UMEM Educational Pearls - Critical Care

Summary

Our group performed a meta-analysis to assess whether it is safe to infuse vasopressor through peripheral venous catheters.  We identified 9 studies with a total of 1835 patients.  The prevalence of complications among the pooled patient population was 9%.  Up to 96% of the complications was extravasation and almost no complications required any treatment.

A few studies reported safe infusion of norepinephrine up to 0.1 mcg/kg/min for up to 24 hours.

In exploratory meta-regression, catheter size 20 or larger was negatively associated with the rate of complications.

We also observed that studies that were published within the past 5 years reported significantly lower rate of complications from older studies.  This suggested that with careful planning and monitoring, it is safe to start vasopressor through peripheral IV.

Limitation

most of the included studies were observational. No studies had enough power to statistically analyze any variables that could predict complications.

Bottom line: we should start vasopressor as soon as indicated, if we have good, reliable IV access.

 

 

 

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Significance: 
There have been few high-quality studies regarding slow continuous infusion (SCI) of hypertonic vs. rapid intermittent bolus (RIB) therapy for patients with symptomatic hyponatremia
 
Study Design:
Multicenter, open-label RCT with 178 patients (both ED and inpatient) with corrected Na of 125 mml/L or lower with moderate/severe symptoms
-Moderate symptoms:  nausea, headache, drowsiness, general weakness, and malaise
-Severe symptoms: vomiting, stupor, seizure, and coma (Glasgow Coma Scale [GCS] score ≤8)
Relevant excluded patient populations: liver disease/cirrhotics, uncontrolled diabetics, primary polydypsia, anuric, hypotensive
 
Intervention:
Slow continuous infusion (SCI) of hypertonic vs. Rapid intermittent bolus (RIB) therapy 
(see treatment algorithms  for specifics)
 
Results:
Primary outcome: No difference in rates of overcorrection 
15 of 87 (17.2%) patients in the RIB group vs.  22 of 91 (24.2%) patients in the SCI group 
-(absolute risk difference, −6.9% [95% CI, −18.8% to 4.9%]; P = .26)
 
Other outcomes:
RIB group showed a lower incidence of relowering treatment than the SCI group 
-(absolute risk difference, −15.8% [95% CI, −30.3% to −1.3%]; P = .04; NNT, 6.3)
 
RIB group had higher proportion of patients achieving target correction rate within 1 hour than the SCI group 
-(absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; NNT, 6.8)
 
No significant differences between the groups were observed in:
- symptoms at 24 and 48 hours after treatment initiation
- first time to an increase in sNa 5 mmol/L or greater after treatment initiation
- incidence of target correction rate
- time from treatment initiation to achievement of sNa greater than 130 mmol/L
- length of hospital stay 
 
There were no cases of osmotic demyelination syndrome in either group
 
Take-home point:
Rapid intermittent boluses of hypertonic saline may be just as effective as slow continuous infusions for certain patient populations with moderate/severe symptomatic hyponatremia (and may actually have decreased rates of need for re-lowering treatment)
 
Limitations:
-smaller study
-high number of dropout due to protocol violation
-remember that ODS is multifactorial (liver disease, chronic alcoholism, malnutrition)

 

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Category: Critical Care

Title: Supraglottic airways to prevent aerosol spread during chest compressions in the COVID-19 era.

Keywords: airway management, cardiac arrest, COVID-10, SARS-CoV-2, cardiopulmonary resuscitation, CPR (PubMed Search)

Posted: 11/3/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

As the number of COVID-19 cases rises worldwide, prehospital and emergency department healthcare workers remain at high risk of exposure and infection during CPR for patients with cardiac arrest and potential SARS-CoV-2. 

Existing evidence supports similar cardiac arrest outcomes in airways managed with a supraglottic airway (SGA) compared to endotracheal intubation (ETT).1  It is generally accepted that the best airway seal is provided with endotracheal intubation + viral filter, but how well do SGAs prevent spread of aerosols? 

