Critical Care Medicine Section Newsletter - August 2011
From the Secretary and Newsletter Editor - Critical Care Medicine Section Newsletter, August 2011
Brian J. Wright, MD, MPH
Department of Emergency Medicine
Hofstra North Shore-LIJ School of Medicine
I’d like to take this opportunity to introduce the latest edition of the ACEP Critical Care Medicine (CCM) newsletter. I’d also like to welcome all of the new Emergency Medicine (EM) Critical Care fellows and EM residents to the ACEP CCM section. We have a very exciting newsletter and the section is grateful for the hard work and contributions from all of the authors.
Leading off, our chair Dr. Emlet discusses the role that EM should take in the future of CCM education and clinical practice. As we further develop a practice model that focuses on evidence based medicine, quality of care and accountability it is important that EM CCM leads the way in providing new fellows and practitioners with the tools to navigate this new landscape while continuing to thrive and provide timely, compassionate, and effective care at the bedside.
Next, our chair elect, Dr. Shiber presents a case of community-acquired Clostridium difficile colitis. In addition to being a frightening and increasingly common trend of a previously “nosocomial” infection gaining a hold in the community, this case highlights one of the more important and professionally satisfying aspects of EM Critical Care--continuity of care! As EM CCM physicians we have the privilege of running the full gambit of CCM, becoming experts in resuscitation and post-resuscitation care. CCM skills benefit patient care in the ED, and EM skills benefit the ICU care of patients.
Dr. Slesinger, our councilor, provides an update from the ACEP 2011 Leadership and Advocacy Conference. These are important times, and it is imperative that EM physicians not be on the sidelines and get involved and advocate for our patients and our profession. In addition to a sometimes hostile political climate that can at times be obsessed with the bottom line and cost control, this country’s population is getting older and sicker. As you are well aware from your everyday practice, these forces are leading to more complex patients and fewer resources (in terms of ED, ICU, and hospital beds) to deal with them. Again, running the full gambit of CCM, we are the experts in patient flow and resource utilization, and the devastating consequences that hospital diversions and ED boarding can have on patient care. As an EM CCM community it is our duty to advocate for critically ill ED and ICU patients. I second Dr. Slesinger’s call to get involved. The EM Action Fund (EMAF) is one way to contribute.
Dr. Mallemat offers his perspective on choice of fluids for the resuscitation of sepsis. There are a bunch of physiological as well as practical “holy grail” topics in CCM (optimal PEEP, fluid responsiveness, etc.) that make CCM such an interesting multidisciplinary specialty. Which Fluid? Normal Saline, Lactated Ringers? Colloids? Albumin or starch? Balanced fluids? Blood products? No fluid? The choice of what, when, and how much fluid that one uses for resuscitation is one of those very practical questions that affects virtually all of our Critically Ill patients, but also a question that can have a controversial answer because of the often conflicting evidence. Dr. Mallemat offers a brief review of the options in the EM CCM armament.
Dr. Arntfield introduces us to the new publication, EM Critical Care. This journal will focus on and review the clinical issues that are important to the EM intensivist and EM physician charged with taking care of the critically ill. EM Critical Care will have the input of many of our section members, and is a great way for the EM CCM community to help facilitate knowledge translation to our non-CCM trained EM colleagues.
I’d like to take this opportunity to highlight two publications not in this newsletter but nonetheless important to the ACEP CCM community. The first is an academic article in the July 2011 issue of the Journal of Trauma by our friends at Shock Trauma in Baltimore, MD. Chiu et al(1) showed that EM fellows over a 4 year period scored just as high (if not slightly better) on their Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP) than their surgical colleagues. The MCCKAP is the Society of Critical Care Medicine’s “inservice” examination that compares critical care knowledge skills across different specialties. The three highest scores were achieved by EM fellows, and 83% of their graduates (10/12) during this time period went on to have attending level responsibilities in inpatient ICUs. There are limits to what standardized tests can and can’t show, but this study by Chiu et al adds to the growing body of evidence and clinical experience at multiple institutions across the United States that the EM CCM physician can be a valuable member and leader of the intensive care team whether it is in the prehospital, ED, ward, or ICU setting.
