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Management of Complications Post-Cardiotomy
17 Plays1 year ago
In this episode, Dr. Sergio Zanotti discusses the management of critically ill patients after cardiac surgery, focusing on the clinical management of two important complications: hemorrhage and cardiac arrest. He is joined by Dr. Christopher Noel, a critical care attending at Cooper University Healthcare. Dr. Noel is also an assistant professor of medicine at Cooper Medical School of Rowan University and associate program director for the Critical Care Medicine Fellowship and the Clerkship Director for Critical Care Medicine Clerkships for Medical Students.
Additional resources:
American Association for Thoracic Surgery (AATS) TSRA Primer- Critical Care:
https://www.aats.org/tsra-primer-post-operative-bleeding
https://www.aats.org/tsra-primer-cardiac-arrest-post-cardiotomy
The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery. Ann Thorac Surg 2017: https://pubmed.ncbi.nlm.nih.gov/28122680/
Society of Cardiovascular Anesthesiologists clinical practice improvement advisory for the management of perioperative bleeding and hemostasis in cardiac surgery patients. J of Cardiothoracic and Vascular Anesthesia 2019: https://pubmed.ncbi.nlm.nih.gov/31613811/
Music mentioned in this episode:
The Outsiders. By Eric Church: https://bit.ly/4fHvxkp
Collective Soul. By Collective Soul: https://bit.ly/3AzLcUd
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Transcript
Introduction to 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.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Managing Postcardiotomy Complications
00:00:33
Speaker
In today's episode of Critical Matters, we will discuss the medical management of postcardiotomy complications in the ICU.
00:00:40
Speaker
Specifically, we will discuss the management of postcardiotomy hemorrhage and postcardiotomy cardiac arrest.
00:00:47
Speaker
Our guest is Dr. Christopher Noll, a critical care attending at Cooper University HealthCare.
00:00:51
Speaker
Dr. Noll is an assistant professor of medicine at Cooper Medical School of Rowan University.
00:00:56
Speaker
He's also the Associate Program Director for the Critical Care Medicine Fellowship and the Clerkship Director for Critical Care Medicine, Clerkship for Medical Students.
00:01:05
Speaker
He's an excellent clinician and clinical educator who has a special interest in critical care echocardiography, extracorporeal support, simulation training, and medical education.
00:01:16
Speaker
We had the opportunity to talk with Chris about temporary pacemakers not too long ago, and I encourage our listeners to check out that episode if they have not heard it.
00:01:25
Speaker
Chris, welcome back to Critical Matters.
00:01:29
Speaker
Thanks for having me, Sergio.
00:01:30
Speaker
Really excited to be here to talk about this.
00:01:32
Speaker
I know this is a topic that...
00:01:36
Speaker
is close to your practice but also to your area of interest.
00:01:39
Speaker
You work with the fellows and getting them ready to take care for CT surgery patients, which obviously are an important part of many ICUs in terms of the patient population today and a growing number of our patients.
00:01:55
Speaker
A lot of times these patients sail through, but sometimes they're difficult.
00:01:59
Speaker
And I think understanding some of the issues related to the management of complications, such as the ones we're talking about today, I think is very important for all our clinicians at the bedside in the ICUs.
Structured Approach to Post-Surgical Complications
00:02:12
Speaker
So why don't we start with just telling us your perspective of why these two complications, post-op bleeding and post-op cardiac arrest, are important topics for bedside critical care clinicians to know.
00:02:26
Speaker
Absolutely.
00:02:27
Speaker
You know, so I think for anyone who's has the privilege of working with postcardiotomy, cardiac surgery patients, they can be, like you said, very straightforward and their care can be very protocolized.
00:02:40
Speaker
But when things go bad, it's important to have an approach and perspective on what we need to do.
00:02:47
Speaker
And
00:02:48
Speaker
like many things that we are there for us providing supportive care as a critical care provider can really make a difference in their post-surgical outcomes and particularly with post-operative bleeding and cardiac arrest we're often the ones there at the bedside the surgeon may be in the OR or maybe we're there at night and they're not around and so recognizing
00:03:11
Speaker
When we're dealing with a problem that needs to go back to the operating room or taking an appropriate intervention in the most severe cases, particularly a cardiac arrest, is really critical and can make a difference to try to save that patient.
00:03:28
Speaker
Excellent.
00:03:29
Speaker
And as we were discussing pre-recording, post-op bleeding is extremely common, right?
00:03:35
Speaker
Not everybody has to go back to the OR, but we'll talk about that.
00:03:38
Speaker
So it's something that intensivists should be very familiar with managing and how to communicate appropriately with our colleagues in the OR.
00:03:47
Speaker
Cardiac arrest is not as common, but quite dramatic, obviously, and interventions that are done in a time-sensitive manner can make the difference.
00:03:55
Speaker
So I think that these both are very important, and I think it's a nice combination to discuss together today.
Causes and Management of Post-Operative Bleeding
00:04:03
Speaker
Let's start with post-cariotomy bleeding or hemorrhage, and maybe you could just give us a little bit of an overview of the causes of post-op bleeding to introduce the topic.
00:04:15
Speaker
Yeah, I think for those who are familiar with managing any type of surgical patient or those who care for any type of surgical patient, whenever there's bleeding, whether that be we see it through the drains that they have in place or otherwise,
00:04:29
Speaker
We always want to think about, is that due to a medical cause, general coagulopathy, or is it due to a surgical problem that needs operative fixation, such as tying off a vessel or fixing something that is going wrong?
00:04:46
Speaker
So when we think about that in terms of medical bleeding, really we're looking at why might they be coagulopathic, and for patients who've undergone cardiac surgery, there's a lot of reasons for that.
00:04:59
Speaker
You know, one is that they may have gotten blood product resuscitation in the OR related to expected operative bleeding.
00:05:08
Speaker
And so, you know, if that wasn't necessarily balanced resuscitation, they may lead to clotting factor depletion.
00:05:16
Speaker
Many of these patients will undergo cardiopulmonary bypass support during their operation.
00:05:21
Speaker
And just contacting with that bypass circuit can cause things such as fibrinolysis or platelet dysfunction.
00:05:28
Speaker
Those who are on cardiopulmonary bypass are heparinized, and while they do receive protamine postoperatively, that may have been not enough or too much.
00:05:40
Speaker
Other things that they come out with often is they may have acidosis, either respiratory or metabolic, that can contribute to the coagulopathy.
00:05:49
Speaker
They're hypothermic after a cardiopulmonary bypass.
00:05:53
Speaker
And really any other common reasons that we can think about for any other patients.
