8 < Back Continuing Med Ed (CME) National Organizations American Association for the Surgery of Trauma [Must log-in to access] Journal of Trauma and Acute Care Surgery articles Archived AAST Virtual Grand Rounds Certain Annual Meeting Master Surgeon Lectures and topic-specific presentations Region VII Sessions Critical Care Committee Journal Reviews American College of Surgeons Journal of the American College of Surgeons [Must log-in to access] Surgical Education and Self-Assessment Program (SESAP®) [$685 for 168 CME credits] Training Courses ATLS Traditional Student Course - 16 AMA PRA credits BEST, ATOM, ASSET ACLS, PALS Annual Medical Conferences Other Sources UpToDate Local conferences at your facility (Morbidity and Mortality, Grand Rounds, etc) Military training courses Previous Next

Difficult Discussions Giving Bad News, #2 < Back Difficult Discussions These are NOT my original ideas. They are tidbits I garnered at the American College of Surgeons Clinical Congress in 2022. The sesions was entitled "A Multicultural Primer on Death and Dying: Improving Goals of Care Discussions for Surgical Patients Facing the End-of-Life" (PS 120). Note: These are NOT universally applicable. Please tailor your conversations for each interaction. How To Break Bad News Fire a warning shot. I'm sorry that I have some bad/ hard news to share with you. Reveal the headline. Your son came to the trauma bay after being shot/ being in an accident and I’m sorry to tell you that he died. Stop talking and be quiet after the headline. Acknowledge and legitimize their response. I recognize how hard this must be for you. Quite honestly this sucks. Other Tips and Tricks If the situation allows, you can ask the family/ patient how they like to receive information. Do they want blunt facts or generalizations? Is there a designated leader who should be the key individual that information is passed through? Note- this isn't beneficial in all situations, such as breaking the news of a family members death in the trauma bay. Avoid euphemisms and medical jargon. Tell me more about that (to encourage them to share emotions). Handling Negative Vibes If you notice tension building, either in yourself or in the room (anger, mistrust, etc), acknowledge it. Can we talk about what’s happening here? Please share your perspective with me on this. You can ask permission to share your own take on the issue. Try to find common ground- often the well being of the patient. Keep the focus on the patient. Maintaining hope and sharing the truth Hope means different things to different people and different things to the same person as they move through their illness. It’s not our job to dole out info in a way that maintains hope. It’s our job to explore what hope means to them as we share this information. Factors that can increase hope- feeling valued, maintaining relationships, time, humor, realistic goals. Adequate pain and symptom control. Factors that can decrease hope. Feeling abandoned, devalued and isolated. Don’t say “there is nothing else I can do for you”. Other Helpful Phrases Are you surprised by this conversation? That was really hard for me to say. I can only imagine how hard it was for you to hear. What would your loved one say if they could talk to us? [This lifts the decision making burden and can help them feel like they’re advocating for what their family would want]. If they’re making a decision that conflicts with your guidance? Consider asking “what are you hoping for” or what is leading you to make this decision?" Previous Next

Places to Go, Things to Do Bucket List Places to Go, Things to Do Places I Want to Visit The Narrows- Zion National Park Apostle Islands National Lakeshore Spain (went as a kid, want to go back) √ Grand Canyon Mexico Alaska Europe Machu Picchu (Peru) Australia Hawaii √ Adventures I want to Experience Watch a Bruins game at TD Gardens in Boston Hang-gliding Backcountry camping Snowboard in Canada and Europe Horseback ride on the beach Eat at a Michelin 3-star Restaurant Things I Want to Accomplish Donate blood √ Become fluent in Spanish Start a charity Own a house in Boston Own a horse ranch Own a dog Publish something non-medical Fears to Overcome Speak in front of a large audience (EAST conference, AAST conference) √ Experiences I don't care to repeat, but glad I did them once Tough Mudder Eaten alligator and shark Things others want to do that I have no desire to do Skydiving Scuba diving Attend the Masters Previous Next

