Author: Bryan Boling

I'm a critical care nurse practitioner and co-director of the Critical Care APP Fellowship Program at the University of Kentucky. I split my clinical time between the Neurocritical Care Service, the Surgical Critical Care Service, and the ECMO Service. I'm also an Adjunct Faculty Member in the Acute Care Nurse Practitioner Program at Georgetown University. I have a passion for education and #FOAM.

Lactic Acidosis

Every student learns the mnemonic “MUDPILES” for the diagnosis of anion gap metabolic acidosis (AGMA), but I think the one on that list that is the most misunderstood is lactic acidosis. In and of itself, “lactic acidosis” is more of a problem than a diagnosis. I’ve never yet had a patient who had spontaneous hyperlactatemia, yet we often want to just says that the patient has “lactic acidosis” and leave it at that.

When approaching the patient with an AGMA, if there is an elevated lactate, we can’t just jump to the conclusion that “lactic acidosis” is the cause, and even if it is, we need to dig in to determine WHY the lactate is elevated. and it turns out, that’s a complex question. There are a number of things than can cause an elevated serum lactate, it’s not just tissue ischemia, and despite the idea of “trending lactates” in sepsis, elevated lactate doesn’t always = sepsis.

Obiajulu Anozie (@icuexplained) has a great post over on Instagram that goes over the basics of classifying and further diagnosing a lactic acidosis. Once the cause has been identified, then you can get to work treating the cause, rather than just bolusing IVF until the “lactate clears.”

Brainstorming

I want to talk about Paroxysmal Sympathetic Hyperactivity (PSH), or brainstorming as it’s sometimes called. This is something we see not uncommonly in neurocritical care, but I feel like it’s often misunderstood. I sometimes hear, “I think they’re brainstorming,” thrown around as a possible explanation to any number of symptoms in a patient with any kind of brain injury. But, not so fast. PSH has specific ways that it presents and is much less common in stroke and anoxic injuries than in TBI. So, let’s don’t be so quick to write those symptoms off.

TBI is the most common condition leading to PSH, with 80% of PSH cases happening in TBI patients. 10% in anoxic injury and 5% each in stroke and “other.” There is also no definitive test for PSH, so it’s largely a diagnosis of exclusion. the other thing to keep in mind is that PSH correlates at least somewhat with the degree of brain injury. So, if you have a patient with a relatively minor ICH but symptoms suggestive of severe acute PSH, that deserves some further investigation.

In the ICU, we mainly use 2 strategies to deal with PSH, stopping the episodes and preventing further ones. In terms of stopping or controlling episodes, propofol, opioids, and benzos are the mainstay. If you have a patient with severe storming, its likely that they’re intubated, so a propofol infusion can help to control the episodes along with providing sedation. Morphine is the commonly used opioid for stopping a storm, but fentanyl may work faster.

In addition to stopping storms, you want to prevent future ones. Propranolol is my first go to drug here, but you have to be careful in people with reasons to avoid beta-blockade(bradycardia, hypotension, heart blocks). Gabapentin can also be helpful, with the added benefit of helping in patients with neuropathic pain. If you don’t need to big gun sedation of propofol to stop a storm, dexmedetomidine can provide some lighter sedation and serve to prevent storms.

Bottom line, the most important take home message is, be sure that you’ve excluded other pathologies before settling in on PSH as the cause of your problems. Josh Farkas has a great article over at the IBCC on PSH. Check it out here.

Docusate for Constipation?

A while back, I read an article in a great series from the Journal of Hospital Medicine called, “Things We Do For No Reason” (and they have a Twitter account too!) It’s a great series and there are a lot of articles applicable to the ICU. The series examines things that we in healthcare do, but for which there is actually no good evidence for. The article in question was on the use of docusate for the prevention or treatment of constipation.

This is a drug that used to be on my standard ICU order set. Everyone got it on admission to prevent constipation. But, it turns out that it doesn’t really work. In fact, it’s no better than placebo. So, I stopped ordering it. I took it out of my order set. I use other drugs (like senna and polyethylene glycol) to prevent and treat constipation.

