“Nihilist” is one of the harshest insults that can be lobbed at a physician. Even while one knows intellectually that every patient can’t be saved, it’s considered odious to openly acknowledge that actuarial reality. Accepting the truth that some patients will inevitably die despite our best efforts is seen by some as the threshold of [… read more]
In acute respiratory distress syndrome (ARDS), using pleural pressure to adjust positive end-expiratory pressure (PEEP) has long been considered a cumbersome but theoretically ideal technique to optimize ventilator management. Using esophageal pressure as a surrogate for pleural pressure can allow one to calculate and minimize the transpulmonary pressure gradient, elevations in which are the putative [… read more]
A review of studies comparing 24/7 in-house intensivist physician coverage with less-intensive models (with no intensivist in the ICU overnight) found no clear or consistent benefits associated with in-house intensivist coverage. Authors informally reviewed about 50 previous studies and meta-analyses. They concluded that in-house intensivists overnight might reduce ICU length of stay by a few [… read more]
A randomized trial confirmed what most intensivists have long believed and practiced: in the moments before endotracheal intubation, we should help patients achieve the highest arterial oxygen saturation possible, using bag-mask ventilation (BMV). This seems self evident — why wouldn’t we? Bag-mask ventilation can distend the stomach with air, potentially increasing the risk for vomiting [… read more]
Guidelines advise physicians give large boluses of intravenous crystalloid infusions (two to three liters, generally) to patients with septic shock. Vasopressors are typically begun only if patients’ blood pressure remains low after fluid administration. A vocal minority of researchers have advised against delaying vasopressors in septic shock, arguing that norepinephrine, not intravenous fluid, is the [… read more]
by Nicole Lou, Contributing Writer, MedPage Today HONOLULU — Andexanet alfa (Andexxa), the reversal agent for anticoagulants in the factor Xa inhibitor class, worked for patients who developed acute major bleeding while on one of these agents, the full report of the ANNEXA-4 study confirmed. A bolus of the antidote saw median anti-factor Xa activity drop more [… read more]
Intensive insulin therapy to maintain blood glucose in the normal range has immense intuitive appeal. Hyperglycemia is associated with bad outcomes in numerous conditions, and we have the tools at hand to rigorously control it. How could that not help people? Unfortunately, intensive insulin therapy doesn’t seem to help at all, and may harm patients. [… read more]
The FDA is advising physicians that in post-approval data, 30-day survival rates with Abiomed’s Impella RP right ventricular assist device have been only 17%, compared to 73% in the RECOVER RIGHT study leading to the device’s approval in 2017. There were only 60 patients in the post-approval study, who had significantly worse clinical status at [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The mechanical power applied to the lung is a risk factor for ventilator or ventilation-induced lung injury [VILI] [1-4]. But can the work done to the lung over time be homogenized into a single value? Could different components of the power equation carry different VILI risk beyond their mathematical inequalities [… read more]
Jon-Emile S. Kenny MD [@heart_lung] A few years ago I was intrigued by a new concept in Ventilator-Induced Lung Injury [VILI] – the mechanical power. I employed this paradigm, introduced by Gattinoni’s group, as an opening for the ‘ARDS Trilogy.’ Since then, I have also discussed this ‘ergotrauma’ in the context of helium-oxygen physiology and [… read more]
Proton pump inhibitors (PPIs) are widely prescribed to mechanically ventilated patients to prevent gastrointestinal (GI) bleeding. The evidence for their use is not strong; individual randomized trials have not shown a clear benefit over histamine blockers, but when many trials were pooled into meta-analyses, PPIs do appear to be superior. The Surviving Sepsis Guidelines have [… read more]
About one in five patients with cancer will develop pulmonary embolism (PE) or deep venous thrombosis (DVT), together called venous thromboembolism (VTE). Cancer patients who develop VTE are four times more likely to have experience another (recurrent) DVT or PE. Twice-daily injections of enoxaparin are advised for patients with cancer-related DVT/PE, or who are at [… read more]
by Molly Walker, Staff Writer, MedPage Today Omadacycline, a novel antibiotic in the tetracycline class, was non-inferior to standard of care for both community-acquired bacterial pneumonia and acute bacterial skin and skin-structure infections, two randomized trials found. There was no significant difference in early clinical response among patients with community-acquired bacterial pneumonia randomized to omadacycline and those [… read more]
(From Dr. Philippe Rola) Join us for a couple of days of awesome learning in an awesome city! Back, bigger and better for its second iteration, this multispecialty cross-training exercise brings you the cutting and bleeding edge of acute care management of the sick patient, from the ED to the wards or the ICU. Combining [… read more]
Stethoscopes have always been an obvious suspect in the transmission of infections to patients by health care professionals. They’re carried room to room, come in contact with each patient, and are almost never disinfected between patient contacts. Testing has shown just what one would expect: stethoscopes are often contaminated with bacteria. One of the latest [… read more]
Most families have never suffered through a loved one experiencing prolonged critical illness and respiratory failure (defined as ventilator dependence for weeks, usually with a tracheostomy). But each year, more do. An estimated 400,000 people currently live with chronic critical illness in long-term acute care hospitals (LTACHs) and other facilities — a population that has [… read more]
by Salynn Boyles, Contributing Writer, MedPage Today Treatment with antibiotics during hospitalization for asthma exacerbation was associated with longer hospital stays and higher hospital costs in a retrospective cohort study of nearly 20,000 adult patients. Mihaela Stefan, MD, PhD, of the University of Massachusetts Medical School in Springfield, and colleagues, found that despite guidelines recommending against routine [… read more]
The U.S. FDA approved the first generic version of blockbuster drug Advair (fluticasone/salmeterol) for asthma maintenance treatment in patients aged 4 and up, and also for maintenance treatment and prevention of exacerbations in chronic obstructive pulmonary disease (COPD). Mylan will make the generic alternative to fluticasone/salmeterol, which will be called Wixela Inhub and come in [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The truth is balance, but the opposite of truth, which is unbalance, may not be a lie.” -Susan Sontag Case A 49 year old man presents with two days of hemoptysis, right-sided pleuritic chest pain and a few hours of ‘confusion’ according to his teammate in a pick-up hockey league. One [… read more]
Theophylline is derived from methylxanthine, naturally present in tea and cocoa beans. Initially used medically in 1895 as a diuretic, theophylline was one of the first drugs for asthma and COPD/emphysema (beginning in 1922), after its bronchodilation effects were discovered. Theophylline also has cardiac and central nervous system stimulant side effects and can produce tachyarrhythmias [… read more]
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