The next publication is the most recent ABEM Memo.(2) It can also found on ABEM’s website (https://www.abem.org/PUBLIC/_Rainbow/Documents/FINAL.pdf ). The ABEM’s update on the recent CCM Subspecialty Application:
In January 2011, ABEM, together with the American Board of Internal Medicine (ABIM), submitted an application to the ABMS to co-sponsor ABIM’s subspecialty in Critical Care Medicine (CCM). A public hearing before the ABMS Committee on Certification, Subcertification, and Maintenance of Certification (COCERT) will be held in July 2011. COCERT can either approve the application, after which it would go to the ABMS Board of Directors in September for final approval, or they can ask for clarification or further information on any part of the application. Should that occur, it would go back to COCERT for a second consideration in February 2012.(2)
This is a near and dear issue to all of us. It appears as if we are still in a holding pattern. Look for more information in upcoming newsletters, the EMCCM listserv, and the upcoming ACEP Scientific Assembly (SA) in San Francisco.
Finally, some section housekeeping issues. First, the 2011 Scientific Assembly is scheduled to take place in San Francisco from October 15-18. The section meeting is tentatively scheduled for Sunday, October 16. This date has not yet been finalized. More information will be provided through the usual channels when it is available. Second, this is an election year for the ACEP CCM section. Please see the announcement at the end of the newsletter, and consider applying if you have an interest in serving the section as chair elect, secretary/newsletter editor, or website editor.
As always, I can be reached at email@example.com
if you have any comments, or would like to contribute to future newsletters. I’d again like to thank the authors for their hard work and contributions and I hope you enjoy the newsletter.
- Chiu WC, Marcolini EG, Simmons DE, et al. Training dedicated emergency physicians in surgical critical care: Knowledge acquisition and workforce collaboration for the care of critically ill trauma/surgical patients. J Trauma. 2011;71(1): 43-48.
- American Board of Emergency Medicine. ABEM Memo, Summer 2011; 13(1):16.
From the Chair - Critical Care Medicine Section Newsletter, August 2011
Collaborating toward a future for all of critical care medicine: The role of EM
Lillian L. Emlet, MD, MS, FACEP
Program Director, Emergency Medicine MCCTP Fellowship
University of Pittsburgh Medical Center
All your strength is in union, all your danger is in discord. - Henry Wadsworth Longfellow
As we stand on the verge of the agreement between ABIM and ABEM to allow EM physicians access to IM-CCM programs and subsequently an examination and path for certification, we begin the exciting process of advancing critical care medicine as a whole. One of the unique perspectives of EM is the desire to care for a wide variety of ages, problems, situations and acuity that involve inpatient, outpatient, and prehospital resources. Our ability to have excelled in medical, trauma, surgical, cardiothoracic, and neurological critical care is due to our background and training in the initial care of all critically ill patients and the collaboration with multiple medical and surgical specialties.
As I have had the opportunity and pleasure to talk with many medical students and residents throughout the country as they consider what their own journey into EM-CCM will look like, a common theme emerges regarding what an ideal training program should contain. A key requirement of a fellowship is exposure to a wide variety of medical and surgical patients in the ICU. Equally important characteristics are the opportunity to develop academic scholarly pursuits, ability to teach residents, and advanced training in skills useful for critical care medicine (ie, parenteral nutrition, renal replacement therapy, bronchoscopy). The flexibility to individually determine the amount of practice split between the ED and the ICU over a lifelong career also weighs into the choice to become both an emergency physician and an intensivist for these young physicians.
EM-CCM physicians bring a unique perspective to critical care medicine with the desire to facilitate patient care from prehospital presentation to the post-resuscitative definitive daily care in the ICU and beyond. As partners with Anesthesia, Medicine, Cardiology, Nephrology, Surgery, Neurology, Neurosurgery, Trauma, Cardiothoracic Surgery, Vascular Surgery, Otolaryngology, Obstetrics and Gynecology, EM naturally coordinates and seeks to facilitate care as best for the patient, whether in the ED or in the ICU. This often requires additional knowledge and comprehension of what is important to each discipline, the eventual trajectory of the patient’s care, and mastering the language and expectations of many. Intensivists of any background perform this same coordination for any given patient in the ICU. Fellowship training allows each trainee to deepen and develop the additional skills and knowledge necessary to care for a broad range of critically ill patients. These are exciting times for all disciplines to collaborate and unify the core practice of intensive care.(1)
Creating a Consistent Intensivist Product
From a patient and family’s perspective, an intensivist should skillfully weave the factual knowledge, procedural skills, and clinical reasoning required to completely care for the critically ill in a professional and ethical manner and in a way that is clearly and effectively communicated. Conceptually, competency-based medical education focuses on performance outcomes, emphasizes progressive development of abilities and skills, de-emphasizes the requirement for time-based training, and promotes learner-centered development. These become the entrustable professional activities that allow one to perform the activities expected of a good physician within a given specialty.(2) Current critical care training is currently obtained via a variety of pathways that should describe the same competencies, expectations, and breadth of practice, yet have different regulations and oversight that are restricted by primary specialty. Educators in critical care medicine should join together to create a unified Model for the Practice of Critical Care capitalizing on the expertise and strength of the many multidisciplinary programs.
We hope that the addition of EM training to the discipline of CCM naturally brings together all the specialities to begin the conversation identifying the skills, knowledge, and attitudes required to care for critically ill patients. Emergency physicians begin their training in negotiating the language and content of the breadth of medical disciplines, from general pediatric to geriatrics, general medical and surgical to subspecialty medical and surgical, inpatient to outpatient, and obstetrical to palliative. We hope that the influx of EM-CCM dually trained physicians begins to normalize the concept of training intensivists to handle this breadth of the critically ill. Resuscitation for the emergency physician begins in the prehospital setting and continues through the ED with progressively more invasive (ScvO2) or non-invasive measures (point of care ultrasound) to guide decision-making, culminating with continued resuscitation and post-resuscitative care in the ICU.
The process of creating a consistent intensivist product begins in fellowship training. As well recognized recently by Pastores et al. in a review discussing the new 2010 ACGME duty hour standards, these new rules regarding resident staffing and supervision in the ICU will likely have unintended consequences. Residents from a variety of disciplines and departments rotating in the same ICUs may have program-specific supervisory policies overseen by separate Residency Review Committees.(3) This is an antiquated concept in the era of team-based practice. Harmonizing across disciplines will be important when residents from a variety of medical, surgical, and surgical subspecialties train on the same team in the ICU.
Multidisciplinary training provides an opportunity to use expertise and resources to cross-train towards an end-product physician that is a more versatile and comprehensive intensivist. Many forward-thinking intensivists across the country direct such programs by collaborating within their institution to provide educational and practice opportunities for their trainees. The structure of these multidisciplinary programs is collaborative with agreements to create a unified curricular content, clinical ICU and elective experience, and research opportunities. Partnering with Anesthesia, Emergency Medicine, Surgery, and Medicine has allowed greater opportunities in research, education, and clinical practice. Chiu et al. has recently demonstrated that emergency physicians trained in Surgical Critical Care can acquire critical care knowledge equivalent to surgeons and that the majority (83%) of their graduates subsequently obtained positions as attending intensivists.(4)
Where will we be 5 years from now?
Medicine overall will remain a balancing act between accountability of performance to the public through increased definition and measurement of competent team-based behaviors, while hopefully maintaining the individual experience at a doctor-patient level. Error reduction, quality improvement, and communication will likely remain cornerstones of Graduate Medical Education in the high stakes and rapidly changing clinical environments of the ICU and the ED. Intensive care medicine may need to work with scarce physician resources in an aging population with increased illness complexity by modifying the structure of the ICU team to include remote tele-intensivists and physician extenders. The physician leadership of critical care cannot afford to become more siloed in the access or structure of fellowship training. Instead, through collaboration, intensive care medicine can become better than any individual discipline could hope to become. Lastly, physicians will need to be better prepared and taught skills for organizational leadership.(5)
Intensive care medicine, at the physician level, will require the multidisciplinary training and organizational leadership that blurs the lines between Medicine, Surgery, Anesthesia, and Emergency Medicine. The strengths of all disciplines will be shared among all intensivists as critical care develops and matures into its next phase of development in order to provide the amount of high quality, regionalized intensive care that this nation will require.
Working together precedes winning together. --John C. Maxwell
- Lipsett PA. Breaking disciplinary borders: A workforce solution or just better care? Critical Connections. June 2011. www.sccm.org/criticalconnections. Last accessed July 11, 2011.
- Frank JR, Snell LS, Ten Cate O, et al. Competency-based medical education: theory to practice. Med Teach. 2010; 32: 638-645.
- Pastores SM, O’Connor MF, Kleinpell RM, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: History, changes, and impact on staffing of intensive care units. Crit Care Med. 2011; 39(11):1-10.
- Chiu WC, Marcolini EG, Simmons DE, et al. Training dedicated emergency physicians in surgical critical care: Knowledge acquisition and workforce collaboration for the care of critically ill trauma/surgical patients. J Trauma. 2011;71(1): 43-48.
