Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory HypotensionA Randomized Clinical Trial François Lamontagne, MD1,2; Alvin Richards-Belle, BSc3; Karen Thomas, MSc3; et al Introduction- Vasopressors are commonly administered to patients in intensive care units (ICUs) to treat in order to prevent hypotension associated myocardial injury, kidney injury, and death. Vasopressors, however, may reduce blood flow in vasoconstricted vascular beds and are associated with effects on cardiac, metabolic, microbiome, and immune function. Balancing risks of hypotension with risks from vasopressors is, therefore, a challenge when managing patients in ICUs. Blood pressure is used to guide the administration of vasopressors. The norm is […]
Oxygen is a vital element and impaired oxygen delivery in critically ill patients is associated with increased mortality. As a consequence, reassuring oxygen delivery has become a cornerstone of many resuscitation protocols and liberal use of supplemental oxygen is common. This is predominantly due to our understanding of physiology. Oxygen is a critical element to fuel oxidative phosphorylation for the generation of ATP by mitochondria. Since ATP is mainly produced by means of oxidative phosphorylation, hypoxemia may impair the production of ATP and thereby lead to cellular ATP depletion. On the contrary, The negative effects of too much oxygen are less clear and many health care professionals […]
Nonsedation or Light Sedation in Critically Ill, Mechanically Ventilated Patients Invasive mechanical ventilation after tracheal intubation is among the most frequently performed procedures in adult patients admitted to the intensive care unit (ICU). Sedation and analgesia are provided at the time of intubation and may be maintained for hours or days. The aim of sedation is to minimize oxygen consumption and facilitate a patient’s ability to remain comfortably connected to a ventilator. Over the past two decades, it has been recognized that prolonged and deep sedation can increase the duration of mechanical ventilation, delay weaning, impair neuromuscular function, produce delirium, […]
The accumulation of a positive fluid balance is a frequent occurrence in critically ill patients. As Paracelsus said, ” All things are poisons, nothing is without poison. Only the dose permits something not to be poisonous.” Like other drugs, it is the dose of fluids which makes them poisonous. What is de-resuscitation? Where did this term originate from?The use of intravenous fluid therapy is universal 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 […]
Sir William Osler said that “except on a few occasions, the patient appears to die from the body’s response to infection rather than from the infection” Sepsis is a major problem across the globe. Apart from the enormous financial costs of sepsis, the human toll of this disease is staggering and new interventions that limit the ravages of this disease are urgently required. Despite numerous RCTs, we still have not found the magic bullet to cure sepsis. The role of Vitamin C in Sepsis has been debated a lot recently. Multiple and overlapping effects of hydrocortisone, vitamin C, and thiamine […]
Lung protective ventilation has become the cornerstone of the management of ARDS patient. As a consequence, hypercapnia is inevitable. However, permissive hypercapnia is not without its own problems. In this podcast, we discuss this dogma and challenge traditional practices. What is permissive hypercapnia? Permissive hypercapnia is a ventilation strategy that allows an unphysiologically high partial pressure of carbon dioxide (PCO2) to permit lung protective ventilation with low tidal volumes. The term “permissive hypercapnia” was coined by Hickling and associates in the early 1990s in their seminal descriptions of improved survival in ARDS in which plateau pressures and tidal volumes were limited. […]
Shame is highly complex, individualised and contextualised construct and should not be used as a pedagogical intervention to facilitate learning. in this podcast, Will Bynum from Duke university shares his thoughts and research on this complex concept. Author’s Bio Will Bynum, M.D Assistant Professor of Family Medicine, Duke University School of Medicine Will Bynum is currently an assistant professor of family medicine in the Duke University School of Medicine and associate program director in the Duke University Family Medicine Residency. After graduating in 2005 from the University of North Carolina in Chapel Hill with a degree in Biology, he completed […]
Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation Design This was a multi-centre cluster randomised trial involving 50 ICUs in Australia, New Zealand, Canada, Ireland, and the UK. The units were randomised (as opposed to individual patient randomization) to one type of stress ulcer prophylaxis for 6 months and then switched over to the other medication. Study Population Included: The study population included adult patients 18 years and older who underwent invasive mechanical ventilation in the first 24 hours of ICU admission. Not included: Patients […]
