In a multicentre RCT of patients with septic shock who were receiving steroids (hydrocortisone) for the septic shock, intensive insulin therapy did not affect outcome but was (once again) associated with a higher incidence of hypoglycaemia. Also, the addition of (enteral) fludrocortisone did not provide benefit compared with hydrocortisone alone.
Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults
JAMA. 2010;303(4):341-348
Category Archives: ICU
Stuff relevant to patients on 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
Differentiating arteries from veins
In a letter to Critical Care Medicine, ultrasound legend Michael Blaivas reminds readers that during ultrasound-guided central venous catheterisation, an additional technique for differentiating the common carotid artery from the internal jugular vein: pulse-wave doppler.
Blaivas states: “The left panel shows a classic arterial tracing from the common carotid artery with a normal velocity. The right panel shows the vessel of choice on the same patient: the right internal jugular vein. The image shows a slightly chaotic venous tracing from the jugular. This a common appearance and is markedly different from the waveform of the carotid.”
Posterior vessel wall penetration by needles during internal jugular vein central catheter placement using ultrasound guidance: is that a real danger? Author’s Reply.
Crit Care Med. 2010 Feb;38(2):736-7
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
Heliox in COPD exacerbation
A 65:35 helium-oxygen mix was compared with 35% oxygen in air in patients with COPD exacerbations requiring non-invasive ventilation. In this RCT there was no difference in intubation rates between the heliox or air/oxygen groups.
A multicenter, randomized trial of noninvasive ventilation with helium-oxygen mixture in exacerbations of chronic obstructive lung disease
Crit Care Med. 2010 Jan;38(1):145-51
Best way to insert NG tube in intubated patients
A randomised controlled trial on 200 anaesthetised, tracheally intubated adults compared four methods of nasogastric tube placement, looking at success rates, time to insertion, and complications.
The four groups were: control, using a ureteral guidewire as stylet, a slit endotracheal tube as an introducer, and head flexion with lateral neck pressure. All intervention groups were more successful than the control group. The time necessary to insert the NG tube was significantly longer in the slit endotracheal tube group, which also had the highest bleeding rate. Complications were fewest in the flexion group.
Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study
Anesth Analg. 2009 Sep;109(3):832-5
Effect on noradrenaline on tissue oxygen delivery
Some persist in thinking and teaching that the ‘vasopressor’ noradrenaline (norepinephrine) increases mean arterial pressure (MAP) simply by increasing systemic vascular resistance, leading to concerns that it may increase blood pressure at the expense of tissue perfusion. This assertion is contested by many, who now have further support from this study.
In 16 patients with septic shock, various measures of peripheral perfusion were recorded while the dose of noradrenaline was increased to achieve target MAPs. The use of noradrenaline to achieve incremental targets for MAP was associated with increases in global oxygen delivery, cutaneous microvascular flow, and tissue oxygenation in patients with established septic shock; there were no associated changes in the preexisting abnormalities of sublingual microvascular flow. The authors state that these findings suggest that in patients with septic shock, improvements in global hemodynamics and tissue oxygen delivery can be achieved with noradrenaline, without exacerbating microcirculatory flow abnormalities.
The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock
Crit Care Med. 2009 Jun;37(6):1961-6
Cuffed tracheal tubes for children
In a prospective randomised controlled multi-centre trial, cuffed tracheal tubes were compared with uncuffed tubes in 2246 children aged from birth to five years undergoing general anaesthesia. There was no significant difference in post-extubation stridor but the need for tube exchange was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).
From the resuscitation point of view, there remain few if any arguments for using an uncuffed tube.
Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children
Br J Anaesth. 2009 Dec;103(6):867-73
Mallampati unhelpful in ED patients
A prospective study of 366 patients requiring intubation in the ED revealed by logistic regression analysis that the only component of the ‘LEMON’ classification* to be independently associated with difficult intubation was a thyroid-hyoid distance of less than 2 finger breadths. They conclude that Mallampati classification is not a useful tool in predicting difficult intubation in the ED and that the LEMON acrostic can be modified to “LEON.”
Determination of difficult intubation in the ED
Am J Emerg Med. 2009 Oct;27(8):905-10
*Further definition of LEMON and information on difficult airways are available in these presentation slides by Rob Vissers FACEP
Cricoid pressure – ?not so useless after all
An interesting MRI-based study of adult volunteers takes a further look at whether cricoid pressure effectively occludes the digestive tract. The authors assert that the part of the digestive tract at the level of the cricoid is the distal hypopharynx, that it is fixed in relation to the airway (making the previously demonstrated lateral oesophageal displacement irrelevant), and that the lumen may be obliterated during Sellick’s manouevre.
Accompanying pro and con editorials reaffirm the need for further clinical evidence on the effectiveness of the technique.
Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant
Anesth Analg. 2009 Nov;109(5):1546-5