- Gunderman R, Kanter SL. Perspective: Educating physicians to lead hospitals. Acad Med. 2009; 84(10): 1348-1351.
From the Chair-Elect - Critical Care Medicine Section Newsletter, August 2011
Community-Acquired Clostridium Difficile Colitis
Joseph Shiber, MD, FACEP, FACP
Emergency Medicine and Critical Care
University of Florida School of Medicine
This case illustrates a relatively new disease process, which is similar to community-acquired MRSA, that is on the rise and can cause a more severe illness than the more common nosocomial infection. I was fortunate to have cared for this patient initially in the ED as well as postoperatively in the SICU, so that I was able to see his complete clinical course.
A 79 year-old man presented to the ED with his wife complaining of three days of diarrhea with abdominal bloating and distention, and minimal oral intake; he had vomited once and admitted to mild diffuse abdominal pain on questioning. He had subjective fever and chills but had not taken his temperature. He had a past history of hypertension, prostate cancer, and intermittent atrial fibrillation. He had undergone appendectomy at age 16 and had a left inguinal hernia repair at age 27. Medications included aspirin, tamulosin, and amlodipine; there was no antibiotic use in the past 12 months. He had not been hospitalized in over a year; he lived at home with his wife and they were very active, reporting doing outdoor activities up to the day of illness onset. He quit smoking over 40 years ago and didn’t drink alcohol.
Vital signs: temperature 99.1 F, heart rate 100, blood pressure 135/76 mmHg, respirations 18, SaO2 97% on room air. His physical examination revealed no scleral icterus, his conjunctiva was pink, oral mucosa was dry, skin was cool with decreased turgor, cardiac sounds were regular without murmur, lungs were clear, abdomen was distended and tympanitic with diminished bowel sounds, there was no focal abdominal tenderness but instead mild diffuse pain on deep palpation, there were no rashes, and he was alert and oriented and able to answer questions and follow commands. His stool was dark green and tested positive for occult blood.
He was ordered 2 liters of intravenous (IV) NS, 4 mg Ondasteron and 4 mg Morphine IV. On recheck one hour later he was sitting up in bed watching TV and was smiling and talking with his wife. His laboratory studies then resulted a WBC of 37 K with 42% bands, Hgb of 15.8 and PLT of 355; his chemistries showed a HCO3 of 15 with an anion gap of 23, BUN of 47 and CRT of 2.8. His acute abdominal series was unremarkable but when he returned from radiology he was diaphoretic and dyspneic, and appeared confused. EKG showed rapid atrial-fibrillation with rates up to 160 on monitor and BP 120/62. Supplemental O2 and 5mg Metoprolol IV was administered with improvement of the heart rate and dyspnea but his abdomen was now more distended and tender. Serum Lactate was measured at 3.6 and since the working diagnosis was now ischemic bowel, IV Metronidazole and Ciprofloxacin were given (the patient had a severe PCN allergery) a nasogastric tube was placed and Surgery was consulted. Cardiology was also consulted for an echocardiogram to evaluate for cardiac thrombus as a possible source of emboli to the mesentery but there was no thrombus seen.
He was admitted to the Surgical ICU overnight for further resuscitation and stabilization while an exploratory laparotomy was planned for the AM expecting to find necrotic bowel. In the morning his stool sample tested positive for Clostridium difficile toxin while his WBC was 44K and CRT was 3.9. He was more critically ill and requiring mechanical ventilation at this point; and he was taken to the OR where his colon was found to be markedly dilated and dusky appearing. A complete colectomy with ileostomy was performed. His course of Metronidazole was continued while Vancomycin was started per rectum. Post-operative day three he was extubated; on day five his WBC was 13K and his CRT was 2.2 (his baseline was found to be 1.7) and he was transferred to a specialty rehabilitation hospital.
Clostridium difficile is a spore-forming, anaerobic gram-positive rod found widespread in the environment. It has been cultured in the stool of 3% of healthy adults but is mostly know as a hospital-acquired nosocomial infection. Pathogenic strains cause disease by secreting exotoxins (toxins A and B) that bind to receptors on intestinal epithelial cells which produce an inflammatory infiltrate of PMNs and monocytes within the mucosa. This acute inflammation results in necrosis of the colonic brush border and sloughing of the cells with secretion of massive quantities of fluid into the lumen of the colon.
