Title: GI Complications of Obesity in Critical Illness

Category: Critical Care

Posted: 5/3/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Gastrointestinal Changes of Obesity that Complicate Critical Illness

Obesity predisposes patients to several gastrointestinal abnormalities that can cause, or complicate, critical illness.
Important abnormalities to keep in mind when managing a critically ill obese patient include:
- Increased intra-abdominal pressure which predisposes to abdominal compartment syndrome
- Increased incidence of nonalcoholic fatty liver disease which may lead to prolonged drug metabolism
- Increased incidence of cholelithiasis which may result in pancreatitis or cholangitis

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Title: Combination Therapy for Bacteremia

Category: Critical Care

Keywords: staphylococcal aureus, aminoglycoside, monotherapy, combination therapy (PubMed Search)

Posted: 4/19/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Combination Antimicrobial Therapy for Gram (+) Bacteremia

Bacteremia is a major cause of morbidity and mortality in the critically ill patient.
S.aureus remains a common isolate in patients with either hospital-acquired or community-acquired bacteremia.
In cases of suspected endocarditis due to S.aureus, traditional teaching has been to give an aminoglycoside (i.e. gentamicin) in combination with vancomycin or an antistaphylococcal penicillin.
Importantly, there is no strong evidence to support this combination in patients with suspected S.aureus bacteremia.
Furthermore, patients receiving the aminoglycoside combination have higher rates of renal impairment without any added clinical benefit.

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Title: Aspiration Pneumonitis/Pneumonia

Category: Critical Care

Posted: 3/22/2011 by Mike Winters, MBA, MD

Aspiration Pneumonitis and Pneumonia

Aspiration of low pH gastric fluid or food matter is common in critically ill patients and often underdiagnosed.
Patients with aspiration initially develop a pneumonitis that, in some, can be complicated by bacterial pneumonia. Up to 33% develop severe ALI/ARDS, with an associated 30% mortality rate.
Aspiration pneumonitis presents with hypoxia and a CXR demonstrating infiltrates in the dependent portion of the lungs. Often, the degree of respiratory distress is worse than the CXR appearance.
Since it is challenging to differentiate aspiration pneumonia from aspiration pneumonitis, current recommendations suggest initiating empiric antibiotics with agents that have adequate Gram-negative coverage. Routine coverage against anaerobic bacteria is not currently recommended, except in patients with severe periodontal disease and those with a lung abscess on CXR or CT.
Despite the initial inflammatory response, steroids are not indicated for patients with aspiration.

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Title: The Severely Hypoxemic ED Patient

Category: Critical Care

Posted: 3/8/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

The Severely Hypoxemic ED Patient

Most define hypoxemia as a P_aO₂ < 60 mm Hg.
Perhaps a better definition of hypoxemia is a P_aO₂ that is associated with continued tissue hypoxia (rising lactate, low S_cvO₂), the need for vasopressor medications, or severe metabolic acidosis.
For ED patients that remain hypoxemic despite increased F_iO₂ and high levels of PEEP, consider the following rescue therapies:
- Recruitment maneuvers - brief periods of high PEEP (35-50 cm H₂O) or pressure-controlled breaths to reopen collapsed alveoli
- High-frequency oscillatory ventilation - employs a high airway pressure to recruit closed alveolar segments
- Prone positioning - believed to improve oxygenation through a redistribution of ventilation and perfusion
- Extracorporeal membrane oxygenation

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Title: Hemodynamic Monitoring in the Ventilated Patient

Category: Critical Care

Posted: 2/22/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Hemodynamic Monitoring in the Ventilated Patient

Consider pulse pressure variation (PPV) as a method to monitor volume responsiveness in your mechanically ventilated ED patients.
The theory behind PPV:
- When a positive pressure breath is delivered via the ventilator, pleural pressure rises and causes a decrease in venous return, right heart filling, and right heart output.
- Simultaneously, the positive pressure breath causes an increase in left heart filling and a decrease in left heart afterload. This is reflected clinically as an increase in blood pressure.
- Within a few beats, the decreased right heart output is transmitted to the left heart resulting in a decrease in blood pressure during expiration.
Patients who are volume depleted can have significant differences in blood pressure between inspiration and expiration - i.e. a large variation in pulse pressure.
PPV values > 12% have been shown to identify patients who are volume responsive.
Importantly, PPV works best in vented patients who have no spontaneous respiratory effort, are in sinus rhythm, and receiving 8 ml/kg tidal volumes.

