Critical Care

Mar 312019
 
Impella RP survival only 17% so far (not 73%), says FDA

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]

Mar 292019
 
ICU Physiology in 1000 Words: The Driving Power & Ventilator-Induced Lung Injury

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]

Mar 262019
 
ICU Physiology in 1000 Words: The Mechanical Power & Ventilator-Induced Lung Injury

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]

Mar 172019
 
Proton pump inhibitors did not improve outcomes in ICUs (SUP-ICU trial)

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]

Mar 142019
 
Register for The Hospitalist and the Resuscitationist (Montreal, May 23-24)

(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]

Mar 102019
 
ICU stethoscopes are covered in bacteria, and you're cleaning yours wrong

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]

Mar 082019
 
How should we relate to "unreasonable" families in the ICU?

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]

Feb 232019
 
Should We Stop Trending Lactate in Septic Shock?  ANDROMEDA-SHOCK Published

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]

Feb 172019
 
Echocardiography Does Not Correlate with Volume Status says CoDE-MiN Study

Jon-Emile S. Kenny MD [@heart_lung] “Nolite te bastardes carborundorum” -Margaret Atwood Case An 86 year old woman presents with two days of decreased intake by mouth and 3 days of melena and vomiting.  She is followed closely by her internist and cardiologist for hypertension, severe mitral regurgitation, pulmonary venous hypertension and right ventricular dysfunction with co-morbid [… read more]

Feb 172019
 
FDA warns of aortic dissection with fluoroquinolones

After a review of reported adverse events, the U.S. FDA is warning physicians that fluoroquinolone antibiotics may increase the occurrence of aortic dissections, resulting in aortic rupture and death. FDA used unusually direct language in advising, “Fluoroquinolones should not be used in patients at increased risk unless there are no other treatment options available.” Patients [… read more]

Feb 172019
 
Cricoid pressure no help during endotracheal intubation in large trial

Pressing fingers against the cricoid cartilage (the Sellick maneuver) during rapid sequence intubation compresses the esophagus beneath the firmer trachea. It has long been espoused that this prevents aspiration (emesis or reflux of gastric contents into the supraglottic space and airway, obscuring the operator’s view and harming the patient). The Sellick maneuver is believed to [… read more]

Feb 082019
 
Former Vanderbilt nurse arrested, charged with homicide for medication error

Tennessee law enforcement agents announced they had arrested and charged a nurse with reckless homicide and patient abuse for a fatal medication error she allegedly committed while working at Vanderbilt University Medical Center in December 2017. The charges allege that the nurse intended to provide an ordered dose of midazolam (Versed) to an anxious patient [… read more]

Feb 082019
 
Decontaminating patients did not reduce bloodstream infections

A large proportion of patients who remain in ICUs for more than a few days develop hospital-acquired infections, including bloodstream infections. Indwelling urinary or venous catheters, gut translocation, aspiration and impaired host defenses can all be causative. Bloodstream infection incidence has been reduced over time, but remains persistently ineradicable. One enticing method of prevention has been [… read more]

Feb 032019
 
ICU Physiology in 1000 Words: Blood Pressure

Jon-Emile S. Kenny MD [@heart_lung] Why is blood pressure measured by units of length [i.e. millimeters of mercury – mmHg]?  What decides systolic and diastolic pressure?  What are the determinants of tissue perfusion and what are the clinical implications of this physiology?  Can we deceive ourselves into thinking a particular mean arterial pressure [MAP] is [… read more]

Jan 232019
 
Is Critical Care Medicine becoming a Cargo Cult of Vitamin C?

By Nicholas Mark, MD During the 1940s, many Melanesian cultures were profoundly altered as the Second World War was waged in the Pacific around them. Western soldiers constructed airstrips out of the jungles and the natives witnessed vast wealth in the form of manufactured goods literally rain down from the skies on parachutes or carried [… read more]

Jan 162019
 
Atrial Fibrillation for the Intensivist – part 2

Jon-Emile S. Kenny MD [@heart_lung] “I’m burnin’ through the sky, yeah Two hundred degrees, That’s why they call me Mister Fahrenheit” -Freddie Mercury Part 1 gave a brief overview of the mechanisms of atrial fibrillation [AF] as well as pertinent features of rate controlling agents and anticoagulation.  In this brief second part, nuanced features of ventricular [… read more]

Jan 152019
 
Atrial Fibrillation for the Intensivist – part 1

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “The habit of writing for my eye is good practice. It loosens the ligaments.” ― Virginia Woolf Case A 28 year old woman with known severe mitral stenosis from rheumatic heart disease presents with acute onset shortness of breath.  Her acute dyspnea began while [… read more]

Jan 092019
 
Hospitals should not implement one-hour sepsis bundles, say SCCM and ACEP

In an unusual turn, the Society for Critical Care Medicine (SCCM) is advising against implementation of the one-hour sepsis bundle originally advocated in Spring 2018 by committee members of its Surviving Sepsis Campaign. SCCM and American College of Emergency Physicians (ACEP) issued a joint statement in which they acknowledged “concerns expressed about the recently released Surviving [… read more]

Jan 062019
 
Keep O2 saturations at 96% or below for hospitalized patients: expert panel

For acutely ill patients, oxygen saturation should not exceed 96%, an international panel recommended. A multidisciplinary team of clinicians was brought together by The BMJ as part of the Rapid Recommendation initiative to focus on the most effective approach to oxygen therapy for patients with acute medical illness. The team used findings from an April 2018 systematic [… read more]

Jan 012019
 
Best of 2018 on PulmCCM

Best of 2018:       Prone positioning for severe ARDS advised by major societies    2018 Update to Surviving Sepsis Guidelines: Cue Backlash   Management of Ground Glass and Subsolid Pulmonary Nodules: Review   Vasopressors and Inotropes for Shock Syndromes: Review     Prophylactic Precedex prevented delirium in ICU patients   Corticosteroids do help [… read more]