Risk factors previously recognized for C. difficile infection are hospital admission within the last 6 months, recent antibiotic use, residing in a long-term healthcare facility, age over 65, the use of gastric acid suppressing medications, and conditions that may affect the colonic flora. Antibiotics disrupt the normal bowel flora which promotes the overgrowth of C. difficile; the antibiotics most highly associated with C. difficile infections are Clindamycin, Fluoroquinolones, and Cephalosporins.
Although not a reportable disease there were cases of severe C. difficile infections in young otherwise healthy people without any identified risk factors reported to state Department of Health agencies in four eastern states in 2005. These reports as well as the increasing frequency and severity of health-care associated C. difficile infections led epidemiologists to suspect that there had been an emergence of a previously uncommon more virulent strain. This epidemic strain has since been identified and is known to have two distinctive features compared to the more common bacteria type that add to the pathogenicity. It has a gene deletion at the tcdC locus that allows markedly increased production of toxins A and B (20 times as much). It also produces a third toxin type known as binary toxin that is associated with more severe disease including leukemoid reactions, severe sepsis, toxic megacolon, bowel perforation, need for colectomy, and death. There also is a higher recurrence rate of infection with the epidemic strain.
This more virulent strain is capable of causing more severe disease in patients at high risk of infection but also appears to be able to cause severe disease in patients at low risk. A close-contact transmission is the suspected route of transmission in the low-risk population. Based on these developments, it is recommended that C. difficile infection should be suspected in any patient with presenting severe diarrhea, even when no obvious risk factors are identified.
- Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(Suppl 6):2-18,
- Kuijper EJ, van Dissel JT. Spectrum of Clostridium difficile infections outside health care facilities. CMAJ. 2008;179(8):747-748.
- Perloff S, Horn D. Community-acquired Clostridium difficile colitis. Emerg Med. 2007;39(7):37-41.
- Warny M, Pepin J, Fang A, et al. Increased toxins A and B production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet. 2005;366:1079-1084.
- Chernac E, Johnson CC, Weltman A, et al. Severe Clostridium difficile- associated disease in populations previously at low risk – four states, 2005. MMWR. 2005;54(47):1201-1205.
From the Councillor - Critical Care Medicine Section Newsletter, August 2011
Todd L. Slesinger, MD, FACEP, FCCM
Director, Fellowship in Critical Care Medicine
Department of Emergency Medicine
North Shore University Hospital
We are a few months away from the next Scientific Assembly and Council Meeting in San Francisco. Please note that the Council Meeting is now on a Thursday and Friday (October 13 & 14) and the educational portion of SA starts on Saturday October 15th, which is a change from prior years when the SA started on a Monday. I would encourage all of you who can attend, to come early for the Council meeting as there will be a lot of discussion on the future of healthcare, and specifically how the Patient Protection and Affordable Care Act (PPACA) will impact emergency medicine. So put in your requests now, and reserve your hotel room!
In the next newsletter, I will discuss the resolutions and elections so you can give me your input and any concerns prior to the council meeting. This year I have had the privilege of being appointed to the Council Steering Committee, so I have been living the council all year. Please contact me if you have any questions about steering committee or visit the ACEP website at https://www.acep.org/Content.aspx?id=23180.
I also had the privilege to attend the 2011 Leadership and Advocacy Conference. This conference is open to all members of the college, and it is highly subsidized. I would encourage any of you that have an interest in advocacy to attend, as it is an exceptional learning experience that provides the tools necessary to maximize your impact as an emergency medicine leader and advocate. We had a record attendance of over 500 members! There are lectures on health policy, advocacy, media training, health economics, and liability reform. There are many great guest speakers, but the best part was when we met with our representatives from Congress to discuss the bills that directly affect our practice. It is a great way to make a difference and educate legislators on the issues that affect our patients and practice.
With PPACA a reality, and the inevitable changes that it will undergo, we all need to make sure our voices are heard at this critical time. So please continue to support NEMPAC. I would like to remind the membership that NEMPAC is now the 3rd largest medical PAC. If you are ever going to make a contribution, this is the year! Go to https://www.acep.org/Content.aspx?id=21850.