00:05:57
Speaker
And so those are the things that when I see a patient who's having, you know, I'm concerned about bleeding, I want to make sure that I'm addressing those while also keeping in mind if this could be a surgical issue.
00:06:09
Speaker
Because when we think about patients going back to the operating room, it's very easy for us to, as the intensivist, say, oh, yeah, they should just go back to the operating room.
00:06:18
Speaker
But in the surgeon's mind, they really want to address anything that's non-surgical up front because these patients who go back to the OR, if they don't need to go there, ultimately that's worse for the patient, more invasive, and they have worse outcomes.
00:06:33
Speaker
And I think another important aspect to mention, Chris, is that most of the patients have medical bleeds, right, that can be resolved.
00:06:42
Speaker
Of those who we think have a surgical bleed and go back to the OR, there's still a big number that they don't find anything, right?
00:06:49
Speaker
So like you said, I mean, having that systematic approach to make sure that we take the ones we need to go and can deal with the other ones in the ICU is very important.
00:07:01
Speaker
Yeah, absolutely.
00:07:01
Speaker
Absolutely.
00:07:03
Speaker
What are some of the risk factors for postcardiotomy bleeding?
00:07:08
Speaker
Yeah, so some of the things you want to think about is just in general, you know, how frail was the patient going into the OR?
00:07:16
Speaker
Things such as age, female sex can predispose, as associated, preoperative anemia, preexisting coagulopathy, any other major comorbidities they may have, lower BMI.
00:07:32
Speaker
And then if someone has chronic renal failure, the coagulopathy is associated with that.
00:07:37
Speaker
And then in intra-op, you want to think about, you know, how long was the procedure?
00:07:43
Speaker
How complicated was it?
00:07:44
Speaker
How much blood product resuscitation did they get?
00:07:47
Speaker
Did they have a longer cardiopulmonary bypass run?
00:07:51
Speaker
So thinking on the order of, you know, more than three hours is quite a very long run and puts a patient at risk for more complications.
00:08:03
Speaker
In terms of, and I think it's important to recognize those, and as you have an effective handoff with anesthesia and CT surgery, recognize, like you said, the patient and operative factors that might predispose somebody for more bleeding, but it's also important to recognize that there are sometimes patients who might not have any of these risk factors who do end up having a surgical bleed and a bleed, and that is always something that can be a surprise for everybody.
00:08:29
Speaker
But when the patient comes to the ICU, what are the things that you monitor?
00:08:34
Speaker
How do you approach the initial care of those patients, trying to figure out if they're bleeding at all?
00:08:41
Speaker
Absolutely.
00:08:41
Speaker
You know, most cardiac surgery patients, when they come out, they're going to have a number of drains, mediastinal as well as pleural.
00:08:48
Speaker
So in most cases, the initial suspicion for bleeding will be quite obvious.
00:08:53
Speaker
You'll see bloody output coming out of these drains.
00:08:56
Speaker
And just having output from the drains is not necessarily a bad thing.
00:09:00
Speaker
That's why they're there to help to evacuate those spaces as coagulathes are corrected.
00:09:07
Speaker
But you really want to keep an eye on what's the color of the blood that's coming out.
00:09:11
Speaker
Is it very bright red thin?
00:09:13
Speaker
Or is it having clots and seeming like it's starting to resolve?
00:09:19
Speaker
You also want to pay attention to particularly to the tempo of bleeding.
00:09:23
Speaker
And if you look in the literature, read guidelines on what rates of bleeding to consider when you might want to think about a surgical bleed versus a medical bleed, you'll see varying recommendations and ranges.
00:09:42
Speaker
One example, some, quote, 400, greater than 400 cc's.
00:09:48
Speaker
In one hour, greater than 300 cc per hour over two to three hours, or greater than 200 cc per hour over four hours.
00:09:57
Speaker
But it comes down, I think, more to what's that tempo and how is it escalating or de-escalating?
00:10:03
Speaker
You know, if you have a patient who's
00:10:07
Speaker
bled 150 cc's from their chest tubes within 10 minutes of coming out of the OR, that's something that should raise your eyebrows and be very concerned and be at the bedside watching what's coming out.
00:10:17
Speaker
And is that resolving very quickly?
00:10:20
Speaker
Or is that something that's continuing?
00:10:22
Speaker
And that can, you know, you want to pay attention and be very on top of that patient.
00:10:28
Speaker
And I think an important reminder for our listeners is to always add context to numbers.
00:10:36
Speaker
So a patient who you expected no bleeding at all might have a 200 an hour bleed, and that might be very concerning.
00:10:43
Speaker
versus a patient who maybe was on pavolopathic, on Plavix, and had a very wet post during surgery, and you've been giving blood products, maybe the surgeon is willing to tolerate a little bit longer because he thinks that eventually that will be corrected.
00:10:59
Speaker
So I think that also making sure that you evaluate a given number in the context of the patient you're treating is always very important.
00:11:07
Speaker
Yeah,
Clotting Assessment and Blood Product Resuscitation
00:11:08
Speaker
absolutely.
00:11:08
Speaker
And as I'm sure we'll probably touch on later, but it's a lot of this comes down to discussion with your surgeon, with the cardiac anesthesiologist can give you a lot of insight onto what they expect and what you're watching for in the post-operative setting.
00:11:23
Speaker
Perfect.
00:11:25
Speaker
I wanted to ask you, go ahead.
00:11:28
Speaker
Some of the things I wanted to mention is, you know, in all these patients, we're getting immediate postoperative labs.
00:11:34
Speaker
So that may give us a clue in terms of our traditional markers of coagulopathy, INR, PTT, et cetera, as we would for any patient who are concerned about bleeding.
00:11:43
Speaker
But some places also, wherever you work, they may also protocolize the use of things such as Rotem or Teg.
00:11:50
Speaker
And that can be particularly helpful if that's available at your center for understanding where, if this is a medical coagulopathy that's leading to their bleeding, how you might best address that and resuscitate them.
00:12:03
Speaker
And is the use of Rotem and Teg increasing, you think, Chris?
00:12:07
Speaker
I don't have a lot of experience with that in our ICU.
00:12:11
Speaker
Yeah, I think it's variable.
00:12:12
Speaker
I think that there's increasing interest.
00:12:15
Speaker
You know, if you look at the literature around, you know, Rotem or Teg, a lot of the studies are kind of before and after in cardiac surgery patients.
00:12:27
Speaker
And the ones that I'm familiar with have shown reduced bleeding or reduced need for transfusion or reduced total overall bleeding, reduced need for transfusion when it's used in a protocolized fashion.
00:12:40
Speaker
So I think there's a number of centers who use it and whether that's used kind of upfront, we see it in the OR, here's what our rotem is, we check it in the ICU, or whether it's ad hoc, this patient is bleeding, therefore we're going to check it, you know, really comes down to the center.
