Grand Rounds Recap 6.7.17

Airway Grand Rounds with Dr. Carleton: The physiologically difficult airway

Case:

Middle aged 100+ kg male with history of IVDA transferred for sudden central vision loss in one eye.  Soft tissue infection at injection site in right forearm.  Presumed septic pulmonary emboli on CT of chest.  Had received antibiotics and 30+ mL/kg crystalloid.  BP 86/31, pulse 113, RR 45, 95% on 4 L NC, shock index 1.3.  Fluids continued, BP improving, norepinephrine weaned off.  Lactate on arrival is 7.1.  During ED course oxygen requirement, BNP, and pulmonary infiltrates are all increasing.  Initiated on bilevel PAP to augment respiratory compensation for metabolic acidosis.  Becomes progressively more confused.  At this juncture the MICU bed becomes available.  

Should we intubate him before he goes to the MICU?

What difficulties should we anticipate in this procedure with him?

Consequences of intubation

• Induction agents are cardiodepressant, many are venodilatory
• Hypoxia is a negative inotrope, arrhythmogenic, and kills neurons and cardiac myocytes
• Acidosis does all these things, too
• Positive pressure ventilation decreases venous return

Hemodynamic kills, and how to prevent them

• Mechanisms

  • underlying disease
  • under resuscitation
  • induction agents
  • PPV
  • hemodynamic effects of progressive acidosis during apnea
• how to prevent it
  • volume resuscitate
  • pressors as needed
  • consider single dose epinephrine prior to intubation
    • give it time to work
  • choose your induction agent wisely
    • use a reduced dose, even with ketamine
      • ketamine is an indirect sympathomimetic, utilizes body’s endogenous catecholamines.  If they’re taxed out, there’s nothing to draw from.
      • has cardiodepressant effect, usually overcome by the above mentioned catecholamines.  When they’re already used up it can manifest.  
        • Intubation priorities
          • Survival first
            • Followed by no physiological compromise > no pain > no memory > no awareness
            • Consider the above when making decisions regarding sedation in critically ill patients
  • Avoid hypoxia
    • pre-oxygenate, avoid de-oxygenation, re-oxygenate
    • keep them seated.  Seated position distribute ventilation/perfusion matching better, easier to oxygenate.
      • intubating position ergonomically can be easier with patient head of bead at 25 degrees.  Can still have head in sniffing position.
    • Use flush flow wall O2 (can crank the O2 output much higher than 15 L per minute
    • Don’t settle for a reservoir mask for pre-oxygenation
      • It’s important to de-nitrogenate as well
        • Try bag valve mask with PEEP valve and tight mask seal
        • NIPPV
        • Active bagging when needed
    • Consider delayed sequence intubation in select patients
      • keep in mind potential complication of vomiting in ketamine
    • Minimize laryngoscopy time, make the first attempt the best attempt
      • Raise your threshold for re-oxygentation to 94%
        • In critically ill patients oxygenation can plummet after reaching this point
      • Increase your paralytic dose in shock
        • Onset time is dependent on cardiac output

Preventing ventilatory kills

• Will bicarb help?
  • Only if they’re able to blow off the CO2 it makes
• What is his minute ventilation pre-intubation?
  • We have no idea unless we measure it
  • Need the number in order to match or exceed it after intubation, can measure via bilevel PAP
  • Will have zero minute ventilation while paralyzed during intubation
    • How should we manage ventilation peri-intubation?
    • Pseudo-NIPPV ventilation in the critical patient with perilous pH
      • apply NIPPV mask and deliver bilevel PAP through ventilator
        • place ventilator on SIMV mode, respiratory rate of 0
          • TV 8 ml/kg IBW
          • 100% FiO2
          • pressure support of 10, PEEP of 5
          • Flow rate 30 L/min
          • measure EtCO2 in circuit
        • Then perform RSI, perform jaw thrust, adjust respiratory rate on ventilator to 12
          • Monitor O2 saturation and EtCO2 during this process
        • Perform intubation once paralysis complete, increase flow rate to 60 L/min and respiratory rate to 30

Remember the seven P’s of intubation.  In some circumstances you need to be flexible.  Consider changes as above

• Preparation
• Pre-oxygenation
• Pre-intubation optimization
• Paralysis/Induction
• Positioning
• Placement
• Post-intubation Management

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R4 Clinical Soapbox with Dr. Riddle: LGBT Healthcare

Case

Transgender female in her 20s presented to OSH with weakness and trouble speaking.  Outside hospital reporting concern for psychiatric presentation and transferred to care, exam on arrival showing flaccid RUE/RLE paralysis and dysarthria, diagnosed with left MCA stroke.

Gender Identity

• the gender an individual identifies with
• often matches the gender assigned at birth

Biological Sex

• Often binary, male or female
• Certain populations may not fall into this binary system, i.e. ambiguous genitalia

More terminology

• Cis = same
• Trans = different
  • in terminology of trans, the gender mentioned is the identified gender
    • i.e. transgender female patient in case identifies as female though assigned male gender at birth
    • cisgender female identifies as female and has assigned female gender at birth
• MSM and WSW
  • utilized in research terms, not typically for patient encounters
• Transsexual isn’t utilized in community anymore unless patient reports they identify as such
• Gender dysphoria
  • no longer gender identity disorder
  • dysphoria individual experiences when assigned/addressed as gender opposite to that with which they identify
    • Can appear as early as 2-3 years of age

LGBT statistics

• LGB 2.5%
• Transgender 0.9%

Barriers to care

• reduced service
• treated differently
• not enough professionals adequately trained
• barriers to emergency care
  • national qualitative survey in Canada
    • largely white transgender male participants
    • Barriers identified
      • fear of being outed: 60%
      • past encounters of personnel mocking or joking: 46%
      • past experiences of professionals refusing to address patient by preferred pronoun: 63%
• What can we do?
  • Ask about and use preferred pronouns
  • Don’t discuss transgender experience unless it’s relevant to the ED care
  • Medical training regarding transgender issues, including hormone therapy, surgeries, etc.

LGBT Youth

• 20-40% of homeless youth identify as LGBT
• 25% of LGBT youth are kicked out of their home
• 7x more likely to be victims of violence/crime
• twice as likely to attempted suicide
• What can we do?
  • Ask open ended questions
  • Speak with patients without their parents present
  • Screen for SI and depression

MSM health disparities

• over 50% of cases of HIV
  • risk even higher in African American cohort
  • Pre-exposure prophylaxis
    • Truvada can be used in high-risk populations as a preventative measure, if on prescription list doesn’t necessarily mean patient is being treated for contracted infection

Transitioning

• Process by which transgender individuals make make steps for physiologic change towards identified gender
• Risks in transitioning
  • exogenous estrogen
    • increasing risk for DVT/PE
    • hypertriglyceridemia
    • increase in cardiovascular disease and diabetes
  • exogenous testosterone
    • polycythemia vera

Transgender Best Practices

• elicit patient name and pronouns
• gender neutral words, partner, spouse, child, sibling, parent, etc
• gender/sex questions
  • i.e. “what sex were you assigned at birth?” rather than “what’s your biological sex?”
• physical exam
  • explain why indicated
  • attention to modesty
  • neutral anatomical terms