Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Acute abdominal complications developing in critically ill patients in the ICU can be associated with significant morbidity and mortality.
Speaker: In patients admitted to the ICU with non-abdominal primary diagnosis, the development of an acute abdomen can be missed by the intensivist, leading to delays in treatment and worse outcomes.
Speaker: In today's episode of Critical Matters, we will discuss a variety of acute abdominal complications, such as abdominal compartment syndrome, acalculus claustis, megacolon, and ischemic bowel.
Speaker: Early recognition and timely surgical consultation are essential in these situations.
Speaker: Our guest is Dr. Samuel Tisherman.
Speaker: Dr. Tisherman is professor of surgery at the University of Maryland School of Medicine.
Speaker: He is a practicing surgical intensivist at the R. Adams Colley Shock Trauma Center, University of Maryland Medical Center, where he also serves as director for the Surgical Intensive Care Unit and director for the Center for Critical Care and Trauma Education.
Speaker: Dr. Tisherman is a renowned surgeon, medical educator, and researcher.
Speaker: He has received numerous awards for his teaching in surgical and multidisciplinary critical care.
Speaker: His research interests include hemorrhagic shock, cardiac arrest, therapeutic hypothermia, education, and surgical skills.
Speaker: He has an extensive list of publications, and we are truly honored to have him as our guest today.
Speaker: Sam, welcome to Critical Matters.
Speaker: Great.
Speaker: Thanks for having me.
Speaker: It's great to be here.
Speaker: So I think that we might start with just a general introduction to this topic, but we're trying to focus on
Speaker: are abdominal complications that may occur in patients who were admitted with a primary diagnosis that's not abdominal, most frequently to a mixed ICU or a medical ICU, who then during their critical illness develop complications that can lead to some problems.
Speaker: Could you just give us an overview of how you see these patients from a surgical critical care perspective?
Speaker: I think these patients can be very challenging because they're
Speaker: obviously quite sick from whatever the primary problem is that brought them to the ICU.
Speaker: And from an evaluation standpoint, the abdomen can become kind of this black box that you can't really easily get a handle on.
Speaker: In the usual situation of somebody coming into an emergency department with belly pain, you can talk to the patient, get a good history, do a nice physical exam, and then based on physical exam, you get a good idea of
Speaker: what's going on, but that doesn't work in the ICU.
Speaker: Patients have all kinds of tubes and lines and they're sick, they're sedated.
Speaker: So the usual history of physical kind of goes out the window.
Speaker: And I think that a compounded problem is our current practice.
Speaker: I think that more and more we're walking away from good physical exams and patients who are already in the hospital.
Speaker: I think a lot of people like to put a stethoscope here and there, pop it real quickly.
Speaker: But we often probably are doing our patients a disservice not by paying attention to the abdomen since some of these problems might first manifest with some subtle findings.
Speaker: Absolutely.
Speaker: So, I mean, even though I say that you can't really do physical exam, it doesn't help as much, I think you need to do that because it can help.
Speaker: The issue is that oftentimes it's hard to get a whole lot of specific sense of what's happening.
Speaker: from your exam because the patient's sedated and it looks like it bothers them when you move them around.
Speaker: But I think it's important to look at the belly.
Speaker: I mean, I've certainly seen plenty of times where it's pretty clear nobody's really examining somebody's abdomen for a little while.
Speaker: Now suddenly the guy's really sick and, yeah, it could be something in the abdomen.
Speaker: It could be something else.
Speaker: And when these patients present, Sam, I guess usually they either have issues with tolerating tube feeds, abdominal distension,
Speaker: where all of a sudden the abdominal exam has changed, and sometimes that change might be quite dramatic, as you said.
Speaker: How do you think about differential diagnosis and how to approach these patients?
Speaker: So I think it's helpful to think about what kind of things can happen in the belly just because you're sick, which is quite different than somebody who's walking around needing a normal life and suddenly they get abdominal pain.
Speaker: Somebody is in the ICU, presumably intubated, might be getting antibiotics, maybe on pressures.
Speaker: There are a few things that really rise to the top of the list that are worrisome.
Speaker: Certainly, ischemic bowel can occur for a number of reasons in a critically ill patient.
Speaker: Perforation, particularly ulcerative,
Speaker: It's certainly much less common now than it was 20, 30 years ago because we give everybody prophylaxis, but it can still happen.
Speaker: Acute achiacus cholecystitis can occur.
Speaker: C. diff is the other.
Speaker: Big E, those are the ones that kind of probably the most common that we worry about.
Speaker: Certainly there are lesser things that can happen too, but like just bleeding or somebody rupturing in aneurysm suddenly while they're here in the hospital for something else.
Speaker: And if you got called for somebody in an ICU as a consult with maybe a rigid abdomen or a significant change in their abdominal exam, what would be the initial workup that you would expect the critical care team to have in place as you come in to see that patient?
Speaker: Well, certainly worth starting with some basic stuff like checking labs, the CBC, maybe liver enzymes, pancreatic enzymes, the lactate level.
Speaker: Although as an aside,
Speaker: It's not that uncommon that somebody is sick, maybe the sepsis from pneumonia or urinary tract infection and the lactate's up because of sepsis and somebody gets worried that, oh, lactate type could be the bowel.
Speaker: And that can be difficult to sort out, but it's worth at least keeping in mind that you can get really high lactates just from being septic and not having dead bowel or dead tissue somewhere.
Speaker: But that would start with basic labs.
Speaker: But I think if you're worried
Speaker: to something going on in the belly, I would get a surgeon involved quickly before you start doing a bunch of films.
Speaker: Because I think playing films in the ICU are generally not terribly helpful.
Speaker: They're helpful to maybe locate where tubes are, like an NG tube or drains or something, but not typically look for anything like free air because you're
Speaker: you're rarely going to see that on a supine plane film.
Speaker: And before you send somebody out for a CAT scan, which kind of tends to be the next test, it's worth having the surgeon weigh in because, you know, there are patients that, you know, the setup is so obvious that this patient is at higher risk of ischemic bowel, the patient's got a rigid abdomen, there's septic shock, that patient doesn't need a CT scan, that patient needs an operation.
Speaker: So I think early surgical consultation is really helpful.
Speaker: And I think that perhaps if anything that people were to take home today, it would be the time-sensitive nature of these interventions and the studies that have looked at these acute abdomens in medical intensive care unit patients have shown over and over again that
Speaker: that probably the most important factor to survival is how quickly you intervene, which means getting surgery on board as early as possible probably is the best way to get that ball rolling.
