Introduction Fluid resuscitation is one of the key early interventions in patients with septic shock. The Surviving Sepsis Guidelines continue to recommend an initial volume of resuscitation of 30 ml/kg, with additional boluses guided by the assessment of volume responsiveness (1). In the landmark ProCESS, ProMisE, and ARISE trials, most patients with septic shock received approximately… Continue reading Resuscitation of septic shock: Do not drown your patient in intravenous fluid!
Uncontrolled hyperglycemia may adversely impact critically ill patients through diverse mechanisms. High glucose levels may impair the innate immune response, with abnormal glycosylation of immunoglobulins.1 Neutrophil migration is inhibited with suppression of phagocytic activity; complement fixation and bacterial opsonization are also disrupted.2 Animal models have suggested that targeting normoglycemia may attenuate hyperglycemia-induced inhibition of bacterial opsonization.3 Furthermore,… Continue reading Aiming for the sweet spot: glycemic control in the critically ill
Intensive care physicians often face the conundrum of deciding when to consider renal replacement therapy (RRT) in acute kidney injury (AKI). RRT may be commenced for the early correction of metabolic complications and prevention of volume overload. However, an early strategy may entail unnecessary therapy for some patients who might recover renal function otherwise. Even… Continue reading Renal Replacement Therapy in Acute Kidney Injury: Is timing all-important?
The 2021 Surviving Sepsis Campaign guidelines for the management of sepsis and septic shock have been published.1 The guidelines continue to emphasize the importance of rapidity and appropriateness in the recognition and care of patients suspected to have sepsis. The recommendations represent an important guidepost for the busy bedside clinician in providing optimal care and… Continue reading The 2021 Surviving Sepsis Guidelines
Timely recognition of intracranial hypertension is a crucial component of neurocritical care. In patients who are sedated and mechanically ventilated, sole dependence on the clinical features of raised intracranial pressure (ICP) including pupillary dilatation may lead to inordinate delays in the performance of critical interventions. Hence, continuous, direct measurement of ICP is often performed combined… Continue reading Intracranial pressure monitoring in acute brain injury
Intravenous fluid administration is one of the most important interventions in the resuscitation of critically ill patients. Titration of fluid resuscitation to optimally fill the intravascular compartment without causing tissue edema from excessive administration holds the key to important clinical outcomes. Injudicious fluid administration without appropriate evaluation of fluid responsiveness has been clearly shown to… Continue reading Is my patient fluid responsive? A key question in the critically ill
The use of normal saline is ubiquitous in clinical practice. The history of saline resuscitation dates back to 1831 when the cholera epidemic swept across Britain leaving a trail of devastation. Out of sheer desperation, Thomas Latta, a young physician from Leith, near Edinburgh, administered intravenous saline solution to an elderly lady who was on… Continue reading Back to the BaSICS: Is normal saline really worth its salt?
Jose Chacko, Gagan Brar Meta-analysis of randomized controlled trials on tocilizumab in COVID-19 Snow TAC, et al. Tocilizumab in COVID-19: a meta-analysis, trial sequential analysis, and meta-regression of randomized-controlled trials. Intensive Care Med. 2021 Jun;47(6):641-652. doi: 10.1007/s00134-021-06416-z. Interleukin-6 antagonism has been one of the therapeutic approaches that have evinced interest in COVID-19 treatment. The REMAP-CAP1 and… Continue reading ICU headlines this fortnight: August 1, 2021
18–25 July 2021 Jose Chacko, Gagan Brar Death and disability after critical illness Higgins AM, et al. Predictors of death and new disability after critical illness: a multicenter prospective cohort study. Intensive Care Med. 2021;47(7):772-781 The PREDICT study was carried out to evaluate the prevalence and predictors of death or new-onset disability after critical illness.1 This… Continue reading ICU headlines this fortnight
The first case of possible aspiration from general anesthesia occurred in 1848, when Hannah Greener, a 15-year-old girl underwent chloroform anesthesia for the removal of a toenail. Her surgeon, Dr. Meggison, who conducted the anesthetic, administered an extra dose of chloroform dropped through a handkerchief placed over her face. However, she began to cough and her… Continue reading Fasting practices in critically ill patients: time for reappraisal?
The size of the functional lung is highly variable in acute respiratory distress syndrome (ARDS). The elastance of the respiratory system (Ers) is more likely to reflect the functional lung size compared to the predicted body weight. It indicates the degree of lung stiffness and is represented by the pressure required to inflate the lungs.… Continue reading Driving pressure: a more appropriate target compared to tidal volume in ARDS?