In CPR simulation studies:

  • Cuffed endotracheal tube + viral filter provides effective seal to prevent aerosolization during CPR.2
  • SGA + viral filter decreases AP spread compared to facemask and compared to bag-valve mask ventilation during CPR.3
  • Notable aerosolization is seen with SGAs, with no difference between AuraGain, I-gel, LMA Proseal, LMA Supreme, Combitube, or LTS-D.2
 
Bottom Line: 
  • Ventilating through an SGA + viral filter is likely better to limit spread of aerosolized particles than bag-valve mask ventilation.
  • SGAs allow egress of aerosolized particles, although the amount and area of distribution in clinical practice is unclear, and endotracheal intubation with a cuffed endotracheal tube remains the best way to avoid ongoing aerosolized particle spread with chest compressions. 
  • Appropriate PPE remains crucial to limiting healthcare workers' risk of infection and must be prioritized, even/especially in the management of patients in cardiac arrest. 

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Category: Critical Care

Title: Use of N-Acetylcysteine for non-acetaminophen acute liver failure

Keywords: NAC, Liver Failure, n-acetylcysteine (PubMed Search)

Posted: 10/20/2020 by Mark Sutherland, MD (Updated: 12/2/2020)
Click here to contact Mark Sutherland, MD

N-acetylcysteine (NAC) is well known as the accepted antidote for acute acetaminophen (tylenol/paracetamol) overdose and is well studied for this indication.  While the literature base is not nearly as strong in other causes of acute liver failure, NAC is increasingly used in these scenarios as well.  In the emergency department in particular, the cause of fulminant hepatic failure is often not known.  NAC may have some protective benefit in non-acetaminophen acute liver failure.  Existing data do not show a mortality benefit to NAC in non-acetaminophen acute liver failure, but do show improvement in transplant-free survival.  The AASLD guidelines (last revised in 2011) do not comment on NAC in non-acetaminophen acute liver failure.  A common practice is to continue NAC until the INR is < 2 and AST/ALT have decreased at least 25% from their peak values.  

Patients in fulminant liver failure should also be strongly considered for transfer to a center that does liver transplant, if presenting to a non-transplant center.  The King's College criteria is the most commonly used prognostic score for determining need of transfer to a transplant center, but in addition to calculating a King's College score providers should generally consider consultation with a transplant hepatologist for any fulminant liver failure patient to discuss the risks/benefits of transfer for transplant evaluation.

 

Bottom Line: While not as strongly indicated as it is in acute acetaminophen induced liver failure, NAC should be considered in both non-acetaminophen liver failure and liver failure of unknown etiology.  In addition, strongly consider consultation with a transplant hepatologist in any case of fulminant hepatic failure.

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Blood Pressure Management in Acute Ischemic Stroke

  • Blood pressure (BP) is elevated in many patients who present to the ED with an acute ischemic stroke (AIS).
  • Severe elevations in BP are associated with hemorrhagic transformation, as well as cardiac and renal complications.
  • As such, it is important to know the various BP goals for patients with an AIS.
    • Permissive hypertension with a BP less than or equal 220/120 mm Hg is recommended for patients not receiving IV-tPA or endovascular therapy.
    • BP should be lowered to less than or equal to 180/105 mm Hg for patients who have received IV-tPA.
    • BP goals for patients who have received endovascular therapy remain controversial and should be individualized based on the degree of recanalization.

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Takeaways

Historically, there has been debate on transporting outside hospital cardiac arrests, as well a trauma, with the question of whether to "scoop and run" or "stay and play". 

Could hasty transportation of cardiac arrest patients put a damper on resuscitation quality? 

A recent propensity-matched study in JAMA analyzed 192 EMS agencies across 10 N American sites.

Methods:

-Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, which counted 43,969 consecutive cases of nontraumatic adult EMS-treated OHCA (median age 67, 37% of whom were women) in 2011-2015.

-25% of these patients were transported to the hospital

-Matched 1:1 with patients in refractory arrest who were resuscitated on scene 

-Primary outcome was survival to hospital discharge, secondary outcome survival to hospital discharge with a favorable neurological status 

 

Results:

-Duration of out-of-hospital resuscitation was only 6 minutes longer in the intra-arrest transport group (29.1 and 22.9 minutes; not a statistically significant difference)

-Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation

-In the propensity-matched cohort, which included 27,705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0- 5.1])

-Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%])

-Intra-arrest transport during resuscitation was associated with worse odds of survival to hospital discharge compared to on-scene resuscitation (4% vs 8.5%, RR 0.48, CI 0.43-0.54)

-Findings persisted across subgroups of initial shockable rhythm vs. non-shockable rhythms (most common initial rhythm was aystole), as well as EMS witness arrests vs. unwitnessed arrests 

 

Conclusion:

-This study does not support the routine transportation of patients in cardiac arrest during rescuscitation.

