A systematic review of 3 trials (n=337) by the Bed Head Elevation Study Group (not to be confused with the Bedhead photo group) found no good evidence that head-of-bed (HOB) elevation to 45′ helps or harms in any way (pneumonia, decubiti, mortality, VTE, or hemodynamic instability). Nevertheless, a consensus panel of 22 experts agrees with previous [... read more]
Remember when you were a third year medical student? Me neither. But that’s when you first started to build that tough & isolating carapace to protect you from all the overwhelming emotions flying through the hospital, & you, this essay suggests. A seasoned clinical educator and a third-year med student have a conversation about our [... read more]
Analyzing 50,481 victims of prolonged mechanical ventilation in Taiwan 1997-2007, Hung et al report outcomes were frankly terrible, with median survival of about 4 months. Those with a primary indication of neurologic damage fared significantly better. Those with a PMV indication of COPD, younger than 85, had 6-18 months median survival. Authors take the additional [... read more]
Cochrane systematic review and meta-analysis: Pooling 11 randomized trials, n=1,971, Blackwood et al suggested there are some benefits to using a standardized weaning protocol. There was a reduction in weaning and ventilation time in the groups that had weaning protocols; we won’t report them here, because they would be misleading in this small space. They [... read more]
Drospirenone is the new progesterone analog in heavily marketed new oral contraceptive pills (trade names Yaz, Yasmin, Angelique). Using a large insurance claims database, Jick et al identified 186 cases of DVT or PE in women aged 15-44 taking oral contraceptives and compared them to controls. Those taking drospirenone-containing OCPs had a nonfatal DVT/PE incidence [... read more]
Sacanella et al prospectively observed 230 generally healthy, cognitively intact, highly functional & independently living Spaniards 65 years or older (mean age 75) after urgent admission to a single MICU. About half received mechanical ventilation (54%). Seventy died in-hospital; 48 died within a year, for a one-year survival of 49%. But among the 112 survivors, [... read more]
Fernandez-Cerrano et al randomized 56 people with CAP in Spain (only 3 needed mechanical ventilation) to receive methylprednisolone bolus-and-taper or placebo, in addition to ceftriaxone and levofloxacin. The steroid-treated group had less hypoxemia (lower PaO2/FiO2). (n=56). Critical Care 2011;15:R96. FREE FULL TEXT MORE ON THIS: In AJRCCM 2005, Confalonieri found less septic shock and need [... read more]
In a rare encouraging positive study in the chronically critically ill, 71% of vent-dependent patients (~6 weeks on MV) who did multiple sets of daily inspirations backwards through a PEEP valve weaned from mechanical ventilation (defined as >72 hrs off the vent), vs. 47% receiving a sham treatment. MIP also improved by 10 cmH2O in [... read more]
Moses & Martin see an impending crisis of public trust in the entire enterprise. They call for an epic shift in national priorities, policy, and funding of research, envisioning a more collaborative, value-based system– while acknowledging that such a sea change would take decades. NEJM 2011;364:567-571. FREE FULL TEXT
Priou et al followed 130 patients with OHS after initiation with noninvasive positive pressure ventilation. Mean follow up was 4 years. Most (96) were started on NPPV in the stable state; 38 had had an acute hypercapneic exacerbation. Survival at 1 year was 97.5%; 2 years (93%); 3 years (88%); 5 years (77%). The large [... read more]
In case there was any question, no you can’t use the femoral vein to collect ScvO2 samples. Davison et al found a bias of 4% between femoral and nonfemoral sources in 39 critically ill patients (with an interestingly wide standard deviation of 12% in blood obtained from either source). In more than half the patients, [... read more]
Cavallazzi et al reviewed 10 cohort studies and concluded that compared to daytime admission, being admitted to an ICU at night did not increase the odds ratio for mortality. Being admitted on a weekend supposedly did, but the odds ratio was only 1.08. CHEST 2010;138:68-75. FREE FULL TEXT
Brower RG et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327-36. Randomized trial among 549 patients with ARDS/ALI conducted by NHLBI/ARDSNet. Compared high and low PEEP strategies, and found no significant difference in mortality, ventilator-free days, ICU-free days, or organ failure-free days between [... read more]
Herridge MS et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003; 348:683-93. Non-pulmonary problems are usually dominant in impairment of ARDS survivors. Low exercise tolerance, fatigue, and weakness are common a year after discharge. Pulmonary function tests usually normalized, other than a diffusion impairment. At 12 months, only 6% [... read more]
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for ALI and ARDS. N Engl J Med 2000;342:1301-8. The ARMA study found the use of low (6 ml/kg predicted weight) rather than “standard” (12 ml/kg predicted weight) tidal volumes reduced mortality from 40 to 30%. This paper established the standard of low [... read more]