Critical Care
Brief Review | Admission to intensive care unit after major surgery
28 Mar, 2023 | 14:39h | UTCAdmission to intensive care unit after major surgery – Intensive Care Medicine
Commentary on Twitter
? Major surgeries common reason for #ICU admission (expected/scheduled or unplanned), with varying practices & mortality. 4 major determinants driving decision
1️⃣ intrinsic procedure risk
2️⃣ patient risk
3️⃣ crashing risk
4️⃣ support outside ICU#FOAMcc
?️ https://t.co/CluprKlYM9 pic.twitter.com/PZC4zmymOp— Intensive Care Medicine (@yourICM) March 23, 2023
Selected articles from the Annual Update in Intensive Care and Emergency Medicine 2023
27 Mar, 2023 | 13:23h | UTCHemodynamic Implications of Prone Positioning in Patients with ARDS
Host Response Biomarkers for Sepsis in the Emergency Room
Quality improvement in the determination of death by neurologic criteria around the world
Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO
A structured diagnostic algorithm for patients with ARDS
Interrogating the sepsis host immune response using cytomics
Managing the Physiologically Difficult Airway in Critically Ill Adults
Metagenomic Sequencing in the ICU for Precision Diagnosis of Critical Infectious Illnesses
The Role of Transcriptomics in Redefining Critical Illness
Brief Review | Long-term outcomes of intensive care unit delirium
27 Mar, 2023 | 13:09h | UTCLong-term outcomes of intensive care unit delirium – Intensive Care Medicine
Commentary on Twitter
#ICU delirium
? well described short-term effects: ⬆️ hospital mortality, MV duration, ICU/hospital LoS
? more recent findings related to long-term outcomes (≥ 6 months post-ICU)
How to mitigate this serious acute BI & its long-term burden? #FOAMcc
?️ https://t.co/kg5TIOmVHm pic.twitter.com/Hnbc1ISKnI— Intensive Care Medicine (@yourICM) March 25, 2023
Guidelines for neuroprognostication in comatose adult survivors of cardiac arrest
27 Mar, 2023 | 12:54h | UTC
Guidelines for neuroprognostication in adults with Guillain-Barré Syndrome
27 Mar, 2023 | 12:52h | UTCGuidelines for Neuroprognostication in Adults with Guillain–Barré Syndrome – Neurocritical Care
Study shows increased bleeding complications in ESKD patients undergoing AF ablation
24 Mar, 2023 | 13:09h | UTCSummary: The study analyzed 347 procedures in 307 patients with end-stage kidney disease (ESKD) undergoing atrial fibrillation (AF) catheter ablation in 12 referral centers in Japan.
Despite a vast majority of patients having subtherapeutic international normalized ratio (INR) values during the peri-procedural period, 35 patients (10%) experienced major complications, with the majority being major bleeding events (19 patients; 5.4%), including 11 cases of cardiac tamponade (3.2%). There were also two peri-procedural deaths (0.6%), both related to bleeding events. A pre-procedural INR value of 2.0 or higher was identified as the only independent predictor of major bleeding.
Current peri-procedural anticoagulation guidelines state that patients undergoing AF ablation should be under therapeutic anticoagulation throughout the peri-procedural period. The findings of this study suggest that these guidelines may not be appropriate for ESKD patients undergoing the procedure, and the role of peri-procedural anticoagulation in this population should be further investigated.
Commentary on Twitter
Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing #afib ablation ? despite undertreatment with warfarin, the rate of haemorrhagic complications is high! https://t.co/3W8gEtZYdy#kidney #afib #anticoagulation #ablation #cardiotwitter #europace pic.twitter.com/vI27UeIpRf
— European Society of Cardiology Journals (@ESC_Journals) March 16, 2023
Review | Unapparent systemic effects of regional anticoagulation with citrate in continuous renal replacement therapy
24 Mar, 2023 | 13:04h | UTC
Guideline | Diagnosis and treatment of myocarditis
23 Mar, 2023 | 12:55h | UTCJCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis – Circulation Journal (see PDF)
Guideline | Diagnosis and treatment of vasospastic angina and coronary microvascular dysfunction
23 Mar, 2023 | 12:53h | UTCJCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction – Circulation Journal (see PDF)
RCT | Hydrocortisone reduces mortality in severe community-acquired pneumonia
22 Mar, 2023 | 13:44h | UTCSummary: Practice-changing! In a phase 3, multicenter, double-blind, randomized controlled trial involving 800 patients with severe community-acquired pneumonia admitted to the ICU, hydrocortisone treatment was found to reduce the risk of death by day 28 compared to a placebo group. The hydrocortisone group had a 6.2% death rate, while the placebo group had an 11.9% death rate.
