Critical Care Archives - PulmCCM
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Critical Care Articles

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]

Oct 162014
 
ICU Physiology in 1,000 Words: Stroke Volume Variation and the Concept of Dose-Response

Stroke Volume Variation and the Concept of Dose-Response Jon-Emile S. Kenny M.D. Awareness of the undulating pattern of an arterial line tracing is high amongst health professionals in the intensive care unit; certainly this is an aftereffect of a cacophony of studies and reviews pertaining to pulse pressure variation and fluid responsiveness in the operating [... read more]

Oct 142014
 
Total parenteral nutrition vs enteral nutrition: no difference in critically ill? (CALORIES trial)

Feeding patients enterally (nasogastric or nasojejunal tube feedings) has been the standard of care for critically ill patients, based on weak evidence that it reduces infection rates; hence the adage “feed the gut, if you can.” That last caveat is included because so many critically ill patients have gastric motility impairment (with inability to achieve [... read more]

Oct 102014
 
Transfusion for hemoglobin above 7 g/dL: no benefit in septic shock (TRISS Trial)

Blood transfusions have been a central component of protocols for care of severe sepsis and septic shock, ever since the single-center 2001 Rivers trial included them in its interventions. Any benefit (or harm) caused by red cell transfusion independently was unknowable, and so the therapy became standard care as part of the so-called sepsis bundle. The Surviving [... read more]

Oct 052014
 
Are traditional protocols for goal directed therapy for sepsis dead? (ARISE trial)

Update: As astute commenters have mentioned below, and as I stated in our post on the ProCESS trial, protocols of some kind could still have a place in the care of sepsis if they ensure more rapid recognition and thorough treatment. Accordingly, I changed the headline to clarify that it’s only traditional sepsis protocols to which I refer, not the [... read more]

Sep 012014
 
ICU Physiology in 1000 Words: The Hemodynamics of Prone

ICU Physiology in 1,000 Words  “The Hemodynamics of Prone” by Jon-Emile S. Kenny MD A physiological maelstrom has recently swirled about the hemodynamic effects of the prone position in severe ARDS [1-5]; but how exactly does this maneuver alter the cardiovascular system?  A good approach to this problem is a Guytonian one whereby we consider [... read more]

Jul 302014
 
What are Ventilator-Associated Events (and why should you care)?

Have you heard of ventilator-associated events (VAEs)? Like it or not, this neologism of healthcare-speak is coming to an ICU near you soon. Here’s the lowdown on VAEs and why they matter to the practicing intensivist. What are Ventilator-Associated Events? Ventilator-associated events are an invention of the Centers for Disease Control and Prevention (CDC), created in [... read more]

Jul 172014
 
Inspiratory collapse of the inferior vena cava: What is it telling us?

image: EM Ultrasonography ICU Physiology in 1,000 Words: “Inspiratory collapse of the inferior vena cava: What is it telling us?” Jon-Emile S. Kenny M.D. With the dissemination of small, portable, ultrasound devices [or SPUDs], it seems that it is every house-officer’s dream to own the ability and wherewithal to place an ultrasound probe on a [... read more]

Jul 112014
 
Prone positioning reduces ARDS mortality by 26%: meta-analysis

Image: Rotoprone Acute respiratory distress syndrome (ARDS) injures the lungs in a heterogeneous pattern, and the damaged areas are particularly vulnerable to further ventilator-induced lung injury. This is why a lung-protective ventilator strategy using low tidal volumes reduces mortality from ARDS, experts believe. Tidal volumes of 6 mL/kg ideal body weight (calculated from height) using conventional [... read more]

Jun 082014
 
PulmCCM Roundup #4

All the best in pulmonary and critical care from around the web. Browse all the PulmCCM Roundups. Asthma Childhood obesity increases the risk for asthma, and obesity is also strongly associated with asthma in adults. The mechanisms are likely multiple, complex and interdependent (pro-inflammatory mediators, etc.), not simply causative. Losing weight does seem to improve [... read more]

Jun 052014
 
Tenecteplase for submassive PE: more conflicting evidence (TOPCOAT)

