Category Archives: Guidelines

Guidelines relevant to the critically ill patient

All Updates, Guidelines, ICU

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

All Updates, Guidelines, ICU, Resus

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

All Updates, Guidelines, Trauma

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 Med, All Updates, Guidelines

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)

Acute Med, All Updates, Guidelines

ACEP pneumonia statement

The American College of Emergency Physicians has conducted an evidence review and issued a policy regarding two critical issues surrounding ED management of pneumonia: whether blood cultures should be taken and in what time frame antibiotics should be administered.
The full document is available from the ACEP website:
Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia