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Mechanical Circulatory Support - Part 2
19 Plays1 year ago
This is the second part in our series discussing temporary mechanical circulatory support (tMCS). Part one, covered different types of devices for tMCS, pathophysiology of shock, clinical indications, and general considerations for critical care clinicians. In Part 2, Dr. Zanotti covers a more detailed discussion of medical management and troubleshooting of patients on tMCS. He is again joined by Bindu Akkanti, MD, an associate professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at UTHealth Houston. Dr. Akkanti is the Medical Director of the Heart Failure ICU and the Director of Critical Care for the Heart & Vascular Institute at Memorial Hermann Texas Medical Center.
Additional Resources:
More about Dr. Akkanti: https://med.uth.edu/internalmedicine/2022/11/17/bindu-akkanti-md/
Mechanical Circulatory Support Part 1 - Critical Matters Podcast. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1828006629
A Comprehensive Review of Mechanical Circulatory Support Devices. V Atti, et al. Heart Intl. 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9524665/
American Society of Artificial Internal Organs website. https://asaio.org/
IABP: Hemodynamics, troubleshooting, technical tips. https://www.youtube.com/watch?v=ULgjuhBgP9U
Composer and Musician A.R. Rahman. https://www.arrahman.com/
Recommended
Transcript
Introduction to the Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Episode Introduction - Mechanical Circulatory Support Part 2
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
00:00:32
Speaker
Today's episode is part two of our discussion on mechanically circulatory support in the ICU.
00:00:37
Speaker
In part one, we cover the different types of devices available for temporary mechanical circulatory support.
00:00:43
Speaker
We discuss clinical indications, pathophysiology of shock, and other general considerations for the intensivist.
Role of Intensivists in MCS Management
00:00:49
Speaker
Today, we will dive deeper in the medical management and troubleshooting of patients on temporary mechanical circuitry support.
00:00:55
Speaker
Our guest is again, Dr. Bindu Akhanti, an associate professor in the Division of Pulmonary Critical Care and Sleep Medicine at UT Health in Houston.
00:01:04
Speaker
Dr. Akhanti is the Medical Director of the Heart Failure ICU, the Director of Critical Care for the Heart and Vascular Institute of Memorial Hermann Texas Medical Center.
00:01:14
Speaker
Bindu, welcome back to Critical Matters.
00:01:18
Speaker
Thanks for having me again.
00:01:21
Speaker
And I think we will continue with our conversation on this really fascinating emerging aspect of critical care support, which is mechanical circulatory support.
00:01:32
Speaker
And I would like to maybe start by framing the role of the intensivist in the care of patients with MCS.
00:01:41
Speaker
So how can intensivist add value and how can they best interact with cardiology and CT surgery colleagues?
00:01:48
Speaker
So one of the things that I think that is different in different programs is who is actually leading this care of MCS patients, right?
00:02:00
Speaker
Because when you look at it from the inpatient perspective, okay, so you have on the floor in many hospitals, hospitalists that will call it cardiology consults.
00:02:10
Speaker
And then as this patient progresses in their advanced heart failure, then advanced heart failure will be involved.
00:02:17
Speaker
And these patients are taken to the medical review board or their complex care conferences.
00:02:22
Speaker
and then decisions are made how to escalate care.
00:02:25
Speaker
So if it's a cardiogenic shock patient that's coming to the ICU, this patient may be in the CCU, they may be housed in a mixed ICU or CV ICU.
00:02:36
Speaker
I think from the quaternary care center's perspective, most of the time it's a well oiled machine, but I want to take back and go, let's take your tertiary care centers, because that's where MCS is gonna really proliferate
00:02:52
Speaker
even more so in the coming decade than it had in the last decade.
00:02:57
Speaker
There, I really think MCS intensivists
00:03:01
Speaker
their main goal is going to be that central figure in coordinating between cardiology, cardiac surgery, nursing, and these other disciplines in ensuring that this patient progresses in their care.
00:03:15
Speaker
And I think that comes naturally to intensivists anyway.
00:03:18
Speaker
But I think the exciting aspect of it is using the expertise and continuous monitoring and interpretation of all these hemodynamics to
00:03:29
Speaker
and predicting, hey, this patient, I know he's posted for like, let's say five, five, two days from now, but he's not doing well today.
00:03:41
Speaker
AST, ALT or lactate may be still normal, but I know based on everything that we have done, because despite CVVHD, look at the CVP.
Best Practices and Daily Checklists in MCS
00:03:50
Speaker
So I think bringing the case together and ensuring that active escalation happens,
00:03:57
Speaker
It comes naturally to us because of our sepsis knowledge about our just, I mean, you know, so many things like whether you take ARDS or sepsis.
00:04:06
Speaker
And we apply it, and I think that ability to quickly troubleshoot and intervene is there's no question that's our backbone, but to predict and prevent, now that's a completely different skill set that we use on an ongoing basis, but we don't really leverage it, especially when it comes to this new field of MCS critical care.
00:04:30
Speaker
And the other aspect that I think comes naturally to us is they lead these units, right?
00:04:36
Speaker
They lead them by having these relationships with the nurses, the nurse educators, and across the hospital with other ICUs, hey, you're doing this.
00:04:45
Speaker
How can we kind of incorporate and do this in the same way?
00:04:49
Speaker
And I think that's the education and training piece.
00:04:52
Speaker
So together, by coordinating care, leveraging their understanding of hemodynamics,
00:04:58
Speaker
and predicting and preventing harm and the ability to troubleshoot and I think really be able to look at the team together and say, this aspect we need ongoing education on, that's, I think that's something that we need to really harness.
00:05:16
Speaker
And that's the reason that I think intensivists play a crucial role in these multidisciplinary meetings or care of these patients.
00:05:25
Speaker
Absolutely.
00:05:27
Speaker
Yeah, one other thing.
00:05:28
Speaker
Go ahead.
00:05:29
Speaker
I was going to say that one of the things that we bring to the table, obviously, Bindu is presence in the ICU, right?
00:05:35
Speaker
And that, I think, is an opportunity to lead the team and connect all the dots and make sure everybody's on the same page.
00:05:42
Speaker
The other thing I was going to ask you was about as these patients become sicker, we also have a lot of other issues to deal with.
00:05:50
Speaker
A lot of them might be on mechanical ventilation.
00:05:52
Speaker
A lot of them might have other critical care issues unrelated to the heart or associated to other organ systems.
00:05:58
Speaker
And I think our expertise there definitely also is a plus for the team.
00:06:03
Speaker
Yeah.
00:06:04
Speaker
And I wanted to get to that, you know, beyond the mechanical ventilator, I think the other aspect is this entire concept of prehab, right?
00:06:16
Speaker
We know that, for instance, an ex-patient's eventual home is a durable LVAD.
00:06:22
Speaker
Now that particular patient is on two drips,
00:06:30
Speaker
us to go there, we know in our head that, hey, you know, if the chest x-ray is still white, it will probably take us another five days to really diurease this patient.
00:06:40
Speaker
It'll probably take us another two days after that to be able to safely extubate.
