Critical Care

ECMO for ARDS

A randomized study sought to answer the continuing debate over the utility of early extracorporeal membrane oxygenation for very severe ARDS.

“Among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy“.

Bleeding and thrombocytopenia were higher in the ECMO group and ischemic stroke less.

There was a clear trend to better mortality but not clinically significant, and the trial was stopped early for futility. Experts question the statistical design and cutoff point for futility. There was also a sizeable crossover to rescue ECMO in the control conventional ventilation group. The debate is unlikely to end, and ECMO will probably remain in the armamentarium of severe ARDS treatment in expert centers as a viable choice.

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Extracorporeal Pediatric CPR

A small retrospective study of 56 Pediatric cardiac arrests (80% related to primary cardiac conditions), mean age 3.5 months (1-53).

Survival to hospital discharge was a very good c. 65%, best in younger age (3.5 months) and those with decreased extracorporeal CPR tones and those exposed to therapeutic hypothermia. Follow up showed a good quality of life and family functioning. Further studies are needed to establish whether the technique should be more widely available in Pediatric critical care.

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Intubation in OR vs ICU

A Spanish study compares OR vs ICU intubation by direct laryngoscopy. Everything was somewhat worse in  the ICU: worse view, lower first attempt success, higher rate of difficult intubation and use of airway adjuncts,  and higher complication rate. They suggest that patient and environmental factors may be of more importance than the operator (even previously known easy intubations were more difficult in ICU). Despite all that, their success rate was better than other studies, which they attribute to high use of neuromuscular blocking agents, an increasingly recommended practice. Videolaryngoscopy has met with better success in many but not all studies.

At the least, greater preparation, optimized positioning and airway equipment,  and trained assistance should be available for non-OR intubation

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Intra-Abdominal Hypertension

A Canadian study to determine the prevalence of intra-abdominal hypertension (IAH) finds a higher than expected rate.

30% at admission, another 15% during admission.

Abdominal Compartment Syndrome 3%

28% in non-ventilated patients.

Higher mortality vs. those without IAH (30% vs. 11%)

Predictors of IAH included obesity, mechanical ventilation and >3L 24 hour fluid balance.

They advocate for possible routine intra-abdominal pressure measurement in ICU, which is simple and inexpensive.

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Traumatic Brain Injury and Hypothermia

A systematic review on therapeutic hypothermia finds the same results as known: “High-quality studies show no significant difference in mortality, poor outcomes, or new pneumonia. In addition, this review shows a place for fever control in the management of traumatic brain injury“. 

As in the post cardiac arrest scenario, 36° is just as good without the potential harmful effects of hypothermia, but fever or hyperthermia should be aggressively managed.

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Surviving Sepsis Update

Sepsis is now considered an emergency and this update seeks to compress the time frame of the treatment bundle into 1 hour:

Measure Lactate, blood cultures, then antibiotics, IV fluids and vasopressors.

There is some debate among experts as to whether all patients need 30mL/kg fluid with increasing awareness of fluid excess harms.

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Sepsis Survival and Acute Organ Dysfunction

A retrospective study finds that acute neurologic dysfunction during sepsis hospitalization most strongly increased the risk of long-term mortality, whereas other types of organ dysfunction had a relatively modest impact on long-term outcomes. It is consistent with the known evidence of the deleterious effects of conditions such as delirium and cognitive dysfunction on mortality.

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Neurological insult was also found to be a critical predictor of pediatric critical care outcome in another earlier study Link

 

 

Hydroxyethyl Starch Ban

Experts have vehemently argued over the European ban on HES, most agreeing on the evidence of increased renal failure and mortality. But a sizeable minority see it as unwarranted and draconian, such as this spirited critique of the flaws in the studies showing adverse outcomes. Note that one of the authors declares competing interest (Fresenius-Kabi makers of  Voluven HES)

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