-The neurologically intact survival benefit associated with on-scene resuscitation is both impressive and intriguing.

-However, what implications could this have on ECPR? 

 

Limitations:

-Potential bias due to observational nature of study 

-Duration of resuscitations very similar, unknown exactly how long transport times were or if this was in urban or rural populations

-External validity not generalizable due to heterogeneity of patient populations and EMS systems

-Further randomized clinical trials are required

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A retrospective study analyzed data from 757 patients with spontaneous intraparenchymal hemorrhage.

Within the first 6 hours of admission, patients who had systolic blood pressure reduction between 40 – 60 mm Hg (OR 1.9, 95% CI 1.1-3.5) or reduction ≥ 60 mm Hg (OR 1.9, 95%CI 1.01-3.8) were associated with almost double likelihood of poor discharge functional outcome (defined as modified Rankin Scale 3-6).

Additionally, large systolic blood pressure reduction ≥ 60 mm Hg in patients with large hematoma (≥ 30.47 ml) was associated with higher likelihood of very poor functional outcome (mRS 5-6).

Take home points: while more studies are still needed to confirm these observations, perhaps we may not want to drop blood pressure in patients with spontaneous intraparenchymal hemorrhage too much and too fast.

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Systematic review and meta-analysis of 5 studies with a total of 929 patients comparing early vs. late initiation of norepinephrine in patients with septic shock

  • all were single-center studies
  • included RCTs, prospective and retrospective cohort studies

Primary outcome:

  • short-term mortality of the early group was lower than that of the late group ([OR] = 0.45; 95% CI, 0.34 to 0.61)

Secondary outcome:

  • no difference in ICU LOS
  • time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, −1.81 to −0.96)
  • in the three studies that assessed the volume of intravenous fluids within 6 h, the volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50L; 95% CI, −0.68 to −0.3)

Caveat:

  • no clear definition of “early” initiation (ranged from within 1 to 6 hrs)

Take home point:

Early norepinephrine usage may improve mortality in septic shock

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Category: Critical Care

Title: VExUS to Detect Venous Congestion

Keywords: resuscitation, ultrasound, VExUS, venous congestion (PubMed Search)

Posted: 9/8/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

While the invasive monitoring of central venous pressure (CVP) in the critically ill septic patient has gone the way of also transfusing them to a hemoglobin of 10 mg/dL, it remains that an elevated CVP is associated with higher mortality1,2 and renal failure.2,3

Extrapolating from existing data looking at hepatic vein, portal vein, and renal vein pulsatility as measures of systemic venous hypertension and congestion,4,5,6 Beaubien-Souligny et al. developed the venous excess ultrasound (VExUS) grading system incorporating assessment of all 3, plus the IVC, using US to stage severity of venous congestion in post-cardiac surgery patients.7 They evaluated several variations, determining that the VExUS-C grading system was most predictive of subsequent renal dysfunction.

 

(Image from www.pocus101.com)
 

High Points

       VExUS Grade 3 (severe) venous congestion:

  • Correlated with higher CVP & NTproBNP levels, as well as overall fluid balance
  • Had a 96% specificity for development of subsequent AKI

 

Caveats

  • Evaluating all parameters yields the most benefit to avoid false positives
  • Can be difficult to obtain all views (>25% of subjects excluded due to poor US image quality)
  • Studied in a limited population, notably not primarily RV failure patients

 

Clinical Uses

  • To limit harmful fluid administration in shock
  • To help answer the prerenal vs cardiorenal AKI question in CHF
  • To indicate when volume removal (diuresis) should be the strategy, even in patients with vasopressor-dependent shock

 

A great how-to can be found here:

https://www.pocus101.com/vexus-ultrasound-score-fluid-overload-and-venous-congestion-assessment/

 

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Category: Critical Care

Title: Early vs. Standard initiation of renal replacement therapy

Keywords: Renal Replacement Therapy (PubMed Search)

Posted: 9/1/2020 by Kim Boswell, MD (Updated: 12/2/2020)
Click here to contact Kim Boswell, MD

STARRT-AKITrial

The Standard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury

The development of acute kidney injury (AKI) in the critical care setting portends a greater morbidity and mortality for patients. Additionally, it places the patient at high risk of complications and requires a greater use of resources. Several studies in the past have examined if the timing of initiation of renal replacement therapy (RRT) would result in a mortality benefit, but have failed to demonstrate consistent outcomes.

