Critical Matters

Rahul Nanchal, a critical care physician and professor specializing in liver disease, shares deep insights on acute-on-chronic liver failure management. He breaks down key differences among acute liver failure types and discusses common triggers, including infections and alcohol. Nanchal emphasizes antibiotic prophylaxis post-GI bleed and the critical timing for interventions like endoscopy and diagnosis of spontaneous bacterial peritonitis. He also highlights the importance of timely transplant referrals, offering invaluable takeaways for clinicians in critical care.

In this episode of Critical Matters, Dr. Zanotti is joined by Dr. Nitin Puri. As a critical care physician, Dr. Puri is the Division Head for Critical Care Medicine, and Co-Director for the Center for Critical Care Medicine at Cooper University Health System. He is an Associate Professor of Medicine at Cooper Medical School of Rowan University, in Camden, New Jersey. Together, they discuss medical errors in healthcare. Additional Resources: “To Err is Human: Building a Safer Health System.” The landmark publication y the Institute of Medicine highlighting medical errors as a critical cause of deaths in the US healthcare system: https://www.ncbi.nlm.nih.gov/pubmed/25077248 Medical error – the third leading cause of death in the US: https://www.ncbi.nlm.nih.gov/pubmed/27143499 The Safety of Inpatient Health Care. New England Journal of Medicine 2023; https://www.nejm.org/doi/full/10.1056/NEJMsa2206117 The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality (AHRQ). CANDOR is a process that health care institutions and providers can use to respond in a timely, thorough and fair way when medical errors occur and cause patient’s harm: https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html A powerful video on to topic of disclosure of medical errors. Worth a view: https://www.youtube.com/watch?time_continue=4&v=xeMWizTodYw Books Mentioned in this Episode: The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. By Amy Edmondson: https://bit.ly/3OQe1zV Pachinko. By Min Lee Jee: https://bit.ly/3DNJegK

In this episode of the podcast, we will discuss oncologic emergencies. Dr. Zanotti is joined by Dr. R Scott Stephens, a pulmonary/critical care physician and associate professor of medicine and oncology at the Johns Hopkins University School of Medicine. He is the Director of Oncology and Bone Marrow Transplant Critical Care at Johns Hopkins Hospital and the Sidney Kimmel Comprehensive Cancer Center. A recognized clinician, educator, and researcher Dr. Stephens has expertise and interest in ARDS, ECMO, and oncologic critical care. Additional Resources: Oncologic Emergencies for the Intensivist – the Old, the New, and the Deadly. Thandra K, et al. J Intensive Care Med 2020: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886674/ Oncologic Emergencies – Traditional and Contemporary. Spring J, and Munshi L. Crit Care Clin 2020: https://pubmed.ncbi.nlm.nih.gov/33190777/ Critically Ill Patients with Cancer: A Clinical Perspective. Martos-Benitez F, et al. World J clin Onco 2020: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643188/ Management of Febrile Neutropenia: ESMO Clinical Practice Guidelines. Annals of Oncology 2016: https://www.annalsofoncology.org/article/S0923-7534(19)31643-6/pdf Books Mentioned in this Episode: The Elements of Style. By William Strunk and EB White: https://amzn.to/3KddG7C The Structure of Scientific Revolutions: By William Kuhn: https://bit.ly/43HkS34 The Physicists: The History of a Scientific Community in Modern America. By Daniel Kevles: https://bit.ly/477Z8jO American Prometheus: The Triumph and Tragedy of j. Robert Oppenheimer. By Kai Bird and Martin Sherwin: https://bit.ly/479AEqn

Dr. Cherylee Chang, a neurointensivist and Professor of Neurology at Duke University, dives into the complexities of acute disorders of consciousness. She highlights the significance of a systematic approach to diagnosis and the importance of objective scoring systems like GCS and NIHSS. Dr. Chang discusses the nuances of neurological examinations and shares insights on imaging strategies, including the use of EEG in critical cases. Her advice on challenging traditional practices reinforces a commitment to evidence-based medicine and improving patient care.

In this episode, we will discuss prone position ventilation in adult respiratory distress syndrome (ARDS). Despite clinical trials demonstrating a benefit on mortality, the adoption of prone position ventilation has been challenging. We will discuss the impact the COVID-19 pandemic had on the use of prone position ventilation and lessons learned that can help increase the proper use of this treatment modality moving forward. Our guest is Dr. Chad Hochberg, a member of the Division of Pulmonary and Critical Care Medicine, Department of Medicine, at John Hopkins University Medical School in Baltimore, Maryland. Additional Resources Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic. Hochberg C, et al. Ann Am Thorac Soc, 2023; https://pubmed.ncbi.nlm.nih.gov/35947776/ Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome. Hochberg C, et al. Crit Care Med 2023: https://pubmed.ncbi.nlm.nih.gov/37294144/ ESICM Guidelines on ARDS 2023. Intensive Care Medicine 2023: https://link.springer.com/article/10.1007/s00134-023-07050-7 ATS/ESICM/SCCM Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome: https://www.atsjournals.org/doi/10.1164/rccm.201703-0548S Prone Position for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Munshi L, et al. Ann Am Thorac Soc 2017: https://pubmed.ncbi.nlm.nih.gov/29068269/ Prone Positioning in Severe Acute Respiratory Distress Syndrome. Guerin C. Et al. PROSEVA Trial. New Eng J Med 2013: https://www.nejm.org/doi/full/10.1056/nejmoa1214103 Books Mentioned in this Episodes The Omnivore’s Dilemma: A Natural History of Four Meals, By Michael Pollan: https://bit.ly/42FpndS

In this engaging conversation, Dr. Catherine Albin, a neurointensivist at Emory University, dives into the complexities of CNS infections like meningitis and encephalitis. She highlights the need for ICU clinicians to be vigilant due to the high morbidity associated with these conditions. Albin discusses risk factors, diagnostic strategies, and effective treatment protocols, emphasizing the importance of early intervention with antibiotics and acyclovir. Additionally, she elaborates on post-ICU recovery and the nuanced decision-making around lumbar punctures and neuroimaging.