Speaker: Right, because the surgeon can give a better sense of maybe honing down the differential before you start doing any imaging or wasting time with other things and working toward getting a patient to either the OR or for
Speaker: drainage of something.
Speaker: I mean, one of the important things about surgical infections in general is those are infections that require either drainage of pus or some fluid collection somewhere or an operation to remove something.
Speaker: And the timeliness of that is, I think, underrated.
Speaker: If you look at things like the surviving sepsis campaign that focuses on
Speaker: getting antibiotics on board quickly, getting fluid resuscitation going, getting pressure started.
Speaker: The notion of source control, which is really what you need for any surgical infection, it kind of seems to take a back seat, whereas it needs to be more upfront.
Speaker: You need to do all the other stuff too and do it quickly, but it shouldn't be put off till, oh, well, we'll schedule tomorrow his X lab for his possibly dead bowel.
Speaker: Yeah.
Speaker: And I think, like you mentioned, there are signs that immediately indicate the need for surgery, such as like a true rigid and acute abdomen on exam, free air that's not supposed to be there on an imaging, plain imaging, are things that quickly can get you to the OR.
Speaker: And like you said, having the surgeon involved early can obviate unnecessary tests that might just delay proper care and wouldn't add much to the decision making.
Speaker: Exactly.
Speaker: So let's start to dive maybe a little bit deeper into some of these situations or clinical scenarios that might appear or might be of interest for our patients.
Speaker: And I wanted to start with one that you hadn't mentioned yet, but I think that is important for our non-surgical colleagues to review, which is abdominal compartment syndrome and abdominal hypertension situations, which historically
Speaker: we're really the purview of surgical patients, but with our emphasis or maybe with our overemphasis on fluoroacitation, a lot of medical patients has become more common, and hopefully as that pendulum shifts back again to more moderation, will decrease, but it's still something that happens very commonly in patients who are critically ill with non-surgical primary diagnoses.
Speaker: Well, yeah, I think it has become really,
Speaker: important issue and so important that there's a society dedicated to the abdominal compartment syndrome and I think is worth keeping in mind certainly most of the time it's going to be related to either trauma or a big operation in the abdomen and in both of those situations particularly if the surgeon is an acute care surgeon is somebody's focused on cervical care and trauma or
Speaker: or specifically a trauma patient, operatively people have gotten away from always trying to close the abdomen.
Speaker: So you kind of remove the potential of abdominal compartment syndrome if the abdomen has been closed.
Speaker: But it's definitely been more and more recognized as an issue, even if nobody has operated in the abdomen just because of massive fluid resuscitation.
Speaker: You see it with burn patients, you see it with patients that get a lot of fluids for other reasons.
Speaker: And hopefully we're moderating that massive fluid resuscitation a bit, but it can still happen.
Speaker: And it's a challenge to deal with because there's always a debate about what point does the patient need
Speaker: to have a decompressive laparotomy.
Speaker: Certainly, it's always important to think about is it really an abdominal compartment syndrome as opposed to intra-abdominal hypertension?
Speaker: So if you measure bladder pressure, which is for better or worse, the easiest way to get at some sort of measure of what's going on inside the abdomen, if it's higher than 12, that becomes
Speaker: what you could call intra-abinominal hypertension, and higher than 20, start really getting kind of worried about it.
Speaker: But it's not really a syndrome until you start seeing organ dysfunction because of it, whether it's acute kidney injury, increasing thoracic pressure, sort of the last thing that's going to be hypotension.
Speaker: Short of any of those things, probably not that much that a surgeon would
Speaker: do.
Speaker: But it's certainly helpful to think about what could easily be done to decrease that pressure short of a big operation.
Speaker: So things like sedation, even neuromuscular blockade, things like if there's a whole lot of fluid in there that's easily drained, draining the fluid can help.
Speaker: If there's a lot of
Speaker: gaseous extension of the stomach or the colon, you can decompress that.
Speaker: So there are some less invasive ways to help the problem if you think that's causing some organ dysfunctional problems for the patient.
Speaker: But then it comes down to the big question of, is it bad enough that the surgeon needs to do something about it?
Speaker: And occasionally we do.
Speaker: And in terms of making that decision for a surgical intervention, so decompressing the abdomen, is that something that you based on numbers, more on acute organ damage, on the failure of therapies, or all of the above?
Speaker: Yeah, it's a little bit of all the above.
Speaker: Certainly the number is probably the least useful.
Speaker: I mean, one thing to keep in mind is patients who are on the larger side,
Speaker: let's say, would not have the same resting intra-abdominal pressure that a thinner person might have.
Speaker: So the normal may be in the teens for a very obese patient.
Speaker: So now if it's higher in the teens or maybe low 20s, that may not be as important as it would be for somebody who's thinner and normally has a pressure that's in single digits.
Speaker: So numbers don't help as much as
Speaker: The physiology, is this really causing physiologic harm to the patient?
Speaker: And have we done everything else that we can do to treat the problem?
Speaker: Sedation, paralysis, drainage of anything that's drainable, minimizing fluids, getting fluids off.
Speaker: D-resuscitation is really an important thing to do is when the patient is able to do that.
Speaker: And what about the physical exam, Sam?
Speaker: I mean, does it tell you anything valuable or not really helpful in this situation?
Speaker: It helps.
Speaker: It can be hard, particularly in obese patients, to really get a sense of how tight the abdomen is.
Speaker: But I think if you feel the abdomen and it's not really tense, it's probably not an abdominal compartment syndrome.
Speaker: But certainly, you know, getting some numbers can kind of help with that.
Speaker: I guess that's why it is a syndrome, and it's kind of a complicated syndrome.
Speaker: So you got to take all these things into account when you're going to decide what to do.
Speaker: And just to remind our audience, what would be some of the clinical slash physiologic manifestations that you would really want to be tuned into as an intensivist?
Speaker: So we can start maybe going from the head down.
Speaker: I guess if you're in a neuro ICU, ICP would be the one thing you would be concerned about, right?
Speaker: Yeah, and actually coming out of this institution, there is a paper describing sort of a multi-compartment syndrome, a patient with head injuries and also intra-abdominal hypertension, even without trauma to the abdomen and help to decompress the abdomen.
Speaker: But that's, you know, somebody who has some kind of severe neurologic syndrome going on and you're monitoring ICP.
Speaker: What about at the lung level?
Speaker: What are the things that usually people should be aware of or looking for if they're concerned about increased pressures in the abdomen?
