Critical Care

Haloperidol and Long Term ICU Outcome

This study examined the use of prophylactic Haloperidol in ICU patients at high risk of delirium. While it is often a treatment agent used when non-pharmacological approaches to delirium fail, this study confirms that prophylactic use exerts no beneficial effect on long-term quality of life in ICU survivors.

The REDUCE study previously showed that neither does it reduce the incidence or duration of delirium.

“The factors age, medical, and trauma admission, baseline quality of life, risk for delirium, and the number of sedation-induced coma days are associated with the decline in long-term outcome parameters.”

And a major message is “Every additional day of sedation-induced coma is associated with further decline of long-term physical and mental function”.

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Driving Pressure and Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome

Driving pressure is the difference between plateau pressure and positive end-expiratory pressure (PEEP), and is known to be associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). This has been demonstrated in controlled mechanical ventilation.

This study viewed it in the spontaneous ventilation/ weaning scenario. They established driving pressure and compliance could be reliably measured and an important finding that “Higher driving pressure measured during pressure support (assisted) ventilation significantly associates with increased intensive care unit mortality, whereas peak inspiratory pressure does not.”

Lower respiratory system compliance also significantly associates with increased intensive care unit mortality.

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Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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Thiamine to Treat Persistent Hyperlactatemia in Pediatric Septic Shock

Numerous studies have advocated combinations of Thiamine, Vitamin C and Steroids in septic shock in adults, but randomized studies have yet to convince majority opinion on outcome improvement.

This Pediatric study used Thiamine and reported improvements in Lactate clearance, but again this is a surrogate outcome measure and does not demonstrate mortality improvement, nor does it prove causation. So it re-emphasizes the need for further randomized controlled studies.

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Vitamin C, Steroids and Thiamine for Sepsis

One might be forgiven for assuming that this is a “revolutionary” and “astounding” treatment for sepsis – the cocktail of steroids, high dose vitamin C and Thiamine propounded almost by a single person, Dr. Paul Marik, based on tiny observational personal studies.

This is an important commentary on the state of wild claims not supported by a single randomized trial in Sepsis.

It is dubbed “science by press release” in this JAMA article. While everyone hopes for a new effective treatment for Sepsis, hype ahead of the evidence is not the way of science.

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Blood Purification and Mortality in Sepsis and Septic Shock

A systemic review and meta-analysis of a variety of modalities such as hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique were compared to conventional therapy in adult patients with sepsis and septic shock.

“Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock.”

Clearly the evidence for these “blood purification” strategies will require further randomized higher quality trials before they can be routinely recommended.

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials

All modern guidelines are in agreement with daily interruption of sedation in the ICU and spontaneous breathing trials but weaning strategies can differ.

This study found: “a spontaneous breathing trial consisting of 30 minutes of pressure support ventilation, compared with 2 hours of T-piece ventilation, led to significantly higher rates of successful extubation. These findings support the use of a shorter, less demanding ventilation strategy for spontaneous breathing trials.”

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Preadmission Statin Use and 90-day Mortality in the Critically Ill

The many advantages of statins has led to trials of their use in many conditions like ARDS, renal outcomes and in the ICU.

This study is retrospective and would require randomized studies to confirm but has interesting suggestions:

ICU Preadmission statin use was associated with a lower 90-day mortality. This association was more evident in the rosuvastatin group and with noncardiovascular 90-day mortality; no differences were seen according to daily dosage intensity.

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Ratio of Fresh Frozen Plasma to Red Blood Cells During Massive Transfusion and Survival Among Patients Without Traumatic Injury

There has been a dramatic shift away from excessive fluid resuscitation and also in favour of 1:1 ratios (or similar) of plasma to blood in trauma.

This retrospective study cautioned that this practice may not be generalizable to the non-trauma setting:

“High FFP:RBC transfusion ratios are applied mostly to patients without trauma, who account for nearly 90% of all massive transfusion events. Thirty-day survival was not significantly different in patients who received a high FFP:RBC ratio compared with those who received a low ratio.”

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