In ARDS, Obesity May Protect Life (But Not Kidneys) by Blair Westerly, MD Obesity is an epidemic and common in intensive care units in the United States. Furthermore, while acute kidney injury (AKI) is also common in critically ill patients, obese patients carry additional risk for AKI because of increased baseline comorbidities. Both obesity and [... read more]
Etomidate: Unsafe for Intubation in Patients with Sepsis? by Blair Westerly, MD Etomidate is commonly used for rapid sequence intubation; however, even after one dose, it has been associated with adrenal axis suppression in critically ill patients. Though both adrenal insufficiency and increased mortality in sepsis have been associated with etomidate, the relationship of the [... read more]
“We’ve got to get that femoral line out of there!” The attending’s face as he says it shadowed with a simmer of fear, a dash of anger. How could the moonlighter have been so incompetent or lazy as to choose the benighted femoral site for a central venous line when the internal jugular and subclavian [... read more]
The Surviving Sepsis Campaign is a collaboration between the U.S. Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine, and the International Sepsis Forum, whose recommendations on the management of sepsis are considered widely. At the 2012 SCCM meeting, the Surviving Sepsis committee revealed some of the planned revisions and additions [... read more]
Image: EIMJM.com Evidence-based practice guidelines adopted by critical care societies in Canada, Germany, Australia and New Zealand recommend starting enteral nutrition shortly after admission to an ICU. In observational studies, critically ill adults get only about 50-70% their caloric goals from enteral feeding; reduced gastric motility is often responsible for the limited caloric intake. Impaired [... read more]
Intuition and the reigning treatment paradigm tell us that in critically ill patients with acute kidney injury (AKI), a.k.a. acute renal failure (ARF), fluid resuscitation should be beneficial. You’ve got to maintain renal perfusion to avoid a worsening of the insult, and extra intravenous fluids should help do that — or so the clinical reasoning [... read more]
Superior Vena Cava Syndrome: A Cancer-Related Medical Emergency (More PulmCCM Topic Updates) Multiple cancers are expected to rise in prevalence in the U.S. over the coming decades, and so is the risk for cancer-related medical emergencies. For a few, superior vena cava syndrome (SVC syndrome) will be the first manifestation of their cancer. It’s important [... read more]
Cancer-Related Medical Emergencies: Acute Tumor Lysis Syndrome (More PulmCCM Topic Updates) The prevalence of multiple cancers are expected to rise in the United States over the coming decades. Despite improved survival with some cancers, some people with malignancy will develop cancer related emergencies; for a few, this will be the first manifestation of their cancer. [... read more]
Human recombinant granulocyte macrophage colony stimulating factor (GM-CSF or Leukine) did not reduce ventilator-days in patients with acute lung injury / ARDS in a randomized trial published in the January 2012 Critical Care Medicine. Why would it have? Interestingly, patients with ARDS with higher levels of GM-CSF in their BAL fluid are more likely to survive. GM-CSF maintains [... read more]
If you and your team just can’t get an arterial line into your critically ill, hypotensive patient for continuous invasive blood pressure measurement, you may be somewhat comforted by the findings of Karim Lakhal, Christine Macq, Xavier Capdevila et al in the April 2012 Critical Care Medicine. They found that among 150 critically ill patients [... read more]
(image: flickrCC) Half of patients transferred to long-term acute care facilities (LTACs) on prolonged mechanical ventilation will die within a year, according to a 2010 review. Only a small minority will ever go home without needing significant caregiver assistance. For those over age 65, the prognosis is even worse. It seems rude, or even cruel, [... read more]
Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA): 2012 Review (More 2012 Topic Updates) From concise clinical reviews by the don of cardiovascular disease, Eugene Braunwald (Harvard) in the May AJRCCM (Blue Journal) and Jeff Trost (Johns Hopkins) in Critical Care Medicine. These review articles on the diagnosis and treatment of non-ST-elevation acute coronary syndrome or NSTE-ACS (NSTE-myocardial infarction and unstable [... read more]
(image: Suburban Wino) Craig Coopersmith of Emory is an amazing guy and a prolific investigator in critical care — and it looks like he’s fed up with having his grants rejected. After some epic bean-counting, his group concludes that critical care research gets short shrift in federal research funding, compared to the huge amounts spent [... read more]
(image: flickrCC) Foam in, foam out, gown on, gown off … ah, the tedium of practicing critical care medicine in the age of rampant, lethal, multi-drug resistant bacteria. As a reminder to keep your guard up and your gear on, here’s a yucky study from Daniel Morgan, Elizabeth Rogawski, and Anthony Harris of the University [... read more]
An observational trial by Jim Kutsoguiannis, Cathy Alberda, Daren Heyland et al published in the December 2011 Critical Care Medicine showed no difference in 60-day survival among critically ill, mechanically ventilated patients started on parenteral nutrition (TPN) “early” (within 48 hours of ICU admission) or “late” (after 48 hours). Only 258 patients were included in the [... read more]
Webb and Samuels (Emory neuro-intensivists) report on a brain-injured patient who, after induced hypothermia and rewarming, had absent brainstem function and a confirmatory apnea test. However, in the O.R. for organ donation 24 hours later, brainstem function transiently returned and the surgery had to be aborted. They urge caution to the rest of us in [... read more]
Targeted temperature management in critical care: A report and recommendations from five professional societies. Nunnally ME et al. Crit Care Med 2011;39:1113-1125. Hypothermia for cardiac arrest guideline. Hypothermia after cardiac arrest review.
Meadow et al followed 560 patients in one University of Chicago MICU throughout their ICU stay, cornering team members (attending, fellow, resident, nurse) each day and asking a simple question: Will this patient survive to discharge? The results were rich and fascinating. Of the 433 survivors, 77% had unanimous predictions of survival on all days. [... read more]
Several favorable randomized trials and a meta-analysis have suggested procalcitonin is a reliable and useful biomarker of infection, including in the ICU. In contrast, Jensen et al report use of a procalcitonin-driven algorithm to guide antimicrobial therapy in 9 ICUs in Denmark seemed to cause a bit of harm. They randomized 1,200 patients to either [... read more]
Muscedere J. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med 2011;39:1985-1991. In short, it probably works to prevent ventilator-associated pneumonia (13 randomized trials, n=2,442. 12 were positive, pooled risk ratio 0.55, associated with 1-1.5 shorter days in the ICU and on the ventilator). So why not use [... read more]