Hydrocortisone also led to fewer endotracheal intubations among patients not on mechanical ventilation at baseline and reduced the need for vasopressor therapy in patients not receiving it at baseline. There was no significant difference in hospital-acquired infections or gastrointestinal bleeding between the two groups, but patients in the hydrocortisone group required higher daily doses of insulin during the first week of treatment.
Article: Hydrocortisone in Severe Community-Acquired Pneumonia – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary: Steroid drug reduces death rate in severe pneumonia, study shows – STAT
Commentary on Twitter
In this randomized trial, hydrocortisone treatment decreased mortality among patients with severe community-acquire pneumonia in the ICU. https://t.co/DZadFMcA5o#ISICEM23 pic.twitter.com/yhkVCjBMWX
— NEJM (@NEJM) March 21, 2023
RCT | Low-calorie, low-protein feeding improves recovery time in ventilated adults with shock
22 Mar, 2023 | 13:42h | UTCSummary: The NUTRIREA-3 study aimed to determine the optimal calorie and protein intakes during the acute phase of severe critical illness. The study was a randomized, controlled, multicenter, open-label, parallel-group trial conducted in 61 French intensive care units (ICUs) involving 3044 adults receiving invasive mechanical ventilation and vasopressor support for shock. During the first seven ICU days, participants were randomly assigned to early nutrition with either low or standard calorie and protein targets. The primary endpoints were time to readiness for ICU discharge and day 90 all-cause mortality, while key secondary outcomes included secondary infections, gastrointestinal events, and liver dysfunction.
The study found that early calorie and protein restriction did not decrease mortality. However, it was associated with faster recovery and fewer complications compared to standard calorie and protein targets. The low-calorie, low-protein group had a shorter median time to readiness for ICU discharge and lower proportions of patients with vomiting, diarrhea, bowel ischemia, and liver dysfunction. The proportions of patients with secondary infections did not differ significantly between the two groups.
In conclusion, the NUTRIREA-3 study provides evidence that patients may benefit from restricted calorie and protein intakes during the acute phase of critical illness, as it expedites recovery and reduces the risk of complications.
Article: Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3) – The Lancet Respiratory Medicine (free registration required)
Commentary on Twitter
NEW Research—Early calorie & protein restriction did not decrease mortality but was associated w/ faster recovery & fewer complications than standard intake targets
NUTRIREA-3 from Prof Jean Reignier & co https://t.co/VCS72qxLPD
Being presented @ISICEM today! #ISICEM23 pic.twitter.com/TpoJnwHP8P
— The Lancet Respiratory Medicine (@LancetRespirMed) March 21, 2023
RCT | 4F-PCC fails to reduce blood product consumption and raises thromboembolic events in trauma patients
22 Mar, 2023 | 13:41h | UTCSummary: The PROCOAG Randomized Clinical Trial aimed to investigate the efficacy and safety of 4-factor prothrombin complex concentrate (4F-PCC) in trauma patients at risk of massive transfusion. Conducted in 12 French trauma centers, this double-blind, randomized, placebo-controlled superiority trial involved 324 patients. All patients were treated according to European traumatic hemorrhage guidelines and received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1). The primary outcome measured was 24-hour blood product consumption (efficacy), while arterial or venous thromboembolic events were assessed as a secondary outcome (safety).
The trial revealed no significant difference in 24-hour blood product consumption between the 4F-PCC and placebo groups, with median consumption of 12 units and 11 units, respectively. However, the study identified a statistically significant higher risk of thromboembolic events in the 4F-PCC group, with 35% of patients experiencing at least one event compared to 24% in the placebo group.
In conclusion, the study found no beneficial effect of incorporating 4F-PCC into a ratio-based transfusion strategy for patients with severe trauma at risk of massive transfusion. Furthermore, the higher rate of thromboembolic events in the 4F-PCC group indicated potential harm. The findings do not support the routine use of 4F-PCC in patients experiencing trauma who are at risk for extensive transfusion.