And so I was really glad to see this Instagram post from Doc Schmidt, an actual gastroenterologist also supporting the practice of ditching docusate! Check out his post and read the paper for yourself. Then delete that from your order set.

Measuring Blood Pressure in Aortic Dissection

Acute Aortic Dissection is a potentially life threatening vascular emergency. We’ve previously discussed the classification of dissection and briefly looked at conservative management in the form of impulse control. The idea is to reduce blood pressure and slow the heart rate to prevent worsening of the dissection either until it can heal or until surgical correction can be performed.

But, what’s the best way to monitor blood pressure in these patients? My practice is to place a radial arterial line in any patient with an acute aortic dissection. But, is a cuff adequate? Which arm should be used? Academic Life in Emergency Medicine (ALiEM) recently featured a post looking at the evidence to possibly answer these questions.

Classically, these patients will have different blood pressures in each arm, although this is not a universal finding. This difference may be predictive of dissection, but a 2018 study found that “any recorded difference in volume/force [of the pulse] or difference in obvious signs of malperfusion” was better at diagnosing acute aortic dissection. In the case of different systolic blood pressures in each arm, the higher of the 2 should be used to guide antihypertensive therapy. So, check both arms with a cuff and place the arterial line in the side with the higher pressure. You can continue to spot check the contralateral arm with a cuff as well.

TXA for SAH?

Tranexamic acid (TXA) is an antifibrinolytic drug that stabilizes clots and helps to control bleeding. It is often used in acute trauma and of cases of massive hemorrhage. It is not prothrombotic, so it can help to control bleeding while not increasing clotting like some other drugs. So, is there a place for it in the initial management of aneurysmal subarachnoid hemorrhage?

Endovascular coiling or surgical clipping is the preferred management of bleeding cerebral aneurysms, but could TXA be useful in situations where surgical management is not readily available? Pharmacy Joe looks at a new study by Long and Gottlieb in Academic Emergency Medicine that seeks to answer that question.

The review of the literature included 13 studies of nearly 3000 patients and essentially concluded that there was no real benefit. Although there was no difference in adverse events between placebo and TXA, there was no difference in mortality or functional outcomes either. There did appear to be a benefit when it came to rebleeding. The study found 8.7% reduction in rebleeding among patients treated with TXA. So, there may be some benefit in reducing further complications, but more study is needed.

Check out Pharmacy Joe’s episode for all the details and links to the relevant evidence.

So, what’s the deal with therapeutic hypothermia?

Therapeutic hypothermia following cardiac arrest was a strategy to improve neurological outcomes first explored in 2002 following the publication of the publication of a trial by Bernard and colleagues in the NEJM. The theory was that metabolic demand slowed when the patient was placed in a hypothermic state. This would improve neurologic outcomes by reducing cerebral oxygen demand. It’s similar to the practice of cooling the patient during deep hypothermic circulatory arrest in the operating room for complex cardiac surgeries such as repair of the aortic arch.

The downside is, there are a number of major consequences and potential complications from hypothermia, as anyone who has treated environmental injuries associated with prolonged cold exposure can tell you. In the intervening 20 years since the initial Bernard study, a number of other studies have been published showing the benefit of cooling, but more than likely, no need for true hypothermia.

Bottom line, it seems that prevention of hyperthermia is probably just as beneficial and hypothermia, with far fewer deleterious effects. The University of Kentucky ICU Pharmacy recently did a great tweetorial summarizing the data surrounding hypothermia. Check it out for more details.

Goals of Care

Previously, we discussed how to deliver bad news. I set it up specifically as a situation that didn’t require much in the way of further discussion. The example I used was telling a family that their loved one had died. But often we have to have other types of difficult conversations with families as well. The most common type of this is the Goals of Care discussion.