Recently there has been a growing interest in driving pressure as a significant parameter for titration in mechanical ventilation for ARDS patients. It has challenged our dogma of 6-8 mls/kg tidal volume ventilation. In this podcast, we discuss the current evidence and future of mechanical ventilation in ARDS. Our understanding of mechanical ventilation in ARDS has evolved significantly since the year 2000. The key concepts that have been accepted in practice include low tidal volumes, low plateau pressure, lower driving pressures and reduced frequency of injurious strain cycles. The main focus is to avoid ventilator-associated lung injury. With the recent […]
Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial Anorexia arises as a physiological response to acute illness and predisposes hospital inpatients to serious caloric and protein deficits. In combination with immobilisation and pronounced inflammatory and endocrine stress response, these nutritional deficits contribute to muscle wasting and progressive deterioration of metabolic and functional status, particularly in medical patients with multiple morbidities. Hospitals don’t provide the best possible food and often patients complain about the quality of the food. More than 30% of medical inpatients are at increased risk of malnutrition, a […]
The role of thrombolysis in submassive PE remains controversial to date. In this podcast, Dr Chacko & I dive deeper to explore the current evidence on this topic. What is Submassive PE and what are the key differences between Submissive and Massive PE The terms massive, submassive, and low-risk PE have been coined to risk stratify PE based on the likelihood of mortality. Massive PE is characterized by sustained hypotension with a systolic pressure of < 90 mm for >15 minutes or the requirement for vasopressor support. A submassive PE does not cause hypotension but causes right heart strain, dilation, […]
Learning is a social rather than an individual activity, and much of it occurs at the unconscious level, resulting in the acquisition of a large body of tacit knowledge. In this podcast, Dr Alice Fornari who is Vice President of Faculty Development at Northwell Health System and Associate Dean at the Donald and Barbara Zucker School of Medicine helps budding educators to understand this novel concept. 3 key characteristics for the successful development of Community of Practice – Relationship Building Passion for the topic Sharing of resources Speaker Bio – Dr Fornari is the Associate Dean of Educational Skills Development, […]
Liberating high-risk patients from mechanical ventilation poses a unique challenge to all intensive care physicians. The use of high flow has increased over the last decade, however, the combination of high flow nasal oxygen and NIV has not been tested so far. The present study published in JAMA tries to answer this dilemma. Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial The decision regarding when to liberate patients from mechanical ventilation faces intensive care unit (ICU) clinicians regularly. While this […]
TBI remains a major cause of death and disability worldwide. Poor outcome is associated in part with the primary insult and importantly from secondary brain injury, which is a complex series of pathologic events triggered in the early phase after TBI that then evolve over time. Apart from treating Primary pathology, modern TBI management focuses on the prevention, identification and management of SBI. Neuromonitoring is central to SBI management. This includes serial clinical examination, imaging and the use of invasive and non-invasive devices that allow cerebral physiology to be assessed over time. Traditionally neuromonitoring has focussed on ICP monitoring which […]
CARDIOLOGY PHYSIOLOGY Describe the cardiovascular events that occur during ventricular systole and diastole The cardiac cycle is made up of two phases defined by the mechanical activity of cardiac muscles, systole which is ventricular contraction lasting about 300miliseconds and diastole which is ventricular relaxation and lasts about 500miliseconds. The cardiovascular events that occur during these phases can be subdivided into mechanical and electrochemical events: Ventricular Systole: Mechanical Isovolumetric contraction At the beginning of ventricular systole, the atrioventricular valves close, heard as the first heart sound, and the intraventricular pressure rises rapidly. This rise in pressure causes the AV valves to […]
Podcast with Dr Ruth Gotian Microaggression is well recognised but less talked problem in medicine. In this podcast, Dr Ruth Gotian from Weil Cornell Medicine, New York talks about this concept and helps us to understand various strategies to deal with Microaggressions in Medicine. Dr Ruth Gotian is Assistant Dean for Mentoring, Executive Director, Mentoring Academy, Chief Learning Officer in Anesthesiology and Assistant Professor of Education in Anesthesiology at Weill Cornell Medicine
Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest CRICS-TRIGGERSEP Network and the ANTHARTIC Study Group Even though controversies persist, targeted temperature management at 32 to 36°C remains recommended in patients with out-of-hospital cardiac arrest. Since it has beneficial effects on morbidity and mortality. However, targeted temperature management is associated with an increased risk of secondary infections and constitutes an independent risk factor for early ventilator-associated pneumonia. What’s known? The key early study suggesting the benefit of single-day administration of cefuroxime in patients with coma was performed more than 20 years ago. Few studies have been conducted since, including one single-centre, […]
