Critical Matters

With over 700 modes of mechanical ventilation available today, it can be overwhelming to find the best application of technology at the bedside. Focused on goal-directed mechanical ventilation, this discussion covers the taxonomy of mechanical ventilation modes and provides a framework for a rational approach at the bedside. Dr. Zanotti is joined by Dr. Eduardo Mireles-Cabodevila, Director of the Medical Intensive Care Unit and the Simulation and Advanced Skills Center at the Cleveland Clinic. In addition, Dr. Mireles-Cabodevila is the Vice-Chair of the Division of Critical Care Medicine, Department of Pulmonary and Critical Care, within the Integrated Hospital-Care Institute at the Cleveland Clinic. Additional Resources: How do I ventilate patients with ARDS: Goal-directed mode selection. E. Mireles-Cabodevila. Med Intensiva 2022: https://pubmed.ncbi.nlm.nih.gov/36220727/ A Rational Framework for Selecting Modes of Ventilation. E. Mireles-Cabodevila, et al. Respir Care 2013: https://pubmed.ncbi.nlm.nih.gov/22710796/ Closing the Gap in Patient-Ventilator Discordance Recognition. A. Liendo and E. Mireles-Cabodevila. Respir Care 2024: https://pubmed.ncbi.nlm.nih.gov/38267228/ Standardized Education for Ventilatory Assistance (SEVA) resources page; https://my.clevelandclinic.org/departments/respiratory/medical-professionals/seva#seva-resources-tab Mechanical Ventilation Mode Taxonomy App: iPhone: https://apps.apple.com/us/app/ventilator-mode-map/id1508307955 Android: https://play.google.com/store/apps/details?id=org.ccf.vmm&hl=en_US Books mentioned in this episode: Solito: A Memoir. By Javier Zamora: https://bit.ly/4b6hPG8

In this episode, Dr. Zanotti discusses the management of acute life-threatening asthma exacerbations in the ICU with this guest, Dr. Haney Mallemat, a physician trained in EM/IM and Critical Care. Dr. Mallemat is currently an Associate Professor of Emergency Medicine and Internal Medicine at the Cooper Medical School at Rowan University. Additional Resources: How Not to Kill an Asthmatic – Presented at CODA Change by Haney Mallemat: https://codachange.org/severe-asthma Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit. Talbot T, et al. Appl. Sci 2024: https://www.mdpi.com/2076-3417/14/2/693 ResusX,- a medical resuscitation conference created by Dr. Mallemat: https://www.resusx.com Last Week Now! - A curated newsletter by ResusX: https://www.resusx.com/newsletter Keynotable – a course for beginners and seasoned speakers: https://www.keynotable.net Books mentioned in this episode: How to Win Friends and Influence People. By Dale Carnegie: https://bit.ly/49WlcOd

In this episode, Dr. Zanotti is joined by Dr. Stephen Pastores to discuss the 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia, published by the Society of Critical Care Medicine. Dr. Pastores is Program Director for Critical Care Medicine and Vice-Chair of Education for the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center. In addition, Dr. Pastores is a professor of anesthesiology and medicine at Weill Cornell Medical College in New York, NY. Additional resources: 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Medicine 2024: https://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=9900&issue=00000&article=00275&type=Fulltext Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. ADRENAL Trial. N Engl J Med 2018. https://www.nejm.org/doi/full/10.1056/NEJMoa1705835 Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. APROCCHSS Clinical Trial. N Engl J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1705716 Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomized controlled trial. The Lancet 2020: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(19)30417-5/abstract Hydrocortisone in Severe Community-Acquired Pneumonia. CAPE-COD Trial. N Eng J Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145 Books mentioned in this episode: Elon Musk. By Walter Isaacson: https://bit.ly/3PVXWsG The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care. By Hannah Wunsch: https://bit.ly/4avevns