00:06:45
Speaker
And I think providing that kind of insight and perspective will really help the heart team navigate these waters, right?
00:06:54
Speaker
The second thing is really having like development of joint protocols and guidelines for your ICU.
00:07:01
Speaker
That's another thing that comes naturally to the intensivist.
00:07:04
Speaker
And I think adhering to these standard protocols may be difficult in a fast changing world of MCS.
00:07:13
Speaker
For instance, you may have an ICU that just started doing Impella, for instance.
00:07:18
Speaker
And I think like buddying up with other programs that have done it
00:07:23
Speaker
and asking for those best practices and saying, hey, do you already have established protocols about anticoagulation management, about transport of these patients, whether it is a VV ECMO, whether it is a VA ECMO or an Impella patient, who is accompanying these patients on transport, let's say an Impella 5.5 patient,
00:07:45
Speaker
needs to immediately have a CT.
00:07:49
Speaker
Who is going to go with that patient?
00:07:50
Speaker
Is it the bedside nurse?
00:07:52
Speaker
Does the hospital have resources?
00:07:54
Speaker
And if they have resources, then who is that team?
00:07:59
Speaker
Should they do a brief huddle before transport, making sure everything is okay?
00:08:04
Speaker
Should they do a brief huddle after the transport, especially with
00:08:08
Speaker
ECMO, you know, I'm sure, Sergio, you've seen it where something as simple as, hey, connect him back to the gas, it does help to have a checklist after visit.
00:08:19
Speaker
Because we can't say we are going to walk every VV ECMO patient, but if you suddenly change that culture, then you need to have a checklist before and after ambulation.
00:08:30
Speaker
And I think that's another role that the intensivists play with the team is
00:08:35
Speaker
He's developing these best practices with cardiology and cardiac surgery.
00:08:40
Speaker
And our nursing colleagues, our physical therapists, social workers, dietitians, I think that is we are like effective communicators with families.
00:08:52
Speaker
But I really think our communication skills are truly about care.
00:08:56
Speaker
navigating with colleagues.
00:08:58
Speaker
How do we, how do we persuade, come to a middle ground and kind of help the field move faster?
00:09:06
Speaker
Absolutely.
00:09:07
Speaker
You mentioned protocols and checklist, Bindu.
00:09:11
Speaker
In terms of the daily management and daily rounds, is there a particular daily checklist that you follow with your patients on MCS?
00:09:19
Speaker
So we don't have a formal checklist, but I think one thing I was just speaking to this at SIO recently,
00:09:31
Speaker
We had a VAD university, a pre-course university, and I was thinking about, they asked me about how do you manage these patients
System-Based Management Approaches
00:09:40
Speaker
that have multi-system issues.
00:09:42
Speaker
And I was telling them that I think you need to go back to your own training and look at the way you write notes, right?
00:09:50
Speaker
Most intensivists are system-based approach.
00:09:53
Speaker
So for me, the checklist is going system-based, for instance, and if you say, no, I prefer to do it as a daily checklist, one suggested way could be whether you want to do device-based, for instance, you can say,
00:10:14
Speaker
I want to write my note for a durable LVAD patient the way I think about them or an ECMO patient the way I separate VV ECMO and VA ECMO management.
00:10:25
Speaker
So a typical system-based approach would be, let's start with, it doesn't matter what device, the complications are the same, right?
00:10:36
Speaker
So for neurologic, in my mind, I am focusing on, is there a possibility of stroke, right?
00:10:45
Speaker
All these devices, even VVACMO, by the way, you know, these patients may have had hypoxic incels and they are at risk for neurological injury.
00:10:56
Speaker
The second thing is obviously, obviously, this physical deconditioning and how do you get them out of bed?
00:11:03
Speaker
The third thing is physical injury or harm just by being in the intensive care, which goes along with, for instance, there could be foot drop on patients that have been on prolonged support that are in bed.
00:11:20
Speaker
The second injury is if you do have upper extremity devices, then you want to make sure that their strength
00:11:29
Speaker
with the, you know, with the neurological changes that have that are happening in the, in just for instance, just when you do the finger exercises, you want to make sure that their grip is okay.
00:11:43
Speaker
It's very, very rare to have any kind of nerve injury.
00:11:49
Speaker
But I think if you have an expanding hematoma, you want to be able to make sure that
00:11:54
Speaker
their strength is preserved in the upper extremities.
00:11:57
Speaker
The durable LVAC patients, when you look at them and you're looking at, okay, I know how to pick up like major devastation, right?
00:12:05
Speaker
Like you suddenly have a paralyzed patient and things of that sort.
00:12:10
Speaker
But what may be subtle is simple, like, you know, I was doing okay yesterday, but I'm having some word-finding difficulties.
00:12:20
Speaker
I feel a little weak on this upper extremity, then you do have to take time and do a thorough physical exam.
00:12:26
Speaker
One of the best practices is to identify a neurologic neurology consultant that gets familiar with these devices alongside you as the ICU team is growing.
00:12:38
Speaker
So for me, neuro is in that bucket.
00:12:42
Speaker
The third one for neuro for patients with MCS is somebody that has already had a neurologic injury, whether it is a small subarachnoid or a subdural patient.
00:12:53
Speaker
and neurology and neurosurgery are like, okay, let's just do follow-up hit CTs, and when it's stable, we're going to restart heparin for anticoagulation.
00:13:04
Speaker
A typical recommendation they give is when the heparin is therapeutic, we would want another CT brain.
00:13:11
Speaker
So those things you need to keep track of, right?
00:13:15
Speaker
Because now the PDT is 60, the patient has not changed necessarily,
00:13:20
Speaker
and now you're about to move the patient and downgrade them onto floors, you want to be able to provide that, okay, right before they left the ICU, the patient's subdural status is X, so that the teams that are picking up these patients know what they are having to deal with.
00:13:39
Speaker
The next system is cardiopulmonary, which is the big one, right, depending upon the device.
00:13:46
Speaker
And there are many ways to do it in cardiology and pulmonary.
00:13:52
Speaker
So I've seen colleagues do.
00:13:54
Speaker
For me, I keep it simple with cardiac space.
00:13:56
Speaker
I just say preload, you know, inotropic support, afterload management, rhythm management, and then overall recovery.
00:14:06
Speaker
strategy in whatever device.
00:14:08
Speaker
For instance, if we say, let's say that we are talking about a veno-artereo-lecmo patient, then the patient is on veno-artereo-lecmo support.
00:14:17
Speaker
So then at the bedside for your checklist is, you know, what is the speed that you've set the patient at?
00:14:23
Speaker
What is the flow that you're getting?
00:14:25
Speaker
What was the flow for the same speed yesterday?
00:14:29
Speaker
And then at every patient, just like you do your sedation assessment, SBT and SATs, you need to ask, what is the patient ready for weaning?
00:14:40
Speaker
Is the patient ready for weaning?
00:14:42
Speaker
Especially when it comes to wean arterial ECMO because you have a cannula in the aorta that is basically throwing strokes.
00:14:50
Speaker
So the sooner that it goes in, the sooner that it needs to come out.
