The human gut microbiome is truly mind-boggling. We are teaming with microorganisms and their presence has been implicated not just in C. difficile colitis but in obesity, cardiovascular disease and a whole host of other diseases. The suggestion has even been made that our genetic code should be described as not only the DNA found within our cells, but as an amalgamation of that and the genes found in the microorganisms that surround and cover us – that the microorganisms are an intrinsic part of ‘us’.
The addition of Metronidazole to an antibiotic regimen is something generally done without much concern. We ‘trust’ Metronidazole to not cause resistance, and to do the job we ask of it. Why is that? I honestly can’t remember ever looking after a patient with an anaerobic infection resistant to Metronidazole.
When a doctor diagnoses atrial fibrillation, 'the guideline' says that a CHA2DS2VASc and HAS-BLED score should be calculated, and depending on the outcome an anticoagulant given. We see a lot of AF in the critical care (not as much as in CICU but that’s a different game), but we don’t follow the guidance. Or at least I don’t, but why?
Neisseria Meningitidis (the Meningococcus) has 13 serogroups, with A, B, C and W being the most common. I must admit I’d never heard of ‘Meningitis W’ before, but as you’ll read it’s a rare disease to be aware of.
As far as complications go, anastomotic leak after emergency bowel surgery is not to be recommended. The early identification of a leak is crucial. C-Reactive Protein (CRP) has been suggested as a marker that may be useful to identifying this complication, but the question is whether it is useful in the case of the high risk emergency laparotomy in the critical care environment.
The avoidance of tissue hypoxia is one of the mainstays of the management of sepsis. A logical hypothesis would be that increasing oxygen delivery through transfusion may be of use (although this hypothesis ignores the fact that in the patient with sepsis it is mitochondrial dysfunction and oxygen uptake that tends to be the problem, not delivery). Clearly profound anaemia would not be beneficial, but the question is how low is too low? Transfusion is not without risks, so if there is not a benefit to transfusion it should be avoided.
The SAILS (Statins in Acutely Injured Lungs in Sepsis) trial is the latest output (and probably the last) from the ARDS clinical trials network.
It is undoubtedly true that treating (resuscitating) patients with sepsis early is a good thing to do. How we do this is determined internationally largely by the guidelines of the surviving sepsis group. These guidelines are often criticised in that they encourage a group of interventions, many of which have been shown to be non-beneficial when looked at independently (the idea of a care bundle is that the overall effect is greater than it's individual parts however). A classic example is the use of CVP as a resuscitation target despite the overwhelming evidence that this is frankly stupid.
The Surviving Sepsis Guidelines use a mixed venous oxygen saturation of 70% as a resuscitation target, but where does the 70% come from?
This Korean RCT looks at whether in complicated endocarditis (vegitations bigger than 10mm with severe valvular dysfunction), early surgery reduces mortality and embolisation.
This is a collection of blog posts written about new research or topics of interest.
This site is written for healthcare professionals. Nothing on it constitutes medical advice, and opinions expressed are those of the authors.
Dr Peter Hersey & Dr Laura O'Connor