Category Archives: ICU

Stuff relevant to patients on ICU

Vasopressin in Pediatric Vasodilatory Shock

This Canadian multi-centre study on 65 children compared vasopressin infusions with placebo in children with vasodilatory shock who had already received fluid resuscitation and catecholamine infusions. No significant difference was observed in the primary endpoint of time to haemodynamic stability or the secondary endpoints of mortality, organ-failure–free days, length of critical care unit stay, and adverse events, although there was a trend toward increased mortality in the vasopressin group.
Vasopressin in Pediatric Vasodilatory Shock
Am J Respir Crit Care Med. 2009 Oct 1;180(7):632-9

Fast Hugs Twice a Day on the ICU?

Two guys from the States have proposed a modification to the FAST HUG mnemonic for reminding ICU teams of some of the evidence-based details to pay attention to every day in ICU patients. In fact, they propose patients receive FAST HUGS B.I.D:
F Feeding
A Analgesia
S Sedation
T Thromboembolic prophylaxis
H Head of bed elevation
U Ulcer (stress) prophylaxis
G Glycemic control
S Spontaneous breathing trial
B Bowel regimen
I Indwelling catheter removal
D De-escalation of antibiotics
The original author of FAST HUG, the famous Belgian intensivist JL Vincent, replies that the expansion of the mnemonic could go on forever, but the challenge is to keep it memorable by all staff.
Vincent W, Hatton KW: Critically ill patients need “FAST HUGS BID” (an updated mnemonic)
Crit Care Med 2009; 37:2326 –2327

Is cerebral oxygenation negatively affected by infusion of norepinephrine in healthy subjects?

An interesting study on nine healthy volunteers demonstrated noradrenaline infusions to increase MAP without increasing cardiac output (by increasing systemic vascular resistance). Measures of cerebral (frontal lobe) oxygenation, jugular venous saturation, and mean flow velocity in the middle cerebral artery all reduced with increasing doses of noradrenaline. The authors conclude that doses greater than 0.1 mcg/kg/min may reduce cerebral oxygenation. However increases in noradrenaline lowered paCO2 (through increases pulmonary ventilation) and it is unknown whether this was the major contributor to reduced oxygenation. It is also hard to ascertain the relevance to patients receiving noradrenaline, who unlike the healthy volunteers are not driven to supranormal blood pressures. In the meantime we will continue to attempt to optimise cerebral perfusion pressure using vasoactive drugs, but should be mindful that gross estimates of CPP may not tell us what we’re doing to cerebral oxygenation.
Br J Anaesth. 2009 Jun;102(6):800-5

Which COPD patients should be admitted to the ICU?

A multicenter ICNARC-supported study of 832 COPD patients admitted to intensive care units showed a 180-day mortality of 37.9%.
A prognostic model was developed that was a better discriminator than the clinicians’ judgement. Factors associated with a poor prognosis included abnormal acute physiology, poor functional status (bed or chair bound, house bound or restricted), atrial fibrillation, male sex, number of days in hospital before intensive care admission, reduced midarm circumference as a measure of nutrition and muscle mass, years of age over 70 and reduced Glasgow Coma Score.
The COPD acute physiology score contains heart rate, mean arterial pressure, pH, sodium, urea, creatinine, albumin and white cell count.
According to a commentary in Thorax, “Results previously published from this study show that a large majority of patients with COPD achieve acceptable quality of life following their stay in the intensive care unit and would want to be readmitted under similar circumstances. This paper suggests that more should be done to help to get them this chance.
Hear, hear.
QJM. 2009 Jun;102(6):389-99

Paeds BVM for adult resus

Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.
BMC Emerg Med. 2009 Feb 20;9:4
http://www.ncbi.nlm.nih.gov/pubmed/19228432
Full text at http://www.biomedcentral.com/1471-227X/9/4

Ad hoc resus teams less effective

During simulated cardiac arrest resuscitations, a comparision was made between those run by teams that had had time to form before the arrest, and those that had to be assembled ad hoc after the arrest occurred. 99 teams of three doctors, including GPs and hospital physicians were studied. ACLS algorithms were less closely followed in the ad hoc formed teams, with more delays to therapies such as defibrillation. Analysis of voice recordings revealed the ad hoc teams to make fewer leadership utterances (eg. ‘we should defibrillate’ or ‘the next countershock will be 360J’) and more reflective utterances (eg. ‘what should we do next?’). The authors suggest that team building is therefore to be regarded as an additional task imposed on teams formed ad hoc during CPR that may substantially impact on outcome. No surprise to those of us who banned ‘cardiac arrest teams’ from our emergency department resuscitation rooms many years ago!
 
Hands-on time during cardiopulmonary resuscitation is affected by the process of teambuilding: a prospective randomised simulator-based trial
BMC Emerg Med. 2009 Feb 14;9:3
http://www.ncbi.nlm.nih.gov/pubmed/19216796
Full text at http://www.biomedcentral.com/1471-227X/9/3

72000 retrievals by Flying Doctors



Over twelve years in Queensland the RFDS undertook over 72000 fixed wing retrievals, including over 4000 critically ill patients. Trauma was the commonest diagnostic category. There were only 90 primary retrievals, from locations without healthcare facilities – less than one per month on average. This fascinating service covers vast distances, low population density, and a high number of indigenous people.
Aeromedical retrieval for critical clinical conditions: 12 years of experience with the Royal Flying Doctor Service, Queensland, Australia
J Emerg Med. 2009 May;36(4):363-8
http://www.ncbi.nlm.nih.gov/pubmed/18814993

NIV for weaning

Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review
The growing evidence base in support of liberating patients from invasive mechanical ventilation by means of non-invasive weaning is summarised in this systematic review of 12 randomised trials. Non-invasive weaning was associated with decreased mortality, ventilator associated pneumonia, length of stay in intensive care and hospital, total duration of mechanical ventilation, and duration of invasive ventilation. It should be noted that most of the trials exclusively enrolled patients with exacerbation of chronic obstructive pulmonary disease; benefits in other types of ventilated patients remain to be firmly proven.
BMJ. 2009 May 21;338:b157
http://www.ncbi.nlm.nih.gov/pubmed/19460803
 

Tibial vs humeral intraosseous approaches

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO
Emergency physicians at Singapore General Hospital found flow rates to be similar when comparing the tibia with the humerus as sites for adult IO access. The EZ-IO had a very high insertion success rate. It took about 12 minutes to infuse a litre of saline, which drops to about 6 minutes if a pressure bag is used.
Am J Emerg Med. 2009 Jan;27(1):8-15
http://www.ncbi.nlm.nih.gov/pubmed/19041528