Fecal Transplants Cure C. difficile Infections, When Drugs Can’t Antibiotics are what cause Clostridium difficile infection to emerge in the first place, so it’s perhaps no surprise that the usual treatment — more antibiotics — often fails. From 15-25% of patients with C. difficile are not permanently cured by their initial treatment with metronidazole, and among those [... read more]
Blood Transfusion: Deadly for GI Bleeds? You read the headline right: in a randomized trial published in the January 3 New England Journal of Medicine, liberal blood transfusions (to a hemoglobin of 9 g/dL) seemed to cause the deaths of people with acute upper gastrointestinal bleeding, as compared to transfusing when hemoglobin fell below 7 [... read more]
Chronic Cough and GERD: A Tangled Connection by Michael Peters, MD Gastroesophageal reflux disease (GERD) is considered to be one of the cardinal causes of chronic cough. A study in Chest challenges that fundamental concept, but comes up short in refuting it. What They Did Samantha Decalmer, Rachel Stovold, Jaclyn A. Smith et al conducted [... read more]
Intensive glucose control in critically ill patients — keeping glucose below 120 with a continuous insulin drip — was all the rage for a few years in the early 2000s after it was shown to improve survival in surgery patients, and then seemed to do the same in non-surgical, critically ill MICU patients who were [... read more]
Tranexamic Acid: Underused for Uncontrolled Bleeding? Tranexamic acid is a simple little molecule, just a synthetic derivative of the amino acid lysine. But it’s also a potent pro-hemostatic drug that binds plasminogen and plasmin and stops the degradation of fibrin (the stuff in blood clots). In the U.S., tranexamic acid is sold as Lysteda (oral) [... read more]
GERD Treatment Improves Survival in Idiopathic Pulmonary Fibrosis? GERD is extremely common in people with idiopathic pulmonary fibrosis, and chronic microaspiration has long been suspected of playing a role in the pathogenesis of IPF. In a retrospective review, Joyce Lee, Jay Ryu, Harold Collard et al collected records on 84 patients with idiopathic pulmonary fibrosis [... read more]
Intensive Glucose Control: Safe for Critically Ill Kids’ Brains? After evangelizing globally for intensive glucose control (~100 mg/dL) to be the standard of care for virtually all critically ill adults for a decade, Greet van den Berghe might be disappointed that mounting evidence shows that a fanatical approach to maintenance of normoglycemia in critical illness [... read more]
Extra Vitamin D Doesn’t Prevent Colds in Healthy Adults (JAMA) It looks like you can add Vitamin D to list of supplements (echinacea, vitamin C, etc.) who’ve gone up against the common cold and lost. (Scorekeepers will note that zinc held its own, though, in a Cochrane analysis.) Vitamin D plays an important role in immune responses, [... 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]
Vitamin D deficiency has been linked to many chronic medical conditions, including asthma and chronic obstructive pulmonary disease (COPD). In some cases, more severe vitamin D deficiency is associated with more severe chronic illness. However, it’s never been shown that vitamin D deficiency supplemenation improves or prevents illness; i.e., that vitamin D deficiency causes or exacerbates [... 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]
For medical researchers, vitamin D deficiency is the new black: it goes with anything. You name the infirmity, someone’s linked vitamin D deficiency to it, and overwrought public health experts have called our supposed collective deficit of the nutrient a “pandemic.” Chronic obstructive pulmonary disease (COPD) and asthma are on the long list of conditions [... read more]
Many people with chronic respiratory failure literally waste away — as evidenced by the contribution of “B” (for body mass index) in the BODE index’s prediction of survival in severe COPD. Although long-term oxygen therapy improves survival and quality of life, and pulmonary rehabilitation improves exercise capacity and QOL, efforts to halt or reverse the [... read more]
October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [... read more]
The new coumadin-killers, direct thrombin inhibitor dabigatran (approved in the U.S.) and direct factor Xa inhibitor rivaroxaban (coming soon) could usher in an awesome new era of anticoagulation, without warfarin’s requirements of cumbersome monitoring and annoying in-hospital titrations. But what happens when patients taking these drugs bleed, or need emergency surgery? Fresh-frozen plasma doesn’t work. [... read more]
Hao et al pooled data from 10 heterogeneous randomized trials (n=3,451) comparing probiotics (various preparations) vs. placebo, with the outcome of upper respiratory tract infections. Those using probiotics had a reduction in number of URTIs and antibiotic prescriptions by ~1/3 to ~1/2. There was significant heterogeneity among the trials, which included very few people over [... read more]
Casaer et al randomized 4,640 critically-ill patients who could not get enough calories by enteral feeding to receive TPN either on ICU day 3, or to wait until ICU day 8. While waiting for their TPN in the late group, patients got calories in sugar water along with liquid vitamins and minerals. There were no differences [... read more]
Pileggi et al analyzed 28 studies and concluded that decontaminating the GI/respiratory tract with antiseptics reduced ventilator-associated pneumonia by 27%; decontamination with antibiotics reduced VAP by 36%. Antibiotic decontamination also reduced ICU infections in general, by 29%. Critical Care 2011;15:R155. FREE FULL TEXT Also see last month’s “Oral / gastric antibiotic decontamination reduced bacteremias in [... 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.