Category: Critical Care
Keywords: SOFA, admission unit, ICU, IMC, Ward, morality (PubMed Search)
Posted: 10/17/2023 by Quincy Tran, MD
(Updated: 12/4/2023)
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Settings: Retrospective study of a national inpatient database (Japan).
Participants:
Outcome measurement: Primary outcome was in-hospital mortality, after propensity score matching.
Study Results:
Discussion:
Conclusion:
Risk-stratifying patients according to SOFA score is a potential strategy for appropriate admission strategies.
1.Ohbe H, Sasabuchi Y, Doi K, Matsui H, Yasunaga H. Association Between Levels of Intensive Care and In-Hospital Mortality in Patients Hospitalized for Sepsis Stratified by Sequential Organ Failure Assessment Scores. Crit Care Med. 2023 Sep 1;51(9):1138-1147. doi: 10.1097/CCM.0000000000005886. Epub 2023 Apr 28. PMID: 37114933.
2.Corwin GS, Mills PD, Shanawani H, Hemphill RR. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017 Nov;43(11):580-590. doi: 10.1016/j.jcjq.2017.04.009. Epub 2017 Jul 25. PMID: 29056178.
Category: Critical Care
Keywords: arterial cannulation, axillary artery, femoral artery, infraclavicular (PubMed Search)
Posted: 8/21/2023 by Quincy Tran, MD
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Settings: Single ICU in Poland, randomized trial
Participants: intubated patients who needed arterial catheter placement. Patients who had adequate access to one axillary and one femoral artery were eligible.
Patients were randomized 1:1 for axillary or femoral artery cannulation.
Outcome measurement: Primary outcome was cannulation success rate. Secondary outcomes were first pass success rate, number of attempts.
Study Results:
Discussion:
Conclusion:
Ultrasound-guided cannulation of the axillary artery via the infraclavicular route is non-inferior to the cannulation of the common femoral artery. When cannulation of the radial or femoral artery is not available, we can consider axillary artery via the infraclavicular approach.
Reference:
Gawda, Ryszard MD, PhD; Marszalski, Maciej MD; Piwoda, Maciej MD; Molsa, Maciej MD; Pietka, Marek MD; Filipiak, Kamil MD; Miechowicz, Izabela PhD; Czarnik, Tomasz MD, PhD1. Infraclavicular, Ultrasound-Guided Percutaneous Approach to the Axillary Artery for Arterial Catheter Placement: A Randomized Trial. Critical Care Medicine ():10.1097/CCM.0000000000006015, August 07, 2023. | DOI: 10.1097/CCM.0000000000006015
Category: Critical Care
Keywords: NEWS, MEWS, IEWS, international Early Warning Score, mortality (PubMed Search)
Posted: 6/27/2023 by Quincy Tran, MD
(Updated: 12/4/2023)
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Settings: Retrospective data from 3 Dutch EDs (development of the score), 2 Denmark ED (for validation of the score). The novel score (International Early Warning Score) will be composed of the National Early Warning Score (NEWS) + Age +Sex
Components of the National Early Warning Score:
Participants: All adult patients in the Netherlands Emergency department Evaluation Database (NEED) and Danish Multicenter Cohort (DMC).
Outcome measurement: in-hospital mortality, including death in EDs.
Study Results:
Discussion:
Conclusion:
This multicenter study showed that IEWS perform better than the NEWS for predicting in-hospital mortality for ED patients.
Candel BGJ, Nissen SK, Nickel CH, Raven W, Thijssen W, Gaakeer MI, Lassen AT, Brabrand M, Steyerberg EW, de Jonge E, de Groot B. Development and External Validation of the International Early Warning Score for Improved Age- and Sex-Adjusted In-Hospital Mortality Prediction in the Emergency Department. Crit Care Med. 2023 Jul 1;51(7):881-891. doi: 10.1097/CCM.0000000000005842. Epub 2023 Mar 23. PMID: 36951452; PMCID: PMC10262984.
Category: Critical Care
Keywords: etomidate, intubation, critically ill, mortality (PubMed Search)
Posted: 5/2/2023 by Quincy Tran, MD
(Updated: 12/4/2023)
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As emergency physicians, we use etomidate to intubate patients most of the time, although there was controversy whether etomidate would suppress critically ill patients’ cortisol production. Whether etomidate was associated with mortality was controversial. A recent meta-analysis investigated the issue again.
Methods: meta-analysis of randomized trials using etomidate for intubation versus other agents. Outcome = mortality as defined by the authors. Mortality was defined from 24 hours to 30 days by study’s authors.
