Critical Matters

For a long time death has been understood as the cessation of cardiopulmonary function. With the advent of mechanical ventilation and life support in the ICU, the concept of brain death emerged. In this episode of Critical Matters, we discuss the determination of death by neurologic criteria. Our guest is Dr. Fred Rincon, Associate Professor of Neurology and Neurological Surgery at Thomas Jefferson University in Philadelphia. Additional Resources: The most recent update to the evidence-based guidelines for determining brain death in adults: https://bit.ly/2TXjSZr Web-based toolkit and educational material for clinicians on brain death: https://bit.ly/2FA7KVj Previous episode of Critical Matters with Dr. Rincon where we discussed neuroprognostication after cardiac arrest: https://bit.ly/2JHFZ1q Books and Albums Mentioned in This Episode: Meditations by Marcus Aurelius: https://amzn.to/2FD1xIy Nevermind by Nirvana: https://amzn.to/2WmVVYd

n this episode of Critical Matters, we provide a quick recap on five things we learned after attending the annual Society of Critical Care Medicine Critical Care Congress. Four recent clinical studies released ahead of print during the congress are briefly discussed in addition to some thoughts on ECMO. Additional Resources: Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults: https://bit.ly/2GRFbEH Effect of Titrating Positive End-Expiratory Pressure (PEEP) with Esophageal Pressure-Guided Strategy vs. an Empirical High PEEP-FiO2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients with Acute Respiratory Distress Syndrome: https://bit.ly/2T38pqV Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: https://bit.ly/2UcyoJ3 Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis: https://bit.ly/2Xx4O35 Books Mentioned in This Episode: The Art of Living: The Classical Manual on Virtue, Happiness, and Effectiveness. Epictetus by Sharon Lebell: https://amzn.to/2ECiYIp

In this episode of Critical Matters, we discuss what happens to patients who survive the ICU. Our guest is Dr. Carla Sevin, Director for The ICU Recovery Center at the Vanderbilt School of Medicine. Dr. Sevin discusses current concepts regarding the post-intensive care syndrome (PICS) and shares her views on how we can prevent, identify, and treat it. Additional Resources: Link to Society of Critical Care Medicine webpage containing a host of resources related to the Post-Intensive Care Syndrome (PICS): https://bit.ly/2S34Xam Link to Understanding Your ICU Stay: Information for Patients and Families booklet: https://bit.ly/2SN6S7u Link to the CIBS Center website, which contains a wealth of resources for intensivists on the topic of ICU liberation and survivorship: https://bit.ly/2HfdQ0n Link to review article, Treatment of the Post-ICU Patient in an Outpatient Setting: https://bit.ly/2UUXkVg Books Mentioned in This Episode: In Shock: My Journey from Death to Recovery and Redemptive Power of Hope by Rana Awdish, MD: https://amzn.to/2SOLwX6 A View from the Edge — Creating a Culture of Caring by Rana Awdish, MD: https://bit.ly/2E6t1FF

In this episode of Critical Matters, we take a deep dive in delirium with Wesley Ely, MD. Dr. Ely is a professor of medicine at Vanderbilt University School of Medicine and the co-director of the Center for Critical Illness, Brain dysfunction, and Survivorship (CIBS Center), which has enrolled thousands of patients into clinical trials answering vital questions about ICU acquired brain disease and other components of ICU survivorship. His team developed the CAM-ICU, and he has published extensively on the topic. Additional Resources: Link to the CIBS Center website, which contains a wealth of resources for intensivists on the topic of delirium: https://bit.ly/2HfdQ0n The MIND-USA trial evaluated haloperidol and ziprasidone in ICU patients with delirium: https://bit.ly/2OQ5gIE Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults: https://bit.ly/2VWLUlm Books Mentioned in This Episode: The Boys in the Boat: Nine Americans and Their Epic Quest for Gold at the 1936 Berlin Olympics by Daniel James Brown: https://amzn.to/2RMmcRe Solzhenitsyn: A soul in exile by Joseph Pearce: https://amzn.to/2RPhpi0 Man’s Search for Meaning by Viktor E. Frankl: https://amzn.to/2VZ2ZLb Being Mortal: Medicine and What Matters in the End by Atul Gawande: https://amzn.to/2HfeQ4D Music Mentioned in This Episode: The Chronic by Dr. Dre: https://amzn.to/2HffeA7

In this episode of Critical Matters, we discuss burnout in healthcare. Burnout is an increasing problem in critical care that impacts growing numbers of providers, nurses and healthcare professionals working in the intensive care unit. This episode is based on a webinar I presented on the topic followed by a panel discussion with physician leaders. Additional Resources: An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action: https://bit.ly/2M1PGFq Why Doctors Hate Their Computers by Atul Gawande, MD: https://bit.ly/2JCw1uz Institute for Healthcare Improvement White Paper – Framework for Improving Joy in Work: https://bit.ly/2zHs16F