There is increasing worldwide experience in the management of ventilation in patients with COVID-19 associated acute respiratory distress syndrome (ARDS). Healthcare systems have been stretched to the limit with a relative lack of resources against the background of a rapid surge in patients who are critically ill. A large majority of critically ill patients with… Continue reading Invasive mechanical ventilation in COVID-19 associated ARDS
Introduction The COVID-19 pandemic has been raging for well over a year in most parts of the world. Several therapeutic agents have been employed, many based on little scientific reasoning, often dictated by desperation. After several months of research, dexamethasone emerged as a possible therapeutic modality that may improve survival in patients with severe COVID-19.… Continue reading Corticosteroids in COVID-19: is discretion the better part of valor?
The COVID-19 pandemic continues to rage unabated in many parts of the world. India is by far the worst affected, with uncontrolled transmission across the country. Mutant variants have been implicated in the second wave that has ravaged most of the states. The quest for therapeutic options continues; monoclonal antibodies have been the focus of… Continue reading Monoclonal antibodies against SARS-CoV-2: a ray of hope?
Thrombo-inflammation in COVID-19 The SARS-COV-2 virus invades endothelial cells leading to microvascular inflammation, which in turn, triggers an intense prothrombotic state, termed thrombo-inflammation. The levels of coagulation factors, including fibrinogen and factor VIII, are often elevated in COVID-19. Circulating thrombotic microparticles and hyperviscosity also contribute to the prothrombotic state. The prothrombotic state in COVID-19 appears… Continue reading Thromboprophylaxis in COVID-19: standard or enhanced dose?
ChAdOx1 nCov-19-associated vaccine-induced immune thrombotic thrombocytopenia (VITT) From February 2021 onwards, there have been several reports of unusual thrombotic phenomena associated with thrombocytopenia among subjects who received the ChAdOx1 nCov-19 vaccine. These reports led to a temporary pause in ChAdOx1 nCov-19 administration across several European countries, pending further investigation regarding a possible link. Subsequently, the… Continue reading ChAdOx1 nCov-19-associated vaccine-induced immune thrombotic thrombocytopenia (VITT)
Incidence of anemia in the ICU Anemia is all too common among critically ill patients, with 30–50% of patients receiving red cell transfusion. The etiology of anemia in the ICU is multifactorial, contributed by intravenous fluid resuscitation with the resulting hemodilution, repeated blood sampling, low erythropoietin levels induced by inflammatory cytokines, and abnormalities of iron… Continue reading Anemia and transfusion thresholds in the critically ill
Background The dysregulated host response observed in severe COVID-19 infection with the release of cytokines has been implicated as a perpetrator of poor outcomes in COVID-19. The “cytokine storm” typically leads to the release of several mediators, including interleukins, interferons, and tumor necrosis factor. Although this innate response is directed to combat and eliminate the… Continue reading Calming the cytokine storm in COVID-19: A new ray of hope?
Background The Oxford-AstraZeneca vaccine against COVID-19 infection has been approved and extensively used in several countries, including India. In contrast to the earlier recommendation to administer the primary and booster doses 4 weeks apart based on previously published randomized controlled trials, the UK has adopted an approach of administering the vaccine in two doses at… Continue reading The Oxford-AstraZeneca vaccine: What is the optimal time interval between the primary and booster doses? Would a single dose be efficacious?
Several vaccines are being employed against COVID-19 following expedited evaluation and manufacturing processes. Currently, more than 50 potential vaccines are undergoing clinical trials in various phases.1 Effective immunization is considered to be an important strategy in the control of the COVID-19 pandemic. Phases of vaccine development The conventional methodology of vaccine development involves several phases. The… Continue reading COVID-19 vaccines: updated 31st January, 2021
The beneficial effects of mechanical ventilation is closely related to the prevention of ventilator-induced lung injury (VILI). The harmful effects of positive pressure ventilation may be mitigated by the application of appropriate levels of positive end-expiratory pressure (PEEP). In their seminal paper, Ashbaugh et al. observed the beneficial effect of PEEP on arterial oxygenation in… Continue reading PEEP titration by the bedside: how do we set it right?
Lactic acidosis commonly occurs in the critically ill, especially among patients in shock of varying etiology. High lactate levels are uniformly associated with poor clinical outcomes, including mortality.1 However, there is considerable interest and conflict of opinion regarding the clinical value of using lactate levels to guide resuscitation in critically ill patients. Although generally considered to… Continue reading Hyperlactatemia in critical illness: time for reappraisal?