6 < Back EGS Resources Society Guidelines EAST Practice Management Guidelines. Evidence-based guidelines developed and published by EAST. Covers EGS, ICU, trauma, and injury prevention. World Society of Emergency Surgery (WSES). Guidelines and reviews covering topics including trauma, pancreatitis, colitis, cholecystitis, and large bowel malignancy, and many others. American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines. Guidelines on common colo-rectal diseases such as diverticulitis, preoperative bowel preparation, hemorrhoids, and colorectal cancer. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines and Clinical Reviews. Guidelines include cholecystitis, ERAS protocol, choledocholithiasis, laparoscopy, to name a few. American Society for Gastrointestinal Endoscopy (ASGE). Evaluation, diagnosis and management of patients undergoing GI endoscopy. Previous Next

< Back Common Conditions Trauma and ICU Patient education: Preventing infection in people with impaired spleen function (Beyond the Basics) For patients who have had their spleen removed (typically related to trauma) Patient education: Pulmonary embolism (Beyond the Basics) Also known as a blood clot in the lung or PE. Disclaimer from UpToDate (included at the end of every patient handout) [This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.] Previous Next

How to be a Terrible First Date Dating, Pt 1 How to be a Terrible First Date I've been dabbling in the world of online dating for years. Some dates have been more successful than others. But until this point, I've always had pleasant encounters. That all changed with my last couple of dates. I've been shocked to discover how different people can behave in public compared to the persona they project via text. I always imagined people would be more reckless in their text and more personable in real life. Oh, how wrong I was… My first date was a few months after I moved to town. We video chatted a handful of times before we met, and he seemed like a nice normal guy. The first clue should have been when he told me he had a lawsuit against him related to a business deal. I'm too trusting and gave him the benefit of the doubt. So…what went wrong? First, he spent the beginning of the date asking me leading judgmental questions. How many guys have I dated/ slept with, etc, etc. He proceeded to tell me I was promiscuous (really? I've dated like 7 people and I'm 35 years old). Next, he proceeded to discuss pornography and sexual preferences. Then he asked whether I thought people could know each other if they don't live together before getting married, and he told me I was wrong when I said yes. Next, he insinuated that he didn't believe that I'm a surgeon. Weird, but whatever. He went on to Google me in front of me. Like, legit. Probably spent about 10 minutes staring at his phone while I ate my dinner. A couple times I told him he should probably pay attention to the person who took time out of their day to come to meet him… Then he decided to tell me he didn't believe I was Hispanic because Hispanic women wear a lot of makeup. He found a picture from a few years ago when I was applying for a job and told me if I put in some effort, I could look better. I told him I'm so much more than my appearance, and I don't value myself based on looks. After a complete shitshow for the first half, I told him I'd give him a chance to start over and consider a different approach. I gave him the benefit of the doubt that he was just nervous. Unfortunately, he didn't adjust his approach in the second half. He then told me more details about his legal issues. Seriously, he spent a year in a work camp for white-collar criminals. He reminisced about the friends he made and the work he did. I had a hard time keeping a straight face. And the cherry on top of the terrible date? He lied about his height. He wasn't 5'6. I'm 5'3 and he didn't have an inch on me. Note- I'm not against short guys. I AM against guys who lie about their height. Don't be that guy. *Note- Grammarly assessed the tone of this post as "sad" and "disapproving". I'm impressed. Previous Next

