicotine replacement therapy in ICU, what does the evidence say?
In patients who are active smokers and admitted to the ICU, we often prescribe Nicotine Replacement Therapy (or NRT) to overcome nicotine withdrawal symptoms and reduce agitation, which could potentially lead to increased sedative and analgesic dosing. But what does the evidence say about its effectiveness and safety? Let's find out! This presentation was prepared by doctor Namareq Aldardeer who is a clinical pharmacist working at King Faisal Specialist Hospital and Research Centre in Jeddah
Congestion Cascade: Harnessing the Power of Doppler!
Dr. Senussi will explore the physiology of venous return and fluid responsiveness, and provide a detailed overview of traditional methods used to assess volume status. He then will delve into the various congestion parameters detected by using doppler ultrasound, including lung ultrasonography, inferior vena cava ultrasound, portal vein doppler, hepatic vein doppler, and intrarenal venous doppler. The presentation will be further enriched by multiple illustrative case examples, which will help to contextualize the concepts of congestion cascade and provide a practical understanding of the application of doppler ultrasound in assessing fluid status. Dr. Murad Senussi is an Assistant Professor of Medicine specialized in Cardiology and Critical Care Medicine at Baylor College of Medicine in Houston, Texas. In addition to his academic role, Dr. Senussi also serves as the Medical Director of the Cardiac Care Unit at Baylor St. Luke's Medical Center
Phenylephrine in Septic Shock
While some studies suggest that phenylephrine may be associated with a lower heart rate compared to the commonly used medication norepinephrine, it remains unclear whether phenylephrine improves clinical outcomes such as mortality and length of hospital stay in patients with septic shock. These studies are limited by their retrospective design and small sample sizes. To better understand the potential benefits and risks of using phenylephrine in septic shock, larger randomized controlled trials are needed. This video provides insights into the current state of knowledge regarding phenylephrine use in septic shock and highlights the importance of ongoing research in this area.
TTM for Cardiac Arrest: Shockable Rhythms, Non-Shockable Rhythms, and Hypothermia
In this video, we explore the use of targeted temperature management (TTM) in patients with cardiac arrest, including those with shockable and non-shockable rhythms, and the role of hypothermia in improving outcomes. We review the early trials that led to the development of TTM guidelines and discuss the results of recent multicenter randomized controlled trials, including TTM-1 and TTM-2. We also examine the results of trials such as HYPERION and Wolfrum et al that evaluated TTM in non-shockable rhythms. Key takeaways: TTM has been found to increase survival with good neurologic outcome in patients presenting with an out of hospital cardiac arrest (OHCA) with shockable rhythms The American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) 2015 guidelines recommend maintaining temperatures between 32°C and 36°C in the immediate post-arrest period TTM to 33°C was not associated with a statistically significant improvement in mortality, composite of death or poor neurologic function, or total complications compared to 36°C in TTM-1 trial TTM-2 trial found no difference in the primary outcome of mortality or secondary outcome of neurologic function at six months between 32°C and 37.5°C, and demonstrated that 32°C was associated with an increased risk of arrhythmias resulting in hemodynamic compromise HYPERION trial concluded a statistically significant increase in survival with good neurologic outcome in 33°C compared to 37°C for OHCA and in-hospital cardiac arrest patients (IHCA) with no difference in death at 90 days across the groups TTM can limit complications associated with shivering and cardiac arrhythmias Don't forget to like, subscribe, and share this video for more informative content about TTM and cardiac arrest. #TTM #cardiacarrest #hypothermia #shockablerhythms #nonshockablerhythms #OHCA #IHCA #neurologicoutcome #mortality #arrhythmias #AHA #ILCOR
Shivering Management During TTM
A multimodal approach to the management of shivering has been shown to reduce the incidence of shivering. As clinical practice shifts the goal of TTM to normothermia shivering management may be able to change as well. A multimodal approach without deep sedation may be utilized to prevent and treat shivering and clinicians can utilize patient specific sedation goals rather than deeply sedating solely for the purpose of TTM.
A Case of Methanol Intoxication
A case of methanol intoxication following a deliberate suicide attempt using a recalled brand of hand sanitizer. The individual's ingestion of the sanitizer led to severe methanol intoxication, accompanied by life-threatening symptoms, metabolic acidosis, high anion gap, and a large osmolar gap. With the methanol level reaching a staggering 293 mg/dL, patient underwent ICU support with mechanical ventilation, fomepizole, IV sodium bicarbonate, folic acid, and hemodialysis with complete recovery.