Results: 11 RCTs, including one new RCT in 2022
319 (1359, 23%) patients received etomidate died vs. 267 (1345, 20%) receiving other agents died; Risk Ratio 1.16, 95% CI 1.01-1.33, P = 0.03.
Etomidate was also associated with higher risk ratio for adrenal insufficiency, when compared with other control agents (147/695, 21% vs. 69/686, 10%, RR 2.01, 95% CI (1.59-2.56), P < 0.01.
Etomidate was also associated with higher risk ratio of mortality, when compared with ketamine, for mortality, as defined by each study’s author (273/1201, 23% vs. 226/1198. 19%. RR 1.18, 95% CI 1.02-1.37, P = 0.03).
Discussion:
The authors used fixed effects model, as they claimed that their meta-analysis had low heterogeneity (I2 =0%). However, fixed effects model should only be used when there is no difference among patient population. In this study, the outcome definitions were different, the patient populations were different (trauma, pre-hospital, ED, ICU). Therefore, random effects model should be used. Random effects models tend to yield larger 95% CI, thus, more likely yield non-statistically significant results.
The authors claimed a Number Needed To Treat (NNT) for etomidate of 31, so basically many ED patients would die, while most of patients being intubated by Anesthesiology, regarding settings, would not die, as anesthesiologists mostly use propofol.
Category: Critical Care
Keywords: ECG; status epilepticus (PubMed Search)
Posted: 3/7/2023 by Quincy Tran, MD
(Updated: 12/4/2023)
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Title: Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry.
As the song goes: “the thigh bone is connected to the hip bone, the hip bone is connected to the back bone.” It turns out that the brain electrical activities are also connected to the heart conduction activities.
In a multi-center (23 French ICUs) retrospective analysis of 155 critically ill patients with status epilepticus, ECGs were done within 24 hours of onset of status epilepticus, and were independently reviewed by cardiologists showed abnormalities in 145 (93.5%) of patients.
Below is a list of events that occurred more than 10% of events.
Abnormal rate (<60 or > 100 beats/min 64 (44%)
Negative T-waves 61 (42%)
Flattened T-waves 18 (12%)
ST elevation 24 (16.6%)
ST depression 26 (17.9%)
Left axis deviation 22 (15.9%)
Discussion:
Major ECG abnormalities were not associated with 90-day functional outcome in multivariable logistic regression.
The brain-heart axis could be affected by antiseizure medication. For example, phenytoin, lacosamide are sodium channel blockers while benzodiazepines, propofol, barbiturates with their GABAnergic effects will also display cardiac side effects. This current study was not able to tease out whether the cardiac effects were from medication. Therefore, further studies are needed to figure out the cardiac effect for patients with status epilepticus.
Chinardet P, Gilles F, Cochet H, Chelly J, Quenot JP, Jacq G, Soulier P, Lesieur O, Beuret P, Holleville M, Bruel C, Bailly P, Sauneuf B, Sejourne C, Galbois A, Fontaine C, Perier F, Pichon N, Arrayago M, Mongardon N, Schnell D, Lascarrou JB, Convers R, Legriel S. Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry. Crit Care Med. 2023 Mar 1;51(3):388-400. doi: 10.1097/CCM.0000000000005768. Epub 2022 Dec 19. PMID: 36533915.
Category: Critical Care
Keywords: thoracic ultrasound, critically ill, ICU, clinical management (PubMed Search)
Posted: 1/10/2023 by Quincy Tran, MD
(Updated: 12/4/2023)
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Title:
The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study
Settings: 4 hospitals (3 in Netherlands and 1 in Italy)
Participants: All adults patients who were admitted to the ICU but patients who died within 8 hours of thoracic ultrasound were excluded.
Thoracic ultrasound procedure: cardiac, lung, diaphragm, inferior vena cava. The main indicators were Respiratory, Cardiac and Volume status.
Study Results:
725 thoracic ultrasound examinations and 534 patients. Clinical management occurred in 247 (88.5%) patients within 8 hours of ultrasound.
Thoracic ultrasound was performed by 111 operators, ranging from inexperienced to very experienced.
Common findings from thoracic ultrasound among these ICU patients.
Discussion:
Conclusion: Thoracic ultrasound provided a significant change in management of critically ill patients.