Speaker: So you'll see worsening lung compliance.
Speaker: Yeah.
Speaker: increased intrathoracic pressure, depending upon what kind of mode you're on a ventilator, if you're on a volume controlled mode, you'll see the pressures go up.
Speaker: If you're on a pressure controlled mode, the volumes may be down.
Speaker: So it's something to think about if those things are happening and you don't see anything new on a chest x-ray, like suddenly the patient has a pneumothorax or something like that, and you examine the belly and the belly seems pretty tight, then...
Speaker: Thanks, I guess, for thinking about that interaction.
Speaker: And at the cardiovascular level?
Speaker: That's usually one of the last things that happen, that the intra-abdominal pressure decreases venous return, and that's going to lead to decreased cardiac output and then hypotension.
Speaker: That's typically not going to happen until all the other things are happening, but it does, and so...
Speaker: is worth, you know, if you start seeing that and you don't have another obvious reason for it, along with some of these other findings like increasing intrathoracic pressure, then you can start thinking more seriously about intra-abdominal hypertension and abdominal compartment syndrome.
Speaker: And I think that the, perhaps, I mean, the organs, I mean, that are most prone to having problems from high intra-abdominal pressures are rightfully so in the abdomen and both at a
Speaker: intestinal and gut level, but also the kidney obviously is very susceptible to increases in pressures.
Speaker: And I know that even increases in intra-abdominal pressure without causing compartment syndrome can lead to allegoria and impaired venous return to the kidney with decrease of chlamyloidrate.
Speaker: And ultimately, with severe increases, you can have etotololoneuria.
Speaker: But the reason why I bring this up is I think that
Speaker: The first response usually in these patients is to give more fluids.
Speaker: And you can get caught in a very vicious cycle unless you start thinking about, well, could this be a problem?
Speaker: Should I stop measure and try to figure out, am I headed here in the wrong direction?
Speaker: Any comments on that?
Speaker: Yeah, I would certainly agree that if it's not clear why somebody's urine op is dropping off, the kidney function is getting worse,
Speaker: and your exam the admin suggests there's some tension there, you need to start thinking about it.
Speaker: And that's where it's really helpful to get a better sense of the patient's hemodynamic status in a more global sense.
Speaker: And we do a lot of echoes can kind of help us with where does the patient stand from volume and cardiac function and all of that.
Speaker: So that can help.
Speaker: It doesn't take a whole lot to decrease your urine output.
Speaker: I mean, one of the things that was
Speaker: recognized as laparoscopy became more and more common is that just inflating the admin with CO2 to do laparoscopy, because you get pressures up in the 15 range, the urine apple would drop off.
Speaker: And anesthesiologists had to recognize this early because they would say, oh, the urine apple's dropped off.
Speaker: I got to give the patient more fluid.
Speaker: Then you get these patients that have too much fluid.
Speaker: So I think the response to oliguria
Speaker: needs to be thoughtful about.
Speaker: Is it really a fluid problem or something else going on?
Speaker: And are there any tips or caveats that you would share with us regarding measuring the endophthalmic pressure via the bladder?
Speaker: Yeah, you need to fully.
Speaker: I don't know you need to go as far as getting the devices that are marketed to measure this because you can
Speaker: All you need to do is hook into a side port on the tubing and then clamp this to all that and you can inflate the fully with or instill, I should say, like 50 c's of saline and you can then just measure the pressure through your normal monitoring devices and there's no great reason to do it continuously.
Speaker: You can do it intermittently pretty easily, so it's not too difficult to do.
Speaker: And it's worth thinking about.
Speaker: If you're possibly going down this route, it's easy enough to at least measure the pressure and then use that as one more factor in deciding what to do next.
Speaker: And I think, like you mentioned earlier, having an early consultation with our surgical colleagues just so they can follow and give their input early is probably preferable for the patient, but also I'm sure
Speaker: for the surgeon as opposed to being called in the middle of the night when the pressure is greater than 25 and everything is going to hell.
Speaker: Right.
Speaker: No, it's definitely better to get people on board in daytime.
Speaker: Excellent.
Speaker: Let's move on to another topic, Sam, and there's something that you did mention earlier when we were talking about the differential diagnosis, which refers to the gallbladder and the development of acalculus colostitis in the critically ill patients, which is something that, I mean, has been described, and I think that most of our
Speaker: listeners have encountered.
Speaker: And maybe you could just start by telling us what are the risk factors and the pathogenesis for developing a calculus colostostitis before we go into the management and clinical manifestations.
Speaker: Well, I think our best understanding of this is that it's mostly related to blood flow to the gallbladder.
Speaker: So the people that are high risk are people who have peripheral vascular disease or diabetics.
Speaker: And then you add on top of that
Speaker: that they're sick for something else, whether it's cardiogenic shock or septic shock, some form of hypotension, hypovolemia on pressors.
Speaker: So you have a gallbladder that now is not getting blood flow that it normally gets.
Speaker: And then on top of that, the patient is not being fed.
Speaker: So the gallbladder will tend to get distended.
Speaker: So when it's distended,
Speaker: and does not have good blood supply with the tension in the wall from this tension, basically the wall will get ischemic and eventually can die.
Speaker: But this ischemia alone will allow the bacteria to get in the wall, even air getting in the wall, you can get an emphysematis and gallbladder, or it can totally necrose.
Speaker: So that's the pathogenesis.
Speaker: Somebody that's sick, which is part of the challenge of how to deal with it,
Speaker: And is this something that usually develops as people get sick days into the presentation as opposed to something that might be the cause of their sepsis that they're coming up to the hospital for that?
Speaker: Well, it is possible for people to come in with a cataclysm cholecystitis.
Speaker: This is not terribly common.
Speaker: And it's not all that common to even develop it in the ICU, but it's something to think about for somebody who's got intolerance to tube feeds,
Speaker: or maybe they just haven't been fed, the abdomen is distended, and you may get some sense on exam that there's tenderness in the right upper quadrant.
Speaker: Okay.
Speaker: And I think that what's important, again, is that despite not being as common, when it does occur, if it goes undiagnosed, it can have a very high mortality, so it needs to be taken care of.
Speaker: Right, and it's one of those things to think about when, if you've got somebody that's sick.
Speaker: How would you evaluate somebody for a Kekoskosastitis?
Speaker: So maybe on exam, like you mentioned, they have right upper quadrant tenderness, and maybe they might be intubated and sedated, they can't really tell you.
