Category: Critical Care
Posted: 12/11/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Ultrasound-Guided Pericardiocentesis
L'Italien AJ. Critical cardiovascular skills and procedures in the emergency department. Emerg Med Clin N Am 2013; 31:151-206.
Tirado A, Wu T, Noble VE, et al. Ultrasound-guided procedures in the emergency department - Diagnostic and therapeutic asset. Emerg Med Clin N Am 2013; 31:117-149.
Category: Critical Care
Keywords: anaphylaxis, tryptase, diagnosis (PubMed Search)
Posted: 12/6/2012 by Ellen Lemkin, MD, PharmD
(Updated: 2/15/2025)
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Simons EF, Ardusso LE, Bilo MB, et al. 2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis.
Category: Critical Care
Posted: 11/27/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Managing Critically Ill Patients with AKI
Brienza N, et al. Protocoled resuscitation and the prevention of acute kidney injury. Curr Opin Crit Care 2012; 18:613-622.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int 2012; 2(S):1-138.
Category: Critical Care
Posted: 11/20/2012 by Haney Mallemat, MD
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A low-tidal volume (or protective) strategy of mechanical ventilation (i.e., tidal volume of 6-8cc/kg of ideal body weight) has previously been demonstrated to be beneficial in patients with acute respiratory distress syndrome (ARDS).
A meta-analysis was recently performed to determine whether this strategy of mechanical ventilation is also beneficial for patients without lung injury prior to initiation of mechanical ventilation.
Dr. Neto, et al. performed a meta-analysis of 20 studies (total of 2,822 mechanically ventilated patients) comparing a conventional ventilation strategy (average tidal volume was 10.6 cc/kg) to a protective ventilation strategy (average tidal volume was 6.4 cc/kg) of mechanical ventilation.
The authors concluded that patients ventilated with a protective lung-strategy had reductions in:
Bottom-line: This meta-analysis supports the notion that a strategy of low-tidal volume ventilation may have benefits for patients without ARDS, however prospective studies are needed.
Neto, S. et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome. JAMA, Oct. 24/31; 308;16.
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Category: Critical Care
Posted: 11/13/2012 by Mike Winters, MBA, MD
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Burn Patients and Antibiotic Dosing
Jamal JA, et al. Improving antibiotic dosing in special situations in the ICU: burns, renal replacement therapy and extracorporeal membrane oxygenation. Curr Opin Crit Care 2012; 18:460-71.
Category: Critical Care
Posted: 11/6/2012 by Haney Mallemat, MD
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Previous pearls have described the increasing evidence against colloid (e.g., hydroxyethyl starch) use during resuscitation. Now it appears that the crystalloid 0.9% normal saline (NS) may be under fire.
The use of large volumes of NS has been associated with hyperchloremic metabolic acidosis and harm in animal studies. The risk of harm in humans, however, has been less clear.
Bellomo et al. conducted a prospective observational study in which patients being resuscitated in the control group received NS at the clinicians' discretion; i.e., chloride-liberal strategy. The use of NS was restricted in the intervention group, where other less chloride containing fluids were used for resuscitation (e.g., Ringer's Lactate); i.e., a chloride-restrictive strategy.
The authors found that when compared to patients in the chloride-liberal group, the chloride-restrictive group had significantly less rise in baseline creatinine, less overall AKI, and a reduced need for renal replacement therapy.
Bottom line: Although this was only an observational study, the liberal use of normal saline during resuscitation may increase the risk of AKI and renal replacement therapy.
Bellomo, R. et al. Association between a chloride-liberal vs. chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012 Oct 17;308(15):1566-72. doi: 10.1001/jama.2012.13356.
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Category: Critical Care
Posted: 10/30/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Serotonin Toxicity in the Critically Ill
Bienvenu OJ, Neufeld KJ, Needham DM. Treatment of four psychiatric emergencies in the intensive care unit. Crit Care Med 2012; 40:2662-2670.
Category: Critical Care
Posted: 10/22/2012 by Haney Mallemat, MD
(Updated: 10/24/2012)
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Perner A., et al. Hydroxyethyl Starch 130/0.4 versus Ringer's Acetate in Severe Sepsis. NEJM. 2012 Jun 27.
Category: Critical Care
Posted: 10/16/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Delirium in the Critically Ill
Bienvenu OJ, Neufeld KJ, Needham DM. Treatment of four psychiatric emergencies in the intensive care unit. Crit Care Med 2012; 40:2662-2670.