Heldeweg MLA, Lopez Matta JE, Pisani L, Slot S, Haaksma ME, Smit JM, Mousa A, Magnesa G, Massaro F, Touw HRW, Schouten V, Elzo Kraemer CV, van Westerloo DJ, Heunks LMA, Tuinman PR. The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study. Crit Care Med. 2022 Dec 23. doi: 10.1097/CCM.0000000000005760. Epub ahead of print. PMID: 36562620.
Category: Critical Care
Keywords: Wellness, ICU, physicians, coping, COVID-19, pandemic (PubMed Search)
Posted: 11/15/2022 by Quincy Tran, MD
(Updated: 12/4/2023)
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This was a cross-sectional survey for the Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society.
Settings: 62 sites in Canada and the US
Participants: Attending physicians who worked in ICUs
Questionaire:
· Measure of Moral Distress for healthcare professionals (27 items),
· Maslach burnout inventory (2 items),
· Stanford Professional Fulfilment Index (14-items), Brief Cope scale (14-items)
Study Results:
1. Demographics:
· 431 participants (approximately 43.3% response rate).
· 334 (65%) participants worked at University-affiliated hospitals
· 387 (89.0%) worked in Adult ICUs.
· Pre-pandemic, clinical days/months was 10.1 (± 14) days, and increased to 13.1 (± 16) days during the pandemic.
2. Measure of moral distress: Average score 95.6 ± 66.9 (maximum 417).
· The highest score (mean 8.5 ± 4.8), for distress, came from the item: “Follow the family insistence to continue aggressive treatment even though it is not in the best interest of the patient.” ((Family wanted to do everything).
3. Stanford Fulfillment Index:
· 387 (91.9%) intensivists found their work meaningful and 365 (86.5%) felt worthwhile at work, although most felt physically (297, 71.6%), emotionally (266 [63.8%]) exhausted.
4. Coping strategies:
· Participants resorted to a wide variety of scoping strategies ranging from Acceptance (90%), Self-distraction (85%) to Substance abuse (32%) and Denial (18%).
· Most physicians (231 [55.9%]) reported that their coping remained the same before and during the pandemic.
Discussion:
· Physicians are quite resilient. The authors found that physicians who worked more days experienced significantly more moral distress but with similar Stanford Professional Fulfillment score.
· This finding was similar to an exploratory analysis from a meta-analysis that showed physicians, among other healthcare workers, were less likely to have severe symptoms of PTSD (2).
· Women and physicians who were persons of color experienced significantly higher moral distress and burn-out.
Conclusion:
There was moderate moral distress and burn-out, although physicians who worked in ICUs still achieved moderate professional fulfillment. Up to 20% of ICU physicians used a maladaptive coping strategy
1. Burns KEA, Moss M, Lorens E, Jose EKA, Martin CM, Viglianti EM, Fox-Robichaud A, Mathews KS, Akgun K, Jain S, Gershengorn H, Mehta S, Han JE, Martin GS, Liebler JM, Stapleton RD, Trachuk P, Vranas KC, Chua A, Herridge MS, Tsang JLY, Biehl M, Burnham EL, Chen JT, Attia EF, Mohamed A, Harkins MS, Soriano SM, Maddux A, West JC, Badke AR, Bagshaw SM, Binnie A, Carlos WG, Çoruh B, Crothers K, D'Aragon F, Denson JL, Drover JW, Eschun G, Geagea A, Griesdale D, Hadler R, Hancock J, Hasmatali J, Kaul B, Kerlin MP, Kohn R, Kutsogiannis DJ, Matson SM, Morris PE, Paunovic B, Peltan ID, Piquette D, Pirzadeh M, Pulchan K, Schnapp LM, Sessler CN, Smith H, Sy E, Thirugnanam S, McDonald RK, McPherson KA, Kraft M, Spiegel M, Dodek PM; Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society. Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey. Crit Care Med. 2022 Oct 27. doi: 10.1097/CCM.0000000000005674. Epub ahead of print. PMID: 36300945.
2. Andhavarapu S, Yardi I, Bzhilyanskaya V, Lurie T, Bhinder M, Patel P, Pourmand A, Tran QK. Post-traumatic stress in healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Psychiatry Res. 2022 Oct 8;317:114890. doi: 10.1016/j.psychres.2022.114890. Epub ahead of print. PMID: 36260970; PMCID: PMC9573911.
Category: Critical Care
Keywords: 30 ml/kg, sepsis, fluid overload, ESRD, CHF (PubMed Search)
Posted: 9/20/2022 by Quincy Tran, MD
(Updated: 12/4/2023)
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Have you ever encountered an ESRD patient who missed dialysis because the patient "felt too sick to go to dialysis"? The patient then had hypotension from an infected catheter line? Do we give 30 ml/kg of balanced fluid now?