Speaker: So, yeah, I mean, sometimes it comes up as one of those things where, all right, the patient looks septic, but I don't have a good source, and there's maybe some vague sense that
Speaker: the abdomen isn't quite right, that they're not tolerating tube feeds, there's a little bit of tenderness.
Speaker: That's where you want to think about it.
Speaker: So like with any of these patients, you start with some labs.
Speaker: One important thing to keep in mind is that if you just have inflammation of the gallbladder, your liver enzymes are going to be normal.
Speaker: So that doesn't help in terms of ruling it out.
Speaker: So unless the inflammation is
Speaker: gets into the cystic duct and then can cause inflammation of the common hepatic duct, which will lead to some obstruction and then increased LFTs.
Speaker: Or sometimes just the inflammation of the gallbladder sitting under the liver causes some elevation of some enzymes.
Speaker: But normal LFTs don't rule us out at all.
Speaker: So if you think about it, then you need to do some imaging.
Speaker: And ultrasound is still the best first test because
Speaker: It's easy.
Speaker: You don't move the patient and can certainly readily make the diagnosis.
Speaker: So that's where I would start with imaging.
Speaker: And what would you see on ultrasound that would lead you in that direction?
Speaker: So you see thickening of the wall of the gallbladder and pericholecystic fluid.
Speaker: Now the part that can make it more complicated is if the patient has
Speaker: just general ascites for some reason, you're going to see some fluid there.
Speaker: So it might, you can have a false positive in that kind of situation.
Speaker: But if it seems like that's where the inflammation is, the thickening of the wall, you can even see if it's really bad, air on the wall by ultrasound.
Speaker: So ultrasound is the place to start.
Speaker: If that's equivocal, then a CT is probably the next.
Speaker: best imaging to do, which will also help make sure it's not something else.
Speaker: And a CT, in terms of, like you said, offers the advantage of ruling out other potential problems, but you have to move the patient, which in some cases might not be ideal.
Speaker: But the finding would be similar.
Speaker: You're looking for thickening of the gallbladder wall, dilation of the gallbladder overall, and fluid around it, right?
Speaker: Right, the same kind of findings, just the CT rather than ultrasound.
Speaker: And it'll help that you don't see anything else that seems to be a source of problems.
Speaker: Now, the only other, sorry, the only other, I mean, the HIDA scans can be done.
Speaker: If you give the HIDA agent and you see it get into the liver and the biliary tree and the small bowel, but never see the gallbladder, that's suggestive of it.
Speaker: MRCP has now become popular, but that's even worse than a CT scan in terms of transporting the patient and a longer time in the magnet and in a place where nobody can actually touch the patient readily, so it's a little more complicated.
Speaker: So really, in terms of ultimately, there is really no kind of gold standard in terms of diagnosis that tells you this is ACC.
Speaker: It's really
Speaker: a combination of images that are consistent within the right context.
Speaker: And that's where I guess having early consultation and discussions of which direction the patient is going really helps in terms of deciding what the next step is.
Speaker: Right.
Speaker: I agree.
Speaker: Now, Sam, I'm just going to ask you to repeat something because I think that we had a little bit of internet issues when you were talking about the LFTs.
Speaker: But what I understood is that a lot of these patients might have a high bilirubin
Speaker: abnormal LFTs, but also you could have ACC with totally normal LFTs, and that's why you shouldn't rule it out just based on the LFTs.
Speaker: Is that correct?
Speaker: Right.
Speaker: I mean, I would say the norm would be that the LFTs and the enzymes and the bilirubin are normal.
Speaker: So you can get an elevation in bilirubin just from any kind of sepsis affecting the liver.
Speaker: The only way to get elevation of
Speaker: the canalicular enzymes like alkyl and phosphatase would be if you have something obstructing the common hepatic duct or the common bile duct.
Speaker: And that generally only happens if you have a stone down there.
Speaker: So you don't see it with achycocytoscholositis.
Speaker: And then the only other thing is just because the gallbladder is sitting under the liver and the gallbladder is very inflamed, it'll cause some inflammation of the parts of the liver that's right there.
Speaker: So you can get some mild
Speaker: elevations of transaminases.
Speaker: So you can get some elevations, but in general, you won't.
Speaker: So you probably, you want to get some MLTs, but don't think that it's a normal, oh, it's not the gallbladder.
Speaker: We're going to move on to something else.
Speaker: Okay, perfect.
Speaker: And once you've decided that this might be contributing to the patient's clinical problems or might be actually a source of their clinical deterioration, how would you approach this from a therapeutic standpoint?
Speaker: So I would start with saying that the gold standard for dealing with acute cholecystitis is to do a cholecystectomy.
Speaker: Having said that, since this is often occurring in patients that are very sick for other reasons, it could be somebody that just had an acute myocardial infarction and maybe is on some inotropes or even on a balloon pump or something like that, or is in septic shock from something else.
Speaker: That's not the kind of patient that you want to take to the operating room and give them a general anesthetic to take the gallbladder out.
Speaker: So we basically, as the next step, would start with draining the gallbladder percutaneously and have radiologists placing drain in it, which will work the majority of the time.
Speaker: So it's worth doing that.
Speaker: It's a relatively low-risk procedure.
Speaker: It can be done.
Speaker: at the bedside or down in the radiology department.
Speaker: But it's usually worth doing that in a really sick patient when you think this is what's going on.
Speaker: And if that is done appropriately and this is what's driving the clinical issues, what do you expect to happen?
Speaker: When do you expect the patient to show some improvement?
Speaker: Well, I think one way to look at it is
Speaker: anybody that's sick from an abscess anywhere in the body, and so now the abscess is the gallbladder itself.
Speaker: So you drain it, you have a patient on antibiotics, and it still may take a day or two to see significant improvement, but they ought to improve.
Speaker: But I'll add that there are failures of this, and particularly if the gallbladder wall itself is necrotic,
Speaker: it'll fall apart.
Speaker: And so putting a drain in there won't solve the problem.
Speaker: So they may need something in addition to that drain.
Speaker: So what would be indications?
Speaker: You mentioned one of them, the necrotic gallbladder wall.
Speaker: What would be other indications to escalate to surgery or go primarily to surgery because the tube wouldn't solve these issues?
Speaker: Well, I think if
Speaker: the patient's not responding relatively promptly.
Speaker: So within a couple of days, the patient's not looking better and the patient's sick enough that the surgeon is worried up front that maybe the gallbladder is necrotic or then sometimes you can get some evidence on your CT, the ultrasound, then people would have to start thinking about taking the patient to the OR for a cholecystectomy.