The STARRT-AKI trial was a multinational, randomized controlled trial designed to determine if early initiation of RRT in critically ill adult patients with AKI lowered the risk of 90-day mortality. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI and over 2900 patients were randomly assigned to two groups over a 4 year period. Exclusion criteria included: recent RRT, a renal transplant within the preceding year, advanced CKD, an overdose necessitating RRT, or a strong suspicion of obstruction or autoimmune/vascular cause of their AKI.

Groups:

  • The accelerated strategy group
    • Initiation of RRT within 12 hours of meeting eligibility criteria (AKI based on KDIGO definition)
  • The standard strategy group –
    • General goal of withholding RRT unless the patient met the following specific parameters:
    • K+ >6.0,  pH <7.20,  HCO3 <12mmol/L,  moderate ARDS with clinical picture concerning for volume overload, or persistent AKI >72hr after randomization

Outcomes/Results:

  • The study’s primary outcome measure was all cause mortality at 90 days
    •  There was no significant difference between the groups
    •  P=0.92 with RR 1.00
  • Secondary outcomes evaluated several things including ventilator and vasoactive free days, hospital length of stay, number of days without RRT at 90 days as well as adverse events directly related to RRT
    • Interestingly, at 90 days, the patients in the accelerated strategy group were more likely to have ongoing RRT needs at 10.4% compared to the standard strategy group at 6.0% (not statistically significant).
    •  Overall, no significant difference between the groups when assessed for death in the ICU, major adverse events, or with regard to hospital length of stay.

Take home points:

  • This was a well done, well randomized trial from many countries and ICU settings
  • No significant mortality benefit between groups at 90 days
  • Interestingly, the patients in the accelerated group were more likely to have suffered adverse events related to RRT and were more likely to be dependent on RRT at 90 days
    • It is unclear why this is, but suggestive that early initiation of RRT may compromise the intrinsic healing of the kidney
    • Emphasizes a greater risk for adverse events without clear benefit
  • Ultimately, the decision to initiate RRT should be based on the patient’s clinical picture, acid/base status, electrolyte abnormalities, and volume status and NOT on a general trend of their renal indices.

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Ketamine In the Critically Ill Patient

  • Ketamine has become a popular agent in the ED for both RSI and procedural sedation.
  • Given the sedative, analgesic, dissociative, antidepressant, and anti-inflammatory properties, ketamine has also been used in a number of other critical illness conditions including:
    • Acute pain management
    • Status asthmaticus
    • Alcohol withdrawal syndrome
    • Status epilepticus
    • Acute agitated delirium
  • The authors of a recent review in Critical Care Medicine found that the evidence supporting the use of ketamine in the critically ill is most robust for adjunctive analgesia in the intubated patient.  Surprisingly, the data is very limited to support the use of ketamine in these other conditions.
  • Pearl: ketamine does have a myocardial depressant effect, which can be unmasked in states of catecholamine depletion and result in hypotension and bradycadia.

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Category: Critical Care

Title: METCOVID

Keywords: COVID-19, ARDS, Pneumonia, Steroids (PubMed Search)

Posted: 8/17/2020 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

Another week, another COVID-19 study...

On August 12th, the Metcovid study was e-published ahead of print in Clinical Infectious Diseases.  This was another study looking at steroids in COVID-19 pneumonia, this time performed in Brazil.  Metcovid was a parallel, double-blind, randomized, placebo-controlled phase IIb clinical trial which enrolled 416 patients at a single academic center for the evaluation of methylprednisolone (MP; 0.5 mg/kg BID x 5 days) vs placebo.  As with all COVID studies, Metcovid has some significant limitations, and some equivocal findings.  However, Metcovid was largely in line with RECOVERY and other trials looking at steroids in COVID-19, which lends it some face validity.  Metcovid found no significant difference in the primary outcome (mortality at day 28), but did find a difference in mortality in patients over 60 years old (a post-hoc analysis).  Metcovid was probably underpowered (sample size was based on a 50% reduction in mortality), and did have a very small trend towards reduced mortality in the MP group (37.1% vs 38.2%, p=0.629).