00:12:56
Speaker
And I think it's worth discussions if that technology is available to you to think with your surgeons and anesthesiologists on how that's best to use.
00:13:04
Speaker
Excellent.
00:13:05
Speaker
And obviously, we talked about getting the basic labs.
00:13:10
Speaker
Any imaging that you usually use for these patients?
00:13:13
Speaker
I know that these patients usually get an x-ray immediately post-op, but what are things that you're looking for?
00:13:20
Speaker
Yeah, so x-ray is...
00:13:22
Speaker
standard, that's going to be very helpful.
00:13:27
Speaker
The most powerful thing, I think, from an x-ray for a patient that's bleeding is, do I see, am I concerned for maybe a pleural effusion that might suggest a retained hemothorax?
00:13:38
Speaker
So while I'm seeing blood coming out of the drains, maybe it's not adequately evacuating that space, and that would be more concerning for me than if I did not see a pleural effusion.
00:13:48
Speaker
all of it, what I'm, all of what the bleeding is occurring is actually coming out of the chest strains.
00:13:52
Speaker
That would be more reassuring to me.
00:13:55
Speaker
The other imaging we can think about is, is echo.
00:14:00
Speaker
However, these patients have had sternotomy or other incision, and they are often very difficult to get our classic trans thoracic views on to really get an assessment of, you know, where is,
00:14:16
Speaker
Do we see collecting blood, whether that be, or do we see collecting blood essentially around the cardiac structures in the kind of where we would typically think of as the pericardial space?
00:14:30
Speaker
And another question I had, Chris, is we talked about chest tube output, right?
00:14:35
Speaker
Something that we were monitoring and obviously the tempo and the consistency or the aspect are both important indicators of potential issues.
00:14:46
Speaker
But what about the situation where somebody is having a profuse output and all of a sudden it stops?
00:14:53
Speaker
Yeah, that's certainly a concerning thing.
00:14:56
Speaker
And while you might think, well, that's good, they've stopped bleeding, the major concern there would be that your chest drains are no longer evacuating those potential spaces and that the patient actually has not stopped bleeding but is now collecting blood.
00:15:11
Speaker
in the pleural space around the paracardial space.
00:15:18
Speaker
And the major concern there would be that you cause compression and can lead to tamponade and cardiac arrest.
00:15:24
Speaker
That's, I guess, I mean, where you want to make sure that the chest tubes are patent and people talk about milking the chest tube, making sure that it's straining, correct?
00:15:34
Speaker
Yeah.
00:15:36
Speaker
Absolutely.
00:15:36
Speaker
And one of the first things that our critical care nurses will do as the patient comes out is making sure that we're stripping those chest tubes.
00:15:46
Speaker
And if you have a patient that's bleeding, we're not only paying attention to the tempo, but we want to make sure that those chest chains maintain patency.
00:15:53
Speaker
So we want more blood to come out.
00:15:55
Speaker
We want to strip those tubes in order to keep that coming out while we address any potential coagulopathy and resuscitate the patient.
00:16:04
Speaker
So we talked about what to monitor, how to evaluate what's going on when they first arrive.
00:16:09
Speaker
Can you talk about your therapeutic approach?
00:16:11
Speaker
What's the strategy that you take with these patients?
Reversible Causes of Bleeding
00:16:15
Speaker
Yeah, so...
00:16:18
Speaker
As we mentioned, we're really trying to address any potentially reversible causes before we commit to this as a surgical bleed.
00:16:25
Speaker
And one of the things that we can think about is if it's due to maybe diffuse kind of oozing coagulopathies, can we decrease any potential spaces?
00:16:35
Speaker
Can we apply essentially pressure on those bleeding sites?
00:16:39
Speaker
So two ways we can think about doing that is, you know, because this is interthoracic, we can try to increase our interthoracic pressure either through application of increased PEEP or increased tidal volume or both.
00:16:55
Speaker
And I think, you know, worth discussing with your surgeons kind of what they prefer or, you know, if they have a preference on one or both of those.
00:17:06
Speaker
So if I have a patient who's bleeding very quickly, if I see that the chest tube output is significant, I'm going to increase my PEEP and it may go up on my tidal volume to try to decrease that potential space and tamponade any sort of oozing coagulopathy type bleeding.
00:17:26
Speaker
So step number one, I mean, just, I mean, obviously some maneuvers you can do to just decrease the available space for blood to accumulate and put some pressure, right?
00:17:35
Speaker
Which is the first thing that we would do in any bleeding that we see is put pressure on, right?
00:17:39
Speaker
So I think that's a good analogy.
00:17:41
Speaker
What are some of the common things that you might overlook that are common in these patients and unrelated to the cardiac issue itself that we need to correct out of the OR?
00:17:53
Speaker
Yeah, I think so.
00:17:55
Speaker
Almost all of them come out cold, so making sure you get them on a bear hug or other external warming device if that's the case.
00:18:02
Speaker
You know, looking at your traditional labs, correcting any platelet deficiencies, say INR, fibrinogen, and then looking at your ionized calcium level.
00:18:16
Speaker
I think it's, and then also your acid-base status, so acidosis can contribute to the coagulopathy as well.
00:18:24
Speaker
I think one of the things is always keep in mind with these patients is that your traditional coagulation markers may not fully reflect the coagulopathy that may be going on.
00:18:33
Speaker
Perhaps they have platelet dysfunction.
00:18:36
Speaker
And so, you know, being...
00:18:40
Speaker
I think more aggressive about giving factors such as cryo, giving factors such as FFP and platelets in the patient who's significantly bleeding, despite of what your lab values see.
00:18:52
Speaker
Because as we know, with someone who's significantly bleeding, those numbers may lag, but also even if they are accurate to that specific time point, they may not fully reflect a coagulopathy that's present.
00:19:06
Speaker
And do you have any guidelines that you use?
00:19:09
Speaker
Obviously, this is going to be mostly, I mean, consensus, expert opinion, I presume, and not studied in randomized trials, but are there targets that you're trying to keep with these regulation and CBC parameters?
00:19:26
Speaker
Yeah, so generally I think, again, I want to stress the importance of discussing with your surgeons kind of what they prefer and also communicating with them in these settings because they may have an idea of something that we're going into the OR with or coming out of the OR with or just in general with their
00:19:44
Speaker
surgical practice.
00:19:46
Speaker
But certainly you want to keep your platelets above 50,000, possibly higher.
00:19:51
Speaker
INR, you know, let's try to keep it less than 1.5 and your fibrinogen above 150.
