Critical Care

SGLT Inhibitors and Diabetic Ketoacidosis

The popularity of SGLT Inhibitors has increased with purported cardiovascular and renal benefits. Issues have arisen however and this consensus addresses the reported cases of normoglycemic diabetic ketoacidosis.

Pertinent to perioperative care, “SGLT inhibitors should be withheld or discontinued prior to any medical procedure (ideally for 3 days), particularly if the patient will be reducing food intake or will not be allowed to eat or drink for some time before and after the procedure.”

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Early Neuromuscular Blockade in ARDS

The fashion that has returned for early neuromuscular block in ARDS was tested in this study.

“Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets”.


Trans-Nasal Evaporative Intra-arrest Cooling

Much of the earlier enthusiasm for therapeutic hypothermia has been tempered with disappointing trial results. This study examined cooling of the brain initiated during cardiopulmonary resuscitation and its impact on survival with good neurologic outcome in patients with out-of-hospital cardiac arrest.

Trans-nasal evaporative intra-arrest cooling did not result in a statistically significant improvement in survival with good neurologic outcome.


Diaphragm and Pectoral Muscle Atrophy in ICU

Ultrasound was used to serially assess diaphragm and pectoral muscles in critical illness.

“Diaphragm and pectoral atrophy occurred in 48% and 29%, respectively, and was associated with septic shock (diaphragm) and steroid use (pectoral); atrophy of the two muscle types appears unrelated.”

The authors further note: “The diaphragm displayed clinically significant atrophy during the first 5 days of critical illness, especially in patients with septic shock, organ failure, or invasive mechanical ventilation. Given the small sample size, the study did not detect a link between atrophy of the diaphragm and clinical outcomes. Pectoral atrophy seemed confined to patients treated with steroids, and was associated with a poor outcome“.


Ventilation in patients with intra-abdominal hypertension

A full text review on ventilation in intra-abdominal hypertension.

Intra-abdominal hypertension (IAH) is defined as a sustained increase in intra-abdominal pressure (IAP) equal to or above 12 mmHg. IAH affects the brain, the cardiovascular system and the lungs.

The average incidence of IAH in critically ill patients is around 25–30% on admission, and the cumulative incidence is around 50% during the first week of ICU stay. There is an association between IAH and respiratory failure.

IAH is associated with a decrease in lung volumes, a decrease in chest wall compliance, and abdomino-thoracic pressure transmission, while decompressive laparotomy results in an improvement in lung volumes.

The presence of IAH affects lymphatic drainage between the thoracic and abdominal cavity and may play an important role in the development of edema formation.

The article discusses recruitment maneuvers, PEEP, protective lung ventilation, prone positioning, hemodynamic changes, and the Abdominal Compartment Society guidelines for managing IAH or abdominal compartment syndrome.



i-gel® insertion and cricothyroid membrane identification

This small study examined cricothyroid membrane identification in adult females, whose anatomy is less pronounced than males. They concluded:

“The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy”.


Beta-lactam antibiotics in critically ill patients

Guidelines to optimize beta-lactam antibiotics from France provide a detailed insight into their use in ICU. Topics covered include assessing renal function, determining plasma albumin levels, achieving therapeutic plasma concentrations, minimizing toxicity, therapeutic drug monitoring, the potential use of continuous infusions, and their use in renal replacement therapy.

A detailed article in full text –

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Night-time Extubation

Night-time extubation is generally fraught, with less expertise, staffing and resources and has been linked to adverse clinical outcomes.

This was a retrospective cohort study of mechanically ventilated adults at a single university-affiliated hospital, extubated between 7:00 PM and 6:59 AM the following day.

Reintubation and mortality did not differ compared to daytime extubation, and was associated with a shortened duration of mechanical ventilation and hospital length of stay.

This was a large urban hospital and may not necessarily apply in smaller centres, but in similar settings may help to improve resource utilization.


Restrictive IV Fluid Trial in Severe Sepsis and Septic Shock (RIFTS)

A small randomized pilot trial compares restrictive vs. usual care fluid administration in severe sepsis and septic shock. It reflects increasing disquiet on the potential harms of excess fluids and their seeming endorsement in the Surviving Sepsis guidelines (although the latest revision allows vasopressors to be started simultaneously).

The restrictive group received significantly less resuscitative IV fluid than the usual care group (47.1 vs 61.1 mL/kg; p = 0.01) over 72 hours.

There were no differences in 30 day mortality, and no difference in hospital or ICU length of stay, organ failure or other serious side effects.

Recognizing this as a small pilot study, the authors recommend large multicenter trials to confirm these findings.