Intra-abdominal hypertension and abdominal compartment syndrome

In a prospective, observational study of 478 patients requiring an open abdomen for the management of intra-abdominal hypertension or abdominal compartment syndrome, surgical intensivists followed a continually revised management algorithm and demonstrated increased patient survival to hospital discharge from 50% to 72%, clinically significant decreases in resource utilization, and an increase in same-admission primary fascial closure from 59% to 81%.

Such a multi-modality surgical/medical management algorithm is available from the World Society of the Abdominal Compartment Syndrome at the link below.

Here are the main algorithms:

World Society of the Abdominal Compartment Syndrome

Differentiating arteries from veins

In a letter to Critical Care Medicine, ultrasound legend Michael Blaivas reminds readers that during ultrasound-guided central venous catheterisation, an additional technique for differentiating the common carotid artery from the internal jugular vein: pulse-wave doppler.

Image reproduced with kind permission of Dr Blaivas

Blaivas states: “The left panel shows a classic arterial tracing from the common carotid artery with a normal velocity. The right panel shows the vessel of choice on the same patient: the right internal jugular vein. The image shows a slightly chaotic venous tracing from the jugular. This a common appearance and is markedly different from the waveform of the carotid.”

Posterior vessel wall penetration by needles during internal jugular vein central catheter placement using ultrasound guidance: is that a real danger? Author’s Reply.
Crit Care Med. 2010 Feb;38(2):736-7

Surviving Sepsis Campaign guideline adherence and mortality

Data from 15,022 subjects at 165 sites at which the Surviving Sepsis Campaign (SSC)  6 hour and 24 hour care guideline bundles were introduced were submitted from 2005 to early 2008. As adherence to the guidelines increased (18.4 to 26.1%), hospital mortality decreased (37 to 30.8%). The study was partly funded by manufacturers of some of the monitoring and therapeutic components of the SSC guidelines.

The Surviving Sepsis Campaign: Results of an international guideline- based performance improvement program targeting severe sepsis
Crit Care Med. 2010 Feb;38(2):367-74

An insightful editorial points out several methodological weaknesses in this study, as well as the interesting point that the guidelines published in 2004 drew on evidence published predominantly between 2000 and 2003, and subsequent research has called a number of components into question. Examples are:

  • The Corticosteroid Therapy of Septic Shock (CORTICUS) study did not confirm that low-dose corticosteroids were beneficial
  • the Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE- SUGAR) study reported that targeting tight glycemic control may be harmful
  • Early goal-directed therapy is the subject of no less than three ongoing clinical trials supported by national research funding agencies
  • and the effect of drotrecogin alfa (activated) is being re-examined in both industry-sponsored and investigator-initiated trials.

While scientific skepticism is healthy, there is no doubt at least that in part due to the efforts of the SSC more clinicians than ever are aware of the importance of timely aggressive management of severe sepsis / septic shock.

The Surviving Sepsis Campaign: robust evaluation and high-quality primary research is still neede
Crit Care Med. 2010 Feb;38(2):683-4

Heliox in COPD exacerbation

A 65:35 helium-oxygen mix was compared with 35% oxygen in air in patients with COPD exacerbations requiring non-invasive ventilation. In this RCT there was no difference in intubation rates between the heliox or air/oxygen groups.

A multicenter, randomized trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease
Crit Care Med. 2010 Jan;38(1):145-51

pain radiation to right arm in ACS

How predictive is the history for acute coronary syndrome? Of 1576 patients entered into a multicentre evaluation of chest pain units, 132 (8.4%)  had ACS, as determined by positive troponin, CK-MB, or early treadmill test.

On multivariate analysis, only age, duration, sex and radiation of pain to the right arm were independently associated with ACS.

Likelihood ratios (95% CI) were:

  • radiation of pain to the right arm, 2.9 (95% CI 1.4 to 6.3)
  • male sex 1.2 (95% CI 1.0 to 1.3)
  • female sex 0.79 (95% CI 0.62 to 1.0).

The area under the receiver operator characteristic curve for age was 0.629 (95% CI 0.573 to 0.686) and for duration was 0.546 (95% CI 0.481 to 0.610).

The authors conclude that clinical features have very limited value for diagnosing ACS in patients with a normal or non- diagnostic ECG, and radiation of pain to the right arm increases the likelihood of ACS.

Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram.
Emerg Med J. 2009 Dec;26(12):866-70

Confidentiality: reporting gunshot and knife wounds

The UK General Medical Council provides guidance on the reporting to police of gun and knife wounds.

The guidance describes a two-stage process:

  1. You should inform the police quickly whenever a person arrives with a gunshot wound or an injury from an attack with a knife, blade or other sharp instrument. This will enable the police to make an assessment of risk to the patient and others, and to gather statistical information about gun and knife crime in the area
  2. You should make a professional judgement about whether disclosure of personal information about a patient, including their identity, is justified in the public interest.

GMC Guidance on Reporting Gunshot & Knife Wounds

Acute Kidney Injury: Must Do Better!

A report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) examines the quality of care of patients who died in UK hospitals from acute kidney injury, and makes several recommendations that are consistent with previous reports into acute hospital admissions.

Recommendations include:

  • checking electrolytes on all acute admissions
  • better physiological monitoring
  • senior medical review of acute patients
  • adequate critical care, diagnostic, and nephrological services for acute hospitals

The authors state: Predictable and avoidable AKI should never occur.

Acute Kidney Injury: Adding Insult to Injury (2009)