00:14:54
Speaker
So when you're at the bedside, you're really assessing
00:14:57
Speaker
What was the initial reason that you put in the veno-arterial ECMO?
00:15:01
Speaker
What is the patient's preload, the native hearts?
00:15:04
Speaker
What is the patient's native heart squeeze?
00:15:07
Speaker
And you can look at the hemodynamics, right?
00:15:09
Speaker
The patient has an arterial line.
00:15:11
Speaker
What is the difference between the systolic and the diastolic?
00:15:14
Speaker
And that's basically your pulse pressure.
00:15:17
Speaker
Now, if the patient's pulsatility has changed and has determined by, like, let's say,
00:15:22
Speaker
less than 15 and now it's less than 10, you know intrinsically that there may be smoke happening in the left ventricle or the atrium and that could potentiate strokes, right?
00:15:34
Speaker
So that patient may need venting.
00:15:36
Speaker
So those are the strategies like, so you have veno arterial ECMO, you've seen what the native heart is, you know what the pump is doing, how the actual management of the pump in itself for device integrity, right?
00:15:48
Speaker
So all checking all the connections,
00:15:50
Speaker
ensuring secure attachments, the patency, any kind of alarms and warnings regardless of the device over the last 24 hours, ensuring appropriate anticoagulation and adjusting based on those values.
00:16:03
Speaker
And then as you're checking the sites, making sure that there's no sites of infection at the cannula or implant sites,
00:16:10
Speaker
ensuring that, you know, these, number one, you have a strategy, and number two, addressing any barriers for physical therapy on these patients.
00:16:19
Speaker
Okay, what are the nurses concerned about of the devices?
00:16:22
Speaker
Then for the respiratory section, similarly, you're like, okay, what is the sweep act?
00:16:26
Speaker
What am I looking at it in the x-ray?
00:16:28
Speaker
If the x-ray shows black lungs, then...
00:16:31
Speaker
You know, honestly, you could do all these sophisticated measures, but if they're black and on the vent, you have good lung compliance, then the patient is being vented, right?
00:16:42
Speaker
So I think those are simple things that you can look at.
00:16:47
Speaker
And there is no reason to keep these patients intubated if you can avoid it.
00:16:52
Speaker
So you want to be able to always try to see what are the barriers towards extubation, right?
00:16:57
Speaker
Head of bed elevation sometimes becomes tricky in these patients if they have large femoral cannulas.
00:17:02
Speaker
So typically, you know, we do reverse Trendelenburg about 30 degrees and see if that alone will suffice.
00:17:08
Speaker
And as you're navigating on this patient, so for a veno-arterial ECMO, you do need to see if there is pulmonary edema, if they need venting.
00:17:17
Speaker
For a 5-5-impeller patient, if you suddenly see a patient that was well diuresing, that was well vented, and now he has opacity, so he or she has more pulmonary edema, then you go back to step two for cardiac management and go, okay, am I venting the ventricle enough?
00:17:33
Speaker
Why did this happen, right?
00:17:36
Speaker
And then from the pulmonary support, you know, what is the sweep gasser?
00:17:40
Speaker
One of the frequent mistakes that you could potentially see is like, you know, the patient is at 7, 4, 5 pH and you still have the patient on sweep.
00:17:50
Speaker
And you're like, well, you know, if you are to the point of metabolic alkalosis, you shouldn't need sweep.
00:17:55
Speaker
So you start coming down and the patient's.
00:17:57
Speaker
Inherent respiratory cycle will eliminate the CO2 and we want to come down to 0.5 because sometimes, especially in the veno arterial ECMO patients, you can't assess the lungs necessarily, right?
00:18:10
Speaker
Because you can't turn off the sweep gas.
00:18:12
Speaker
So you need to, you can't do a true shunt run.
00:18:16
Speaker
So you want to be able to look at the X-ray, make sure that the lung mechanics can hold it.
00:18:21
Speaker
and see your PAO2s.
00:18:24
Speaker
And in different devices, you want to look at PAO2 in different ways, but most commonly, you know, as a general rule of thumb, if you just remember that having an ABG helps and that an ART line is absolutely fruitful, that's a step one.
00:18:43
Speaker
And if you want to separate it out in a veno-arterial ECMO patient, how do you assess for oxygenation and ventilation?
00:18:50
Speaker
We recommend a best practice is right radial art line.
00:18:54
Speaker
And the reason for that is you have the flow being delivered in the distal aorta, right?
00:18:59
Speaker
So if that oxygen molecule, let's just follow that molecule, is able to come down across the aortic arch all the way,
00:19:10
Speaker
then you know that your brain, the carotids are well oxygenated.
00:19:15
Speaker
But however, if the mixing cloud from your native ventricle and the ECMO are beyond the carotids, then you are at risk for hypoxemia in the patient.
00:19:31
Speaker
especially with anoxic injury, so that's called north-south syndrome or the Harlequin syndrome.
00:19:38
Speaker
So those are the patients you would not have picked up if you didn't have that right radial art line.
Infection and Gastrointestinal Management in MCS
00:19:43
Speaker
But in some patients, yes, there are many ways.
00:19:45
Speaker
You could just put in a pulse oxmeter.
00:19:47
Speaker
You could just put in a pulse ox probe on the right ear, for instance.
00:19:51
Speaker
But the bigger thing is, just like you're approaching preload, squeeze, afterload, pulsability in the heart for the lungs, you're looking at what is my gas exchange, the native lung gas exchange.
00:20:04
Speaker
You're looking at what is my compliance doing?
00:20:07
Speaker
What is the volume status?
00:20:09
Speaker
Is there pulmonary edema in these lungs?
00:20:12
Speaker
And what is the big picture, right?
00:20:16
Speaker
What is my exit?
00:20:17
Speaker
So if they have cardiopulmonary issues and these lungs are not getting better, you will not be able to, for instance, clear them for an LVAD because now you have pulmonary, you really need to get that better.
00:20:29
Speaker
Now for we know venous ECMO, when you look at the pulmonary issues, and this is not the intent of MCS, this podcast, but like you're able to lean down on the ventilator, you're able to get them to awake ECMO.
00:20:43
Speaker
Then you start weaning down on the flow and the sweep to be able to get to a shunt run.
00:20:49
Speaker
So you can actually see, hey, you know, he's maintaining his PAO2.
00:20:53
Speaker
We don't need this ECMO anymore.
00:20:57
Speaker
The next thing that we look at is, you know, infection control.
00:21:02
Speaker
Now, there's really no robust RCTs on infection control practices in MCS.
00:21:08
Speaker
So the intensivist role does become more important.
00:21:13
Speaker
In the past, in the very distant past, we used to actually do vancomycin because it's a big cannulas.
00:21:20
Speaker
And then we looked at patients that are on just doxy alone, and then the infection rate was the same.
00:21:26
Speaker
So we do prophylaxis doxy.
00:21:27
Speaker
There are some sites that don't do anything, and they just do local control for ECMO cannulas.
00:21:35
Speaker
Same with Impella.
00:21:36
Speaker
Some of the best practices are actually don't do antibiotics if they don't need it.
