Top 100 secrets in critical care medicine
1. Elevated lactate levels suggest tissue hypoperfusion, and normal lactate clearance is
suggestive of adequate fluid resuscitation.
2. Always assume that even a single episode of hypotension in a trauma patient is due tobleeding, and proceed accordingly.
3. Good cardiopulmonary resuscitation can make a difference for a successful resuscitation from cardiac arrest. Know and perform it well.
4. Time to defibrillation is the most important factor in a return of spontaneous circulation from ventricular tachycardia and/or ventricular fibrillation.
5. Pulse oximetry is good for continuous monitoring, but arterial blood gases (ABGs) are best for diagnosis and acute management. If oximetry does not fit the clinical picture,obtain an ABG.
6. Use the alveolar gas equation to help understand mechanisms of hypoxemia.
7. Hemodynamic monitoring assesses whether the circulatory system has adequate performance to supply oxygen and sustain the “fire of life.” Monitoring provides data to guide therapy but is not therapeutic.
8. There is no proved benefit to colloid over crystalloid in acute resuscitation.9. Starting enteral nutrition early in critically ill patients increased survival.
10. Enteral feeding in patients with shock is acceptable after the patient is resuscitated and hemodynamically stable, even if the patient is receiving stable lower doses of
11. The primary indications for mechanical ventilation are inadequate oxygenation, inadequate
ventilation, and elevated work of breathing.
12. Low tidal volume mechanical ventilation can lead to improved outcomes in the patient withacute respiratory distress syndrome.
13. Daily weaning assessments improve patient outcomes.
14. The rate of central venous catheter–related bloodstream infections can be reduced through a combination of the use of maximal sterile barrier precautions, 2% chlorhexidine-based antiseptic, centralization of line insertion supplies, and daily evaluation of the need for continued central access.
15. Subclavian venous catheters have the lowest risk of bloodstream infection.
16. Lung sliding on ultrasound examination effectively rules out pneumothorax at the site of the transducer.
17. Extracorporeal membrane oxygenation can be used successfully in patients with respiratory failure in whom low tidal volume ventilation is failing.18. Nonrecognition of an esophageal intubation leads to death; direct visual confirmation or detection of carbon dioxide must be done to confirm the proper location of an endotracheal tube.19. If a tracheostomy tube falls out of its stoma within the first 1 to 5 days of placement, do not attempt to reinsert it blindly. Perform translaryngeal intubation instead because blind attempts at reinsertion misplace the tube into a paratracheal track, compress the trachea,and cause asphyxia.20. Any airway or stomal bleeding that develops more than 48 hours after tracheotomy should suggest the possibility of a tracheoarterial fistula, which develops as a communication between the trachea and a major intrathoracic artery.
21. A retrospective study showed that positive pressure ventilation (PPV) does not influence the rate of recurrent pneumothorax or chest tube placements after removal. Consequently, presence of mechanical PPV is not anindication to leave a chest tube in place.22. Chest physiotherapy appears to be as effective as bronchoscopy in treating atelectasis, although bronchoscopy has a role in retained, inspissated secretions or foreign bodies.23. Pulmonary artery line placement in patients with a newly implanted (less than 3 months)implantable cardioverter defibrillator or pacemaker is associated with high risk of lead dislodgment, especially if there is a coronary sinus lead.24. Intraaortic balloon pumps should be considered in patients who may benefit from increased diastolic pressures (persistent refractory angina, cardiovascular compromise from myocardial ischemia/infarction) or decreased afterload (acute mitral regurgitation,cardiogenic shock).25. Clinical judgment should supplement severity of illness scores in defining patients with severe community-acquired pneumonia.26. The use of clinical criteria alone will lead to the overdiagnosis of ventilator-associated pneumonia.27. A normal PCO2 in acute asthma is a warning sign of impending respiratory failure.28. Noninvasive mechanical ventilation reduces the need for intubation in patients with achronic obstructive pulmonary disease exacerbation and impending respiratory failure.
29. Chronic hypoxemia is the most common cause of pulmonary hypertension.30. Patients with acute lung injury and acute respiratory distress syndrome die of multiorgan dysfunction far more frequently than they do of refractory hypoxemia.
