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Catalog
Current Concepts in Adult Critical Care
Panel 1 Discussion and Questions
Panel 1 Discussion and Questions
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Video Transcription
So, you all have heard the three talks, one about trauma, one about hemostatic resuscitation, and the last one about toxidromes. So if any, I'm actually going to open up the floor to questions. If anyone has any, please come up to the mic. And if you would just announce your name and where you're from and your discipline. Thank you. Hi. I'm Bush Ramina from Northern Wichita Hospital in Northwell. I actually have two questions. What's your policy for patients who does not require, for religious reasons, don't accept any blood transfusion in a trauma? And the second question is, the concept of it, we're always afraid the patient, okay, as you mentioned, we're getting elderly patients, some of them have coronary heart disease, heart failure, and we're in a trauma, flu resuscitation. Some people have the concept, okay, I'm going to put them in pulmonary edema. So try to do it safely. That's what you, what do you recommend? We don't do any swans anymore. So what do you recommend at this point? For patients, for whatever reasons, don't accept blood, if they're an extremist, let's be honest, a lot of times we probably don't know about it until after the fact. And then you do the best you can for, you know, we do have a bloodless program. Most of that, those really geared towards limiting blood withdrawals, right, and everything else kind of is standard. Some people do accept alternatives, like albumin, so you've got to ask about those to see if that's an option for you. And you're stuck giving crystalloids, and we have had those patients where we're sometimes, you know, for maybe less so trauma, because I think for trauma patients, if they're showing up an extremist in our trauma bay, we're in full action mode. And I don't know that any of us, to be honest, have ever asked, are you, have some prohibition against blood. But by the time we find out, we've probably already given something. But for emergency general surgery patients, it becomes a problem, and you end up having to try to get them through that. And usually, I think it's probably significant on age and their reserve capacity. For the elderly, I have certainly myself, but I remember one patient in fellowship I did put into pulmonary edema from MTP for major pelvic fracture. So again, I think this is why, especially in the trauma bay, I think it's also worthwhile, I will actually, even if I don't really have a suspicion of any cardiac injury, I will actually do a quick assessment of their cardiac function in the trauma bay and see what their contractility is like. And if we're having to give blood, see what their response is by doing serial assessments live. And that's just me and what I do. There's no protocol for it. Nobody has a protocol about this. I think we're all learning from experience as the trauma, elderly trauma patient population is rising. And I think in the ICU, again, the biggest things that we're really focused on is prevention, right? So you have a very low threshold to triage them as a trauma. So many of these, unfortunately, end up in the emergency room and they get shuffled up to medicine. We're very much more proactive at admitting them to our service and that we are the primary caretakers, understanding that resuscitation becomes challenging and monitoring them in the ICU. I think this is where most of them have AFib, right, so then the flow track is not that helpful. But I think this is where that cardiac bedside ultrasound and POCUS is very effective in managing these patients. Any thoughts? I would agree with what you just said. I would say that the bleeding issue, when you have somebody in hemorrhagic shock, that's what's going to kill them. So I'm going to focus on treating that and dealing with the complications. And as they stabilize and they move into that de-resuscitation phase, I'm going to think more about, OK, these were some of the complications of our therapy and we're going to start to de-resuscitate. So think about volume assessment and optimizing their volume status. But in that moment when they're in shock and you see them actively bleeding, you obviously want to resuscitate them. And if they have pulmonary edema and they get intubated, you just have to do that and support them, provide supportive care until they're ready for you to de-resuscitate them. Great session. Samir Sharma, neurointensivist in Jackson, Mississippi. My question is, has anyone looked at, are there studies looking at neurological outcomes with permissive hypertension and polytrauma? So they are looking at this. And so, again, we don't know what that magical number is for head injury and that maybe it can tolerate a little bit lower. But I don't know that anyone's been bold enough to really see what the long-term outcomes are. So I think certainly without TBI, myself, I feel pretty comfortable with permissive hypertension down to the systolics of 80s. There's just still not enough data to know how much permissive hypertension the brain can tolerate. And I think it also probably deals a lot with also what kind of brain injury. I think that also matters. And so sometimes with our trauma patients, especially if we're