A systematic review of 3 trials (n=337) by the Bed Head Elevation Study Group (not to be confused with the Bedhead photo group) found no good evidence that head-of-bed (HOB) elevation to 45′ helps or harms in any way (pneumonia, decubiti, mortality, VTE, or hemodynamic instability). Nevertheless, a consensus panel of 22 experts agrees with previous [… read more]
Trouillet et al randomized patients requiring mechanical ventilation 4 days after cardiac surgery to either immediate perc-trach, or delayed percutaneous tracheostomy at 15 days. There were no differences in ventilator-free days at 60 days, nor in survival at 28, 60, or 90 days, nor in rates of VAP; however, the early-trach group had a lower [… read more]
Analyzing 50,481 victims of prolonged mechanical ventilation in Taiwan 1997-2007, Hung et al report outcomes were frankly terrible, with median survival of about 4 months. Those with a primary indication of neurologic damage fared significantly better. Those with a PMV indication of COPD, younger than 85, had 6-18 months median survival. Authors take the additional [… read more]
Long-term complications of critical care: Desai SV, Crit Care Med 2011;39:371-379.
The EMShockNet team previously claimed in JAMA that hyperoxia (paO2>300) after cardiac arrest could be deadly (63% in-hospital mortality vs 45% in normoxic patients). After looking at 12,108 database records in Australia/New Zealand, Bellomo et al beg to differ. By applying severity of illness/propensity models, they found no increased risk of death in those with [… read more]
THIS STUDY HAS BEEN RETRACTED. Kupfer et al looked retrospectively at 168 vented patients with transudative pleural effusions at Maimonides in Brooklyn. The half that got chest tubes (with an average of 1,200 mL drained) spent 3.8 days on the vent, vs 6.5 days for the group that got only thoracentesis, with no complications reported. [… read more]
Cochrane systematic review and meta-analysis: Pooling 11 randomized trials, n=1,971, Blackwood et al suggested there are some benefits to using a standardized weaning protocol. There was a reduction in weaning and ventilation time in the groups that had weaning protocols; we won’t report them here, because they would be misleading in this small space. They [… read more]
Sacanella et al prospectively observed 230 generally healthy, cognitively intact, highly functional & independently living Spaniards 65 years or older (mean age 75) after urgent admission to a single MICU. About half received mechanical ventilation (54%). Seventy died in-hospital; 48 died within a year, for a one-year survival of 49%. But among the 112 survivors, [… read more]
Roquilly et ses amis francais randomized 150 critically ill victims of severe French trauma to hydrocortisone or placebo for 7 days. The treated group had an absolute 16-19% lower risk for hospital-acquired pneumonia, the primary endpoint (36% vs. 51-54% depending on which intention-to-treat analysis you prefer, p=0.007 to 0.01). (n=150). JAMA 2011;305:1201-1209.
Fernandez-Cerrano et al randomized 56 people with CAP in Spain (only 3 needed mechanical ventilation) to receive methylprednisolone bolus-and-taper or placebo, in addition to ceftriaxone and levofloxacin. The steroid-treated group had less hypoxemia (lower PaO2/FiO2). (n=56). Critical Care 2011;15:R96. FREE FULL TEXT MORE ON THIS: In AJRCCM 2005, Confalonieri found less septic shock and need [… read more]
In a rare encouraging positive study in the chronically critically ill, 71% of vent-dependent patients (~6 weeks on MV) who did multiple sets of daily inspirations backwards through a PEEP valve weaned from mechanical ventilation (defined as >72 hrs off the vent), vs. 47% receiving a sham treatment. MIP also improved by 10 cmH2O in [… read more]
ARDS and multi-organ failure: Curr Opin Crit Care 2011;17:1-6. Hemodynamic monitoring of ventilated patients: Ibid, pp. 36-42 The ‘ABCDE’ bundle for critical care: Ibid, pp. 43-49. Managing severely hypoxemic patients: Ibid.
Meade MO et al. (Lung open ventilation study investigators) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637-45. Higher PEEP provided no benefit in 28-day mortality (28 vs 32%, p = 0.2), although it reduced refractory hypoxia (~5% [… read more]
Brower RG et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004;351:327-36. Randomized trial among 549 patients with ARDS/ALI conducted by NHLBI/ARDSNet. Compared high and low PEEP strategies, and found no significant difference in mortality, ventilator-free days, ICU-free days, or organ failure-free days between [… read more]
Herridge MS et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003; 348:683-93. Non-pulmonary problems are usually dominant in impairment of ARDS survivors. Low exercise tolerance, fatigue, and weakness are common a year after discharge. Pulmonary function tests usually normalized, other than a diffusion impairment. At 12 months, only 6% [… read more]