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Jul 022015
 
Direct thrombin inhibitors associated with heart attack risk in multiple trials

Direct thrombin inhibitors (DTIs) are anticoagulants (blood thinners) most often used as alternatives to heparin and warfarin. DTIs are approved by the FDA for prevention and treatment of venous thromboembolism (deep venous thrombosis and pulmonary embolism) and to prevent blood clots in people with atrial fibrillation. But multiple randomized trials suggest these widely used anticoagulants might cause heart [… read more]

Jul 012015
 
Families stall end of life talks, say doctors. True?

Doctors and nurses said patients and their families created the largest obstacles to end-of-life decision making in the ICU, in a large survey published in JAMA Internal Medicine. About 1,300 staff at 13 academic hospitals in Canada rated barriers to end-of-life goals of care on a 1-7 scale. Doctors and nurses considered the largest barriers [… read more]

Jun 252015
 
PulmCCM Journal Vol. 1, Issue 3 Now Available

Issue #3 of PulmCCM Journal, an open-access, peer-reviewed journal in pulmonary and critical care medicine, is now available online. Click the link, or the “Journal” tab in the menu bar on PulmCCM to read the latest issue of PulmCCM Journal. This issue’s featured concise clinical review is “Who should undergo intracranial pressure monitoring in acute liver failure?” by [… read more]

May 312015
 

Part 2 of a video lecture by Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; [… read more]

May 292015
 
FDA approves once-daily tiotropium with olodaterol (Stiolto)

Image: Stuart Fisher The FDA approved Boehringer Ingelheim’s Stiolto, the latest of the new generation of once-daily inhalers for maintenance treatment of COPD. Stiolto contains the long-acting antimuscarinic agent tiotropium (Spiriva) and the long acting beta agonist olodaterol (marketed separately as Striverdi). Stiolto made it to approval based on 2 separate year-long phase III randomized [… read more]

May 282015
 
Restricting calories by 50% during critical illness results in no harm

Everyone agrees that providing adequate nutrition in critical illness is vitally important. The problem is, no one knows for sure what “adequate” means. Caloric targets are not based on evidence from randomized trials with meaningful clinical outcomes. They emerge as consensus from educated guesses by researchers conducting physiology studies. One camp believes that extra calories should [… read more]

May 272015
 
High flow oxygen by nasal cannula saves lives over noninvasive ventilation

Image: F&P Healthcare Noninvasive ventilation (NIV), often referred to by the trade name “BiPAP®,” can prevent intubation and save lives in patients with COPD exacerbations or pulmonary edema due to heart failure. Its proven benefits and low risk have led to NIV being used for patients in respiratory failure in virtually every acute care setting [… read more]

May 172015
 

Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine contributes this excellent educational video. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; metabolic acidosis; metabolic alkalosis; [… read more]

May 172015
 
The only VAP prevention method that saves lives is the one you’re not using

There’s always been doubt about the efficacy of the numerous “ventilator bundles” hospitals use to prevent ventilator-associated pneumonia (VAP). A provocative new analysis concludes that none of these methods save lives — except the one that almost no ICUs are using today. Healthcare associated pneumonias (HAP), especially ventilator-associated pneumonias (VAP), are associated with increased mortality, excess antibiotic use, lengthened hospital [… read more]

May 062015
 
Is more than one patient per ICU nurse dangerous?

The fewer patients an ICU nurse has to juggle, the better those patients’ chances of making it out of the hospital alive, according to a large observational study published in Critical Care Medicine. Data from the large EPIC II study suggested that two patients per nurse may be too many for safe, high-quality critical care. Nurse-to-patient [… read more]

May 022015
 
Kids experiment with e-cigarettes (and are smoking less than ever)

A new report from the Centers of Disease Control and Prevention (CDC) confirms U.S. teenagers and pre-adolescents are experimenting with e-cigarettes in dramatically greater numbers. But mentioned almost as an afterthought in the scare pieces presented as public health stories: fewer kids are smoking deadly real cigarettes than ever before. E-cigarette use by students in junior high and high school [… read more]

Apr 202015
 
FDA warns against use of OTC homeopathic asthma treatments

The US Food and Drug Administration (FDA) is advising the public not to use over the counter homeopathic asthma products. Thanks to protection from friendly legislators, the multibillion dollar homeopathic and supplement industry is allowed to mislead the public by labeling homeopathic products as “promoting lung health,” or even advertising them specifically as “providing relief [… read more]

Apr 192015
 
Do long-acting beta agonists for asthma cause birth defects?

