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Rethinking arterial lines
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In this episode, Dr. Sergio Zanotti discusses arterial catheters in shock through the lens of the recently published EVERDAC trial. He is joined by Dr. Gregoire Muller, a critical care physician in the Department of Intensive Care Medicine and Resuscitation at the University Hospital Center of Orléans, Orléans, France. Dr. Muller is an accomplished clinician and researcher. He is the principal investigator/lead author of the EVERDAC clinical trial published in the New England Journal of Medicine.
Additional resources:
Arterial lines in the ICU: A call for rigorous controlled trials. CHEST 2014.
Noninvasive BP monitoring in the critically ill: time to abandon the arterial catheter? CHEST 2018.
Books mentioned in this episode:
Getting Things Done: The Art of Stress-Free Productivity. By David Allen.
Recommended
Transcript
Introduction to Critical Matters 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. 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. And now your host, Dr. Sergio Zanotti.
Use of Arterial Catheters in ICUs
00:00:33
Speaker
The use of an arterial catheter to invasively monitor blood pressure is common in the intensive care unit and is recommended for the treatment of patients with shock.
Everdeck Trial Overview
00:00:42
Speaker
In today's episode of Critical Matters, we will discuss arterial catheters in shock through the lens of the recently published Everdeck trial, entitled Deferring Arterial Catheterization in Critically Ill Patients with Shock and published late last year in the New England Journal of Medicine.
00:00:59
Speaker
Our guest
Meet Dr. Gregoire Mueller
00:01:00
Speaker
is Dr. Gregoire Mueller, a critical care physician in the Department of Intensive Care Medicine and Resuscitation at the University Hospital Center of Orleans in Orleans, France. Dr. Mueller is an accomplished clinician and researcher. He is the principal investigator and lead author of the Everdact Clinical Trial published in the New England england Journal of Medicine.
00:01:21
Speaker
Gregoire, welcome to Critical Matters. Hello. Thank you for having me, Sergio. I would like to start with a just a general a question about arterial lines for patients in shock. Is that dogma or evidence so far?
00:01:38
Speaker
Oh, before the Verdac trial, it was easier to to answer this question. and I think arterial line is tough.
00:01:56
Speaker
a little bit of dogma and evidence. They are very useful for ah blood pressure monitoring for blood sampling. I think we will discuss it later. And
Origins of Non-Invasive Monitoring
00:02:10
Speaker
and when i when i graduate in intensive care, it was ah very used to put arterial lines. So the There is not a lot of evidence that arterial lines could be useful, but how can we and monitor patients if we don't use arterial line? It was a question.
00:02:35
Speaker
Excellent. and And I probably trained even farther away from you back in time. And and I remember in one of our ICUs where we we really relied a lot on a point of care testing, everybody had an arterial line because we would sample them and try to figure out what was going on. But as you said...
00:02:54
Speaker
It's like many things in critical care. We do them because that's the way people before us did it, right? And it makes sense, but it's always interesting to the study. And that's one of the reasons why I'm so and attracted to the Everdark trial, because it's an example of an investigator-led study, initiated study that addresses something we do every day.
00:03:17
Speaker
Yet we have never really taken the effort and time to to study because it's hard. But tell us a little bit about what was the origin of the Everdeck trial in your mind as an investigator?
00:03:29
Speaker
So, the beginning was a trial from my colleague and mentor, Dr. Thierry Boulin. He was the head of the ICU, of my ICU, and he worked with Karim Lacan, located in North, in France, and Stéphane Hermann, who recently published in the New England the amykinel
Benefits and Drawbacks of Monitoring Methods
00:03:54
Speaker
study. and he's located in Tours. And ah the the three of them worked on non-invasive blood pressure monitoring. They published, I think it was in 2009, Anesthesia Analgesia, and
00:04:16
Speaker
ah ah first to the study evaluating the accuracy of non-invasive blood pressure monitoring to assess mean arterial pressure.