Non-invasive respiratory support using a high-flow nasal cannula (HFNC) is an emerging modality of therapy in patients with acute hypoxemic respiratory failure. Although widely established to be efficacious in respiratory illnesses of varying etiology leading to hypoxia, there is limited information regarding its usefulness in COVID-19 pneumonia. Concerns have been raised regarding aerosolization and transmission… Continue reading High-flow nasal cannula in COVID-19
The COVID-19 pandemic continues to cause perturbation worldwide, with healthcare systems struggling to cope with second waves and increasing incidence of newly infected patients. India may be witnessing a plateau effect, but the worst may be far from over. Today, we have a clearer understanding of effective therapeutic interventions compared to the early phase of… Continue reading Remdesivir in COVID-19: A tale of two trials
At the onset of the COVID-19 pandemic, there was a considerable lack of information regarding the pathophysiology of lung involvement, with several implausible hypotheses being proposed.1 With a better understanding of the disease, it is abundantly clear that COVID-19 related acute respiratory distress syndrome (ARDS) is characterized by diffuse alveolar damage with significant involvement of the… Continue reading Respiratory support of COVID-19: evolving strategies
Introduction Lung ultrasonography has been established to offer diagnostic capability similar to chest CT; it is more efficacious compared to chest radiography in the evaluation of pneumonia and the adult respiratory distress syndrome (ARDS). Besides, lung ultrasonography is easily carried out at the point of care, with the added advantage of repeated examination as required.… Continue reading Lung ultrasonography in COVID-19
The COVID-19 outbreak continues to surge in most parts of India, with health systems being stretched to the limit across the country. Several studies have been carried out in the past few months in the quest for therapeutic options that may have a favorable impact on clinical outcomes. Although there have been no dramatic breakthroughs,… Continue reading COVID-19 therapeutic update: September 22, 2020
Mechanical ventilation in the prone position has been employed for more than four decades to treat severe hypoxemia in acute respiratory failure. In a report from 1976, Piehl and Roberts described the use of prone ventilation in five patients using a special type of bed that could rotate the patient through 180 degrees.1 The authors reported… Continue reading How does prone ventilation help? What is the evidence?
The epidemiology and clinical characteristics of COVID-19 are much better understood today compared to the early stage of the pandemic several months ago. However, our knowledge of the pathophysiological changes in the lung remains largely elusive. Many patients with COVID-19 present with severe hypoxemia, yet remain remarkably comfortable, a phenomenon that has been alluded to… Continue reading COVID-19: the mystery behind “happy” hypoxemia
Critical care medicine is a relatively new area of specialization. Several landmark studies have been published over the years that have transformed the way we practice and added a new dimension to our approach to patient care. I have summarized the groundbreaking literature that has captivated our attention over the years and continues to influence… Continue reading Trailblazers in critical care: ten studies that changed the way we practice
Severe COVID-19 infection is characterized by coagulopathy, with manifestations related to arterial and venous thrombosis. Often unrecognized, lethal complications may ensue, including stroke and acute coronary syndrome. COVID-19-associated coagulopathy (CAC) is similar to, yet distinctively different, from sepsis-induced coagulopathy (SIC) and disseminated intravascular coagulation (DIC). There are several reports of sudden, out-of-hospital deaths associated with… Continue reading COVID-19 associated coagulopathy: more questions than answers?
The cytokine storm, arising from a dysregulated host response, has captivated mainstream and scientific media in recent times with its possible role leading to poor outcomes in COVID-19. It is characterized by the release of mediators, including chemokines, interleukins, interferons, and tumor necrosis factors. This innate response that commonly occurs in bacterial and viral infections… Continue reading Weathering the storm of COVID-19: the role of cytokine inhibitors
An intense inflammatory response is often seen in patients with COVID-19 infection leading to multiorgan dysfunction, including lung injury and severe acute respiratory distress syndrome (ARDS). Complement pathways are activated, resulting in microvascular injury and a procoagulant state.1 The hyperinflammatory response in COVID-19 may resemble secondary hemophagocytic lymphohistiocytosis (sHLH), characterized by high levels of C-reactive protein,… Continue reading Corticosteroids in COVID-19: A ray of light at the end of a dark tunnel?
There is ongoing search for effective therapies in COVID-19 infection in the face of the unabated spread of the disease in several countries, including India. Considering the lack of a vaccine and therapeutic breakthroughs, several drugs already in use for other diseases are being investigated and repurposed for use in COVID-19 infection. Recently, there have… Continue reading COVID-19: update on therapeutic options
The acute respiratory distress syndrome (ARDS), characterized by hypoxemia and bilateral alveolar infiltrates, was described in 1967 by Ashbaugh et al.1 Ventilation strategies in ARDS have undergone considerable refinement over the years. A lung-protective ventilation strategy using low tidal volumes may be one of the key interventions to reduce ventilator-induced lung injury (VILI).2 Beneficial effects of… Continue reading Neuromuscular blocking agents in severe acute respiratory distress syndrome: benefit or harm?
