Grand Rounds Recap 7/9/2014

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Central Line Complications w/ Dr. Bill Knight

  • Rate of adverse events during central line placement is 2-26%.
  • Common complications
    • Early: mechanical, ie misplacement, pneumothorax
    • Late: infection, thrombosis, occlusion
    • 50% of femoral lines are misplaced during cardiac arrest
    • 20% DVT risk with femoral vein puncture
    • CLABSI (Central Line Associated Blood Stream Infection): 250,000/year
      • 3rd most common cause of nosocomial infection
      • related to duration of catheterization
      • mortality 12-25%
      • increases morbidity, mortality and prolongs length of stay
      • The most important thing you can do to prevent CLABSI is sterile technique
    • Arterial vs Venous placement
      • Confirm with Ultrasound
      • agitated saline under US
      • transduce waveform
      • send a blood gas
      • if in doubt, do not dilate
      • ALWAYS check your own x-ray and if you feel resistance, do not push but start over
    • Operator factors:
      • Failure more than 3 times increases risk of complications by 6 times
      • If you have > 50 insertions, your risk of complications is reduced by 50%
      • 3 unsuccessful attempts = new operator

Health Care Associated Pneumonia (HCAP) Update with Dr. Justin Benoit*

  • Criteria for HCAP
    • Hospitalization for 2+ days within 90 day period
    • SNF resident
    • Receives home IV therapy, chemotherapy or is a hemodialysis patient
    • HCAP treatment
      • Cefepime 2 g or zosyn (weight based dosing)  AND
        • Tobramycin (Cr based dosing)   AND
        • Vancomycin 20 mg/kg or linezolid 600 mg IV
    • Outpatient CAP treatment: monotherapy with azithromycin not recommended due to high resistance
      • levofloxacin 750 mg x 5 days: do not give in pregnancy, adolescents, CKD, pts on chronic steroids  OR
      • Z-pak + amoxicillin 1 g TID x7 days
    • CAP with admission
      • Floor: azithromycin + Rocephin/ampicillin  OR levofloxacin IV
      • ICU/stepdown: azithromycin + Rocephin/Augmentin OR aztreonam + levofloxacin
      • When to get blood cultures: ICU admission, alcoholics, leukopenia, ESLD, pleural effusion, asplenia
      • CURB-65: scoring system to help determine need for admission
        • Confusion
        • BUN > 19
        • RR > 30
        • SBP < 90 or DBP < 60
        • age > 65

* Note that these are based on local resistance patterns and may not be broadly applicable in other regions/locales.

Indications for Non-Invasive Positive Pressure Ventilation w/ Dr. Erin McDonough

  • CPAP = PEEP. Use for oxygenation
  • BiPaP = Pressure support + PEEP. Use for ventilation
  • Pros of NIPPV
    • Decreases intubation rate and thus decreases resource utilization, decreases risk of VAP, decreases airway trauma and preserves speech/swallow
  • Cons of NIPPV
    • Risk of vomiting and aspiration
    • Increased secretions
    • Unable to give oral intake
    • Can cause facial pressure ulcers
    • Can delay intubation
  • NIPPV in COPD
    • Good data that shows that NIPPV decreases mortality, decreases need for intubation and decreases treatment failure
    • Leads to rapid improvement of CO2 and symptoms
    • Decreases length of stay
  • NIPPV in asthma: no evidence for or against but reasonable to try
  • NIPPV in CHF: mainly data for CPAP as issue is with oxygenation
    • Opens alveoli and improves gas exchange
    • Improves work of breathing
    • Decreases afterload
  • NIPPV in pneumonia: no studies looking at this however PNA is one of the predictors of failure of NIPPV
  • Predictors of failure of NIPPV
    • High APACHE II score
    • Low pH
    • Altered mental status
    • Secretions
    • Poor initial response
    • Presence of pneumonia
    • Other indications: extubation to NIPPV (especially in COPD), preoxygenation for RSI/DSI
    • Pitfall: any condition that will last for more than 24 hours is unlikely to improve with NIPPV
    • The most important factor when putting patient on NIPPV is reassess in 1 hour

Leadership Curriculum w/ Dr. Brian Stettler

  • Components of our leadership curriculum:
    • Large group lectures
      • Academies: education,  research, operations
        • Optional small group meetings and workshops
        • Mentored project: this is an optional one-on-one labor intensive project of self-exploration and service
      • Small groups on how to solve some issues that came up in program evaluations:
        • Attributes of a leader to make these changes possible: humility, trust, communication, approachability, broad perspective, flexibility, collaborative
        • These decisions and changes will always include representatives from multiple circles: residents, RLT, operations leaders, MLP and nursing leadership