00:04:28
Speaker
And at the beginning, they showed that non-invasive blood pressure had a good accuracy to predict low MAP, I mean below 65 millimeters of mercury. And next, they performed multiple studies in arrhythmic patients, in who were under vasopressor also, and they always showed a good accuracy of and non-invasive monitoring to predict LOMAP. in the the middle of the 2010
00:05:11
Speaker
ah years ah I think it was Alan Garland published in Chests in Edito discussing the fact that we always use monitoring in the ICU because our previous colleague did it. For example, the pulmonary arterial catheter. And since we have a lot of publication now to avoid ah systematic monitoring of arterial pulmonary pressure, at the beginning we we put this kind of catheteria in a lot of patients. so
00:05:58
Speaker
It was a a story of first, evaluation of non-invasive blood pressure, and second, this editorial from Garland saying that b beware that a lot of things we do have not been evaluated yet, and when they are evaluated, the result is not always a good result.
Trial Design and Objectives
00:06:25
Speaker
In general, the pros of having arterial line are obviously we have we believe we have more accurate measurement of blood pressure minute to minute, whether it's very high or very low blood pressure, whenever we're using vasoactive drugs to raise or lower blood pressure that we as clinicians believe to be helpful.
00:06:46
Speaker
And also, you mentioned the blood sampling. But there's also, I guess, negatives to having arterial line, some of them from the patient perspective. Can you comment on some of those potential downfalls of having an arterial line in every patient?
00:06:59
Speaker
but Yeah, um about blood sampling, there is a lot of of paper demonstrating that in patient with an arterial line, when you when you compare patient with a line and patient without with the same gravity, it's the same severity. and The patient with the airline are exposed to more frequent blood sampling that can lead to anemia and ah the need for blood cell transfusion. So arterial line may expose blood
00:07:39
Speaker
to
00:07:42
Speaker
non-appropriate blood sampling anemia. There is ah also a risk of complications such as hematoma, pseudoaneurysm also, or infection. There is ah some data yeah that arterial line may be infected ah as well as ah CVC, for example.
00:08:10
Speaker
So that's a great example of unintended consequences. We do something because we we have the ability to do it easier, right? And we don't think about the impact it might have on patients. Not to mention that a patients probably don't find arterial lines when they're conscious and awake too cut too comfortable, right? They can cause also pain and and discomfort.
00:08:31
Speaker
And yeah. even though I guess a lower rate than central venous catheters, they can still get infected and are also a source of potential infection. So clearly something and to consider, right? and and And worth studying. So let's talk about the Everdeck clinical trial itself.
00:08:49
Speaker
What was the objective? And could you tell us about the design of the trial? Yeah, um the Everdac trial was designed to assess whether non-invasive monitoring using brachial cuff is non-inferior to arterial catheterization in a shock patients in terms of death at 28.
00:09:19
Speaker
So we compare two groups, the invasive group, and in the invasive group, the patient had to ah have arterial catheter inserted within the four first hours after the randomization and keeps the arterial line until day 28.
00:09:43
Speaker
eight except if there was futility criteria such as a very low dose of norepinephrine below 0.2. It was tartarate of norepinephrine, not the base of norepinephrine. So I mean 0.1 in ah American base norepinephrine. And in case of
00:10:22
Speaker
such as um palliative care, decision the medical decision of palliative care. Do you want me to reformulate the answer or it's okay for you? This is perfect.
00:10:35
Speaker
Okay. Okay. Go ahead.
00:10:40
Speaker
The inclusion criteria, we aim to include adult patient within the first 24 hours after ICU admission, having an acute circulatory failure. The acute circulatory failure was defined by low blood pressure, ah systolic blood pressure below 90 millimeters of mercury, or main arterial pressure below 65 and or the need ah for vasopressor and at least one sign of tissue hipoperfusion such as alteration of mental status, skin modeling, oliguria, elevated blood lactate below 2 and low central venous oxygen saturation.
00:11:30
Speaker
And the exclusion criteria were an invasive blood pressure value displayed by the monitor, the brachial cuff placement impossible in case the patient was under extracorporeal rumban oxygenation. If the patient required high dose of vasopressor, it's the sum of norepinephrine, tartrate, plus epinephrine above 2.5 micrograms per kilogram per minute. If the patient had a severe traumatic brain injury, was obese, or refused to participate. so the in Go ahead. Yeah. Go ahead.
00:12:13
Speaker
dean The intervention was in case the acute ecclotary failure occurred within the first 24 hours, the patient was run the may randomized with a stratification according ah the need for invasive mechanical ventilation. as The center and the vasopressor dose above are below 0.36.