__________________________
Title: Outcomes of CMS-mandated ?uid administration among ?uid-overloaded patients with sepsis: A systematic review and meta-analysis.
Settings: This is a meta-analysis
Patients: Septic patients who have underlying fluid overload conditions (CHF or ESRD).
Intervention: intravenous fluid administration according to the mandate by the Center for Medicare/Medicaid as 30 ml per kilograms of bodyweight.
Comparison: fluid administration at less than 30 ml/kg of body weight.
Outcome: 30-day mortality, rates of vasopressor requirement, rates of invasive mechanical ventilation
Study Results:
Discussion:
Conclusion:
Pence M, Tran QK, Shesser R, Payette C, Pourmand A. Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med. 2022 May;55:157-166. doi: 10.1016/j.ajem.2022.03.004. Epub 2022 Mar 10. PMID: 35338881.
Category: Critical Care
Keywords: Awareness, mechanical ventilation, Emergency Department, Rocuronium (PubMed Search)
Posted: 7/26/2022 by Quincy Tran, MD
(Updated: 12/4/2023)
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Have you ever wonder what patients feel after being intubated in the ED?
The study " Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study" aimed at answering just that.
Settings: Emergency Departments from 3 hospitals; This was a secondary analysis of a prospective trial.
Patients:
Patients who received neuromuscular blockade in ED
Intervention: None.
Comparison: None.
Outcome: Primary outcome was Awareness while paralyzed, secondary outcome was Perceived threat, which is considered the pathway for PTSD.
Study Results:
The study evaluated 388 patients. There were 230 (59%) patients who received rocuronium.
Patients who received rocuronium (5.5%, 12/230) were more likely to experience awareness than patients receiving other neuromuscular blockade (0.6%, 1/158).
Patients who experienced awareness during paralysis had a higher threat perception score that those who did not have awareness (15.6 [5.8] vs. 7.7 [6.0], P<0.01).
A multivariable logistic regression, after adjustment for small sample size, showed that Rocuronium in the ED was significantly associated with awareness (OR 7.2 [1.39-37.58], P = 0.02).
Discussion:
With the increasing use of rocuronium for rapid sequence intubation in the ED, clinicians should start to pay more attention to the prevalence of awareness during paralysis. According to the study, patients reported pain from procedures, being restrained, and worst of all feelings of impending death.
One of the risk factors for awareness during paralysis would be the long half-life of rocuronium, compared to that of succinylcholine. Therefore, clinicians should consider prompt and appropriate dosage of sedatives for post-intubation sedation. Previous studies showed that a mean time from intubation till sedatives was 27 minutes (2), and propofol was started at a low dose of 30 mcg/kg/min for ED intubation (3).
Conclusion:
Approximately 5.5% of all patients or 4% of survivors of patients who had invasive mechanical ventilation in the ED experienced awareness during paralysis. They also were at high risk for PTSD.
1. Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022 Jul 22. doi: 10.1097/CCM.0000000000005626. Epub ahead of print. PMID: 35866657.
2. Watt JM, Amini A, Traylor BR, Amini R, Sakles JC, Patanwala AE. Effect of paralytic type on time to post-intubation sedative use in the emergency department. Emerg Med J. 2013 Nov;30(11):893-5. doi: 10.1136/emermed-2012-201812. Epub 2012 Nov 8. PMID: 23139098.
3. Korinek JD, Thomas RM, Goddard LA, St John AE, Sakles JC, Patanwala AE. Comparison of rocuronium and succinylcholine on postintubation sedative and analgesic dosing in the emergency department. Eur J Emerg Med. 2014 Jun;21(3):206-11. doi: 10.1097/MEJ.0b013e3283606b89. PMID: 23510899.
Category: Critical Care
Keywords: low tidal volume, Emergency Department (PubMed Search)
Posted: 5/31/2022 by Quincy Tran, MD
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Background:
Lung-protective ventilation with low-tidal volume improves outcome among patients with Acute Respiratory Distress Syndrome. The use of low tidal volume ventilation in the Emergency Departments has been shown to provide early benefits for critically ill patients.
Methodology:
A systemic review and meta-analysis of studies comparing outcomes of patients receiving low tidal volume ventilation vs. those who did not receive low tidal volume ventilation.
