Critical Matters

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.

Dr. Andre Kalil discusses the evaluation of fever in adult ICU patients, highlighting the importance of determining underlying causes. Topics include defining fever considering age, comorbidities, and medications, administering antimicrobials promptly, importance of blood cultures, culturing blood in ICU patients, testing for viral pathogens, and accepting uncertainty in patient care.

Dr. David Greer, a neurologist and chair of the Boston University School of Medicine Department of Neurology, discusses the clinical guidelines for brain death and death by neurologic criteria. They cover topics such as evaluating brain death and donation, conducting the apnea test, limitations of ancillary tests, determining brain death and consent, and the importance of providing comfort to patients and families. They also share book recommendations and emphasize finding joy in everyday work.

Dr. Naomi O'Grady, a critical care and infectious disease physician at the National Institutes of Health, discusses Central Line-Associated Bloodstream Infections (CLABSI). The podcast covers the impact of CLABSI on patient outcomes, the definitions and pathophysiology of CLABSI and CRBSI, catheter contamination and prevention strategies, the importance of hand hygiene before sterile glove insertion, the use of chlorhexidine dressings to reduce CLABSI rates, and improving the healthcare system and emphasizing self-care.

To err is human. In today’s episode, we will discuss the science behind learning to fail, in other words: “failing well”. We will discuss our flawed relationship to failure, how to better understand failure, and how to learn from failure. I am joined by Amy Edmondson, the Novartis Professor of Leadership and Management at the Harvard Business School. For the last 2 decades, she has studied the elements of high-performing teams in complex environments. She has coined the term “psychological safety” and has made critical insights into teaming, learning from failure, and innovation. She is the author of several books and multiple academic papers and a regular contributor to the Harvard Business Review. Her latest book “Right Kind of Wrong: The Science of Failing Well”, was released in September of this year on hardback. Additional Resource: Right Kind of Wrong. The Science of Failing Well. By Amy Edmondson: https://www.amazon.com/Right-Kind-Wrong-Science-Failing-ebook/dp/B0BTZT9CXV#:~:text=In%20Right%20Kind%20of%20Wrong,from%20flubs%20of%20all%20stripes Critical Matters podcast episode – The Fearless ICU, a discussion with Amy Edmondson on Psychological safety and teaming: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1220843524 Faculty page for Amy Edmondson. A great jumping point to her vast body of work: https://www.hbs.edu/faculty/AmyEdmondson Strategies for Learning from Failure. By A. Edmondson. Harvard Business Review 2011: https://hbr.org/2011/04/strategies-for-learning-from-failure Books Mentioned in this Episode: Adapt: Why Success Always Starts with Failure. By Tim Hartford: https://shorturl.at/mpQU1 Being Wrong: Adventures in the Margin of Error. By Kathryn Shulz: https://shorturl.at/qAHJ0 Principles: Life and Work. By Ray Dalio: https://shorturl.at/JRSZ1

Organ transplantation has proven to be life-saving for thousands of patients and a growing number of disease processes. However, the gap between available organs for transplant and patients on organ transplant waiting lists continues to grow. In this episode, we will discuss the ICU management of the organ donor. Our guest is Dr. George Williams. He is a Professor of Anesthesiology, Critical Care and Pain Medicine, and Vice Chair for Critical Care Medicine at the McGovern Medical School of the University of Texas in Houston. Dr. Williams is also Medical Co-Director of the Surgical Intensive Care Unit at Lyndon B. Johnson General Hospital, and Executive Medical Director, for the Donor Specialty Care Unit- Memorial Hermann Hospital TMC. He is an Immediate Past-President of the Texas Society of Anesthesiologists and currently serves as Chair, for the American Society of Anesthesiologists Committee on Critical Care Medicine. Additional Resources: Management of the Potential Organ Donor in the ICU. A clinical guideline published by the Society of Critical Care Medicine: https://www.sccm.org/Clinical-Resources/Guidelines/Guidelines/Management-of-the-Potential-Organ-Donor-in-the-ICU Website for the United Network for Organ Sharing (UNOS): https://unos.org/ Critical Matters podcast episode – Death By Neurological Criteria: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1304762116 The rise of organ donation after circulatory death: a narrative review. Gardiner D, et al. ANESTHESIA 2020: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15100 Books Mentioned in this Episode: The Holy Bible, KJV: https://shorturl.at/wyLM4