Because of the importance of the upcoming changes in healthcare, in January 2011, the ACEP Board of Directors voted to create the Emergency Medicine Action Fund (EMAF) to generate additional financial support for our existing advocacy efforts in Washington DC. Where NEMPAC gives money to support candidates who actively support emergency medicine, EMAF was designed to target regulatory agencies directly, like the Department of Health and Human Services, AHRQ, CDC, CMS, FDA, and NQF to advocate for our interests. Donations to EMAF are typically tax-deductible (check with your accountant). Again, now is the time to reach into our pockets and contribute to these advocacy efforts in order to ensure a proper future for our specialty, patients and ourselves; no one else is going to do it for us. Information about EMAF can be found at: https://www.acep.org/EMActionFund/. Please go to this site and read about EMAF and the issues we face.
See you in San Francisco -Todd
Which solution is the best solution (to resuscitation in sepsis)? - Critical Care Medicine Section Newsletter, August 2011
Haney Mallemat MD
Department of Critical Care / Emergency Medicine
University of Maryland Medical Center
Before you spend any time reading this be warned: this article does not answer the question, “which is the best fluid for resuscitating septic patients.” I do not think there is a proven evidence-based answer. This paucity of evidence disturbs me because every day we give crystalloid fluids thinking it is harmless, but perhaps this intervention is all wrong. For example, it was recently shown that children with impaired perfusion due to malaria did worse with fluid boluses compared to no boluses.(1) This is completely counterintuitive, but that is the newest evidence. This paper intends to re-examine the evidence for fluid choice in septic shock (crystalloids, colloids and blood) to see if it makes physiologic sense during resuscitation.
Let us start with some physiology. One of the major goals in sepsis is to “fill the tank” (ie, increasing intravascular volume). This increases cardiac filling, increasing cardiac output (steeper portion of starling curve), and subsequently improve tissue perfusion. Filling the tank “too much”, however, may cause both tissue edema (with subsequent organ dysfunction) and reduce cardiac output (Over-stretching myocardial fibers; the flat portion of starling curve). All this must be considered as intravascular volume is seeping out of a vasodilated system with leaky capillaries (from the septic milieu) causing interstitial edema and potential organ dysfunction. The second physiologic consideration is to avoid “over-filling” the tank. Recent studies demonstrated better outcomes with a “conservative” or “drier” fluid strategy.(2,3,4) Therefore, the mantra of “give more fluid” must be tempered by the negative effects of too much fluid.
Let’s move on and discuss common sepsis resuscitation fluids. I believe the best fluid should have the following properties: 1) immediately expands the intravascular space 2) stay in the vascular space (ie, minimal capillary leak) 3) have minimal effects on the patient. With this “wish-list” in mind, let’s investigate our choices.
Crystalloids: Normal Saline, Lactated Ringers, and Hypertonic Saline
Normal saline (NS) and lactated ringers (LR) have historically been the resuscitation fluid of choice. Many head-to-head studies comparing normal saline (NS) and lactated ringers (LR) in sepsis have not provided a clear answer to which is better (try doing a Pubmed search to verify this statement). The tangible differences between them are: NS is slightly hypertonic to plasma and causes metabolic acidosis in large volume, while LR is slightly hypotonic to plasma, contains sodium, chloride, potassium, calcium, lactate and causes metabolic alkalosis in high doses. Similarities include being cheap, well-studied, and relatively harmless (in moderate doses). They have more than one thing in common; only 20% of the infused volume remains intravascular. The rest goes into the interstitial space potentially causing tissue edema and organ dysfunction.(5) So with comparable efficacy and side effect profile the choice between NS and LR may depend more on preference (or residency training) than overwhelming evidence.
Hypertonic saline (HTS) is another class of crystalloid available in a variety of concentrations (eg, 3% and 7.5%). Compared to plasma (Osm ~280 mmol/L), HTS is very hypertonic (7.5% ~ 2400 mmol/L), but the theoretical benefit is more volume stays intravascular with less interstitial loss. Although the HTS's benefits have been demonstrated in trauma patients (especially with brain injury);(6,7) no major trials have demonstrating benefit in sepsis.
Blood (Red blood cells)
On some level, red blood cells (RBCs) seem the most logical resuscitation fluid. RBCs are “all natural” (come from us), contain hemoglobin (to deliver oxygen to septic anaerobic tissues) and has protein (ie, oncotic pressure) keeping infused volume intravascular. Furthermore, (and very controversial) it may reduce mortality in an early goal-directed protocol.(8) Unfortunately, blood has negative effect (eg, immunomodulation, infections, Transfusion-Associate Lung injury, etc.). Furthermore, the ABC, TRICC, and CRIT trials(9,10,11) did not demonstrate benefit transfusing to a hemoglobin goal greater than 7, but found harm when doing so. Supporters of transfusion state that these trials should not completely eliminate transfusions during resuscitation (especially as part of a goal directed algorithm) because patients in these trials were different than Rivers’; they were hemodynamically stable. While Rivers’ data requires replication and external validation, for now the benefits of transfusing blood must be weighted against the demonstrated harms.