Category: Critical Care
Posted: 10/9/2012 by Haney Mallemat, MD
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70 year-old male recently treated for community-acquired pneumonia presents with bloody diarrhea, fever, and severe abdominal pain. Abdominal Xray is shown below. Diagnosis?
Answer: Toxic Megacolon
Toxic megacolon (TM) is an acute colitis with segmental or total colonic dilation (>6cm) plus systemic toxicity.
Actual incidence is unknown, but it is believed that TM is rising because of increasing cases of Clostridium difficile and the aging population.
The most common etiologies are ulcerative, chron, and pseudomembranous colitis, but other causes exist and can be categorized as:
The diagnosis is made based on clinical evidence of colitis plus evidence of colonic dilation on abdominal XR (diameter > 6cm, loss of haustra, or free intraperitoneal air secondary to perforation) or CT scan (demonstrating dilation or perforation).
Treatment includes:
Autenrieth, D et al. Toxic Megacolon Inflammatory Bowel Dis. 2011 Aug 29.
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Category: Critical Care
Posted: 10/2/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Thrombotic Thrombocytopenic Purpura (TTP)
Kessler CS, et al. Thrombotic thrombocytopenic purpura: A hematological emergency. J Emerg Med 2012; 43:538-44.
Category: Critical Care
Posted: 9/25/2012 by Haney Mallemat, MD
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Intubated patients may occasionally meet certain criteria for extubation while in the Emergency Department. Extubation is not without its risk, however, as up to 30% of patients have respiratory distress secondary to laryngeal and upper airway edema, with some patients requiring re-intubation.
Prior to extubation, Intensivists use a brief “cuff-leak” test (deflation of the endotracheal balloon to assess the presence or absence of an air-leak around the tube) to indirectly screen for the presence of upper airway edema and ultimately the risk of re-intubation. The cuff-leak test is performed by deflating the endotracheal balloon followed by one or more of the following maneuvers:
Ochoa et al. performed a systematic review to determine the accuracy of the “cuff-leak” test to predict upper airway edema prior to extubation. The authors concluded that a positive cuff-leak test (i.e., absence of an air-leak) indicates an elevated risk of upper airway obstruction and re-intubation. A negative cuff-leak test (i.e., presence of an air-leak), however, does not reliably exclude the presence of upper airway edema or the need for subsequent re-intubation.
Bottom line: No test prior to extubation reliably predicts the absence of upper airway edema. Patients extubated in the Emergency Department require close observation with airway equipment located nearby.
Ochoa, ME et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: A systematic review and meta-analysis. Intensive Care Med (2009) 35:1171–1179
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Category: Critical Care
Posted: 9/18/2012 by Mike Winters, MBA, MD
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The Lung Transplant Patient in Your ED
Fuehner T, et al. The lung transplant patient in the ICU. Curr Opin Crit Care 2012; 18:472-8.
Category: Critical Care
Posted: 9/11/2012 by Haney Mallemat, MD
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40 year-old male with severe uncontrolled hypertension presents with altered mental status (head CT below). The CXR is from the same patient. What's the connection?
Answer: Neurogenic pulmonary edema (NPE)
NPE is defined as acute pulmonary edema following central nervous system (CNS) insult; NPE has been recognized for over 100 years, but its incidence is underreported due to a lack objective clinical criteria.
The pathophysiology of NPE is poorly understood but it is generally believed that both cardiogenic and non-cardiogenic pulmonary edema play a role. CXR (see above) demonstrates a pattern similar to acute respiratory distress syndrome (i.e., bilateral interstitial infiltrates).
CNS insults that are abrupt, rapidly progressive, and increase intracranial pressure (e.g., subarachnoid hemorrhage, intraparenchymal hemorrhage, traumatic brain injury, subdural, etc.) have the highest risk for NPE. Neural injury leads to sympathetic activation, the release of catecholamines, and one or all of the following:
Treatment of NPE includes:
Davidson, D. et al. Neurogenic pulmonary edema. Crit Care. 2012 Mar 20;16(2):212.
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Category: Critical Care
Posted: 9/4/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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Right Heart Failure in the Critically Ill
Greyson CR. Right heart failure in the intensive care unit. Curr Opin Crit Care 2012; 18:424-31.
