High Flow Nasal Oxygen in Immunocompromised Patients

High Flow Nasal Oxygen has become an increasingly popular alternative to non-invasive ventilation as well as use after invasive ventilation. The same devices are now used during apneic ventilation during difficult intubations or for fibreoptic intubation. Previous studies have found positive effects on ventilator free days and mortality.

However immunocompromised patients may differ and this study found that in critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy.

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Oxygen Guidelines

The automatic administration of oxygen to sick patients is deeply ingrained but evidence has been emerging in critical illness and ER settings that it can in fact worsen outcome and increase mortality.

An international expert panel make the following guideline:

  • For patients receiving oxygen therapy, aim for peripheral capillary oxygen saturation (SpO2) of ≤96% (strong recommendation)

  • For patients with acute myocardial infarction or stroke, do not initiate oxygen therapy in patients with SpO2 ≥90% (for ≥93% strong recommendation, for 90-92% weak recommendation)

  • A target SpO2 range of 90-94% seems reasonable for most patients and 88-92% for patients at risk of hypercapnic respiratory failure; use the minimum amount of oxygen necessary.

A full discussion including the nuances and non-applicable cases is at BMJ link

 

Weekly Medical and Health News

Opioids killing more than  AIDS at peak epidemic link

Polio-like acute flaccid paralysis appearing in Canada, cause not certain, presumed viral  link

Pre-eclampsia linked to later dementia risk  link

Exercise in pregnancy can reduce complications (unless contraindications)  link

New flu drug Xofluza approved in US but debatable if any better than Tamiflu – and no substitute for vaccination  link

Could ACE Inhibitors increase lung cancer risk?  link

Heart attacks linked to cold weather as well as low sunshine, low atmospheric pressure and high winds  link

Use oxygen judiciously – too much can harm  link

Higher cortisol (linked to stress) associated with impaired memory in younger to middle aged, especially women link

Pantoprazole for ICU GI Bleeding Prophylaxis

The use of PPIs in critical care for gastrointestinal bleeding prophylaxis has been part of many bundles of ICU care but concerns exist as to side effects like increased nosocomial pneumonia and C. Difficile infection.

This study found “Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo”.

It may be the more common use of enteral nutrition today lessens the risk. Higher risk groups could still be considered for prophylaxis.

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NEJM editorial link

 

NAFLD and Post-operative Hyperglycemia

Record reviews of those with image-confirmed non-alcoholic fatty liver disease (NAFLD) and abdominal waist adiposity detected an independent association with post-operative hyperglycemia, more strongly in Type 2 Diabetes and waist circumference to height ratio > 0.65.

Associated hyperglycemia complications include increased wound complications and length of stay.

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Infographic link

 

ABCDEF Bundle in ICU and Outcome

The ABCDEF bundle has been formulated to reduce pain, delirium and improve long term ICU outcomes ( link ).

This prospective multi-centre study found: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

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Cardiac Events and Mortality with ECT

A systematic review and meta analysis sought to establish cardiac sequelae associated with ECT. The most commonly reported events were acute heart failure, pulmonary edema and arrhythmias. Overall events were infrequent and occur in about 1 of 50 patients and after about 1 of 200 to 500 electroconvulsive therapy treatments.

The question demanding future study is if or how these events can be minimized or prevented, eg. with use of  short acting Beta Blockers.

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