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Title: LV Dysfunction in the Critically Ill

Category: Critical Care

Posted: 2/8/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Acute LV Dysfunction in the Critically Ill

Approximately one-third of critically ill hospitalized patients develop acute LV dysfunction, most often due to a stress-induced cardiomyopathy.
In these patients, up to 25% develop an acute dynamic LV outflow tract obstruction.
Consider acute LV outflow tract obstruction in hypotensive patients with a new systolic ejection murmur in the left parasternal area.
Aggressive IVFs is central to the management of these patients with LV outflow tract obstruction.

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Title: Valproic Acid and Status Epilepticus

Category: Critical Care

Posted: 1/26/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Valproic Acid in Status Epilepticus

In previous pearls, we have discussed the treatment of status epilepticus (SE) with first-line (benzodiazepines) and second-line agents (phenytoin/fosphenytoin).
Refractory SE is defined as the failure to respond to both first- or second-line antiepileptic medications.
Valproic acid is listed in many algorithms as a third-line agent for treating SE.
Avoid valproic acid in refractory SE patients who have hepatic disease or dysfunction.
Although rare, valproic acid can cause a fatal hepatotoxicity in these patients.

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Title: Sedation and Analgesia in Acute Neurologic Disease

Category: Critical Care

Posted: 1/11/2011 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Dexmedetomidine for Sedation in Acute Neurologic Disease

Critically Ill patients with acute neurologic disease are managed daily in the ED.
Due to the need for frequent neurologic assessments, these patients can be challenging should they require sedation.
Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, has emerged as an alternative to traditional sedatives (i.e. opioids and benzodiazepines).
Dexmedetomidine provides sedation and anxiolysis, while producing little effect on level of arousal and cognitive function. In essence, it reduces discomfort while permitting the patient to arouse for a neurologic examination.

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Title: Pharmacotherapy in the Critically Ill Obese Patient

Category: Critical Care

Posted: 12/28/2010 by Mike Winters, MBA, MD

Vancomycin Dosing in the Critically Ill Obese Patient

Obesity related changes to drug metabolism and distribution can significantly impact the critically ill obese patient.
Many meds can either be underdosed or overdosed depending on which body weight (ideal vs. actual) is used.
With the increased incidence of MRSA infections, vancomycin is often included in the initial antibiotic selection for most critically ill ED patients.
Importantly, vancomycin is one of the most studied antibiotics in obese patients.
Recent guidelines recommend that an initial vancomycin dose of 25-30 mg/kg actual body weight be considered for any critically ill patient, with subsequent dosing dependent upon renal function and trough levels.

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Title: Antibiotic Timing

Category: Critical Care

Posted: 12/15/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

The Importance of Antibiotic Timing for Sepsis and Septic Shock

Septic shock is perhaps the most common critical illness that emergency physicians manage.
In several studies, delays in initiating antibiotics for patients with septic shock were the strongest predictor of mortality.
Broad spectrum antibiotics should be administered ASAP (preferably within 60 minutes) to patients with septic shock.
Selection of antibiotics should be based on the presumed source, the antibiogram at your institution, and the patient's risk factors for resistant organisms.

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Title: Patient Positioning in the Critically Ill Obese Patient

Category: Critical Care

Posted: 11/30/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Beware Trendelenburg Positioning in the Critically Ill Obese Patient

When inserting a central venous catheter (CVC) into the internal jugular or subclavian vein, clinicians often place patients in the Trendelenburg position to increase the size of the vein.
When possible, avoid Trendelenburg position for CVC placement in the morbidly obese patient.
These patients can quickly deteriorate in this position due to reduced lung volumes, increased right heart pressures, decreased cardiopulmonary reserve, and the effects in intra-abdominal pressure.

