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Driving Pressure Vs Tidal Volume in ARDS Dr Swapnil Pawar
EFFORT Trial Dr Swapnil Pawar
Thrombolysis in Submassive PE Dr Swapnil Pawar
CVS Physiology Part 3 Dr Swapnil Pawar

Opinion

Background

eCritCare Podcast

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Driving Pressure Vs Tidal Volume in ARDS

Dr Swapnil Pawar January 20, 2020

Recently there has been a growing interest in driving pressure as a significant parameter for titration in mechanical ventilation for ARDS patients. It has challenged our dogma of 6-8 mls/kg tidal volume ventilation. In this podcast, we discuss the current evidence and future of mechanical ventilation in ARDS. Our understanding of mechanical ventilation in ARDS has evolved significantly since the year 2000. The key concepts that have been accepted in practice include low tidal volumes, low plateau pressure, lower driving pressures and reduced frequency of injurious strain cycles. The main focus is to avoid ventilator-associated lung injury. With the recent […]

eCritCare Podcast

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EFFORT Trial

Dr Swapnil Pawar January 13, 2020

Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial Anorexia arises as a physiological response to acute illness and predisposes hospital inpatients to serious caloric and protein deficits. In combination with immobilisation and pronounced inflammatory and endocrine stress response, these nutritional deficits contribute to muscle wasting and progressive deterioration of metabolic and functional status, particularly in medical patients with multiple morbidities. Hospitals don’t provide the best possible food and often patients complain about the quality of the food. More than 30% of medical inpatients are at increased risk of malnutrition, a […]

eCritCare Podcast

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Thrombolysis in Submassive PE

Dr Swapnil Pawar December 31, 2019

The role of thrombolysis in submassive PE remains controversial to date. In this podcast, Dr Chacko & I dive deeper to explore the current evidence on this topic. What is Submassive PE and what are the key differences between Submissive and Massive PE The terms massive, submassive, and low-risk PE have been coined to risk stratify PE based on the likelihood of mortality. Massive PE is characterized by sustained hypotension with a systolic pressure of < 90 mm for >15 minutes or the requirement for vasopressor support. A submassive PE does not cause hypotension but causes right heart strain, dilation, […]

Educator's Podcast

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Community of Practice in MedEd

Dr Swapnil Pawar December 29, 2019

Learning is a social rather than an individual activity, and much of it occurs at the unconscious level, resulting in the acquisition of a large body of tacit knowledge. In this podcast, Dr Alice Fornari who is Vice President of Faculty Development at Northwell Health System and Associate Dean at the Donald and Barbara Zucker School of Medicine helps budding educators to understand this novel concept. 3 key characteristics for the successful development of Community of Practice – Relationship Building Passion for the topic Sharing of resources Speaker Bio – Dr Fornari is the Associate Dean of Educational Skills Development, […]

eCritCare Podcast

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High Wean Trial

Dr Swapnil Pawar December 23, 2019

Liberating high-risk patients from mechanical ventilation poses a unique challenge to all intensive care physicians. The use of high flow has increased over the last decade, however, the combination of high flow nasal oxygen and NIV has not been tested so far. The present study published in JAMA tries to answer this dilemma. Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial The decision regarding when to liberate patients from mechanical ventilation faces intensive care unit (ICU) clinicians regularly. While this […]

eCritCare Podcast

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ICP Monitoring in TBI

Dr Swapnil Pawar December 1, 2019

TBI remains a major cause of death and disability worldwide. Poor outcome is associated in part with the primary insult and importantly from secondary brain injury, which is a complex series of pathologic events triggered in the early phase after TBI that then evolve over time. Apart from treating Primary pathology, modern TBI management focuses on the prevention, identification and management of SBI. Neuromonitoring is central to SBI management. This includes serial clinical examination, imaging and the use of invasive and non-invasive devices that allow cerebral physiology to be assessed over time. Traditionally neuromonitoring has focussed on ICP monitoring which […]

ICU Primary Prepcast

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CVS Physiology Part 2

Dr Swapnil Pawar December 1, 2019

CARDIOLOGY PHYSIOLOGY Describe the cardiovascular events that occur during ventricular systole and diastole The cardiac cycle is made up of two phases defined by the mechanical activity of cardiac muscles, systole which is ventricular contraction lasting about 300miliseconds and diastole which is ventricular relaxation and lasts about 500miliseconds. The cardiovascular events that occur during these phases can be subdivided into mechanical and electrochemical events: Ventricular Systole: Mechanical Isovolumetric contraction At the beginning of ventricular systole, the atrioventricular valves close, heard as the first heart sound, and the intraventricular pressure rises rapidly. This rise in pressure causes the AV valves to […]

