Sharing my interests

Call me a nerd but there are a few concepts I want to do a deeper dive into. Maybe you have the same questions that I have.

1. The concept of the diastolic blood pressure and its effect on coronary artery perfusion (or coronary perfusion pressure) and in turn cerebral artery perfusion (cerebral perfusion pressure). Most of us medical people at times only care about systolic blood pressure (SBP) or mean arterial pressure (MAP). If our MAP is low, most of the time we may default our inotropes and pressors to achieve SBP>90-100mmHg because it’s “only the diastolic that’s bringing it down.” I wonder if that has detrimental affects? EM/Critical care doc Frank Lodeserto, MD simplifies that low DBP is low SVR. But it’s also the moment that blood is not ejected forward and where blood fills the ventricles (in turn RV perfusion) and the aortic root.
2. Type 1 and type 2 lactic acid. I’m bringing up Lodeserto, MD a lot but he proposes that elevated lactate from anaerobic respiration and tissue hypo-perfusion is a myth and is actually from increased beta-adrenergeric stimulation from exogenous adrenaline (your epi gtts) or natural beta stimuation from high output shock (vasodilatory shock). I’ve been observing more “type 2 lactatemias” in the absence of shock (I guess I have to add metformin use, too). Throwback to cyclic-AMP, pyruvate, acetyl-coA and ATP, Kreb Cycle anyone?
3. What to try more of: Using more capillary refill time (CRT) for shock and end-organ perfusion measurement (more than just using measured lactate levels) in my clinical practice in the CCU. ANDROMEDA-SHOCK trial. Note: this is was only tested in septic shock patients and not cardiogenic shock. The results of this trial found no difference in 28-day mortality between using serial lactate measurements and CRT. But it proposes CRT may be just as good as lactate measurement. CRT also lowered SOFA-score and fluid boluses compared to lactate measurement.
4. Consider: obtaining higher MAP goals (even more than >65) during post-arrest therapeutic hypothermia if there is more evidence of cerebral swelling on initial head CT in order to increase cerebral perfusion.
5. Need to look more at magnesium sulfate administration and its role in post-resuscitation syndrome. Does it really help with cerebral dilation and help neurological outcomes during cooling?
6. More more conscious of: where I insert my art lines when I’m in the groin. Common femoral? External iliac? Internal iliac? Superior femoral?

Proximal>distal order: Common iliac>branches to internal iliac, external iliac>common fem>>deep fem>superior fem.

Imagine cannulating your ECMO VA limb into the internal iliac? That sounds like badness.

More to come.

Dk