The authors identified 11 studies with approximately 11000 patients. The studies were mostly observational studies and there was no randomized trials.
The authors included 10 studies in the analysis, after excluding a single study that suggested Non-low tidal volume ventilation was associated with higher mortality than low tidal volume ventilation (1).
Results:
Comparing to those with NON-Low tidal volume ventilation in ED, patients with Low-Tidal volume ventilation in ED were associated with:
Discussion:
Conclusion:
Although there was low quality of evidence for low tidal volume ventilation in the ED, Emergency clinicians should continue to consider this strategy.
1. Prekker ME, Donelan C, Ambur S, Driver BE, O'Brien-Lambert A, Hottinger DG, Adams AB. Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention. Am J Emerg Med. 2020 Apr;38(4):763-767. doi: 10.1016/j.ajem.2019.06.026. Epub 2019 Jun 15. PMID: 31235218.
2. De Monnin K, Terian E, Yaegar LH, Pappal RD, Mohr NM, Roberts BW, Kollef MH, Palmer CM, Ablordeppey E, Fuller BM. Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact. Crit Care Med. 2022 Jun 1;50(6):986-998. doi: 10.1097/CCM.0000000000005459. Epub 2022 Feb 7. PMID: 35120042.
Category: Critical Care
Keywords: APRV, low tidal volume, COVID-19 (PubMed Search)
Posted: 4/5/2022 by Quincy Tran, MD
(Updated: 12/4/2023)
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During the height of the pandemic, a large proportion of patients who were referred to our center for VV-ECMO evaluation were on Airway Pressure Release Ventilation (APRV). Does this ventilation mode offer any advantage? This new randomized control trial attempted to offer an answer.
---------------
1.Settings: RCT, single center
2. Patients: 90 adults patients with respiratory failure due to COVID-19
3. Intervention: APRV with maximum allowed high pressure of 30 cm H20, at time of 4 seconds. Low pressure was always 0 cm H20, and expiratory time (T-low) at 0.4-0.6 seconds. This T-low time can be adjusted upon analysis of flow-time curve at expiration.
4. Comparison: Low tidal volume (LTV) strategy according to ARDSNet protocol.
5. Outcome: Primary outcome was Ventilator Free Days at 28 days.
6.Study Results:
7.Discussion:
8.Conclusion:
APRV was not associated with more ventilator free days or other outcomes among patients with COVID-19, when compared to Low Tidal Volume strategies in this small RCT.
Ibarra-Estrada MÁ, García-Salas Y, Mireles-Cabodevila E, López-Pulgarín JA, Chávez-Peña Q, García-Salcido R, Mijangos-Méndez JC, Aguirre-Avalos G. Use of Airway Pressure Release Ventilation in Patients With Acute Respiratory Failure Due to COVID-19: Results of a Single-Center Randomized Controlled Trial. Crit Care Med. 2022 Apr 1;50(4):586-594. doi: 10.1097/CCM.0000000000005312. PMID: 34593706; PMCID: PMC8923279.
Category: Critical Care
Keywords: Saline, balanced fluid, critically ill, mortality (PubMed Search)
Posted: 2/8/2022 by Quincy Tran, MD
(Updated: 12/4/2023)
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The debate is still going on: Whether we should give balanced fluids or normal saline.
Settings: PLUS study involving 53 ICUs in Australia and New Zealand. This was a double-blinded Randomized Control trial.
Study Results:
Discussion:
Conclusion:
Category: Critical Care
Keywords: bacterial infection, sepsis, Emergency Department, broad spectrum antibiotics (PubMed Search)
Posted: 12/14/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
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When we initiate the sepsis bundle in the ED for patients with suspected sepsis, what probability that those patients who received broad spectrum antibiotics in the ED would have bacterial infection.
This study (Shappell et al) provides us with a glimpse of those number.
Settings: Retrospective study of adults presenting to 4 EDs in Massachusetts.
Patients: patients with suspected serious bacterial infection in ED, defined as blood cultures and initiation of at least one broad spectrum antibiotics. Random selection of 75 patients per hospital.
Patients were categorized in 4 groups:
Outcome: Prevalence of each category.
Study Results: 300 patients who received broad spectrum antibiotics.
3. For patients who were admitted to the ICU (P = 0.26)
a. Definite 16.5%
b. Likely 8.6%
c. Unlikely 16.4%
d. Definitely no 20.4%
4. Source of infection
Discussion:
Conclusion:
Approximately 30% of patients who had blood cultures drawn and received broad spectrum antibiotics in ED have low likelihood of bacterial infection.