00:19:57
Speaker
But again, I think that
00:20:00
Speaker
Don't hang your hat on those values.
00:20:03
Speaker
Think about the overall picture and be suspicious for a coagulopathy that you can't recognize through just looking at those numbers or that they don't represent our time point now, which reflects ongoing blood loss and ongoing depletion of coagulation factors.
00:20:19
Speaker
Perfect.
00:20:20
Speaker
Any comments on correcting acidosis, Chris?
00:20:24
Speaker
Yeah, so, you know, I'm not aware of great literature to, you know, support that that's a huge difference maker, but the surgeons that I work with, they are, you know, in favor of using some bicarbonate to help to correct metabolic.
00:20:41
Speaker
acidosis coming out of surgery.
00:20:44
Speaker
One thing that is fairly common that we will do is if you see the patient has a respiratory acidosis or can compensate respiratory-wise, then you want to think about your minute ventilation on the ventilator increasing their respiratory rate to compensate until that is further corrected.
00:21:02
Speaker
And is there a role for recombinant factor 7?
00:21:06
Speaker
Is that something that people have used in this situation?
00:21:11
Speaker
Yeah, great question.
00:21:12
Speaker
So thinking about your patient who is bleeding and you're resuscitating them with various blood products, trying to address the coagulopathy, as we mentioned, if they're still bleeding and it's to the point where you're thinking, hey, this is not working, I may be thinking about going back to the OR, then I think it's worth the discussion with your surgeon about their preference for recombinant factor VII.
00:21:36
Speaker
So this is something that is published in the literature for use most validated in post-cardiac surgery to help to correct severe coagulopathies.
00:21:49
Speaker
It's really something that I would think about if you can't correct it with all of your usual measures, increasing the PEEP, tidal volume, resuscitation, correcting your acid-base status, correcting your hypothermia.
00:22:03
Speaker
It does tend to work in cases where, at least anecdotally for me, where cases are severe bleeding, which are not secondary to a surgical problem.
00:22:14
Speaker
And that's shown in some studies.
00:22:17
Speaker
They're not...
00:22:19
Speaker
beautiful randomized trials, but there is some improvement in bleeding with its use in cardiac surgery patients.
00:22:26
Speaker
But I think this is really important.
00:22:28
Speaker
You got to talk with your surgeon about this because it does carry a non-
00:22:34
Speaker
it's not an insignificant risk for thrombosis associated with its use.
00:22:39
Speaker
So we're talking on the order of 5%, and that can include stroke, MI, DVT, or intercardiac thrombus, or potentially your grafts from a CABG being occluded.
00:22:50
Speaker
And I think it will very much depend on the surgeon, whether that's something they want to consider or whether they would prefer just to take the patient back to the operating room.
00:23:02
Speaker
So I guess, I mean, it's a tool to have, but not to deploy lightly, right?
00:23:09
Speaker
I mean, obviously in conversation with your surgeon and my sense is that a lot of situations, the patient probably will go back to the OR before they do that.
00:23:17
Speaker
But it is important to have that in the back of our mind as an option.
00:23:22
Speaker
Right.
00:23:24
Speaker
So when does the patient go back to the OR?
00:23:25
Speaker
Obviously, that's, I think, like you mentioned at the beginning, Chris, it's easy for us as clinicians at the bedside, non-surgical clinicians, to always say, oh, they should just go back to the OR.
00:23:37
Speaker
But there's a lot that comes with that.
00:23:40
Speaker
And it's not always something that is successful.
00:23:43
Speaker
And when you take somebody back and you don't find anything, you wonder, well, maybe we wait a little bit longer.
00:23:47
Speaker
We would have saved, I mean, this patient a lot of grief, right?
00:23:51
Speaker
And reopening and all that that entails.
00:23:54
Speaker
So obviously, this is a surgical decision.
00:23:56
Speaker
But can you tell us a little bit more about how you see that?
00:24:00
Speaker
Yeah, I think I see it with one is do I feel like I'm addressing all the things that we talked about?
00:24:08
Speaker
Have I, you know, and that includes empiric blood product resuscitation.
00:24:13
Speaker
I've given platelets.
00:24:14
Speaker
I've given FFP.
00:24:15
Speaker
I've given fiberinogen.
00:24:17
Speaker
In the patient who I'm still able to support their hemodynamics, that's a patient I'm on the phone with my surgeon multiple times about whether we should go back to the operating room.
00:24:29
Speaker
The other scenario is someone who's just profoundly hematomically unstable and we're not able to keep up with the resuscitation.
00:24:35
Speaker
That may be someone we pulled the trigger earlier on going back to the OR rather than still trying to resuscitate at the bedside.
00:24:45
Speaker
I think I mentioned some numbers that are published or talked about in various textbooks and articles.
00:24:53
Speaker
They can give a guide, but it's really no replacement for what you're seeing at the bedside.
00:24:58
Speaker
What's the tempo over the last 10 minutes?
00:25:00
Speaker
What's the tempo over this 10 minutes for your chest tube output?
00:25:04
Speaker
How's the patient doing from a hematomagic standpoint?
00:25:07
Speaker
And I think one of the responsibilities that we have is communication with the surgeon, but also they're sometimes relying on us to make the case that, hey, we've done everything else that we can think of or all the things that we discussed doing.
00:25:23
Speaker
And it's still not working.
00:25:24
Speaker
And it's the middle of the night.
00:25:25
Speaker
And I need you to come in and take the patient to the OR because I think we're running out of options.
00:25:30
Speaker
And we're going to end up in a much more dangerous and emergent situation, you know, potentially leading to things like cardiac arrest.
00:25:38
Speaker
And since you mentioned cardiac arrest, and before we go on to that topic, when is a bedside ICU emergent thoracotomy indicated?
00:25:47
Speaker
Yeah, so this is really with the surgeon and the patient's stability to get out of the ICU to the operating room.
00:25:56
Speaker
I think any surgeon will tell you that they prefer to operate in the OR where they have all their tools, the nice sterile environment, familiar equipment, etc.
00:26:08
Speaker
But if that patient is not stable enough and
00:26:10
Speaker
there's high suspicion for a surgical cause of bleeding, then an ICU emergency re-exploration would be indicated.
00:26:19
Speaker
And then also, it sounds like we'll talk about pretty shortly about whether if they do have a cardiac arrest, that would be another time when that would be considered.
00:26:30
Speaker
Is there anything else you want to add on the management of post-op bleeding?
00:26:36
Speaker
We will definitely talk about communication interaction with itchy surgery as a whole topic a little bit later.
00:26:41
Speaker
But anything else you want to add on this particular topic before we move on to cardiac arrest?