The physiological benefits and improvement in clinical outcomes with prone ventilation are well established in patients who are intubated and mechanically ventilated (1). Would the favorable physiological effects of the prone position benefit non-intubated, spontaneously breathing patients with acute hypoxemic respiratory failure? In light of an increasing number of patients with COVID-19 pneumonia and constrained healthcare… Continue reading Awake proning in non-intubated patients
The COVID-19 pandemic continues to wreak death and devastation across most parts of the world. The curve may have flattened in many parts of Europe, but the worst may not yet be over for the US. We are still unclear about the trajectory in India. In the meantime, theories abound regarding mechanisms of causation of… Continue reading COVID-19 update: April 24, 2020
The COVID-19 pandemic has spread to 210 countries, affecting approximately 1.7 million people and resulting in more than 103,000 deaths until now. More than one-third of the world population, including India, is currently in lockdown. Although the epidemic curve has flattened in some countries, others continue to struggle. There has been an upsurge of literature… Continue reading COVID-19 update: April 11, 2020
It has been a long, hard week of complete lockdown in India. We have not seen a significant impact yet, it is probably too early. However, there is a disturbing trend in the number of new COVID-19 cases, although, thankfully, the mortality has remained low. Many other countries are struggling, with a seemingly uncontrollable increase… Continue reading COVID-19 update: April 3, 2020
We are entering an extremely crucial phase of the COVID-19 pandemic, with many countries, including India, closing their borders and enforcing complete lockdown. Clinicians are passing through a learning curve with increasing real-world experience. New information regarding the causative virus, transmission control, and innovative modalities of treatment are being addressed. This review attempts to summarize… Continue reading COVID-19 update: 26th March, 2020
COVID-19 disease has spread far and wide across the globe. At the time of writing, more than 225,000 patients have been affected, leading to more than 9,300 deaths (1). The number of seriously ill patients who require intensive care is likely to increase, requiring several-fold increase in the requirement for caregivers and equipment. The clinical management… Continue reading Management of the critically ill patient with COVID-19 disease
Beginning from December 8, 2019, several cases of pneumonia of unknown origin were reported from Wuhan, the capital of the Chinese province of Hubei. The initial cluster of cases was traced to the Huanan live animal and seafood market. The causative pathogen has hence been identified as an enveloped RNA beta coronavirus with genealogical similarity… Continue reading Coronavirus disease 2019 (COVID-19) update for critical care physicians
Our planet was born approximately 4.8 billion years ago. A billion years later, the oxygen levels began to rise on the earth’s atmosphere. With the rise in oxygen levels, the first signs of life also appeared on the face of the earth. However, it took several billion years before Joseph Priestly (1774) identified oxygen as… Continue reading Oxygen: the elixir of life or a double-edged sword?
The use of intravenous fluid therapy is ubiquitous among critically ill patients to optimize tissue perfusion and oxygen delivery. Apart from intravenous fluids administered during initial resuscitation, fluid accumulation occurs from nutrition, maintenance fluids, and diluents used for intravenous drug therapy. An aggressive resuscitation strategy may be appropriate during the “ebb” phase of septic shock,… Continue reading Getting rid of excess fluid: the strategy of de-resuscitation
From the 1990s, lung-protective ventilation using low tidal volumes and limitation of plateau pressures emerged as a pivotal strategy in patients with acute respiratory failure, especially with acute respiratory distress syndrome (ARDS), who undergo mechanical ventilation (1). Amato et al., in a landmark study, titrated positive end-expiratory pressures (PEEP) levels to higher than the lower inflection… Continue reading Hypercapnia during ARDS ventilation: testing the limits of permissibility
The acute respiratory distress syndrome (ARDS) constitutes 23.4% of mechanically ventilated patients (1). Prevention of ventilator-induced lung injury has typically revolved around the use of tidal volumes of 5–8 ml/kg of predicted body weight and limitation of plateau pressures to 30 cm H2O. However, the lung available for ventilation is significantly reduced and highly variable in… Continue reading Lung protective ventilation: targeting tidal volume and plateau pressure vs. driving pressure
Thrombolytic agents lead to the activation of plasminogen to plasmin, resulting in accelerated clot lysis. They have been used in a variety of thrombotic disorders, including acute pulmonary embolism (PE). Thrombolytic therapy in acute PE has been clearly established to improve arterial oxygenation, reduce pulmonary artery pressure, and results in resolution of filling defects on… Continue reading Thrombolysis for acute pulmonary embolism: one size may not fit all!
The spectrum of clinical disorders arising from raised intra-abdominal pressure (IAP) was recognized from the 19thcentury onwards. Abdominal compartment syndrome (ACS) was first described three decades ago among four patients who underwent surgery for ruptured abdominal aortic aneurysm. ACS manifested within the first 24 hours postoperatively with massive abdominal distension and was characterized by rising ventilation… Continue reading When rising intra-abdominal pressure turns silent killer: the abdominal compartment syndrome
One of the guiding principles in the management of traumatic brain injury (TBI) is based on the Munro-Kellie doctrine. According to this principle, the volume of the intracranial compartment is fixed and comprises of the brain parenchyma (80%), intracranial blood volume (10%), and the cerebrospinal fluid volume (10%). An increase in the intracranial volume is… Continue reading Does intracranial pressure monitoring help in patients with severe traumatic brain injury?