00:21:41
Speaker
And I think local control, local management of cannulas and local, basically the graft site monitoring is really the key.
00:21:52
Speaker
And daily imaging in terms of whenever they do physical therapy to make sure that the device is positioned and it has not migrated, that depends upon the strength of your ICU team.
00:22:05
Speaker
Once you get comfortable, you may go down on the need for daily imaging.
00:22:10
Speaker
And then the next system is GI.
00:22:14
Speaker
Now, from the standpoint of durable LVADs for MCS, yes, they come in with GI bleeds.
00:22:22
Speaker
There are multiple etiologies, including the one, the Libren factor, the shear stress, the hemolysis, the AV malformations that may happen.
00:22:31
Speaker
But from the acute shock standpoint, gastritis, previous ulcers that are bleeding, new ulcers, they're all, you know, these patients, it depends upon your length of stay.
00:22:44
Speaker
If they're a quick patient, you know, bridge to recovery, five days, they're out, then probably not.
00:22:50
Speaker
But that's rarely the case in really sick patients, right?
00:22:54
Speaker
So when they're there for two weeks, two and a half weeks,
00:22:58
Speaker
um ppi use definitely has been now that's that's a practice i don't know we really don't have any robust robust trials in the space now but the minute that they do have a gi bleed i think acting early from the icu standpoint especially discontinuing the anticoagulation coming up with the strategy hey
00:23:22
Speaker
For instance, if it is an impeller patient, like do we want to use the system, like, you know, remove the regular anticoagulation and just for the impeller system, do we want to use the purge or do we want to change that as well?
00:23:38
Speaker
Is the GI team ready to go and to actually diagnose?
00:23:42
Speaker
Do you have a robust interventional radiology team for backup?
00:23:46
Speaker
Yeah.
00:23:48
Speaker
I think the concept of GI shock team, so the ability for them to scope, I think is really important.
00:23:56
Speaker
Similarly, you need to have massive transfusion protocols in your ICU for MCS critical care patients to ensure that you're able to rescue these patients.
00:24:07
Speaker
Otherwise, the management of upper GI bleed and lower GI bleed is literally standard practice.
00:24:14
Speaker
I think it's just how soon you can intervene and rescue this patient that becomes important.
00:24:21
Speaker
Now, overall, then how do you put it together, right?
00:24:26
Speaker
Then, you know, I know you have a quality tool, whether it is lines, GI prophylaxis, DVT prophylaxis, therapeutic in terms of physical therapy, and the big time disposition and goals of care.
00:24:40
Speaker
So by taking a multi-system approach to MCS critical care, then I think you can make progress on these patients, right?
00:24:49
Speaker
to number one, having a strategy on how do you get them home.
00:24:53
Speaker
But really on a daily basis, patient assessment is their neurological status, their peripheral perfusion, and overall organ function assessment.
00:25:03
Speaker
I hope that was a broad overview, Sergio, before we go into troubleshooting.
00:25:10
Speaker
For sure.
00:25:11
Speaker
And one thing I wanted to ask you, I mean, I think that was a great comprehensive overview of kind of how you think about these patients on a daily basis.
00:25:19
Speaker
And before we go to troubleshooting, I think since we talked about a lot of the systems, I wanted just to ask you, Bindu, if you could tell us how you manage hematologic complications, bleeding, hemolysis, and thrombosis, just some general thoughts, and then we can definitely go into troubleshooting the different devices.
00:25:37
Speaker
Okay.
00:25:37
Speaker
So that's good that you mentioned that because now for under heme section, right, that's the...
00:25:47
Speaker
The key aspect is to look at it together, meaning, okay, you have a VA ECMO patient, you've been weaning the patient, you have not been able to do therapeutic anticoagulation for whatever reason, bleeding, brain bleed, etc.
00:26:06
Speaker
Now, you know these are pumps, and these pumps have increased shear stress and hemolysis.
00:26:12
Speaker
If the patient is making urine, something as simple as looking at the urine, getting a urine analysis is an important good start.
00:26:20
Speaker
And then you look at your total bilirubin.
00:26:23
Speaker
You can look at haptoglobin.
00:26:25
Speaker
We rarely do.
00:26:27
Speaker
We use plasma-free hemoglobin and LDH.
00:26:31
Speaker
One of the clinical pearls with that is if you have an acute shock patient and the ASD, ALT are in the thousands, then your LDH alone may not help you, but trends help you.
00:26:42
Speaker
Okay, that's number one.
00:26:44
Speaker
So using LDH to dictate, hey, I know we are on impella, but there's been ongoing hemolysis.
00:26:51
Speaker
We need to do something.
00:26:53
Speaker
Can we make sure that the device is working properly, the axial flow, for instance?
00:26:57
Speaker
Is there a change in the P in terms of the power, number two?
00:27:03
Speaker
And number three, how significant is the hemolysis would be the question.
00:27:07
Speaker
Now, the bleeding aspect is we use PT, PT.
00:27:18
Speaker
the question for you is twofold.
00:27:21
Speaker
Is it overall bleeding risk?
00:27:23
Speaker
Is it because of coagulopathy?
00:27:26
Speaker
Or is it a site-specific wound that just needs an extra suture or exploration?
00:27:31
Speaker
That's a key.
00:27:33
Speaker
Because if it is a site-specific and you're approaching it with this overall, then potentially you've contributed to thrombosis even because you're readjusting your anticoagulation when all it needed was a second look, a stitch, or exploration.
00:27:50
Speaker
Now, when you go into thrombosis, one of the things that you need to recognize is the longer you do the field at the bedside, you'll develop your own methods.
00:28:01
Speaker
But...
00:28:02
Speaker
Thrombosis is something that you need to recognize by multiple methods.
00:28:08
Speaker
One is LDH suddenly has gone up.
00:28:12
Speaker
Suddenly, for the same speed, you're not getting flow.
00:28:16
Speaker
And then the third thing is, you know, most importantly, remember prediction and prevention.
00:28:23
Speaker
So if you have this thrombosis, the chance of stroke can go up.
00:28:28
Speaker
Then you can look at your coagulation panel.
00:28:33
Speaker
And I want you to also pay attention to D-dimer.
00:28:36
Speaker
Trends in D-dimer matter.
00:28:40
Speaker
Single D-dimer value could be useless.
00:28:45
Speaker
Trends can help you.
00:28:47
Speaker
So when you then look at the patient together, then you can optimize managing and balancing that bleeding risk with the hemolysis, with the thrombosis.
00:28:59
Speaker
And I think we can talk about it a little bit more with each device, but I think that's the overall way I look at those three issues.
00:29:08
Speaker
Perfect.
00:29:09
Speaker
Let's talk about troubleshooting like the different devices.
Troubleshooting MCS Devices
00:29:13
Speaker
And I know that there may be a long list of complications or troubleshooting situations, but I wanted just to focus on maybe one or two relevant situations that are common with the different devices.
00:29:27
Speaker
So maybe we can start with the impella and just tell us, I mean, what are some of the things that as an intensivist we have to be aware of for potentially troubleshooting?
00:29:38
Speaker
So first with the impeller, you want to know, is it a left-sided or the right-sided device?
