Aug 202017
 
Adherence with low tidal volumes for ARDS is poor at top centers; reduces survival

Anyone with the keys to a ventilator knows (or should), low tidal volume ventilation (~6 mL/kg ideal body weight) for patients with acute respiratory distress syndrome (ARDS) is standard care. Low tidal volume ventilation can prevent or ameliorate ventilator-associated lung injury ; if early clinical trials represent current reality, one in 11 people with ARDS treated by low tidal [… read more]

Aug 202017
 
Is intravenous contrast safer for kidneys than we thought?

Iodinated IV contrast has long been considered a significant contributor to acute kidney injury in hospitalized patients. But so-called “contrast nephropathy” is hard to accurately identify in real clinical circumstances. Acute kidney injury (AKI) can happen from a variety of causes, or their combination, during acute illness. And no randomized trial has established the risk of [… read more]

Aug 092017
 
Heparin-Induced Thrombocytopenia (HIT) Review

HIT Overview Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin exposure. In HIT, the body creates an autoantibody against the complex of platelet factor 4 bound to heparin. The anti-PF4 autoantibodies can activate platelets and cause life- and limb-threatening clots in arteries and veins. In HIT, platelets generally fall by more than 50% five [… read more]

Jul 292017
 
ICU Physiology in 1000 Words: IVC Collapse, Revisited – Part 2

Jon-Emile S. Kenny MD [@heart_lung] Please read part 1 and view the vodcast on IVC collapse prior to reading below; this post seeks to explain the interesting findings of Juhl-Olsen & colleagues [1] as well as provide a physiological rationale to Dr. Marik’s comments on my vodcast; there is a new explanatory animation at the [… read more]

Jul 222017
 
ICU Physiology in 1000 Words: IVC Collapse, Revisited – Part 1

Jon-Emile S. Kenny MD [@heart_lung] Three years ago I wanted to share my physiology website heart-lung.org; I needed a topic to stoke some interest, so I sent a brief essay to Matt here at pulmccm.org.  In it, I briefly described inspiratory IVC collapse and its relationship to volume status and volume responsiveness.  With this, the [… read more]

Jul 082017
 
Intubation during CPR was associated with worse survival and brain health

“Stop chest compressions for a minute while I intubate this patient!” That refrain must have been heard tens of thousands of times during CPR after cardiac arrest before 2010, when the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS) guidelines advised resuscitation teams not to interrupt chest compressions to place advanced airways, unless a patient [… read more]

Jun 282017
 

The US Food and Drug Administration (FDA) approved betrixaban (Bevyxxa), a new oral anticoagulant for prevention of venous thromboembolism (VTE) in hospitalized medical patients with risk factors for DVT/PE. With betrixaban, manufacturer Portola will seek to expand a tiny market niche it could immediately dominate: prophylaxis of DVT/PE extending for about a month after hospital [… read more]

Jun 272017
 
Is hypothermia harmful after in-hospital cardiac arrest?

Will “therapeutic” hypothermia someday need to be renamed? After a rush of optimism surrounding small trials showing large benefits from hypothermia to 33° after out-of-hospital cardiac arrest, hospitals and intensivists flocked to provide hypothermia to all victims of cardiac arrest (in- or out-of-hospital). When the much more powerful TTM trial showed no benefit of deep cooling [… read more]

Jun 232017
 
ICU Physiology in 1000 Words: The Mean Systemic Filling Pressure – Part 2

Jon-Emile S. Kenny MD [@heart_lung] Briefly, part 1 of this reflection on the mean systemic filling pressure [Pmsf] considered an analogy for volume status as the vastness of an ocean beyond the hull of a leaking ship; I argue that looking only inside the hull of the ship cannot tell you the volume of the [… read more]

Jun 162017
 
ICU Physiology in 1000 Words: The Mean Systemic Filling Pressure – Part 1

Jon-Emile S. Kenny MD [@heart_lung] It’s 4 in the morning; I am somewhere between Riga and Stockholm.  The moon is full and bright and rippling across the black, Baltic Sea.  This warm, June darkness is cut like onyx by deep vibrations of a cruise ship and its collections of giggling Swedes; they karaoke ‘Spaceman’ by [… read more]