In this episode, Dr. Zanotti discusses the delicate balance of conflict resolution in healthcare. Conflict is common in our daily work in the ICU. Many clinicians avoid conflict and have negative feelings towards it. However, conflict, when managed appropriately, can lead to significant benefits for our patients and teams. Dr. Zanotti's discussion is based on a webinar he presented earlier this month as part of Sound Critical Care Leadership Week. Additional Resources: Watch the full webinar: https://youtu.be/R3wz29W3C4g Conflict Management in the ICU. Previous Critical Matters podcast episode with Dr. Joshua Kayser. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1378454077 Books Mentioned in this Episode: Nonviolent Communication. By Marshal B. Rosenberg: https://bit.ly/4a8h0fp Getting to YES: Negotiating Agreement Without Giving In. By Roger Fisher and William Ury: https://bit.ly/3TSD5J3 Possible: How We Survive (and Thrive) in an Age of Conflict. By William Ury: https://bit.ly/4aauFCK Crucial Conversations: Tools For Talking When Stakes are High. By Joseph Grenny, et al: https://bit.ly/43AU6La The Anatomy of Peace: Resolving the Heart of Conflict. By the Arbinger Institute: https://bit.ly/4a1v0HL

In this episode, Dr. Zanotti is joined by Dr. Craig Rackley to discuss the role of ECMO – extracorporeal membrane oxygenation in supporting patients with acute respiratory failure. Dr. Rackley is a practicing pulmonary critical care physician and an associate professor of Medicine at Duke University School of Medicine. He is the medical director of Adult ECMO in the Duke Division of Pulmonary, Allergy, and Critical Care Medicine. Dr. Rackley is also a recognized clinician, educator, and researcher interested in respiratory failure, ARDS, and ECMO. Additional Resources Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. The CESAR Trial. Lancet 2009: https://pubmed.ncbi.nlm.nih.gov/19762075/ Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The EOLIA Trial. N Eng J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385 Bertini P, Guarracino F, Falcone M, et al. ECMO in COVID-19 Patients: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2022: https://pubmed.ncbi.nlm.nih.gov/34906383/ Books mentioned in this episode Endurance: Shackleton’s Incredible Voyage. By Alfred Lansing: https://bit.ly/43g71C1 South!: The Story of Shackleton’s Last Expedition 1914-1917. By Ernest Shackleton: https://bit.ly/49NyJbU

In this episode, we will discuss critical care management of acute neuromuscular disorders. We will focus on the Guillain-Barre Syndrome and Myasthenia Gravis. My guest is Dr. Kamran Athar, who is trained in critical care medicine and neurocritical care. He is a practicing neurointensivist at the Farber Institute for Neuroscience in Philadelphia. Dr. Athar is an assistant professor of Medicine and Neurology at the Jefferson School of Medicine in Philadelphia. Additional Resources: Neuromuscular Disorders in the Intensive Care Unit. T B Birch. American Academy of Neurology 2021: https://pubmed.ncbi.nlm.nih.gov/34618763/ The clinical management of neuromuscular disorders in intensive care. M S Damian and EFM Wijdicks. Neuromuscular Disorders 2019: https://www.sciencedirect.com/science/article/abs/pii/S0960896618304231 Books Mentioned in this Epsiode: When Breath Becomes Air. By Paul Kalanithi: https://www.amazon.com/When-Breath-Becomes-Kalanithi-Paul/dp/1784701998/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1706814212&sr=8-1

In this episode, Dr. Zanotti is joined by Dr. Eddy Fan for a discussion about Respiratory Support in ARDS. Dr. Fan is an associate professor in the Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management, and Evaluation at the University of Toronto. He is also a staff intensivist at the University Health Network/Mount Sinai Hospital. Dr. Fan is currently the Medical Director of the Extracorporeal Life Support Program at the Toronto General Hospital and the Director of Critical Care Research at the University Health Network/Mount Sinai Hospital. Dr. Fan’s research has focused on advanced life support for acute respiratory failure and patient outcomes from critical illness. He is a co-author of the ESICM ARDS Clinical Guidelines. Additional Resources: ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping, and respiratory support strategies. Intensive Care Med 2023: https://pubmed.ncbi.nlm.nih.gov/37326646/ An Update on Management of Adult Patients with ARDS. Official ATS Clinical Practice Guideline. Am J Respir Crit Care Med 2024; https://www.atsjournals.org/doi/full/10.1164/rccm.202311-2011ST Prone Positioning in Severe Acute Respiratory Distress Syndrome. PROSEVA Clinical Trial. N Engl J of Med 2013: https://www.nejm.org/doi/full/10.1056/nejmoa1214103 Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. The EOLIA Trial. N Eng J of Med 2018: https://www.nejm.org/doi/full/10.1056/NEJMoa1800385 Books mentioned in this episode: A Portrait of the Artist as a Young Man. By James Joyce: https://bit.ly/49kzmtn