Article: Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial – JAMA (free for a limited period)
See also: Visual Abstract
Mechanical power of ventilation and driving pressure: two undervalued parameters for pre ECMO ventilation and during daily management?
22 Mar, 2023 | 13:24h | UTCRelated: Brief Review | Mechanical power: meaning, uses and limitations
M-A | Intravenous vitamin C in sepsis and septic shock – no influence on mortality outcomes
22 Mar, 2023 | 13:23h | UTCRelated:
Parenteral Vitamin C in Patients with Severe Infection: A Systematic Review – NEJM Evidence
M-A | Risk factors of hemorrhagic transformation in acute ischaemic stroke
22 Mar, 2023 | 13:21h | UTC
Pro-con debate | Should videolaryngoscopy be standard of care for tracheal intubation?
21 Mar, 2023 | 13:19h | UTCPro-Con Debate: Videolaryngoscopy Should Be Standard of Care for Tracheal Intubation – Anesthesia & Analgesia (free for a limited period)
RCT | Videolaryngoscopy improves first-pass tracheal intubation success compared with direct laryngoscopy
21 Mar, 2023 | 13:21h | UTC
Critical care outreach teams: a service without walls
20 Mar, 2023 | 13:27h | UTCCritical care outreach teams: a service without walls – Intensive Care Medicine
Commentary on Twitter
Critical care outreach teams
? unanswered questions
? future directions
Early recognizing deterioration/implementing time-critical interventions save lives! CCOTs offer holistic, supportive approach pre/post #ICU, beyond clinical assessment.#FOAMcc
?️ https://t.co/s9F9v25cNO pic.twitter.com/5uwPvZ04Ye— Intensive Care Medicine (@yourICM) March 18, 2023
Perspective | Trials on oxygen targets in the critically ill patients: do they change our knowledge and practice?
20 Mar, 2023 | 13:26h | UTCTrials on oxygen targets in the critically ill patients: do they change our knowledge and practice? – Intensive Care Medicine (if the link is paywalled, try this one)
Commentary on Twitter
? Trials on liberal/conservative O2 targets in #ICU: conflicting results! Many studies in progress. Waiting for evidence, consider O2 as powerful drug to be carefully titrated, for most of critically ill pts in normoxia-mild hyperoxaemia range. #FOAMcc
?️ https://t.co/ECWgmQkmAZ pic.twitter.com/gIwB9ax0k1— Intensive Care Medicine (@yourICM) March 15, 2023
Brief Review | High-risk pulmonary embolism in the ICU
20 Mar, 2023 | 13:24h | UTCHigh-risk pulmonary embolism in the intensive care unit – Intensive Care Medicine (free for a limited period)
Review | Neuromonitoring in critically ill patients
20 Mar, 2023 | 13:18h | UTCNeuromonitoring in Critically Ill Patients – Critical Care Medicine (free for a limited period)
Related: The importance of neuromonitoring in non-brain injured patients – Critical Care
Review | Surviving sepsis campaign
20 Mar, 2023 | 13:17h | UTCSurviving Sepsis Campaign – Critical Care Medicine
Review | Neurogenic shock: definition, identification, and management in the ED
20 Mar, 2023 | 13:09h | UTCNeurogenic Shock: Definition, Identification, and Management in the ED – emDocs
Guidelines for the management of patients with substance intoxication presenting to the ED
17 Mar, 2023 | 13:09h | UTC
RCT | Preliminary study suggests early methylene blue administration reduces vasopressor duration in septic shock patients
16 Mar, 2023 | 13:25h | UTCSummary: The study aimed to evaluate the efficacy and safety of early adjunctive methylene blue (MB) administration in patients with septic shock. In this single-center randomized controlled trial, 91 patients were randomly assigned to receive MB or placebo, with the primary outcome being the time to vasopressor discontinuation at 28 days.
The study found that the MB group had a significantly shorter time to vasopressor discontinuation, one more day of vasopressor-free days at day 28, a shorter length of stay in the ICU and hospital, and no serious adverse effects related to MB administration.
However, the study was limited by its small sample size and single-center design. Therefore, larger multicenter randomized clinical trials are needed to confirm the potential benefit of MB as an early adjunctive therapy in patients with septic shock.