Why look for alternatives for the circulatory support of septic patients? Vasopressor therapy in patients with septic shock has centered around the use of noradrenaline titrated to a target mean arterial pressure. The surviving sepsis guidelines recommend noradrenaline as the first-line vasopressor in sepsis.1 Noradrenaline increases venous return and the left ventricular end-diastolic volume by… Continue reading Circulatory support in septic shock: looking beyond catecholamines
Inappropriately prolonged use of antibiotics has several deleterious effects in critically ill patients. Injudicious administration of broad-spectrum antibiotics for an extended period may lead to new-onset infections with resistant organisms due to selective pressure. Besides adding to the cost of care, drug-related adverse effects resulting from prolonged use may also impact clinical outcomes. Let us… Continue reading Knowing when to stop: shorter duration of antibiotic therapy in the critically ill
High spontaneous respiratory drive in acute hypoxemic respiratory failure There is increasing concern that continued vigorous spontaneous respiratory efforts may be harmful in the presence of severe lung injury. The adverse impact of using high tidal volumes during invasive mechanical ventilation is well known. The swings in transpulmonary pressure (airway pressure – pleural pressure), representing… Continue reading Early invasive ventilation as a lung-protective strategy in acute hypoxemic respiratory failure
What is augmented renal clearance? Augmented renal clearance (ARC) is the phenomenon of enhanced renal function in critically ill patients. ARC is characterized by a higher than predicted increase in the renal elimination of solutes. It occurs due to an increase in glomerular filtration and altered renal tubular function, usually manifest as an increase in… Continue reading Augmented renal clearance: when supranormal renal function may cause harm
Introduction Acute pancreatitis runs a relatively mild course in most patients and responds rapidly to supportive therapy, including adequate pain relief, intravenous fluids, and oral intake when feasible. However, the severe form of the disease is characterized by organ failures and leads to a protracted and often complicated clinical course. Nutritional support is crucial and can… Continue reading What may be the ideal nutritional strategy in acute pancreatitis?
Introduction Acute pancreatitis results from an intense inflammatory reaction resulting most commonly from excessive alcoholism or the presence of gall stones. It runs a relatively mild course in most patients and responds rapidly to supportive therapy including adequate pain relief, intravenous fluids, and oral intake when feasible. However, the severe form of the disease occurs… Continue reading Contentious topics in the management of severe acute pancreatitis
More than half a century ago, Kantrowitz et al. first described the use of an “intra-aortic cardiac assistance system” using a balloon-tipped catheter inserted into the descending thoracic aorta.1 They described two patients who developed cardiogenic shock after acute myocardial infarction. The blood pressure remained low, followed by anuria, in spite of high-dose vasopressor therapy.… Continue reading Intra-aortic balloon counterpulsation in critically ill patients
The rationale for the administration of corticosteroids in septic shock The use of corticosteroids as adjunctive therapy in septic shock has captivated intensive care physicians for over five decades. Many of the early studies used industrial doses of synthetic glucocorticoids, and predictably, led to poor clinical outcomes. The concept of corticosteroid insufficiency related to critical… Continue reading Corticosteroids in septic shock: to do or not to do, that is the question
Administration of fluid boluses is considered to be one of the cornerstones of sepsis resuscitation. The surviving sepsis guidelines continue to ardently recommend a fluid bolus of 30 ml/kg within 3 h of presentation to hospital in patients who are hypotensive and considered to have sepsis.1 Let us consider the physiological rationale behind fluid administration… Continue reading The challenge of fluid therapy in sepsis: when less is more
The physiologic rationale ARDS is a heterogeneous disease process, characterized by a mix of relatively normal, collapsed, fluid-filled, and consolidated alveoli. The functional lung tissue is relatively small, and has been described as the “baby lung” (Fig 1). Cyclical opening and closure of collapsed alveoli leads to shear stress at alveolar interphases and leads to… Continue reading The ART of lung recruitment maneuvers
Control of blood glucose levels among critically ill patients continues to evoke intense attention. Van den Berghe et al., in a landmark study, demonstrated that maintaining blood glucose levels within a narrow range, between 80–110 mg/dl may improve clinical outcomes, including ICU and hospital mortality among patients admitted to a surgical ICU.1 In a similar… Continue reading Blood glucose control in the critically ill: hitting the sweet spot
Following the discovery of penicillin in 1928, and its widespread use in clinical practice from the 1940s, several new antibiotic classes were introduced. Vancomycin was introduced in 1958, followed by the cephalosporins, beta-lactamase inhibitors, and quinolones. However, since the introduction of carbapenems in the 1980s, no new class of antibiotic has been added to our… Continue reading Multidrug-resistant gram-negative bacteria: new therapeutic options
Hospital-acquired infections are generally considered preventable and used as a quality assessment tool in health care by regulatory bodies. Ventilator-associated pneumonia (VAP) is one of the quality indicators employed by accreditation bodies, including the National Accreditation Board for Hospitals and Healthcare Providers (NABH) in India. It is not unusual for hospital administrators and ICU staff,… Continue reading Ventilator-associated events: are we losing the plot?
