Critical Care

Aug 032018
 
Scheduled nebulization with acetylcysteine didn't help ventilated patients

by Salynn Boyles, Contributing Writer, MedPage Today Regular nebulization proved to be no more effective than nebulization on demand in a randomized trial involving critically ill patients receiving invasive ventilation, researchers reported. Among ICU patients expected to need invasive ventilation for at least 24 hours, scheduled nebulization four times a day involving acetylcysteine with salbutamol did not [… read more]

Jul 252018
 
FDA approves new hyperkalemia drug Lokelma

The FDA approved oral sodium zirconium cyclosilicate (ZS-9), to be marketed as Lokelma, for the treatment of hyperkalemia. The drug seems to work better than sodium polystyrene sulfonate (Kayexalate), reducing serum potassium levels within an hour and restoring normal levels after about 2 hours in most patients. The drug was tested against placebo (not Kayexalate) [… read more]

Jul 232018
 
Sodium Bicarbonate Administration in Severe Metabolic Acidemia: the BICAR-ICU Trial

Jon-Emile S. Kenny MD [@heart_lung] “What is REAL?” -Velveteen Rabbit A 42 year old woman with poorly-controlled type II diabetes is admitted with a severe soft tissue infection of her left lower extremity.  She is hypotensive with altered sensorium and she is noted to have a rapidly progressing border of deep, crimson erythema and edema [… read more]

Jul 202018
 
Prophylactic Precedex prevented delirium in ICU patients

Quick Take: This small (n=100), two-center, industry-funded (Hospira) study showed a remarkable 80% prevention rate of ICU delirium (compared to 20% with placebo) with patients given dexmedetomidine prophylactically during their ICU stay. Although associated with poor outcomes in critically ill patients, delirium is not known to be an independent predictor of those outcomes. This small [… read more]

Jul 192018
 
Prophylactic haloperidol did not prevent delirium in the ICU

Delirium occurs in a large proportion of critically ill patients, and ICU patients who get delirious tend to have longer hospital stays and higher mortality. However, it has never been shown that delirium independently increases the risk for poor outcomes, or is just a fellow traveler with severe illness, i.e., a signal of more severe [… read more]

Jul 082018
 
Hospitalists Are the New Intensivists

Intensivists may get all the credit, but over 37,000 hospitalists provide much of the care for ICU patients in the U.S. According to a recent survey, they often do it without the presence or availability of intensivists for consultation or support, especially outside urban centers. The internists aren’t happy about it, feeling uncomfortable, unsupported and [… read more]

Jun 242018
 
FDA Warns of Pneumothorax, Death Associated With High-Tech Nasogastric Tubes

The U.S. Food and Drug Administration (FDA) warned health care teams about the risk of pneumothorax caused by certain enteral feeding tubes that use technology to guide their insertion, also called enteral access systems (EAS). It issued a safety communication stating, Most reports indicate these pulmonary events required urgent intervention, including needle decompression or chest [… read more]

Jun 182018
 
Driving Pressure in Airway Pressure Release Ventilation: a fool’s errand?

Jon-Emile S. Kenny MD [@heart_lung] “One of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important.” -Bertrand Russel I read with great interest a recent letter penned by Taylor and Camporota in response to an investigation on airway pressure release ventilation [APRV] by Zhou and colleagues.  Their brief [… read more]

Jun 142018
 
Vitamin C cocktail for sepsis: randomized trials to test efficacy

Since Marik et al announced exceptional survival rates among patients with septic shock given a cocktail of vitamin C, thiamine, and hydrocortisone, physicians taking care of septic patients have expressed both enthusiasm and skepticism about the cocktail’s reported lifesaving effects. Soon, more rigorous testing from randomized, double-blind placebo-controlled trials should provide harder data about the [… read more]

Jun 132018
 
Bougies for all intubations led to high success rates, even on difficult airways

Bougies are long, stiff plastic wands inserted into the trachea through the glottis during direct laryngoscopy (DL), providing a “guidewire” over which an endotracheal (ET) tube can then be more easily advanced into the trachea. Bougies have traditionally been used after one or more failed intubation attempts with direct laryngoscopy, at which point the airway [… read more]

