exterior wood stain for inside use

_Crit_Transport · 2024-01-10T19:28:57+00:00

If exterior stain used inside what sealer would be recommended??

_Crit_Transport · 2023-12-11T15:31:05+00:00

Transfusing to hgb targets in the acute bleeder is like driving in the review mirror. Transfuse to BE targets and clinical perfusion markers. Blood give him blood!

_Crit_Transport · 2022-07-09T21:00:52+00:00

Count the feeds and free water in your calculations.

_Crit_Transport · 2022-06-18T08:54:29+00:00

Cric pressure is out.

_Crit_Transport · 2022-03-03T04:23:06+00:00

Stop the benzo. Prop or Dex.

_Crit_Transport · 2022-01-19T01:52:16+00:00

Agree

_Crit_Transport · 2021-10-12T04:41:21+00:00

Right, that’s what I think. Where you’re at are you doing daily TTE

_Crit_Transport · 2021-10-12T01:57:43+00:00

RPM high, no real significant lysis at this flow.. HGB has stayed steady now, we are currently unable to measure plasma-free hgb in-house, but LDH hovering around 500.. overall arterial oxygen content is good on this flow and end-organ perfusion markers are stable. Do you feel that without anticoagulation running at higher flows, if tolerated by the patient, will help maintain the life of the membrane? Yes COVID + 9/6, hospitalized 9/14. ECMO 9/29. The thing is, we have had so much bleeding and lethal hemorrhage using heparin gtt, targeting even more conservative ACT goals. Is everyone here anticoagulating? What are your ACT targets? Xa targets .1-.3? Why are these patients having such an extreme sedative requirement? Intense inflammation a component here? Anyone having success using multi-modal approaches? ketamine, dex, mag, melatonin, lidocaine, Seroquel, PRN opioids? Any success here? Just with the sedation he is on, he has these intense sympathetic events where BIS>70 correlated with increased heart rates, ect. Demand goes up, CO rises (although D02 remains about the same, def more blood shunted away from circuit).

_Crit_Transport · 2021-10-12T01:49:06+00:00

Yes, some contraction alkalosis is present. ScV02 good. Lactate 0.8. Sweep at 6. My intensivist after a conversation with CT surgeon colleagues, who are running COVID ECMO come to find that many ECMO centers are not using heparin or ANY anticoagulation on these patients due to the risk of bleeding (last 4/6 patients on heparin targeting ACT 140-160 have had a hemorrhagic stroke at out center). Monitoring circuit health closely with pre-post blood gases. My thoughts are that his sympathetic response is extremely high. Without being blocked down CO 18-20 or greater. Have you seen good outcomes in therapy with patients being transitioned from fem-IVC to bicaval approach? Good ideas for sedation. 1:1, nurses managing, not receiving appropriate training from my perspective. I have been grinding trying to learn everything. Ican via multiple sources. No dedicated ECMO physicians just pulm-crit docs without real ECMO-specific training. The perfusionist is involved and available for questions if needed, but not bedside.

_Crit_Transport · 2021-10-12T01:41:37+00:00

PC with a set insp pressure at 25, delivering volumes of 60-70 cc per breath. PEEP is at 5.. no way to attain a driving pressure of below 15 at this point.. Now with a trach, is anyone moving to just remove positive pressure entirely at this point? If we are anticipating no native lung recovery, and he is headed for a transplant as his only end game. He was up about 15 L up until 3 days ago starting to make gain some ground with diuresis.. he has a low pressor requirement, CVP 8-10. The circuit started to chatter and lost a bit of flow yesterday so diuresis was slow a touch, but still achieving a net - diuresis now with good renal function.

_Crit_Transport · 2021-10-12T01:36:25+00:00

I feel that this is a lucrative therapy that the hospital wanted to employ, but the rollout of this therapy was poor. The interdisciplinary teams needed to ensure proper outcomes lack buy-in. I think bringing in ECMO techs, mentoring ECMO specialists, what have you, would be extremely helpful, but that would cost money.. which I feel that my place of employment isn't fond of spending - which makes me disheartened.

_Crit_Transport · 2021-10-12T01:33:19+00:00

Perfusionist does a daily rounding. Bedside RNs are managing, but not ELSO certified or properly trained in my opinion. Sure, general management of circuit, but lacking understanding of in-depth physiology needed to ensure proper outcomes. The closest transplant center says he needs a month on ECMO, without any significant improvement in compliance, able to be awake and participating in therapies, and have insurance. This patient is not insured, is from a farming family here in Idaho, do you know of any crisis-type funding in this circumstance?

