Critical Matters

Join Bindu Akkanti, an expert in pulmonary and critical care, as she dives deep into temporary mechanical circulatory support. Discover the vital role of interdisciplinary collaboration for ICU teams managing complex patients. Learn about overcoming challenges with LVAD patients experiencing GI bleeds and the intricate management of device complications like Impella. Bindu also reflects on the importance of work-life balance in healthcare and the comforting power of music, connecting personal experiences with professional insights.

Dr. Bindu Akkanti, an esteemed associate professor and Medical Director of the Heart Failure ICU at UTHealth Houston, dives into the crucial role of mechanical circulatory support in treating cardiogenic shock. The conversation highlights shock management, emphasizing timely interventions and the complexity of patient dynamics. They explore the differences between various mechanical support devices, their physiological benefits, and the importance of teamwork in critical care. Additionally, they touch on pioneering research aimed at improving survival rates for critically ill patients.

With over 700 modes of mechanical ventilation available today, it can be overwhelming to find the best application of technology at the bedside. Focused on goal-directed mechanical ventilation, this discussion covers the taxonomy of mechanical ventilation modes and provides a framework for a rational approach at the bedside. Dr. Zanotti is joined by Dr. Eduardo Mireles-Cabodevila, Director of the Medical Intensive Care Unit and the Simulation and Advanced Skills Center at the Cleveland Clinic. In addition, Dr. Mireles-Cabodevila is the Vice-Chair of the Division of Critical Care Medicine, Department of Pulmonary and Critical Care, within the Integrated Hospital-Care Institute at the Cleveland Clinic. Additional Resources: How do I ventilate patients with ARDS: Goal-directed mode selection. E. Mireles-Cabodevila. Med Intensiva 2022: https://pubmed.ncbi.nlm.nih.gov/36220727/ A Rational Framework for Selecting Modes of Ventilation. E. Mireles-Cabodevila, et al. Respir Care 2013: https://pubmed.ncbi.nlm.nih.gov/22710796/ Closing the Gap in Patient-Ventilator Discordance Recognition. A. Liendo and E. Mireles-Cabodevila. Respir Care 2024: https://pubmed.ncbi.nlm.nih.gov/38267228/ Standardized Education for Ventilatory Assistance (SEVA) resources page; https://my.clevelandclinic.org/departments/respiratory/medical-professionals/seva#seva-resources-tab Mechanical Ventilation Mode Taxonomy App: iPhone: https://apps.apple.com/us/app/ventilator-mode-map/id1508307955 Android: https://play.google.com/store/apps/details?id=org.ccf.vmm&hl=en_US Books mentioned in this episode: Solito: A Memoir. By Javier Zamora: https://bit.ly/4b6hPG8

In this episode, Dr. Zanotti discusses the management of acute life-threatening asthma exacerbations in the ICU with this guest, Dr. Haney Mallemat, a physician trained in EM/IM and Critical Care. Dr. Mallemat is currently an Associate Professor of Emergency Medicine and Internal Medicine at the Cooper Medical School at Rowan University. Additional Resources: How Not to Kill an Asthmatic – Presented at CODA Change by Haney Mallemat: https://codachange.org/severe-asthma Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit. Talbot T, et al. Appl. Sci 2024: https://www.mdpi.com/2076-3417/14/2/693 ResusX,- a medical resuscitation conference created by Dr. Mallemat: https://www.resusx.com Last Week Now! - A curated newsletter by ResusX: https://www.resusx.com/newsletter Keynotable – a course for beginners and seasoned speakers: https://www.keynotable.net Books mentioned in this episode: How to Win Friends and Influence People. By Dale Carnegie: https://bit.ly/49WlcOd

In this episode, Dr. Zanotti is joined by Dr. Stephen Pastores to discuss the 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia, published by the Society of Critical Care Medicine. Dr. Pastores is Program Director for Critical Care Medicine and Vice-Chair of Education for the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center. In addition, Dr. Pastores is a professor of anesthesiology and medicine at Weill Cornell Medical College in New York, NY. Additional resources: 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Medicine 2024: https://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=9900&issue=00000&article=00275&type=Fulltext Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. ADRENAL Trial. N Engl J Med 2018. https://www.nejm.org/doi/full/10.1056/NEJMoa1705835 Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. APROCCHSS Clinical Trial. N Engl J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1705716 Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomized controlled trial. The Lancet 2020: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(19)30417-5/abstract Hydrocortisone in Severe Community-Acquired Pneumonia. CAPE-COD Trial. N Eng J Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145 Books mentioned in this episode: Elon Musk. By Walter Isaacson: https://bit.ly/3PVXWsG The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care. By Hannah Wunsch: https://bit.ly/4avevns

