Sccmtexaschapter.org texaschapter.sccm@gmail.com SCCM Texas Chapter

Mailing Address: TSCCM, 2429 Bissonnet Suite 461, Houston, Texas, 77005

The Texas Chapter Society of Cri�cal Care Medicine has concluded another great year un-

der the leadership of Brad Domonoske, Pharm.D. Thanks to Brad, the Execu�ve Board and

the Board of Directors, the Texas Chapter has exceeded 300 members, and is the largest

chapter of the SCCM Chapters Alliance. We con�nue to have very ac�ve educa�onal

mee�ngs in Dallas, Houston and San Antonio and held our first annual symposium. Addi-

�onally, we provided 2 Alan Fields Scholarships for abstract presenta�ons at the SCCM

Congress in San Juan. Our opera�onal procedures are well developed, the Board is ac�vely

engaged and we are well represented at the SCCM Central level.

For 2013 our goals are somewhat ambi�ous:

• Increase membership by 10%, through a targeted membership drive

• Hold a two Day 2nd

Annual Symposium in the fall of 2013

• Develop an awards commi3ee to recognize outstanding prac��oners in each of the

disciplines of our chapter

• Revise/modernize the chapter by-laws to reflect current opera�onal prac�ces and

expand representa�on of the districts on the Board

We are always looking for individuals that want to get involved, and we are always willing

to entertain new and exci�ng ideas of how to provide benefits to the membership. If you

are willing to put in a li3le work, want to contribute, and want to add to your resume you

can get involved by contac�ng one of the board members or myself. I’m looking specifically

for members that want to contribute to the program commi3ee and help organize this

year’s symposium. Thanks again and here’s to another

successful year for our chapter!

Ken Harge3, MHA, RRT, FAARC, FCCM

President – Texas Chapter SCCM

President’s Address President’s Address President’s Address President’s Address ---- Ken HargettKen HargettKen HargettKen Hargett

INS IDE THIS I SSUE :

Committee updatesCommittee updatesCommittee updatesCommittee updates 2222----3333

Updates from the Updates from the Updates from the Updates from the

surviving sepsis surviving sepsis surviving sepsis surviving sepsis

guidelinesguidelinesguidelinesguidelines

4444----5555

Interview with Alan Mintz Interview with Alan Mintz Interview with Alan Mintz Interview with Alan Mintz

on his experience in on his experience in on his experience in on his experience in

the militarythe militarythe militarythe military

6666----8888

Society of Critical Care Medicine - Texas Chapter

Critical Care CornerCritical Care CornerCritical Care CornerCritical Care Corner

M A R C H 2 0 1 3 , V O L U M E 3 , I S S U E 1

EDUCAT I ONAL EDUCAT I ONAL EDUCAT I ONAL EDUCAT I ONAL

PROGRAMSPROGRAMSPROGRAMSPROGRAMS

HOUSTON HOUSTON HOUSTON HOUSTON

TBATBATBATBA D A L LAS/ FORT WORTHDALLAS/ FORT WORTHDALLAS/ FORT WORTHDALLAS/ FORT WORTH

TBATBATBATBA SAN ANTON I OSAN ANTON I OSAN ANTON I OSAN ANTON I O

MAY 29THMAY 29THMAY 29THMAY 29TH

For complete program details,

go to the Chapter EventsChapter EventsChapter EventsChapter Events

page at

Sccmtexaschapter.orgSccmtexaschapter.orgSccmtexaschapter.orgSccmtexaschapter.org

Society of Critical Care Medicine Texas Society of Critical Care Medicine Texas Society of Critical Care Medicine Texas Society of Critical Care Medicine Texas

The Texas Chapter would like to thank Brad Domonoske, immediate past-president, for his hard work and contributions to the chap-ter over the last 12 months. (Brad Domono-ske (right) pictured with current president Ken Hargett, accepting an award at the March

Chapter meeting in Houston)