31. For most patients, bronchial artery embolization is the treatment of choice to stop hemorrhaging in massive hemoptysis. 32. Because death from massive hemoptysis is more commonly caused by asphyxiation than
exsanguination, it is important to emergently maintain airway patency and protect the
nonbleeding lung.33. Deep venous thrombosis and pulmonary embolism are common and often
underdiagnosed in critically ill patients.34. The key to treating heart failure is determining the cause, that is, reduced ejection fraction,normal/preserved ejection fraction, restrictive cardiomyopathy, hypertrophic cardiomyopathy, or right ventricular failure.35. The best clinical guide to help in choosing which treatment is appropriate for the critically ill patient with heart failure is to assess volume and perfusion status.36. Acute myocardial infarction, complicated by out-of-hospital cardiac arrest, has a very high mortality, and hypothermia may improve chances for survival and neurologic recovery.37. It is important to distinguish hemodynamically unstable arrhythmias that need immediate cardioversion/defibrillation from other more stable rhythms.38. When managing acute aortic dissection, adequate beta blockade must be established before the initiation of nitroprusside to prevent propagation of the dissection from a reflex increase in cardiac output.39. Pulsus paradoxus is when there is respiratory variation on arterial waveform seen during pericardial tamponade of >10 mm Hg.40. Severe sepsis ¼ sepsis plus acute organ dysfunction.
41. Early diagnosis and therapeutic interventions in patients with severe sepsis or septic shock
are associated with better outcomes.42. Between 60% and 80% of cases of endocarditis result from streptococcal infection.Staphylococcus aureus tends to be the most common etiologic agent of infective endocarditis in intravenous (IV) drug users.43. Streptococcus pneumoniae remains the most common cause of community-acquired
bacterial meningitis, and treatment directed to this should be included in the initial empiric regimen.44. Most patients do not require computed tomographic scan before lumbar puncture;however, signs and symptoms that suggest elevated intracranial pressure should prompt imaging. These include new-onset neurologic deficits, new-onset seizure, and papilledema. Severe cognitive impairment and immune compromise are also conditions that warrant consideration for imaging.45. If you suspect disseminated fungal infection, do not wait for cultures to treat.
46. Reducing multidrug-resistant bacteria can only be accomplished by using fewer antibiotics, not more.47. Clinical or laboratory identification of an unusual pathogen (i.e., anthrax, smallpox, plague) should raise suspicion for a biologic attack.48. Pain disproportionate to physical findings; skin changes including hemorrhage, sloughing, or
anesthesia; rapid progression; crepitus; edema beyond the margin of erythema; and systemic involvement should prompt intense investigation for deep infection and involvement of surgical consultants as needed in the case of necrotizing fasciitis or gas gangrene.49. During influenza season all persons admitted to the intensive care unit (ICU) with respiratory illness should be presumed to have influenza and be tested and treated.50. Asplenic individuals are at risk for infection with encapsulated organism.
51. The greatest degree of immunosuppression in solid organ transplant recipients is in the 1
to 6 months after transplantation.52. Severe hypertension in absence of end organ damage can be safely treated outside the setting of intensive care and reduction in blood pressure be achieved gently over hours to days.53. The serum creatinine level may not change much during acute renal failure in patients with decreased muscle mass.
54. In the analysis of acid-base disorders, a normal serum pH does not imply that there is not an acid-base disorder; rather it points to mixed disorder.55. Serum magnesium level should be checked and corrected, if low, in patients with refractory hypokalemia.56. Overly rapid correction of hyponatremia or hypernatremia can result in devastating
long-term neurologic sequelae.57. If a patient has neurologic symptoms associated with hyponatremia, one of the immediate goals of therapy should be correction of serum sodium to a safe level.58. Be systematic in your workup of gastrointestinal tract bleeding. Follow an algorithm.59. In a patient with acute pancreatitis, make sure the patient’s fluid is replenished with an adequate amount of IV fluid. This is as important as, if not more important than, the other facets of treatment, including pain control, nutritional support, correcting electrolyte abnormalities, treating infection (if present), and treating the underlying cause.60. Steroids should be considered for the treatment of severe alcoholic hepatitis as defined by a Maddrey’s discriminate score 32.
61. Abdominal compartment syndrome is an underappreciated diagnosis.62. This is no secret—we all share the responsibility for reducing nosocomial infections.63. Worsening confusion or a new impairment in mental state during treatment of diabetic ketoacidosis or hyperosmolar hyperglycemic state is life-threatening cerebral edema until proved otherwise. 64. Administering insulin without adequate fluid replacement during treatment of diabetic ketoacidosis or hyperosmolar hyperglycemic state can lead to profound hypotension,shock, or cardiovascular collapse.65. An IV insulin infusion is the safest and most effective way to treat hyperglycemia in critically
ill patients.66. If the blood pressure of an ICU patient with septic shock responds poorly to repeated fluid boluses and vasopressors, hydrocortisone should be given regardless of cortisol levels.67. In most cases you do not need to treat nonthyroidal illness syndrome with levothyroxine despite low thyroxine, triiodothyronine, and thyroid-stimulating hormone levels; instead follow expectantly, and recheck laboratory values in 4 to 6 weeks.68. Stable anemia is well tolerated in critically ill patients. Transfuse blood products only when necessary or if hemoglobin level drops below 7 gm/dL.69. Although disseminated intravascular coagulation typically presents with bleeding or
laboratory abnormalities suggesting deficient hemostasis, hypercoagulability and accelerated thrombin generation actually underlie the process.70. Surgery for cord compression can keep people ambulatory longer than radiation alone.
