Critical Matters

Burnout is a major problem in critical care medicine. The COVID-19 pandemic has exacerbated this problem. However, we as clinicians should aspire to more from our careers than the mere elimination or mitigation of burnout. In today's episode of the podcast, we will explore some ideas that go beyond burnout. This is a recent talk given by Dr. Zanotti entitled, “Finding Joy in our Work, The Path to Professional Transcendence”. Additional Resources: Video - Professional Transcendence: https://spaces.hightail.com/space/oOIGXeROd7/files/fi-68608c75-317c-4c74-a067-9b5fe8897866/fv-30bff5a8-1deb-4579-ad57-4fff440edf40/Finding Joy in Work_ The Path to Professional Transcendence .mp4 Books Mentioned in this Episode: The Enchiridion by Epictetus: https://www.amazon.com/Enchiridion-Epictetus/dp/1503226948/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1611795176&sr=8-6 Man’s Search for Meaning by Viktor E. Frankl: https://www.amazon.com/Mans-Search-Meaning-Viktor-Frankl/dp/0807014273/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1611795263&sr=8-1 Deep Work by Cal Newport: https://www.amazon.com/Deep-Work-Focused-Success-Distracted/dp/0349411905/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1611795325&sr=8-1

In this episode of Critical Matters, we will continue our discussion on the management of acute-on-chronic liver failure (ACLF) in the ICU. Part 2 will cover pulmonary, rena,l and endocrine recommendations for ACLF patients. In a previous episode (Management of ACLF: Part 1) we covered an introduction to ACLF, cardiovascular, and hematology management recommendations. Our guest is Dr. Nanchal, a practicing critical care physician with an interest in liver disease. He is a Professor in the Division of Pulmonary and Critical Care Medicine, at the Medical College of Wisconsin, in Milwaukee. Dr. Nanchal is the lead author of the Society of Critical Care Medicine’s Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU. Additional Resources: Executive Summary for Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: journals.lww.com/ccmjournal/Fullt…cute_and.17.aspx Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: journals.lww.com/ccmjournal/Fullt…cute_and.29.aspx SCCM Liver Guidelines: www.sccm.org/getattachment/Rese…s-Table-Part-1.pdf Books Mentioned in this Episode: Thinking Fast and Slow by Daniel Kahneman: www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman

In this episode of Critical Matters, we will discuss the management of acute-on-chronic liver failure (ACLF) in the ICU. Our guest is Dr. Nanchal, a practicing critical care physician with an interest in liver disease. He is a professor in the Division of Pulmonary and Critical Care Medicine at the Medical College of Wisconsin in Milwaukee. Dr. Nanchal is the lead author of the Society of Critical Care Medicine’s Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU. This episode is part of a two-part series focused on ACLF. Part 1 will cover an introduction to ACLF, cardiovascular, and hematology. Part 2 will cover pulmonary, renal, and endocrine recommendations for ACLF patients. Additional Resources: Executive Summary for Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: https://journals.lww.com/ccmjournal/Fulltext/2020/03000/Guidelines_for_the_Management_of_Adult_Acute_and.17.aspx Guideline for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: https://journals.lww.com/ccmjournal/Fulltext/2020/03000/Guidelines_for_the_Management_of_Adult_Acute_and.29.aspx SCCM Liver Guidelines: https://www.sccm.org/getattachment/Research/Guidelines/Guidelines/Guidelines-for-the-Management-of-Adult-Acute-and-A/SCCM-Liver-Guidelines-Table-Part-1.pdf Books Mentioned in this Episode: Thinking Fast and Slow by Daniel Kahneman: https://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman

In this episode of Critical Matters, we will discuss thrombosis in COVID-19. We will discuss the pathophysiology, diagnosis, and management of arterial and venous thrombosis in COVID-19. Our guest is Dr. Gregory Piazza, a cardiovascular medicine specialist at Brigham and Women’s Hospital in Boston. Dr. Piazza is the Director of the Vascular Medicine Section, in the Division of Cardiovascular Medicine, and Associate Professor of Medicine, at Harvard Medical School. Additional Resources: Diagnosis, Management, and Pathophysiology of Arterial and Venous Thrombosis in COVID-19: https://jamanetwork.com/journals/jama/fullarticle/2773516 Registry of Arterial and Venous Thromboembolic Complications in Patients with COVID-19: https://www.jacc.org/doi/full/10.1016/j.jacc.2020.08.070 ACCP Guidelines for Management Thromboembolism in COVID-19: https://journal.chestnet.org/article/S0012-3692(20)31625-1/fulltext ISTH Guidelines for Management of Thromboembolism in COVID-19: https://onlinelibrary.wiley.com/doi/10.1111/jth.14929 Books Mentioned in this Episode: Dune by Frank Herbert: https://www.amazon.com/Dune-Frank-Herbert

In this episode of Critical Matters, we will discuss how to make teams better. Teams are ubiquitous in the practice of critical care medicine. Understanding the elements that are required for a high functioning team is essential in our quest to deliver high-value critical care. This episode is based on a presentation given by Dr. Zanotti during the latest Sound Critical Care Leadership Week. Additional Resources: Video - "Above Average: How to Make Teams Better": https://comms.soundphysicians.com/PoliteMail/default.aspx?page=T_URXujah06Y_lZQ2A3mwA&ref_id=Elw9rkGRI0iH80DrpDyi4w The Firm Specificity of Individual Performance: Evidence from Cardiac Surgery: https://pubsonline.informs.org/doi/10.1287/mnsc.1050.0464 Evidence for a Collective Intelligence Factor in the Performance of Human Groups: https://pubmed.ncbi.nlm.nih.gov/20929725/ The Global Study of Engagement: https://www.adp.com/Global_Study_Engagement Learning New Technical and Interpersonal Routines in Operating Room Teams: https://www.emerald.com/insight/content/doi/10.1016/S1534-0856(00)03003-6/full/html Previous Episode - “Circle Up”: https://soundphysicians.com/podcast-critical-matters/?episode=circle-up

