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
All posts by Cliff
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
Ambulance transport induces stress
Plasma levels of adrenaline and noradrenaline increased signficantly in patients with acute coronary syndrome during ambulance transportation – a finding in keeping with studies on normal volunteers. I wonder how much more of an effect helicopter retrieval might have?
Emergency ambulance transport induces stress in patients with acute coronary syndrome
Emerg Med J. 2009 Jul;26(7):524-8.
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
CRP improves mortality prediction by prognostic scales in community-acquired pneumonia
In admitted patients with community acquired pneumonia, adding CRP to either the CURB-65 score or pneumonia severity index improved the area under the receiver operator curve for those prediction tools. In fact, CRP levels greater than 25 mg/dl on admission double the probability of death previously computed in the same class of initial risk
Thorax. 2009 Jul;64(7):587-91
Preparing your emergency department for pandemic 'flu
Ten points to consider in preparation for pandemic influenza
* Ensure emergency department representation at the Trust level.
* Talk about pandemic flu with your staff.
* Establish a process for fit testing all your staff.
* Institute a training programme for staff in the use of personal protection equipment (PPE).
* Consider stockpiling PPE.
* Agree the processes for managing potentially infected patients within the emergency department.
* Consider how roles in the hospital and within the emergency department may change during a pandemic.
* Establish a method for communicating with staff during a pandemic.
* Consider what you can do to improve staff morale.
* Consider and discuss the ethical decisions we will be required to make.
Emergency Medicine Journal 2009;26:497-500
Pleural effusions – exudate or transudate?
Light’s criteria may misclassify some transudates as exudates. Measuring NT-Pro BNP in pleural fluid may identify heart failure-associated effusions
Chest. 2009 Sep;136(3):671-7