Critical Care

Sepsis-Associated Acute Kidney Injury

The BMJ provides a comprehensive article on Sepsis-associated acute kidney injury (AKI). It discusses risk factors such as advanced age, chronic kidney disease, cardiovascular disease, diabetes, and liver disease. Review of sepsis definitions and kidney injury scores like RIFLE, AKIN and KDIGO are discussed. Markers beyond creatinine are surveyed, like albuminuria, urine microscopy for casts, NGAL etc.

As well as early detection, early resuscitation is important, with balanced electrolyte solutions rather than 0.9% Saline; controversy exists as to the Surviving Sepsis recommendations of 20mL or more per kg fluid, and the potential negative effects of excess fluid are highlighted.

Vasopressor choices to maintain mean arterial pressure include Norepinephrine and Vasopressin. Dopamine and Phenylephrine have not achieved comparable results or safety. Angiotensin II may have promise in future studies.

Mechanical ventilation, although unavoidable often, may increase AKI risk from multiple mechanisms like changes in intrathoracic pressure, reducing venous return, cardiac output, and renal perfusion, as well as neurohormonal and inflammatory pathways.

Pharmacological treatments for AKI are largely preliminary. Renal Replacememt therapy should not begin too early from recent trials, optimal dose being 20-25mL/kg/hour. Removal of toxins via hemoperfusion has not been proven effective. Nephrotoxic agents should be avoided (NSAIDS, contrast, Hydroxyethyl Starch).

BMJ link

Health related quality of life after ICU

Much has been reported on neuropsychiatric and cognitive sequelae of critical illness. This systematic review found that health-related quality of life was worse for ICU survivors compared to population norms. Pre-existing quality of life was poorer also. The improvement that did occur was in the first year, in the domains of physical function, physical role, vitality and social function. The ICU pathologies were heterogeneous, including sepsis and ventilated patients.

The study confirms current views that cure does not occur at ICU, or even hospital discharge and follow-up and interventions should occur in the first year to maximize better health-related quality of life.

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POCUS and Blunt Thoracoabdominal Injuries

A Cochrane review urges caution with negative findings from point of care ultrasound (POCUS). While positive findings are helpful, it was found that in blunt abdominal trauma “a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor”. The now ubiquitous ultrasound in the Emergency Dept. has its limitations!

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Succinylcholine Use and Dantrolene Availability

Malignant hypothermia is considered an anaesthesia disease but can also be precipitated by the use of Succinylcholine without volatile anesthesia gas use, as is noted in this analysis.

Succinylcholine is often used to facilitate difficult mask ventilation, and indeed current practice advice is to administer without waiting to check mask ventilation ease.

This study surveyed such cases in the MH registry and other sources documenting 24 cases. They contend Dantrolene should be immediately available in all locations where Succinylcholine (or volatile anesthetics gases) are used as treatment delay is critical.

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Perioperative Atrial Fibrillation in Cardiac Surgery

A practice advisory is issued from cardiovascular anesthesiologists for the prophylaxis and treatment of perioperative atrial fibrillation, which has an occurrence of 30 – 50% in this population.

They review such strategies as Beta-Blockers, Amiodarone, cardioversion, Calcium Channel Blockers, Vernakalant, Colchicine etc.

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Recommendations table

Antimicrobials and ICU Delirium

This study enrolled non-neurological critically ill adults from a medical or surgical intensive care unit (ICU) with daily follow-up to 30 days; the independent variable was exposure to previous-day antimicrobial class: beta-lactams (subclasses: penicillins, first- to third-generation cephalosporins, fourth-generation cephalosporins, and carbapenems), macrolides, fluoroquinolones, and other.

The findings were: “First-, second-, and third-generation cephalosporins doubled the odds of delirium after baseline co-morbidities, ICU type, the course of critical care, and other competing antimicrobial and psychotropic medication risks were adjusted for. We did not find an association between delirium and cefepime, penicillins, carbapenems, fluoroquinolones, or macrolides”. 

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Cuffed Tracheal Tubes in Pediatrics

Traditional use of non-cuffed tracheal tubes in neonates and children is being replaced by low pressure cuffs such as micro-cuffed tubes. This study reviewed subglottic stenosis found on micro-laryngoscopy within 6 months of invasive ventilation.

The only cases requiring surgical correction were in fact ex-premature neonates initially intubated with non-cuffed tubes.

Conclusion: “The introduction of a policy of appropriate placement and maintenance of low‐pressure, high‐volume cuffed endotracheal tubes in the pediatric critical care unit was not associated with an increased rate of endotracheal tube‐related subglottic trauma”.

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“Mild” ARDS

Mild ARDS is considered something less than severe ARDS but this study shows: Approximately 80% of cases of mild acute respiratory distress syndrome persist or worsen in the first week; in all cases, the mortality is substantial (30%).

Substantial ventilation durations occurred and   “admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening”.

Anesthesiology link

 

Management of Anesthesia for Sickle Cell Disease

An educational article on anaesthesia management for children with sickle cell disease.  End-organ damage like cerebrovascular disease, heart failure secondary to thrombotic disease or pulmonary hypertension is seen less frequently now as is chronic kidney disease caused by ischaemic damage and loss of renal tubules. Vaccination should be comprehensive. The most common acute complications are infection and vaso-occlusive episodes. “Multiple splenic microinfarcts secondary to sickling is an early complication, with 90% of affected children reported to have functional asplenia by age 6 yr. This leads to an increased risk of bacterial infections, most notably with S. pneumoniae in addition to atypical organisms”.

Sepsis is less common with vaccination. The most common postoperative complications are vaso-occlusive episodes and Acute Chest Syndrome, reported especially after appendectomy and Cesarean, but also high after umbilical hernia repair, cholecystectomy, and splenectomy. Stroke and death were reported more rarely.

Anesthesia goals are to maintain oxygenation and hydration, avoid acidosis, and maintain normocarbia, normotension, and normothermia, as well as adequate analgesia.

Bja link