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?
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?
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