In this episode, we discuss the management of seizures in the intensive care unit. Our guest is Dr. Brandon Foreman – an internist and neurologist with fellowship training in epilepsy and Neurocritical care. Dr. Foreman is an Associate Professor of Neurology at the University of Cincinnati Medical College. He is the Associate Director for Neurocritical Care Research. An excellent clinician, researcher, and educator focusing on Clinical Neurophysiology and Neurocritical care. Additional Resources: Seizure Management in the Intensive Care Unit. Boggs JG. Curr Treat Options Neurol 2021: https://pubmed.ncbi.nlm.nih.gov/34697528/ American Epilepsy Society – Website with multiple clinical Guideline: https://pubmed.ncbi.nlm.nih.gov/34697528/ Treating Rhythmic and Periodic EEG Patterns in Comatose Survivors of Cardiac Arrest. Ruijter BJ, et al. N Engl J Med 2022: https://pubmed.ncbi.nlm.nih.gov/35196426/ Books mentioned in this episode:  Siddhartha: A Novel. By Hermann Hesse: https://www.amazon.com/Siddhartha-Novel-Hermann-Hesse Netflix- Reference Guide on Our Freedom and Responsibility Culture https://igormroz.com/documents/netflix_culture.pdf

In this episode, we discuss the evaluation of fever in the adult ICU patient. We discuss updates from the recently published Society of Critical Care Medicine and Infectious Diseases Society of America clinical guidelines. My guest is Dr. Andre Kalil, a critical care and infectious disease physician. Dr. Kalil is a Professor in the Division of Infectious Disease and Director of Transplant Infectious Disease at the University of Nebraska Medical Center (UNMC). A renowned clinician, educator, and researcher, Dr. Kalil has received many distinctions, including the 2021 Scientist Laureate Award at UNMC. Dr. Kalil is an author of the 2023 Society of Critical Care Medicine and The Infectious Disease Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Additional Resources: Society of Critical Care Medicine and the Infectious Diseases Society of America guidelines for Evaluation New Fever in Adult Patients in the ICU. Crit Care Medicine 2023. https://pubmed.ncbi.nlm.nih.gov/37902340/ Executive Summary: Guidelines for Evaluating New Fever in Adult Patients in the ICU. Crit Care Medicine 2023. https://pubmed.ncbi.nlm.nih.gov/37902339/ Guidelines for the evaluation of new fever in critically ill adult patients: 2008 Update. Crit Care Medicine 2008/ https://pubmed.ncbi.nlm.nih.gov/18379262/ Books mentioned in this episode: Splendid Solution: Jonas Salk and the Conquest of Polio. By Jeffrey Kluger https://www.amazon.com/Splendid-Solution-Jonas-Conquest-Polio/dp/0425205703/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1702571365&sr=8-2

In this episode, we discuss the topic of Brain Death / Death by Neurologic Criteria. We discuss updates from the recently published American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine clinical guidelines. Our Guest is Dr. David Greer. Dr. Greer is a neurologist with additional vascular neurology and neurocritical care training. He is the Chair of the Boston University School of Medicine Department of Neurology. Dr. Greer is a renowned clinician, educator, and researcher. He has an extensive list of publications and awards. He is the first author of the “Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline” we will discuss today. Additional Resources: Pediatric and Adult Brain Death / Death by Neurologic Criteria Consensus Guideline. David Greer, et al. Neurology 2023: https://n.neurology.org/content/early/2023/09/13/WNL.0000000000207740 Determination of Brain Death / Death by Neurologic Criteria. The World Brain Death Project. D. Greer et al. JAMA 2020 https://pubmed.ncbi.nlm.nih.gov/32761206/ Determination of Brain Death / Death by Neurologic Criteria. The World Brain Death Project. VIDEO: https://edhub.ama-assn.org/jn-learning/video-player/18529668 Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU. S Biel, et al: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223748/ Books mentioned in this episode: The Boys in the Boat. By Daniel J. Brown: https://www.amazon.com/Boys-Boat Team of Rivals: The Political Genius of Abraham Lincoln. By Doris Kearns Goodwin: https://t.ly/7F1My Nine Stories. By JD Salinger: https://t.ly/qM5w_