High versus low intensity renal replacement therapy

What’s the optimal dose of continuous renal replacement therapy? The Australasian RENAL investigators compared 25ml/kg/hr vs 40ml/kg/hr (effluent flow) of post-dilution continuous venovenous haemodiafiltration in over 1500 intensive care patients. There was no difference in 90 day mortality or renal recovery, but the high intensity group had significantly more hypophosphataemia.

Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients
NEJM 2009;361:1627-1638

Hypothermia reduced cerebral palsy in asphyxiated newborns

An RCT of induced hypothermia to 33.5 degrees for 72 hours was undertaken in 625 newborns at least 36 weeks gestation who had evidence of asphyxial encephalopathy.
The intervention (hypothermia) group had improved scores in mental, psychomotor, and gross motor function and a reduced risk of cerebral palsy. There was an increased rate of survival without neurological abnormality. Overall survival was not different between groups.

Moderate hypothermia to treat perinatal asphyxial encephalopathy
N Engl J Med. 2009 Oct 1;361(14):1349-58

Burns formulas and fluid resuscitation

In most cases either the modified Brook formula or the Parkland formula was used for burned military casualties in Iraq and Afghanistan over the three years covered in this study.

The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight.

The Parkland formula is 4mls x body surface areas burned (BSAB) x weight.

Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.

In this study which compared outcomes between the Brooks and Parkland groups, there were no differences in clinical outcomes. In both groups many patients were overresuscitated in terms of urine output goals. The authors’ main conclusion is that burns resuscitation can be successfully accomplished with lower initial fluid volumes. Take home message: individualise fluid resuscitation to patient’s clinical response, and avoid the ‘fluid creep’ of unphysiologic resuscitation management.

Resuscitation of severely burned military casualties: fluid begets more fluid
J Trauma. 2009 Aug;67(2):231-7

New Paediatric DKA guidelines

The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.

Their summary:

• DKA is caused by either relative or absolute insulin deficiency.

• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently

• Begin with fluid replacement before starting insulin therapy.

• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.

• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.

• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy

• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion

• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.

• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.

• There is no evidence that bicarbonate is either necessary or safe in DKA.

• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.

• In case of profound neurological symptoms, mannitol should be given immediately.

• All cases of recurrent DKA are preventable.

Full guidelines available here
Other ISPAD guidelines available here

Successful trauma airway management

Of 6088 patients requiring intubation within the first hour of arrival at a Level 1 trauma centre, 21 (0.3%) required a surgical airway for unanticipated difficult upper airway anatomy. There were no deaths from failed airway management. The authors ascribe their effective airway management to a simple protocol based on rapid sequence induction of anesthesia, judicious use of selected adjunctive devices (bougie, LMA), and the supervision by a small group of experienced anesthesiologists.

The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center
Anesth Analg. 2009 Sep;109(3):866-72

‘Shock Room’ belongs to both ED & ICU

Belgian authors describe a four-bedded ‘shock room’, situated between the ED and the ICU and managed jointly by ED and ICU staff, which is used to stabilise all acutely ill patients in the hospital, whether they are from outside or inside the hospital. 2514 patients were treated in their shock room in 2006, managed by either senior emergency physicians or intensivists, and nurses from both departments. 21.5% were admitted to ED shock room from other wards, and 14.5% were transfers from other hospitals.

Comment: I personally visited this unit in Brussels in 2007 and liked the concept – sick patients in the ED and patients who go off on the wards often have similar needs in terms of skills and equipment. Why not manage them all in the resus room, and have intensivists and emergency physicians working more collaboratively?

A ‘shock room’ for early management of the acutely ill
Anaesth Intensive Care. 2009 May;37(3):426-31

Rectal exam for urethral injury a waste of time?

Of 41 male patients with proven blunt urethral injury over a thirteen year period at a major trauma centre, only one had an abnormal prostate on digital rectal examination (DRE). Meatal blood and haematuria prior to catheterisation were more common findings (8 and 7 patients, respectively). All patients had haematuria after catheter insertion. In blunt urethral injuries, DRE has very low sensitivity.

Traumatic urethral injuries: Does the digital rectal examination really help us?
Injury. 2009 Sep;40(9):984-6

Small infant IJV cannulation tip

Simple taping using Transpore tape of the skin over the internal jugular vein insertion point increased IJV cross sectional area and AP diameter, and shortened to time to successful cannulation in this RCT on 28 infants and neonates undergoing cardiac surgery. Also, the degree of IJV collapse during advancement of the needle was less in the taped group.

The skin over the right IJV (RIJV) was lifted up with several pieces of tape in the cephalad and caudad directions. The skin cephalic to the RIJV was stretched cephalad, whereas the skin caudal to the RIJV was stretched caudad. The other ends of the tape were attached to the metal edge of the operating table.

A Novel Skin-Traction Method Is Effective for Real-Time Ultrasound-Guided Internal Jugular Vein Catheterization in Infants and Neonates Weighing Less Than 5 Kilograms
Anesth Analg. 2009 Sep;109(3):754-9

emergence with ketamine overstated

A prospective study of 746 children sedated in the emergency department with iv or im ketamine revealed 2.1% may have experienced ’emergence delirium’ although the authors concede this was difficult to define. In contrast, 291 (38%) reported pleasant altered perceptions. Follow up revealed at least one nightmare in the following weeks in 3.4% of patients, which may be well under the rate reported in the normal unsedated paediatric population.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?
Emerg Med Australas. 2009 Aug;21(4):315-22