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
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