In this episode, Dr. Zanotti discusses the delicate balance of conflict resolution in healthcare. Conflict is common in our daily work in the ICU. Many clinicians avoid conflict and have negative feelings towards it. However, conflict, when managed appropriately, can lead to significant benefits for our patients and teams. Dr. Zanotti's discussion is based on a webinar he presented earlier this month as part of Sound Critical Care Leadership Week. Additional Resources: Watch the full webinar: https://youtu.be/R3wz29W3C4g Conflict Management in the ICU. Previous Critical Matters podcast episode with Dr. Joshua Kayser. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1378454077 Books Mentioned in this Episode: Nonviolent Communication. By Marshal B. Rosenberg: https://bit.ly/4a8h0fp Getting to YES: Negotiating Agreement Without Giving In. By Roger Fisher and William Ury: https://bit.ly/3TSD5J3 Possible: How We Survive (and Thrive) in an Age of Conflict. By William Ury: https://bit.ly/4aauFCK Crucial Conversations: Tools For Talking When Stakes are High. By Joseph Grenny, et al: https://bit.ly/43AU6La The Anatomy of Peace: Resolving the Heart of Conflict. By the Arbinger Institute: https://bit.ly/4a1v0HL

The podcast discusses the role of ECMO in acute respiratory failure, covering historical developments, patient selection, and outcomes. It explores optimizing patient care with correct tidal volume and early engagement with the ECMO team. The chapter also touches on anticoagulation, complications, proning ARDS patients on ECMO, and weaning off ECMO support. Lessons from Shackleton's expedition highlight the importance of embracing change for better patient outcomes.

Discussing critical care management of Guillain-Barre Syndrome and Myasthenia Gravis in the ICU, featuring insights from Dr. Kamran Athar. Topics include differential diagnosis, specific treatments like plasma exchange and IVIG, respiratory management, autonomic dysfunction, myasthenia crisis, and the importance of thymectomy in myasthenia patients with thymomas. Also, explores rare neuromuscular disorders that require ICU care and reflects on forgiveness, reconciliation, and humility in medicine and life.

In this episode, Dr. Zanotti is joined by Dr. Eddy Fan for a discussion about Respiratory Support in ARDS. Dr. Fan is an associate professor in the Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management, and Evaluation at the University of Toronto. He is also a staff intensivist at the University Health Network/Mount Sinai Hospital. Dr. Fan is currently the Medical Director of the Extracorporeal Life Support Program at the Toronto General Hospital and the Director of Critical Care Research at the University Health Network/Mount Sinai Hospital. Dr. Fan’s research has focused on advanced life support for acute respiratory failure and patient outcomes from critical illness. He is a co-author of the ESICM ARDS Clinical Guidelines. Additional Resources: ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping, and respiratory support strategies. Intensive Care Med 2023: https://pubmed.ncbi.nlm.nih.gov/37326646/ An Update on Management of Adult Patients with ARDS. Official ATS Clinical Practice Guideline. Am J Respir Crit Care Med 2024; https://www.atsjournals.org/doi/full/10.1164/rccm.202311-2011ST Prone Positioning in Severe Acute Respiratory Distress Syndrome. PROSEVA Clinical Trial. N Engl J of Med 2013: https://www.nejm.org/doi/full/10.1056/nejmoa1214103 Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The EOLIA Trial. N Eng J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385 Books mentioned in this episode: A Portrait of the Artist as a Young Man. By James Joyce: https://bit.ly/49kzmtn

Dr. Brandon Foreman, an expert in epilepsy and neurocritical care at the University of Cincinnati, shares invaluable insights on managing seizures in the ICU. He discusses the high prevalence of nonconvulsive seizures among critical care patients and the importance of accurate diagnosis. Dr. Foreman details essential diagnostic steps, emphasizes the need for timely treatment to prevent neuronal injury, and explores the role of continuous EEG monitoring. He also highlights the philosophical aspect of clinical care, encouraging diagnostic flexibility and humility.