Speaker: Now, there are some
Speaker: less drastic approaches.
Speaker: People have described, you know, if there is some leakage from the gallbladder, that can be contained with another drain, that that can help.
Speaker: So if you have an abscess or a collection outside of the gallbladder drain, that may do the trick and get the patient through this.
Speaker: And the main thing is to get adequate drainage, and that's the basic surgical principle here.
Speaker: If you can get adequate drainage with percutaneous drains and the patient can get better, then that can be way better than putting the patient into a bigger operation.
Speaker: There are also smaller operations you can do from a surgical standpoint.
Speaker: You can just make a small incision and do better drainage of the gallbladder and the fluid around it than what's happened with the percutaneous drain, short of trying to do a full cholecystectomy, which is
Speaker: often is circumstances very difficult to do because of all the inflammation.
Speaker: So there are a few other things in between, but all those decisions need to be made in concert with the surgical team.
Speaker: Absolutely.
Speaker: And does the presence of air or emphysematous acocystitis mandate surgery, or that can also be treated with a percutaneous tube initially?
Speaker: It doesn't mandate it, but
Speaker: People need to have a lower threshold to recognize that the percutaneous drainage isn't working, that now the patient needs something more.
Speaker: And sometimes, you know, surgeons get forced in doing this sort of a partial cholecystectomy, take out whatever they can easily get out without causing harm, putting some bigger drains in there, and then just getting out.
Speaker: So I have a question actually related to those patients who do well.
Speaker: leave the ICU.
Speaker: So I've had a couple in my practice that have left the ICU and they leave the ICU with their tubes.
Speaker: What happens to them afterwards?
Speaker: Just out of curiosity for follow-up.
Speaker: That's a good question because nobody's really studied that very well.
Speaker: Typically people want to keep the tube in for a good four or six weeks just so that you have a safe track for removing it.
Speaker: And then
Speaker: one can debate about should you take the gallbladder out now or not.
Speaker: There have been some studies suggesting that after all this inflammation and drainage, that at the end of all that, assuming the patient's doing well, the gallbladder is now shrunken down, scarred down, and it's almost impossible for it to actually cause trouble again.
Speaker: So I think people have kind of gotten away from routinely saying, oh,
Speaker: Patient with colitisitis when he was really sick after his MI, I got to bring him back in a couple of months to take his gallbladder out.
Speaker: You know, if there aren't stones there, you know, probably, probably not.
Speaker: And certainly people will study the gallbladder through the drain to be sure that there's nothing left that's causing any trouble before taking the drain out.
Speaker: No, I think the reason why I'm asking is because a patient had asked me once and I really didn't know the answer.
Speaker: And I think it's like, it's interesting.
Speaker: And obviously for those who are well enough to leave the ICU with a tube, when the ICU team knows what the natural course is, I think it always helps also with communicating to patients, decreasing their anxiety and them understanding also and hearing the same kind of story from multiple team members of
Speaker: what's going to happen next.
Speaker: But I think it's an interesting just kind of fact that a lot of these patients don't get their gallbladders ultimately removed because it probably at that point is not needed anymore.
Speaker: Yeah.
Speaker: And just look at the risk-benefit ratio.
Speaker: Trying to take out a hard, scarred-in gallbladder is going to be difficult.
Speaker: The likelihood of causing more harm
Speaker: is greater than the potential benefit because it's probably not going to cause trouble again.
Speaker: Yeah.
Speaker: And in your practice, is there, like you said, a lot of these patients might be being treated already, but obviously you mentioned earlier that there's a high risk of bacterial translocation and infection or super infection, although this is not originally an infectious problem.
Speaker: Any comments on your antibiotic of choice or how do you approach these?
Speaker: Well, the...
Speaker: Dan, at the beginning, usually there aren't very resistant organisms.
Speaker: So just like anything else, most other things in the abdomen, if you use something that covers gram negatives, maybe streps, you'll get good coverage.
Speaker: And if the gallbladder isn't going to have a ton of anaerobes, that's not as big of an issue as covering the colon and pretty much...
Speaker: fungal infection is usually not part of it either.
Speaker: So, you know, simple things like Piptasa or even Amcelbactam is probably okay.
Speaker: People sometimes use quinolones, but you don't need big gun antibiotics.
Speaker: Excellent.
Speaker: So I think a good, a good, it would be a good segue to talk about the colon now.
Speaker: And one of the things that we sometimes get called on, you know,
Speaker: x-rays or a patient who might not be tolerating two feet, who's intubated for several days, and they call us from radiologists saying that the colon is significantly dilated.
Speaker: Can we talk a little bit about these megacolons and what are the differential diagnosis and what are some of the things that we should be concerned about in the ICU?
Speaker: Yeah, I think it's a pretty common problem.
Speaker: It's often related to immobility, to
Speaker: deep sedation to narcotic use, that can certainly lead to this problem.
Speaker: And I think it's important to keep on top of somebody's bowel function.
Speaker: We don't always ask, did the patient have a bowel movement today?
Speaker: And suddenly you have somebody who the nurses say, oh, I think his last one was last Monday.
Speaker: And you're then way behind.
Speaker: So it's important to make sure people
Speaker: continue to have bowel function as you're feeding the gut in the ICU.
Speaker: If you do get into this distended colon, the question becomes, is it just sort of a pseudo obstruction kind of picture, like, oh, we'll be from immobility and narcotics, or we always worry about C. diff.
Speaker: And that has other implications.
Speaker: not always easy just by seeing the stentive colon to figure out what's going on.
Speaker: It's important to look at the rest of the patient.
Speaker: Does the patient have a fever?
Speaker: Does the patient h ave a high white count?
Speaker: Does the patient have diarrhea?
Speaker: You can certainly have bad C. diff without diarrhea and then put all that together to figure out what you think is going on.
Speaker: And what would be some of the
Speaker: differential in terms of maybe imaging or other than clinical you mentioned, but between UGLIVs or non-obstructive pseudobstruction and a toxic megacolon from C. diff?
Speaker: Are there any things that help you differentiate?
Speaker: Well, up front, if the patient isn't systemically that ill from this, and again, this brings up the challenge of dealing with
Speaker: an acute abdominal problem in the ICU because the patient could have fever or white count for a lot of reasons.
Speaker: Certainly C. diff, you'll typically get an impressive leukocytosis.