Reference:
1. Shappell CN, Klompas M, Ochoa A, Rhee C; CDC Prevention Epicenters Program. Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department. Crit Care Med. 2021 Nov 1;49(11):e1144-e1150. doi: 10.1097/CCM.0000000000005090. PMID: 33967206; PMCID: PMC8516665.
2. Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015 Sep 7;19(1):319. doi: 10.1186/s13054-015-1035-1. PMID: 26346055; PMCID: PMC4562354.
Category: Critical Care
Keywords: decompensated heart failure, hypertonic saline, furosemide (PubMed Search)
Posted: 10/19/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
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Settings & Designs: a meta-analysis of 11 randomized controlled trials among patients with fluid overload.
Patients: This meta-analysis included 2987 patients with acute decompensated heart failure.
Intervention: intravenous hypertonic saline + intravenous furosemide.
Comparison: intravenous furosemide
Outcome: all-cause mortality, hospital length of stay
Study Results:
· Hypertonic saline + furosemide treatment was associated with lower relative risk of mortality (RR 0.55, 95% CI 0.33-0.76%, P< 0.05, I-square = 12%).
· Hypertonic saline + furosemide treatment was also associated with 3.8 shorter hospital length of stay (mean difference = -3.38 days, 95% CI -4.1 to -2.4, P< 0.05, I-square = 93%).
· Sodium creatine also decreased about 0.46 mg/dl (mean difference, -0.46, 95% CI -051, -0.41, P<0.05, I-square 89%) for patients received both hypertonic saline and furosemide.
Discussion:
· Most studies only included patients with advanced heart failure (NYHA class IV, EF < 35%)
· For these patients with advanced heart failure, most studies infused 150 ml of 1.5%-3% saline. However, all studies used very high doses of furosemide (500mg -1000mg BID).
Conclusion:
In patients with acute decompensated heart failure, a combination of hypertonic saline and intravenous furosemide was associated with improved outcomes, compared with a single therapy of furosemide.
Liu, Chang PhD, MD; Peng, Zhiyong PhD, MD; Gao, Xiaolan MD; Gajic, Ognjen MD; Dong, Yue MD; Prokop, Larry J. MLS; Murad, M. Hassan MD; Kashani, Kianoush B. MD, MSc, FASN, FCCP; Domecq, Juan Pablo MD. Simultaneous Use of Hypertonic Saline and IV Furosemide for Fluid Overload: A Systematic Review and Meta-Analysis, Critical Care Medicine: November 2021 - Volume 49 - Issue 11 - p e1163-e1175 doi: 10.1097/CCM.0000000000005174.
Category: Critical Care
Keywords: SOFA, sepsis, oxygen saturation (PubMed Search)
Posted: 8/25/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
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Background: SOFA score has been used as a predictor for poor outcomes in patients with sepsis. However, the original SOFA score utilizes PaO2/FiO2 ratio to calculate the SOFA’s respiratory component. When there are no ABG, thus no PaO2, we have to convert patients’ spO2 to PaO2, and the amount of oxygen support to FiO2 (for example, 2 liters of oxygen via nasal cannula = 0.27). This is cumbersome.
Objective: This study assessed whether spO2 can be used instead of PaO2/FiO2 ratio for SOFA’s respiratory score.
Settings: 8 hospitals across Sweden and Canada
Patients: Adults with sepsis. 19396 patients were included for the derivation group while there were 10586 patients for the validation cohort.
Study Results:
Discussion:
Valik JK, Mellhammar L, Sundén-Cullberg J, Ward L, Unge C, Dalianis H, Henriksson A, Strålin K, Linder A, Nauclér P. Peripheral Oxygen Saturation Facilitates Assessment of Respiratory Dysfunction in the Sequential Organ Failure Assessment Score With Implications for the Sepsis-3 Criteria. Crit Care Med. 2021 Aug 18. doi: 10.1097/CCM.0000000000005318. Epub ahead of print. PMID: 34406170.
Category: Critical Care
Keywords: OHCA, hypothermia, normothermia (PubMed Search)
Posted: 6/29/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
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Settings: International multicenter trials; 1:1 randomization, blinded assessment of outcomes.
Patients: adults with witnessed OHCA, regardless of initial rhythm. Patients had more than 20 minutes of CPR. Eligible patients were unconscious, not able to follow command, no verbal responses to painful stimuli.
Intervention: hypothermia to target of 33C for 28 hours, then rewarming at rate of 1/3C every hour until 37C.