Dr Jose Chacko & Dr Swapnil Pawar Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. A survey of 58 ICUs in North America, mainly in university teaching hospitals, revealed that 84% of patients admitted to the ICUs received SUP, with proton pump inhibitors being the most commonly used agents. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and the […]
Conservative Oxygen Therapy during Mechanical Ventilation in the ICU The ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group Oxygen is a vital element in medical practice and among the most universally used agents for the treatment of critically ill patients. Guidelines for the provision of oxygen give recommendations for target oxygen saturations and for the weaning of oxygen therapy. Despite this, the titration of supplemental oxygen in mechanically ventilated patients is infrequent with resultant hyperoxia being common in the intensive care unit (ICU). Hyperoxia can be defined as a state in which supraphysiological levels […]
Dr. Jose Chacko & Dr. Swapnil Pawar Anaemia is a common condition associated with critically ill patients admitted to an intensive care unit (ICU). The World Health Organization (WHO) defines anaemia as a haemoglobin (Hb) level less than 13 g/dL(milligram per decilitre) in men and less than 12 g/dL in women. Various studies have shown that approximately two-thirds of critical patients admitted to an ICU have a haemoglobin concentration of less than 12 g/dl on the day of admission, and 97% of the patients become anemic after a week in ICU. The cause of anemia in critical illness is complex […]
Dr Ben Symon & Dr Swapnil Pawar There has been a trend of the increasing use of infographics in Medical Education. In this thought-provoking podcast, Dr Ben Symon from Brisbane advises budding educators to use it as an adjunct rather than the primary pedagogy. He talks about the role of infographics in promoting scholarship in MedEd and shares his insights in designing the better infographics. Resources – Martin L et al. Exploring the Role of Infographics for Summarizing Medical Literature. Health Professions Education 5 (2019) 48–57 Huang, S., Martin, L.J., Yeh, C.H., Chin, A., Murray, H., Sanderson, W.B., Mohindra, R., […]
Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial Intro – As we know, TRANEXAMIC ACID is a synthetic analogue of the amino acid Lysine. It reduces bleeding by preventing the breakdown of fibrin clots i.e fibrinolysis. The CRASH-2 trial showed that in patients with trauma with major extracranial bleeding, early administration (within 3 h of injury) of tranexamic acid reduces bleeding deaths by a third. Subsequent analyses showed that even a short delay in treatment reduces the benefit of tranexamic acid administration. However, […]
Dr Swapnil Pawar & Dr Jose Chacko Noninvasive ventilation (NIV) is a well-established treatment for acute respiratory failure, especially in patients with hypercapnia and cardiogenic pulmonary edema. Conversely, the use of NIV for hypoxemic respiratory failure, including acute respiratory distress syndrome (ARDS), is still controversial. What’s the pathophysiology of ARDS? ARDS is characterized by diffuse alveolar damage and pulmonary capillary endothelial injury. The alveolar-capillary barrier is formed by the microvascular endothelium and the epithelial lining of the alveoli. A variety of insults resulting in damage either to the vascular endothelium or to the alveolar epithelium could result in ARDS. Early ARDS […]
HYPERION TRIAL Dr Jose Chacko & Dr Swapnil Pawar Targeted temperature management with a target of 32 degrees C to 36 degrees C (moderate therapeutic hypothermia) is currently advocated by ILCOR guidelines for all patients with coma after successful resuscitation from cardiac arrest. TTM Trial results published in 2013, however, showed inconclusive effects of this treatment in 19% of patients who had cardiac arrest with a nonshockable rhythm (asystole or pulseless electrical activity), and the use of hypothermia subsequently decreased in this situation. the study by Paul young et al showed the dramatic change in practices in ANZ post TTM […]
Dr Swapnil Pawar & Dr Jose Chacko What is ARC? 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 the creatinine clearance. ARC leads to increased clearance of drugs excreted through the kidneys resulting in suboptimal concentrations of important medications, including antibiotics, and may lead to treatment failure. This phenomenon was first described more than 40 years ago in […]
Dr Swapnil Pawar & Dr Jose Chacko Coronary Angiography after Cardiac Arrest without ST-Segment Elevation Lemkes et al https://www.nejm.org/doi/10.1056/NEJMoa1816897 Background – Out-of-hospital cardiac arrest is a leading cause of death. A recent study reported a mortality of approximately 40% among patients who had been successfully resuscitated after out-of-hospital cardiac arrest associated with ventricular fibrillation or pulseless ventricular tachycardia. The most frequent cause of cardiac arrest is ischemic heart disease, and coronary artery disease has been reported in up to 70% of patients who have been resuscitated and are referred for immediate coronary angiography. However, the cause of arrest is often unclear immediately after the event, and the lack of […]