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Title: Obesity and Mechanical Ventilation

Category: Critical Care

Posted: 11/16/2010 by Mike Winters, MBA, MD

Positioning for Ventilated, Critically Ill Obese Patients

Up to one-quarter of patients in the ICU are obese, as defined by a BMI > 35 kg/m²
Obesity can significantly alter pulmonary physiology causing
- reduced lung volumes
- decreased compliance
- abnormal ventilation to perfusion relationships
- respiratory muscle inefficiency
For intubated obese patients, body position can affect ventilatory management
In the supine position, obese patients can have collapse of lung segments along with increased impedance of the diaphragm
Elevating the head of the bed to 30-45 degrees in intubated obese patients has been shown to improve tidal volumes and lower respiratory rates.

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Title: Ventilation in the Post-Cardiac Arrest Patient

Category: Critical Care

Posted: 11/2/2010 by Mike Winters, MBA, MD

Ventilation Pearls in the Post-Cardiac Arrest Patient

Some ventilation pearls from the recently released 2010 AHA guidelines include:
- Set the tidal volume to 6-8 ml/kg ideal body weight
- Titrate minute ventilation to achieve a P_aCO₂ between 40-45 mm Hg or P_ETCO₂ between 35-40 mm Hg
- Reduce the F_iO₂ to maintain S_pO₂ > 94%

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Title: Ketamine for RSI in Unstable ED Patients

Category: Critical Care

Posted: 10/19/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Ketamine for RSI in Hemodynamically Unstable ED Patients

Recall that ketamine acts as a sympathomimetic resulting in increases in heart rate, blood pressure, and ultimately cardiac output.
Because of its rapid transport across the blood-brain barrier, its sympathomimetic effects, and lack of significant adverse effects, ketamine is recommended by many organizations as a first line agent for RSI in unstable patients.
Important contraindications to ketamine include an acute coronary syndrome, aortic dissection, and acute heart failure.
Take Home Point: Consider using ketamine the next time you need to intubate a hypotensive, critically ill ED patient.

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Title: Peak and Plateau Pressures in Intubated ED Patients with Respiratory Distress

Category: Critical Care

Posted: 10/5/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Respiratory Distress in the Ventilated ED Patient

In the ventilated patient with respiratory distress, evaluation of peak and plateau pressures can help to identify the cause.
Isolated increases in peak pressure suggest increased resistance to airflow and should prompt consideration of the following:
- kinked or twisted ET tube
- patient biting ET tube
- obstructed ET tube
- bronchospasm
- lower airway obstruction
Increases in plateau pressure suggest decreased pulmonary compliance and should prompt consideration of the following:
- unilateral intubation
- pneumothorax
- pulmonary edema
- worsening pneumonia
- abdominal HTN/compartment syndrome

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Title: Hemophilia A and Life-threatening bleeding

Category: Critical Care

Posted: 9/21/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Life-threatening Bleeding in Hemophilia A Patients

Although an infrequent occurrence, patients with Hemophilia A can present with life-threatening hemorrhage (e.g. ICH).
Recall that normal clotting factor levels range from 50-150 IU/dL - reported by the lab as 50-150%.
Life-threatening bleeding requires Factor VIII levels between 80-100%. In general, each unit of FVIII/kg raises plasma levels by 2%.
Recombinant Factor VIII products are preferred over plasma derived concentrates or blood products and are dosed as:
- FVIII - 50 IU/kg loading dose followed by infusion of 3 IU/kg/hr
In the event you don't have access to recombinant or plasma derived FVIII concentrates, cryoprecipitate (contains FVIII) can be used.

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Title: Pulmonary Contusion Ventilator Management

Category: Critical Care

Posted: 9/7/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Pulmonary Contusion and Ventilator Management

Pulmonary contusion is the most common injury in blunt thoracic trauma.
Patients with pulmonary contusion often present with hypoxia, hypercarbia and increased work of breathing.
Importantly, patients with pulmonary contusion have a low cardiopulmonary reserve. Maintain a low threshold for initiating mechanical ventilation is these patients.
When starting mechanical ventilation, think about the following:
- Patients are at high risk for developing ARDS
- Most centers use a low tidal volume ventilatory strategy
- Higher levels of PEEP may be necessary to recruit collapsed alveoli
- High frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV) are modes of ventilation that are gaining in popularity for ventilating patients with pulmonary contusions.