71. For a neutropenic fever, draw cultures, give broad-spectrum antibiotics, then complete the workup.72. In a patient in the ICU who is seen with multiorgan failure or a clinical picture resembling fulminant sepsis, consider the diagnosis of systemic lupus erythematosus or vasculitis.73. Respiratory pattern, autonomic functions, and brain stem reflexes are critical in identifying the cause of coma and should be recorded in all patients.74. No ancillary test can replace an experienced clinical examination for determination of brain death.75. The mainstay of treatment for status epilepticus includes stabilizing the patient, controlling the seizures, and treating the underlying cause.
76. ICU admission, invasive hemodynamic monitoring, and respiratory support with frequent vital capacity measurements are keys to following patients with Guillain-Barre´ syndrome.77. Tachypnea is often the first sign of respiratory muscle weakness. Respiratory muscle strength is ideally measured by maximum inspiratory flow and vital capacity (VC) in patients with myasthenia gravis. A quick surrogate for forced VC is to ask the patient to
count to the highest number possible during one expiration.78. Benzodiazepines are the preferred agents for the treatment of alcohol withdrawal.79. Time should not be wasted pursuing radiographic confirmation when a tension
pneumothorax is suspected in a hemodynamically unstable patient. Either formal tube thoracostomy should be immediately performed or an Angiocath inserted into the second intercostal space along the midclavicular line.
80. The condition of a significant number of patients with flail chest and/or pulmonary contusion can be safely and effectively managed without intubation by using aggressive pulmonary care, including face-mask oxygen, continuous positive airway pressure, chest physiotherapy, and pain control.
81. The model for end-stage liver disease (MELD) calculates the severity of liver disease.82. Delirium is a disturbance of consciousness with inattention, accompanied by a change in cognition or perceptual disturbances that develop over a short period of time, fluctuate over days, and remain underdiagnosed.83. Therapeutic hypothermia (temperature 30 -34 C) improves neurologic outcomes in comatose survivors of cardiac arrest.84. Heat stroke is a true medical emergency requiring immediate action: Delay in cooling increases mortality.85. When caring for a critically ill poisoned patient, the diagnostic and therapeutic interventions should be started on the basis of the clinical presentation, with use of the history, the physical examination, and recognition of toxidromes.86. Syrup of ipecac and gastric lavage have no role in the routine management of the poisoned patient.87. Oral or IV N-acetylcysteine should be administered promptly to any patient with suspected or confirmed acetaminophen toxicity.
88. Patients with methanol and ethylene glycol ingestions present with an osmolal gap, which closes with metabolism and develops an anion gap acidosis. Isopropanol toxicity begins with an osmolal gap but is not metabolized to an anion gap.89. Patients with toxic alcohol ingestion and any vision disturbance, severe metabolic acidosis,or renal failure should undergo urgent hemodialysis.90. The treatment of choice for calcium channel blocker toxicity is hyperinsulinemiaeuglycemia therapy to maximize glucose uptake into cardiac myocytes.
91. Neuroleptic malignant syndrome can occur at any age in either sex with exposure to any antipsychotic medication.92. Although radiologic investigations and drug treatment may carry some risk of harm to the fetus, necessary tests and treatment should not be avoided in the critically ill mother.93. Patients and their families are the experts on the patient’s goals and values, and clinicians are the experts on determining which clinical interventions are indicated to try to achieve reasonable clinical goals.94. Timely ethics consultation in the ICU may mitigate conflict and reduce ICU length of stay,hospital length of stay, ventilator days, and costs.95. Only discuss treatment choices after the patient or family has been updated on medical condition, prognosis, and possible outcomes and once overall goals of medical care are agreed on.96. Family conferences are more successful when providers listen more and talkless. Encourage the family to discuss their understanding of illness, their emotions,
and who the patient is as a person. Then respond with statements of support and understanding.97. All patients with impending brain death or withdrawal of care should be screened for the possibility of organ donation.98. The gap between those patients awaiting a transplant and those donating organs is widening exponentially—the vast majority of those on the transplant list will die waiting.99. The hospital systems investing today in advanced informatics, automated decision analysis, telemedicine, and/or regionalized care will be the leading systems tomorrow.
100. Patient safety remains a concern in critically ill patients, and a primary barrier to improving patient safety is physicians’ inability to change their practice patterns.