P A G E 2

Programs Committee Update: Programs Committee Update: Programs Committee Update: Programs Committee Update: Brian Dee, PharmD, BCPS, BCNSP

The Program Committee had a busy start to 2013! Our Dallas membership enjoyed a presentation

by Dr. Oladapo Afolabi, MD, on “Understanding Hyponatremia: Treating Beyond the Primary Di-

agnosis” on March 7th. Dr. Cesar Arias, MD, presented “The Challenges of Managing MRSA

Bacteremia and Skin and Skin Structure Infections: Use of Broad Versus Targeted Therapy” in

Houston on March 20th. Members in San Antonio had the opportunity to learn more about “The

Role of Procalcitonin in Sepsis” from Dr. Mark Broyles, PharmD, on March 27th. We’re looking

forward to providing more exceptional education and networking opportunities for the remainder

of the year!

The tentative date for our upcoming chapter meeting in San Antonio is May 29th. The dates for

the next chapter meetings in Dallas and Houston are currently pending. Be sure to check out our

website (www.sccmtexaschapter.org) for the latest information on all the upcoming chapter meet-

ings in Dallas, Houston, and San Antonio! If you have any suggestions for future meetings, or

would like to become involved in the Program Committee, please contact Brian Dee, PharmD, at

programs@sccmtexaschapter.org.

Membership Committee Update: Membership Committee Update: Membership Committee Update: Membership Committee Update: Rina Patel, PharmD, BCNSP

Communications Committee Update: Communications Committee Update: Communications Committee Update: Communications Committee Update: Brandon Sterling, RN, BSN, CCRN

The Texas Chapter membership has grown greatly over the past several years, and we currently

have 308 active members in the chapter! This great expansion for the chapter couldn’t have been

done without the efforts of many current members. We would like to thank the following members

for their recruitment efforts!!

Houston: Michelle Galvan - recruited 10 new members!!

Houston: Gay Sevilla - recruited 3 new members

San Antonio: Rebecca Attridge - recruited 3 new members

Dallas: Lyndsay Sheperd - recruited 2 new members

Thanks to everyone for their help. Remember with 3 newly recruited members (2 if outside of

Houston area) you can earn a free year of membership dues (does not include free in-training

memberships)

The 2013 chapter symposium is sure to be a success thanks in part to the individuals who help

coordinate and volunteer their time for the event. Interested in helping out? Go to the chapter

webpage and click the link on the homepage to sign up for any volunteer committee’s that you are

interested in!

We will be kicking off a membership drive very soon….be on the lookout for communications

from our committee regarding flyers, social media recruiting and email correspondence. We are

also launching a twitter account so be sure to follow our chapter on Twitter for important updates

and communications….more details to come soon!

FUTURE

CONGRESSES

Jan 9-13, 2014 Moscone Center

San Francisco, CA

Jan 17-21, 2015

Phoenix Convention

Center

Phoenix, AZ

Feb 20-24, 2016

Orange County

Convention Center

Orlando, FL

Jan 21-25, 2017 Hawaii Convention

Center

Honolulu, HI

Feb 24-28 2018 San Antonio

Convention Center

San Antonio, TX

Feb 16-20, 2019 San Diego

Convention Center

San Diego, CA

Feb 15-19, 2020 Orange County

Convention Center

Orlando, FL

50th Annual

Critical Care

Congress

Jan 23-27, 2021 Los Angeles

Convention Center

Los Angeles, CA

P A G E 3

V O L U M E 3 , I S S U E 1

Looking for those interested to help on committees Looking for those interested to help on committees Looking for those interested to help on committees Looking for those interested to help on committees and special projectsand special projectsand special projectsand special projects

Port Authority Signature® - Cool Mesh™ Polo with Tipping Stripe Trim

This soft, garment washed polo makes whatever comes your way a breeze.

The breathable mesh weave helps keep you cool while the cotton knit as-

sures you look it.