Bottom Line: 

  • Steroids (methylprednisolone 0.5 mg/kg BID x 5 days in this case) may have some mild benefit in severe cases of COVID-19 pneumonia, especially in patients who are elderly or have more aggressive inflammatory responses (as measured by CRP here).  
  • Steroids in COVID-19 may be associated with some theoretical downsides like reduced viral clearance, but are relatively safe.  Main side effect is the well known hyperglycemia induced by corticosteroids.
  • When using steroids in COVID pneumonia, both to stick with the evidence and for theoretical pharmacologic reasons, it may make sense to use dexamethasone or methylprednisolone, as these medications have a higher glucocorticoid:mineralocorticoid activity ratio.  It is hypothesized that using high mineralocorticoid steroids (like cortisone or hydrocortisone) may lead to increased water retention, which could be deterimental in ARDS.  This is purely theoretical.
  • There was a signal towards harm in younger and less sick patients in this study, and it probably remains prudent to reserve steroids for older, sicker COVID-19 pneumonia patients, similar to the RECOVERY trial.

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Category: Critical Care

Title: HALT-IT Trial: TXA in GI bleeds

Keywords: gastrointestinal bleeding, TXA (PubMed Search)

Posted: 7/30/2020 by Lindsay Ritter, MD (Emailed: 8/4/2020) (Updated: 8/4/2020)
Click here to contact Lindsay Ritter, MD

Takeaways

Prior to this study, a Cochrane review and meta-analysis of TXA for upper GI bleeds with 7 trials (1654 patients), showed a large reduction in mortality with TXA (RR 0.61, 95% CI 0.42-0.98, p=0.01)

Design:

-Randomized, international, multicentre, placebo-controlled trial at 164 hospitals in 15 countries Juy 2013-2019

->16/18 years old with upper or lower GI bleeding

-1 g TXA IV over 10 minutes followed by maintenance dose 3 g TXA over 24 hours 

 

Results:

-Main outcome death due to bleeding within 5 days 

-4% (222/5994) died in TXA group vs 4% (226/5981) placebo risk ratio RR 0.99, 95% CI 0.82-1.18 

-Arterial thromboembolic events MI/CVA similar in both groups (0.7% vs 0.8%)

-Venous thromboembolic events PE/DVT higher in TXA group (0.8% vs 0.4%)

 

Pitfalls:

-Initially calculated all cause mortality until realization that over half deaths were due to non-bleeding causes, changed to death related to bleeding, allowing study appropriate power to detect difference 

-Majority of patients had UGIB/variceal bleeding due to liver disease, over 75% deaths in those with liver disease 

-Only 16% patients randomized in <3 hours, most >8 hours (CRASH-2 trial found benefit TXA in trauma patients only <3 hrs to administration) 

 

Takeaway:

-TXA should not be used in the management of GI bleeds

-Increased venous thromboembolic events associated with TXA administration for GI bleeds

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Patient 

  • Single Center, double-blinded, randomized trial. 

  • Patients with cancer and septic shock 

Intervention 

  • 4% albumin + lactate ringer bolus in 10 minutes 

  • 180 patients 

Comparison 

  • Lactate ringer bolus in 10 minutes 

  • 180 patients 

Outcome 

  • Primary: Any mortality within 7 days of randomization. 

  • Secondary: Mortality within 28 days, renal replacement therapy (RRT) 

Results: 

  • 7-day mortality: 46 (25%) for LR + albumin vs. 40 (22%) for LR only 

  • 28-day mortality: 96 (53%) for LR + albumin vs. 83 (46%) for LR only 

  • RRT: 16 (9%) for LR + albumin vs. 12 (7) for LR only 

Conclusion: 

Adding albumin for early resuscitation to crystalloids did not improve mortality in cancer patients with septic shock. 

 

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Design
-Two-center prospective observational study with 157 patients admitted to the ICU for pneumonia and being treated with HFNC
-ROX (Respiratory rate-OXygenation) index = ratio of SpO2/FIO2 to RR

Results:
-ROX index ≥4.88 at 12 hours after HFNC onset with a sensitivity of 70.1%, a specificity of 72.4%, PPV of 89.4%, NPV of 42%, LR+ of 2.54, and LR- of 0.41 in predicting treatment failure

Validation study: Roca, 2019
-results similar, but ROX index ≥4.88 at 12 hour with LR+ of only 1.82
-also found that a ROX index of <3.85 at 12 hours had a sensitivity of 23.5%, specificity of 98.4%, PPV of 88.9, NPV 69.9, LR+ of 14.47, and LR- 0.78

Pitfalls:
-decision to intubate was not made based on ROX index
-criteria for intubation was also part of the ROX index
-NIV was not part of their treatment algorithm
-created and validated prior to current COVID-19 pandemic

Takeaways:
- The ROX index can be a tool to help predict whether a patient with pneumonia on HFNC may need mechanical ventilation or higher level of care
- May be most helpful with patients with pneumonia on HFNC boarding in the ED
- At 12 hours of HFNC, ROX index of >4.88 suggests patient likely to succeed with HFNC vs. <3.85 which suggests likely need for mechanical ventilation

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Category: Critical Care

Title: Dexamethasone: Improving Mortality in COVID-19?