Cracking the Code - Controversies in ACLS Pharmacotherapy
In this video, Sam Markle, a clinical pharmacist, explores the controversies surrounding ACLS pharmacotherapy and dives deep into the utility of common interventions used in ACLS. With a focus on evidence-based practices, this video provides a comprehensive overview of the current state of knowledge on ACLS pharmacotherapy. Sam Markle begins by reviewing the evidence supporting epinephrine in ACLS and comparing it with vasopressin. He discusses the benefits and limitations of each medication and their effectiveness in cardiac arrest situations. The video then delves into the controversial role of the combination of vasopressin, steroids, and epinephrine (VSE) in cardiac arrest, examining the evidence and weighing the pros and cons of their use. Finally, Sam Markle compares outcomes between amiodarone and lidocaine in shockable arrest, discussing the evidence and controversies around these medications and their respective effectiveness. 0:00 - Intro 6:30 - Epinephrine in ACLS 17:40 - Vasopressin in ACLS 24:54 - Controversial Role of Vasopressin, Steroids, and epinephrine in Cardiac Arrest 35.04 - Comparing Amiodarone and Lidocaine Outcomes in Shockable Arrest 46:06 - Conclusion & Final Thoughts 50:17: Questions and Answrs #ACLS #Pharmacotherapy #CardiacArrest #EmergencyMedicine #ClinicalPharmacist #EvidenceBasedMedicine #Epinephrine #Vasopressin #Steroids #VSE #Amiodarone #Lidocain
Insights on Post Cardiac Arrest Care Management: Controversies, Risks, and Therapies
Jennifer Spadgenske. a clinical pharmacist, shares her expert insights on targeted temperature management (TTM) after cardiac arrest, the risks associated with TTM, and the detriment of shivering in patients post cardiac arrest. She will describe the pharmacological therapies for the management of shivering in patients undergoing TTM therapy and assess the mean arterial pressure goals for a patient post cardiac arrest. Video Content: Jennifer will start by explaining the controversy surrounding TTM in patients post cardiac arrest. She will discuss the current guidelines and research on this topic and provide her expert opinion on the optimal temperature range to use for cooling. Next, Jennifer will discuss the risks of TTM and the detriment of shivering. She will share her insights on the potential complications associated with TTM, such as infections, electrolyte imbalances, and cardiac arrhythmias. Additionally, she will explain how shivering can negate the beneficial effects of TTM and discuss strategies for managing this side effect. Jennifer will then describe the pharmacological therapies for the management of shivering in patients undergoing TTM therapy. She will discuss the advantages and disadvantages of each therapy and provide her recommendations for their use based on her clinical experience. Finally, Jennifer will assess the mean arterial pressure goals for a patient post cardiac arrest. She will discuss the current guidelines and recommendations for mean arterial pressure goals in post cardiac arrest patients and provide her expert insights on how to achieve these goals. 🩺 Video Content: 00:00 - Introduction 02:28 - Controversy Surrounding TTM in Post Cardiac Arrest Patients 23:30 - Risks of TTM and the Detriment of Shivering 35:50 - Pharmacological Therapies for Shivering Management 38:21 - Mean Arterial Pressure Goals in Post Cardiac Arrest Patients 44:54 - Conclusion 45:14: Questions and Answers 📣 Hashtags: #PostCardiacArrestCare #TTM #ShiveringManagement #MeanArterialPressure #PharmacologicalTherapies #Healthcare #MedicalEducation #ExpertInsights #ClinicalPharmacist
A case of second degree AV block associated with hyperkalemia and myocardial ischemia
The focus of this video is on a case involving a second degree AV block triggered by hyperkalemia and myocardial ischemia, with the added complication of right ventricular infarct. We demonstrate how a timely diagnosis and appropriate treatment can lead to a positive outcome. Hashtags: #AVblock #hyperkalemia #myocardialischemia #medicalcasestudy #cardiovascularhealth #ECG #treatmentoptions #heartfunction #pacemaker #cardiology
Blood Pressure Targets in Acute Stroke
Blood pressure management is crucial in both intracerebral hemorrhage and acute ischemic stroke. To optimize patient outcomes, intensivists should aim to keep systolic blood pressure in intracranial hemorrhage below 140 mm Hg. In acute ischemic stroke, treatment is recommended for blood pressure above 220/110 if no intervention of thrombolytics is planned. For patients eligible for intravenous alteplase therapy, maintaining a goal of less than 185/110 prior to thrombolytic therapy and below 180/105 after thrombolytic therapy or in cases of thrombectomy is recommended by guidelines. By following these guidelines, intensivists can provide the best possible care for patients with intracerebral hemorrhage and ischemic stroke.
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