00:29:45
Speaker
And then the next one is to figure out, is it the impeller CP system?
00:29:50
Speaker
That's the femoral.
00:29:51
Speaker
Or is it the impeller 5-5 system?
00:29:54
Speaker
That's the axillary.
00:29:57
Speaker
And to briefly overview from the first talk, it essentially is a pigtail catheter that is venting the left ventricle and releasing the vented blood right over the aortic valve.
00:30:13
Speaker
So the signs of migration could include like, you know, you have a sudden drop in device flow, your changes in hemodynamics,
00:30:25
Speaker
And the impeller, the AIC is pretty smart.
00:30:27
Speaker
It will tell you if there's small position, but at the end of the day, it's a machine, right?
00:30:34
Speaker
So you want to be able to interact with it in a meaningful way.
00:30:39
Speaker
The way when I go to the bedside, the way I look for device migration is not when it is migrating.
00:30:47
Speaker
In the morning, what did we look for to see if it is working properly?
00:30:52
Speaker
Step one for me, I look at the motor current, which is the green line.
00:30:57
Speaker
As long as it has a nice pulse at all, like that signal, you know that there is a pressure difference in two chambers.
00:31:03
Speaker
And my test tube method of teaching is it's suctioning blood from the LV and putting it in the aorta, right?
00:31:10
Speaker
So the second step then is how much is it doing that?
00:31:14
Speaker
And that's the P value.
00:31:15
Speaker
If it is a P7, then it is a higher amount of suctioning that is coming from the LV.
00:31:23
Speaker
Then I look for the flow.
00:31:25
Speaker
Okay, with that P7, how much flow am I getting at baseline in the morning, let's say, and it says 3.8.
00:31:30
Speaker
You know, like, okay, that's good.
00:31:33
Speaker
Now I want to look at the two other waveforms, which is the white one, which is the LV signal, and the red flow, that is the aorta signal.
00:31:43
Speaker
Now remember, the LV signal, which is the
00:31:48
Speaker
is less than P4, not because it doesn't see it, it's just it's not as accurate, okay?
00:31:55
Speaker
But if it is more than P4, it's actually going to give you what is going on in the LD at the bottom, which is the diastolic pressures, okay?
00:32:05
Speaker
And if it has a nice waveform and then you have the aorta, then you know that, hey, at P7, I'm getting this much flow and my LVEDP has been okay and I'm not getting any diastolic suctions.
00:32:18
Speaker
And my aorta waveform is showing you what my pressure there is.
00:32:22
Speaker
So things are going well.
00:32:24
Speaker
Now, if you suddenly have a sign of migration, it could be that both the red and the white are over each other.
00:32:34
Speaker
For instance, if the red waveform starts looking like the LV waveform, then you know that the device is too far in and it needs to be pulled back.
00:32:44
Speaker
Conversely, if you lose the LV waveform and suddenly it's over the aortic valve, you know that the cannula has been moved too far out, right?
00:32:59
Speaker
your inability to support the patient because there is a sudden drop in flow because that's how he's being supported.
00:33:06
Speaker
There is a native aortic valve in there, and this kind of an axial flow pump moving in and out, which rarely happens, is beyond just, oh, it's a small position, it needs to be corrected.
00:33:20
Speaker
It could cause injury.
00:33:24
Speaker
So it's an urgency, okay?
00:33:26
Speaker
Okay.
00:33:27
Speaker
Like you never leave a patient with aortic insufficiency, right?
00:33:31
Speaker
Because that patient is a surgical severe AI, is the surgical emergency.
00:33:35
Speaker
It's the same thing.
00:33:37
Speaker
You could have a surgical emergency on your hand if you ignore these warnings.
00:33:42
Speaker
So immediately, the way you manage is I want to confirm the position.
00:33:47
Speaker
Let me get my pocus.
00:33:48
Speaker
Let me get my x-ray.
00:33:50
Speaker
Let me get the team ready and whoever it is.
00:33:53
Speaker
Now, each team may work independently, but you need to be able to, for instance, if it's a surgeon, hey, this is what I'm seeing.
00:34:00
Speaker
These are the waveforms.
00:34:02
Speaker
Here is the transthoracic view.
00:34:05
Speaker
We have everything ready and then we will probably need to either pull it in or pull it out.
00:34:10
Speaker
Number two, remember again that if you're at P7 and all of this is happening, you may need to drop the impeccable flow, right?
00:34:19
Speaker
P, because otherwise your pump would be harmful.
00:34:23
Speaker
Number two,
00:34:24
Speaker
you need to be ready to take over for the hemodynamics because you have had the privilege of this patient being supported on the pump you have not needed to use inotropes and you know your uh you know your pressures so if there is sudden decompensation sudden flash pulmonary edema sudden inability to support the patient then you need to go back and have everything ready whether it is access to a central line that you have removed
00:34:52
Speaker
or whether it is having the ventilation be on standby.
00:34:56
Speaker
Very rarely do you need it.
00:34:58
Speaker
I mean, you can easily take over, put some, if things are that bad, use some BiPAP support, but it's the ability to rescue that defines MCS critical care, right?
00:35:10
Speaker
So that's how I would look at it for the impeller in terms of device migration for the left side device.
00:35:17
Speaker
What about the right-sided devices as the RP Flex is in the market, RP Impella?
00:35:23
Speaker
You know, the RP Flex and the RP Impella, and I think that's something that should come even more naturally to MCS critical care physicians because it's essentially you just have a SWAN, right?
00:35:35
Speaker
And the SWAN is a Theranostic device.
00:35:38
Speaker
It's giving you therapeutic, in this case, with the RP Flex, and it's giving you true diagnostic measures, right?
00:35:46
Speaker
So similarly, you're looking at the same thing is that if you have sudden drop in device flow, did it migrate down?
00:35:53
Speaker
Does it need to be repositioned?
00:35:56
Speaker
And always get comfortable with the alarm overview on the console because the console has built in the ability to kind of help.
00:36:05
Speaker
Hey, you know, you'll need to push it back, pull it in and kind of navigate along with that.
00:36:13
Speaker
That's for the Impelda, Sergio.
00:36:14
Speaker
And now when you go into Vino-Arterial ECMO, I think VA ECMO, we already talked about it in the first part of the conversation about Harlequin syndrome.
00:36:25
Speaker
Really, in terms of things to look out for are, do you have an oxygenator failure?
00:36:32
Speaker
Do you have cannula problems?
00:36:34
Speaker
And managing it is where is your cannula?
00:36:37
Speaker
Do you have like, you know, IBC appropriate drainage?
00:36:41
Speaker
Does it need to be readjusted?
00:36:44
Speaker
And the best time to readjust cannulas for VA ECMO, especially with the venous limb is at the time of cannulation, right?
00:36:51
Speaker
The arterial really gives you issues.
00:36:53
Speaker
I mean, it's a small cannula.
00:36:55
Speaker
The 17th French, it stays there.
00:36:57
Speaker
But, and you can manage the complications of bleeding and ischemia.
00:37:02
Speaker
The number one thing for VA ECMO is the leg.