00:26:49
Speaker
No, I don't think so right now.
00:26:50
Speaker
I think we've covered some, you know, we've covered it.
Cardiac Arrest Post-Surgery: Causes and Protocols
00:26:54
Speaker
And I think, again, the take-home message for me here, Chris, is this is a common problem.
00:27:01
Speaker
Most patients don't have to go back to the OR, but I think it's important for us to have a systematic approach of correcting the things that we can correct.
00:27:09
Speaker
making sure that we're addressing the general things, the quagulopathy, that we're in close contact with our surgical team and communicating and portraying to them exactly what's going on at the bedside so that the best decision can be made for the patient.
00:27:26
Speaker
And there is a subset of patients that will go back to the OR.
00:27:30
Speaker
And I think that trying to figure out the timing of that in a time-sensitive way is what's really, really important for our patients.
00:27:40
Speaker
So you did mention that, obviously, bleeding that is not controlled can lead to a cardiac arrest.
00:27:46
Speaker
So let's talk a little bit about postcardiotomy cardiac arrest.
00:27:49
Speaker
And maybe we can start with the etiology of cardiac arrest postcardiac surgery.
00:27:55
Speaker
Sure.
00:27:55
Speaker
So obviously a scary thing.
00:27:57
Speaker
We don't want this to happen to our patients, but it is not that uncommon.
00:28:03
Speaker
Somewhere in the order of less than 1% to 8%, depending on which literature study you look at, we'll talk about post-cardiotomy, cardiac arrest.
00:28:14
Speaker
The most common etiology of that is going to be ventricular arrhythmias, V-FIV, V-TAC, followed closely by tamponade and bleeding.
00:28:27
Speaker
In addition to all the other typical causes of cardiac arrest that we can think about in a critically ill patient, but the big ones that really pertain to the surgical patient is going to be ventricular arrhythmias, blood loss,
00:28:43
Speaker
leading to profound hypovolemic shock and tamponade from the situations we talked about where that blood is not adequately evacuated from the space and then can collect and cause that.
00:28:58
Speaker
Obviously, these patients are usually out of the OR and in the ICU.
00:29:04
Speaker
They're usually intubated.
00:29:06
Speaker
They usually have an sternotomy and have pacing wires very frequently.
00:29:12
Speaker
So the management...
00:29:14
Speaker
of the cardiac arrest has some nuances right that are particular and I think are important for us to review I know that the Society of Thoracic Surgeons many years ago had a expert consensus post-cardic and surgery management of these cardiac arrests could you just walk us through that protocol and how you think about it mentioning what is the same what is different that we need to be paying attention to
00:29:40
Speaker
Yeah, absolutely.
00:29:41
Speaker
And I encourage the listeners to refer to the 2017 article published by STS because I think it's very informative and talks through this in much more detail.
00:29:50
Speaker
But really what this group was trying to do was to highlight what are the common reasons that these patients arrest and also balance.
00:30:01
Speaker
And so to address those very rapidly, which our standard ACLS algorithm may not focus on.
00:30:09
Speaker
to one, address those, but two, to balance addressing the problem with the risks of doing things like CPR or administering high-dose epinephrine empirically in these patients.
00:30:24
Speaker
And so with that, there's a few differences with resuscitating these patients in the event of a cardiac arrest from our standard cardiac arrest patient.
00:30:35
Speaker
So one is if they, and a lot of it has to do with the, or it all has to do with the rhythm.
00:30:41
Speaker
So what they recommend is if your patient has a V-fib arrest, the difference between AHA and the STS guidelines is that they advocate to delay CPR for up to a minute.
00:30:55
Speaker
and deliver three sequential shocks without intervening CPR.
00:31:01
Speaker
So how does that look?
00:31:03
Speaker
Patient goes into ventricular fibrillation, immediately deliver defibrillation,
00:31:10
Speaker
If they're not converted to sinus and, again, perfusing, immediately deliver another defibrillation.
00:31:16
Speaker
And then, again, if they still remain in BFIP, immediately another defibrillation prior to proceeding with BLS or closed chest compressions or usual resuscitation and then administration of amiodarone, which they advocate to give through a central line, which most of these patients will have.
00:31:36
Speaker
So that's one.
00:31:37
Speaker
We'll talk about how this progresses once you've started BLS.
00:31:41
Speaker
But the other is if you have a patient in asystole, what they advocate for is
00:31:50
Speaker
not an insignificant portion of these patients will have pacing dependence coming out of the OR.
00:31:56
Speaker
And so if they have epicardial wires, they again recommend that we can delay CPR for up to a minute while trying to pace these patients with their epicardial wires or transcutaneously if those are not available prior to initiating our usual closed chest compressions.
00:32:14
Speaker
And then finally, if the patient is in PEA, they do advocate for immediate administration closed chest compressions, but they also recommend that if the patient is paced and you're seeing this PEA as a paced rhythm on the monitor to briefly turn off the pacemaker to make sure that they're not in V-fib underlying that.
00:32:36
Speaker
So in those categories, V-fib, acetylsy, and PEA, again, trying to address common things right up front with slight delay in initiation of closed chest compressions if possible, but again, initiating those within a minute, don't delaying those beyond a minute if maybe you're gathering equipment or it's just not happening, go ahead and start that.
00:33:03
Speaker
And all these things are to try to address common reasons that the patient can go into a cardiac arrest while also preparing what's important to prepare for a re-sternotomy.
00:33:14
Speaker
And the reason that we're thinking about a re-sternotomy and why they recommend proceeding with that if these are not addressing the issues is the common reasons for cardiac arrest in the post-article patient.
00:33:25
Speaker
So thinking about bleeding, thinking about tamponade.
00:33:30
Speaker
So the...
00:33:34
Speaker
So to summarize that, again, we're starting with our patient who goes into cardiac arrest.
00:33:40
Speaker
We are having slight nuanced approach to various rhythms.
00:33:45
Speaker
while at the same time in parallel we're getting prepared to perform a restrenotomy to open up that chest in order to address those potential complications.
00:33:56
Speaker
So if I'm the code leader and I'm called into the room and a patient who has a post-cardiac surgery who's just had a rest, I'm immediately asking for equipment
00:34:08
Speaker
The recommendation from STS is that that happens within five minutes of the arrest for patients within 10 days of their surgery.
00:34:20
Speaker
Beyond 10 days, we're thinking that they may have had adhesions, and that's a discussion that would be completely up to the surgeon, but generally not recommended beyond 10 days.
00:34:31
Speaker
So I'm the code leader.
00:34:33
Speaker
I'm asking for that equipment.
00:34:35
Speaker
As I'm quickly addressing the rhythm,
00:34:39
Speaker
administering three sequential shocks for V-fib prior to chest compressions if that is immediately available.