Educator's Podcast

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MicroAggression in Medicine

Dr Swapnil Pawar November 30, 2019

Podcast with Dr Ruth Gotian Microaggression is well recognised but less talked problem in medicine. In this podcast, Dr Ruth Gotian from Weil Cornell Medicine, New York talks about this concept and helps us to understand various strategies to deal with Microaggressions in Medicine. Dr Ruth Gotian is Assistant Dean for Mentoring, Executive Director, Mentoring Academy, Chief Learning Officer in Anesthesiology and Assistant Professor of Education in Anesthesiology at Weill Cornell Medicine

eCritCare Podcast

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ANTHARTIC Trial

Dr Swapnil Pawar November 24, 2019

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest CRICS-TRIGGERSEP Network and the ANTHARTIC Study Group Even though controversies persist, targeted temperature management at 32 to 36°C remains recommended in patients with out-of-hospital cardiac arrest. Since it has beneficial effects on morbidity and mortality. However, targeted temperature management is associated with an increased risk of secondary infections and constitutes an independent risk factor for early ventilator-associated pneumonia. What’s known? The key early study suggesting the benefit of single-day administration of cefuroxime in patients with coma was performed more than 20 years ago. Few studies have been conducted since, including one single-centre, […]

eCritCare Podcast

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Stress Ulcer Prophylaxis in ICU

Dr Swapnil Pawar November 17, 2019

Dr Jose Chacko & Dr Swapnil Pawar Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. A survey of 58 ICUs in North America, mainly in university teaching hospitals, revealed that 84% of patients admitted to the ICUs received SUP, with proton pump inhibitors being the most commonly used agents. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and the […]

eCritCare Podcast

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ICU ROX Trial

Dr Swapnil Pawar November 10, 2019

Conservative Oxygen Therapy during Mechanical Ventilation in the ICU The ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group Oxygen is a vital element in medical practice and among the most universally used agents for the treatment of critically ill patients. Guidelines for the provision of oxygen give recommendations for target oxygen saturations and for the weaning of oxygen therapy. Despite this, the titration of supplemental oxygen in mechanically ventilated patients is infrequent with resultant hyperoxia being common in the intensive care unit (ICU). Hyperoxia can be defined as a state in which supraphysiological levels […]

eCritCare Podcast

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Transfusion Thresholds in ICU

Dr Swapnil Pawar November 3, 2019

Dr. Jose Chacko & Dr. Swapnil Pawar Anaemia is a common condition associated with critically ill patients admitted to an intensive care unit (ICU). The World Health Organization (WHO) defines anaemia as a haemoglobin (Hb) level less than 13 g/dL(milligram per decilitre) in men and less than 12 g/dL in women. Various studies have shown that approximately two-thirds of critical patients admitted to an ICU have a haemoglobin concentration of less than 12 g/dl on the day of admission, and 97% of the patients become anemic after a week in ICU. The cause of anemia in critical illness is complex […]

Educator's Podcast

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The Role of Infographics in Medical Education

Dr Swapnil Pawar October 28, 2019

Dr Ben Symon & Dr Swapnil Pawar There has been a trend of the increasing use of infographics in Medical Education. In this thought-provoking podcast, Dr Ben Symon from Brisbane advises budding educators to use it as an adjunct rather than the primary pedagogy. He talks about the role of infographics in promoting scholarship in MedEd and shares his insights in designing the better infographics. Resources – Martin L et al. Exploring the Role of Infographics for Summarizing Medical Literature. Health Professions Education 5 (2019) 48–57 Huang, S., Martin, L.J., Yeh, C.H., Chin, A., Murray, H., Sanderson, W.B., Mohindra, R., […]

eCritCare Podcast

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CRASH 3 – A Fairy Tale of Victory of Tranexamic acid & Dr Utako Okamoto