In this episode of Critical Matters, we discuss the management of critically ill patients with cirrhosis. Our guest is Dr. Ram Subramanian, Medical Director of Liver Transplantation at the Emory School of Medicine in Atlanta. In his dual role as a transplant hepatologist and an intensivist, Dr. Subramanian is involved in the inpatient care of patients before and after liver transplantation and provides a unique perspective on caring for this complex patient population. ADDITIONAL RESOURCES: Management of critically ill cirrhotic patients: a multidisciplinary perspective: https://bit.ly/2Et9hN5 A detailed review on ACLF and the impact of scoring systems on prognosis: https://bit.ly/2AcTtev A recent study evaluating the incidence and outcomes for patients with cirrhosis admitted to the ICU with an associated editorial by our guest: https://bit.ly/2BnQaAJ hhttps://bit.ly/2QzuPPc BOOKS MENTIONED IN THIS EPISODE: The McKinsey Edge: Success Principles from the World’s Most Powerful Consulting Firm by Shu Hattori: https://amzn.to/2QVVvZW The McKinsey Mind: Understanding and Implementing the Problem-Solving Tools and Management Techniques of the World’s Top Strategic Consulting Firm by Ethan M. Rasiel and Paul N. Friga: https://amzn.to/2Glph6c

In this episode of Critical Matters, we discuss the role of procalcitonin as a biomarker in lower respiratory tract infections and sepsis. Our guest is Dr. David Huang, the primary investigator in the recently published Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infections (ProACT) clinical trial. He discusses lessons learned from this very important study and offers insight into the use of procalcitonin in clinical practice. ADDITIONAL RESOURCES: Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infections (ProACT) clinical trial: https://bit.ly/2BTZNsf A meta-analysis evaluating the effect of procalcitonin-guided treatment on mortality in acute respiratory infections: https://bit.ly/2Un6Lgz FDA Executive Summary on Procalcitonin assay: https://bit.ly/2EiBN4r BOOKS MENTIONED IN THIS EPISODE: 7 Habits of Highly Effective People by Stephen R. Covey: https://amzn.to/2Ss0mPq Partners of the Heart by Vivien Thomas: https://amzn.to/2QC6vLP

Lung protective ventilation for ARDS includes the use of low tidal volumes, positive-end expiratory pressure (PEEP), and limiting of airway plateau pressure to minimize ventilator-induced lung injury. However, in the sickest subset of patients with ARDS hypoxemia may persist despite optimal lung protective strategies. In this episode of Critical Matters, we discuss salvage therapies for patients with refractory hypoxemia. Our guest is Dr. Robert Hyzy, Medical Director of the Critical Care Medicine Unit and Co-Chair of the Critical Care Committee at the University of Michigan Hospital.

Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure that affects approximately 200,000 patients each year in the United States, resulting in nearly 75,000 deaths annually. In this episode of Critical Matters, our guest Dr. R. Phillip Dellinger discusses the current management of patients with ARDS. Dr. Dellinger is a recognized thought leader in the field, a prolific author, an accomplished researcher, and the recipient of multiple awards for his contributions to critical care. ADDITIONAL RESOURCES: The PROSEVA clinical trial showed that in patients with severe ARDS prone position ventilation improved mortality: https://bit.ly/2Dp3LdS The ACURASYS clinical study showed that in patients with severe ARDS 48 hours of neuromuscular blockade was associated with improved mortality: https://bit.ly/2FqI7Zn The EOLIA study was stooped early for futility. However, many think that it still has important findings regarding the use of ECMO in severe ARDS: https://bit.ly/2QI1Cxu BOOKS MENTIONED IN THIS EPISODE: Evidence-Based Critical Care: A Case Study Approach: https://amzn.to/2PYeD8V

Caring for critically ill pregnant patients poses a series of unique challenges for the intensivist. In part two of this two-episode series, we discuss critical care in pregnancy with Dr. Stephen Lapinsky. Dr. Lapinsky is a practicing intensivist and professor of medicine at the University of Toronto. He is a member of the editorial board of the journal, Obstetric Medicine, and sits on the steering committee of the North American Society of Obstetric Medicine. Dr. Lapinsky is also the executive of the Women’s Health Network of the ACCP. Today (Part 2) we will cover general conditions that may lead to critical illness in pregnant women. Additional Resources: Practice bulletin on Critical Care in Pregnancy from the American College of Obstetrics and Gynecology (ACOG): https://bit.ly/2OtJARU A comprehensive review on acute respiratory failure in pregnancy: https://bit.ly/2DKzwjl AHA scientific statement on cardiac arrest in pregnancy: https://bit.ly/2QpGWtK