Category: Critical Care
Posted: 8/28/2012 by Haney Mallemat, MD
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A Cochrane review of 37 studies concluded that Succinylcholine (SUC) is superior to Rocuronium (ROC) during rapid sequence intubation.
The authors claim that compared to ROC, SUC has a faster onset of action (45 vs. 60 seconds) and overall a shorter duration of action (10 vs. 60 minutes).
Dr. Reuben Strayer wrote a letter to the journal editors and stated that these findings should be interpreted carefully; he highlighted that most of the studies in the review used doses of ROC less than 0.9 mg/kg (most studies used 0.6mg/kg).
Dr. Strayer asserted that ROC’s onset of action is dose dependent; when using doses of 1.2 mg/kg, ROC’s onset is indistinguishable from that of SUC. He also stated another major benefit of ROC is the lack of adverse effects that SUC possesses (hyperkalemia and malignant hyperthermia).
What are your thoughts on this? Go to http://www.facebook.com/Criticalcarenow and take the poll (there are 5 choices). Results will be posted next week.
Seupaul RA, Jones JH. Evidence-based emergency medicine. Does succinylcholine maximize intubating conditions better than rocuronium for rapid sequence intubation? Ann Emerg Med. 2011 Mar;57(3):301-2. Epub 2010 Nov 18.
Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med. 2011 Aug;58(2):217-8.
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Category: Critical Care
Posted: 8/21/2012 by Mike Winters, MBA, MD
(Updated: 2/15/2025)
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AKI and Fluid Balance
Bellomo R, et al. An observational study fluid balance and patient outcomes in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy trial. Crit Care Med 2012; 40:1753-60.
Category: Critical Care
Posted: 8/14/2012 by Haney Mallemat, MD
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Femoral venous access is typically limited to the acute resuscitation of critically-ill patients. Several practice-guidelines recommend avoiding the femoral site, or removal once admitted to the ICU, because of the risk of catheter-related bloodstream infection (CRBI) and deep-vein thrombosis (DVT).
A recent systematic review and meta-analysis (including two randomized-control trials and eight cohort-studies) evaluated the risk of CRBI and DVT for catheters placed in either the internal jugular, subclavian, or femoral-venous sites. No difference in the rate of CRBI or DVT was found between the three sites, although the DVT data was less robust (i.e., contained heterogeneous data).
The authors hypothesized that improvements in sterility during central-line placement (e.g., full-barrier precautions), improved nursing care (e.g., central-line site care), and ultrasound guidance may have led to a reduction in femoral site complications.
Although a prospective randomized-control trial is necessary to confirm these results, this meta-analysis challenges the traditional teaching that femoral central-access should be avoided.
Marik, P. et al. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systematic review of the literature and meta-analysis Crit Care Med. 2012 Aug;40(8):2479-85.
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Category: Critical Care
Posted: 8/7/2012 by Mike Winters, MBA, MD
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Lung Protective Ventilator Settings Still Underutilized
Needham DM, et al. Lung protective mechanical ventilation and two-year survival in patients with acute lung injury: A prospective cohort study. BMJ 2012;344:e2124.
Category: Critical Care
Posted: 7/31/2012 by Haney Mallemat, MD
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Crystalloids (i.e., 0.9% saline and lactated ringers) have been used during resuscitation for more than a century. Their invention, however, was more accidental than intentional.
Crystalloids were first used during the European Cholera epidemic of 1831. Hartog Hamburger later modified this solution in 1896 to the solution we know today as "normal" saline. Hamburger's solution was only intended for in vitro study of RBC lysis and was never intended for clinical use.
Around this time, Sydney Ringer was testing several fluids to use for physiologic studies. Ringer's lab assistant was erroneously substituting tap water for distilled water when preparing these solutions. Ringer later discovered that this tap water contained minerals making the solution "physiologic", isotonic, and safe for human use; Alexis Hartmann later added sodium lactate to create Ringer's Lactate.
Since the invention of crystalloids, many types of resuscitation fluids have been created and studied (i.e., albumins, gelatins, and starches); all have been shown to be more expensive, with no more benefit, and with possibly more harm when compared to crystalloids.
The "perfect" resuscitation fluid still alludes us today, but of all of the solutions marketed crystalloids are arguably the best...despite their accidental history.
Awad, S. et al. The history of 0.9% saline. Clinical Nutrition 2008 Apr;27(2):179-88.
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