00:12:41
Speaker
In case the patient was randomized in the indian non-invasive strategy group, and no arterial catheter was allowed until date in 28 or safety criteria and the safety criteria were inability to monitor of the monitor to display blood non-invasive blood pressure or pulse oximetry. The absolute need for arterial blood gas sampling after five consecutive failed arterial punctures attempts. The need for ECMO or the need for high dose of vasopressors above 2.5%.
00:13:24
Speaker
And the last, the need for high-risk surgery. In this case, the arterial catheter was allowed only during the time in the operating room and had to be removed within four hours after the surgery.
00:13:41
Speaker
And if the patient already had arterial catheter at time of randomization and was randomized in the non-invasive strategy group, the arterial catheter had to be removed within one hour after the randomization.
00:13:57
Speaker
In case the patient was randomized in the invasive strategy group, the arterial catheter had to be inserted quickly yeah within four hours and not removed until considered to be futile, such as low dose of norepinephrine without epinephrine and without hypoperfusion tissue signs or medical decision of palliative care.
Results and Patient Care Protocols
00:14:25
Speaker
Excellent. ri In terms of general patient care, could you comment on any hemodynamic protocols that were indicated? Was that left to the discretion of the treating clinicians? Because this this cohort was randomized, but obviously, for obvious reasons, it wasn't blinded. People could see where the arterial line was.
00:14:44
Speaker
Yeah, it's a very good question. Thank you. but to To be a pragmatic study, we did not provide algorithm or protocols to to manage a patient in acute circulatory failure. We left it at the physician decision.
00:15:05
Speaker
And in terms of outcomes, you mentioned the primary outcome was 28-day all-cause mortality between both groups, and this was designed as a non-inferiority trial. So the hypothesis was that non-invasive monitoring in patients with shock would be non-inferior in terms of this outcome to invasive monitoring, correct?
00:15:24
Speaker
Yeah, yeah, yeah. We decide to answer the question, it's really safe to monitor patients without an arterial line. We choose to use a day 28 mortality to to say, okay, you can use non-invasive blood pressure monitoring. The patient ah will will not die more often more often and than if you put an arterial line.
00:15:53
Speaker
Could you comment on some of the secondary outcomes? So the secondary outcomes were SOFA score fastcore and so fastco decrease and from the from 10 to five ah points in the the week after randomization. And it's the same in both groups.
00:16:16
Speaker
There were also and and ventilator free days, a number of ah renal replacement three days, sorry, vasopressor three days, the mean duration of ICU stay and the mean duration of hospital stay. We also recorded pain and discomfort in patients.
00:16:45
Speaker
We recorded also the number of ah blood samples in both groups. And that's it, think. and that's it i think In terms of the actual results, could we start by a description of the patient population, the number of patients, and then talk about the primary outcome and the secondary outcomes that you find most relevant?
00:17:13
Speaker
Okay, so we randomized 110 patients 60, 506 were randomized in the non-invasive group, 504 in the invasive group, two patients in the both groups were excluded because of concern issues.
00:17:37
Speaker
The population was a standard population of shock patients in ICU. The mean age was 66, 64 years old. Two-thirds of the population were male. The SOFA score was 10 points. mean SOFA score was 10 points in both groups.
00:18:01
Speaker
and the ah the um main cause of acute circulatory failure was septic shock, 52 and 57%. And the primary admission diagnosis was medical in 94% of cases.
00:18:21
Speaker
ah Most of patients were under me mechanical ventilation 67 and at randomization. and ninety percent were under va pressureer at on the midation um In the invasive strategy group, 65 patients already had an arterial catheter atronomization and most of them, 98% underwent arterial catheterization quickly with a median time of one hour.
00:18:56
Speaker
In the non-invasive strategy group, sixty four already had an arterial catheter atronomidation that was removed for all but one patient.
00:19:09
Speaker
And 72 underwent arterial catheteridation mainly for safety reasons. They have 33 for high dose of vatopressor above 2.5, 20 for high risk surgery with the requirement to remove the arterial catheter after come back in the ICU. 15 for failure to monitor blood pressure and invasively, 7 for failure to monitor pulse oximetry, 6 for 5 puncture attempts failure, 6 because patient underwent ECMO therapy and 6 for other reasons.