Jun 072018
 
Prolonged infusions of beta-lactam antibiotics save lives in sepsis: meta-analysis

Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials. Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three [… read more]

May 242018
 

Introduction Respiratory failure is a commonly encountered disease process in both the emergency department (ED) and intensive care (ICU) setting.  Respiratory failure most frequently results from exacerbations of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), respiratory infections, encephalopathy, or a combination of these etiologies. Obesity, with or without obesity hypoventilation syndrome, reduces [… read more]

May 232018
 
A Free On-Line Hemodynamic Curriculum Grows

Jon-Emile S Kenny MD [@heart_lung] “What is memory but a story about how we have lived?” -Mark Doty During the recent ‘Hospitalist and the Resuscitationist’ conference in Montreal, there were discussions around the hemodynamics of prone positioning as well as using venous Doppler as a hemodynamic metric.  Much of this discussion was generated and driven [… read more]

May 162018
 
ICU Physiology in 1000 Words: Airway Pressure Release Ventilation – Part 3

Jon-Emile S. Kenny MD [@heart_lung] Lung Stress in Pulmonary & Extrapulmonary ARDS Initially described in the late 1990s, the distinction between direct pulmonary insults [i.e. pulmonary ARDS] and indirect pulmonary insults [i.e. extra-pulmonary ARDS] is important [1].  Additionally, direct pulmonary injury such as gastric acid aspiration may have a different molecular phenotype from indirect, extra-pulmonary [… read more]

May 152018
 
ICU Physiology in 1000 Words: Airway Pressure Release Ventilation – Part 2

Jon-Emile S. Kenny MD [@heart_lung] In the previous segment, time constants [t] – and their limitations – were described as a lesson in applied respiratory physiology for setting T-Low and prediction of auto-PEEP in airway pressure release ventilation [APRV].  In this brief missive an alternative approach to titrating T-low is described and critiqued.  As well, [… read more]

May 142018
 
ICU Physiology in 1000 Words: Airway Pressure Release Ventilation – Part 1

Jon-Emile S. Kenny MD [@heart_lung] While the lung in the throes of acute respiratory distress syndrome [ARDS] is shrunken, edematous and inflamed, a basic management maneuver is to ‘recruit’ lost pulmonary surface area.  In other words, unfold alveolar-capillary units with the ventilator like a respirothoracic party horn.  One ‘unconventional’ method of maximizing and maintaining lung [… read more]

Apr 232018
 
Lectures from the Inaugural 'Hospitalist and the Resuscitationist' Conference in Montreal, Canada

Jon-Emile S. Kenny MD [@heart_lung] “The real process of education should be the process of learning to think through the application of real problems.” -John Dewey On April 18 & 19, 2018, I had the pleasure of participating in the inaugural conference “The Hospitalist and the Resuscitationist” in Montreal.  The entirety of this meeting was [… read more]

Apr 042018
 
Are balanced crystalloids better than saline? SMART Talk with Dr. Michael Pinsky

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “Each time new experiments are observed to agree with the predictions, the theory survives and our confidence in it is increased; but if ever new observation is found to disagree, we have to abandon or modify the theory.” — Stephen Hawking A 47 [… read more]

Mar 242018
 
High-Flow Nasal Cannula, Work of Breathing & Mechanical Power: is there benefit?

Jon-Emile S. Kenny MD [@heart_lung] “I grow old … I grow old … I shall wear the bottoms of my trousers rolled.” -T. S. Eliot Background While it is tempting to isolate nasal high flow [NHF] into one’s cognitive schema for hypoxemia, NHF rightly deserves an esteemed position within one’s cerebral scaffolds for both hypercapnia [… read more]

Mar 122018
 
Is There Synergy between PEEP & Prone Position in ARDS?

Jon-Emile S. Kenny MD [@heart_lung] “… when you walk around a kitchen, you will say to yourself, this is interesting, this is grand, this is beautiful like Chardin.” -Marcel Proust Background Titration of positive end-expiratory pressure [PEEP] in the acute respiratory distress syndrome [ARDS] is achieved by a diverse assortment of practices undergirded by equally [… read more]