Nov 112017
 
ICU Physiology in 1000 Words: Venous Excess & the Myth of Venous Return

Jon-Emile S. Kenny MD [@heart_lung] In the last few weeks I have been contacted by curious clinical physiologists craving my conceptions of ‘venous excess’ [1].  These words will address this model, concisely and – I pray – clearly. The Myth of Venous Return The roots of venous excess took hold within the fertile soil of [… read more]

Nov 092017
 
FDA approves new phrenic nerve stimulator for central sleep apnea

The US Food and Drug Administration (FDA) approved an implanted phrenic nerve-stimulator device as a new treatment for moderate-to-severe central sleep apnea (CSA). The remedē System (Respicardia) consists of a pacemaker-like battery pack that’s surgically implanted in the upper chest beneath the skin. Wires electrically stimulate the phrenic nerve as it travels from the neck [… read more]

Nov 032017
 
Mepolizumab reduced exacerbations in COPD with eosinophilia, but missed target

The injectible monoclonal antibody mepolizumab (Nucala, GSK) is FDA-approved for severe asthma with blood eosinophilia, uncontrolled with standard controller inhaler treatments. Two randomized placebo-controlled trials keep alive for GSK the possibility of an FDA indication to reduce exacerbations in people with chronic obstructive pulmonary disease (COPD) with high blood eosinophil counts, expanding the drug’s market. The ~1,500 [… read more]

Nov 012017
 
Doctors aren't complying with the CMS sepsis quality measure

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]

Oct 282017
 
Home BiPAP reduced readmissions after COPD exacerbations

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the top causes of hospital admission — and readmission: up to 30% of patients “bounce back” to the hospital within 90 days after a COPD exacerbation. Patients with severe COPD exacerbations with acute hypercapneic respiratory failure often receive noninvasive ventilation (NIV), commonly known as [… read more]

Oct 252017
 
Empiric micafungin didn't save lives in ICU-acquired sepsis

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]

Oct 202017
 
Pain Control and Sedation in Mechanically Ventilated Patients: Review

Treating Pain in Mechanically Ventilated Patients Adult patients in the intensive care unit (ICU) frequently experience pain, resulting from acute and chronic illness as well the positioning and interventions standard to ICU care.1,2 Besides being ethical and humane, adequately treating pain prevents agitation and delirium in mechanically ventilated patients. There are also many physiologic responses to [… read more]

Oct 192017
 
ICU Physiology in 1000 Words: Fighter Pilots!

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD Pilots of high-performance, tactical fighter jets each have continuous positive airway pressure [i.e. CPAP] masks as a part of their flight suit.  Strikingly, beyond the clinically-commonplace airway pressure of 5-15 cm of H2O, a fighter pilot may endure a mask-applied pressure of 90 [… read more]

Oct 132017
 
Don't give Kayexalate within 3 hours of other drugs, says FDA

The FDA is warning physicians not to provide other enterally-absorbed drugs within 3 hours before or after giving sodium polystyrene sulfonate (Kayexalate, Concordia Pharmaceuticals) for hyperkalemia. In testing performed 59 years after its launch, it was discovered that Kayexalate can bind to many prescription drugs, potentially rendering them ineffective. For patients with gastroparesis or ileus, FDA [… read more]

Oct 122017
 
Age of transfused red cells had no effect on mortality (TRANSFUSE)

U.S. medical centers vary widely in the average shelf life of the blood in their blood banks. Trauma and high-volume surgical centers receive the oldest blood from the Red Cross, on the premise that they’ll be likely to transfuse it. All blood banks tend to dispense the oldest units first. This reduces waste of donated [… read more]

Oct 082017
 
In sepsis, aggressive fluid resuscitation was harmful in randomized trial

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]

Sep 292017
 
State-of-the-ART Trial: Do Recruitment Maneuvers & Higher PEEP Raise Mortality?

Jon-Emile S. Kenny MD [@heart_lung] “To believe in medicine would be the height of folly, if not to believe in it were not a greater folly still.” -Proust A 32 year old man with no past medical history save for a BMI of 51 is admitted with severe acute pancreatitis following a large intake of [… read more]

Sep 282017
 
Use sepsis bundles, or you're breaking the (New York) law

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]

Sep 192017
 
FDA approves first three-in-one inhaler for COPD

GlaxoSmithKline and Innoviva reported the U.S. Food and Drug Administration (FDA) has approved Trelegy Ellipta, the first once-daily, three-drugs-in-one inhaler for treatment of chronic obstructive pulmonary disease (COPD). Trelegy Ellipta contains the antimuscarinic umeclidinium, the corticosteroid fluticasone furoate, and the long acting beta agonist vilanterol. The drugs provide bronchodilation and anti-inflammatory effects through three different [… read more]

Sep 142017
 
ICU Physiology in 1000 Words: High Flow Oxygen Therapy

Jon-Emile S. Kenny MD [@heart_lung] That high flow oxygen applied via nasal cannula lends itself to treating hypoxemic respiratory failure may be obvious.  With adequate heat and humidification, oxygen can be employed relatively comfortably at very high flow rates – upwards of 60 L/min – to the nares.  At such rates, the effort of the [… read more]

Sep 082017
 
Angiotensin II, a new vasopressor for septic shock, coming soon (probably)

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]

Sep 082017
 
Tiotropium helped in early COPD in randomized trial

Tiotropium (trade names Spiriva, Stiolto) was originally FDA-approved after patients with severe chronic obstructive pulmonary disease (COPD) had improved lung function and fewer COPD exacerbations taking Spiriva compared to placebo.  In a recent randomized trial of 841 patients in China, tiotropium showed benefits in milder, early COPD as well. Patients with COPD GOLD stage 1 or [… read more]

Aug 302017
 
An Illustrated Guide to the Phases of ARDS: Implications for management

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]

Aug 242017
 
Procalcitonin Testing in Suspected Infection: Review

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]

Aug 232017
 

Scleroderma-Related Interstitial Lung Disease Scleroderma (SSc) is an autoimmune disease characterized by vasculopathy and fibrosis with multi organ involvement. Pulmonary complications such as interstitial lung disease (ILD) and pulmonary hypertension contribute significantly to mortality and morbidity of the disease. Up to 90% patients with scleroderma can have interstitial changes on high resolution CT scan (HRCT) [… read more]