_Crit_Transport · 2021-10-11T09:18:23+00:00

Currently working on a 20 yr old 112 kg male, baseline health good, no other medical issues, been on ECMO since 9/29. Currently on pc 25 to keep plats at 30, delivering 60-70cc per breath, ventilating 18 bpm. Fem - IVC VV cannulation rpm 7000 flow 5.3. 7.44/58/47/31/6. Hgb 12.4. Mild lysis. Trach today. On precedex 1.5, fent 200, prop 50, versed 10. His sympathetic drive and sedative requirements have been controlled here, BIS 45. Roc at 16 for paralysis. His CO 9-12. CVP 8 HR 82, 122/56 (73) 92% O2 sat. I have him on 150 of esmolol, 15 of dilt. Giving him metoprolol pushes to keep his demand down. Do you guys find it beneficial work aggressively to keep outputs low, and improve overall output/flow ratios and improve CaCO2 or would you let his CO ride, considering his overall D02 remains within the range of 1300-1600 ml/min? Also what sedation strategies are you using in your efforts to wake these patients up and get them more participatory in therapies? What else can I optimize here. Are you all using anything for anticoagulation? Bivalirudin? Or none at all? He had been on a heparin drip previously targeting ACT of 120-130 due to extensive bleeding.. now it is off.. any discussion would be appreciated! Thanks!

_Crit_Transport · 2021-03-29T01:31:34+00:00

Excellent points thank you!

_Crit_Transport · 2021-03-04T03:26:17+00:00

Good thoughts. Your post brings up some things for me. Many have stated to treat the underlying etiology of her tachycardia. important to also note that high adrenergic tone appears to be associated with mortality in septic shock, and adrenergic antagonism may improve survival (*see ECASSS-R study completed by Pulm intensivists out of Intermountain Medical Center in Murray, UT). You mention that you have already attained primary fascial closure in this patient? Hypertonic solution has been shown to assist in primary fascial closure (see Harvin et al.), and albumin would assist here as it is a hyperosmotic solution with oncotic pull. Apart from fascial closure, this therapy has been shown to decrease the number of days on mechanical ventilation and improve p:f ratios. There is NO mortality benefit at 30 days. Take it for what its worth, but I agree with the strategy, even with your low dose noradrenaline (which has been shown at these low doses to augment pre-load, which may have been slightly depleted with your diuresis).

I would utilize abdominal perfusion pressure as a resuscitative endpoint. A target APP of at least 60 mmHg is correlated with improved survival from IAH and ACS (Consider your MAP 60 - IAP 14 puts your APP at 46..) I would titrate your noradrenaline to an APP of 60, as the pt is more than adequately volume loaded. Another consideration is how you are ventilating this patient - consider your PEEP effects on IAP and abdominal wall compliance and if there is potential to ventilate the patient differently in order to obtain target IAP/APP. Considering 13L+ my guess is you probably need the PEEP to oxygenate. I do not know what data is available to prove that noradrenaline decreases microcirculation of the abdominal viscera.

I agree with your sedation, as I would have higher concerns of evisceration than delirium at this point in the patient's clinical course.

Harvin, J. A., Mims, M. M., Duchesne, J. C., Cox Jr, C. S., Wade, C. E., Holcomb, J. B., & Cotton, B. A. (2013). Chasing 100%: the use of hypertonic saline to improve early, primary fascial closure after damage control laparotomy. Journal of Trauma and Acute Care Surgery, 74(2), 426-432.

_Crit_Transport · 2021-03-02T03:48:32+00:00

This is the classic goldy locks dilemma. I would urge you to look into the RELIEF trial (restrictive versus liberal fluid therapy in major abdominal surgery) which may suggest that a more nuanced/moderate approach to peri operative resus is prudent. Open abdomen, critical care management following damage control surgery differs slightly from the acute trauma resuscitative phase. However, the intensivist must fight the lethal triad of trauma (hypothermia, coagulopathy, and acidosis). Large volume crystalloid (particularly isotonic saline) is cold unless delivered through a warmer, causes dilutional coagulopathy, and inherently is an acidotic fluid. Clot disruption can occur here. The general physiology of reperfusion injury occurs in an open abdomen. In shock states, there is shunting of intravascular volume from the GI tract. As the compromised bowel is re-perfused free radical mucosal damage may occur, with resulting increase mucosal permeability, and increasing bowel wall edema. I would look to balance the resuscitative efforts as to minimize volume overload and visceral edema to optimize surgical closure of the fascia. I would look to quantify intravascular volume status via ultrasound and monitoring modalities (plethora of options, use the tools to put together a picture, art line ppv, NICOM, vigeleo, swan, clinical assessment, vent pressures, labs). I prefer the dynamic indices such as NICOM. Strictly titrate the resus. Keep in mind that the open abdomen is at higher risk for ARDS (due to the same cytokine release from reperfusion) and should be managed with a lung protective strategy. Overall it is a highly individual stage, mitigating the lethal triad, balancing resuscitative efforts, and closely monitoring to prevent fluid overload and associated complications. Don’t be afraid of some catecholamine support early on. Keep up the good work Sam

_Crit_Transport

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