Critical Care

Dec 222011
 

Neither a large 2009 multicenter study nor a 2011 meta-analysis showed any clinical benefit from the use of ICU telemedicine. Lilly et al report the results of a large single-center study in which they progressively implemented ICU telemedicine among 6,290 patients in 7 ICUs (a stepped-wedge design), with non-telemedicine groups acting as controls at each [… read more]

Dec 182011
 

Dumas et al prospectively observed 1145 consecutive victims of out-of-hospital cardiac arrest who survived to admission in France between 2000 and 2009. Among VT/VF patients, 65% got therapeutic hypothermia, while 60% of PEA/asystole patients did, with higher proportions receiving hypothermia later in the study period (86 and 73% respectively) . Most people in the PEA/asystole [… read more]

Dec 182011
 

For one year, Dallas et al prospectively followed 2,060 intubated MICU/SICU patients at Barnes-Jewish, and concluded that 83 (4%) developed VAP and 28 (1.4%) got VAT, which was defined as fever and 100,000 CFUs in tracheal secretions, without an infiltrate. By their reckoning, a third of VATs progressed to VAPs. Pathogens (mainly MDR bacteria) overlapped. [… read more]

Dec 182011
 
It's official -- Someone's being too negative

ICU Prognosis is Easy, Except When It’s Not How accurate are predictions of mortality by ICU team members? For 560 consecutive patients admitted to a single MICU at the University of Chicago, the authors polled the patient’s attending, fellow, resident, and nurse privately each day, asking simply: “Will this patient survive to discharge?” They collected [… read more]

Dec 182011
 

In a well-intentioned performance improvement initiative, Daniel Kett and the IMPACT-HAP team prospectively observed 303 patients at risk for MDR pneumonia at four academic hospitals. Surprisingly, more of those who got appropriate antibiotics died (34%) than those treated off-ATS/IDSA guidelines (20%), with Kaplan-Meier-modeled 28-day survival of 65% vs. 79%, p=0.0044. The authors were concerned enough [… read more]

Dec 182011
 

In the longest longitudinal study of acute respiratory distress syndrome (ARDS) yet, Herridge et al followed 109 young survivors of severe ARDS (medians: age 44; Lung Injury Score 3.7 out of 4) in Canada for 5 years, enrolling 1998-2001. Twelve died in the first year. At 5 years, the survivors remained below their pre-ARDS exercise tolerance; they [… read more]

Dec 182011
 

Dalteparin is a low-molecular weight heparin that, unlike enoxaparin, is safe for people with renal failure. Among 3,746 ICU patients in 6 countries, followed until hospital discharge, there was no difference in the rate of proximal deep venous thrombosis (5.1% vs 5.8%, 1′ endpoint) between once-daily dalteparin and twice-daily UFH, as detected by twice-weekly ultrasounds. [… read more]

Dec 102011
 

Severe sepsis has had a 35-45% mortality rate in clinical trials. Gagan Kumar et al use national observational data to suggest that while population rates of severe sepsis are increasing, survival has likely improved, with mortality falling from 39% to 27%, 2000-2007. However, most of the new survivors are not going home, but rather to [… read more]

Nov 252011
 

According to compelling new data, you can win the genetic lottery and live healthy all your life, and you’ll still be more likely to die from your first heart attack than the diabetic guy in the next bed who keeps going outside to smoke to relieve his chest pain. But you’ll at least have had more time [… read more]

Nov 242011
 

Even my neighbor’s cat knows that giving high-concentration oxygen to people with COPD and acute hypercapneic respiratory failure can cause them to hypoventilate further, causing life-threatening respiratory failure. (And he’s not even a very smart cat.) Perrin, Beasley et al asked, does a similar mechanism operate in severe asthma exacerbations? They randomized 106 patients presenting [… read more]

Nov 112011
 

Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]

Nov 092011
 

Duke’s Momen Wahidi and other luminaries bring you a consensus statement on use of peri-procedure medications during bronchoscopy. I’m assuming you’ve done a few already, so here are some highlights (with slight liberties in paraphrasing): Use topical anesthesia as well as moderate sedation in all patients, unless there are contraindications or you practice at a secret CIA prison. [… read more]

Nov 062011
 

Doctors are generally lousy at predicting death in terminally ill patients, and in ICU patients with indeterminate outcomes. Mortality prediction models have proliferated to improve our performance, but in the critical care literature, have mostly shown high predictive accuracy only at the tail ends of probability (high probability of survival or death). Siontis et al (led [… read more]

Nov 062011
 

Thanks to defibrillators, burly-armed EMTs, speedier cardiac revascularization, and induced hypothermia, the mortality rates after ventricular tachycardia or fibrillation have improved markedly for both in- and out-of-hospital cardiac arrests. But mortality rates after PEA and asystole remain stubbornly steady, seemingly resistant to any of the above interventions. Background: People suffering cardiac arrest in an ICU have the advantage [… read more]

Nov 012011
 

October’s Seminars in Respiratory & Critical Care Medicine brings you 110 pages and 11 articles on organ failure in the intensive care unit, with articles including: Organ failure scoring and predictive models Cardiac alterations due to organ failure The microcirculation as a therapeutic target in shock Immuologic derangements in organ failure Acute lung failure Cardiogenic [… read more]

Nov 012011
 

More than 40 small, middling-quality studies (n~80, some randomized) showing inconsistent results as to whether antioxidant therapy with acetylcysteine or other drugs reduces the risk for contrast nephropathy / acute kidney injury after angiography or CT-angiography. A 2008 meta-analysis concluded Mucomyst was helpful, reducing risk of nephropathy by almost 40% vs saline alone. However, the authors noted [… read more]

Nov 012011
 

The 2009 randomized CESAR trial in Lancet concluded that in severe ARDS in the U.K., referral to an ECMO center saved lives. However, patients in the control (non-ECMO) group didn’t consistently get low-tidal ventilation, and many patients randomized to ECMO never received it, creating skepticism of the findings. A case series from Australia/New Zealand (ANZ ECMO) in JAMA showed a 70% survival [… read more]

Oct 242011
 

Adaptive support ventilation (ASV) has entered wide use based on its attractive premise: it’s patient-centered ventilation, adapting breath-by-breath to deliver precisely the right amount of pressure support to achieve a targeted minute ventilation. However, evidence for any superiority over conventional ventilator modes is limited to cardiac surgery patients who were extubated in ~6 hours regardless of [… read more]