by Dr Jose Chacko & Dr Swapnil Pawar Acute pancreatitis is the leading cause of acute hospital admission for gastrointestinal disorders in many countries, and its incidence continues to rise worldwide. The annual incidence of AP ranges from 13 to 45 cases per 100,000 population with the global estimate of 33.74 cases per 100,000 population, causing uneven burden across the globe. The health-care cost in the United States is reported to be $2.5 billion. The overall mortality ranges from 5 to 20% depending on severity. In patients who develop severe necrotizing pancreatitis, mortality is approximately 15%. In cases of infection […]
by Dr Swapnil Pawar & Dr Jose Chacko Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation A Randomized Clinical Trial Background – The latest American Thoracic Society guidelines for weaning recommend PSV SBTs with moderate-quality evidence. Among patients receiving mechanical ventilation, readiness for extubation and liberation from ventilatory support is evaluated with a spontaneous breathing trial (SBT). Daily screening of respiratory function by SBT is associated with a shorter duration of mechanical ventilation. After a successful SBT and extubation, 10% to 25% of patients require reintubation, and reintubation […]
Dr Swapnil Pawar & Dr Jose Chacko A Pilot, Randomised, Double-Blind Study of Vitamin C in the treatment of Vasoplegic Shock after Cardiac Surgery https://doi.org/10.1053/j.jvca.2019.08.034 Background- High dose vitamin C has a strong biological rationale in post-cardiac surgery vasoplegia. Vitamin C scavenges reactive oxygen species, which likely contribute to vasoplegia after cardiac surgery, stimulates norepinephrine synthesis, decreases the incidence of atrial fibrillation, cardiac enzyme release, and the level of markers of oxidative stress. In addition, cardiac surgery patients have decreased vitamin C levels compared to preoperative values suggesting increased consumption and/or dilution. What’s Known- high dose intravenous vitamin C has […]
Although increasingly less frequent, placement of a tracheostomy has become a viable alternative to prolonged endotracheal intubation, with the benefits of improving patient comfort, reducing need for sedation, lowering airway resistance, and allowing for easier airway care. There has been considerable debate on the technique, timing and selection of ICU patients. In this review, I cover what’s the current consensus and share my preferred approach.
ARDS is a syndrome and our current approach of “one size fits all” is probably not the right approach to deal with this beast. In this doodly, I managed to summarise my evidence based approach in a graphical way. We need to be cautious while interpreting the evidence and should not jump to the conclusion about certain interventions such as recruitment.
Critical Care Patterns Intensive care is about recognizing the right pattern and then treating accordingly. It’s similar to game of Chess, where grand masters look at the board, recognize the pattern and make a next move. In this series, I will bring different critical care patterns, which will be helpful to all ICU trainees for their exam preparation and day to day patient management.
by Swapnil Pawar and Mike Gisondi What is Networking? Networking is the sharing of ideas through a conversation between individuals who have something in common. It’s that simple. The word, ‘networking’, carries a negative connotation, an activity carried out by the ruthless to get ahead. Not true of networking in medical education. The wonderful example of the power of networking in medical education is ALiEM: Academic Life In Emergency Medicine. ALiEM is a globally distributed digital community of practice hosted as a blog and podcast out of the United States. The organization has grown and enriched over the past 5 […]
In this thought-provoking talk, Dr Arvind Rajamani from Nepean Intensive Care speaks about his approach towards the end of life care in ICU. The second week in ICU deserves a second look, and we need to ask ourselves a question regarding the appropriateness of treatment in the select group of patients, says Dr Rajamani.
In this thought-provoking talk, world-renowned intensive care researcher Professor Simon Finfer shares his viewpoint on this highly controversial topic. Not only he exposes the flaws in previous trial designs but acknowledges the change in his practice after the publication of ADRENAL trial.
In this epic debate, two experts Dr Sam Orde & Dr Yang Yang along with echo stalwart A/Prof Konstantin Yastrebov explore the current role of echocardiography in fluid status assessment in critically ill patients. This is a highly controversial topic and choosing a winner is merely impossible.
The left ventricle (LV) gets the glory typically. Any echo request usually relates to LV ejection fraction, filing status or regional wall motion abnormality. Perhaps this is fair enough as the LV is a significant contributor to blood flow and organ perfusion, but as Pinsky said at the CICM ASM in Hobart “Right ventricle (RV) function is not considered important for cardiac function until it is … and then it’s everything”. RV dysfunction is rife in the ICU: as a direct result of diseases such as sepsis, and indirectly by mechanical ventilation or pulmonary hypertension, and it is strongly associated […]