This is a talk where you are delivering bad news of a sort, that their loved one is unlikely to have meaningful recovery. But in this conversation, there are decisions to be made. Unlike telling a family that someone has died, there isn’t total finality to this conversation. You need to help the family decide what to do next.

Often we consult palliative care for this, but I think that that is not the best practice for 2 reasons. First, any healthcare provider, especially an ICU provider, should be able to handle a basic goals of care discussion. Palliative care is helpful and should be involved in complex situations, especially those that involve tricky ethical or legal questions. But, the palliative care team is busy and just like you wouldn’t consult cardiology for every arrhythmia, you shouldn’t consult palliative for every goals of care discussion. Most often, people consult palliative care for these talks because they’re uncomfortable and the ICU provider would rather not have them.

And that brings me to reason number 2 to handle this without consulting palliative. It’s your responsibility. They are your patient and you shouldn’t abandon them when it becomes uncomfortable. In many cases, the ICU provider probably has some sort of relationship with the family (although not always, because patients may show up to the ICU in a non-salvageable condition). It’s going to better for the family to hear this from you than from a palliative care provider that they just met.

So, how do you approach this conversation? It’s similar to the breaking bad news discussion we talked about last time, but you often have a little advantage of prior relationship. I start by prefacing the conversation like this: “I’m going to speak very frankly to you because, if I were in your shoes, that’s how I’d want to be spoken to. I apologize if anything I say comes across as harsh, that’s not my intent. But, it’s been my experience that families prefer to get the straight truth rather than beating around the bush.” In several years, I’ve never had a family disagree.

Too often, we use medical jargon and euphemisms. Or, we just skirt around the issue without addressing it head on. I’ve been in conversations where the person leading the discussion does this and then leaves the room, feeling that they’ve been understood. But the family will walk away with a different understanding. “Your husband has had a very serious stroke and he’s not progressing like we had hoped. I think that looking at everything, the odds of him coming off the ventilator are very poor. It’s likely that he will never be much better than he is right now.”

The next thing to do is to discuss what the patient would value and how he or she would define quality of life. I know how I would want to live and how I would not want to live, but that isn’t for me to impose on others. For some people, if they could recognize their families, living in a nursing home on a ventilator might be something they’d be ok with. Others wouldn’t want to go on if they couldn’t be independent.

This is where predicting the future becomes tricky, but you need to lay out the best case scenario, the worst case scenario, and what you think is the most likely scenario. In some cases, the best case (which may still be a long shot) isn’t good enough for what they patient would want.

If the family indicates that the patient would not want to continue, this is when I lay out the options for end of life care. “We can transition to a different type of care in that case. One focused not on cure but on providing comfort and allowing a natural death.” I then will ask them if it’s ok for me to share with them what that looks like. This is all a lot to take in. Some families may need time to process. Simply hearing the poor prognosis may be enough. They may need time to come to grips with that before they’re ready to discuss comfort care.

Goals of care meetings may be one meeting where everything is decided, or they may take multiple days. You’ll need to gauge what they can handle. If they decide they want to continue, I describe the process of comfort care. “We stop doing tests and giving medicines that are not aimed specifically at comfort. Then, when you’ve had time to spend with them, the last step is to remove the breathing tube and take them off the ventilator.”

At this point, I usually ask if they’re waiting on other family members to arrive. If there are others coming within a reasonable amount of time (a few days), I suggest that we continue minimal life support (mechanical ventilation, vasopressors) to keep the patient stable until everyone has had a chance to arrive and say goodbye.

These are some of the most difficult conversations to have and can easily be the most exhausting part of your day. Despite what I said earlier, if you’re not comfortable with this conversation, call your palliative care team. But, use that as an opportunity to learn so that next time, you don’t have to call them. Once you do this a few times, you’ll get comfortable with it and it can become a very rewarding part of working in the ICU. If we only seeing curing patients as wins, then we lose a lot. And that can lead to burnout. However, if you take the view that we did everything we could and now we can focus on keeping them comfortable and allowing them to die with dignity, it can help turn what would normally be perceived as a negative outcome into a positive one.

