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
Category Archives: Resus
Life-saving medicine
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
A Systematic Review of Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults
This thorough review confirms that steroids have no clear benefit on mortality in severe sepsis / septic shock. Looking at prolonged courses of low dose steroids, there may be a beneficial effect but this did not reach statistical significance.
JAMA. 2009 Jun 10;301(22):2362-75
http://www.ncbi.nlm.nih.gov/pubmed/19509383
Etomidate versus ketamine for rapid sequence intubation
Finally a well designed blinded randomised controlled trial on this subject. 0.3 mg/kg etomidate was compared with 2mg/kg ketamine for RSI in 655 patients requiring emergency intubation in the pre-hospital, emergency department, or intensive care unit environments. No difference was observed in intubation conditions or the primary endpoint of maximum SOFA score in the first three days, although the etomidate group had a higher rate of adrenal insufficiency as defined by response to an ACTH test.
Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial.
Lancet. 2009 Jul 25;374(9686):293-300
Ketamine lowered ICP in brain-injured kids
Ketamine lowered ICP in brain-injured kids
Ventilated children between the ages of 1 and 16 with traumatic brain injury and elevated intracranial pressure (ICP) were given ketamine and effect on cerebral perfusion pressure (CPP) and ICP was measured. Ketamine decreased ICP while maintaining blood pressure and CPP.
These results refute the notion that ketamine increases ICP. The authors conclude: “Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations”
Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension
J Neurosurg Pediatr. 2009 Jul;4(1):40-6 (Full text)
Guidelines for D.I.C.
2009 Guideline for the Diagnosis and Managment of Disseminated Inravascular Coagulation
DIC guideline available here
Other useful guidelines from the the British Committee for Standards in Haematology
NINDS does not support 'time-is-brain' when re-presented
The first ‘positive’ trial that really started it all for stroke thrombolysis has been re-presented by showing that the change in NIHSS score at 90 days differs little between tPA and placebo groups.
A Graphic Reanalysis of the NINDS Trial
Acute Kidney Injury Survivors – What happens next?
What happens to acutely ill patients with acute kidney injury requiring in-hospital dialysis after their acute admission? How many recover and how many require chronic dialysis? A Canadian study of 3769 such patients followed up for an average of 3 years demonstrated that the incidence rate for chronic dialysis was only 2.63 per 100 person years, and that all cause mortality compared with matched controls was unchanged.
JAMA. 2009 Sep 16;302(11):1179-85
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