In this discussion, Dr. David Greer, Chair of Neurology at Boston University, delves into the complexities of brain death and the World Brain Death Project. He emphasizes the importance of conservative diagnostic criteria to prevent misdiagnosis. Greer explains necessary prerequisites for brain death testing, the significance of the apnea test, and the role of ancillary testing. He also highlights the ethical challenges families face and the need for precise documentation in declaring time of death, ensuring clarity and trust in critical care.

In this episode of Critical Matters, we will discuss innovation in care through the lens of process and workflow. Over the last several months, we have discussed new drugs, novel therapeutic approaches, and ventilator management strategies. However, the most vital source of innovation and success has been adapting to COVID-19 with new ICU workflows. Our guest is Dr. Laura Rock, a pulmonary and critical care physician at Beth Israel Deaconess Medical Center in Boston. Dr. Rock is also faculty at Harvard Medical School, at the Center for Medical Simulation and is a trained Vital Talk instructor. She shares with us the concept of "Circle Up". Additional Resources: "Circle Up": Workflow Adaptation and Psychological Support via Briefing, Debriefing, and Peer Support: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0240 Emotions and COVID-19: GIVE to Connect, Understand, and Support: https://litfl.com/emotions-and-covid-19-give-to-connect-understand-and-support/ Don't Answer Feelings with Facts: https://blogs.bmj.com/bmj/2020/04/13/laura-k-rock-dont-answer-feelings-with-facts/ An excellent resource to learn more about "Circle Up": https://harvardmedsim.org/circleup/ VitalTalk - Resource for Patient/Family Communication: https://www.vitaltalk.org/resources/ Books Mentioned in this Episode: In Shock by Rana Awdish: https://www.amazon.com/Shock-Journey-Death-Recovery-Redemptive/ What Doctors Feel by Daniel Ofri: https://www.amazon.com/What-Doctors-Feel/ Being Mortal by Atul Gawande: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/ Humble Inquiry by Edgar Shein: https://www.amazon.com/Humble-Inquiry-Gentle-Instead-Telling/

Dr. Eduardo Mireles-Cabodevila, a pulmonary and critical care physician at the Cleveland Clinic, dives into the critical aspects of liberation from mechanical ventilation. He highlights the importance of distinguishing between 'liberation' and 'weaning'. Listeners learn about weaning classifications, SBT methods like pressure support vs. T-piece, and protocols that improve patient care. He also discusses nuances of managing COVID-19 patients, including sedation challenges and monitoring steroid side effects. This insightful conversation offers valuable strategies for critical care practices.

In this episode of Critical Matters, we will take a deep dive into the topic of corticosteroids in COVID-19 ARDS. Our guest is Todd Rice, MD, an Associate Professor of Medicine in the Division of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University. Dr. Rice is an accomplished physician-scientist focused on research in patients with sepsis, ARDS, and acute respiratory failure. He recently co-authored an editorial published in JAMA; “Corticosteroids in COVID-19 ARDS: Evidence and Hope During the Pandemic.” Additional Resources: Corticosteroids in COVID-19 ARDS: https://bit.ly/3bFbFig PROSPERO Meta Analysis: https://bit.ly/3m69rgD RECOVERY Clinical Trial: https://bit.ly/35t59Ka REMAP-CAP Clinical Trial: https://bit.ly/3m2Hkz3 CODEX Clinical Trial: https://bit.ly/3bJQdbU CAPE-COVID Clinical Trial: https://bit.ly/3it8Xz7 Books Mentioned in this Episode: When Breath Becomes Air by Paul Kalanithi: https://amzn.to/2ZlVZeX

In this episode of Critical Matters, we will discuss hypotension and new data on Angiotensin II within the context of our path towards personalized vasopressor support. Our guest is Dr. Ashish K. Khanna. Dr. Khanna is an anesthesia and critical care practicing physician. He is Associate Professor, and Section Head for Research, in the Department of Anesthesiology, Section on Critical Care Medicine of the Wake Forest School of Medicine, in Winston-Salem, North Carolina. He is a prolific author and researcher and was the lead author of the ATHOS-3 study in the New England Journal of Medicine. The results of which led to the approval of Angiotensin II as a vasopressor for the treatment of refractory hypotension in adults with septic or other types of distributive shock. Links: The Relationship Between ICU Hypotension and In-Hospital Mortality and Morbidity in Septic Patients: https://bit.ly/2D1epJQ Association between Mean Arterial Pressure and Acute Kidney Injury and a Composite of Myocardial Injury and Mortality in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis: https://bit.ly/2QuyStz Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3 Trial): https://bit.ly/2G27hhB Survival After Shock Requiring High-Dose Vasopressor Therapy: https://bit.ly/2EkLm4P Renin as a Marker of Tissue-Perfusion and Prognosis in Critically Ill Patients: https://bit.ly/3jiKT1L Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock: https://bit.ly/2G1tZGB Additional Content Related to Angiotensin II: Angiotensin II for Vasodilatory Shock: 2019 Update: https://bit.ly/3hvVkyA Personalization of Vasopressor Therapy in the Treatment of Vasodilatory Shock: https://bit.ly/3hy7wyD