00:37:06
Speaker
Right?
00:37:07
Speaker
That catheter that, you know, some places, because, you know, it's a very short run, it doesn't need an anti-grade, so you need to watch the leg.
00:37:18
Speaker
Some of the best practices have been you could use NEARS, you know, tissue oximetry to pick it up earlier, or you do the anti-grade and every single day you go touch the leg and you make sure that the compartment pressures are okay.
00:37:34
Speaker
It's scary that when you can save a patient from AMI, cardiogenic shock with VAF more, and then you lose the legs for more reasons than one, right?
00:37:44
Speaker
Because it could have been a potentially preventable condition.
00:37:48
Speaker
You look for signs for poor flow, hematomas, a sudden drop in blood pressures in veno arterial, like more remember you have anticoagulated patient.
00:37:59
Speaker
that have been recently intervened on.
00:38:02
Speaker
So RP hematomas are not going to show up on your bedside POCUS.
00:38:06
Speaker
So you do need to have imaging and access to, hey, let me see what the hemoglobin is.
00:38:12
Speaker
Let me see if I need to quickly go down and see, make sure that he's not bleeding.
00:38:16
Speaker
So those are the for the cannula and RP bleed.
00:38:20
Speaker
Oxygenator failures, you need to look for increasing transmembrane pressure gradients and decreasing oxygenation and obviously divisible clots.
00:38:30
Speaker
And the management is, you know, it's a multidisciplinary effort to just replacing the oxygenator as soon as possible.
00:38:38
Speaker
The third device that I wanted to talk about was, I think, and Sergio put down for Tandem Heart.
00:38:46
Speaker
Now, Tandem, made by Levanova, is no longer on the market.
00:38:51
Speaker
But you want to know about this because there may be some patients that you may use the cannulas in the Tandem configuration.
00:39:00
Speaker
So a left-sided Tandem Heart is a cannula that is deployed in the femoral vein
00:39:07
Speaker
and it is transversing that into right atrium, across the pre-F4, into the left atrium, suctioning blood, oxygenated blood, taking it back to a centrifugal pump outside the body, so pericorporeal, and then giving it in the aorta.
00:39:24
Speaker
So this is a centrifugal pump.
00:39:26
Speaker
Compared to an axial venting device, right, that's the impeller, that's an axial pump intracorporeal.
00:39:35
Speaker
This is a pericorporeal device.
00:39:37
Speaker
So let's say that the patient has severe mitral stenosis and severe pulmonary hypertension, and you want to decompress before you take them for the MVR.
00:39:47
Speaker
An impella is not going to work because, you know, it's mitral stenosis.
00:39:50
Speaker
The blood didn't even make it into the ventricle.
00:39:53
Speaker
So with this device, our team, Dr. Carr, is our lead and basically has shown that you could actually decompress the left atrium.
00:40:09
Speaker
And you don't need an oxygenator because these patients already have the oxygenated blood being removed, right?
00:40:16
Speaker
So what are some issues that can happen?
00:40:19
Speaker
Remember, there's no suture holding this cannula in.
00:40:22
Speaker
So when the patients move, literally the cannula can get dislodged.
00:40:26
Speaker
So typically these patients are bed bound.
00:40:29
Speaker
We don't ambulate them.
00:40:32
Speaker
We used to intubate.
00:40:34
Speaker
We keep them all extubated mostly now.
00:40:36
Speaker
The second group of patients this could help is your ventricular septal defect patients.
00:40:41
Speaker
We published on that.
00:40:43
Speaker
And the issues for you to monitor are
00:40:48
Speaker
Basically making sure that the cannula has not migrated.
00:40:51
Speaker
And it's very easy for you to see that because the blood that was very bright red.
00:40:56
Speaker
Now, if it is in the right atrium, it's going to become very dark and the patient will become immediately hypoxemic, right?
00:41:03
Speaker
Because now you're giving...
00:41:05
Speaker
deoxygenated blood straight into the aorta.
00:41:08
Speaker
So if that happens, you need to go down on the pump flow immediately.
00:41:12
Speaker
And one way to rescue them if they need the support, obviously, is you can splice an oxygenator in and convert that into a veno arterial ECMO.
00:41:21
Speaker
Okay.
00:41:23
Speaker
What about balloon pump?
00:41:25
Speaker
Now, balloon pump is one of our counterpulsation devices.
00:41:32
Speaker
It will be here for a long time.
00:41:35
Speaker
Sudden loss of augmentation and alarms, I think a lot of you know about it.
00:41:40
Speaker
Very rare to have balloon rupture, but signs could include blood in the catheter, loss of augmentation and not working properly.
00:41:48
Speaker
So you want to remove the balloon pump and just consider alternative support.
00:41:52
Speaker
And in terms of improper timing, there's multiple cheat sheets online for teaching you guys signs of early inflation, signs of late inflation, early deflation and late deflation so that you can synchronize them with the cardiac cycle.
00:42:12
Speaker
And the best way to learn more about the balloon is when you go to the bedside
00:42:17
Speaker
looking at it and then with you know if there's any alarms actively managing those alarms that's that's for those four devices in terms of how do we look at it at the bedside Sergio perfect and we'll try to include some links to online and resources for the improper timing of the intra-aortic balloon pump and another obviously other references but thanks for
00:42:46
Speaker
for going over those because I think that for many intensivists who are not as used to working with these patients, the alarms and these problems can be quite daunting.
00:42:56
Speaker
And even though obviously it requires a team effort, just understanding what is happening to our patients and who we need to call can be very, very helpful.
00:43:05
Speaker
So I really appreciate you going over those in detail.
Weaning and End-of-Life Considerations
00:43:09
Speaker
The next topic as we close, I wanted to talk about is kind of how do you move forward with the care of these patients on MCS?
00:43:17
Speaker
We talked about in part one, a little bit about, and you alluded to it a little bit when we were talking about management, about instances when we might need to upgrade the amount of support.
00:43:29
Speaker
So if they're on an intracuric balloon pump and go to another type of device, or if they're an impella,
00:43:36
Speaker
upgrade to an Impala 5 or to a VA ECMO.
00:43:39
Speaker
But what I wanted to talk a little bit more and hear from you in more detail, Bindu, was about weaning versus withdrawal.
00:43:47
Speaker
And first, maybe talk about weaning a patient from temporary mechanical support.
00:43:52
Speaker
If you could share with us some pearls and pitfalls.
00:43:59
Speaker
So...
00:44:01
Speaker
One of the things that I look at the, I mean, the pearls and fitfalls are, I think the more you do, the better you get.
00:44:09
Speaker
There's no question.
00:44:10
Speaker
But looking at it as a process, you have supported the patient, you have rescued the patient.
00:44:18
Speaker
It's similar to a ventilator, right?
00:44:20
Speaker
You intubate a patient, you leave them at 100%.
00:44:23
Speaker
You never leave them at 100%.
00:44:24
Speaker
You go just enough support.
00:44:26
Speaker
Some people may go to 50 or 60%.
00:44:29
Speaker
So gradually reducing support while monitoring hemodynamics and managing the clinical status is a daily, multiple times a day, ongoing process.