00:19:56
Speaker
and In the non-invasive strategy group, arterial cateterization was avoided in 85% of patients. And that's the first thing very
Reliability of Non-Invasive Monitoring
00:20:09
Speaker
important. And the second is... We used to say that in sharp patient, non-invasive monitoring doesn't work. And we observed that only 15 patients, in 15 patients, the monitor failed to show non-invasive blood pressure. And ah in only seven patients, the the monitor failed to show pulse oximetry.
00:20:40
Speaker
And that's an important finding, i believe, because a lot of the the push for arterial catheters over time was based on very small studies that had actually and talked about the inability of non-invasive monitoring yeah to detect very low blood pressures. But as technology has improved, them we and in this much larger study, you've demonstrated that it's a small group of patients in whom we can't get an adequate reading, correct? Yes.
00:21:06
Speaker
Yeah, it's correct. And I think it's a very important result in our study.
00:21:16
Speaker
Absolutely. In terms of some of the other secondary outcomes, obviously a lot of it was related to SOFA scores and the need for support of different organ failures. So you measure that in the and the number of rest m and mechanical ventilation, free days, three days from face suppressors, free days from renal replacement therapy. Any differences between both groups and that?
00:21:41
Speaker
No, there ah there were no differences between both groups. Just in the vasopressor therapy, we can see a little bit more vasopressor use.
00:21:59
Speaker
and less vasopressor free days in the invasive strategy group. But according to the journal policy, we did not perform statistical analysis and no adjustment for multiplicity of tests. So it just, and it's not, ah we we can't say it's test statistically relevant.
00:22:26
Speaker
Perfect.
Safety and Limitations of the Trial
00:22:28
Speaker
Could you comment on some of the post hoc safety and subgroup analysis that were done during the trial? Yeah. and For the primary outcome of and non-inferiority in terms of deaths at day 28, we observed the same results in the two pre-specified pair protocol analysis.
00:22:52
Speaker
And for the safety ah outcome, ah we recorded ah adverse events of special interest. I mean, arterial line complication and noninvasive blood pressure complication in the other end.
00:23:13
Speaker
About the arterial line complication, we observed more arterial catheter related hematoma and MRH in the invasive strategy group. and We observed less a little bit less than 10% of patients having NAR-Cathedial-related hematoma or em MRH. We did not record severity of this hematoma or MRH, but one patient in 10 had eat
00:23:50
Speaker
and ah only few patients in the non-invasive strategy group because only a few people had an RTL catheter in this group. about the non-invasive blood pressure adverse events. We recorded pain and discomfort and we recorded ah ah more pain, more day with pain and and discomfort in the non-invasive strategy group.
00:24:20
Speaker
And that's a very important point of our study because and we recorded pain and discomfort only in awake patients that were able to assess it.
00:24:37
Speaker
So first, it was a very little group of patients in this study who were awake and able to answer the question, and does this blood pressure monitoring ah give you some pain or discomfort? And also,
00:24:59
Speaker
I think that patients who are able to answer this kind of question If they previously required arterial line because of a big septic shock, at the moment they are able to ah to assess their pain and discomfort. They probably ah don't need arterial line for the for the future. So I think we did not assess the pain and discomfort as we i think as we expected. It's ah an issue in this paper.
00:25:42
Speaker
Well, and and like you explained, those are limitations of of the methodology that are imposed by the the nature of the patients we're studying and and what we're studying. But it's a fair point, right? the The patients who reported this, by definition, were less sick because they were awakened. They were a smaller subgroup of the total population of over 1,000 patients. So the power of that finding, it will be diluted. Yeah, absolutely.
00:26:09
Speaker
In terms of discussion, and what were some of the other limitations of the trial from your perspective? And then we can jump into what what do you think these findings mean and what was the conclusion of of the investigators?
00:26:24
Speaker
So um about the limitation, as you previously said, it was an open level study, but I don't know how we we could have blind this ah this blood pressure assessment.
00:26:40
Speaker
So as I previously said, pain and discomfort assessment may not be complete because only few patients were capable to to answer the question. and The patient who were capable probably no longer need an arterial line if they had one And ah we did not assess ah for pain associated with vascular punctures. And in the secondary outcome, we recorded more frequent arterial puncture for blood sampling in the non-invasive strategy group than in the invasive one.
