Critical Care

Safe Use Of High-Flow Nasal Oxygen (HFNO)

The Anesthesia Patient Safety Foundation provide an excellent overview of the popular and expanding use of High Flow Nasal Oxygen (HFNO), devices which are in many cases supplanting BIPAP, and  used to provide apneic ventilation during intubation, as well as post extubation and weaning from ventilation. This review also adds some caution, in particular the danger of fire, and contraindications.

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Mental Health after Major Trauma

A retrospective analysis in Ontario showed that survivors of major trauma are at a higher risk of developing mental health conditions or death by suicide in the years after their injury. Thise with pre-existing mental health disorders or who are recovering from a self-inflicted injury are at particularly high risk.

This study adds to the huge developing body of evidence of health issues after critical illness – mental, PTSD, neurocognitive, other health issues.

cmaj link

 

Energy-Dense vs. Routine Enteral Nutrition in ICU

Critically ill patients often receive less than recommended amounts of nutritional support and this study compared energy-dense (1.5 kcal per milliliter) with routine (1.0 kcal per milliliter) enteral nutrition at a dose of 1 ml per kilogram of ideal body weight per hour, commencing at or within 12 hours of the initiation of nutrition support and continuing for up to 28 days while the patient was in the ICU. The primary outcome was all-cause mortality within 90 days.

No advantage was found with the energy-dense formulation in these patients on mechanical ventilation, the rate of 90 day survival being no different. Neither was there any difference in infective events or need for organ support.

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Cricoid Pressure Alternative

Cricoid Pressure has been a controversial practice as illustrated by this recent study casting doubt on it: link

It continues to be analyzed due to conflicting views on its effectiveness, interference with placing tubes, and lack of true Level-1 evidence. This latest study uses the technique of ultrasound to assess gastric insufflation during mask ventilation and found that the more effective technique was left paratracheal  compression just above the clavicle and between trachea and sternocleidomastoid muscle, using the thumb when performed manually.

Several caveats are advised: entry of air into the stomach is not synonymous with aspiration of gastric contents, a maximum pressure of 25cm H2O was used, it may not be extrapolated to anesthesia or with the use of neuromuscular blocking agents or obese patients.

As always, further studies are needed before it becomes practice changing…

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Dexmedetomidine and ICU Delirium

The use of anti-psychotics has consistently failed to provide significant improvement in critically ill patients with delirium, as in this study ( link ).

Dexmedetomidine has on the other hand signalled promising effects and this systematic review and meta‐analysis suggests that dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients, evidence ranged from moderate to high.

The incidence of hypotension and bradycardia were also higher, as is common with this agent.

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High Flow Nasal Oxygen in Immunocompromised Patients

High Flow Nasal Oxygen has become an increasingly popular alternative to non-invasive ventilation as well as use after invasive ventilation. The same devices are now used during apneic ventilation during difficult intubations or for fibreoptic intubation. Previous studies have found positive effects on ventilator free days and mortality.

However immunocompromised patients may differ and this study found that in critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy.

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Pantoprazole for ICU GI Bleeding Prophylaxis

The use of PPIs in critical care for gastrointestinal bleeding prophylaxis has been part of many bundles of ICU care but concerns exist as to side effects like increased nosocomial pneumonia and C. Difficile infection.

This study found “Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo”.

It may be the more common use of enteral nutrition today lessens the risk. Higher risk groups could still be considered for prophylaxis.

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NEJM editorial link

 

ABCDEF Bundle in ICU and Outcome

The ABCDEF bundle has been formulated to reduce pain, delirium and improve long term ICU outcomes ( link ).

This prospective multi-centre study found: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

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Anti-Psychotics for Delirium

The use of anti-psychotics for critical illness delirium has been controversial with a trend towards lack of beneficial effect for treatment or prophylaxis.  This latest study shows: “The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium.”

Non-pharmacological management remains the ideal goal although some would still use as a last resort for patient or staff safety.

NEJM link