10 < Back Research Resources Literature Search PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. For a more extensive list of surgical and critical care references, please see Medical Literature . References Zotero . Free computer program that organizes all your medical literature. Highly recommend. You can create folders and add tags to help index your documents. If you want to sync your documents across devices (phone, tablet, etc), you can purchase a storage subscription. 2 GB costs $20/ year, 6 GB costs $60/ year and $120/ year gives you unlimited data storage. Tools and shortcuts in Zotero: Automatically add articles from any electronic resource (PubMed, journal website, etc). Easily tag and sort documents into categories to help easily locate articles on a particular topic. Search your entire database of documents for any author, title, year of publication, and journal source, and perhaps most usefully- search for any individual words to find a comprehensive list of documents that address a particular topic. There is a note panel on the right side of the document that allows you to type a note while reading the article. Automatically create a note from the text you highlight while reading an article. Alternatively, if you choose to type your own notes, you can also highlight text and add a single highlighted section to the note. EndNote . Free application that simplifies citation management. Use Cite While You Write to embed references while writing manuscripts. Data Analysis Covidence . Systematic review management program. It requires a subscription. GraphPad QuickCalcs . I do NOT endorse this as the most reliable/ valid/ precise options for doing statistics. HOWEVER, I have used it for simple calculations and it always matches or is incredibly close to what my formally trained statistician reported. PubMed . National Library of Medicine, database to search for biomedical and life sciences literature. Cochrane Library . Leading journal and database for systematic reviews in health care. Research Manuscript Submission Manuscript Title Page Template .docx Download DOCX • 49KB Manuscript Cover Letter Template .docx Download DOCX • 49KB Previous Next

< Back GERD What is GERD? Gastroesophageal Reflux Disease (GERD), more commonly known as heartburn, is caused by acid from the stomach moving into the esophagus, which causes a burning pain in the middle of the chest. Anatomy After swallowing, food moves down the esophagus and into the stomach. The lower esophageal sphincter (LES), which is at the connection between the esophagus and stomach, prevents stomach contents from moving back into the esophagus. The lower esophageal sphincter is located below the diaphragm, where pressure from the abdominal organs helps keep the sphincter closed. There are different causes of GERD, but the lower esophageal sphincter is key to preventing reflux. See below for more details about why GERD occurs. Source: UpToDate Images: Gastroesophageal Reflux (GERD) Causes of GERD Decreased pressure of the lower esophageal sphincter- if the lower esophageal sphincter is too loose/ relaxed, stomach contents move more easily into the esophagus. This can be a pre-existing condition but it can also be caused or worsened by lifestyle habits. For example, tobacco and certain foods such as alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods, can also decrease the pressure of the sphincter. Eating too much/ too fast→ overfilling the stomach leads to increased pressure, causing stomach contents to be pushed into the esophagus Laying flat- when you are standing or sitting upright gravity helps avoid reflux by keeping food in the stomach, but when laying flat, stomach contents can move into the esophagus more easily. This is why symptoms are often more severe at night or first thing in the morning. Hiatal hernia - when the lower esophageal sphincter is able to move into the chest, it no longer has the external pressure normally present when it’s in it’s correct position, and it more easily allows stomach contents to move into the esophagus. See link for image. Obesity or pregnancy- increased pressure on the abdomen from excess weight can put pressure on the stomach and allows stomach contents to move into the esophagus for easily. GERD: Symptoms and Causes [Mayo Clinic: Patient Care & Health Information] Diagnosis Symptoms are often adequate to diagnosis GERD. A swallow study can provide further information. This study is performed in radiology, and involves drinking contrast material and having x-ray images taken to evaluate the esophagus and stomach while you swallow. This study can diagnose esophageal problems, such as poor muscle function leading to swallowing difficulty. In addition, a hiatal hernia can be identified. John Hopkins Medicine: Barium Swallow An esophagogastroduodenoscopy (EGD), also known as an upper endoscopy (see