Comparison: maintaining temperature at 37.5C or less. Cooling if body temperature reached 37.8C to 37.5C
Outcome: primary outcome was Any cause mortality at 6 months; secondary outcome was poor functional outcome at 6 months (modified Rankin Scale 4-6).
Study Results:
1. 930 hypothermia, mortality 465/925 (50%, RR 1.04, 95%CI 0.94-1.14); 488/881 (55%) had mRS 4-6 (RR 1.0, 95%CI 0.92-1.09).
2. 931 normothermia, mortality 446/925 (48%); 479/866 (55%) had mRS 4-6.
Discussion Points:
Conclusion:
Normothermia in coma patients after OHCA did not lead to higher morality or worse neurologic outcomes.
Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullén S, Rylander C, Wise MP, Oddo M, Cariou A, B?lohlávek J, Hovdenes J, Saxena M, Kirkegaard H, Young PJ, Pelosi P, Storm C, Taccone FS, Joannidis M, Callaway C, Eastwood GM, Morgan MPG, Nordberg P, Erlinge D, Nichol AD, Chew MS, Hollenberg J, Thomas M, Bewley J, Sweet K, Grejs AM, Christensen S, Haenggi M, Levis A, Lundin A, Düring J, Schmidbauer S, Keeble TR, Karamasis GV, Schrag C, Faessler E, Smid O, Otáhal M, Maggiorini M, Wendel Garcia PD, Jaubert P, Cole JM, Solar M, Borgquist O, Leithner C, Abed-Maillard S, Navarra L, Annborn M, Undén J, Brunetti I, Awad A, McGuigan P, Bjørkholt Olsen R, Cassina T, Vignon P, Langeland H, Lange T, Friberg H, Nielsen N; TTM2 Trial Investigators. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. doi: 10.1056/NEJMoa2100591. PMID: 34133859.
Category: Critical Care
Keywords: cardiac arrest, massive pulmonary embolism, Venoarterial, ECMO (PubMed Search)
Posted: 5/4/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
Click here to contact Quincy Tran, MD
Background:
Cardiac arrest from massive pulmonary embolism (PE) can be up to 90% (1). A recent systemic review evaluated the efficacy of Venoarterial-Extracorporeal Membrane Oxygenation (VA-ECMO) for PE-related cardiac arrest.
Results:
The authors screened 1115 articles and included 77 articles, including gray literature. The authors performed a quantitative analysis of a total of 301 patients.
Overall, 183/301 (61%) patients survived to hospital discharge, a significant improvement from 90%.
Patients who were cannulated during chest compression were associated with 7x higher odds of death (OR, 6.84; 95% CI, 1.53–30.58; p = 0.01), compared to those who were cannulated after ROSC. However, cannulation in the ED was not associated with improved outcomes, compared with other cannulation site.
No increased risk of death among patients who received tPA prior to VA-ECMO vs. those who did not (OR, 0.78; 95% CI, 0.39–1.54; p = 0.48).
Patients whose age > 65 years of age were associated with 3X risk of death, compared to those with age < 65 years (OR, 3.56; 95% CI, 1.29–9.87; p = 0.02).
Take-home points
Please consider “early” VA-ECMO for eligible patients who have cardiac arrest from massive PE. However, it will take great convincing to push the PERT team to cannulate for VA-ECMO while the patient is still receiving chest compression.
1.Lavonas EJ, Drennan IR, Gabrielli A, et al: Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132:S501–S518.
2. Scott JH, Gordon M, Vender R, Pettigrew S, Desai P, Marchetti N, Mamary AJ, Panaro J, Cohen G, Bashir R, Lakhter V, Roth S, Zhao H, Toyoda Y, Criner G, Moores L, Rali P. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 May 1;49(5):760-769. doi: 10.1097/CCM.0000000000004828. PMID: 33590996.
Category: Critical Care
Keywords: cardiac arrest, massive pulmonary embolism, Venoarterial, ECMO (PubMed Search)
Posted: 5/4/2021 by Quincy Tran, MD
Click here to contact Quincy Tran, MD
Background:
Cardiac arrest from massive pulmonary embolism (PE) can be up to 90% (1). A recent systemic review evaluated the efficacy of Venoarterial-Extracorporeal Membrane Oxygenation (VA-ECMO) for PE-related cardiac arrest.
Results:
The authors screened 1115 articles and included 77 articles, including gray literature. The authors performed a quantitative analysis of a total of 301 patients.