• 6.3-ounce, 100% ring spun combed cotton

• Double-needle stitching throughout

• Flat knit collar and cuffs

• 3-button placket with horn-tone buttons

$35

Research Committee Update: Research Committee Update: Research Committee Update: Research Committee Update: Raj Gandhi, MD, PhD, FACS, FCCM, FCCP

The research committee has several exciting ideas planned for the upcoming year and would

love for you to get involved. One of our ideas is to help current chapter members with their ap-

plications for Fellow of Critical Care Medicine. The deadline for submission just passed but it is

a long process and it’s never too early to start. Please contact the research committee for advice

with you application!

Are you currently a Fellow of the Society of Critical Care Medicine? If so, and you would like

to serve as an advisor to other chapter members, please let us know. The chapter has many

accomplished clinicians and our members can greatly benefit from your advice!

To get involved with FCCM mentoring or for any other research ideas please contact the

research committee at: research@sccmtexaschapter.org

Official TSCCM polo! Available now! Official TSCCM polo! Available now! Official TSCCM polo! Available now! Official TSCCM polo! Available now! To order, go to sccmtexaschapter.orgTo order, go to sccmtexaschapter.orgTo order, go to sccmtexaschapter.orgTo order, go to sccmtexaschapter.org

• Want to help organize local meetings?

Contact Brian Dee, our Programs Chair @ programs@sccmtexaschapter.org

• Interested in keeping things organized?

Contact Rina Patel, our Memberships Chair, membership@sccmtexaschapter.org

• Want to help and curious about how to maintain a website or write these newsletters?

Contact Brandon Sterling, our Communications Chair @ webmaster@sccmtexaschapter.org

• Love research and want to help promote it?

Contact Raj Gandhi, our Research Chair @ research@sccmtexaschapter.org

We expect big things from the Texas Chapter in 2013 and would love for you to get involved!

Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) guidelines 2013guidelines 2013guidelines 2013guidelines 2013

Iqbal Ratnani M.D., Salim Surani M.D, Irfan Jindani PAC

Sepsis is defined as a suspected or documented infection in conjunction with systemic manifestations of infec-

tion. The presence of sepsis-induced organ dysfunction and/or tissue hypoperfusion confers the diagnosis of severe

sepsis. 1 Sepsis causes millions of deaths globally each year, and contributes to more than 200,000 deaths in the US

each year. It is the second-leading cause of death in non-coronary ICU patients, and the tenth-most-common cause of

overall death.2

The first Surviving Sepsis Campaign guidelines were published in 2004, with the second update released in

2008. The most recent guidelines are based on literature available through the fall of 2012, and were published in the

January 2013 edition of Critical Care Medicine.

We hereby summarize the salient changes in the 2012 guidelines when compared to the 2008 guidelines. This

article will not address the changes as they relate to ARDS, sedation-analgesia, nutrition, ventilator-associated pneu-

monia and other ICU bundles. Those details can be viewed via the weblink provided at the end of this document.

The most relevant clinical recommendations pertain to following two bundles:

First Bundle: TO BE COMPLETED WITHIN 3 HOURS:

• Measure lactate level

• Obtain blood cultures prior to administration of antibiotics

• Administer broad spectrum antibiotics

• Administer 30 mL/kg crystalloid for hypotension or lactate level greater than or equal to 4mmol/L

Second Bundle: TO BE COMPLETED WITHIN 6 HOURS:

• Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arteri-

al pressure (MAP) ≥ 65 mm Hg

• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate more

than or equal to 4 mmol/L (36 mg/dL):

Measure central venous pressure (CVP): volume resuscitate with the target CVP of ≥8 mm Hg

Measure central venous oxygen saturation (ScvO2): with the target ScvO2 of 70%,

• Re-measure lactate if initial lactate was elevated: Target towards normalization of lactate.

