Critical Care Archives - PulmCCM
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Critical Care Articles

Aug 252015
 
Are central lines really needed for vasopressor infusions?

image: Wikipedia There’s only one sure way to prevent complications from a central line: don’t place one. Like many invasive interventions, some of central venous catheters’ indications have been called into question in recent years. Monitoring of central venous pressure and central venous oxygen saturation via central IV access — once considered essential to good care [… read more]

Aug 012015
 

ICU Physiology in 1000 Words Veno-Arterial Extra-Corporeal Membrane Oxygenation (VA-ECMO) Jon-Emile S. Kenny M.D. [@heart_lung] Perhaps the most memorable patient of both my pulmonary and critical care fellowships was that of a very young woman who suffered from propofol-related infusion syndrome [PRIS]. As a consequence of PRIS, she endured multiple cardiac arrests and was placed [… read more]

Jul 012015
 
Families stall end of life talks, say doctors. True?

Doctors and nurses said patients and their families created the largest obstacles to end-of-life decision making in the ICU, in a large survey published in JAMA Internal Medicine. About 1,300 staff at 13 academic hospitals in Canada rated barriers to end-of-life goals of care on a 1-7 scale. Doctors and nurses considered the largest barriers [… read more]

May 312015
 
SICU Basic Training (Video, Part 2 of 2)

Part 2 of a video lecture by Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; [… read more]

May 282015
 
Restricting calories by 50% during critical illness results in no harm

Everyone agrees that providing adequate nutrition in critical illness is vitally important. The problem is, no one knows for sure what “adequate” means. Caloric targets are not based on evidence from randomized trials with meaningful clinical outcomes. They emerge as consensus from educated guesses by researchers conducting physiology studies. One camp believes that extra calories should [… read more]

May 272015
 
High flow oxygen by nasal cannula saves lives over noninvasive ventilation

Image: F&P Healthcare Noninvasive ventilation (NIV), often referred to by the trade name “BiPAP®,” can prevent intubation and save lives in patients with COPD exacerbations or pulmonary edema due to heart failure. Its proven benefits and low risk have led to NIV being used for patients in respiratory failure in virtually every acute care setting [… read more]

May 172015
 
SICU Basic Training (Video, Part 1)

Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine contributes this excellent educational video. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; metabolic acidosis; metabolic alkalosis; [… read more]

May 172015
 
The only VAP prevention method that saves lives is the one you’re not using

There’s always been doubt about the efficacy of the numerous “ventilator bundles” hospitals use to prevent ventilator-associated pneumonia (VAP). A provocative new analysis concludes that none of these methods save lives — except the one that almost no ICUs are using today. Healthcare associated pneumonias (HAP), especially ventilator-associated pneumonias (VAP), are associated with increased mortality, excess antibiotic use, lengthened hospital [… read more]

May 062015
 
Is more than one patient per ICU nurse dangerous?

The fewer patients an ICU nurse has to juggle, the better those patients’ chances of making it out of the hospital alive, according to a large observational study published in Critical Care Medicine. Data from the large EPIC II study suggested that two patients per nurse may be too many for safe, high-quality critical care. Nurse-to-patient [… read more]

Mar 282015
 
Surviving Sepsis Says EGDT Not Needed in All Patients with Septic Shock

As regular PulmCCM readers know, the ProCESS, ARISE and ProMISe randomized trials showed no benefit of protocolized early goal-directed therapy as compared to usual conscientious care in the treatment of severe sepsis and septic shock. In response to ProCESS and ARISE, the influential Surviving Sepsis Campaign now advises that measurement of central venous pressure (CVP) and [… read more]

Mar 272015
 
Endovascular therapy helps in ischemic stroke, again (ESCAPE)

Endovascular Therapy Improves Outcomes from Ischemic Stroke By Parth Rali, MD and Igor Titoff, DO Endovascular therapy for ischemic stroke has long been an attractive treatment modality for ischemic strokes, but until recently large randomized trials have not confirmed a benefit [1,2,3]. Two of these—IMS III1 and SYNTHESIS2—failed to prove the benefit of endovascular therapy (with-or-without tissue plasminogen activator) [… read more]

