As we were preparing for our “Critical Care Week” here at the EM Ottawa Blog, I was thinking I should definitely tap into the knowledge of an ICU physician whom I know very well. That physician is also my awesome wife, Dr. Erin Rosenberg. She’s been a staff intensivist at The Ottawa Hospital for nearly 6 years now and has always had an interest in how the ICU and ED interact, given that she gets to hear about “the other side” a lot.On a number of occasions, I have picked her brain for some suggestions so that I may provide better care in the ED. It has taken us a while, but we sat down and put them down on paper and were hoping to share them with you today. Of course, these are suggestions from some of our discussions on what we both see with ED critically ill patients and in NO WAY, is it meant to disparage the incredible work Emergency Physicians already provide in the ED. If you have any other tips you’d like to share, we’d love to hear about them below!
1. Think about sedation after you intubate
We’ve all been there, the complete catecholamine rush one gets after you intubate that sick patient on the first pass, with no desaturation and no drop in the blood pressure. You smile at the team, high-five anyone within a 10-foot radius and go on with the rest of your investigations/treatment. However, on many occasions we forget to properly sedate patients after intubation. The SCCM Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (1) make two key suggestions:
- LIGHT sedation. The goal is a range somewhere between awake/calm (yes, you can be awake with an ETT!) and sleepy (but easily wakes and makes eye contact when spoken to). Deep sedation (i.e. patients who either barely wake up or don’t wake up at all to stimulation) leads to longer duration of mechanical ventilation, longer ICU and hospital length of stay, more tracheostomies, and other morbidity.
- Analgesia-first sedation – assess and treat pain first (e.g. pain from ETT, abdominal pain, etc), then if patient is still agitated, sedate using non-benzodiazepine sedatives (e.g. Propofol).
This is felt to be the best approach to post-intubation sedation, and it is what our ICU’s are doing. If we as emergency physicians do the same, this would allow for the smoothest transition for patients from the ED to the ICU.
2. Pay close attention to Blood Pressure targets for septic patients
I as much as anyone, am a believer in more is better (more steak, more ice cream, more beer…you get the idea). However, when it comes to septic shock patients that we are treating with vasopressors, the current evidence tells us to aim for a MAP around 65-70 for most patients, and try not to go much higher than that. The SEPSISPAM study (2) looked at patients with septic shock, and compared a goal MAP of 80-85 to a goal MAP of 65-70 mmHg. The authors found there was no reduction in all-cause mortality at 28 days. Furthermore, targeting a higher MAP was associated with more arrhythmias (double the risk). On subgroup analysis, there was a decrease in renal-replacement therapy in patients with chronic hypertension, however the clinical implications of this are unclear. Now this is not to imply that we should just “turn off” our brains and only use one MAP target. In someone with a low blood pressure at baseline (e.g. chronic dialysis patient, cirrhotics), a lower blood pressure may be targeted if there are no other signs of end organ perfusion (mentating well, not mottled, normal lactate, good urine output if they make urine). Conversely, in a patient with chronic hypertension you may also consider a slightly higher target as well. The key point is that for all patients make sure that you set a MAP target, with 65-70 being an appropriate target for most patients, and do your best to maintain that range.
3. Sepsis leads to poor outcomes (especially in the elderly)
Mortality from sepsis has decreased 26% globally thanks to the amazing work done in ED’s and ICU’s, however, this has inevitably lead to more survivors of sepsis who have a significant morbidity associated with their septic illness. In the chaos of a resuscitation, we tend to focus on short-term survival, however the patient in front of us has a tough road ahead of them. Although there is some conflicting evidence, sepsis survivors, especially over the age of 65, have an increased risk of all-cause mortality which extends for up to 10 years after the initial sepsis event. In the first year following index sepsis episode, approximately 60% of sepsis survivors have at least one re-hospitalization episode, which is most often due to infection. (3)
Additionally, there is a 3-fold increased risk of cognitive decline in sepsis survivors, increased risk of cardiovascular disease (greatest in the year following the sepsis event), and impaired quality of life for as long as 5 years after index-admission.
What does this all mean? Keep doing the amazing jobs that you are doing with your septic patients, however consider the patient, their age and comorbidities. It is important to make patients and families aware of these harsh realities. In some cases, a 4-alarm fire type of resuscitation may not be the right approach for all patients.
4. Lines? Don’t worry about lines – just make sure you have good access
I was once panicking because I could not get an arterial-line in a patient, and a smart ICU veteran staff told me; “Hans, in my 25 years in the ICU I have never seen a patient die because they didn’t have an art-line”. This has stuck with me, and the ED resuscitation can often be initiated and completed without central and arterial lines. The PROCESS Trial had equivalent results in all their groups analyzed including those without central lines. (4) In addition, CVP is really a dinosaur looking for a tar pit, as such, there is no role for central lines in order to measure this outcome. (5) One of the main reasons people suggest that deep lines are necessary is to administer vasopressor agents. However, there is a plethora of evidence (mainly from the anesthesia world) and emergency medicine guidelines that support the use of peripheral IVs for vasopressors in the initial resuscitation of a patient. (6) Large-bore, proximal sites and you are good to go (for most patients)!
5. Emergency and critical care physicians should collaborate together – administratively and clinically
Much like my wife and I always work together to try to keep our two kids from harming themselves, EP’s and Critical Care physicians need to work together. There is so much overlap in the provision of critical care between an ED and ICU that having common approaches, for example protocols for sedation/analgesia/sepsis/head injured patients etc., is intuitively safer for patients and easier for all the care providers.
In the clinical setting, consider involving the ICU earlier. Use your intensivist’s expertise in the same way we would ask a radiologist to assist with the interpretation of a difficult X-ray. You don’t always have to wait until you have an intubated patient to call the ICU, especially in cases where ICU care may be futile. If you are having a discussion with a patient or family regarding the appropriateness of invasive procedures or care, an intensivist can be a key resource to help you have an informed discussion.
Some of the above suggestions are simple, but in our opinion, might help you and your patients out the next time you have a critically-ill patient. Please let us know your thoughts in the comments below.