Speaker: I think certainly if the patient doesn't have a fever, doesn't have a white count, the risk of C. diff is relatively low and
Speaker: One of the challenges with that, too, is that there are people who are carriers of it.
Speaker: So at least at our institution, the infectious disease people have now set up within the electronic health record that there has to be an attending sign-off to get a C. diff sent on a patient.
Speaker: Because if a patient just has some diarrhea and somebody has a knee jerk of sending off,
Speaker: the C. diff, without a fever, without a white count, without any abdominal complaints, without anything, you may get a false positive that's not going to be very helpful.
Speaker: So it's important to think about those other things.
Speaker: And the other side is if you're thinking that it's an Ogilvy's or pseudo-obtruction kind of picture, if that's the only issue, then the patient should not really have a fever or white count unless they are now
Speaker: either perforated or the bowel wall is ischemic from the distension.
Speaker: So the worrisome thing up front is certainly, does the patient look sick?
Speaker: Does the patient have fever, white count?
Speaker: Belly tenderness, that's not just some distension, but actual peritonitis, that definitely is way more worrisome than now.
Speaker: Either the pseudo obstruction is bad enough that the bowel is in trouble, or it's something else like C. diff.
Speaker: So I guess, I mean, if you're going down the direction, the patient truly, I mean, is toxic and there might be indications of, like you said, a severe complication caused by one of these.
Speaker: You obviously are going to go down probably a much more aggressive route very, very quickly.
Speaker: It might end up, I mean, in the operating room.
Speaker: But let's talk about the other case where you have Augliebius syndrome.
Speaker: and just have a dilated colon.
Speaker: And a lot of times I think these can be quite dramatic, and especially, I think, and people have not seen a lot of them, it can become very difficult to understand what to do.
Speaker: How would you approach these patients who are not toxic, who have Ogilvie syndrome and have a dilated colon?
Speaker: And what do you mean by dilated colon in terms of numbers as well, just to give people some reference?
Speaker: Well, people look at the cecum and when it gets...
Speaker: to be, I mean, there are various numbers around, so pick 10 centimeters is something worrisome.
Speaker: But everybody's a little different in terms of how big it can get and how much trouble it can cause.
Speaker: But certainly simple things up front are making sure the patient's well hydrated and perfusing everything well, minimize narcotics, get the patient moving around,
Speaker: start trying to decompress the colon from below, whether starting with simple things like suppositories or enemas, and then if that's not working, thinking about how getting GI to scope the patient to decompress them if it's not getting better.
Speaker: There are pharmacologic things like neostigmine you can give to get the bowel to function, but that should be
Speaker: And when you get to that kind of stage, you've tried simple things like stopping narcotics and minimizing narcotics, getting the patient moving around.
Speaker: You've tried suppository enemas, and now you're thinking about something else.
Speaker: Then it's important to either have a surgeon involved or GI involved to assist with that decision making.
Speaker: And in terms of my experience, Sam, with Ogilvy has been that usually you can avoid surgery, obviously, right?
Speaker: I mean, unless they have a perforation or a complication.
Speaker: And I have utilized in conjunction, obviously, with our consultants, like you mentioned, from the surgical and the GI teams, neostigmine infrequently, but have had experience with it.
Speaker: And usually I think that what's important, and I'll still remind the audience, is that neostigmine
Speaker: It can have serious cardiovascular complications.
Speaker: Obviously, it can cause bradycardia, hypotension, blocks.
Speaker: So you should have some atropine at the bedside and also can cause bronchoconstriction in some patients.
Speaker: So these patients need to be monitored in ICU.
Speaker: It's not something you would give in a non-monitoring setting.
Speaker: But can you talk a little bit about...
Speaker: when we do colonic decompression via endoscopes or via colonoscopes.
Speaker: Is that something that is commonly done?
Speaker: I have not had a lot of experience with that.
Speaker: No, it's not common.
Speaker: Well, because I don't go over to the medical ICU here, I haven't seen it done.
Speaker: Previously, it was something done very rarely for these kind of refractory cases.
Speaker: certainly methyl naltrexone is another drug you could give so it certainly it could be easier to start with the simple stuff before going to that because putting a scope up there has its risks too you know if you've got a distended colon now you put a little more air in it now there's a risk of perforation so and then simple rectal tubes can help too even just
Speaker: you know, blindly inserting erectile tubes of various sorts that have been around for years can help if the air is down that far.
Speaker: And it sounds like Ogilvy's is more of a, almost like a board question that usually is asked.
Speaker: I mean, and they want you to recognize it and talk about pharmacological therapy, it seems like.
Speaker: But clearly, I mean, recognize that when it's dilated and the patient is not toxic,
Speaker: That's probably what's going on and that maybe ruling out mechanical obstruction might be useful sometimes, but ultimately some basic principles like hydration, movement, decompression from above and below with NG tubes and rectal tubes and maybe decreasing of the narcotics are good first steps, getting surgery and GI involved.
Speaker: And for those that have a higher risk of perforation, which I presume is based on the diameter,
Speaker: So you mentioned 10 centimeters.
Speaker: The literature also talks of 12 centimeters as being kind of a cut point of increased danger.
Speaker: Do the neostigmatic, if that doesn't work, colonoscopy.
Speaker: And as an ultimate resort, I mean, you would really do something surgical.
Speaker: Is that correct?
Speaker: If it really came down to it, but you really want to try to avoid surgery because you can maybe get away with just a
Speaker: a stoma somewhere, but typically people will operate because they're worried that the bowel is now in jeopardy, that it's ischemic or it's perforated, and short of that, try not to operate.
Speaker: And what about in the other case that you mentioned was a toxic megacolon related to severe C. diff infection?
Speaker: Obviously, you would be treating the C. diff
Speaker: with stopping the fending antibiotics, giving the proper antibiotics for C. diff.
Speaker: But at what point do you consider taking somebody to the operating room for a toxic megacolon from severe C. diff?
Speaker: That's a really important point because oftentimes what seems to happen is that the patient has C. diff and gets started on enterovancomycin, maybe IV metronidazole, and
Speaker: It's not until a couple of days later and the patient's now more floridly septic that the surgical team gets involved.
Speaker: So like pretty much all the other topics we talked about, early surgical consultation is very important.
Speaker: When to take the patient to the operating room can be a difficult decision.
Speaker: It's certainly you don't want to wait till clearly the medical therapy has failed.
Speaker: Now the patient's on death's doorstep.
Speaker: But on the other hand, you're talking about a big operation for the most part.
Speaker: You don't want to take that too lightly either.