The administration of supplemental oxygen is ubiquitous in medical practice, especially among critically ill patients. Hyperoxia is fairly common during oxygen therapy, and generally considered to be less deleterious than the potential harm that may arise from hypoxia. However, there has been an increased understanding of the detrimental effects of hyperoxia in recent times. How… Continue reading Oxygen : the elixir of life or the kiss of death?
Severe traumatic brain injury (TBI) due to focal or diffuse lesions leads to raised intracranial pressure (ICP). The normal ICP is less than 15 mm Hg; if the ICP remains persistently high, cerebral perfusion is compromised. Unrelieved intracranial hypertension culminates in irreversible neurological deterioration leading to fatal brain herniations. Raised ICP may be controlled by… Continue reading Decompressive Craniectomy for Severe Traumatic Brain Injury: Does It Make Life Worth Living?
Many conventionally held dogmas in trauma resuscitation have been disproven in the past decade. Generous use of crystalloids during the early resuscitation phase of trauma, recommended by the Advanced Trauma Life Support Course, based on earlier studies, has been largely shown to be harmful. Coagulopathy was considered unlikely with up to transfusion of six… Continue reading Damage control resuscitation: redefining trauma management
History has witnessed intense debates on the behavior of intravenously administered fluids in critically ill patients. The basic concepts of capillary permeability have changed in recent times. There has been an increasing understanding of the crucial role played by the glycocalyx that lines the endothelium on the behavior of intravenously administered fluids. The Starling principle… Continue reading The endothelial glycocalyx, the modified Starling principle, and rational fluid therapy
In patients with septic shock, one of the key initial interventions is fluid resuscitation. The Surviving Sepsis Guidelines recommend an initial volume of resuscitation of 30 ml/kg, followed by additional boluses guided by volume responsiveness (1). In fact, most patients with septic shock receive around 5 liters of fluid in the first few hours… Continue reading Fluid resuscitation in septic patients: Is it a case of “less is more”?
Intensive care physicians often face the conundrum of deciding when to consider renal replacement therapy (RRT) in acute kidney injury (AKI). RRT may be commenced for the early correction of metabolic complications and prevention of volume overload. However, an early strategy may entail unnecessary therapy for some patients who might recover renal function otherwise. Even… Continue reading Renal Replacement Therapy in Acute Kidney Injury: It Is All About Timing!
Intensive care units (ICUs) are the breeding grounds for resistant microorganisms. The use of invasive devices that breach physiological defensive barriers predispose to nosocomial infections in ICUs. A state of “immunoparalysis” often accompanies critical illness, including sepsis, trauma, and major surgery. Furthermore, therapy with powerful, broad-spectrum antibiotics, appropriate or otherwise, is common in the… Continue reading Superbugs vs. superdrugs: are we waging a losing battle?
Mechanical ventilation in acute respiratory distress syndrome (ARDS) aims to maintain gas exchange and support respiratory muscles during the critical phase of illness. It is important to prevent possible harm from ventilation-induced lung injury (VILI) during this period. Limiting tidal volumes to 6 ml/kg of predicted body weight and plateau pressures to 30 cm… Continue reading Tidal volume and plateau pressure vs. driving pressure targeted ventilator management in ARDS
The acute respiratory distress syndrome (ARDS) was first described half a century ago by Ashbaugh et al. (1). They considered several therapeutic options to combat refractory hypoxemia and proposed that appropriate titration of positive end-expiratory pressure (PEEP) may be the sole effective intervention. Ever since the publication of this seminal paper, the pursuit of… Continue reading The rocket science behind PEEP titration in ARDS
Supplemental oxygen is conventionally delivered through nasal prongs or various types of masks. Although these devices increase the inspired oxygen concentration, they have significant limitations. The inability to generate adequate flows in patients who are dyspneic is a major drawback. Respiratory failure is characterized by high peak inspiratory flow rates ranging from 30–120 L/min (1).… Continue reading High flow nasal oxygen therapy: A breath of fresh air?
The diaphragm is the principal muscle of respiration and is innervated by the phrenic nerves through the C3–C5 nerve roots. There is a high prevalence of diaphragmatic weakness among critically ill patients. No correlation seems to exist between weakness of the limbs and diaphragmatic weakness; in fact, diaphragmatic dysfunction may be twice as common… Continue reading When the most important muscle in the body fails…
The efficacy of acid suppression in the prevention of stress ulcers using antacids was first investigated more than four decades ago among burns patients (1). Many different classes of acid suppressant medication have evolved since then, but their utility in the prevention of stress ulcers in critically ill patients remains unresolved. It has been… Continue reading Does pantoprazolization prevent gastrointestinal bleeding in critically ill patients?
