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.
ICU Prognosis is Easy, Except When It’s Not How accurate are predictions of mortality by ICU team members? For 560 consecutive patients admitted to a single MICU at the University of Chicago, the authors polled the patient’s attending, fellow, resident, and nurse privately each day, asking simply: “Will this patient survive to discharge?” They collected [... 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]
For 10 years, Zahar et al prospectively observed 3,588 patients developing severe sepsis & septic shock who ended up in French ICUs. Their sample captured a broad array of infections acquired in the community, the hospital ward, or the ICU (about 1/3 each). After multivariate assessment, they could not find an independent influence on mortality [... read more]
Johnson et al reviewed charts in a retrospective case-control cohort study on 754 consecutive patients at Barnes-Jewish with severe sepsis or shock due to Gram-negative bacteremia. The exposure was receipt of antibiotics in the previous 90 days. 310 of the bacteremic patients had received antibiotics previously. Compared to unexposed controls, the previously antibiotic-exposed had a [... read more]
3% saline infusions have become standard care for increased intracranial pressure at many centers, based on mostly anecdotal evidence. Hauer et al looked retrospectively at 100 patients receiving 3% saline for severe stroke in 2008-2009 (intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic) and compared them to 115 historical controls, 2007-2008 with “equal” underlying disease. Hypertonic saline [... read more]
Hyperbaric oxygen in the critically ill. Weaver LK. Crit Care Med 2011;39(7):1784-1791.
Fragou et al randomized 401 ICU patients to undergo subclavian vein central line placement with guidance either by ultrasound or anatomic landmarks. All cannulations were with an infraclavicular approach. The ultrasound group had a higher success rate (100% vs 87.5%), shorter time to access and fewer number of attempts, and a lower rate of complications. [... read more]
Stapleton et al report results of a phase II trial of 14 days of omega-3 fish oil vs. placebo in 90 people with acute lung injury or ARDS. There was no difference in the primary endpoint (inflammatory marker IL-8 in BAL fluid), nor in any clinical outcome. Crit Care Med 2011;39:1655-1662.
That’s what Banerjee et al argue, after retrospectively comparing ICU costs before/after implementation of 24-hour in-house intensivist coverage. They found that total costs for patients admitted at night declined by 61%, while daytime costs were unchanged. Crit Care Med 2011;39:1257-1262.
Potential metabolic consequences of statins in sepsis. Brealy DA et al. Crit Care Med 2011;39:1514-1520.
Survival of trauma patients after massive red blood cell transfusion using a high or low red blood cell to plasma transfusion ratio. Rajasekhar et al. Crit Care Med 2011;39:1507-1513. Meta-analysis.
Toxic epidermal necrolysis and Stevens-Johnson syndrome. Gerull et al. Crit Care Med 2011;39:1507-1513.
Of 421 patients admitted to ICUs after cardiac arrest, 281 (67%) developed 373 infections, mostly pneumonias, report Mongardon et al. Crit Care Med 2011;39:1359-1364.
Bafadhel et al collected procalcitonin and CRP on 161 people admitted for COPD exacerbations, 96 for asthma exacerbations, and 62 for pneumonia (groups were discriminated by presence of consolidation on chest film), at 2 UK hospitals. The assays performed extremely well (area under the curve >0.93 for each) at differentiating pneumonia from non-infectious causes of [... read more]
Rice et al randomized 200 mechanically ventilated patients to either trophic feedings (10 mL/hr) or full enteric feedings for 6 days. There were no differences in mortality or ventilator-free days. The trophic-fed patients had fewer episodes of “high residuals.” (n=200) Crit Care Med 2011;39:967-974.
End-stage liver disease, critical care management of: Al-Khafaji A et al. Crit Care Med 2011;39:1157-1166. Hepatic failure review.