Speaker: So usually it's when the patient's in septic shock and not responding to the antibiotics.
Speaker: The other piece of the surgical side of this is the loop ileostomy idea.
Speaker: So the traditional surgical approach is to do a subtotal colectomy, which means taking out all the colon that's in the abdomen and basically leave the rectum because the rectum is not typically part of C. diff.
Speaker: And so that's obviously a big operation.
Speaker: The patient will have an ileostomy and may or may not get reversed down the road.
Speaker: The alternative that was started by my former colleagues at the University of Pittsburgh was to consider the fact that
Speaker: The reason people get sick with C. diff is because of the toxin, not so much that it's invading tissues like other surgical infections and you don't have pus somewhere.
Speaker: So if you could just wash the colon out, you could get rid of the toxin and the patient can get better.
Speaker: So you do this loop ileostomy, which gives you access to put a tube in the distal part of the loop and just irrigate the colon with just
Speaker: Saline, add vancomycin.
Speaker: There's a protocol they came up with of just washout along with some vancomycin, and you put in a rectal tube so you can just drain out on the other end, and you basically wash the colon out with a relatively minor operation.
Speaker: I mean, it still requires a general anesthetic, but it's a quick little procedure to do.
Speaker: And in their hands, a lot of people who are really sick, even in septic shock,
Speaker: responded well to that.
Speaker: It's not universally embraced by general surgeons, so people often will still do the subtotal colectomy.
Speaker: Here I've seen both done more of the colectomy, but it's like a lot of things where the patient needs to be sick enough that it's worth putting them through a big operation, but not so sick that they're going to die no matter what you do.
Speaker: And I think that's something that we also can talk at the end in terms of the fact that the patient has one of these extreme or acute abdomen problems doesn't always mean that surgery is the right choice because, like you said, they're not going to survive the surgery and there's a lot of other things going on.
Speaker: It might require a different conversation.
Speaker: But even so, that's why we need the surgical team on board early to be part of all those conversations.
Speaker: Right.
Speaker: I think the important thing is never –
Speaker: Never assume that either the patient needs an operation or that an operation won't help the patient.
Speaker: That's why you have to have the consultation.
Speaker: Absolutely.
Speaker: So the last topic I wanted to touch about was related to bowel ischemia.
Speaker: We talked a little bit about that at the beginning, but non-occlusive esoteric ischemia is one of the types of esoteric ischemia, but I think it's the one that is more commonly associated just with being critically ill from
Speaker: other causes.
Speaker: Can you talk a little bit about how that presents and who are the patients who are at risk?
Speaker: The call from the medical ICU about some of the possible ischemic bowel is the nightmare for general surgeons because there's no easy test to either rule it in or rule it out.
Speaker: So non-ischemic, I mean, non-occlusive ischemia
Speaker: can certainly happen in anybody that's on high doses of pressors, or more often, it's not so much pressors as people with really bad heart failure.
Speaker: One of the challenges in dealing with patients in septic shock is you might give them fluids, and they're also vasodialists, you put them on vasopressors.
Speaker: And usually, the overwhelming majority of the time,
Speaker: If your volume is resuscitated inadequately as you're putting them on pressers, you're not going to cause that much distal ischemia to like fingers or toes or bowel or other things because particularly when you're talking about bowel or kidneys or liver, those organs need a perfusion pressure.
Speaker: So you got to give them the pressure to get the pressure up.
Speaker: So it's possible.
Speaker: But the organs do need that perfusion pressure.
Speaker: So you just don't want to give them the vasopressors without giving them a reasonable amount of fluid at the same time.
Speaker: So this then is more of an issue with patients who have really bad heart failure and just don't have enough pump flow to adequately perfuse organs.
Speaker: That's where you get into trouble.
Speaker: The challenge is that there's no simple test.
Speaker: The patient looks sick.
Speaker: You may or may not get something on exam that suggests that the patient's having pain or tenderness.
Speaker: You'll have elevated white count, elevated lactate, which can be really high without bowel ischemia, just from being septic, or you can have
Speaker: small parts of the bowel that are actually infarcted and the lactate is not terribly above normal.
Speaker: So you want to check those things.
Speaker: The one other lab that can confuse people a bit is looking at amylase because we typically get amylase and or lipase looking at the pancreas.
Speaker: But in fact, if you have ischemic bowel or perfed bowel, you can get a mild elevation of amylase just because it's in the
Speaker: GI tract, and now the bowel wall is falling apart or it's perforated, so you leak some of the amylase and it gets reabsorbed.
Speaker: And so in my mind, if I saw somebody with belly pain, distension, intolerance of two feeds, and the amylase is like 300 or something like that, I'm actually more worried that the patient has a surgical abdomen than if the amylase is 3,000, because the only way you get to 3,000 is tancartitis.
Speaker: So the labs can kind of help, but they aren't the be-all and end-all.
Speaker: And that's why this becomes a nightmare from a surgical perspective, because even if you send the patient for a CT scan, it can be falsely negative.
Speaker: What are you looking for on the CT scan?
Speaker: You're looking for, well, if you see free air, that's easy, but thickening of the bowel wall,
Speaker: can be suggestive of ischemia, some fluid around that bowel wall suggesting inflammation.
Speaker: More obvious would be if there's pneumatosis, there's actually air in the bowel wall, and that would prompt the need for an operation.
Speaker: And the free air or the perforation in ischemic bowel, that's a very late, late phenomenon, right?
Speaker: That's the problem.
Speaker: That's the problem, right.
Speaker: And you could have bowel that is in the process of dying and making the patient sick, and the CT may not show it to you.
Speaker: So that's why it can be very challenging from a surgical perspective, because if you think about it long enough and you haven't clearly ruled it out by finding something that seems more obvious for causing the problem, you may end up
Speaker: being stuck with, oh, the only way to really roll it out is to operate on the patient, take a look around.
Speaker: So that becomes an issue.
Speaker: And that's a challenge because you got a sick patient that you're putting through a general anesthetic and a big operation.
Speaker: And I think that also part of the important aspect that I encounter sometimes with families is if the patient has ischemic bowel and not a candidate for surgery, they're really not a candidate
Speaker: for a lot of other critical care interventions at that point, because without that surgery, it's unlikely that if they have true ischemic bowel and necrotic bowel that they would survive, right?
Speaker: Yeah, I think that, and that's, that adds to the risks involved in making this kind of decisions, because if that's the case, then you know the patient's not going to make it without an operation.
