CCC Update 012

Here’s what is new in the CCC since CCC Update 011:

Abdominal Aortic Aneurysm (AAA)

Thanks to suggestions from Dr Jason Chuen (@OzVascDoc) multiple sections of this page have been overhauled. Of note, reference to ‘acute expansion’ has been largely removed. ‘Acute expansion’ as a presentation is not a good reason for ED referral or admission, it generally means that the AAA is bigger than when it was last checked. Pain, however, is always an aortic emergency until proven otherwise in a patient with a AAA, but isn’t typically simply due to an increase in size, rather some other another nasty event such as inflammation, rupture, dissection or thrombosis is going on.

Apnoeic oxygenation

Always a favourite topic in the CCC, apnoeic oxygenation via nasal prongs is now bread-and-butter for emergency intubations in the ED (still less so in the OR and the ICU unfortunately…). I’ve expanded the evidence section, including John Dyett’s recent prospective observational study suggesting an NNT of 6 for preventing hypoxaemia (yes, the study design is subject to confounders, but it is getting increasingly difficult to justify NOT doing this!)

Cardiac arrest management after cardiac surgery

We do things differently for cardiac arrests if they happen to occur after cardiac surgery… As well as explaining the key team roles and the important management considerations I’ve updated the enigmatic ‘Other Information’ section. In particular, more justification is provided for why things are done differently after cardiac surgery compared to the standard ALS approach to cardiac arrest.

ECMO and Pharmacokinetics

As Jason Roberts (@jasonroberts_pk) recently reminded me at the ‘2015 Infectious diseases and Critical Care Conference’, getting antibiotic doses right in the critically ill can be very difficult… especially so in patients on ECMO. This is a tricky area with lots of unknowns. The pharmacokinetic effects of ECMO vary with different drugs and drug characteristics, as well as with different types and compositions of ECMO circuit components. The end result can be therapeutic failure, drug toxicity and/or worsening antimicrobial resistance… None of which are good.

Long-term cognitive impairment in critically ill patients

This page is a little unsatisfactory… why you ask? Well, because LTCI-CI (not my abbreviation) is probably a big problem but we don’t really know how prevalent or severe it is. Furthermore, although there are various things we can do both inside and outside the ICU to prevent or ameliorate it, it is hard to know how effective those interventions are. More work needed.

Vascular gas embolism

The previous separate pages on venous and arterial gas embolism have been combined into one, now imaginatively called ‘Vascular gas embolism’. Always anticipate the possibility of causing a gas embolism when inserting a line in a patient – and take the necessary steps to prevent it. It is bad when it happens, so make sure you know what to do.

OK gang, that’s it until the next installment. Enjoy!