Keywords: dexamethasone, steroids, respiratory failure, COVID-19, SARS-CoV-2, RECOVERY (PubMed Search)

Posted: 7/14/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

The RECOVERY (Randomized Evaluation of COVid-19 thERapY) investigators recently published a non-peer reviewed article on their findings utilizing dexamethasone to treat patients with COVID-19. 

Rx: Dexamethasone 6mg daily* x 10 days (PO or IV) *or steroid equivalent

  • 2104 in the dexamethasone group vs 4321 in the “usual care” group
  • Did not exclude children or pregnant/breastfeeding mothers
  • Follow-up at 28 days, hospital discharge, or death

Primary outcome:         All-cause mortality at 28-days

Secondary outcomes: 

  • Major arrhythmia
  • Time to discharge from hospital
  • Duration of mechanical ventilation
  • Need for renal replacement therapy
  • In patients not ventilated at enrollment, need for intubation/ECMO & death

Results:

  • Decrease in overall mortality at 28-days with 3% absolute risk reduction.
    • NNT of 25 in patients requiring O2, HFNC, or NIV
    • NNT of 8 in patients requiring invasive mechanical ventilation
  • More mortality benefit seen the higher the respiratory support required, with no benefit and apparent trend towards increased mortality in the group not requiring any respiratory support at all. 
  • When stratified by symptoms < or > 7 days, mortality benefit only seen in the >7 days group (which was more of the ventilated patients).
  • Less progression to intubation, shorter hospital duration, greater likelihood of hospital discharge.

Limitations:

  • Not yet peer-reviewed, haven't seen all the data, additional analyses could be helpful in determining if treatment effect is real
  • Unblinded study
  • 7% of control group received dexamethasone

 

Bottom Line: Strongly consider admininstering dexamethasone to your patients with known COVID-19 who require respiratory support, and look for the peer-reviewed publication from the RECOVERY Trial investigators.

 

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Category: Critical Care

Title: Use of IV contrast for CT a consensus statement

Keywords: Contrast induced nephropathy; acute kidney injury; consensus statement (PubMed Search)

Posted: 7/7/2020 by Kim Boswell, MD
Click here to contact Kim Boswell, MD

We all know the frustration that comes with the phone call from radiology asking if you “really want IV contrast” for your patient’s CT because the creatinine is elevated…

Recently, a joint statement was published between the American College of Radiology and the National Kidney Foundation regarding the safety of IV contrast in patients with kidney disease. The recommendations are based on GFR and apply to those with both chronic kidney disease as well as those who have an acute kidney injury. Summary points of the statement are below:

  • Prophylaxis is not indicated with a GFR > 45mL/min
  • Prophylaxis should be given to patients with a GFR < 30mL/min (Other conditions such as heart failure or hypervolemia may preclude prophylaxis based on clinical judgement)
  • Prophylaxis is NOT indicated in those with GFR > 30mL/min even if patients also have diabetes, dialysis dependent renal failure or those at risk of heart failure.
  • High risk patients (Recent AKI, borderline GFR, or numerous risk factors) with GFR 30-44mL/min can be considered for prophylaxis based on clinical judgement

 

  • Preferred prophylaxis is with isotonic fluid, such as normal saline. Volumes and timing are uncertain but should begin prior to contrast administration.
  • Bicarbonate and N-acetylcysteine are not recommended fluids for prophylaxis

 

  • There is no need for acute HD or CRRT following contrast administration in ESRD patients

Every decision to use contrast should be made based on clinical need for contrast as well as individual patient risk factors and underlying disease processes.

