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]
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]
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]
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]
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]
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]
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]
The new coumadin-killers, direct thrombin inhibitor dabigatran (approved in the U.S.) and direct factor Xa inhibitor rivaroxaban (coming soon) could usher in an awesome new era of anticoagulation, without warfarin’s requirements of cumbersome monitoring and annoying in-hospital titrations. But what happens when patients taking these drugs bleed, or need emergency surgery? Fresh-frozen plasma doesn’t work. [… read more]
Here’s a free “head-to-head” discussion with arguments for and against implementation of routine mild hypothermia for all patients with out-of-hospital cardiac arrest. The benefits of hypothermia after out-of-hospital ventricular fibrillation cardiac arrests are reasonably well-established, and multiple society guidelines (SCCM’s, AHA’s) advocate the practice. The question is whether to induce mild hypothermia / targeted temperature management in all [… read more]
In 2006, Medicare (we) spent 25% of our dollars on treatment for people in their last year of life. The debate rages, waged with euphemism in public and painful, conflicting emotions in private: how can we let Grandma go peacefully and with dignity, without feeling too guilty or ending up in front of a Senate subcommittee? [… read more]
Zhang et al pooled 20 studies that compared ultrasound, chest X-ray, or both against a reference standard (usually CT scan) for the diagnosis of pneumothorax. Chest X-ray had a pooled sensitivity of 52% and specificity 99% for diagnosis of pneumothorax. Ultrasound’s pooled sensitivity was 88% and specificity, 100%. Unsurprisingly, the accuracy of ultrasonography to diagnose [… read more]
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]
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]
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]
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]
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]
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]
Antimicrobial Stewardship for the Community Hospital: Practical Tools & Techniques for Implementation. Clin Infect Dis 2011;53(suppl 1).
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]
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]
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