Critical Care

Antibiotic Choice for E. Coli & Klebsiella Sepsis

Attempts are made to spare carbapenems like meropenem for Gram Negative blood stream infections  to discourage resistance but this study does not support the use of Piperacillin-Tazobactam for that purpose. “The MERINO trial make clear that piperacillin-tazobactam should no longer be considered an alternative to meropenem for definitive treatment of bloodstream infection due to ceftriaxone-resistant E coli or K pneumoniae.”

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Surviving Sepsis Update

The most recent update of the Surviving Sepsis guidelines ( blog link ) has engendered some controversy in implementing the 1-hour bundle. While there is agreement on prompt recognition and treatment of sepsis, disagreement has occurred with some aspects, such as the need for longer time to establish a diagnosis, avoiding unnecessary or inappropriate antibiotics or large fluid volumes, and the lack of clarity between sepsis and septic shock (e.g. discussion here link ).

Therefore the SCCM and ACEP have issued an interim statement advising that the 1-hour bundle not be followed in its current form pending review Statement

Proteinuria and Postoperative Kidney Injury

While proteinuria is well documented as a medical risk factor for morbidity, this retrospective review of pre-operative proteinuria in surgical patients finds: “Proteinuria was associated with postoperative acute kidney injury and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management”.

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Crystalloids vs. Colloids in Surgical Hypovolemia

Immense concern has existed regarding the evidence that colloids, in particular starches, increase mortality and renal injury, especially in septic shock. A previous study in critical care however found no mortality difference ( link ). The present subgroup analysis was focussed on critically ill surgical hypovolemic shock needing surgery before or within 24 hours of ICU admission. Again, no difference in mortality or renal injury was found.

Nuances like differentiation between synthetic colloids and albumin, and potential benefits of balanced salt solutions were not addressed so once again, the debate will continue. In particular the results should not at this point be extrapolated to the different population of septic shock patients.

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Troponin Elevation in Critical Care

Troponin elevations are associated with increased mortality and adverse cardiovascular outcomes in critical illness, but not necessarily implying myocardial infarction, often better termed injury.  Such a diagnosis needs integration of clinical history, EKG, Echocardiogram etc. How this affects diagnosis and management of patients with elevated Troponin is discussed in the link below:

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Nicotine Replacement in Hospitalized Coronary Patients

Some concern exists as to the cardiac safety of using nicotine replacement patches in cardiac disease. The majority of studies indicate it safe to use in stable disease but this observational study is reassuring in finding: “Among smokers hospitalized for treatment of coronary heart disease, use of nicotine replacement therapy was not associated with any differences in short‐term outcomes”.

Outcomes included inpatient mortality, hospital length of stay, and one-month readmission.

These patients had a high degree of cardiac acuity but the authors caution that, due to the known cardiovascular effects of nicotine, randomized along with longer term studies are needed to confirm these reassuring findings in tackling smoking cessation at an early stage of hospitalization.

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Transfusion in Pediatric ARDS

The Pediatric Critical Care Transfusion and Anemia Expertise Initiative issues consensus recommendations on red cell transfusion in critically ill pediatric ARDS. The guidelines are in keeping with the widespread trend of restrictive blood policies.

“Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/d”.

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Prothrombin Complex Concentrates For Vitamin K Antagonist Reversal

The following figures emerge from this Anesthesiology review: Annual rates of major hemorrhagic events ranged from 1.0 to 7.4% in a systematic review of patients with atrial fibrillation receiving vitamin K antagonist therapy, while rates of intracranial hemorrhage in the same population ranged from 0.1 to 2.5%. Major bleeding occurred in 3.3% of warfarin-treated patients undergoing elective surgery, but 21.6% in patients in emergency surgery

Fresh Frozen Plasma brings risks of fluid overload, lung injury, infection and is slow to act and less effective. Vitamin K alone is feasible only when surgery can be delayed 24-48 hours.

Current guidelines recommend prothrombin complex concentrates (PCC), specifically four-factor prothrombin complex concentrates, with concomitant intravenous vitamin K, as the preferred therapy for urgent vitamin K antagonist reversal, which are effective in 30 minutes or so. PCCs reduces bleeding and some studies suggest mortality also. Many studies show them to be more effective than FVIIa. Thromboembolism has not been found to be increased to date.

Whereas specific reversal agents are in use or being introduced for Factor Xa Inhibitors and Direct Thrombin Inhibitors, PCCs may be worth considering for hemorrhage in such patients in the interim although their efficacy is very variable for non-vitamin K antagonist reversal.

The full review surveys all the published studies and also examines evidence in various scenarios such as intracranial hemorrhage, cardiac surgery and trauma.

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Central venous line failure and complications

A systematic search on this issue revealed: Central venous access device failure was 5% with the highest rates in hemodialysis catheters. Overall central line-associated bloodstream infection rate was 4.59 per 1,000 catheter days with the highest rate in nontunneled central venous access devices. Removal of central venous access device due to suspected infection was high at 17% (20.4 per 1,000 catheter day).

The authors note the disconnect between reported infection rate and removal rate and suggest better practice recommendations for removal of central lines.

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