Dr Swapnil Pawar October 26, 2019

Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial Intro – As we know, TRANEXAMIC ACID is a synthetic analogue of the amino acid Lysine. It reduces bleeding by preventing the breakdown of fibrin clots i.e fibrinolysis. The CRASH-2 trial showed that in patients with trauma with major extracranial bleeding, early administration (within 3 h of injury) of tranexamic acid reduces bleeding deaths by a third. Subsequent analyses showed that even a short delay in treatment reduces the benefit of tranexamic acid administration. However, […]

eCritCare Podcast

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NIV iN ARDS

Dr Swapnil Pawar October 20, 2019

Dr Swapnil Pawar & Dr Jose Chacko Noninvasive ventilation (NIV) is a well-established treatment for acute respiratory failure, especially in patients with hypercapnia and cardiogenic pulmonary edema. Conversely, the use of NIV for hypoxemic respiratory failure, including acute respiratory distress syndrome (ARDS), is still controversial. What’s the pathophysiology of ARDS? ARDS is characterized by diffuse alveolar damage and pulmonary capillary endothelial injury. The alveolar-capillary barrier is formed by the microvascular endothelium and the epithelial lining of the alveoli. A variety of insults resulting in damage either to the vascular endothelium or to the alveolar epithelium could result in ARDS. Early ARDS […]

eCritCare Podcast

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Targeted Temperature Management & Non-shockable Rhythms

Dr Swapnil Pawar October 13, 2019

HYPERION TRIAL Dr Jose Chacko & Dr Swapnil Pawar Targeted temperature management with a target of 32 degrees C to 36 degrees C (moderate therapeutic hypothermia) is currently advocated by ILCOR guidelines for all patients with coma after successful resuscitation from cardiac arrest. TTM Trial results published in 2013, however, showed inconclusive effects of this treatment in 19% of patients who had cardiac arrest with a nonshockable rhythm (asystole or pulseless electrical activity), and the use of hypothermia subsequently decreased in this situation. the study by Paul young et al showed the dramatic change in practices in ANZ post TTM […]

eCritCare Podcast

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Augmented Renal Clearance in ICU

Dr Swapnil Pawar October 5, 2019

Dr Swapnil Pawar & Dr Jose Chacko What is ARC? Augmented renal clearance (ARC) is the phenomenon of enhanced renal function in critically ill patients. ARC is characterized by a higher than predicted increase in the renal elimination of solutes. It occurs due to an increase in glomerular filtration and altered renal tubular function, usually manifest as an increase in the creatinine clearance. ARC leads to increased clearance of drugs excreted through the kidneys resulting in suboptimal concentrations of important medications, including antibiotics, and may lead to treatment failure. This phenomenon was first described more than 40 years ago in […]

eCritCare Podcast

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ICU Journal Club- COACT Trial

Dr Swapnil Pawar September 29, 2019

Dr Swapnil Pawar & Dr Jose Chacko Coronary Angiography after Cardiac Arrest without ST-Segment Elevation Lemkes et al https://www.nejm.org/doi/10.1056/NEJMoa1816897 Background – Out-of-hospital cardiac arrest is a leading cause of death. A recent study reported a mortality of approximately 40% among patients who had been successfully resuscitated after out-of-hospital cardiac arrest associated with ventricular fibrillation or pulseless ventricular tachycardia. The most frequent cause of cardiac arrest is ischemic heart disease, and coronary artery disease has been reported in up to 70% of patients who have been resuscitated and are referred for immediate coronary angiography. However, the cause of arrest is often unclear immediately after the event, and the lack of […]

eCritCare Podcast

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Gastrointestinal

Nutrition in Acute Pancreatitis

Dr Swapnil Pawar September 23, 2019

by Dr Jose Chacko & Dr Swapnil Pawar Acute pancreatitis is the leading cause of acute hospital admission for gastrointestinal disorders in many countries, and its incidence continues to rise worldwide. The annual incidence of AP ranges from 13 to 45 cases per 100,000 population with the global estimate of 33.74 cases per 100,000 population, causing uneven burden across the globe. The health-care cost in the United States is reported to be $2.5 billion. The overall mortality ranges from 5 to 20% depending on severity. In patients who develop severe necrotizing pancreatitis, mortality is approximately 15%. In cases of infection […]

eCritCare Podcast

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ICU Journal Club – SBT T-piece Vs PSV

Dr Swapnil Pawar September 15, 2019

by Dr Swapnil Pawar & Dr Jose Chacko Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation A Randomized Clinical Trial Background – The latest American Thoracic Society guidelines for weaning recommend PSV SBTs with moderate-quality evidence. Among patients receiving mechanical ventilation, readiness for extubation and liberation from ventilatory support is evaluated with a spontaneous breathing trial (SBT). Daily screening of respiratory function by SBT is associated with a shorter duration of mechanical ventilation. After a successful SBT and extubation, 10% to 25% of patients require reintubation, and reintubation […]

eCritCare Podcast

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IABP in Cardiogenic Shock

Dr Swapnil Pawar September 7, 2019

by Dr Swapnil Pawar & Dr Jose Chacko

eCritCare Podcast

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ICU Journal Club – VICCSS Study