Delivering Bad News

Having difficult conversations is probably the most overlooked, underappreciated skill in all of healthcare. Very few providers are taught this skill in any sort of structured way. It’s often something that they learn by watching others more senior to them. The problem with that is, those people learned it by watching people more senior to them, who learned it by watching…well, you get the idea. If whoever started the chain didn’t know how to do it, then bad habits kept getting passed down.

As a critical care nurse practitioner, I’ve been involved in hundreds of these conversations. And many of them were very poorly done. And it’s not just trainees. Some of the worst conversations were led by attending physicians with years of experience. And it’s not totally their fault. They were never taught how to do this.

I’ve had the good fortune to learn this skill from some excellent teachers. In school, during my trauma rotation, Dr Cindy Talley taught me how to deliver bad news to a family in a specific way, citing actual research in the field. As an NP, I’ve been fortunate to learn from some great palliative care providers like Dr Jessica McFarlin and see how to expand those principles into leading a goals of care discussion. Here’s how I approach the difficult conversation.

Delivering Bad News

This is the hardest conversation to have. When a patient has died, or is in a position where they are not going to survive, despite our best efforts. Often the difficulty is compounded by shock. Rarely are these expected.

Step 1: Just say it. In most of these cases, a family has been gathered together and placed in a room. They know very little except that their loved one is hurt or sick. Something bad has happened and they’re waiting to find out. The biggest mistake people make at this point is going into all the details. They won’t hear any of that because they’re waiting for the other shoe to drop. I quickly introduce myself and get right to the point.

“Your son was involved in a very serious car accident. He was brought in very badly hurt. We did everything we could. I’m very sorry, but he died.”

You have to say “died” (or “won’t survive if it’s imminent but hasn’t happened yet). Too often, we try to soften the blow by using euphemisms like, “passed” or “gone.” Although we know what we mean, in their worried state, the family can misunderstand that. There is a definite finality to the word death.

Step 2: Sit. This is when you need to shut up and resist the urge to say things or the (overwhelming) urge to leave). It will be uncomfortable. They may cry, they may scream. They will grieve and it will be awkward. But this is what they need to do right now. Let them.

Step 3: Questions. This is why you can’t run away during the grief. Because at some point, they will come around and they’ll be ready to hear all those details that you wanted to give at the start. They’ll have questions and it’s only after they’ve dealt with the initial shock that they can ask them.

That’s the basics of how to deliver bad news to a family. Next time, we’ll talk about how to have a goals of care conversation.

OPCABG

There is a way to do a CABG without going on cardiopulmonary bypass (CPB) and arresting the heart. It’s called Off-Pump Coronary Artery Bypass Grafting, or OPCABG. How do they do it? Why do they do it? Well, the why is easy. CPB has a lot of downsides to it, including risks from cannulating and risks from the CPB pump itself, and so if you can avoid it, you avoid those risks. However, not every patient is suitable for OPCABG, so the CPB isn’t going away just yet.

How do they do it? Surgeons use a special stabilizer device to hold the heart in place, allowing it to continue beating while the part where the surgeon is working is held still and stable. I assume that it is much easier to suture on something that isn’t moving! (After spending a semester in school first-assisting in cardiac surgery, I’m not sure I could suture coronary arteries on a heart that was perfectly still, much less one that was beating!)

In this great Instagram post, Dr Rishi Kumar not only explains this process in more detail, but shows you a great video of the process itself.

If You’re Going to Bolus Fluid…Bolus It!

A pet peeve of mine is when a fluid bolus is given, but it’s given over an extended period of time. There is a term for that, “maintenance fluid.” And maintenance fluid is not generally helpful at all, and it certainly isn’t helpful to the patient who needs a bolus. Dr Obiajulu Anozie has a great Instagram post detailing why this is and how to address fluid boluses in your patient. It should go without saying, make sure that your patient needs a fluid bolus first. But, then, if you’re going to give a bolus, give a bolus.