Every so often we have a patient who has had their coagulopathy corrected before the insertion of a central line. Although this is done with the best of intentions, it’s not my own practice and I think it increases rather than reduces risk. In fact, it’s one of those areas where I’ve always thought there’s an evidence base, but until writing this was never sure where I heard/read it.
Survival from critical illness can bring with it a whole host of unwanted physical and psychological consequences. To try and reduce the duration and impact, rehabilitation seems like an attractive and intuitive idea - but does it make a difference?
We have already looked at the ProCESS trial in the journal club, under the heading “3 and 6 hour sepsis bundles – pointless?” – you might want to read that post first. The ProCESS study was never planned to be the end of the story, rather it was one of three studies looking at the same question i.e. “Can large, multicentre trials of early goal directed therapy for sepsis, as advocated by the Surviving Sepsis Campaign, produce similar results to those shown by Rivers?”
One of our simulation scenarios involves treating a head injured patient. Just before we leave to get into the ambulance, the pupils become fixed and dilated. We then discuss whether to transfer the patient or not, with all groups to date feeling that yes, we should. But what is the prognosis for patients with bilateral fixed dilated pupils (BFDPs) after an acute extradural or subdural haemorrhage?
When you're deciding on your career you should probably have a think about how it will impact on your life - clearly that's not all there is to it or we'd all be doing one of these jobs but it is important. Also, ICM is a new specialty and departments are still working out how it should all be organised, each coming up with their own solutions. It was not a bad idea, therefore, for the authors of this study to try and give a picture of how units are staffed nationwide.
Sunderland is a UK outlier in how we deliver RRT to our patients, predominately using renal specialist prescribed dialysis (often SLED) rather than critical care physician prescribed CVVHF. Clearly we feel there is a benefit to this practice, but as an outlier we should be mindful that we’re not blindly carrying on when we shouldn’t.
The CONVINT trial is the latest to compare CVVHF to IHD in the critical care population.
Massive PE causes haemodynamic collapse up to and including cardiac arrest. Although the evidence is unlikely to be strong, the recommendation is that thrombolysis should be given.
But what about the patient who has not collapsed, but shows signs of a struggling RV (raised Tn, strain on echo). Should they be thrombolysed?
Two papers for your perusal this month, each looking at throwing all medicine has to offer at two diseases with potentially awful outcomes – cardiac arrest and ischaemic stroke.
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 TTM trial is important for several reasons. Firstly, by instituting therapeutic hypothermia you will be subjecting the family of the patient to an increased period of uncertainty about neurological outcome and for that you need to believe the intervention is beneficial. The second reason you should know about this trial is that other people do – your colleagues in EM, cardiology and medicine will all expect that you have an intelligent opinion about how this paper might change your management.
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