taking them emergently to the operating room with no CT data, we don't have a lot to go by. So we're having to assume the worst. And so then I'm shooting my systolic for 90s to 100s. We do know the brain injury mechanism. And we're having to dual operate from a trauma side along with neurosurgery. And so for those, also, if they're needing an emergent decompression, then we're certainly shooting for higher systolics. But we don't know the answer to that, although that's a very good question. And we should all be researching that. Absolutely. Just to follow up, we had a case when I was a fellow, came to neuro ICU after polytrauma, stabilized from trauma standpoint, became hypotensive, fast, became positive, went down for exploratory laparotomy. By that time, we already had a bulletin for ICP monitoring. So in OR, I, as a fellow, went down and we kept the map so that the CPP stayed above 70 while the surgeon was operating. But he felt the oozing was more because we were keeping the maps up. But he was OK with it. Is that an approach that we can think of? I think that's a very good example. And also be mindful that there's actually some push away from bolt placement, right? So there's some, a lot, you know, I think there was a time when we were very aggressive about it. And it's kind of swung the other way pendulum wise. So if you're going to take that approach, you need some sort of measurement. You need some sort of way to follow this patient neurologically. So you know, there's not much written about that approach and that's something interesting. But my main concern nowadays is that we, especially with the polytraumas and this is why for hemorrhage, it's so critical. I focus a lot about just hemorrhage control, but with the polytraumas, when you have a head injury and you don't have a great neuro exam and neurosurgery is now, the culture is moving away from the bolt. This is where you really have to stay on top of your patient and turning the loctate, making sure that they're hemodynamically stable and there's no evidence of ongoing hemorrhage because again, we can't do anything about that first insult to the brain, but we can definitely prevent secondary injury to the brain. We've got to avoid hypotension and hypoxia. And so I think that's a big question. We don't know and it is a little bit more, you know, because the data behind the bolt use is not that great anyway. And so I don't know. That's very interesting though. I'd like to read more about that. Hello. My name is Ahmed. I'm a clinical care pharmacist specialist. So I have three questions. The first is when we stop doing Rotem and TIG, we have Rotem in the ICU and we keep doing it for every time there is an abnormality and then replacing based on the parameters. So when we start to say that there is no need to do Rotem anymore, this is the first question. The second question, we are trying to bring the dried plasma onto our formulary. So the dried plasma, is there any clinical benefit compared to the FFP or it's just decreased the time to infusion? And my last question is, in elderly population or population who are very sensitive to opioids and benzodiazepines, not waking up after a few days in the ICU and then we give them either the antidote, clomazenil or naloxone, is there any data showing we should do a test to test either qualitatively or quantitatively of benzos or opioids before we give the antidote or we just do a trial? Thank you. So I'm going to see if I could just summarize just to make sure everyone caught the question. So the first question was about whether we should continue to use Rotem or any other viscoelastic test. The frequency of using it, okay. The second one was, I'm sorry, if you can remind me about dried plasma, okay. And then the third one, okay, so the dosing of antidotes or dosing of opioids as opposed to using antidotes. Did everyone catch that? Yeah. Okay. Okay, so when it comes to Rotem, to be honest with you, I don't have a lot of experience with it, but my understanding is Rotem and TEQ give you similar information with different values. So you can use either one, whatever is available at your institution. What was the other part of that question? Oh, yeah. So how often? You also asked how often to actually use it. And that really depends on the situation and the patient you have in front of you. If you're actively in the trauma bay resuscitating a patient that's actively bleeding, you're not going to really rely on any of that data. You have your massive transfusion protocol activated and you're resuscitating. And then as you see the patient is becoming more stable, that's when you're starting to have more of a goal-directed, you know, approach to repleting blood product. Does that answer your question? I'm not really sure about dry plasma. I don't know if you want to... What's the question about it? I'm sorry, I missed it. The use of dry plasma as opposed to FFP. I don't really have much experience with that to tell you. I think they are pretty similar. Maybe functional-wise, the dry plasma has a little bit more function, but I can't say that I have ever specifically asked for dry plasma. I don't know if you have anything to add. I think the last question was probably addressed to Mr. Hogan. Yeah, so I think what you were alluding to was delirogenic medications and how we can help prevent that with patients. Yes, what