link) can be used to assess the inner lining of the esophagus, stomach and the first part of the small intestine (duodenum). There are many things that can be identified on an EGD, but specifically related to GERD, damage to the lining of the esophagus and the presence of a hiatal hernia can be identified with an EGD. Patient education: Upper endoscopy (Beyond the Basics) [UpToDate] Upper Endoscopy [Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)] Additional testing can be performed based on symptoms, results of initial testing and response to treatment. Esophageal manometry- a study to evaluate the muscle function of the esophagus ( pH test- a study to evaluate how much acid the esophagus is exposed to, which is one measure of the severity of GERD. GERD: Diagnosis and Treatment [Mayo Clinic: Patient Care & Health Information] Treatment Lifestyle Modifications [ Patient Handout: Anti-Reflux Diet and Lifestyle Modifications ] Eat slowly, avoid eating large meals and stop eating before you feel full. Avoiding alcohol, chocolate, caffeine, carbonation, mint, citrus/ tomato-based foods, spicy/ fried/ fatty foods. Avoid lying down for at least 2-3 hours after meals. Don't snack after dinner/ before bed. Elevating the head of the bed by 6-8 inches. This is NOT done by placing multiple pillows under your head- multiple pillows would actually increase pressure in the abdomen (like doing a sit-up or crunch). For more information, see this guide from the Kingsley clinic. Lose weight. Stop smoking. Avoid tight-fitting clothing. Medication Over the counter antacids Prescription medication Surgery Depending on how well medication and lifestyle modifications improve your GERD symptoms, and depending on the results of your other studies, such as your swallow study, esophageal manometry and pH testing, surgery may be an option for GERD. UpToDate Patient Education Patient Education: Gastroesophageal reflux disease in adults (Beyond the Basics) Previous Next

< Back Respiratory Failure- it hurts to breathe A 47-year-old male sustains multiple traumatic injuries after being struck by a vehicle while on the side of the road. He had severe thoracic trauma (bilateral pulmonary contusions), bilateral femur fractures and a liver laceration. He also had a severe TBI, requring intubation shortly after his arrival. 10 days into his hospital stay, he still requires ventilatory support. What are some of the potential causes of the patients ongoing requirement for mechanical ventilatory support? Pain from rib fractures, pneumonia, ARDS, pulmonary embolism, fat embolism, pulmonary contusions, loss of chest wall stability due to severe thoracic trauma, hypomagnesemia, volume overload, retained hemothorax, poor nutrition from inadequate protein delivery. He is undergoing a trial of spontaneous ventilation, but he develops tachypnea and hypoxemia and appears to be struggling on the ventilator. What are some of the initial steps in evaluating this patient? Physical exam (pulmonary exam, assess for edema), bedside ultrasound (pleural effusion, pneumothorax). Chest x-ray- look for infiltrates. ABG, EKG, review volume status. His chest x-ray is shown below. What do you see? Trachea midline, no effusions. Bilateral fluffy infiltrates. His current ventilator settings and ABG results are shown below. Ventilator settings: RR 12, TV 450, PEEP 10, FiO2 50. Arterial blood gas: pH 7.34, PaCO2 42, PaO2 64, HCO3 24 What does this tell you about his oxygenation? PaO2:FiO2 ratio is an indicator of oxygenation. This patients P:F ratio is 182. See below for explanation. What diagnosis is this consistent with? Acute respiratory distress syndrome. What are the management principles when caring for a patient with ARDS? What are your initial ventilator management strategies? ARDS is not a primary diagnosis, so it is important to treat the underlying cause (pancreatitis, pneumonia, etc). Minimize further insults to the lungs. Optimize ventilator strategies- low tidal volume, target PEEP/FiO2 combination to target SpO2 88-95% Diagnosis and Management of ARDS Etiologies of ARDS Pneumonia, pulmonary contusions, aspiration, inhalation Trauma, burn Pancreatitis Transfusion-related acute lung injury (TRALI) ARDS diagnostic criteria: The Berlin Definition [1] Onset of respiratory failure within 1 week of an insult that is known to cause ARDS Bilateral fluffy infiltrates on CXR not explained by effusions/ infiltrates/ contusions/ lung collapse Respiratory failure not related to heart failure