00:34:46
Speaker
I'm looking at the patient acetyl and attempting to pace them.
00:34:50
Speaker
And for the patient who looks like they're in PEA but they have a paced rhythm on the monitor, I'm briefly turning off that pacer in order to just make sure that they're not in V-fib underneath.
00:35:00
Speaker
And then I'm proceeding with my usual resuscitation with chest compressions while preparing for a re-sternotomy in discussion with the cardiac surgeon over the phone.
00:35:13
Speaker
Chris, go ahead.
00:35:14
Speaker
I was going to ask you a little bit, two specific questions about, like you said, the usual CPR.
00:35:20
Speaker
So I wanted to hear a little bit about airway and ventilation, if you could give some tips to the team.
00:35:25
Speaker
Oh, yeah.
00:35:27
Speaker
And then also, if you had any recommendations for the actual chest compressions.
00:35:32
Speaker
Absolutely.
00:35:32
Speaker
So when we think about, certainly these patients in cardiac arrest could have other reasons for that, all the usual things we want to think about.
00:35:42
Speaker
One of the recommendations that the STS guidelines have is that, similar to what we do for patients who are in cardiac arrest for other reasons, is removing them from the mechanical ventilator and
00:35:56
Speaker
applying zero PEEP and the rationale for that is that one potential cause of arrest may be attention pneumothorax and they want to obviously mitigate that but also if the patient is severely hypovolemic from bleeding, they want to try, their recommendation is to use zero PEEP in order to improve your venous return in any way you can so that maybe you can regain a ROSC and regain a perfusing pressure.
00:36:22
Speaker
Also, you know, certainly we do this for, you know, all of our other aquatic arrests, but administering 100% oxygen as we would normally do.
00:36:33
Speaker
What about epinephrine?
00:36:36
Speaker
Great question.
00:36:37
Speaker
So the guidelines, really what they say is they do not recommend routine administration of epinephrine unless guided by, quote, a senior clinician.
00:36:48
Speaker
And this recommendation that they make based on the argument that if this is a rapidly reversible condition, they want to avoid the risk of severe hypertension that can occur after receiving epinephrine, thinking about that leading to potential catastrophic bleeding.
00:37:08
Speaker
And that also is...
00:37:11
Speaker
one of the reasons why they make the recommendation that if you can address these other causes such as defibrillation, pacing the patient, to delay chest compressions for up to a minute.
00:37:23
Speaker
because in patients with postcardiotomy and a sternotomy, there are a number of case reports and described injuries that can occur with closed chest compressions, as you might imagine from that sternum, which has just recently been opened, and the heart, which has just been operated on.
00:37:42
Speaker
So just, again, these are balancing the need for perfusion,
00:37:47
Speaker
addressing common reversible causes and the potential risks of doing our usual ACLS algorithm with closed chest compressions and epinephrine leading to surgical complications and bleeding.
00:38:02
Speaker
Is there any particular care or recommendations for the actual chest compressions?
00:38:11
Speaker
Yeah, so same rate as we would normally do.
00:38:14
Speaker
So, you know, they advocate for 100 to 120.
00:38:18
Speaker
They also advocate for watching.
Re-sternotomy in Cardiac Arrest
00:38:21
Speaker
Many of these patients will have an arterial line in place.
00:38:24
Speaker
So watching your systolic blood pressure, and they recommend that we target above a systolic blood pressure of 60 in their guidelines.
00:38:32
Speaker
I would say that as a practice for the people who are actually doing CPR, while this isn't really addressed in the guidelines, is one thing that we often do at our institution is use something such as maybe a board in order to protect potentially the person who's doing the chest compressions.
00:38:49
Speaker
So put that board over the stern.
00:38:51
Speaker
them and then they compress on the board in order to you know avoid if they're perhaps they end up with a fractured wire from their sternotomy we don't want that provider to become injured have a you know stick injury related to that can you comment on a how to manage the intra-aric balloon pump in case a patient has one of those which is not uncommon in some of these patients
00:39:17
Speaker
Yeah, so the guidelines advocate to change these to pressure trigger mode.
00:39:23
Speaker
So why is that?
00:39:24
Speaker
So a lot of our balloon pumps may trigger off the EKG in order to time the inflation and deflation of the balloon.
00:39:31
Speaker
If you have a patient who's in cardiac arrest, as you've probably seen when we do cardiac arrest, if you look at the monitor while CPR is ongoing, it can show, it may look like the patient's in ventricular tachycardia.
00:39:46
Speaker
They may have other artifacts on their EKG, which could cause the bloom pump to...
00:39:53
Speaker
inflate and deflate inappropriately and not actually provide any perfusing displacement of blood within the aorta.
00:40:03
Speaker
So if you do it based on pressure, that allows it to synchronize with the chest compressions that are happening and potentially improve perfusion to the heart and other organs.
00:40:14
Speaker
And like you mentioned earlier, Chris, obviously the goal is to get return of spontaneous circulation, stabilize the patient, which a lot of times, I mean, the outcomes for these patients is obviously, especially when it's immediately post-op, is good because commonly there are things that we can reverse post-surgery.
00:40:33
Speaker
But if you're not getting ROSC, the next step within five minutes is re-sternotomy.
00:40:41
Speaker
Can you talk a little bit about emergency re-sternotomy?
00:40:45
Speaker
Yeah.
00:40:45
Speaker
So again, this is the recommendation is to try to address things such as severe bleeding.
00:40:51
Speaker
So trying to get hemorrhage control or tamponade by just opening that chest, you may be able to relieve that pressure and relieve the tamponade and get ROSC.
00:41:01
Speaker
So, you know, they're, they advocate, and you should think about it for resuscitating these patients in cardiac arrest is getting all the equipment, getting the personnel ready right away from the start, being prepared to do that within five minutes.
00:41:13
Speaker
How does that look is,
00:41:15
Speaker
Essentially, you're doing your resuscitation.
00:41:19
Speaker
If we're not getting ROSC, then we will be prepping the chest
00:41:24
Speaker
and then opening through the midline sternotomy.
00:41:28
Speaker
And the guidelines acknowledge that, you know, it's not always that the surgeon is immediately available at bedside 24-7.
00:41:36
Speaker
And so they advocate for any trained personnel to do this.
00:41:39
Speaker
And this could be an advanced practice provider, another physician.
00:41:43
Speaker
They even advocate for, you know, cardiac and even
00:41:47
Speaker
you know, bedside nurses who've been appropriately trained to do this.
00:41:51
Speaker
And they recommend that protocols be set up within your hospital in discussion with your surgeons about what that looks like.