I meant that many times patients not waking up after five days, instead of testing that they have a high doses of opioids or benzos in their blood, we just randomly give them the antidotes and see if they are waking up or not. And sometimes they suffer the side effects of antidotes like flumazenil or even naloxone, especially of those with low physiological reserve patients. So is there any guidance to say or to measure the levels of what we are hypothesizing that they have a toxicity for or just in critical care we give the antidote? Yeah, okay. I think I understand that a little more fully now. Thank you for elaborating. This is a multi-loaded question in terms of what certainly when we're dealing with any neurological status at the time. And you have to go back to the initial insult and injury as opposed and even the overdose to see with these patients and that supportive care. So first and foremost, if required, I would certainly still look to rule out with a CT head if they're not waking up, those sorts of items that come into play clinically. And taking a look at the medication that may have impacted them or why they are not waking up for that. Generally speaking, five days out is enough time for most medications to have been metabolized by the body. With that, these antidotal medications are generally given up front, generally when we have confirmation or near enough confirmation, either with physical or clinical data, that is what is being exhibited by that overdose and or if we have something from their prescriptions or whatnot or family members in with that. So the tincture of time is a quote that we like to use a lot as well in there. And then the five day out period, I think you will most definitely get into our own potential iatrogenic solutions or interventions that we're doing for these patients. That supportive care help keep them safe, the delirogenic medications that we may be given or other medications or if there's some component of renal failure or uremia that's now impacting this and whatnot. So is anyone else going to say anything to that? Okay. So we'll take one, maybe two questions depending on how much time we have and then we'll move to the break. So for... Hi. Ting Zhou, Neuro ICU from New York. So how far are we from widely available use of synthetic blood products for patients who cannot receive or refuse to receive blood products? I think that's a great question. And I don't know that I have an answer for you. I can say that at any institution that I've ever been at, that conversation hasn't really come up. I would say we need more research in that area. So in terms of a timeframe, I think it's hard to say, but it is definitely a very interesting area that's actively being investigated. And it's definitely going to be helpful to those patients that are not amendable to receiving blood products. But I'm not sure we have, at this point in time, we have an answer to that question. Hi. Adi Gerblich from Cleveland Clinic. We have recently experienced increase in fentanyl and xylosine lacing, severe intoxication in sort of casual users even. Unfortunately, we had two cases where it was associated severe abdominolosis with CPKs in the hundreds of thousands, involving exposed muscle as well as non-exposed muscle that led to the death of the patient. I wonder whether you have any experience in this complication of xylosine, and what can we do besides compartment and amputation? That's an excellent question. Just let me summarize it to make sure I, so the xylosine case that you have seen, that you have seen essentially rhabdomyolysis, severe rhabdomyolysis from it. Extensive in internal muscles as well as external muscles. Yeah. No, it's a great question. This has come up. There's not a tremendous amount of literature be given the newness of this. And one of the thoughts that's out there right now is the initial, the basal constriction properties, very similar to cocaine-induced rhabdomyolysis that you can certainly have with that tremendous CK bump, which is actually associated more with smoking cocaine, the correlation there as well. So the thought is at those injection sites with that initial basal constriction, because our tissue is not like the horse or cow tissue, and the chemical makeup of it was to get into the muscle and or vessel very quickly and to penetrate that. So I, and as I said, I'm certainly speculating, but what I have heard is that initial of those basal constrictive properties around the muscle, the muscle depth and whatnot that lead to that.
Video Summary
The presentation covered trauma, hemostatic resuscitation, toxidromes, and a Q&A session. Topics included managing trauma patients who refuse blood transfusions for religious reasons, preventing pulmonary edema in elderly trauma patients, neurologic outcomes with permissive hypertension in polytrauma, and usage of viscoelastic tests like Rotem. Discussions also touched on synthetic blood products for patients who can't receive blood, addressing severe rhabdomyolysis from fentanyl and xylazine lacing, and dosing antidotes for opioid and benzodiazepine sensitivities. The need for more research in these areas was emphasized, with limited experience and literature available currently.
Keywords
trauma
hemostatic resuscitation
toxidromes
blood transfusions
antidotes
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