N Engl J Med Archives - PulmCCM
Advertisement


N Engl J Med Articles

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 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]

Mar 292014
 
No benefit from higher mean arterial pressure in most with septic shock

In Septic Shock, Goal of MAP > 65 mm Hg Remains Standard by Abhishek Biswas, MD In the 13 years since Rivers et al published their seminal paper that established “early goal directed therapy” for sepsis as the standard of care, treatment for severe sepsis and septic shock have evolved dramatically. Newer research questions the wisdom [... read more]

Mar 212014
 
Early goal directed therapy does not improve outcomes in septic shock (ProCESS)

Can we finally “Just Say No” to the mandatory use of central venous catheters and central venous saturation in severe sepsis and septic shock? by Muhammad Adrish, MD In a single center study published in 2001, Rivers et al reported that patients with severe sepsis and septic shock had significantly lower mortality (30.5% vs 46.5%) [... read more]

Mar 162014
 
Bleeding and Coagulation Disorders in the ICU (Review)

Because coagulopathies (an impairment of blood clotting), thrombotic states, and bleeding are all interrelated through the coagulation cascade, and because they occur often in critically ill patients, it makes sense to consider these bleeding and clotting disorders together. That’s what Beverly Hunt did in a review in the February 27 2014 New England Journal of [... read more]

Mar 082014
 
Community Acquired Pneumonia (Review)

Community-acquired pneumonia (CAP) is “ordinary” pneumonia, usually (but not always) caused by one of a short list of pathogens susceptible to common antibiotics. Pneumonia remains one of the main reasons for hospital admissions, and causes an estimated 3.5 million deaths yearly, including more than 50,000 in the U.S. Catching pneumonia also increases the risk for [... read more]

Mar 012014
 
Resuscitation Fluids in Critical Illness (Review)

Resuscitation fluids may be the most common intervention in critical care, with more than 200 million liters of normal saline infused each year in the U.S. alone. However, there is scarce evidence to guide the best use of resuscitation fluids in the ICU. John Myburgh and Michael Mythen’s review article in the September 26 2013 [... read more]

Feb 282014
 
Bloggers correct the New England Journal on ICU decontamination article

Blogger Peer Review Corrects NEJM Article’s Error In June 2013, PulmCCM unquestioningly reported the results of a major randomized trial in the New England Journal of Medicine by Susan S. Huang et al, showing that decontaminating patients upon arrival to the ICU with chlorhexidine baths and nasal mupirocin resulted in a dramatic drop in nosocomial infections [... read more]

Feb 152014
 
Tight glycemic control in critically ill kids: benefits, risks still unclear

Intensive insulin therapy for critically ill adults was rapidly adopted as standard care after 2001 when an apparent benefit was established after cardiac surgery, then medical ICU patients. Eleven years later, after a wave of minor harm signals, the NICE-SUGAR study confirmed for most intensivists that the excess hypoglycemia from intensive glucose control was potentially lethal in adults, and [... read more]

Feb 092014
 
Sedation and Analgesia in the Critically Ill (Review)

Pain, agitation, and delirium are all extremely common in ICU patients–so much so that they’ve been termed the “ICU triad.” No one knows exactly how common each is, because ICU patients are often too delirious to complain of pain; or their agitation hides their delirium; or their unidentified pain may cause their agitation; or …. [... read more]

Feb 012014
 
Spiriva and heart attack risk: new safety kerfuffle

Last year, PulmCCM reported on the TIOSPIR safety trial comparing the Spiriva dry-powder HandiHaler against the Respimat mist-delivery device. TIOSPIR showed no difference in all-cause mortality or composite cardiovascular risk endpoints between either Spiriva preparation. But this week, a group of drug safety researchers report their granular analysis of TIOSPIR data shows the Respimat device [... read more]

Jan 182014
 
Implantable tongue-buzzer improves obstructive sleep apnea by 70%

Source: Inspire Med Systems Hypoglossal Nerve Stimulation Markedly Improves OSA An estimated 15% of men and 6% of women in the U.S. have clinically significant obstructive sleep apnea, meaning it worsens their daytime cognitive functioning, cardiovascular risk, or both. In obstructive sleep apnea, muscle tone in the soft tissues of the pharynx (throat) is insufficient [... read more]

Jan 122014
 
Cognitive impairment after critical illness as bad as Alzheimer's

People who survive critical illness often experience long-term cognitive impairment, even among those with normal or near-normal pre-hospital brain function. Cognitive impairment after critical illness is poorly understood; relatively few prospective clinical trials in critical care have followed patients after hospital discharge, and measuring cognitive impairment and determining its onset is difficult. Cognitive impairment reduces [... read more]

Jan 052014
 
Acute Liver Failure: Causes & Initial Management (Part 1 of 2)

Acute Liver Failure: Causes and Initial Management See also: Treatment of Acute Liver Failure Acute liver failure, also called fulminant liver failure, has been defined as “a severe liver injury, potentially reversible in nature and with onset of hepatic encephalopathy within 8 weeks of the first symptoms in the absence of pre-existing liver disease.” Acute [... read more]

Jan 052014
 
Acute Liver Failure: Treatment (Part 2 of 2)

Acute Liver Failure: Treatment (Part 2 of 2) See also: Acute Liver Failure: Causes & Initial Management Management of acute liver failure is largely supportive critical care for the multiorgan failure that frequently results. Severe acute liver failure results in rapidly progressive hepatic encephalopathy and lethal cerebral edema; this complication requires special vigilance and expert [... read more]

Dec 082013
 
Ventilator-Induced Lung Injury Review (Part 2 of 2)

Prevention and Management of Ventilator-Induced Lung Injury See also Part 1: Mechanisms of Ventilator-Induced Lung Injury The recognition that lifesaving mechanical ventilation can also be harmful, even lethal, has led to a sea change in the use of mechanical ventilation in critically ill patients — at least in theory. For people with acute respiratory distress [... read more]

Dec 072013
 
Ventilator-Induced Lung Injury Review (Part 1 of 2)

Mechanisms of Ventilator-Induced Lung Injury (Part 1) See also Part 2: Prevention and Management of Ventilator-Induced Lung Injury Although invasive mechanical ventilation saves tens of thousands of lives each year, it can also be harmful, especially when misapplied. The repetitive stretching of lung tissue during positive pressure ventilation can damage fragile alveoli already made vulnerable [... read more]

Nov 232013
 
Hypothermia did not help after out-of-hospital cardiac arrest, in largest study yet

No Improvement in Cardiac Arrest Outcomes With Hypothermia Therapeutic hypothermia, or targeted temperature management, has become a standard component of post-cardiac arrest care. The evidence supporting this practice came from two small-to-medium-sized randomized trials, both published in the New England Journal of Medicine in 2002: Among 273 patients with out-of-hospital cardiac arrest due to shockable [... read more]

Nov 162013
 
Shock Review: Mechanisms and Therapies

Shock Review (Part 1 of 2) (See also Shock Review Part 2: Goals of Therapy) Jean-Louis Vincent, editor in chief of Critical Care, has a new review article on circulatory shock in the New England Journal of Medicine, where he’s also the editor of their new critical care section. Daniel De Backer co-authors. (See also [... read more]