Moffitt Morning Report Pearls 6/2/17 – PEA + ARDS

Hello Moffitt!

Thanks for welcoming us to our first Morning Report! And a special thanks to Salman for presenting a great case of an older woman found down at home with asystole who developed shock and refractory hypoxemia.

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Top Pearls:

  1. Causes of PEA include both cardiac and non-cardiac etiologies. In women and non-whites, the non-cardiac etiologies, such as SAH and massive PE, are more common! (see more below)
  2. Some centers are using esophageal balloon catheters to estimate pleural pressures and guide PEEP therapy (see attached NEJM reference)!
  3. Therapeutic strategies with treating refractory hypoxemia include the 6 Ps:
  • Higher PEEP
  • lung Protective ventilation
  • Paralytics
  • Prostacylcins
  • Proning
  • P-ECMO (A-V)

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For those who want more info:

  1. Satvik Ramakrishna presented a fantastic R3 Talk on Thursday about redefining sudden cardiac death (SCD) using insights from the San Francisco POST SCD Study. Working with Dr. Zian Tseng, UCSF researchers used comprehensive autopsy data to determine the cause of death of nearly all out of hospital “sudden deaths” in San Francisco during a 3 year period. The group found that while under previous definitions, 80% of the nearly 5000 deaths would have been classified as SCD, including autopsy information reduced this proportion to 56%! They also found important disparities based on gender and race. Publication soon to come!
  2. Esophageal pressures to manage PEEP: NEJM RCT comparing MV directed by esophageal-pressure measurements with that according to ARDSNet recommendations. This study demonstrated the feasibility of using repeated measurements of esophageal pressures to determine the transpulmonary pressures and make timely adjustments to PEEP. Patients with ARDS in the esophageal pressure arm had improved oxygenation based on the P:F ratio and improved respiratory-system compliance. The researchers found that the 28 day mortality was lower among the patients with esophageal-pressure-guided MV, however, mortality at 180 days was the not different between the two groups.
  3. The supportive strategies that have shown mortality benefits for patients with ARDS include lung protective ventilation (pioneered here at UCSF!), early neuromuscular blockade and prone positioning. Prostacyclines, recruitment maneuvers, and ECMO are all used and can improve oxygenation, but a mortality benefit has not been shown. Each of the ground-breaking papers that showed mortality benefits for ARDS supportive therapies are below!

References:

Talmor et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. http://www.nejm.org/doi/full/10.1056/NEJMoa0708638#t=article

ARDS-net. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. http://www.nejm.org/doi/full/10.1056/NEJM200005043421801#t=abstract

Papazian L, et al. Neuromuscular blockers in early acute respiratory distress syndrome.

http://www.nejm.org/doi/full/10.1056/NEJMoa1005372

 

Guerin et al. Prone positioning in severe acute respiratory distress syndrome. http://www.nejm.org/doi/full/10.1056/NEJMoa1214103#t=article

Blog:

Evernote: https://www.evernote.com/shard/s462/sh/7b428e2c-0771-49cf-ab44-2a8262dee775/ce84685da30f0cc865557bc94ee80226

Have a great weekend!

Your super sweet Moffitt chiefs – DKA

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