Dr Swapnil Pawar September 1, 2019

Dr Swapnil Pawar & Dr Jose Chacko A Pilot, Randomised, Double-Blind Study of Vitamin C in the treatment of Vasoplegic Shock after Cardiac Surgery https://doi.org/10.1053/j.jvca.2019.08.034 Background- High dose vitamin C has a strong biological rationale in post-cardiac surgery vasoplegia. Vitamin C scavenges reactive oxygen species, which likely contribute to vasoplegia after cardiac surgery, stimulates norepinephrine synthesis, decreases the incidence of atrial fibrillation, cardiac enzyme release, and the level of markers of oxidative stress. In addition, cardiac surgery patients have decreased vitamin C levels compared to preoperative values suggesting increased consumption and/or dilution. What’s Known- high dose intravenous vitamin C has […]

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Critical Care Pattern 4 – Tracheostomy

Dr Swapnil Pawar July 28, 2019

Although increasingly less frequent, placement of a tracheostomy has become a viable alternative to prolonged endotracheal intubation, with the benefits of improving patient comfort, reducing need for sedation, lowering airway resistance, and allowing for easier airway care. There has been considerable debate on the technique, timing and selection of ICU patients. In this review, I cover what’s the current consensus and share my preferred approach.

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Critical Care Pattern 3- ARDS

Dr Swapnil Pawar July 14, 2019

ARDS is a syndrome and our current approach of “one size fits all” is probably not the right approach to deal with this beast. In this doodly, I managed to summarise my evidence based approach in a graphical way. We need to be cautious while interpreting the evidence and should not jump to the conclusion about certain interventions such as recruitment.

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Critical Care Pattern 2- Traumatic Brain Injury

Dr Swapnil Pawar July 9, 2019

Traumatic brain injury is one of the common patterns that is seen in major ICUs. This doodly is created to discuss the evidence-based approach for the management of traumatic brain injury.

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Critical Care Patterns

Dr Swapnil Pawar June 7, 2019

Critical Care Patterns Intensive care is about recognizing the right pattern and then treating accordingly. It’s similar to game of Chess, where grand masters look at the board, recognize the pattern and make a next move. In this series, I will bring different critical care patterns, which will be helpful to all ICU trainees for their exam preparation and day to day patient management.

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Networking as a Medical Educator

Dr Swapnil Pawar January 1, 2019

by Swapnil Pawar and Mike Gisondi What is Networking? Networking is the sharing of ideas through a conversation between individuals who have something in common. It’s that simple. The word, ‘networking’, carries a negative connotation, an activity carried out by the ruthless to get ahead. Not true of networking in medical education. The wonderful example of the power of networking in medical education is ALiEM: Academic Life In Emergency Medicine. ALiEM is a globally distributed digital community of practice hosted as a blog and podcast out of the United States. The organization has grown and enriched over the past 5 […]

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Life & Death in Intensive Care- Not Quite Straight Forward

Dr Swapnil Pawar November 10, 2018

In this thought-provoking talk, Dr Arvind Rajamani from Nepean Intensive Care speaks about his approach towards the end of life care in ICU. The second week in ICU deserves a second look, and we need to ask ourselves a question regarding the appropriateness of treatment in the select group of patients, says Dr Rajamani.

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Steroids for Septic Shock – Do We Finally Know The Answer ?

Dr Swapnil Pawar August 10, 2018

In this thought-provoking talk, world-renowned intensive care researcher Professor Simon Finfer shares his viewpoint on this highly controversial topic. Not only he exposes the flaws in previous trial designs but acknowledges the change in his practice after the publication of ADRENAL trial.

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Echo Debate- Should We Use Echocardiography for Fluid Status Assessment in Critically Ill Patient

Dr Swapnil Pawar July 30, 2018

In this epic debate, two experts Dr Sam Orde & Dr Yang Yang along with echo stalwart A/Prof Konstantin Yastrebov explore the current role of echocardiography in fluid status assessment in critically ill patients. This is a highly controversial topic and choosing a winner is merely impossible.