00:42:00
Speaker
I think from, you know, our, at my institution, that practice would be a discussion with the surgeon on the phone, whether that would be something that we would proceed with.
00:42:09
Speaker
I know there are other institutions that that's already in place, that that is what is going to happen and doesn't necessarily need, you know, the discussion with the surgeon over the phone, that that's the right thing to do in the setting of the arrest.
00:42:24
Speaker
Any tips?
00:42:25
Speaker
Obviously, this is something, like you said, that people need to be trained for, but it's not exclusive domain of surgeons.
00:42:31
Speaker
So CT surgery intensivist or people who have training can get to do this.
00:42:40
Speaker
But any tips or any suggestions?
00:42:42
Speaker
I think that the take-home message that I take as somebody who's not trained to do these is
00:42:46
Speaker
is that if a patient under my care arrests, I start getting ready immediately, getting things ready for the person who can do it, but also obviously immediate communication with the surgical team.
00:43:00
Speaker
Yeah, absolutely.
00:43:01
Speaker
I think those are the key things.
00:43:02
Speaker
And once it's identified who would be performing that and that's indicated, essentially the procedure involves, well, so the procedure involves essentially opening up the incision along the sternum and then cutting the sternal wires and removing them with a needle driver.
00:43:20
Speaker
And that alone should allow the chest to open up to some degree.
00:43:27
Speaker
But the next steps would involve putting in a sternal retractor, opening up that space, using sterile suction to suck at any hematoma or manually evacuating any hematoma that you may see, and then performing, getting control of any surgical bleeding you see, as well as performing internal cardiac massage.
00:43:48
Speaker
And so...
00:43:50
Speaker
how this is achieved, it really doesn't require that many steps.
00:43:54
Speaker
And the guidelines advocate for a very simple kit to have ready for this, not a full sternotomy tray with many surgical instruments, which can be overwhelming in the setting of an emergency or certainly someone who's not a surgeon who's asked to perform this.
00:44:11
Speaker
And so they recommend really just having a scalpel, wire cutters,
00:44:17
Speaker
needle driver, sternal retractor, and a suction device within that kit.
00:44:21
Speaker
And that's really all you need to perform a re-sternotomy and potentially get rust just from relieving tamponade or evacuating hematoma.
00:44:34
Speaker
Any aid for echocardiography, bedside ultrasound, or TEE in these situations, or usually just because of the time frame you're focusing on other things?
Echocardiography in Post-Surgical Complications
00:44:46
Speaker
Yeah, I think it comes down to the resources you have available.
00:44:49
Speaker
I think all the patients who are bleeding and there's concern for potentially retained blood products, I think it's always worth trying a trans-thoracic bedside echo.
00:45:01
Speaker
There's no harm in doing that, but often you're not going to get great pictures and not get great images.
00:45:07
Speaker
And the other thing that you can, the pitfall is that you can also have localized tamponade where only one cardiac
00:45:14
Speaker
hematoma that you really can't see on transthoracic images.
00:45:19
Speaker
So I think while something to do and try, don't rely fully on that and have a high index of suspicion for tamponade because you can get fooled and not actually see those focal collections.
00:45:36
Speaker
Now, TE is much more powerful in that sense because you're not limited by your poor trans-thoracic windows in the post-cardiotomy setting.
00:45:45
Speaker
And you can get more detail on perhaps where that hematoma or if there's a focal collection may be.
00:45:53
Speaker
So I think in settings where you have that resource immediately available, I think it's worth deploying it early on, not necessarily after the patient arrests
00:46:05
Speaker
to try to get an idea of what we're dealing with.
00:46:07
Speaker
Are we seeing all the blood product from this bleeding patient being evacuated, or is there retained hemothorons that we need to be particularly concerned about and getting on the phone sooner with our surgeon that this actually needs to go back to the operating room?
00:46:22
Speaker
Excellent.
00:46:23
Speaker
So as we close, Chris, obviously this is all a very collaborative enterprise.
00:46:30
Speaker
And I think it's a growing trend that intensivists are helping care for post-op cardiac patients.
00:46:38
Speaker
We talked in other episodes of the podcast about the increasing growth of mechanical circuitry support, a different population, but definitely we're seeing, I think, a growth of cardiac patients in our ICUs.
Communication and Collaboration with Surgery Teams
00:46:54
Speaker
So like anything where there's multiple stakeholders and parties involved, I think communication is the key to providing the best care possible.
00:47:06
Speaker
So I wanted to close with maybe some comments on your side in terms of how to optimize communication and collaboration with CT surgery.
00:47:15
Speaker
Maybe start with some of the common pitfalls that we should avoid.
00:47:20
Speaker
Absolutely.
00:47:20
Speaker
I think some common pitfalls would be, one, to just go kind of do something on your own without, you know, discussing with them or discussing.
00:47:32
Speaker
you know, having them involved in that decision, because these really, if you think about these, the surgeons, they're taking these patients into their office, bringing them in often for, for planned, you know, semi-elective surgeries.
00:47:45
Speaker
And so they, they really invest an incredible amount in,
00:47:49
Speaker
I think it's even difficult for us to imagine kind of being in their shoes in these settings.
00:47:53
Speaker
So they should really be involved with discussion about what's going on.
00:47:58
Speaker
So I think, you know, certainly do that.
00:48:00
Speaker
It's a huge pitfall to not do that.
00:48:03
Speaker
And I think it can only, you know, lead to trouble.
00:48:06
Speaker
You know, in that regard, the...
00:48:11
Speaker
I think what's helpful is to establish relationships with them.
00:48:15
Speaker
And then as they kind of understand what your capabilities are, your knowledge base, then you can have a framework within to practice and also have them know what's going on.
00:48:34
Speaker
What are some of the pearls that you have learned over the years in terms of optimizing the collaboration interaction with CT surgery, which ultimately is most important for our patients, but I think it's also a great way to have a better practice, right?
00:48:48
Speaker
The better we work with those around us, the more satisfying our job is.
00:48:52
Speaker
You mentioned some of the things, but anything else you want to add as a pearl?
00:48:57
Speaker
Yeah, I think setting expectations or understanding what expectations are is helpful.
00:49:02
Speaker
I think it gives us more freedom to act and take care of the patients and also can free us up from having to make phone calls in situations where we kind of know the next step and also letting the surgeon maybe get some sleep.
00:49:19
Speaker
So at our institution, one of the things we have is an escalation protocol.
00:49:22
Speaker
So if certain triggers are met,
00:49:25
Speaker
the surgeon will want a phone call.
00:49:27
Speaker
So let's say we're transfusing for a particular amount of blood product or we're escalating our vasopressor support significantly.