or fluid overload Oxygenation PaO2/FiO2 ratio with PEEP ≥5 cm H2O. Mild 200-300, moderate 100-200, severe ≤100. Basic principles of ARDS management [2,3] Low tidal volume ventilation- 4-8 mL/kg predicted body weight. Prevent volutrauma. Permissive hypercapnia- low TV ventilation leads to decreased minute ventilation, which leads to CO2 retention (hypercapnia). Hypercapnia is tolerated as long as pH remains above 7.2. Positive end-expiratory pressure (PEEP)- goal is avoiding overdistension and optimizing recruitment If ↑PEEP→ ↓plateau pressure: recruitmentIf ↑PEEP→ ↑plateau pressure: overdistension Optimizing mean airway pressure (MAP). Prolonged inspiratory:expiratory ratio Target plateau pressure <30, driving pressure ≤15. Recruitment manuevers Advanced strategies for persistent hypoxemia Prone positioning Airway Pressure Release Ventilation (APRV) Neuromuscular blockade Inhaled vasodilators Prostacyclin and nitric oxide ECMO High frequency oscillatory ventilation Open lung ventilation Dexamethasone Extracorporeal carbon dioxide removal (ECCO2R) References Ferguson ND et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573-1582. Narendra DK et al. Update in Management of Severe Hypoxemic Respiratory Failure. Chest. 2017 Oct;152(4):867-879. SCCM Clinical Practice Guideline. Fan E et al. ATS/ SCCM CPG: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. Basic Principles of Ventilatory Management of ARDS Previous Next

< Back Anorectal Disease Anorectal pain is an incredibly common condition . Thanks to our low-fiber Western diet and often inadequate hydration, constipation is a frequent occurrence. People also often spend long periods on the toilet. We used to read books, but now many play games or text on their smartphone. Constipation and prolonged sitting on the toilet can lead to several different problems. While discussing these symptoms can be awkard or uncomfortable, please talk to your doctor if your symptoms don't go away on their own. So what is anorectal pain? Although "butt pain" may be a common complaint, I want to be clear with my explanations. In reality, “butt” more accurately refers to the gluteal region, which is also known colloquially as derriere, buttock, backside, or fanny. It may be simplest to describe the butt as the area that rests on the surface of a chair when you sit. Anorectal refers to a more specific location, the anus and rectum, where stool passes through when you have a bowel movement. Please see the anatomically correct depiction below. What are the common causes of anorectal pain? Fissures Hemorrhoids Pruritis Ani Abscesses Less common- pelvic floor dysfunction, cancer Anatomy of the anus and rectum Two sphincter complexes encircle the rectal vault. The internal sphincter provides 85% of the resting tone. It is under involuntary control- this is how your body controls when you have a bowel movement. The external sphincter provides 15% of resting tone- it is under voluntary control, which means this is how you consciously control holding in a bowel movement. The internal hemorrhoids are veins that line the inside of the rectum, while the external hemorrhoid plexus is on the anal verge. These means that hemorrhoids are a NORMAL part of anatomy! They fill with blood to aid in incontinence, helping you control when you have a bowel movement. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. See “Hemorrhoids” below for more details. Glands line the inside of the rectum and help lubricate stool. When the glands become obstructed, they can lead to abscesses. What are the common symptoms of anorectal disease? Pain Bleeding- either blood dripping in the toilet, blood on the toilet paper with wiping, and blood mixed with or on the stool's surface. Mucus drainage (constant moisture), which can cause challenges with perianal hygiene Pruritis (itching) Palpable mass Constipation/ diarrhea, incomplete voiding What causes anorectal disease? Prolonged straining or prolonged time sitting on the toilet, often due to constipation (hemorrhoids) Constipation and passing a hard stool can lead to tears in the skin (fissure) Underlying gastrointestinal disease (inflammatory bowel disease, etc.) How do I prevent anorectal disease? The goal is to improve bowel habits and minimize constipation. High fiber diet. Most Americans have a low-fiber diet, consuming way less than the recommended 20-35 grams of fiber per day. Fiber can come from dietary intake (the foods you eat) as well as supplements. Take the time to