Critical Matters

Dr. Sara Nikravan, a leading cardiothoracic anesthesia critical care physician, discusses the groundbreaking role of transesophageal echocardiography (TEE) in cardiac emergencies. She highlights TEE's superior imaging capabilities over traditional methods for assessing cardiac function during critical situations. The importance of high-fidelity simulation training and timely interventions is emphasized, aiming to improve outcomes in resuscitation efforts. Dr. Nikravan also addresses the gaps in research on TEE’s impact in ICU settings and the need for enhanced training protocols for clinicians.

Dr. Sharad Patel, a critical care physician known for his expertise in nephrology and echocardiography, dives into the transformative world of artificial intelligence in healthcare. He discusses how AI enhances decision-making in intensive care units by processing vast medical data. Dr. Patel debunks myths surrounding AI, emphasizing its role as a supportive tool rather than a replacement for clinicians. He also shares insights on the importance of coding skills and AI literacy for future healthcare professionals, along with the personal growth benefits of embracing stillness.

Dr. Mervyn Singer, a leading figure in critical care at University College London, joins Dr. Sergio Zanotti to challenge outdated practices in the ICU. They discuss the pitfalls of prolonged antibiotic use and advocate for personalized treatment durations. The conversation also critiques rigid diabetic management protocols, emphasizing the need for tailored patient care. They touch on the misconceptions surrounding bicarbonate therapy in metabolic acidosis and encourage a critical reassessment of established medical norms while reflecting on the evolution of healthcare and the role of music.

Dr. Cameron Dezfulian, a pediatric and adult critical care physician at Texas Children's Hospital, delves into the complexities of managing adults with congenital heart disease in intensive care. He discusses the unique challenges these patients face, including chronic conditions and the need for specialized care transitions. The conversation also highlights the intricacies of airway management in congenital anomalies and the critical role of multidisciplinary collaboration and effective communication for optimal patient outcomes.

February 7-14 marks the observance of Congenital Heart Disease Awareness Week. In this podcast episode, Dr. Sergio Zanotti provides a unique perspective on adult congenital heart disease, drawing from his journey as a lifelong patient. He offers reflections shaped by his own experiences with complex adult congenital heart disease, including insights gained from a recent medical procedure that granted him a firsthand view of patient care in the ICU. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 The Bell Curve. By Atul Gawande. The New Yorker 2004: https://www.newyorker.com/magazine/2004/12/06/the-bell-curve Website for the Adult Congenital Heart Association: https://www.achaheart.org/ Books and music mentioned in this episode: Montaigne. By Stefan Zweig: https://bit.ly/4gEOVP2 The Heart. A Novel. By Maylis De Kerangal: https://bit.ly/41ehqin The Essays: A Selection (Penguin Classics). By. Michel de Montaigne: https://bit.ly/3EvFwvW

The discussion dives into the challenges of timing renal replacement therapy in critically ill patients. Experts analyze the balance between delaying treatment and the benefits of early intervention for acute kidney injury. Real-world insights reveal how various factors influence patient outcomes. There's a focus on the intricacies involved in managing dialysis for both chronic and acute conditions, shedding light on the critical decision-making process in the ICU.

Adrian Wong, a consultant and clinical lead at King’s College Hospital in London, explores rational fluid therapy's complexities in critical care. He emphasizes evidence-based practices for better patient outcomes. Wong discusses the 'four Ds' framework and the significance of fluid stewardship. He addresses recent IV fluid shortages and the implications for hospitals. The conversation also highlights the 'ROSE' framework for managing critically ill patients and examines ethical considerations in treatment choices, urging a focus on quality of life.

This episode of Critical Matters will close 2024 with a year in review. Dr. Sergio Zanotti is going solo and will discuss a couple of relevant clinical guidelines and review five clinical trials. To close, he'll share some of his favorite books for 2024. Additional Resources: Critical Care Management of Patients Post Cardiac Arrest (AHA/NCS): Hirsch KG, Abella BS, Amorim E, et al. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care. 2024;40(1):1-37: https://bit.ly/4087o1w 2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support: Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2024: https://bit.ly/4fD4o1R PREOXI Trial. Gibbs KW, Semler MW, Driver BE, et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024;390(23):2165-2177. doi:10.1056/NEJMoa2313680: https://bit.ly/4fD4pCX AMIKINHAL Trial. Ehrmann S, Barbier F, Demiselle J, et al. Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia. N Engl J Med. 2023;389(22):2052-2062. doi:10.1056/NEJMoa2310307: https://bit.ly/4iQQvzU REVISE Trial. Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024;391(1):9-20. doi:10.1056/NEJMoa2404245: https://bit.ly/3Pc4nqH TIGHT K Trial. O'Brien B, Campbell NG, Allen E, et al. Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery: The TIGHT K Randomized Clinical Trial. JAMA. 2024;332(12):979-988. doi:10.1001/jama.2024.17888: https://jamanetwork.com/journals/jama/fullarticle/2823246 BALANCE Trial. Daneman N, Rishu A, et al. Antibiotic Treatment for 7 versus 14 Days in Patients with Bloodstream Infections. N Engl J Med. Published online November 20, 2024. doi:10.1056/NEJMoa2404991: https://www.nejm.org/doi/abs/10.1056/NEJMoa2404991 CMD Study. Bodien YG, Allanson J, Cardone P, et al. Cognitive Motor Dissociation in Disorders of Consciousness. N Engl J Med. 2024;391(7):598-608. doi:10.1056/NEJMoa2400645: https://www.nejm.org/doi/full/10.1056/NEJMoa2400645 Books Mentioned in this Episode: Slow Productivity: The Lost Art of Accomplishment Without Burnout. By Cal New Port: https://amzn.to/4gTbkJ2 Meditations for Mortals: Four Weeks to Embrace Your Limitations and Make Time for What Counts. By Oliver Burkeman: https://bit.ly/4gURU6N Knife: Meditations After an Attempted Murder. By Salman Rushdie: https://bit.ly/3ZPsAIt

Dr. Steven Hollenberg, a critical care and cardiology physician at Emory University, discusses the evolving role of pulmonary artery catheters in modern medicine. He explores their historical significance and recent skepticism, particularly in cardiogenic shock cases. The conversation emphasizes the importance of proper patient selection and the benefits of accurate hemodynamic monitoring. It also touches on the need for clinician proficiency in catheter use, along with insights into the literature and personal growth through reading.

Dr. Joanna Hart, a pulmonary critical care physician and educator at the University of Pennsylvania, joins the discussion on how choice framing affects ICU goals of care meetings. They delve into decision architecture, emphasizing how the presentation of options shapes outcomes. The conversation reveals how loss aversion and cognitive biases impact high-stress decisions. Hart highlights the importance of empathy, effective communication, and aligning decisions with patients' true preferences during critical moments, particularly in emotionally charged situations.