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?
Fluid resuscitation is the cornerstone of the established management of sepsis-related hypotension. Guidelines recommend an initial bolus of 30 ml/kg of crystalloids with administration of repeated boluses if the hemodynamic parameters continue to improve (1). The physiological rationale behind this approach is the extensive vasodilatation and capillary leak that characterize sepsis. Adequate intravascular volume expansion… Continue reading Early vasopressors or a fluid-liberal resuscitation strategy in sepsis-related hypotension?
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?