Speaker: But that doesn't always mean that
Speaker: the right thing to do is in operation because the patient may have so many comorbidities and be so sick that even if you do operate and resect some dead bowel, the patient's not going to survive.
Speaker: So that becomes a difficult conversation.
Speaker: Absolutely.
Speaker: Is there any role, Sam, for interventional radiology for angiography in these patients?
Speaker: Not usually.
Speaker: I mean, if somebody came in
Speaker: that maybe has some evidence of chronic mesenderic ischemia or even it's kind of acute but they're not that ill, then you potentially could just try to revascularize either it's interventional radiology or now a lot of vascular surgeons are doing all these things from an endovascular approach.
Speaker: If there's concern that the bowel is
Speaker: in trouble, then the only way to know that is to operate and then be prepared to figure out how to revascularize.
Speaker: So you go in there and if the bowel just looks kind of dusky but still potentially viable, then you get the vascular surgeons or the general surgeons that might do some of those kind of procedures to open up the vessels and try to restore perfusion.
Speaker: The non-occlusive mesothereic ischemia patients are complicated, and that's where optimizing their hemodynamics is really the most important thing until they show evidence that maybe there's actually dead bowel now.
Speaker: But people can certainly have elevation of lactate and some belly pain when they're horrible heart failure.
Speaker: You improve their hemodynamics,
Speaker: in one way or another, and the belly pain goes away.
Speaker: That's something that certainly people see in cardiac surgery ICUs.
Speaker: Yeah, I think like you said, I mean, it's commonly seen in patients in low flow states and these heart failure patients that's more commonly encountered.
Speaker: Sam, this has been, I think, a great conversation about things that are not daily occurrences, but I think that are important for us to recognize when they do occur.
Speaker: And perhaps the two overriding messages I heard over and over again relate to just being vigilant and think about all these potential abdominal complications early, but also to make sure that we have our surgical colleagues on board in consultation early so that the proper decisions in terms of triage to the OR or not and appropriate support can take place in a timely fashion.
Speaker: Right.
Speaker: Exactly right.
Speaker: If it's okay with you, we'd like to end the podcast with some questions that are not related to the topic but that tap into the wisdom of our guests.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: I don't know how much wisdom I have, but I'll see what I can say.
Speaker: So the first question relates to, are there any book or books that have influenced you tremendously or that you have gifted very often to others?
Speaker: The one that came to mind is...
Speaker: Atul Gawande's book on complications.
Speaker: I think it really kind of makes you think about all the things we do to patients and what their implications are.
Speaker: And certainly as surgeons, we think about complications all the time, and we have morbidity and mortality conferences, but all of us in medicine are doing things to patients, whether it's prescribing medications or supporting them in the ICU or doing procedures on them and
Speaker: They all have implications, so I think it gives a good perspective on how what we do can affect our patients.
Speaker: Yeah, and I think that it also talks, I mean, to how we think about complications, and sometimes I think complications that are very vivid in terms of maybe procedural complications I think are very present in physicians' minds, but then again, we sometimes don't think about starting heparin, and that could kill somebody.
Speaker: or giving them a medication that leads to an allergic reaction that could give them an aphylactic shock.
Speaker: And everything that we do, no matter how trivial, sometimes, I mean, can have a very severe complication.
Speaker: And always, I think, being aware of that is very, very valuable.
Speaker: Right.
Speaker: That's why I think it's a useful book to read for any of us.
Speaker: So we'll definitely put that in the – link that in the show notes.
Speaker: And I do think it's a great read.
Speaker: And I think it's his first book, actually, one of the first books that he wrote that really –
Speaker: started his writing career, but it is a tremendous read.
Speaker: The second question relates to beliefs and whether it's something that you believe to be true in medicine or in life that most other people don't believe or act as if they don't believe.
Speaker: Yeah, I thought about that for a little bit.
Speaker: I guess the first thing that came to my mind, though, was that there are no magic bullets.
Speaker: We all kind of
Speaker: try to find quick answers to the problems that we face in medicine and outside of medicine.
Speaker: And there usually aren't easy answers.
Speaker: There's nothing that magically changes whatever the problem is that we're trying to fix.
Speaker: And the other piece of that in medicine in particular is a lot of things that come along that seem really exciting
Speaker: We also are giving a certain drug that's going to fix sepsis.
Speaker: And then some subsequent studies show that it didn't really work.
Speaker: So that was the first thing that came to my mind is searching for quick answers or magic bullets has generally not been very fruitful.
Speaker: Not that we shouldn't keep looking for answers to problems, but it's not going to be simple.
Speaker: But I think it's a great point.
Speaker: I mean, if it's too good to be true, it probably isn't true, right?
Speaker: Exactly.
Speaker: Exactly.
Speaker: And I think the other thing that comes to mind is that there's no easy answers, just tough questions.
Speaker: That's right.
Speaker: And we keep coming up with new questions.
Speaker: But I think that's a great point.
Speaker: And the last question really relates to, is there anything that you want to make sure that everyone who listens to this podcast knows or something you want to share with the audience before we leave?
Speaker: Well, I think from an intensive standpoint, actually my thought stems from my comment just now about no magic bullets and having done all this for a while now, I think what helps our patients more than anything is fixing the physiology as quickly as possible.
Speaker: And it's maybe simplistic, but I think it really is true in terms of what's changed, what we do in medicine and in the ICU.
Speaker: over the past 20 plus years.
Speaker: We've learned that if you have a cardiac arrest, the sooner you can shock somebody and get their own rhythm back, the sooner you can do good CPR on them, the better the chances of surviving.
Speaker: If they have sepsis, early goal-directed therapy, fixing their physiology makes a difference.
Speaker: For us that manage surgical problems and particularly trauma, if somebody's bleeding, it seems simple and obvious, but
Speaker: stopping the bleeding and giving them blood is what's going to make them better.
Speaker: So I think working on fixing the physiology and not overdoing it, because that's the other piece of this that we've found that doing too much isn't good either.
Speaker: Sometimes less is more.
Speaker: So I focus on quickly getting this patient's physiology back to normal.
Speaker: That's going to be the best way to get the patients through whatever their acute illness is.
Speaker: And I think that's a great place to stop, Sam.
Speaker: I really want to thank you for your time and sharing your expertise with us.
Speaker: It was a phenomenal conversation and that we look forward to having you back on the podcast maybe in the future.
Speaker: Sure.
Speaker: Happy to do it.
Speaker: A lot of fun.
Speaker: Thanks.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a sound critical care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