Colloids: Starches and Albumin
The two main colloid classes are starches (eg, Voluven and Venofundin) and albumin. Starches are synthetic amylopectin and have been shown to stay intravascular with less extravasation compared to isotonic crystalloids. The drawbacks are risk of coagulopathy and renal dysfunction; increased when exceeding recommended doses. New generation starches are safer and may find a role in septic resuscitation, but for now its benefit has only been shown for hypotension in the operating room.(12,13)
Albumin has been the prototypical colloid. Its oncotic pressure keeps albumin within the vascular space and may pull extravascaular fluid into the intravascular space for more preload. Like HTS, albumin may increase intravascular volume to the same degree when compared to larger volumes of NS or LR (recall that a conservative fluid strategy may be better). Albumin’s opponents claim it is expensive, it is technically a blood product (made from expired RBCs), and the SAFE trial (Saline versus Albumin in Fluid Evaluation);(14) concluded no outcome difference between “resuscitation” with albumin or saline. With regard to the SAFE trial, however, two things must be pointed out; 1) most patients were not being resuscitated and were stable (see Table 1 in that paper) 2) Some conclude the SAFE trail proves that albumin is actually a safe resuscitation fluid and we should use it more 3) Subgroup analysis showed sicker patients did better with albumin (though not statistically significant). I have spoken to several sepsis experts who use albumin as part of their initial resuscitation strategy. They reason that early in resuscitation albumin is better than crystalloid when capillaries are leakiest, so it makes physiologic sense to use a fluid that stays intravascular. A newer meta-analysis of albumin use in resuscitation seems to suggest the same.(15)
So after reviewing some of the evidence, which fluid is best? We want a good plasma expander, with little extravascular leak, and minimal harm to patients. NS and LR are cheap, cause little harm, but only 20% stays intravascular. HTS stays intravascular with supporting literature in trauma resuscitation, but lacking in sepsis. Blood has some evidence as part of an early goal directed protocol, but there is little evidence for its use alone in the critically-ill (albeit hemodynamically stable ones). Finally, albumin does not appear to be any better (or worse) in hemodynamically stable patients compared to saline, but there may be benefit to albumin in the sickest ICU patients.
There does not appear to be a definitive answer to support one fluid over another; perhaps future research will provide an answer. Until then it may make physiologic sense to use fluids that stay intravascular when the capillaries are the “leakiest”, especially considering improved outcomes when patients are in “negative” balance after resuscitation.
Please email any comments to firstname.lastname@example.org or on Twitter @criticalcarenow.
- Maitland K, Kiguli S, Opoka RO,et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011. May 26.
- Wheeler AP. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-75. Epub 2006 May 21.
- Wiedemann HP. A perspective on the fluids and catheters treatment trial (FACTT). Fluid restriction is superior in acute lung injury and ARDS. Cleve Clin J Med. 2008;75(1):42-8.
- Boyd JH, Forbes J, Kanada TA, et al. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality Crit Care Med. 2011;39(2):259-65.
- Muller L, Lefrant J. Metabolic Effects of Plasma Expanders. Posted: 11/04/2010; Transfusion Alter Transfusion Med. 2010;11(3):10-21.
- Wade CE, Grady JJ, Kramer GC. Efficacy of hypertonic saline dextran fluid resuscitation for patients with hypotension from penetrating trauma. J Trauma. 2003; 54: S144-8.
- Wade CE, Kramer GC, Grady JJ, et al. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery. 1997; 122: 609-16.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-77.
- Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002 Sep 25;288(12):1499-507.
- Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-417.
- Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med. 2004 Jan;32(1):39-52.
- Hanart C, Khalife M, De Ville A, et al. Perioperative volume replacement in children undergoing cardiac surgery: albumin versus hydroxyethyl starch 130/0.4. Crit Care Med. 2009; 37: 696–701.
- Godet G, Lehot JJ, Janvier G, et al. Safety of HES 130/0.4 (Voluven(R)) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery: a prospective, randomized, controlled, parallel-group multicentre trial. Eur J Anaesthesiol. 2008; 25: 986–94
- Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;350(22):2247-56.