Following are the salient features to be remembered:

Blood cultures: Blood cultures should be obtained before antimicrobial therapy is initiated, providing no

significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both

aerobic and anaerobic bottles) should be obtained with at least 1 drawn percutaneously and 1 drawn through

each vascular access device, unless the device was inserted within the last 48 hours (grade 1C).

Antibiotics: Initiate initial empir ic anti-infective therapy of one or more drugs that have activity against all like-

ly pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues pre-

sumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential

de-escalation (grade 1B). Duration of antimicrobial therapy should be typically 7–10 days; longer courses

may be appropriate in patients who have a slow clinical response as in the case of bacteremia with Staphylo-

coccus aureus, some fungal and viral infections, or patients with immunologic deficiencies, like neutropenia

(grade 2C).

P A G E 4

Fluid Therapy: Crystalloids are the initial fluid of choice in the resuscitation of severe sepsis and septic

shock (grade 1B). Albumin should be used for fluid resuscitation only when patients require substantial

amounts of crystalloids (grade 2C).

Vasopressors

Norepinephrine (NE) is the vasopressor of choice (grade 1B).

Epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed

to maintain adequate blood pressure (grade 2B).

Vasopressin with maximum dose of 0.03 units/minute can be added to NE with the intent of either raising

MAP or decreasing NE dosage (UG).

Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg. Pa-

tients with low risk of tachyarrhythmias and absolute or relative bradycardia (grade 2C).

Low dose vasopressin is not recommended as the single initial vasopressor.

Phenylephrine is not recommended in the treatment of septic shock except in circumstances of serious

arrhythmias, or as salvage therapy.

All patients requiring vasopressors should have an arterial catheter placed as soon as practical if resources

are available (UG).

Dobutamine/inotropes: A tr ial of dobutamine infusion up to 20 micrograms/kg/min can be administered or

added to a vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated car-

diac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion, despite achieving ade-

quate intravascular volume and adequate MAP (grade 1C).

Corticosteroids: Intravenous hydrocortisone should not be used to treat adult septic shock patients if ade-

quate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. For patients where

fluid resuscitation/vasopressors do not restore hemodynamic stability, the recommended dose is 200 mg per

day oh hydrocortisone(grade 2C), given as a continuous infusion (grade 2D).

Blood transfusion should be used judiciously only if there is an evidence of myocardial ischemia, severe hy-

poxemia, acute hemorrhage, or if hemoglobin concentration is <7.0 g/dL (Grade 1B). FFP should not be given

routinely. Administer platelets prophylactically only when platelet count is <10,000/mm3 (10 x 109/L) or <

20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding (Grade 2D).

Glucose: A protocol-based approach to blood glucose management should be target to achieve blood glucose of

less than 180 mg/dL. (Grade 1A).

Bicarbonate Therapy: Should only be use only in severe acidemia with pH < 7.15 (grade 2B).

Procalcitonin: Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinu-

ation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of in-

fection (grade 2C).

There is no role for Selenium, Immunoglobulins or Recombinant Activated Protein C (rhAPC).

Complete Guidelines can be obtained at http://www.sccm.org/Documents/SSC-Guidelines.pdf

References:

Levy MM, Fink MP, Marshall JC, et al; SCCM/ESICM/ACCP/ATS/SIS: 2001 SCCM/ESICM/ACCP/ATS/SIS International

Sepsis Definitions Conference. Crit Care Med 2003; 31:1250–1256

Martin, Greg S.; Mannino, David M.; Eaton, Stephanie; Moss, Marc (2003). "The Epidemiology of Sepsis in the United

States from 1979 through 2000". New England Journal of Medicine 348 (16): 1546–54

http://www.sccm.org/Documents/SSC-Guidelines.pdf

Appendix:

Guidelines were formulated following the principles of the Grading of Recommendations Assessment, Development and Evaluation

(GRADE) system to guide the following: Assessment of quality of evidence from high (A) to very low (D), and to determine the strength

of recommendations as strong (1) or weak (2)

Recommendations were classified into three groups: Those directly targeting severe sepsis; Those targeting general care of the critically

ill patient and considered high priority in severe sepsis; and pediatric considerations. Some recommendations were ungraded (UG).