Overall, 183/301 (61%) patients survived to hospital discharge, a significant improvement from 90%.
Patients who were cannulated during chest compression were associated with 7x higher odds of death (OR, 6.84; 95% CI, 1.53–30.58; p = 0.01), compared to those who were cannulated after ROSC. However, cannulation in the ED was not associated with improved outcomes, compared with other cannulation sites.
No increased risk of death among patients who received tPA prior to VA-ECMO vs. those who did not (OR, 0.78; 95% CI, 0.39–1.54; p = 0.48).
Patients whose age > 65 years of age were associated with 3X risk of death, compared to those with age < 65 years (OR, 3.56; 95% CI, 1.29–9.87; p = 0.02).
Take-home points
Please consider “early” VA-ECMO for eligible patients who have cardiac arrest from massive PE. However, it will take great convincing to push the PERT team to cannulate for VA-ECMO while the patient is still receiving chest compression.
1.Lavonas EJ, Drennan IR, Gabrielli A, et al: Part 10: Special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132:S501–S518.
2. Scott JH, Gordon M, Vender R, Pettigrew S, Desai P, Marchetti N, Mamary AJ, Panaro J, Cohen G, Bashir R, Lakhter V, Roth S, Zhao H, Toyoda Y, Criner G, Moores L, Rali P. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review. Crit Care Med. 2021 May 1;49(5):760-769. doi: 10.1097/CCM.0000000000004828. PMID: 33590996
Category: Critical Care
Keywords: sepsis recognition, antibiotics administration, mortality, (PubMed Search)
Posted: 3/10/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
Click here to contact Quincy Tran, MD
Background:
The association between time intervals of ED antibiotic administration and outcome has been controversial. While single studies showed there was increased mortality associated with delayed antibiotic administration (1-3). A meta-analysis of 13 studies and 33000 patients showed that there was no mortality difference between septic patients receiving immediate Abx (< 1 hour) vs. those receiving early abx (1-3 hours) (4).
Since delay in recognition of sepsis (defined as ED triage to Abx order) and delay in antibiotics delivery (Abx order to administration) contribute to total delay of Abx administration, a new retrospective study (3) attempted to investigate the contributions of either factor to hospital mortality.
Results:
The study used generalized linear mixed models and involved 24000 patients.
For All patients and outcome of hospital mortality:
Recognition delay (ED triage to Abx order): OR 2.7 (95% CI 1.5-4.7)*
Administration delay at 2-2.5 hours (Abx order to administration): OR 1.5 (1.1-2.0)
These results was associated with non-statistical significance in patients with septic shocks.
Conclusion:
Delayed recognition of sepsis was associated with higher hospital mortality. Longer delay of abx administration was also associated with increased risk of hospital mortality.
1.Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006; 34:1589–1596
2. Ferrer R, Martin-Loeches I, Phillips G, et al: Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: Results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749–1755
3. Seymour CW, Gesten F, Prescott HC, et al: Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017; 376:2235–2244.
4. Rothrock SG et al. Outcome of immediate versus early antibiotics in severe sepsis and septic shock: A systematic review and meta-analysis. Ann Emerg Med 2020 Jun 24; [e-pub]. (https://doi.org/10.1016/j.annemergmed.2020.04.042)
Category: Critical Care
Keywords: COVID-19, Awake proning, intubation (PubMed Search)
Posted: 1/12/2021 by Quincy Tran, MD
(Updated: 12/4/2023)
Click here to contact Quincy Tran, MD
A single center (Nebraska, USA), retrospective analysis investigated the prevalence of intubation during hospital stay for 105 patients who had COVID-19 between March 24 to May 5, 2020 (1). 40 patients underwent awake proning vs. 60 patients did not undergo awake proning.
After adjusting for either SOFA or APACHE scores, patients with awake proning were associated with lower Hazard Ratios of intubation for SOFA (HR 0.30, 95% CI 0.09-0.96, p=0.043) and APACHE (HR 0.30, 95%CI 0.1-0.91, p=0.034).
Discussion
While this US study seemed promising, another Brazilian study being published earlier in July 2020 showed no difference in the prevalence of intubation between COVID-19 patients with proning or without proning (2).
These 2 studies highlighted the nature of this disease: high practice variability, uncertainty of therapeutic modalities. However, the complications from awake proning had been very low.
Conclusion:
Awake proning for hypoxic COVID-19 patients is a promising intervention but we will need more studies. In the meanwhile, we can try this therapeutic modality as the risk is low.