Aug 122018
 
Increasing inhaled steroids to abort asthma attacks: does it work?

When patients with asthma feel their symptoms worsening and fear a full-blown exacerbation is imminent, what should they do? Doctors and researchers have never found a good answer to this question for most patients. The options are, generally: 1) continue current controller inhalers and observing; 2) increase the dose of inhaled steroid inhalers; or 3) [… read more]

Aug 072018
 
In-Flight Medical Events & Emergencies: part 2

Jon-Emile S. Kenny MD [@heart_lung] “I’m learnin’ to fly … but I ain’t got wings … comin’ down … is the hardest thing.” -Tom Petty Common Events Continued … Abdominal Pain Like chest pain, abdominal pain carries a wide differential diagnosis.  Abdominal pain comprises 4% of all in-flight events and 10% of all diversions.  An [… read more]

Aug 032018
 
Scheduled nebulization with acetylcysteine didn't help ventilated patients

by Salynn Boyles, Contributing Writer, MedPage Today Regular nebulization proved to be no more effective than nebulization on demand in a randomized trial involving critically ill patients receiving invasive ventilation, researchers reported. Among ICU patients expected to need invasive ventilation for at least 24 hours, scheduled nebulization four times a day involving acetylcysteine with salbutamol did not [… read more]

Jul 252018
 
FDA approves new hyperkalemia drug Lokelma

The FDA approved oral sodium zirconium cyclosilicate (ZS-9), to be marketed as Lokelma, for the treatment of hyperkalemia. The drug seems to work better than sodium polystyrene sulfonate (Kayexalate), reducing serum potassium levels within an hour and restoring normal levels after about 2 hours in most patients. The drug was tested against placebo (not Kayexalate) [… read more]

Jul 232018
 
Sodium Bicarbonate Administration in Severe Metabolic Acidemia: the BICAR-ICU Trial

Jon-Emile S. Kenny MD [@heart_lung] “What is REAL?” -Velveteen Rabbit A 42 year old woman with poorly-controlled type II diabetes is admitted with a severe soft tissue infection of her left lower extremity.  She is hypotensive with altered sensorium and she is noted to have a rapidly progressing border of deep, crimson erythema and edema [… read more]

Jul 202018
 
Prophylactic Precedex prevented delirium in ICU patients

Quick Take: This small (n=100), two-center, industry-funded (Hospira) study showed a remarkable 80% prevention rate of ICU delirium (compared to 20% with placebo) with patients given dexmedetomidine prophylactically during their ICU stay. Although associated with poor outcomes in critically ill patients, delirium is not known to be an independent predictor of those outcomes. This small [… read more]

Jul 202018
 
Pulmonary Embolism Causes <1% of Syncope in ER, Study Argues

by Nicole Lou, Contributing Writer, MedPage Today Researchers concluded from a large retrospective study that pulmonary embolism is unlikely to cause syncope that results in a trip to the emergency room. Fewer than 1% of nearly 1.7 million patients treated at emergency departments for syncope had pulmonary embolism, according to databases from Canada, Denmark, Italy, and the [… read more]

Jul 192018
 
Prophylactic haloperidol did not prevent delirium in the ICU: REDUCE trial

Delirium occurs in a large proportion of critically ill patients, and ICU patients who get delirious tend to have longer hospital stays and higher mortality. However, it has never been shown that delirium independently increases the risk for poor outcomes, or is just a fellow traveler with severe illness, i.e., a signal of more severe [… read more]

Jul 152018
 
How to manage bleeding from oral anticoagulant drugs

The new generation of oral anticoagulants have revolutionized management of venous thromboembolism and atrial fibrillation. The changes in clinical practice have also created new questions and confusion around management of bleeding associated with these newer anticoagulants. The American College of Cardiology issued an expert consensus document in December 2017 to help guide physicians on the [… read more]

Jul 152018
 
Should antibiotics for sepsis be given in the ambulance?

Observational studies of patients in sepsis strongly suggest that outcomes are improved by giving antibiotics as soon as possible after recognition of sepsis. The Surviving Sepsis Campaign recently decided everyone with suspected sepsis should receive antibiotics within one hour of emergency department arrival. So why not give antibiotics before the patient even arrives to the [… read more]

Jul 082018
 
Ceftazidime and avibactam (Avycaz) approved for hospital-acquired pneumonias

The FDA approved a new indication for the antibiotic combination ceftazidime and avibactam (marketed as Avycaz), for treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults. The drug was approved originally in 2015 for complicated intra-abdominal infections (in combination with metronidazole) and got another indication in 2017 for complicated urinary tract infections and pyelonephritis. The [… read more]

Jul 082018
 
Hospitalists Are the New Intensivists

Intensivists may get all the credit, but over 37,000 hospitalists provide much of the care for ICU patients in the U.S. According to a recent survey, they often do it without the presence or availability of intensivists for consultation or support, especially outside urban centers. The internists aren’t happy about it, feeling uncomfortable, unsupported and [… read more]

Jun 242018
 
DVT-PE in cancer: Oral anticoagulant edoxaban non-inferior to enoxaparin

Most patients with cancer-associated deep venous thrombosis (DVT) or pulmonary embolism (PE) in the U.S. are treated indefinitely with subcutaneous injections of low-molecular weight heparin (LMWH), like enoxaparin. LMWH has been shown to be better than warfarin at preventing DVT/PE in cancer patients, with similar rates of bleeding. A new generation of oral anticoagulants have [… read more]

Jun 242018
 
FDA Warns of Pneumothorax, Death Associated With High-Tech Nasogastric Tubes

The U.S. Food and Drug Administration (FDA) warned health care teams about the risk of pneumothorax caused by certain enteral feeding tubes that use technology to guide their insertion, also called enteral access systems (EAS). It issued a safety communication stating, Most reports indicate these pulmonary events required urgent intervention, including needle decompression or chest [… read more]

Jun 182018
 
Driving Pressure in Airway Pressure Release Ventilation: a fool’s errand?

Jon-Emile S. Kenny MD [@heart_lung] “One of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important.” -Bertrand Russel I read with great interest a recent letter penned by Taylor and Camporota in response to an investigation on airway pressure release ventilation [APRV] by Zhou and colleagues.  Their brief [… read more]

Jun 142018
 
Vitamin C cocktail for sepsis: randomized trials to test efficacy

Since Marik et al announced exceptional survival rates among patients with septic shock given a cocktail of vitamin C, thiamine, and hydrocortisone, physicians taking care of septic patients have expressed both enthusiasm and skepticism about the cocktail’s reported lifesaving effects. Soon, more rigorous testing from randomized, double-blind placebo-controlled trials should provide harder data about the [… read more]