Extracorporeal membrane oxygenation (ECMO) is widely used in patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia. With the technological refinement of pumps and circuitry, along with increasing clinical expertise, many centers across the world seem to have adopted ECMO as an early treatment strategy. However, is this necessarily the most optimal management… Continue reading Does prone ventilation make them less prone to ECMO in severe ARDS?
The potential efficacy of adrenaline in cardiac arrest was first highlighted by Criley and Dolley in 1901.(1) In a study of anesthetic agent or asphyxiation induced-cardiac arrest in dogs, the infusion of a therapeutic dose of adrenaline resulted in improved aortic blood pressures and enabled resuscitation. Subsequent animal studies by Redding et al. further… Continue reading Adrenaline in cardiopulmonary resuscitation: time to rethink?
Nutritional support is one of the key elements of care in critically ill patients. Providing adequate nutrition to patients with multiorgan failure can pose several challenges. Many new concepts have emerged over the years that have enabled optimization of the nutritional strategy. I will address key issues related to feeding the critically ill in… Continue reading Controversies in feeding the critically ill…
One of the earliest references in history to a procedure that vaguely resembles a tracheostomy is alluded to in the Rig Veda, with the description of the healing of a throat incision.1 The Egyptians, ancient pioneers of “modern” medicine as we know it today, were past masters of many different surgical procedures in their time… Continue reading Tracheostomy: how do you get the timing right?
Ventilator-associated pneumonia (VAP) caused by multidrug-resistant bacteria continues to be a major cause of morbidity and mortality in our ICUs. We have a limited choice of antibiotics to combat the resistant bacterial flora prevalent in many units. Besides, most systemically administered antibiotics fail to attain therapeutic concentrations in the lung. This has led many clinicians… Continue reading Aerosolized antibiotics for ventilator-associated pneumonia
Background: Non-invasive ventilation (NIV) has been established to be an effective modality to facilitate extubation in the presence of hypercapnia, especially in patients with chronic obstructive pulmonary disease, cardiogenic pulmonary edema, and following abdominal surgery.(2) However, NIV use to expedite liberation from invasive mechanical ventilation (iMV) in non-hypercapnic patients with hypoxemic respiratory failure has not… Continue reading Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial (1)
There is increasing emphasis by regulatory bodies and expert group guidelines to administer antibiotics expeditiously once an infection is suspected. The surviving sepsis campaign proposes a “1-h bundle” comprising of a slew of measures, including antibiotic administration. Unarguably, antibiotic therapy should not be delayed in patients who are truly septic; however, would a tight timeframe… Continue reading “Early” antibiotics: absolute sine qua non or unjustified paranoia?
Commercial preparations of albumin have been in use from the 1940s. The first protein to be extracted from human plasma, it was extensively used in the battles of World War II and subsequently, in civilian practice. A major controversy erupted and continues to surround the use of albumin since the publication of the systematic… Continue reading Albumin infusion in the critically ill: are we wiser today?
Consider the following case scenario: A 42-year-old man is brought to the Emergency Department following a car crash. He has a GCS of 6 and is intubated and ventilated. The CT scan shows acute subdural hemorrhage with a midline shift of 3 cm and cerebral edema. He needs urgent evacuation of the subdural hematoma;… Continue reading Salt or sugar for the swollen brain?
In the 2018 iteration of the Surviving Sepsis Guidelines, a 1-h bundle is recommended for expeditious resuscitation and management of severe sepsis. Serial lactate measurements are advocated to guide resuscitation with the aim to normalize levels. High lactate levels are considered to indicate tissue hypoperfusion in sepsis.1 Glucose metabolism Aerobic pathway Let us consider how… Continue reading Lactate in Sepsis: Much Maligned, but Not Quite the Evil Devil!
Invasive mechanical ventilation may be complicated by ventilator-associated lung injury, ventilator-associated pneumonia, the need for sedation and muscle paralysis, and the possibility of airway-related problems. Noninvasive ventilation (NIV) is widely used by clinicians in community-acquired pneumonia (CAP), in the hope of avoiding intubation thereby improving clinical outcomes. Although the efficacy of NIV in patients… Continue reading Noninvasive Ventilation in Severe Community-Acquired Pneumonia: To Do or Not to Do, That Is the Question!
The quest for suitable intravenous fluids began with the cholera pandemic of the 1830s. The deadly disease was characterized by repeated evacuation of large volumes of a rice-water-like fluid leading to severe dehydration among those afflicted. It spread from India to South East Asia and the Middle East, then towards Russia and the rest… Continue reading Is normal saline really worth its salt?