P A G E 5

Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) Updates from the surviving sepsis campaign (SSC) guidelines 2013 (continued)guidelines 2013 (continued)guidelines 2013 (continued)guidelines 2013 (continued)

Interview with Alan Mintz Interview with Alan Mintz Interview with Alan Mintz Interview with Alan Mintz ---- Military service opportunities and insight from a Military service opportunities and insight from a Military service opportunities and insight from a Military service opportunities and insight from a clinician currently stationed in Afghanistanclinician currently stationed in Afghanistanclinician currently stationed in Afghanistanclinician currently stationed in Afghanistan

This interview was conducted via email, in late December 2012. Alan is currently stationed in Afghanistan and will

try to correspond to the chapter as he is able throughout his current tour. For additional insight/correspondence from

Alan, check out the SCCM Texas Chapter Website!

What is your professional background? I have been a RN since 1985 and working in critical care since 1987. I started with a diploma in nursing and

currently hold a MSN. I have my CCRN and have worked as a staff nurse, assistant manager, critical care

educator and manager. I have also worked in the emergency department.

How long have you been in the Naval Reserves? What are your commitments to the Naval Reserves? I have been in the Navy Reserve for 16 years. I am attached to Expeditionary Medical Facility (EMF) Great

Lakes 1, which is a Commissioned Reserve Fleet Hospital. I currently am attached to the headquarters de-

tachment. I currently drill 1 weekend a month, and perform annual trainings yearly that vary from 13 to 21

days, depending upon the needs. I also spend additional time at home during the month performing required

tasks for the Head Quarters Unit.

What motivated you to join the Naval Reserves? I joined the Reserves late in life at age 37. I had always had a desire, but timing never seemed quite right. I

finally decided if I was going to do this, I had to do it before I was too old.

Have you already been deployed, or are you still in the mobilization phase? If you haven’t been de-

ployed, what is your deployment date? When you receive this I will be flying in country. I have completed all my remobilization training. The trip to

Afghanistan is a staged trip. We fly from our last training site on a chartered jet to Bishek, Kyrygzstan

(Manas Air Base) where we will be for 12-96 hours waiting on a military flight to take us into Afghanistan.

Our flight will have several fuel stop/layovers. Since we are flying a contracted flight into a war zone, we are

taking weapons with us. Because of that we don’t go through the security at the airport so we don’t have the

limitations on what

can be carried on the

plane. Each of us will

be taking 3-4 sea bags

full of gear and

uniforms in addition

to our weapons. To

assure security of the

weapons, we have to

sign for them, and

then maintain security

of them. At any layo-

vers where we leave

the plane, the weapons

will stay on the plane

and members will be

assigned to maintain weapons security. I should end up in Kanda-

har Afghanistan by the first of the year, and hopefully before.

P A G E 6

Me enjoying an early morning with Ma Deuce

What occurs during this mobilization period and how long does this period last?

The mobilization process can vary depending upon where you are going and what your specific job will

entail. My process included 10 days at Naval Station Great Lakes completing required on line courses,

medical screening, legal and family assistance meetings. After that I went back home for a short period of

time. I then reported to Gulfport, MS for activation, which was a 4 day process. This included being

gained to active duty for pay and benefit purposes, completing a lot of paper work. More medical screen-

ing and receiving small pox vaccination, as well as any other needed vaccines. We were measured for and

received 2 complete sets of uniforms. One set for our combat training, and then a complete set of multi-

cams, which are only worn in Afghanistan. These multicams are both insect repellent and fire retardant.

