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]

Apr 102017
 

A document that looks like an unsigned, unpublished letter to the Wall Street Journal was posted on Scott Weingart’s EMCrit blog. It is signed only “The Department of Emergency Medicine – Henry Ford Hospital” and responds to the 2008 WSJ piece that suggested irregularities or mishandling of the data in the seminal 2001 trial on EGDT for sepsis. Scott’s [… read more]

Apr 062017
 
Free Online Hemodynamic Physiology Modules: an update & request

Jon-Emile S. Kenny MD [@heart_lung] “Oh, East is East and West is West, and never the twain shall meet …” -Kipling Last year, I began adding physiology modules to heart-lung.org as a part of a Master’s Degree I am undertaking at the Karolinska Institutet in Stockholm, Sweden.  The goal of these modules has been to encourage [… read more]

Apr 052017
 
Meta-analysis confirms EGDT for sepsis is unhelpful and wasteful (PRISM)

Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]

Apr 052017
 
Pre-hospital hypothermia hurt, not helped after cardiac arrest

Therapeutic hypothermia after cardiac arrest was almost immediately accepted as standard care in 2002 when two smallish, unblinded randomized trials (n=77 and n=273) showed a significant benefit from hypothermia after out-of-hospital ventricular fibrillation cardiac arrest. Hospitals and their cardiac care units quickly adopted resource-intensive protocols to manage patients’ special needs while being cooled to an icy 33° [… read more]

Mar 312017
 
USPSTF does not advise screening for obstructive sleep apnea

After an extensive review, the U.S. Preventive Services Task Force (USPSTF) concluded that there is insufficient evidence to recommend for or against screening adults for obstructive sleep apnea (OSA). In a statement posted to the website of the Journal of the American Medical Association the USPSTF panel said that in adults who are not actively complaining of symptoms of [… read more]

Mar 292017
 
Could vitamin C save lives in sepsis? These hospitals aren't waiting for proof.

After hundreds of trials failing to show benefit of drug treatments for sepsis, could a simple, cheap and effective treatment — high-dose vitamin C — be hiding in plain sight? A respected leader in critical care medicine thinks so, and his hospital system is all in. Vitamin C (ascorbic acid) is depleted during sepsis. That might be bad, [… read more]

Mar 232017
 
Fish oil in pregnancy prevented asthma in kids at age 5

Can fish oil supplements taken during pregnancy prevent asthma in children? According to a randomized trial in the New England Journal of Medicine, yes. Children of 736 pregnant women who took supplements containing given n-3 long-chain polyunsaturated fatty acid during their third trimester had a 31% relative reduction in risk of developing asthma or persistent [… read more]

Mar 202017
 
ICU Physiology in 1000 Words: Heliox & Mechanical Power

Jon-Emile S. Kenny MD [@heart_lung] Of the countless things taught to me by Dr. Chitkara at the Palo Alto VA Health Care System, one that sticks is the difference between density-dependent and viscosity-dependent airflow.  He often used the chronic bronchitic suffering through the viscous, humid New York City summers as a teaching example.  The importance [… read more]