It is not unusual to see physicians painstakingly titrate oxygen flows with elaborate precision, especially in CO2 retaining patients with chronic obstructive pulmonary disease (COPD). I have occasionally come across novice ICU trainees cease oxygen therapy in dyspneic patients ostensibly to stimulate the hypoxic drive. The driving principle behind this line of thinking is the… Continue reading The hypoxic drive – an urban legend?
Most of us routinely insert central venous catheters under real-time ultrasound guidance. The technique is time-tested, and there is robust evidence that it is safer and more reliable compared to the landmark-based approach. However, peripheral venous access can, at times, be even more challenging in critically ill patients. Quite often, access may be difficult due… Continue reading Peripheral Venous Cannulation Under Ultrasonographic Guidance
Pulmonary artery pressure (PAP) is an important parameter in mechanically ventilated patients. In cardiology practice, the pulmonary artery systolic pressure (PASP) is measured by transthoracic echocardiography by continuous wave Doppler interrogation of the tricuspid regurgitation (TR) jet. The measurement is based on the following equations: Tricuspid pressure gradient (Right ventricular systolic pressure – right atrial… Continue reading Is Doppler-based calculation of pulmonary artery pressure valid in critically ill patients on mechanical ventilation?
There has been a growing interest regarding the utility of procalcitonin to guide appropriate initiation and duration of antibiotic therapy in critically ill patients. Two randomized controlled studies in critically ill patients suspected to have bacterial infections arrived at disparate conclusions (De Jong et al. 2016; Bouadma et al. 2010). In patients presenting with… Continue reading Do Procalcitonin Levels Help Guide Antibiotic Therapy in Acute Exacerbation of Chronic Obstructive Airway Disease?
Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock Woolum JA. Crit Care Med 2018; 46:1747–1752 doi: 10.1097/CCM.0000000000003311 Clinical Question: Does the administration of thiamine lead to more rapid lactate clearance and improved clinical outcomes in patients with septic shock? Background: Septic shock is characterized by a hypermetabolic state… Continue reading Journal Critique
Several years ago, when the dinosaurs among us were in training, we used to look upon each pulmonary artery catheter that we inserted with a sense of pride and fulfillment. Thankfully, the era of inflating balloons with the pulmonary artery, measurement of wedge pressures, and serial cold saline injections to measure cardiac output seem to… Continue reading Hemodyanamic monitoring of the future
We are in the middle of yet another H1N1 epidemic in India. Karnataka has been particularly affected, with several new cases being reported every day. Several deaths have been reported so far, and the toll is likely to mount in the days to come. The current epidemic shares several common features with the global… Continue reading Corticosteroids in H1N1 pneumonia – damned if you do, and damned if you don’t?
There is a long-drawn-out history with the use of corticosteroids in septic shock. In the 1980s, methylprednisolone was used in industrial strengths as a short course treatment, with predictably poor results.After several studies that suggested poor outcomes in septic shock, the use of corticosteroids slowly faded away. However, in the 1990s, there was a… Continue reading Contentious Use of Corticosteroids in The Critically Ill
Extracorporeal membrane oxygenation (ECMO) is being increasingly used in acute respiratory failure. It is employed as a rescue intervention when conventional measures including titration of PEEP and prone positioning fail to achieve the desired effect. Historically, two randomized controlled trials (RCTs) had failed to demonstrate efficacy; however, these studies were performed several decades ago,… Continue reading Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Failure – the EOLIA Study
The World Sepsis Day is held on the 13th of September every year. We held a meeting of local intensive care physicians in Bangalore the other day to mark the occasion. It offered us an opportunity to reflect upon where we stand and the progress we have made over the years in battling this deadly… Continue reading The Sepsis Scenario in India
Colistin is often used as combination therapy in multidrug-resistant infections. The antibiotics used in combination with colistin include meropenem, rifampicin, and minocycline. Combination therapy is favored for several theoretical reasons. Colistin levels in the lung have often resulted in subtherapeutic levels in animal models. Heteroresistance, a phenomenon by which subsets of bacteria may be resistant,… Continue reading Do we need to combine meropenem with colistin in multidrug-resistant infections?
In the BICAR-ICU study Jaber et al. randomized critically ill patients with metabolic acidosis with pH less than 7.2 and bicarbonate less than 22 mmol/L to receive 4.2% bicarbonate, targeting a pH of 7.3. They compared outcomes with a control group that did not receive bicarbonate. Three hundred and eighty-nine patients were enrolled, with 195… Continue reading The BICAR study – does bicarbonate therapy help in metabolic acidosis?
Following the monsoon rains, we see several cases of Dengue in our ICUs. Many of these patients develop severe thrombocytopenia, with the counts often dropping below 20,000. I feel most clinicians would strongly consider prophylactic platelet transfusion (without any evidence of clinical bleeding) when the count drops to between 10–20,000. However, there is a reasonably… Continue reading Platelet transfusion in Dengue Fever