read labels. The foods we commonly think of as “high-fiber,” including lettuce, are not as fiber-rich as we think. A word of warning If you quickly add a significant amount of fiber to your diet, this can lead to gastrointestinal distress (gas, diarrhea, cramping, etc.). Add fiber slowly until you reach your goal! Stay hydrated! Fiber without adequate hydration will create hard stools (rabbit pellets), making constipation worse. The recommendation is a minimize of 64 ounces of water per day. Plain water is best, but flavoring with Crystal Light, lemon, or lime can make it more palatable. Listen to your body regarding bowel movements. Hold it until socially acceptable, but don’t hold for longer than necessary. But just as important, don’t force a bowel movement if you don’t feel the urge. Some people may be trained to try to have a bowel movement before leaving for work- if this works for you, that’s fine. But don’t let the clock dictate when you have to use the bathroom. Minimize the amount of time sitting on a toilet. Prolonged sitting increases pressure, which predisposes to pathology. If you are still having challenges, consider investing in a device to facilitate improving your posture. We are accustomed to using toilets…unfortunately, sitting creates an angle that makes it difficult to have a bowel movement. Squatting, with knees elevated closer to the chest, creates a straighter path leading to more optimal conditions to have a bowel movement. Consider a squatty potty! Specific Anorectal Pathology Hemorrhoids Anal Fissures Pruritis Ani Patient Info- Fiber Guide .pdf Download PDF • 68KB Patient Info- Hemorrhoids .pdf Download PDF • 58KB Patient Info- Anal Fissure .pdf Download PDF • 59KB Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Constipation .pdf Download PDF • 54KB Previous Next

Learning how to live with an ostomy Peer Support < Back Learning how to live with an ostomy Acute Care Surgery can lead to a need for subsequent elective procedures, including ostomy reversals, abdominal wall reconstruction after open abdomen management, and various wounds. I frequently see young, healthy males with ostomies. Thankfully, most patients are great candidates for reversal. But there are a variety of reasons why patients can't undergo reversal, at least not immediately. Injury to the anorectal sphincter complex would put the patient at a very high risk of incontinence. Another possibility is when the ostomy was created in the setting of acute bowel perforation, with an undiagnosed underlying inflammatory process. Reversing an ostomy without further workup could be problematic. I have seen several young, healthy males who have to spend at least a handful of months with their ostomy while undergoing preoperative workup, and more than one who will likely have a prolonged or permanent ostomy. This can be daunting, especially when they were anticipating minimal delay before undergoing a reversal. Common concerns include how to wear normal clothes and how to manage the odor. While I can be supportive, I don't have any first-hand experience of living with an ostomy. One particular patient expressed a desire to return to college, but he was convinced that he couldn’t go to class with an ostomy. Essentially he was resigned to putting his life on hold until his ostomy was reversed. His situation inspired me to seek out a peer who could show him it's possible to live with an ostomy. I reached out to my network of medical personnel that might know how to connect a patient with a peer support group. We have multiple support groups, including trauma survivors, epilepsy, and stroke, to name a few. Unfortunately, I quickly realized there is no group or service to link patients with someone who will answer their questions and hopefully decrease their fears and worries. Many of the trauma patients who have an ostomy are young and healthy, leading active lives. Unlike elective ostomies, such as for inflammatory bowel disease, waking up after trauma with an ostomy is unanticipated and can be very distressing. Also, there is minimal or no chance for preoperative patient education. There is a certain taboo associated with talking about certain bodily functions, and I don't think many young males would ask their trauma surgeon if there is someone they can talk to about having an ostomy. But I think this could be an opportunity to improve the quality of life for a population that is likely overlooked. Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next