In this episode of the podcast, we will discuss Hospital Sepsis Programs with the recently released CDC Hospital Sepsis Program Core Elements document as an anchor. Our guest is Dr. Hallie Prescott, an Associate Professor in Pulmonary & Critical Care Medicine at the University of Michigan, and a staff physician at the Ann Arbor Veterans Affairs Healthcare System. Dr. Prescott’s primary focus of research has been on sepsis care and outcomes. She serves as co-chair of the international Surviving Sepsis Campaign Guidelines and as lead for the Michigan Hospital Medicine Safety Consortium’s Sepsis Initiative. Additional Resources: CDC Hospital Program Sepsis Program Core Elements: https://www.cdc.gov/sepsis/pdfs/sepsis-core-elements-H.pdf CDC Additional Sepsis Clinical Resources: https://www.cdc.gov/sepsis/core-elements/resources.html SCCM Surviving Sepsis Guidelines: https://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=2021&issue=11000&article=00021&type=Fulltext Characterising an implementation intervention in terms of behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle. Steinmo S, et al. Implementation Science 2015: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0300-7 Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial. Crit Care Medicine 2022: https://escholarship.org/content/qt4j222757/qt4j222757_noSplash_ad94a5b7db24a75b6176198a51129f5a.pdf Books mentioned in this episode: The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care. By Hannah Wunsch: https://www.amazon.com/Autumn-Ghost-Against-Epidemic-Revolutionized/dp/1771649453/ref=sr_1_1?crid=K1OFKS5NTQM4&keywords=the+autumn+ghost+hannah+wunsch&qid=1694808152&sprefix=autumn+ghosts%2Caps%2C108&sr=8-1

In this episode, Dr. Zanotti discusses advances in the management of cardiogenic shock. His guest is Dr. Jacob Jentzer, a cardiac intensivist trained in both Cardiology and Critical Care Medicine who practices full-time in the Cardiac Intensive Care Unit at Mayo Clinic in Rochester, MN. As the Director of Cardiac Intensive Care Unit Research at Mayo Clinic, he is active in Intensive Care Unit patient outcomes research, with a particular focus on the outcomes of patients with cardiogenic shock and cardiac arrest. Additional Resources Concise Definitive Review: Advances in the Management of Cardiogenic Shock. Jentzer JC et al. Crit Care Medicine 2023: https://pubmed.ncbi.nlm.nih.gov/37184336/ SCAI clinical expert consensus statement on the classification of cardiogenic shock. Baran DA, et al.: https://www.ncbi.nlm.nih.gov/pubmed/31104355 SCAI stages of cardiogenic shock stratify mortality risk. Jentzer JC et al.: https://www.ncbi.nlm.nih.gov/pubmed/?term=SCAI+stages+of+cardiogenic+shock+stratify+mortality+risk Advances in the Staging and Phenotyping of Cardiogenic Shock: Part 1. Jentzer JC, et al. JACC Advances 2022: https://www.jacc.org/doi/10.1016/j.jacadv.2022.100120 Machine Learning Approaches for Phenotyping in Cardiogenic Shock and Critical Illness: Part 2. Jentzer JC, et al. JACC Advances 2023: https://www.jacc.org/doi/10.1016/j.jacadv.2022.100126 Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. ECLS-SHOCK Investigators. New Eng J of Med 2023: https://pubmed.ncbi.nlm.nih.gov/37634145/ Book Recommendations: The Hobbit by JRR Tolkien: https://bit.ly/44S0tZD The Lord of the Rings Trilogy by JRR Tolkien: https://bit.ly/45Q9NP0 The House of God. By Samuel Shem: https://bit.ly/48gnusc