Jun 042017
 
Tight blood sugar control did not help critically ill kids

Remember when intensive glucose control in adults became all the “lifesaving” rage — and was then revealed to actually be harmful? Well, it doesn’t seem to work in kids either. Tight glucose control in critically ill children with hyperglycemia failed to reduce ICU days as compared with a higher target glucose range, in a large randomized [… read more]

Jun 042017
 

The FDA has expanded the indication for tiotropium (Spiriva Respimat) to include children age 6 and older, based on efficacy data similar to that in adults. Tiotropium (Spiriva Respimat) was approved by FDA in 2015 for adults with asthma after clinical trials showed benefit of Spiriva as an add-on therapy to patients with persistent asthma [… read more]

May 152017
 
Sepsis drives far more readmissions than we realized

Sepsis may contribute to far more hospital readmissions than previously recognized — more than any other monitored condition. Recognition of this by federal and private payers could result in increased intensity of oversight of health teams’ care delivery for patients with sepsis. Hospital readmissions are squarely in the sights of the Centers for Medicare and Medicaid [… read more]

May 142017
 
Heparin prophylaxis no help after knee arthroscopy or leg casting (POT-KAST, POT-CAST)

Low molecular weight heparin (LMWH) at preventive doses after arthroscopic knee surgery or leg casting did not prevent venous thromboembolism (DVT or PE), in two Dutch randomized trials. The study helps fill a large gap in knowledge regarding risks and benefits of prophylactic anticoagulation in patients undergoing these procedures. In one (POT-KAST), 1,543 patients received [… read more]

May 072017
 
Video laryngoscopy was no better than directly intubating in the ICU, and may have been worse (MACMAN)

Video laryngoscopy provides beautiful close-up views of the larynx, by navigating a sensor past the tongue and pharyngeal tissues that can obstruct direct laryngoscopy views. These visual advantages led to its wide adoption by anesthesiologists, emergency physicians, and intensivists after video laryngoscopy’s introduction in the late 1990s. The intuition that better visualization must result in improved intubation rates — [… read more]

May 072017
 
Fleischner Society Guideline Update 2017: Management of Solid Pulmonary Nodules

Updated 2017 Fleischner Society guidelines advise a less intensive approach to the management of most small pulmonary nodules incidentally discovered on CT scans. The Fleischner Society now recommends that solid nodules 6 mm or less in diameter in low-risk adults >35 years old generally need no further follow-up. In higher-risk patients, a follow-up CT scan should [… read more]

Apr 262017
 
Can early warning systems predict (and prevent) cardiac arrest?

The increasingly data-saturated modern health care milieu has been catnip to technologists and statisticians. If only we could manage and analyze the data better, as this appealing narrative has it, we could improve health outcomes in the hospital. Predictive modeling algorithms represent the apotheosis of this paradigm, offering hope to detect patients’ impending deterioration and cardiac arrest [… read more]

Apr 222017
 
ICU Physiology in 1000 Words: Weaning-Induced Cardiac Dysfunction & the Passive Leg Raise

Jon-Emile S. Kenny MD [@heart_lung] Reminder: Help me with my master’s thesis!  Please complete a learning module, and fill out this exceptionally brief survey! Perhaps the landmark trial elaborating an evolving cardiac dysfunction during the spontaneous breathing trial [SBT] is that of Lemaire and colleagues – published in 1988 [1].  One particularly memorable patient of [… read more]

Apr 122017
 
Which position is safest for central line placement: subclavian, jugular, femoral? (3SITES)

Where to place a central venous catheter is a decision driven mainly by individual experience and preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause pneumothorax, compared to other sites. A large French randomized trial adds significantly to the evidence base. [… read more]

Apr 112017
 
600,000 albuterol (Ventolin) inhalers recalled

GlaxoSmithKline is voluntarily recalling more than 590,000 albuterol inhalers (brand name Ventolin), citing a defect that may cause the inhalers to deliver fewer doses of the medicine than prescribed, the British drugmaker announced. Patients complained about a bulging of the outside wrapper of Ventolin’s packaging; a leak of the medicine’s propellant is suspected to be [… read more]