Critical Care

Early Acute Kidney Injury and Outcome in Acute Respiratory Distress Syndrome

The authors carried out a secondary analysis of an observational study. Patients with severe respiratory failure were categorized based on worst serum creatinine or urine output.

Highlighting the significance of renal dysfunction, they concluded: The development of acute kidney injury, even when mild-moderate in severity, is associated with a substantial increase in mortality in patients with acute respiratory distress syndrome.

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Emergency Department to ICU Time and Hospital Mortality

This was a retrospective observational cohort study using data from the Dutch quality registry National Intensive Care Evaluation evaluating ER to ICU times.

“Prolonged emergency departmentto ICU time (> 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality.”

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Mannitol in Critical Care

Mannitol has a long history of use to decrease intracranial pressure in neurosurgery and traumatic brain injury but it’s effect on long term outcome is still uncertain.

This free full text review – a meta-analysis and systematic review – surveys its history and usage. Its conclusion is essentially:

“Mannitol is effective in accomplishing short-term clinical goals, although hypertonic saline is associated with improved brain relaxation during craniotomy. Mannitol has a favorable safety profile although it can cause electrolyte abnormality and renal impairment. More research is needed to determine its impacts on long-term outcomes.”

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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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