Category Archives: ICU

Stuff relevant to patients on ICU

Dexmedetomidine vs midazolam

An industry-sponsored double-blind randomised controlled trial comparing midazolam with the central alpha-2 agonist dexmedetomidine showed the newer drug to provide similar levels of sedation with less delirium and a shorter time to extubation. It was associated with more episodes of bradycardia not requiring intervention.
This new sedative drug, related to clonidine, provides some analgesia and anxiolysis, and is noted for its lack of respiratory depression. An accompanying editorial points out the known association between benzodiazepines and delirium, and asks whether a comparison with propofol would have shown the same improved outcomes.
Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial
JAMA. 2009 Feb 4;301(5):542-4

Neonatal prostaglandin E1 and apnoea

The risk of apnoea in neonates requiring prostaglandin E1 infusions for duct-dependent congenital heart disease is well described and often results in the recommendation to intubate prior to transfer. An American study of 202 transported infants on PGE1 shows a higher rate of transport-related complications in those that had been intubated. None of the 73 (36%) unintubated patients required intubation for apneoa during transport. These data are in keeping with a previous Australian study of 300 infants receiving PGE1 in which only 2 of 78 unintubated patients experienced apnoea.
To intubate or not to intubate? Transporting infants on prostaglandin E1
Pediatrics. 2009 Jan;123(1):e25-30

Failed prehospital intubation attempts and pneumonitis

A review of 1954 out-of-hospital tracheal intubation (ETI) attempts by EMS crews revealed 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25). The authors conclude that out-of-hospital ETI errors are not associated with mortality, but failed out-of-hospital ETI increases the odds of pneumonitis.

Nurse-delivered prehospital CPAP

A nurse-based pre-hospital care system in Holland describes its experience with pre-hospital CPAP for acute cardiogenic pulmonary oedema. It appears that the simple Boussignac apparatus is straightforward to apply in the ambulance environment. Arguments about lack of outcome studies aside, if it’s necessary to undertake an interhospital transfer of a patient established on CPAP then this might be a relatively straightforward means of doing so.