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Acute RV Failure

Dr Swapnil Pawar July 20, 2018

The left ventricle (LV) gets the glory typically. Any echo request usually relates to LV ejection fraction, filing status or regional wall motion abnormality. Perhaps this is fair enough as the LV is a significant contributor to blood flow and organ perfusion, but as Pinsky said at the CICM ASM in Hobart “Right ventricle (RV) function is not considered important for cardiac function until it is … and then it’s everything”. RV dysfunction is rife in the ICU: as a direct result of diseases such as sepsis, and indirectly by mechanical ventilation or pulmonary hypertension, and it is strongly associated […]

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Research Ethics in Clinical Medicine – Doing Good Research

Dr Swapnil Pawar July 10, 2018

Clinical research helps mankind to save lives. Yet, there are many dark pages in the history of clinical research that can not be ignored. In this informative talk, A/Prof Ian Seppelt talk about research ethics in clinical medicine and how we should get it right in order to do a good research.

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Reappraisal of Fluid Therapy in ICU

Dr Swapnil Pawar July 3, 2018

World renowned expert Prof John Myburgh AO sharing his pearls of wisdom about the rational approach towards IV fluid therapy in Intensive Care.

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Post-Cardiac Arrest Management – Time to Say Goodbye to Self Fulfilling Prophesy

Dr Swapnil Pawar July 3, 2018

Robert Rosenthal defined the Pygmalion effect as “the phenomenon whereby one person’s expectation for another person’s behavior comes to serve as a self-fulfilling prophecy” (1) 2015 ILCOR guidelines (2) seem to sway away from self-fulfilling prophesy approach in prognostication post cardiac arrest patients. Successful return of spontaneous circulation (ROSC) is the first step towards the goal of complete recovery from cardiac arrest. The complex pathophysiological processes that occur following whole-body ischemia during cardiac arrest and the subsequent reperfusion response during CPR and following successful resuscitation have been termed the post-cardiac arrest syndrome. The post-cardiac arrest syndrome comprises post-cardiac arrest brain […]

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Mechanical Chest Compression Devices, are we looking at the new MAST suit?

Dr Swapnil Pawar July 2, 2018

Similarities between the implementation and withdrawal of the military antishock trousers (MAST suit) and the implementation of mechanical chest compression devices are made. The MAST suit has a specific place in the history of prehospital care and emergency care rising in popularity and being withdrawn over a period of approximately 30 years. Both devices demonstrated effectiveness against the surrogate markers of raising blood pressure for the MAST suit and improving perfusion under CPR for the mechanical chest compression devices. Unfortunately, both have provided disappointing results against the ultimate outcome marker of survival. The possibility that the chest compression devices will […]

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Lung Recruitment in ARDS:To Be Or Not To Be

Dr Swapnil Pawar June 18, 2018

ART trial created a lot of confusion in intensive care community with regards to use of Lung recruitment in ARDS. In this presentation, I tried to present a comprehensive overview of the use of lung recruitment. As Hippocrates mentioned, it’s time to understand which person has a disease rather what disease a person has.

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Ecology in ICU- How Can We Get It Right ?

Dr Swapnil Pawar May 10, 2018

Critical Care infection landscape is constantly changing, which poses numerous challenges to ICU physicians. In this thought provoking talk, Professor Jon Iredell from University of Sydney shares his thoughts about the approach to get it right.

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HepatoRenal Syndrome- Contain the Beast, if You Can

Dr Swapnil Pawar May 8, 2018

Introduction Hepato-renal syndrome is a major complication of decompensated cirrhosis, entailing significant morbidity and mortality in the absence of liver transplant. It still remains a clinical diagnosis of exclusion due to lack of specific diagnostic markers. It is classified as either rapidly developing acute kidney injury (AKI) HRS type 1 or slowly developing chronic kidney disease (CKD) type 2. Both types of HRS are associated with significant decrease in renal blood flow and GFR. The median survival after diagnosis is roughly 1 month for HRS type 1 and 6.7 months for HRS type 2.(1) History and Pathophysiology The association of […]

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Reappraisal of Fluid Therapy in ICU

Dr Swapnil Pawar March 10, 2018

World renowned expert Prof John Myburgh AO sharing his pearls of wisdom about the rational approach towards IV fluid therapy in Intensive Care.

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Organ Donation – Past, Present & Future

Jose Chacko March 8, 2018

Welcome to ANZICS NSW Critical Care Pearls Series. In this inaugural lecture, A/Prof Michael O’Leary shares his thoughts on changing landscape of Organ donation in Australia.