Critical Care

Oct 062011
 

Goncalves-Pereira and Povoa meta-reviewed 57 reviews of pharmacokinetics of common beta-lactam antibiotics (piperacillin, meropenem, cefepime, ceftazidime, etc.) on patients in ICUs. The results were troubling or at least confusing: studies reported wide variability in pharmacokinetics of beta-lactam antibiotics in critically ill patients, with volume of distribution and drug clearance varying more than 2-fold for the [… read more]

Sep 292011
 

Increasing urine output should reduce the risk for contrast nephropathy, as should hustling contrast metal past vulnerable Na-K-Cl transporters using loop diuretics. However, furosemide alone increases the risk for contrast nephropathy. Some hypothesized that was due to diuretic-induced hypovolemia. Briguori et al report results of REMEDIAL-II. They randomized ~300 patients at very high risk for [… read more]

Sep 272011
 

Perhaps the most contentious debate in critical care is whether and when to transfuse blood to patients, especially those with acute lung injury and/or septic shock. FACTT showed less fluids (which could include blood) are better for ALI/ARDS, but transfusion wasn’t controlled and its contribution to the outcomes is unknown. Practicing physicians vary widely in [… read more]

Sep 112011
 

An impedance threshold device (essentially a one-way valve) attached to an endotracheal tube prevents air from leaving the chest during compressions, improving venous return, cardiac output and (in animal studies) perfusion. Auferheide and the ROC investigators report results of a huge randomized trial testing the ITD. 8,718 victims of out-of-hospital cardiac arrest were randomized to [… read more]

Sep 112011
 

Stiell et al (the ROC investigators) report results of a 10-center randomized trial in the U.S. and Canada. Among 9,933 patients with out-of-hospital cardiac arrest randomized to receive either 30-60 seconds or 2 minutes of uninterrupted CPR before rhythm analysis, there were no differences in survival, or survival to discharge with good functional status (primary [… read more]

Sep 082011
 

Part 1 of Levine et al’s excellent review on toxicology in the ICU. Some of their helpful recommendations/reminders: False positive UDS are common for tricyclics (diphenhydramine/Benadryl, carbamazepine, quetiapine/Seroquel), as are false negatives for benzodiazepines (lorazepam/Ativan, alprazolam/Xanax). The osmolal gap is elevated in ethanol, methanol, ethylene glycol, isopropanol, propylene glycol toxicity, but also in shock and [… read more]

Aug 242011
 

Muscedere J. Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med 2011;39:1985-1991. In short, it probably works to prevent ventilator-associated pneumonia (13 randomized trials, n=2,442. 12 were positive, pooled risk ratio 0.55, associated with 1-1.5 shorter days in the ICU and on the ventilator). So why not use [… read more]

Aug 212011
 

For 10 years, Zahar et al prospectively observed 3,588 patients developing severe sepsis & septic shock who ended up in French ICUs. Their sample captured a broad array of infections acquired in the community, the hospital ward, or the ICU (about 1/3 each). After multivariate assessment, they could not find an independent influence on mortality [… read more]

Aug 172011
 

Johnson et al reviewed charts in a retrospective case-control cohort study on 754 consecutive patients at Barnes-Jewish with severe sepsis or shock due to Gram-negative bacteremia. The exposure was receipt of antibiotics in the previous 90 days. 310 of the bacteremic patients had received antibiotics previously. Compared to unexposed controls, the previously antibiotic-exposed had a [… read more]

Aug 112011
 

Do we need to worry about pre-existing heparin-induced thrombocytopenia antibodies in people admitted with pulmonary embolism / deep venous thrombosis? Or can we keep happily slinging heparin at first sight? Warkentin et al analyze data from the Matisse VTE studies, which enrolled 3,994 patients with DVT or PE. All had ELISA HIT antibodies collected at [… read more]

Jul 292011
 

O’Connor et al report results of a randomized trial of 7,141 people with acute decompensated heart failure who got nesiritide or placebo in addition to standard care. To sum up, nesiritide didn’t seem to do much of anything at all (for dyspnea, risk of rehospitalization or death, or any other endpoint). NEJM 2011;365:32-43.

Jul 152011
 

3% saline infusions have become standard care for increased intracranial pressure at many centers, based on mostly anecdotal evidence. Hauer et al looked retrospectively at 100 patients receiving 3% saline for severe stroke in 2008-2009 (intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic) and compared them to 115 historical controls, 2007-2008 with “equal” underlying disease. Hypertonic saline [… read more]

Jul 142011
 

Tranexamic acid has a small beneficial effect on hemorrhage from trauma or surgery. Among 270 subjects with intracranial hemorrhage due to trauma, those randomized to tranexamic acid showed a trend toward improved outcomes (mortality, hemorrhage extension, new bleeding foci) compared to placebo. Authors propose a large trial to explore further. BMJ 2011;343:d3795. FREE FULL TEXT