In this recently published Brief Report in the Journal of Academic Emergency Medicine Patanwala et al. looked retrospectively at first pass intubation success by comparing Ketamine to Etomidate. The final cohort included 2098 patients and even after adjusting for potential confounders there was no difference in success rates between the two drugs. In regards of recent discussions on the safety of Etomidate (e.g. adrenal suppression) this study seems to be another puzzle piece favoring other induction agents than Etomidate. Looking at recent publications on paralyzing agents and personal experience I feel that Ketamine and Rocuronium is a favorable combination for rapid sequence inductions in the ICU... what do you think? Patanwala A et al.Academic Emergency. 2014 Feb Curley J et al. Critical Care. 2011,15:190 Marsch SC et al.Crit Care. 2011 Aug 16;15(4):R199 Targeted Temperature Management Trial: Is it Time to Stop Cooling Patients after Cardiac Arrest?6/1/2014
In 2002 two published articles in the New England Journal of Medicine changed ICU management of out of hospital arrests profoundly. According to these two articles (cited below) the American Heart Association labeled this to be good evidence (Level1) to recommend induced hypothermia in comatose survivors of out of hospital cardia arrest caused by VF. The target temperature was recommended to be between 32-34°C and to be maintained for 12-24 hours. And now this... Nielsen et al. present the Targeted Temperature Management Trial showing, that there is NO difference between patients cooled to 33°C and patients kept at 36°C. Is this the end of the cooling era, should we change our management? I personally think think that this trial basically adds up to our knowledge in the field of post cardiac arrest care, but not necessarily contradicts the previous two trials. We now have one trial showing that there seems to be no difference between 33°C and 36°C but we also know, that hyperthermia (pyrexia) is troublesome and associated with worse neurological outcome. So, as pronounced hypothermia (33°C) makes no difference to ‘mild’ hypothermia (36°C) and pyrexia is proven to be harmful... the question is: What is the right temperature? We seem to head towards normothermia or mild hypothermia in order to provide best management for our patients. It’s going to be interesting to see how recommendations will change in the near future. The Targeted Temperature Management Trial: Nielsen N, et al. New Engl J Med. 2013 Dec;369(23):2197-206 The 2 trials that introduced therapeutic hypothermia into ICU practice: The Hypothermia After Cardiac Arrest Study Group, Holzer at al. New Engl J Med. 2002 Feb;346(8):549-556 Bernard S.A. et al. New Engl J Med. 2002 Feb;346(8):557-563 Review article on therapeutic hypothermia for non-VF/VT cardiac arrest: Sandroni S. et al. Crit Care Med; 2013;17:215 Pyrexia and neurological outcome: Leary M. et al. Resuscitation. 2013 Aug;84(8):1056-61 Intensivists have repeatedly been warning on the potential effect side effects when infusing bigger quantities of normal saline like acidosis and potentially worse outcomes. It is well recognized that infusion of normal saline can lead to metabolic acidosis, but the link between the acidity of saline solution and the acidaemia it can produce might be not straightforward! This article from the beginning of this year shows a surprising insight on the various components involved when using normal saline infusions and comes to the conclusion that the acidaemia complicating saline infusions is actually unrelated to the acidity of the normal saline solution itself. It turns out that in vitro the acidity of a normal saline solution is mainly due to dissolved CO2 and PVC degradation of the bag containing the solution. The metabolic acidosis by saline infusions in vivo though mainly results from from buffer base dilution and is not directly related to the pH of the infusion at all. Got interested? Reddi B, et al. Int J Med Sci. 2013 Apr;10(6):747-50 Back in 2011 a primary analysis of the EPaNIC trial was published in the New Engalnd Journal of Medicine and showed that delaying total parenteral nutrition (TPN) for one week in critically ill patients resulted in better outcomes from a range of measures includung risk of infection and earlier release. The role of weakness remained unclear. This time Hermans et al. published a prospectively planned subanalysis of this trial, where weakness was assessed in 600 ICU patients out of which 122 patients had muscle biopsies performed to study for autophagy and atrophy. They were able to show that early TPN resulted in a significant greater number of patients with weakness compared to late TPN (not before day eight after admission to ICU). Weakness also recovered faster with late TPN. Interestingly autophagy marker were higher in patients given late TPN and this was independently associated with less weakness. Dr. Van den Bergen says:"The late PN strategy, that is, not using artificial (parenteral but maybe also forcing enteral) feeding during the acute phase of critical illness, should be standard of care, as there is absolutely no good data to support benefit from such forceful feeding and there is, as we have shown, risk for harm."... and I get the feeling he might be right. Hermanns G. et al. The Lancet Respiratory Medicine, 10 September 2013; volume 1, issue 8 Casaer MP et al. N Engl J Med. 2011 Aug 11;365(6):506-17 Inspired by an excellent post by Dr. Pat Nelligan on AnaesthesiaWest we would like to provide even more evidence against routine change of IV catheters... just because you are told to do so for hospital policy reasons. Brown D. et al. have provided an excellent overview article on this issue. It is clearly shown that peripheral IV catheter should be replaced as clinically indicated, rather than on a routine basis. The level of evidence here is: A. This means that this recommendation of this treatment/ procedure is effective! We add another 3 articles supporting this recommendation. We do many other things on ICU with lower levels of evidence, or even no evidence at all. So it is definitely time to change this bad habit. So Pat, I won’t do it either... full stop! Bregenzer T, et al. Arch Intern Med, January 1998; 158(2):151-6 Lee WL, et al. Am J Infect Control, 2009 Oct;37(8):683-6 Lai KK, et al. Am J Infect Control, 1998 Feb;26(1):66-70 |
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