00:49:34
Speaker
That's a phone call that they want to have versus some lesser concerns.
00:49:39
Speaker
They trust our judgment and tact on that.
00:49:43
Speaker
So I advocate for setting those expectations early on.
00:49:52
Speaker
Yeah, and I think that's very helpful.
00:49:54
Speaker
And again, them getting to know you and understand what's going on.
00:49:59
Speaker
I mean, it's about building a relationship, right?
00:50:01
Speaker
And learning together, but also I think being very clear on when escalation is needed, what are the things that we should be managing, and it's an ongoing process.
00:50:13
Speaker
But
00:50:15
Speaker
I do believe that this is not going away from critical care.
00:50:17
Speaker
It's going to keep growing.
00:50:19
Speaker
And it's important for our listeners, wherever they are, if they're taking care of CT surgery patients, to build really a culture of growth at their institution where they collaborated with surgery.
00:50:30
Speaker
And I think that one of the things I would add, Chris, is that empathy on both sides is very helpful, right?
00:50:37
Speaker
Trying to understand, like you said, empathy.
00:50:39
Speaker
The surgeon meets the patient in their office.
00:50:42
Speaker
They say everything's going to be okay.
00:50:44
Speaker
They're measured by all these parameters that are publicly reported that we don't have.
00:50:49
Speaker
And I think recognizing a little bit of that as well is important.
00:50:53
Speaker
And again, the surgeon can also see our position that we're there when they're not there in the OR and making sure that they're also available and giving us the best support to obtain the best outcomes, which at the end I think is something that everybody can agree on.
00:51:08
Speaker
Yeah, absolutely.
00:51:09
Speaker
I think a lot of our patients in the ICU, particularly surgical patients, I think of them as we're helping provide a service for those surgeons, and I think we should always keep that in mind.
00:51:23
Speaker
Excellent.
00:51:24
Speaker
Well, this was a, I think, a fascinating discussion of problems that I'm sure a lot of our listeners have encountered.
00:51:31
Speaker
And we definitely will add some of the references you mentioned in the show notes.
00:51:36
Speaker
You've been on the podcast before, Chris, you know how we roll.
Personal Insights from Dr. Noll
00:51:39
Speaker
So we're going to talk about a couple of things that are unrelated to the clinical topic.
00:51:43
Speaker
Is that okay?
00:51:45
Speaker
Yeah, absolutely.
00:51:46
Speaker
So the last time you were on, we talked about books.
00:51:50
Speaker
So we're not going to talk about books today, but I'm curious to hear a little bit about your preferences or what has impacted you from a musical perspective.
00:51:59
Speaker
So the question is, what music or album, I'm a little bit of an old school, I like vinyl, and would you want to have with you if you were stuck on an island or we were back in the isolated for a new pandemic?
00:52:14
Speaker
Well, I think I'd pick being stuck on an island than a new pandemic, but, um, for sure.
00:52:19
Speaker
If I had, if I had to choose a, an album, I think, um, you know, one, one that comes to mind is the outsiders by Eric church.
00:52:29
Speaker
Um, some great songs on there.
00:52:31
Speaker
Talladega, like a wrecking ball.
00:52:33
Speaker
Um,
00:52:34
Speaker
So I enjoy that album and his work.
00:52:38
Speaker
The other might be the title album from Collective Soul.
00:52:43
Speaker
So Collective Soul by Collective Soul is another great album that I would like to have with me.
00:52:49
Speaker
And I have to admit that these are not on my radar and I'll have to pick them up and listen to them.
00:52:55
Speaker
So we were talking about this before we started recording.
00:52:58
Speaker
I think it just tells us that Chris is expecting I'm a grandfather, right?
00:53:02
Speaker
That's usually the difference in age.
00:53:05
Speaker
But definitely thanks for these.
00:53:07
Speaker
I mean, I will look into those.
00:53:11
Speaker
Second question is, could you share with us something you have changed your mind about over the last couple of years?
00:53:20
Speaker
You know, that's a tough one.
00:53:24
Speaker
I think, I mean, there's many things I'm sure the same amount about.
00:53:30
Speaker
Well, this may be
00:53:32
Speaker
an odd, odd answer, but, um, you know, I've, I've come around to using roller suitcases at the, at the airport.
00:53:39
Speaker
So I, um, was resistant and always wanted to, uh, to carry my duffel, but now I've come around to, uh, to using the roller suitcase and find them very convenient and helpful to get around.
00:53:50
Speaker
Wheels are powerful.
00:53:52
Speaker
They do move the world.
00:53:53
Speaker
So I think that that's something to, to, that you definitely have changed.
00:53:56
Speaker
And I think we've all gone through that transition at one point.
00:53:59
Speaker
Yeah.
00:54:01
Speaker
The last question, Chris, to close is, what would you want every intensivist listening to us to know?
00:54:07
Speaker
Could be a quote, a fact, or just a departing thought.
00:54:11
Speaker
Yeah, I think I have actually two things.
00:54:16
Speaker
One, I think I've realized in my practice it's never really about one piece of data.
00:54:23
Speaker
So I think it's easy whether you –
00:54:26
Speaker
read a paper or listen to a podcast or, you know, hear a learning point from someone about, you know, if I see this, then this is going on, you know, whether that be a value on your Swann-Gans catheter, a finding you have in your ultrasound.
00:54:43
Speaker
I think the
00:54:44
Speaker
my recommendation is, you know, don't always hang your hat on those things.
00:54:48
Speaker
It's about the whole picture and, uh, keep it in mind as a piece of data, but don't get, don't get fixated or stuck or on a soapbox about it because you'll, you'll be proven wrong or, um, you know, go down the wrong path with that.
00:55:01
Speaker
And then the same token is, I think it's really important.
00:55:04
Speaker
We listen to, you know, what the patient's telling us or what the family's telling us.
00:55:08
Speaker
Cause while it may be, uh,
00:55:12
Speaker
you know, not necessarily related to their condition.
00:55:15
Speaker
A lot of times their concerns or suggestions are very pertinent and they'll pick up on things that you don't necessarily see as someone who doesn't know them very well.
00:55:27
Speaker
Awesome.
00:55:28
Speaker
I think this is a perfect place to stop.
00:55:30
Speaker
Chris, always a pleasure to have you on the podcast.
Conclusion and Subscription Info
00:55:33
Speaker
Look forward to having you back soon.
00:55:35
Speaker
Thanks for sharing your expertise and being so generous with your time with our audience.
00:55:41
Speaker
Thank you so much for having me.
00:55:43
Speaker
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00:55:46
Speaker
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00:55:52
Speaker
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00:55:57
Speaker
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