00:44:41
Speaker
That's the best pearl I can give you.
00:44:43
Speaker
You don't walk in the room, make a plan, and leave the room and assume that it will take care of itself.
00:44:49
Speaker
It's a daily thing.
00:44:51
Speaker
And always be prepared for, obviously, rapid re-escalation as you do it.
00:44:56
Speaker
And then, but to get there, we need to know what are the criteria for weaning.
00:45:03
Speaker
So each device is dependent upon what is the etiology on the patient.
00:45:07
Speaker
The patient, for instance, that had a RP flex placed because the patient has an RCA infarct is a whole different strategy for when you would wean.
00:45:19
Speaker
Maybe that patient had already been taken to the cath lab and we are just waiting for the RV function, the native function to improve, the pulsatility to improve before you take that RV ad out.
00:45:29
Speaker
Similarly, a balloon patient, you know, we typically go down in support and then if their native hemodynamics are good, great.
00:45:37
Speaker
The Impella, the console will give you as you're coming down on the p-value, what's happening to the cardiac output.
00:45:45
Speaker
Once if you have the swan and you know that, you know, if your VO2, the oxygen delivery is fine, then, you know, you can start weaning.
00:45:53
Speaker
The best pearl is end organ function.
00:45:57
Speaker
As you are weaning this support, remember the first time we talked about how you can have a hemodynamic problem to go to a hemometabolic problem, then that hemometabolic problem, are you worsening?
00:46:08
Speaker
Are you getting it better?
00:46:09
Speaker
So if your AST, ALT are getting worse, if your AST, ALT are getting worse,
00:46:15
Speaker
then you know that you have a hemo metabolic problem that you have not rescued and now you wanna DC the device and that's gonna get worse.
00:46:26
Speaker
let's say because of decompression.
00:46:29
Speaker
Let's say you were AKI, and now that AKI is progressing.
00:46:35
Speaker
So there's another hitting age that there may be endorgan dysfunction.
00:46:40
Speaker
So I think on a daily basis, the best pearl I can give you is by assessing with hemodynamics plus echocardiogram with adequate endorgan perfusion,
00:46:54
Speaker
then you know that the patient is ready to wean, provided you're going back into the room multiple times to ensure that process that you have in your mind, you're able to quickly rescue for rapid re-escalation.
00:47:12
Speaker
So what are some of the indications that you need to go upgrade immediately?
00:47:17
Speaker
If you are inadequate support with the current device, progression of the disease and the complications that you can't manage with the current support, then you have to.
00:47:25
Speaker
And for instance, you have a balloon and the balloon may be upgraded to an impeller and you put in a 5.5 or an impeller and the RV is taking a hit.
00:47:35
Speaker
And then you may need to add a right-sided device or the patient is in Sky E extremis, PEA about to happen, Udobe ECMO, and then you de-escalate the same way.
00:47:47
Speaker
So escalation and de-escalation, I think, are always this highway that you're going back and forth on.
00:47:55
Speaker
And that's the reason that I think as an intensivist that has a good eye on things with cardiology and CV surgery, navigating those waters becomes very important.
00:48:06
Speaker
And so as in terms of, you know, looking at these patients, the best pearl I can give you is the sense of urgency.
00:48:16
Speaker
Because urgency for us is a lot more clearer than urgency for other fields.
00:48:23
Speaker
So I think it's helpful to be a pain sometimes.
00:48:27
Speaker
What are your plans?
00:48:29
Speaker
When are we taking the patient to the OR?
00:48:32
Speaker
And in our team, it's the other way around too, because I joke with that, everyone is an intensivist, our CV surgeons, our heart failure docs.
00:48:41
Speaker
So it's really nice to witness that growth, because if you grow
00:48:45
Speaker
If you literally grow older together in your MCS critical care units and you have this team, then you have cross trained each other.
00:48:52
Speaker
Right.
00:48:53
Speaker
They they have trained you and you've trained them.
00:48:56
Speaker
So that's those are the best pearls I can give you guys.
00:48:59
Speaker
Perfect.
00:49:00
Speaker
And obviously, you talked about urgency, but some patients, we might have put them with a bridge to decision, and the decision might be that there is no other therapy and they're not progressing.
00:49:13
Speaker
Any comments on considerations for the intensivist on when withdrawal of a mechanical device is in place, recognizing that the patient is likely to die?
00:49:27
Speaker
So...
00:49:30
Speaker
Out of everything that we've talked about between this talk and the previous, I think this is the best role for the intensivist is recognizing and coming to a conclusion with the team.
00:49:47
Speaker
What we are doing is not working.
00:49:50
Speaker
AMI cardiogenic shock continues to have a high mortality rate.
00:49:54
Speaker
We need to develop these devices to rescue patients, but we owe it to the technology for MCS so that you don't use the device on a patient that it doesn't work on.
00:50:12
Speaker
And when that state is reached, we owe it to the patient that we give them a good death.
00:50:22
Speaker
I think...
00:50:25
Speaker
my mentors of the past, I've noticed it's not what they do at the bedside with utmost competence.
00:50:32
Speaker
I'm like inspired and in awe of, but it's the commitment to the patient to see that they're not suffering that makes them a wholesome physician.
00:50:45
Speaker
And I think we are really aptly suited to kind of navigate those waters
00:50:54
Speaker
and ensure that we communicate because when you're in the forest it's very difficult to see the big picture inside but hey we have had him on maximal support for x number of days i've talked to the family just as you have but they may not be telling you but they don't want to proceed with this and i think ensuring palliative care involvement and actually as we're about to
00:51:21
Speaker
published in terms of how few of patients actually have palliative care involvement in cardiogenic shock.
00:51:28
Speaker
And I think that's because the ownership, the ICU teams do it themselves.
00:51:34
Speaker
But I think sometimes it's good to share your mental bandwidth with other colleagues because you're only one person and you may go into the room for 40 minutes and discuss this, but the other team may have 40 minutes to just discuss that single point.
00:51:51
Speaker
So we do get palliative care involved.
00:51:54
Speaker
In fact, we have it as a dashboard.
00:51:57
Speaker
How many times have we called palliative care on ECMO patients, on WAD patients?
00:52:02
Speaker
And we try to engage with our colleagues on that.
00:52:06
Speaker
Because it's not about palliative care.
00:52:09
Speaker
It's not just utilization, right?
00:52:11
Speaker
Because we can't measure if we have taken time out as a huddle and ensured that somebody...
00:52:18
Speaker
has had their goals of care discussed in a meaningful way, but at the end of the day, we owe it to the patient and their family that their passing is as painless as possible and with the team at the bedside.
00:52:34
Speaker
So I think that's the withdrawal pearl that I want to share.
00:52:39
Speaker
Perfect.
00:52:40
Speaker
And I think that we had a very, I think, comprehensive discussion of many, many aspects of MCS management in the ICU.
00:52:50
Speaker
And you're already a pro on the podcast, Bindu, and you know we would like to finish on a note that really digs into your wisdom as a whole, as a whole physician, not only as an expert, obviously, in critical care and MCS,
00:53:06
Speaker
So would it be okay if we ask some questions not related to the clinical topic?
