Category: Critical Care
Posted: 6/15/2016 by Mike Winters, MBA, MD
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Heat Stroke
Gaudio FG, Grissom CK. Cooling methods in heat stroke. J Emerg Med 2016; 50:607-16
Category: Critical Care
Keywords: PPI, GI bleed, UGIB, GI hemorrhage (PubMed Search)
Posted: 6/7/2016 by Daniel Haase, MD
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1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. doi: 10.1038/ajg.2011.480. Epub 2012 Feb 7. Review. PubMed PMID: 22310222.
2. Barkun AN, et al; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009. PubMed PMID: 20083829.
3. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014 Nov;174(11):1755-62. doi: 10.1001/jamainternmed.2014.4056. Review. PubMed PMID: 25201154; PubMed Central PMCID: PMC4415726.
4. Neumann I, et aI. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2013 Jun 12;(6):CD007999. doi: 10.1002/14651858.CD007999.pub2. Review. PubMed PMID: 23760821.
5. Pantoprazole. Micromedex 2.0. Truven Health Analytics, Inc. Available at http://micromedexsoultsions. Accessed June 7, 2016.
Category: Critical Care
Posted: 5/31/2016 by Haney Mallemat, MD
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Category: Critical Care
Keywords: ATS, non invasive ventilation, aspirin, nighttime extubation, dialysis (PubMed Search)
Posted: 5/24/2016 by Feras Khan, MD
(Updated: 7/16/2024)
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American Thoracic Society (ATS) Conference Highlights
The ATS conference was last week in San Francisco and a few cool articles were presented. They are briefly summarized below:
1. Using a helmet vs face mask for ARDS: Non-invasive ventilation is not ideal for ARDS for a variety of reasons. At the same time, endotracheal intubation and ventilation carries some risks as well. Could a new design of a "helmet" device make a difference? This one center study from the Univ of Chicago suggests that it would: decreased rate of intubation, increase in ventilator free days, and decrease in 90 day mortality. http://jama.jamanetwork.com/article.aspx?articleid=2522693
2. Can aspirin prevent the development of ARDS in at risk patients in the emergency department? Unfortunately, it does not appear to help. http://jama.jamanetwork.com/article.aspx?articleid=2522739
3. Should you start renal-replacement therapy (HD, CRRT etc) in critically ill patients with AKI sooner or later? Seems to have no difference and may actually lead to patients not needing any dialysis. Really a great read if you have time. http://www.nejm.org/doi/full/10.1056/NEJMoa1603017?query=OF&
4. Should I extubate at night? Lastly, probably don’t extubate at night if you can avoid it. Or just be cautious. http://www.atsjournals.org/doi/abs/10.1164/ajrccmconference.2016.193.1_MeetingAbstracts.A6150
Category: Critical Care
Posted: 5/17/2016 by Mike Winters, MBA, MD
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Situations Where ECMO Will Likely Fail
Schmidt M, et al. Ten situations in which ECMO is unlikely to be successful. Intensive Care Med 2016; 42:750-752.
Category: Critical Care
Keywords: Zika, Guillain-Barre, GBS, ITP, Critical Care (PubMed Search)
Posted: 5/10/2016 by Daniel Haase, MD
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Zika virus has received significant media attention in the US due to its recent link with teratogenicity. But Zika is also associated with critical and life-threatening complications, including death. Differentiating it from other Flavivirus diseases such as Dengue or Chikungunya can be challenging.
Diagnosis
Complications
1. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika Virus. N Engl J Med. 2016 Apr 21;374(16):1552-63. doi: 10.1056/NEJMra1602113. Epub 2016 Mar 30. Review. PubMed PMID: 27028561.
2. LaBeaud, AD. Zika virus infection: An overview. uptodate.com. Accessed 5/10/2016.
3. Cao-Lormeau VM, et al. Guillain-Barr Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet. 2016 Apr 9;387(10027):1531-9. doi: 10.1016/S0140-6736(16)00562-6. Epub 2016 Mar 2. PubMed PMID: 26948433.
4. Centers for Disease Control and Prevention. Zika virus - What clinicians need to know? Clinician Outreach and Communication Activity (COCA) Call, January 26, 2016. Available at: http://emergency.cdc.gov/coca/ppt/2016/01_26_16_zika.pdf. Accessed May 10, 2016.
1605101507_Zika_Dengue_Chikungunya.jpg (131 Kb)
Category: Critical Care
Keywords: in hospital cardiac arrest, cardiac arrest (PubMed Search)
Posted: 4/26/2016 by Feras Khan, MD
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A recent survey looked at resuscitation practices that could help improve survival during in-hospital cardiac arrest
Category: Critical Care
Posted: 4/19/2016 by Mike Winters, MBA, MD
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Can NIV be Used in ARDS?
Demoule A, et al. Can we prevent intubation in patients with ARDS? Intensive Care Med 2016; 42:768-771.
Category: Critical Care
Keywords: seizure, status epilepticus, pregnancy (PubMed Search)
Posted: 4/13/2016 by Daniel Haase, MD
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Disclaimer: Talking about seizures/status that is NOT due to eclampsia
TAKE HOME: While no AEDs are completely safe in pregnancy, treatment and stabilization of maternal status epilepticus is paramount for fetal health. Involve neurology/epileptology and OB/maternal-fetal medicine.
1. Hern ndez-D az S, et al; North American AED Pregnancy Registry; North American AED Pregnancy Registry. Comparative safety of antiepileptic drugs during pregnancy. Neurology. 2012 May 22;78(21):1692-9.
2. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994 Nov-Dec;8(6):461-75.
3. Lexicomp online accessed via uptodate.com.
Category: Critical Care
Posted: 4/5/2016 by Haney Mallemat, MD
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Category: Critical Care
Keywords: cardiorenal syndrome, heart failure, kidney failure (PubMed Search)
Posted: 3/29/2016 by Feras Khan, MD
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What is cardio-renal syndrome CRS?
There are 5 types
1. Acute CRS: abrupt worsening of heart function leading to kidney injury
2. Chronic CRS: chronic heart failure leads to progressive kidney disease
3. Acute renocardiac syndrome: abrupt kidney dysfunction leading to acute cardiac disorder
4. Chronic renocardiac syndrome: chronic kidney disease leading to decreased cardiac function
5. Systemic CRS: Systemic condition leading to both heart and kidney disease
Category: Critical Care
Posted: 3/22/2016 by Mike Winters, MBA, MD
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Cerebral Venous Thrombosis
Fam D, Saposnik G. Critical care management of cerebral venous thrombosis. Curr Opin Crit Care 2016; 22:113-9.
Category: Critical Care
Keywords: Pharmacology, Hypertension, Vasoactive (PubMed Search)
Posted: 3/15/2016 by Daniel Haase, MD
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There are multiple vasoactive infusions available for acute hypertensive emergencies, many having serious side effect profiles or therapeutic disadvantages.
Clevidipine (Cleviprex) is rapidly-titratable, lipid-soluable dihydropyridine calcium channel blocker which has become increasingly used in the ICU in recent years [1]:
ECLIPSE trial compares clevidipine, nicardipine, nitroglycerin and nitroprusside in cardiac surgery patients. .
Clevidipine was as effective as nicardipine at maintaining a pre-specified BP range, but superior when that BP range was narrowed (also studied in ESCAPE-1 and ESCAPE2 with similar results) [2-3]
TAKE-HOME: Clevidipine is an ultra short-acting, rapidly-titratable vasoactive with favorable cost, pharmacokinetics, and side-effect profile. Consider its use in hypertensive emergencies.
1. Lexicomp (accessed via UpToDate on 3/15/2016)
2. Aronson S, Dyke CM, Stierer KA, et al, "The ECLIPSE Trials: Comparative Studies of Clevidipine to Nitroglycerin, Sodium Nitroprusside, and Nicardipine for Acute Hypertension Treatment in Cardiac Surgery Patients," Anesth Analg, 2008, 107(4):1110-21.
3. ESCAPE-2 Study Group.Treatment of acute postoperative hypertension in cardiac surgery patients: an efficacy study of clevidipine assessing its postoperative antihypertensive effect in cardiac surgery-2 (ESCAPE-2), a randomized, double-blind, placebo-controlled trial.Anesth Analg. 2008 Jul;107(1):59-67.
Category: Critical Care
Posted: 3/8/2016 by Haney Mallemat, MD
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Category: Critical Care
Keywords: ARDS (PubMed Search)
Posted: 3/1/2016 by Feras Khan, MD
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Category: Critical Care
Posted: 2/24/2016 by Mike Winters, MBA, MD
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Sepsis-3
Singer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:801-10.
Category: Critical Care
Posted: 2/9/2016 by Haney Mallemat, MD
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Category: Critical Care
Keywords: aki, renal failure, acute kidney injury (PubMed Search)
Posted: 2/2/2016 by Feras Khan, MD
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KDIGO Clinical Practice Guidelines, 2012.
Category: Critical Care
Posted: 1/26/2016 by Mike Winters, MBA, MD
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Shock Index
Kristensen AKB, Holler JG, Hallas J, et al. Is shock index a valid predictor of mortality in emergency department patients with hypertension, diabetes, high age, or receipt of beta or calcium channel blockers? Ann Emerg Med 2016; 67:106-13.
Category: Critical Care
Keywords: Pulmonary Embolism, PE, submassive PE, thrombolysis, catheter-directed thromblysis, thrombectomy, echo (PubMed Search)
Posted: 1/19/2016 by Daniel Haase, MD
(Updated: 2/10/2016)
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What classifies "submassive PE"?
Submassive PE has early benefit from systemic thrombolysis at the cost of increased bleeding [1].
Ultrasound-accelerated, catheter-directed thrombolysis (USAT) [the EKOS catheters] has been shown to be safe, with low mortality and bleeding risk, as well as immediately improved RV dilation and clot burden [2-4]. USAT may improve pulmonary hypertension [4].
USAT is superior to heparin/anti-coagulation alone for submassive PE at reversing RV dilation at 24 hours without increased bleeding risk [5].
Long-term studies evaluating chronic thromboembolic pulmonary hypertension (CTEPH) need to be done, comparing USAT with systemic thrombolysis and surgical thombectomy.
Take-home: In patients with submassive PE, USAT should be considered over systemic thombolysis or anti-coagulation alone.
1. PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11.
2. Engelhardt TC, Taylor AJ, et al. Catheter-directed ultrasound-accelerated thrombolysis for the treatment of acute pulmonary embolism. Thromb Res. 2011 Aug;128(2):149-54
3. Bagla S, Smirniotopoulos JB, et al. Ultrasound-accelerated catheter-directed thrombolysis for acute submassive pulmonary embolism. J Vasc Interv Radiol. 2015 Jul;26(7):1001-6.
4. SEATTLE II Investigators. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015 Aug 24;8(10):1382-92.
5. Kucher N, Boekstegers P,et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014 Jan 28;129(4):479-86.