In addition, all service wear them so service members don’t stand out based upon uniforms. After leaving

Gulfport, I reported to Camp McCrady which is on Fort Jackson, in Columbia, South Carolina for NIACT

(Navy Individual Agumentee Combat Training) training. This was a 3 week course that focused primarily

on combat skills. We did weapons qualifications, convoy operations, communications, basic first aid,

map reading, and gear issue. We received more gear to bring our total gear going in country to about 200

pounds of gear and uniforms. I was also originally scheduled to do a 2 week course at Camp Pendelton,

however my mobilization was moved up by 6 weeks, so due to the need that training was eliminated. (I

have completed that training several times in the past, so I wasn’t missing out).

Are there any additional skills/training that you needed to obtain prior to deployment? (example....

ACLS, trauma certification, etc.)

To work in ICU as a RN, I first have to maintain my credentials through the Navy. This is a renewal pro-

cess every 2 years that basically verifies your license, BLS, and are working clinically. For this mission, I

had to also have ACLS, PALS, and TNCC. In addition I

was 1 of 5 nurse going that was tasked to attend the Army

En Route Care Course, which is a 2 week course dealing

with rotary wing (helicopter) aeromedical evacuation. This

course covers medical protocols, safety, patient transport,

basic survival skills, communication and different patient

scenarios. We spent a lot of time in simulators with different

patient situations that have actually occurred during

transport of patients in Iraq and Afghanistan. This transport

training includes US, NATO, as well as local nationals, in-

cluding peds patients, thus the requirement for PALS.

You said this was your first time to Afghanistan, but

not your first deployment. Where else have you been deployed?

My first deployment was to Landstuhl, Germany Army Hospital ICU. I was there in 2006-2007. Patient

movement is from battalion aid station, to Role 2 hospital to Role 3 hospital to Landstuhl, to the US. In

Landstuhl I was receiving patients from Role 3 hospitals. Now I will be sending patients to Landstuhl. A

role 3 is the evacuation hospital, which has the highest level of care available in theatre.

P A G E 7

Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)

Standard issue Army linen…..anyone for a green blanket?

Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)Interview with Alan Mintz (cont’d)

What is your role during deployment?

My role during this deployment is as division officer of the ICU (manager) as well as in charge of the

Navy En Route Care Nurses.

What is something that would surprise the non-military nurse about being deployed?

The amount of weapons training that is completed. We spent 6 days of weapons training. We had training

on the M9 pistol, the M4 carbine rifle and the M240, M249 and M2 machine guns.

Of all of your deployments, what has been your most memorable experience?

My most memorable experience has been the patients. There are several patients I cared for in Landstuhl

I will never forget. To a person each patient was more concerned about their buddies than their own inju-

ries.

Is there something about being in the Naval Reserves or other military branches that you think non-

military people should know?

The amount of care provide to the Afghan citizens provided by US military Health Care. As many as 50% of

the patients in ICU have been Afghanis.

Is there anything we can do from the States to make your deployment easier?

The best thing is to keep all the US Military in your thoughts and prayers. Thank a service member for their

service.

Where can health care providers interested in military involvement get more information to help

them make an informed decision?

Health Care Providers interested in Military service should contact an officer recruiter. The Army, Navy and

Air Force have intrinsic medical facilities.

Are their opportunities for other health care providers such as physicians, pharmacists, therapists,

etc.?

A military hospital has all the same specialties and same equipment that you will find in a civilian hospital.

Some of the equipment is more durable or

cased differently for mobile environments.

How is the transition back to your dai-

ly hospital job after returning from

deployment?

Once I complete my 210 days in country, I

will have a 3 step process to demobilize. I

will transition back to Germany for about a

week to turn in gear and start decompress-

ing from being in a war zone. From there I

will come back to a Navy mobilization site

for 2 weeks. 1 week is the transition back

to reserve, medical screenings and brief-

ings and the second phase is training on

reemployment, VA health care and bene-

fits.

P A G E 8

The Navy filing in through our receiving

line for Christmas Dinner