Join Dr. Ryan Tedford, a renowned cardiologist and expert in heart failure, as he delves into the often-overlooked role of the right ventricle in critical health scenarios. He discusses how right ventricular failure significantly impacts conditions like COVID-19 and highlights key determinants of RV function. Dr. Tedford also provides insights into effective assessment techniques, imaging tools, and emerging treatment strategies, including innovative catheter therapies. Plus, he shares recommendations for future research and resources for deeper understanding.

May is National Critical Care Awareness and Recognition Month, a time to celebrate our ICU teams and honor our patients. In this episode of the podcast, we will focus on the forgotten patient – the loved ones and families of critically ill patients. We will explore the topic through the lens of a cardiac arrest co-survivor. Our guest is Kristin Flanary, a cognitive neuroscientist and social psychologist. Kristin is a co-survivor of cancer(twice) and a co-survivor of sudden cardiac arrest. She is also known for her social media alter ego – Lady Glaucomflecken. In 2022 Kristin co-founded Glaucomflecken LLC, where she works to advocate for caregivers and co-survivors of medical trauma and critical illness, community CPR and AED use, and sudden cardiac arrest survivorship. She has written about her experience as a co-survivor in medical journals and has received an EMS Cardiac Arrest Save Challenge Coin, the Citizen CPR Foundation’s '40 Under 40' award, and the American Heart Association’s Resuscitation Champion award. Additional Resources: The Quiet Place. K. Flanary. Journal of Cardiac Failure, 2021: https://www.onlinejcf.com/article/S1071-9164(21)00403-6/fulltext Roger. K Flanary. CHEST. 2022: https://journal.chestnet.org/article/S0012-3692(22)04029-6/fulltext Life after Cardiac Arrest: The importance of engaging with the “forgotten patient.” K Haywood & K Dainty. Resuscitation, 2018: https://www.resuscitationjournal.com/article/S0300-9572(18)30195-3/pdf Link to the Glaucomflecken’s website: https://glaucomflecken.com/ Books Mentioned in this Episode: In Shock. By Rana Awdish: https://bit.ly/441b0Cx

Transitions of care during a patient’s hospitalization are points of vulnerability with a high potential for harm. In this episode, we will discuss transitions of care from the ICU to the wards. We will explore the ICU-PAUSE framework and how it can be implemented to improve this critical process of care delivery in the ICU. Our guest is Dr. Lekshmi Santhosh, a practicing pulmonary critical care physician at UCSF Health. She is an Associate Professor of Medicine in the Divisions of Pulmonary/Critical Care Medicine & Hospital Medicine at the University of California San Francisco. Dr. Santosh is one of the creators and leaders of the ICU-PAUSE initiative. Additional Resources American Thoracic Society (ATS) ICU-PAUSE initiative. https://www.thoracic.org/professionals/education/ats-icu-pause-initiative.php Creating the ICU-PAUSE Tool for Intensive Care Unit-Ward Transitions. L Santosh et al. ATS Scholar 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341494/ Characterizing ICU-ward handoffs at three academic medical centres: process and perceptions. L Santosh, et al. BMJQS 2018. https://pubmed.ncbi.nlm.nih.gov/30636201/ Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. A Starmer, et al. J Hosp Med 2023. https://pubmed.ncbi.nlm.nih.gov/36326255/ Books Mentioned in this Episode In Shock. By Rana Awdish: bit.ly/441b0Cx Every Deep Drawn Breath. By Wes Ely: bit.ly/3Aqt4IC Mom Milestones. By Grace Farris: bit.ly/3ArT06z Dare to Lead. By Brene Brown: bit.ly/3n3N54O Quiet. By Susan Cain: bit.ly/3HcuHxk The Credibility Code (Speech Skills). By Cara Hale Alter: bit.ly/40ErQE8

Despite all the advances developed in critical illness, survivors of the ICU have a long journey to healing and recovery. In this episode of the podcast, we will discuss outcomes after critical illness. Our guest is Dr. Margaret Herridge, Professor of Medicine, Senior Scientist in Critical Care and Respiratory Medicine at the University of Toronto. Dr. Herridge is also Director of Critical Care Research. Director of the RECOVER Program, and Clinical Director of the Grace RECOVER Program for Chronic Critical Illness, in the University Health Network, Toronto, Canada. Additional Resources: Outcomes after Critical Illness. M. Herridge and E. Azoulay: https://pubmed.ncbi.nlm.nih.gov/36884324/ Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Hopkins RO, et al: https://pubmed.ncbi.nlm.nih.gov/10390379/ One-year outcomes in survivors of the acute respiratory distress syndrome. Herridge m, et al: https://pubmed.ncbi.nlm.nih.gov/12594312/ Long-term cognitive impairment after critical illness. Pandharipande PP, et al: https://pubmed.ncbi.nlm.nih.gov/24088092/ The RECOVER Program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation. Herridge M, et al: https://pubmed.ncbi.nlm.nih.gov/26974173/ Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study. Gayat E, et al: https://pubmed.ncbi.nlm.nih.gov/29347987/ Symptoms of anxiety and depression in family members of intensive care unit patients. Pochard F, et al: https://pubmed.ncbi.nlm.nih.gov/11588447/ Books Mentioned in this Episode: Bel Canto. By Ann Patchett: bit.ly/3nWs7Vp Commonwealth. By Ann Patchett: bit.ly/43pWSCt