Jon-Emile S. Kenny MD [@heart_lung] “…. She was here on earth to grasp the meaning of its wild enchantment and to call each thing by its right name …” -Boris Pasternak Background Over the last half-decade, there has been a distinct shift in the approach to lactate elevation. The long-held belief that elevated serum lactate [… read more]
Overview Vasopressors and inotropes are cornerstones in the management of shock syndromes. Understanding vasopressors’ receptor activity and resultant pharmacological response enables clinicians to select the ideal vasopressor(s) for a patient suffering from shock. The following table outlines common vasopressors/inotropes and their general receptor activity profiles.1,2 Drug Dose α1 ß1 ß2 DA V1 V2 cAMP Norepinephrine [… read more]
The FDA approved angiotensin-II (Giapreza) as a new intravenous vasopressor for septic shock and other forms of distributive shock. The first new FDA-approved vasopressor in decades, angiotensin-II could significantly change the management of severe septic shock. FDA based its expedited approval (under priority review) on the ATHOS-3 trial enrolling 321 patients with shock refractory to [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Background If venous pressure were always the downstream pressure of an artery, then when flow is zero, the arterial pressure should equal the venous pressure. For example, if one were to measure the coronary artery pressure and coronary sinus pressure at zero flow, their pressures should be equal. Yet, this [… read more]
Intensivists have another antibiotic combination to treat severe infections caused by gram-negative bacteria with the FDA’s approval of Vabomere (meropenem, combined with the beta-lactamase inhibitor called vaborbactam). FDA approved Vabomere only for the treatment of complicated urinary tract infections (such as pyelonephritis). However, licensed U.S. physicians routinely prescribe FDA-approved antibiotics “off-label” for other indications. Meropenem-vaborbactam [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “… And you may ask yourself … well, how did I get here? … And you may tell yourself … my God! What have I done?” -David Byrne A 92 year old woman is transferred to the coronary care unit for treatment of pulmonary edema. She [… read more]
When the Centers for Medicare and Medicaid Services (CMS) released its 2015 performance measure for the treatment of sepsis — called SEP-1 or the Severe Sepsis/Septic Shock Early Management Bundle, physicians responded with general befuddlement: the measure demanded they follow such unusual practices as giving 3-liter boluses of saline to anuric, hypertensive, hypoxemic patients with [… read more]
The antifungal micafungin is often given empirically to patients in ICUs with sepsis who are also at high risk for invasive fungal infections. IDSA guidelines endorse the use of empiric antifungals for patients with unresolving ICU-acquired sepsis, but any benefits of this are unknown. A randomized trial published in JAMA sheds light on the practice. French [… read more]
In the U.S., the federal government strongly encourages physicians to give most patients with sepsis aggressive crystalloid fluid boluses (~2-3 liters), without regard to a patient’s individual condition. In a randomized trial in JAMA, a similar standardized approach to aggressive fluid resuscitation in Africa appeared to cause the deaths of a significant proportion of patients [… read more]
In 2013, New York’s state government began regulating the care of sepsis. The state has since required its hospitals (and thus its doctors) to adhere to some version of a sepsis protocol that included a “bundle” to be delivered within 3 hours after sepsis recognition: blood cultures before antibiotics; lactate measurement; broad-spectrum antibiotics The Empire [… read more]
Physicians may soon have another vasopressor to add to their toolkit in treating patients with septic shock and other vasodilatory shock. Angiotensin II infusions improved blood pressure in critically ill patients with vasodilatory shock who remained hypotensive on high doses of conventional vasopressors, in the phase III ATHOS-3 trial. Patients with hypotension despite catecholamine infusions [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD “Our life consists partly in madness, partly in wisdom: whoever writes about it merely respectfully and by rule leaves more than half of it behind.” -Montaigne Marking the 50 year anniversary of the first description of the adult respiratory distress syndrome – later [… read more]
Procalcitonin Test: Overview Procalcitonin (PCT) is the precursor of the hormone calcitonin and is mainly produced by the thyroid. Procalcitonin is a so-called acute phase reactant, rising in response to tissue inflammation and injury. Outside the thyroid, PCT is secreted by the lungs, intestines and other tissues in increasing amounts in response to bacterial endotoxin [… read more]
Sepsis may contribute to far more hospital readmissions than previously recognized — more than any other monitored condition. Recognition of this by federal and private payers could result in increased intensity of oversight of health teams’ care delivery for patients with sepsis. Hospital readmissions are squarely in the sights of the Centers for Medicare and Medicaid [… read more]
A document that looks like an unsigned, unpublished letter to the Wall Street Journal was posted on Scott Weingart’s EMCrit blog. It is signed only “The Department of Emergency Medicine – Henry Ford Hospital” and responds to the 2008 WSJ piece that suggested irregularities or mishandling of the data in the seminal 2001 trial on EGDT for sepsis. Scott’s [… read more]
Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]
After hundreds of trials failing to show benefit of drug treatments for sepsis, could a simple, cheap and effective treatment — high-dose vitamin C — be hiding in plain sight? A respected leader in critical care medicine thinks so, and his hospital system is all in. Vitamin C (ascorbic acid) is depleted during sepsis. That might be bad, [… read more]
In 2008 hospitals were informed they would no longer be paid for treating hospital acquired infections like ventilator associated pneumonia. Miraculously, the rates of VAP (self-reported by hospitals to the Centers for Disease Control and Prevention) fell dramatically by 60 to 70% between 2006 and 2012, to less than one VAP per 1,000 ventilator days [… read more]
By Scott Aberegg, MD, MPH Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient. On my first MICU rotation in 1997, I was so swept [… read more]
Sepsis is sneaky. Physicians, nurses, and epidemiologists struggle to accurately identify patients with sepsis in the emergency department, hospital ward, and in data sets. The so-called SIRS criteria were abandoned as insensitive and nonspecific in the most recent iteration of sepsis care. Sepsis is instead now defined as “life-threatening organ dysfunction caused by a dysregulated [… read more]
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