00:27:24
Speaker
And we did not assess pain for that. a This result suggests that the guideline to preferentially use the CVC for blood draws may have not been follows followed as anticipated. Also, we did not record workload and ah satisfaction of healthcare workers and mainly nurse.
00:27:51
Speaker
And then that's, I think, an issue. And ah the recruitment of patients were mainly medical patients. So we we did not include trauma or post-surgical patients. So it's difficult to extrapolate Everdak results to this kind of population.
00:28:13
Speaker
Like you mentioned earlier, this was a highly predominant, what we would call a medical ICU or MICU yeah population, which is still obviously a very important and a large number of of our patients in critical care.
Impact on Clinical Practice
00:28:28
Speaker
What was the conclusion of the investigators of the trial? So the conclusion the study was among critical patients with shock, deferring the insertion of an arterial catheter was non-inferior to an early insertion strategy with regard to get to death from any close at day 28.
00:28:53
Speaker
And one of the important aspects of this trial, Gregoire, is that Not only it's a first in many ways, but there's nothing even close in scope of number of patients looking at this question.
00:29:06
Speaker
So like we mentioned before, a lot of our practice was based on what other people did before us and dogma. And this is the first large randomized study that's trying to give us more insight into what is the real need or or safety of using a ah less invasive strategy.
00:29:26
Speaker
Herbert Spencer said that the objective of research is not knowledge but action. So let's talk about practical implications from your perspective. How do you monitor shock patients and how do you incorporate the results of Everdak into your day-to-day practice?
00:29:43
Speaker
Yeah, thank you for for the question. and By now, and and we changed our practice. Previously, the arterial line was a sort of component of a welcome bag at ICU admission. Welcome ICU, I will put you a chest tube, a CVC, arterial line, i will intubate you and put under mechanical invasive ventilation.
00:30:11
Speaker
from From now, we we can say that arterial line is not the ah and the urgent things to do when you admit a patient for acute circulatory failure.
00:30:29
Speaker
You have to do a diagnosis. You have to give fluids, some vatopressor, some antibiotics. You have to put your patient on a CT scan or ah ah to the operating room to be treated. But don't take the golden hours to put an artery online. It's not a welcome bag.
00:30:55
Speaker
In case your patient is still very severe, despite all your medication and worsening few days later, and you need other things than only the MAP assessment, maybe you can put an OTL line to have other information.
00:31:24
Speaker
In terms of, it and that's an important lesson, right? More and more we're seeing that sometimes doing less is focused and better for patients. But in addition, the arterial line is a diagnostic procedure and what really makes a difference is our interventions. So focusing on interventions upfront,
00:31:43
Speaker
seems to be safe from the results of the Everdac, starting with non-invasive, probably in most patients will work initially. And then, like you said, we're not saying that do not use arterial lines, but to be more thoughtful about which are the patients that will actually, the benefits outweigh the risk and in whom you should proceed then to an arterial line.
00:32:05
Speaker
I
Future Research Directions
00:32:06
Speaker
think that the patient who would benefit for ah from an RCL line are patients in whom we need to assess ah and fluid responsiveness, for example, using a pulse pressure we do not have with an non-invasive monitoring.
00:32:31
Speaker
ah If you need cardiac output monitoring also and ah perform a pulmonary, transpilmonary termodilution. In case of non-pulsatile patient, patient under VA ECMO,
00:32:50
Speaker
um and inpatient whom you need to assess extravascular lung wear or things like that. i want to give you some information for ah all the all the people that are hearing this this podcast.
00:33:11
Speaker
the non-invasive monitoring of blood pressure only measures the mean arterial value. And it's a very important thing. The systolic and diastolic values the monitor gives you are not measured, they are extrapolated with ah an algorithm, a computing algorithm of the monitor. so the the only think The only thing that is really accurate is the mean arterial pressure. And in most cases, you only need the mean arterial pressure to resuscitate patients with shock. And in some cases, you will need other information, pulse pressure or diastolic pressure to assess vasoplasia, for example, or things like that. So in most cases, only the map and non-invasive monitoring is is the good one. And in some cases, you need more information and this is the patient in whom it's necessary, it's ah it's okay to put another line.
00:34:30
Speaker
Excellent.