By Parth Rali, MD and Marvin Balaan, MD Submassive pulmonary emboli (PE) are those that are severe enough to produce right ventricular dysfunction on echocardiogram or elevated biomarkers (mainly troponin), but not hemodynamic instability (i.e., systemic blood pressure and cardiac output are preserved). The management of the patient with submassive PE is a matter of controversy with several [... read more]

May 162014
 
How to provide nutrition for critically ill patients (Review)

Nutritional Support During Critical Illness This PulmCCM topic review will be periodically updated and expanded as new research is published. Originally published 22 September 2013. Most recent update: 16 May 2013. During critical illness, catabolism (breakdown of muscle protein, fat and other complex molecules) occurs faster than anabolism (synthesis of these same macromolecules). Historically, the [... read more]

May 082014
 
Red blood cell transfusions increase hospital-acquired infections (meta-analysis)

Red Cell Transfusions Increase Risk for Nosocomial Infection: Meta-Analysis Transfusing blood to anemic patients has an almost irresistible intuitive and theoretical appeal both to physicians and the patients who get transfused. It’s perhaps the archetypal example of the “find it – fix it” approach to doctoring: correct all laboratory abnormalities and ipso facto, the patient [... read more]

May 022014
 
Diaphragmatic ultrasound could predict extubation success

Source: criticalecho.com Diaphragmatic Ultrasonography to Assess Readiness for Extubation By Muhammad Adrish, MD Weaning a patient from mechanical ventilation is a challenge that intensivists face routinely. Clinical examination and objective measurements like minute ventilation, respiratory rate, maximal inspiratory pressure, and ratio of respiratory rate to tidal volume have all been used with varying reported sensitivity [... read more]

Apr 182014
 
Thrombolytics (tPA) improve intermediate risk PE outcomes, with a few head bleeds (PEITHO Trial)

The use of thrombolytics for pulmonary embolism is not controversial — that is, if the PE is massive with hypotension (give thrombolytics) or mild, with normal blood pressure and right ventricular function (don’t give them). It’s the patients with intermediate risk pulmonary emboli — with normal blood pressure but with evidence of right ventricular dysfunction [... read more]

Apr 182014
 
Steroids did not improve outcomes in severe COPD exacerbations (RCT)

Image: 1800petmeds Systemic steroids in COPD exacerbations requiring ventilator support: Are we treating our patients, or ourselves? By Muhammad Adrish, MD Acute exacerbations of COPD are a major cause of hospitalizations, and are associated with more rapid decline in lung function and reduced survival. Because COPD exacerbations are associated with increased inflammatory responses, corticosteroids have [... read more]

Apr 132014
 
Albumin for severe sepsis and septic shock: More confusing findings (ALBIOS Trial)

Source: KP Albumin: Better Than Crystalloid in Septic Shock? Human albumin boosts oncotic pressure, and has a number of important biologic functions (protein binding, antioxidant, etc.) that could in theory support the body during critical illness. In the 2004 SAFE study, which tested albumin against crystalloid solutions in ~7,000 critically ill patients of various etiologies, 4% [... read more]

Apr 112014
 
PulmCCM Roundup #3

PulmCCM Roundup #3 All the best in pulmonary and critical care we’ve found lately. Browse all the PulmCCM Roundups. Surviving Sepsis Campaign Responds to ProCESS Trial In the wake of the ProCESS trial demonstrating no benefit from use of protocols for septic shock, the Surviving Sepsis Campaign released a statement in which they “continue to recommend [... read more]

Apr 042014
 
Catheter directed thrombolysis for submassive PE: better than heparin? (RCT)

Image: EKOS Patients with acute pulmonary embolism (PE) fall into three general clinical categories: Massive PE, most often defined as hypotension due to right ventricular dysfunction. Short-term mortality is high (more than 1 in 7 die in-hospital). Systemic thrombolytic therapy (tissue plasminogen activator or tPA) is considered standard care by AHA and ACCP, because it [... read more]

Apr 032014
 
PulmCCM Roundup, Issue #2

PulmCCM Roundup #2 Welcome back to the PulmCCM Roundup, formerly the Critical Care Roundup. Let’s jump right in to issue #2. Browse all the PulmCCM Roundups here. Etomidate for intubation in sepsis: what’s the risk, really?  Etomidate has been suspected of causing adrenal insufficiency and potentially death in patients with severe sepsis, when used as an anesthesia-induction agent [... read more]