Mar 152015
 
How safe is thoracentesis? Giant case series sheds light

Thoracentesis for pleural effusion — that is, inserting a long needle between someone’s ribs to drain a fluid collection from the chest — has always come with a scary menu of potential risks, including pneumothorax, hemothorax and pulmonary edema. A new study reports a low complication rate from thousands of thoracenteses. But debate will remain whether the safety results — achieved [… read more]

Mar 062015
 
Chlorhexidine baths in ICU don't prevent infections in large trial

Throwing the Baby out with the (Chlorhexidine) Bathwater? New Data on Disinfectant Baths By Lekshmi Santhosh, MD As a critical care community, we’ve been forever searching for a magic bullet to eradicate healthcare-acquired infections. So when the pair of 2013 NEJM trials on daily chlorhexidine bathing showed statistically significant reductions on the incidence of hospital-acquired [… read more]

Feb 012015
 
ICU Physiology in 1,000 Words: Cardiopulmonary Resuscitation

Cardiopulmonary Resuscitation by Jon-Emile S. Kenny, MD The first time I performed cardiopulmonary resuscitation [CPR] on a patient was in the emergency department of Sunnybrook Hospital in Toronto, Canada; it was certainly an indelible moment in my training. As an intern, and especially as medical consult at Bellevue Hospital in New York City, I was [… read more]

Jan 192015
 
Should video-guided intubation be standard training in critical care? (And should anesthesiologists teach it?)

Image: Airwaycam Endotracheal intubation is a routine but high-stakes maneuver, performed uneventfully thousands of times daily throughout the developed world. In the U.S., elective (routine) intubation is almost exclusively the domain of anesthesiologists, who become masters of the technique through thousands of iterations throughout training and their careers. The vast majority of these intubations take [… read more]

Jan 112015
 
Nutrition in severe pancreatitis: none at all (for 3 days) worked fine

Image: Wikipedia Acute pancreatitis is a common and usually self-limited illness resolving after a few days of rest and not eating. A minority of people develop severe pancreatitis with necrosis, which can transform pancreatitis into an ordeal lasting weeks or months, characterized by multi-organ failure, infections, and a >15% mortality rate. Those infections are believed to be caused by [… read more]

Jan 052015
 

Here are some of the biggest stories and most important published research findings in critical care and respiratory medicine for 2014. Enjoy, and subscribe to the PulmCCM weekly email newsletter to stay up to date in pulmonary and critical care. Early goal directed therapy does not improve outcomes in septic shock (ProCESS) Are traditional protocols [… read more]

Dec 212014
 
Ischemic stroke: Interventional treatment + alteplase = new standard of care? (MR CLEAN)

In the early 1990s, the clot-busting drug alteplase (intravenous recombinant tissue plasminogen activator or rTPA) revolutionized stroke treatment when it was shown to significantly increase the chances of a good outcome after ischemic stroke when given in the first 4.5 hours since symptom onset. But alteplase is not a miracle drug. In a meta-analysis of 9 randomized trials, rTPA improved [… read more]

Dec 052014
 

In Defense of the Central Venous Pressure Jon-Emile S. Kenny M.D. In the waning days of my fellowship I received a hemoptysis consult in the cardiac care unit. Sifting through CT scans, I overheard two house-officers giving sign-out for the evening. When reviewing the clinical data, one of the residents referred to the central venous pressure [… read more]

Oct 312014
 
Life after sepsis protocols: What now? (You decide.)

2014 has been a rough year for advocates of sepsis protocols. First, the long-awaited ProCESS trial did not show any benefit from use of the original early goal-directed therapy (EGDT) protocol used in the single-center 2001 trial by Rivers et al that, despite criticism, became the standard of care for the following decade. Patients cared for in the 2 non-EGDT arms [… read more]