Conclusion and Personal Influences
00:34:31
Speaker
What are areas that are still unanswered and potential targets for future research in your mind, Grigua? and we We don't have the information for surgical and post-trauma patients. And ah I don't know why it could be different, but we don't have the data. And um i think there is a lot of research to do and about blood sampling and the CVC blood sampling to avoid arterial line blood sampling and to avoid transcutaneous needle punctures that are painful. um We also need to assess the nurse workload.
00:35:24
Speaker
ah In case the patient don't have arterial line, because I think it needs more ah nurse work if the patient don't have an arterial line. And we did not assess that. And it's a question.
00:35:43
Speaker
And again, just want to thank you for conducting such a wonderful trial. It gives us a lot of pause. And it's a reminder that a lot of the things we do on a daily basis have not been studied. And studying them has a lot of value because it opens new questions, but also helps us hopefully tailor our treatments in a more thoughtful way for each patient.
00:36:07
Speaker
and Not every patient needs an arterial line. and Choose the right patients. And it's quite interesting, Gregor, how these pendulums swing, right? When I was training, everybody got a PA catheter. Then nobody got a PA catheter. And now we're realizing that some people do benefit from a PA catheter probably. Yeah, also. And I think that in many other examples, as in the arterial lines, we probably will see that in light of this wonderful trial that you and your team have published. yeah
00:36:37
Speaker
I totally agree. Greg, we'd love to finish the the podcast with a couple of questions that are unrelated to the clinical topic. Would that be okay? Yeah. The first question relates to books.
00:36:50
Speaker
Is there a book that has influenced you significantly ah or a book that you have gifted often to friends? Yeah, so I'm not a bookworm, I'm not a big reader, but I remember that one of my colleagues, Stefan Hermann, co-author of this paper, and e they gave me Getting Things Done from David Allen.
00:37:17
Speaker
And it's a a book to learn how to organize your your day, your week, your month, and probably your life. And I read it with a big interest and i use all the method provided by David Allen in a many tasks of my days and weeks. Excellent. And I think ah getting things done is really a a GTD that we call it here the United States after David Allen's publication became like a big thing in many many circles.
00:37:52
Speaker
But really, ah it's a great read. And what I find is... the the concept that what stresses you is what's lingering in your brain or what you think you might forget, right? So when you have a method to get rid of that, I call it my brain dump, right? It it it liberates a lot of bandwidth and to to think about more important things. So we definitely will link that in the in the show notes. And we'll thank David Allen since he probably helped you get this trial completed, correct? Yeah.
00:38:22
Speaker
Probably, i don't know, but i put I put a lot of things out of my brain about Everdex, thanks to David Allen. Excellent. Second question relates to changing your mind.
00:38:36
Speaker
Could you share something you changed your mind about over the last few years? Yeah, it's a need for invasive procedure in the ICU because when I graduated in the ICU, I loved to to perform invasive procedures. And now I try to demonstrate that they are not all required.
00:38:59
Speaker
Excellent. and i And I do believe that's a change in in a lot of our our careers because, like you said, a lot of our colleagues who get gravitate towards intensive care medicine like the procedural aspect, the the the nature of of critical illness.
00:39:15
Speaker
And it's fun to do a lot of these procedures, right? But maybe not so much fun for the patients. And again, they're... The key, I believe, requires to to be thoughtful about when we do things to patients to really pause and consider, right? Is this really going to make a difference or not? What does the evidence support in this particular patient?
00:39:36
Speaker
I totally agree. Yeah. To close, is there a a thought and or quote or general thought that you would want every listener to know as as we finish?
00:39:49
Speaker
I used to say to my resident that you have to treat patients the way you would want or your loved ones or yourself be treated.
00:40:01
Speaker
i think that's a great concept ah in life in general, but definitely something we can apply in the ICU with a little bit more vehemently. Revoir, thank you for sharing your time with us. Thank you for sharing your knowledge and especially thanking for being willing to talk with me in English since I speak zero French. So I have i have learned a lot and I look forward to having you back with with further studies in the ICU.
00:40:26
Speaker
Thanks a lot, Sergio. Thank you.
00:40:31
Speaker
Thank you for listening to Critical Matters, a sound podcast. Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network. Sound's transforming the way critical care is provided in hospitals across the country.
00:40:45
Speaker
To learn more, visit www.soundphysicians.com.