“Decolonizing” New ICU Patients Reduces Bloodstream Infections: NEJM In humankind’s battle against bacteria, the ICU is the front line. And with MRSA infection rates doubling in the past 5 years, and the more recent and scary spread of lethal pan-resistant Enterobacteriae, lately the bugs have won a few rounds. The problem isn’t just catching a deadly [... read more]
Prone Positioning Saves Lives in Severe ARDS Patients: NEJM It’s long been known that positioning patients with ARDS on mechanical ventilation face-down (prone) improves their oxygenation. (There are various theories why prone positioning helps, such as by reducing ARDS’s injurious heterogeneous alveolar overdistension.) The improved oxygen levels have never translated into improved outcomes in ARDS [... read more]
image: Lighthouse Med. Equip. No Benefit Seen From Monitoring Gastric Volume in Ventilated Patients on Tube Feedings Starting tube feedings early for patients on mechanical ventilation is considered the standard of care. It’s been assumed that delayed gastric emptying, resulting in a stomach full of liquid nutrition, predisposes patients to have aspiration events and develop [... read more]
Staph Vaccine Fails in Cardiothoracic Surgery Patients Staphyloccocus aureus wound infections and bacteremia commonly complicate cardiothoracic surgery, even with meticulous attention to infection prevention. Staph mediastinitis, a deep infection of the surgical wound, is particularly feared and lethal. Vance Fowler et al randomized 8,031 people undergoing sternotomy to receive the V710 vaccine against S. aureus, [... read more]
Apixaban (Eliquis) Prevents Recurrent DVT-PE Long-Term People with unprovoked venous thromboembolic disease (pulmonary embolism or deep venous thrombosis, or DVT) are at high risk for recurrence, and current ACCP guidelines advise consideration of “indefinite” anticoagulation. Warfarin (Coumadin) is a wonder drug efficacy-wise, reducing the risk of pulmonary embolism and deep venous thrombosis by ~90%. However, [... read more]
Families Allowed to Witness CPR Felt Better, Had Fewer Regrets Should family members be allowed, or even encouraged, to witness the health care team’s attempts to revive their family member with CPR after a cardiac arrest? In the interests of openness and transparency, many have argued “yes,” with the thought that witnessing the heroic efforts [... read more]
Acetazolamide Improved Obstructive Sleep Apnea at High Altitudes by Blair Westerly, MD Obstructive sleep apnea (OSA) is common, and so is travel to the mountains for work and play, therefore encounters with patients with OSA who travel to mountain destinations is not infrequent. We all learn early in training that altitude affects oxygenation, and patients [... read more]
Bactrim/Septra for Idiopathic Pulmonary Fibrosis? by Brett Ley, MD Idiopathic pulmonary fibrosis (IPF) is a fatal fibrotic lung disease that lacks proven, effective treatments. Many novel medications have been trialed and painfully failed. So I commend Ludmila Shulgina and colleagues for trying an old medication, trimethoprim-sulfamethoxazole (TMP-SMX), with some preliminary evidence for potential benefit. What [... read more]
(image: Wikipedia) High-Frequency Oscillatory Ventilation (HFOV) for ARDS Two Randomized Trials: Early HFOV Doesn’t Help, May Harm High-frequency oscillatory ventilation (HFOV) has been proposed as a first-line therapy for acute respiratory distress syndrome (ARDS). By delivering 3-15 breaths per second of tiny tidal volumes (~70 mL), HFOV has appeal as the “ultimate” lung protective ventilator [... read more]
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]
Ultrafiltration No Better Than Diuresis for CHF Exacerbations by Blair Westerly, MD Cardiorenal syndrome — simultaneous heart failure and renal failure — is a frequently encountered problem in people with acute decompensated heart failure. Treatment with diuretics for congestive heart failure exacerbations is standard care, but diuretics may at times worsen renal function. Venovenous ultrafiltration [... read more]
“Trach Collar” Trials Beat Pressure Support for Long-Term Ventilator Weaning By Blair Westerly, MD Patients requiring prolonged mechanical ventilation linger in ICUs and long-term acute care hospitals for weeks, accounting for a significant portion of intensive care unit costs and often suffering serious complications while dependent on the ventilator. Despite this issue’s rising importance, the [... read more]
Time to Retire Routine Replacement of Peripheral IVs Study question: Do peripheral I.V.s need to be changed every 72-96 hours per the CDCs recommendations or can they be changed as clinically indicated? How many times as a resident did you receive a call at 4 a.m., often at the very moment you were about to [... read more]
Use of BNP May Speed Weaning from Mechanical Ventilation by Blair Westerly, MD Weaning mechanical ventilation is a time-consuming process that is often impeded by volume overload. Minimizing fluid balance for patients on mechanical ventilation has been shown to decrease the duration of mechanical ventilation (Wiedemann et al). Brain natriuretic peptide (BNP) is released as [... read more]
Etomidate: Unsafe for Intubation in Patients with Sepsis? by Blair Westerly, MD Etomidate is commonly used for rapid sequence intubation; however, even after one dose, it has been associated with adrenal axis suppression in critically ill patients. Though both adrenal insufficiency and increased mortality in sepsis have been associated with etomidate, the relationship of the [... read more]
Do “Sedation Vacations” Really Speed Weaning From Mechanical Ventilation? Daily interruptions of sedation (“sedation holiday” or “sedation vacation”) became the standard of critical care for weaning from mechanical ventilation in ICUs around the world after J.P. Kress et al’s landmark 2000 New England Journal of Medicine paper showing daily sedation interruptions freed ~64 patients from ventilators [... 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]
(image: Wikipedia) As we reported a few months ago, the PANTHER-IPF trial was stopped early for safety, when it became clear that the combination of prednisone and azathioprine was hurting people with idiopathic pulmonary fibrosis (IPF). Ganesh Raghu (U-Washington), Kevin Anstrom (Duke), Talmadge King (UCSF) et al report the final results in the May 24 New [... read more]
Precedex Takes Step Toward FDA Indication for Longer-Term Use Precedex (dexmedetomidine) only has existing FDA indications for short-term sedation (< 24 hours) in both mechanically ventilated and non-intubated patients. That short leash is because of dexmedetomidine’s tendency to produce hypotension and bradycardia, and has limited Precedex’s approved uses mainly to elective surgeries and other invasive procedures. Many intensivists use Precedex off-label for critically [... read more]
Azithromycin for non-CF Bronchiectasis Bronchiectasis — the permanently dilated, tortuous bronchi that can result after previous lung infections — is a frustrating problem for pulmonologists to treat, but not nearly as frustrating as it can be for patients to live with. People with bronchiectasis are plagued by chronic coughing, and many experience a steady decline [... read more]