 

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Category: Critical Care

Title: Neutrophil to Lymphocyte Ratio

Keywords: Neutrophils, Lymphocytes, NLR, ANC, ALC, Sepsis, COVID (PubMed Search)

Posted: 6/30/2020 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

As has been previously noted, the white blood cell count is "the last refuge of the intellectually destitute."  However, within a CBC (especially if a differential is obtained), there is information that can sometimes be of value.  One measure, which was noted before COVID but has come under increasing attention in the current pandemic, is the Neutrophil-To-Lypmhocyte Ratio (NLR).  Because physiologic stress typically causes the Absolute Neutrophil Count (ANC) to increase and the Absolute Lymphocyte Count (ALC) to decrease, the ratio of the two values (NLR = ANC/ALC) should increase when the body is under stress.  Similar to the WBC however, it should be noted that ANY source of physiologic stress can cause abnormalities of the NLR, and thus this is not limited strictly to infectious etiologies.  

With that caveat in mind, the NLR can sometimes be a clue to the degree of physiologic stress the patient is under.  As lymphopenia is a frequent finding in COVID, the NLR has come under particular interest in the setting of COVID and appears to have prognostic value in COVID+ patients.

It should be kept in mind that inflammatory stressors (e.g. sepsis) are likely to disproportionately raise the NLR relative to noninflammatory stressors (e.g. pulmonary embolism), so a septic patient with an NLR of 10 might not be all that ill, whereas a PE patient with an NLR of 10 may be sicker.  As with any single lab, and particularly one so nonspecific, there are no hard and fast cutoffs, and the NLR has to be interpreted in the context of other clinical data (it is very much possible to have a high NLR and not be that sick, or to have a low NLR and be sick... this is only one datapoint and does have pitfalls associated with it).  As a rough guide however, a Pulmcrit post by Josh Farkas from 2019 suggested the following interpretation of the NLR:

1-3: Normal

6-9: Mild stress (e.g. uncomplicated appendicitis)

9-18: Moderate stress, may be associated with critical illness

>18: Severe stress, commonly associated with critical illness

The post (see references below) provides an excellent overview of NLR, further information on the uses and pitfalls of NLR, and several additional sources on the subject.  It's a very worthwhile read.  

 

Bottom Line: The Neutrophil-To-Lymphocyte Ratio (NLR = ANC/ALC) is one indicator of the degree of physiologic stress, and may be used in conjuction with other clues to determine how sick your patient is.  

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Category: Critical Care

Title: STILL no evidence to support platelet transfusion of platelets for non-surgical ICH

Keywords: ICH, stroke, hemorrhagic, platelet, DDAVP, desmopressin (PubMed Search)

Posted: 6/23/2020 by Robert Brown, MD
Click here to contact Robert Brown, MD

Takeaways

Mortality is high in intracranial hemorrhage, and even higher for anti-platelet associated ICH (AP-ICH). The Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Hemorrhage Associated with Antiplatelet Therapy (PATCH) trial was shocking: it demonstrated platelet transfusion was associated with worse outcomes, excluding those patients who were planned to go to surgery in the next 24 hours. SCCM and the Neurocritical Care Society recommend AGAINST platelet transfusion in non-operative ICH, but encourage a dose of DDAVP.

But who knows who will go to surgery? If you've been giving platelets and DDAVP to non-operative AP-ICH, you're not alone. So in the July Issue of Crit Care Medicine, the authors of the PATCH trial published a retrospective study of 140 patients, excluding those who immediately had surgery. In this group in which a quarter eventually had decompressive craniectomy and a fifth had an external ventricular drain placed, half received platelets and DDAVP instead of DDAVP alone. 

The result? Still no benefit to platelet transfusion (despite the inclusion of patients who went on to have surgery). We all WANT to give platelets to AP-ICH, but there is NO evidence of BENEFIT and we may cause HARM. A test of platelet function (like the TEG) should be performed at the very least to select for patients with actual platelet dysfunction, and transfusion should be limited to patients going to surgery.

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Analgesics & Sedatives in the Critically Ill Obese Patient

  • Analgesic and sedative medications are frequently administered to critically ill patients.
  • Weight-based dosing regimens for these medications can lead to significant over-, or under-, dosing in the critically ill obese patient (BMI > 40 kg/m2).
  • In order to avoid harm, it is important to know when to use actual body weight (ABW), ideal body weight (IBW), or adjusted body weight in weight-based dosing regimens.
  • Recommendations for weight-based dosing regimens for commonly used analgesic and sedative medications include:
    • Opioids: use IBW or adjusted body weight
    • Ketamine: use IBW or adjusted body weight
    • Propofol: use IBW or adjusted body weight
    • Etomidate: use adjusted body weight or ABW
    • Midazolam: use IBW or adjusted body weight

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