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Introducing a new journal for the ED-intensivist in all of us: EM Critical Care - Critical Care Medicine Section Newsletter, August 2011
Robert T. Arntfield, MD, FRCPC
Instructor, Department of Emergency Medicine, Mount Sinai School of Medicine
New York, NY
Editor-in-Chief, EM Critical Care
Emergency physicians are now frequently caring for critically ill patients well past their golden hour(s) of resuscitation. This is being done out of necessity at most centers due to boarded, sick patients lingering in the ED instead of finding their way to the ICU. That being said, there are also some centers that have their own ED-based ICU setup where ongoing critical care is provided regularly, independent of overcrowding. Further, the pursuit of critical care training by graduating EM residents is at an all time high. Thus, when overcrowding isn’t bringing the ICU to us, many seem to be quite eager to go to it.
A willingness or even enthusiasm from emergency physicians toward playing the role of ED-intensivists and dwelling in the expanding overlap between EM and critical care is not surprising. Typically replete with procedures, complex medical decision making, and collaboration with other disciplines, being a resuscitation specialist is fundamental to the identity of many emergency physicians.
Yet, if we are to be honest, this expanded EM-ICU interface has left many of us feeling a little outside of our clinical comfort zone at times. We were all trained for the initial intubation, initiation of vasopressors, or insertion of central or arterial lines. The ongoing management of these devices, troubleshooting ventilator settings, titration and dosing of vasopressors, advanced invasive (and non-invasive) monitoring, and advanced resuscitation strategies are, for many of us, the required skills that our residencies may not have taught us.
To support the necessity and surging interest for critical care skills and knowledge, EB Medicine, in collaboration with a distinguished editorial board, has launched the first ever publication devoted strictly to the EM-critical care provider. Aptly named EM Critical Care, this peer-reviewed publication provides a bi-monthly succinct, evidence-based review on the most pressing topics in EM-critical care today. Topics in press or in authorship right now include:
- Update on non-invasive ventilation
- High risk scenarios in blunt trauma
- Post cardiac-arrest cerebral resuscitation
- Vasopressor and inotrope review for the ED
- Dying in the ED
- Life-threatening asthma
- Coagulopathy in intracranial hemorrhage
- Air transport of the critically ill: indications and considerations
- Management of the critically ill pregnant patient
- Troubleshooting ventilator alarms in the ED
- And many more
In addition to providing the emergency medicine community with a succinct, trustworthy new resource, this journal provides a voice for a growing list of fully trained ED-intensivists. The editorial board for EM Critical Care is composed of many of the brightest and most experienced EM-intensivists and emergency physicians on the continent. This editorial board provides superb input, as well as authorship, in directing the publication to match the ravenous appetite of emergency physicians for high-level critical care and resuscitative content.
Interest has been staggering for this publication already, with more than a quarter of our subscribers coming from international venues. As the community and the readership begin to know our work, we expect our reach and influence will continue to broaden and raise the level of EM-critical care practice wherever emergency medicine is practiced.
If you are interested in peer reviewing for EMCC, please contact Stephanie Ivy, Publisher, at email@example.com or 678-366-7933.
Announcements - Critical Care Medicine Section Newsletter, August 2011
CCM Section Nominations and Election
The CCM Section will elect officers in preparation for the meeting held during ACEP’s Scientific Assembly in San Francisco October 15-18th. The positions open for nomination are:
If you -- or someone you know -- are interested in sub-specialization in critical care medicine and in the interface between emergency medicine and critical care medicine, and willing to serve as a leader of the Section, then, WE WANT YOU!
Terms of office are for two years. For position descriptions, and election procedures, please refer to the section operational guidelines <https://www.acep.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=45475&libID=45499>.
Nominations are due by August 20th. Please submit all nominations via email to Margaret Montgomery, staff liaison via e-mail c/o firstname.lastname@example.org.
Nominees are requested to prepare a short, written statement (maximum 1page) for the Section e-list. Please include where you are working, title and a photo. Nominees will be announced in early September. Electronic ballots will be sent after nominees are announced via elist and voting will be open for two weeks. Results will be announced at the CCM Section meeting in San Francisco.
If you have any questions or need other information, please contact Lillian Emlet, MD, FACEP, Chair, Margaret Montgomery, staff liaison, or Julie Rispoli, and we will be happy to assist you as needed.