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Title: Hemostatic Therapy for ICH

Category: Critical Care

Posted: 8/24/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Hemostatic Therapy for ICH - Updated Guidelines

The AHA/ASA just published updated guidelines for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage (ICH).
Regarding hemostatic therapy, new/revised recommendations from the 2007 AHA/ASA guidelines include:
- Patients with severe thrombocytopenia or factor deficiency should receive platelets or factor replacement
- Patients with ICH due to oral anticoagulants (warfarin) should receive intravenous vitamin-K and vitamin-K dependent factor replacement
  - Prothrombin complex concentrates (PCCs) are being increasingly used and are considered a reasonable alternative to FFP. To date, studies have not shown improved outcome with PCCs.
  - Recombinant factor VIIa (rFVIIa) is not recommended as a sole agent for warfarin-related ICH
- rFVIIa is not recommended in unselected patients
- Usefulness of platelet transfusions for patients using antiplatelet medications is unclear and currently investigational.

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Title: Drug-Induced Hypophosphatemia

Category: Critical Care

Posted: 8/10/2010 by Mike Winters, MBA, MD (Updated: 3/5/2026)

Drug-Induced Hypophosphatemia

Hypophosphatemia is seen in almost 30% of critically ill patients.
As discussed in a prior pearl, hypophosphatemia can result in respiratory failure along with cardiac and neurologic abnormalities.
Although common ED causes of hypophosphatemia include sepsis, hypothermia, and dialysis, don't forget about medications.
Medications that can cause significant hypophosphatemia in the critically ill (along with their mechanism) include:
- Decreased GI intake: antacids, sucralfate
- Transcellular shift: aspirin overdose, albuterol, catecholamines, insulin, and bicarbonate
- Increased urinary excretion: diuretics, acetaminophen overdose, and theophylline overdose

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Title: Hypocapnia and the Injured Brain

Category: Critical Care

Posted: 8/3/2010 by Mike Winters, MBA, MD

Hypocapnia and Brain Injury

Hypocapnia indirectly reduces cerebral blood volume through reductions in arterial cerebral blood flow.
Despite its continued and frequent use, hypocapnia can actually aggravate cerebral hypoxia through reductions in oxygen supply and increases in cerebral oxygen demand.
In addition to inducing further cerebral injury, hypocapnia can cause deleterious effects on the heart, lung, and GI tract.
To date, there is no evidence that hypocapnia improves outcome in patients with traumatic brain injury or acute stroke.
Induced hypocapnia in critically ill ED patients with acute brain injury should primarily be reserved for those with imminent brain herniation.

181-200 of 354 results by Mike Winters

Title: GI Complications of Obesity in Critical Illness

Title: Combination Therapy for Bacteremia

Title: Aspiration Pneumonitis/Pneumonia

Title: The Severely Hypoxemic ED Patient

Title: Hemodynamic Monitoring in the Ventilated Patient

Title: LV Dysfunction in the Critically Ill

Title: Valproic Acid and Status Epilepticus

Title: Sedation and Analgesia in Acute Neurologic Disease

Title: Pharmacotherapy in the Critically Ill Obese Patient

Title: Antibiotic Timing

Title: Patient Positioning in the Critically Ill Obese Patient

Title: Obesity and Mechanical Ventilation

Title: Ventilation in the Post-Cardiac Arrest Patient

Title: Ketamine for RSI in Unstable ED Patients

Title: Peak and Plateau Pressures in Intubated ED Patients with Respiratory Distress

Title: Hemophilia A and Life-threatening bleeding

Title: Pulmonary Contusion Ventilator Management

Title: Hemostatic Therapy for ICH

Title: Drug-Induced Hypophosphatemia

Title: Hypocapnia and the Injured Brain