Or, How to Treat Asthma in Pregnancy Do long-acting beta agonists cause birth defects when taken by pregnant women? A new study can’t settle the question, but might give women and their doctors more peace of mind when LABAs are necessary to control asthma during pregnancy. Current guidelines for treating asthma during pregnancy advise that for [… read more]

Apr 122015
 
Antibiotics for community-acquired pneumonia: Is azithromycin out?

Is it time for a change in the standard treatment of community-acquired pneumonia? A new Dutch study says, maybe. The Infectious Diseases Society of America (IDSA) says, not so fast. IDSA’s guidelines for treatment of community acquired pneumonia were last updated in 2007. For patients admitted to the hospital but not needing the ICU, they have [… read more]

Mar 282015
 
Surviving Sepsis Says EGDT Not Needed in All Patients with Septic Shock

As regular PulmCCM readers know, the ProCESS, ARISE and ProMISe randomized trials showed no benefit of protocolized early goal-directed therapy as compared to usual conscientious care in the treatment of severe sepsis and septic shock. In response to ProCESS and ARISE, the influential Surviving Sepsis Campaign now advises that measurement of central venous pressure (CVP) and [… read more]

Mar 272015
 
Endovascular therapy helps in ischemic stroke, again (ESCAPE)

Endovascular Therapy Improves Outcomes from Ischemic Stroke By Parth Rali, MD and Igor Titoff, DO Endovascular therapy for ischemic stroke has long been an attractive treatment modality for ischemic strokes, but until recently large randomized trials have not confirmed a benefit [1,2,3]. Two of these—IMS III1 and SYNTHESIS2—failed to prove the benefit of endovascular therapy (with-or-without tissue plasminogen activator) [… read more]

Mar 202015
 
ProMISe Trial for Sepsis: Usual Care 3, Goal-Directed Therapy 0*

* (since 2014) The ARISE (Australasia) and ProCESS (U.S.) trials, published in 2014, each demonstrated no advantage of protocolized care for sepsis over conscientious usual care. For those remaining unconvinced, the U.K.-based ProMISe trial is available in the New England Journal of Medicine. ProMISe extends the growing global footprint of what some will call the [… read more]

Mar 192015
 
ICU Physiology in 1,000 Words: The Right Ventricular Afterload (Part 2 of 2)

ICU Physiology in 1000 Words The Right Ventricular Afterload [Part 2 of 2] Jon-Emile S. Kenny M.D. [@heart_lung] Having considered the short-comings of Laplace’s Law and the PVR with respect to the RV afterload in part 1, we will now turn to each of the following in turn: the pulmonary arterial input impedance, a measureable [… read more]

Mar 152015
 
How safe is thoracentesis? Giant case series sheds light

Thoracentesis for pleural effusion — that is, inserting a long needle between someone’s ribs to drain a fluid collection from the chest — has always come with a scary menu of potential risks, including pneumothorax, hemothorax and pulmonary edema. A new study reports a low complication rate from thousands of thoracenteses. But debate will remain whether the safety results — achieved [… read more]

Mar 132015
 
ICU Physiology in 1,000 Words: Right Ventricular Afterload (Part 1 of 2)

ICU Physiology in 1,000 Words: The Right Ventricular Afterload (Part 1 of 2) By Jon-Emile S. Kenny M.D. With my trusted-resident – Dr. Lina Miyakawa – at my side we watched as our patient could not maintain his oxygen saturation above 82%. The patient had terrible aspiration pneumonia superimposed upon horrendous methamphetamine-related pulmonary arterial hypertension [… read more]