00:53:11
Speaker
Yes, yes, yes.
Personal Insights - Music and Work-Life Balance
00:53:12
Speaker
So last time we spoke, we talked about books and that I want to ask you now about music.
00:53:18
Speaker
So, and I'm old school, Bindu, I still play vinyl.
00:53:24
Speaker
So I think of music and albums.
00:53:26
Speaker
But if you were stranded on an island or you were isolated for some sort of new infection like COVID, God forbid, what music, album or artist would you want to have with you?
00:53:40
Speaker
Um, so I came here when I was about 15.
00:53:47
Speaker
So I think somehow the music of my teenage years, you know, coming of age in India really calms me.
00:53:57
Speaker
And that's, um, this, I mean, he sings now, but A.R.
00:54:01
Speaker
Rahman is a musician, a director, a
00:54:06
Speaker
And he has thoroughly, like, I think, between when I was like 10 and 15, changed the way Indian Bollywood music.
00:54:18
Speaker
And Tollywood is the place in India that I'm from, which is Andhra Pradesh.
00:54:22
Speaker
And he has changed that.
00:54:24
Speaker
So...
00:54:25
Speaker
If I was stuck on an island, I think I would probably just ping Rahman and say, hey, dude, you know, what are you doing?
00:54:34
Speaker
Bring your team over.
00:54:37
Speaker
We have an intensivist group here.
00:54:39
Speaker
Perfect.
00:54:40
Speaker
And he can play the music for us.
00:54:42
Speaker
Beautiful.
00:54:43
Speaker
And one of the reasons why I love to ask these questions is because it's a way of learning about new things.
00:54:47
Speaker
And I have not been exposed to this music, but we put a link in the show notes and I definitely will check it out.
00:54:53
Speaker
So thanks for sharing that, Bindu.
00:54:55
Speaker
The second question is, could you share something that you have changed your mind about over the last couple of years?
00:55:05
Speaker
I think I have changed my mind about the importance of work-life balance.
00:55:11
Speaker
I truly, because my dad was a physician, I really believed that relentless dedication and long hours were the keys to success and like true, true professional satisfaction.
00:55:21
Speaker
And I still believe it because Dr. Carr, Dr. Baila Patel, these people that work day and night like to really do what they do.
00:55:32
Speaker
But I've also noticed that they do take some time and they just do their rest in different ways.
00:55:37
Speaker
But that it is incumbent upon me and a team to pursue our own hobbies and pursue our own time with loved ones if we were to last in that hallway.
00:55:50
Speaker
And I say that metaphorically.
00:55:54
Speaker
Like really, truly, because I look at this hallway that I've been in in 11 years, MCS hallway, right?
00:56:00
Speaker
If I need to exist in that hallway with my infinite energy and love for patients, for colleagues, and I keep wanting to give this energy back.
00:56:11
Speaker
What charges me is, yes, these are patients that do better.
00:56:14
Speaker
That charges me.
00:56:16
Speaker
But so do my roses.
00:56:17
Speaker
So do my travel.
00:56:18
Speaker
So do meeting new people through teaching avenues, such as I'm doing here when I go to conferences.
00:56:25
Speaker
I think sustained productivity and creativity will only come with balance.
00:56:32
Speaker
And I think after COVID, I think I speak with all of you, for all of you,
00:56:39
Speaker
that there has never been a better time to focus on our own mental and physical health so that we lead like truly fulfilling professional lives to create that mastery in our brain of whatever niche you want to create.
00:56:59
Speaker
Like Sergio, like you have this handle on everything I see you.
00:57:04
Speaker
But to love it and to give that energy, I think you need to have a creative outlet.
00:57:10
Speaker
And it may be different for you guys, but that's, I love gardening, travel, spending time with my children and mentoring and like young minds.
00:57:21
Speaker
I love being surrounded by youthful idealism.
00:57:25
Speaker
There are kids around us that are like, just want to change the world.
00:57:29
Speaker
And I love being inspired by them.
00:57:32
Speaker
They teach me every day, including the fact that you cannot give hard exams that you did not teach in class.
00:57:39
Speaker
So I teach med school.
00:57:40
Speaker
So I've been taught that.
00:57:41
Speaker
So I've become a better teacher.
00:57:45
Speaker
But that's that's my that's what I think is that I've definitely changed my mind about that.
00:57:51
Speaker
Awesome.
00:57:52
Speaker
Thanks for sharing that, Bindu.
00:57:53
Speaker
And I think very pointed and you're right.
00:57:57
Speaker
I'm a big student of philosophy and there is a Latin phrase that says memento mori.
00:58:04
Speaker
which really means remember you will die.
00:58:07
Speaker
And the point being in terms of balance is that if you knew you were going to die tomorrow, what are the things that you want to make sure you do today?
00:58:14
Speaker
Right?
00:58:14
Speaker
Yes.
00:58:14
Speaker
Part of that is professional for sure.
00:58:16
Speaker
It's our impact and how we grow, but there are so many other dimensions in our lives.
00:58:23
Speaker
And I think it's different for each person, but to find the time and create the space to enjoy that for each person, I think is very important.
00:58:30
Speaker
So that's a great, a great message.
00:58:33
Speaker
The final question to end Bindu would be, what would you want every intensivist listening today to know?
00:58:40
Speaker
Could be a quote, a fact, or just a thought.
00:58:45
Speaker
I think I just got back from SIO that was in DC and I stayed in Gettysburg with my children because we went camping for a day or hiking in Cattoptic Mountains.
00:59:01
Speaker
And I think Abraham Lincoln, there was a quote in one of the museums and it said, you know, in the end, it's not the years in your life that count.
00:59:11
Speaker
It's the life in your years.
00:59:13
Speaker
And I think as intensivists of a particular generation that has gone through COVID, I think we are living our lives a thousand times over.
00:59:25
Speaker
I tell people that I'm in my bonus round of life.
00:59:29
Speaker
Right.
00:59:30
Speaker
We've been called to duty.
00:59:32
Speaker
We have delivered that care.
00:59:34
Speaker
And now we are in the bonus round.
00:59:36
Speaker
I think we can make a profound difference with our skill set, with our competence and the compassionate dialogue.
00:59:47
Speaker
And there's no question it's stressful and uncertain environments in the ICU.
00:59:52
Speaker
But I think if every day we wake up and go, you know, I'm just going to do the very best job today.
00:59:59
Speaker
And tomorrow may not happen or it's not promised.
01:00:02
Speaker
But for today, I can look at myself in the mirror and go, okay, decent job.
01:00:08
Speaker
Good job.
01:00:10
Speaker
Perfect.
01:00:11
Speaker
I think that's a great place to stop, Bindu.
01:00:14
Speaker
I want to thank you again for sharing your expertise with us, for sharing your precious time with us.
01:00:20
Speaker
And I look forward to having you back on the podcast soon.
01:00:24
Speaker
Thank you so much, Sergio.
01:00:26
Speaker
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01:00:30
Speaker
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01:00:36
Speaker
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01:00:40
Speaker
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