Opinion

play_arrow Diaphragmatic Dysfunction in Critically Ill patients Dr Swapnil Pawar This episode discusses the potential causes, management, and prevention strategies for diaphragmatic dysfunction in ICU patients. For further reading, please refer to the book – Controversies in Critical Care.      

play_arrow PATCH Trial – Pre-hospital TXA in Severe Trauma Dr Swapnil Pawar   Prehospital Tranexamic Acid for Severe Trauma. Gruen RL, Mitra B, Bernard SA, et al. N Engl J Med. 2023 Jun 14.                                                                         Blog written by Dr Jose Chacko Introduction Continued hemorrhage is a leading cause of preventable deaths in patients with severe trauma. Exacerbating the fibrinolytic process in trauma due to tissue […]

play_arrow ICU Journal Club – Craniotomy vs Decompressive Craniectomy in Acute SDH Dr Swapnil Pawar   Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma Hutchinson PJ, et al. The RESCUE-ASDH Trial Collaborators. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. N Engl J Med. 2023 Jun 15;388(24):2219-2229 Blog written by Dr Jose Chacko  Introduction Acute subdural hematomas occur in nearly two-thirds of patients with traumatic brain injury and are associated with poor functional recovery and relatively high mortality (1). An acute subdural hematoma is evacuated through a large craniotomy. The surgeon raises a skull flap to enable access and removal […]

play_arrow PACER Trial Dr Swapnil Pawar Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia (the PACER trial) Van Baarle FLF, Van De Weerdt EK, Van Der Velden WJFM, Ruiterkamp RA, Tuinman PR, Ypma PF, et al. Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. N Engl J Med. 2023 May 25;388(21):1956–65. Blog written by Dr Jose Chacko    Background The risk of major bleeding complications associated with the insertion of central venous catheters (CVC) in thrombocytopenic patients is considered to be low. Variable thresholds are followed for prophylactic platelet transfusion, ranging between 20 –50,000, based on guideline recommendations […]

play_arrow CLOVERS Trial – Early restrictive vs liberal fluid resuscitation for Septic shock Dr Swapnil Pawar   Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension (The CLOVERS trial) National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network; Shapiro NI, Douglas IS, Brower RG, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023 Jan 21. doi: 10.1056/NEJMoa2212663. Epub ahead of print. PMID: 36688507. Blog written by Dr Jose Chacko Background Fluid resuscitation is one of the key early interventions in patients with septic shock. However, […]

play_arrow TEAM Trial – Early Mobilisation in Intensive Care Dr Swapnil Pawar   Early Active Mobilization during Mechanical Ventilation in the ICU The TEAM Study Investigators and the ANZICS Clinical Trials Group Blog Written by – Dr Jose Chacko  Population and setting The study was held from February 27, 2018, to November 19, 2021, across 49 hospitals in 6 countries, including Australia, New Zealand, Ireland, the UK, Germany, and Brazil. Patients were on mechanical ventilation. Ventilation was expected to continue beyond the calendar day after randomization. Patients were judged to be stable to enable mobilization. Could be on norepinephrine ≤0.2 […]

play_arrow Targeted Temperature management in TBI Dr Swapnil Pawar In this episode, we discuss the role of therapeutic hypothermia and targeted temperature management in severe TBI. We dive deeper into the available literature on this topic and share our recommendations on this controversy. The key controversies on this topic include – .    1. Selective Brain Cooling versus Whole Body Cooling 2. Target Temperature 3. Duration of Temperature Management Our recommendation – Targeted Temperature Monitoring for severe Traumatic Brain Injury remains the mainstay treatment and avoiding hyperthermia in the acute phase seems more rational than inducing hypothermia. Hypothermia has proven […]

play_arrow LOVIT trial – Final Nail in the Coffin for Vit C in Septic Shock? Dr Swapnil Pawar Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit Blog Written by Dr Jose Chacko Setting   Thirty-five medical–surgical ICUs in Canada, France, and New Zealand.   Included: Adult patients with infection, receiving vasopressors, who were admitted to the ICU for no longer than 24 hours   Excluded: Patients with contraindications for vitamin C, those who received open-label vitamin C, expected to die, or undergo withdrawal of life-support measures within 48 hours.   Intervention   Vitamin C, 50 mg/kg […]

play_arrow Resuscitation Targets in Septic Shock Dr Swapnil Pawar In this podcast, we discuss the evidence behind different resuscitation targets used in the treatment of a patient with septic shock Lactate Capillary refill time MAP Echo/USG based measurements. Microcirculation assessment Our strategy – A multimodal approach to resuscitation of a patient with Septic shock. No single parameter is adequate to guide us in the choice of treatment options.

play_arrow Noradrenaline Vs Adrenaline in OHCA Patients Dr Swapnil Pawar Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock (Bougouin et al. Intensive Care Med. 2022 Mar;48(3):300-310) Blog Written by – Dr Jose Chacko Study population and design: In this registry-based observational study, the authors identified patients admitted alive after OHCA to five university hospitals in France over a 7-y period between May 2011 and May 2018. Patients were in post resuscitation shock: the need for vasopressors for more than 6 h in spite of adequate fluid resuscitation while targeting a MAP >65 mm Hg. Excluded: non-cardiac cause of […]

play_arrow PLUS Study Dr Swapnil Pawar Join us for our 90th episode of the eCritCare podcast, where Jose Chacko & I discuss the recently published landmark trial PLUS. This trial demonstrated no significant difference in 90-day mortality between the saline group and the plasmalyte-148 group. It raises the question – Does the choice of IV fluid in ICU really matter? Should we stop worrying about the choice of fluid and focus on not giving so-called “maintenance fluids” to critically ill patients? The key message is “anything in excess is bad, don’t give something that patient doesn’t need.”

play_arrow ICU Journal Club – CONTROLING Study Dr Swapnil Pawar Individualised versus conventional glucose control in critically ill patients: the CONTROLING study—a randomized clinical trial Blog written by Dr Jose Chacko Background –  Hyperglycaemia is an adaptive response to stress and is commonly seen in critically ill patients. Individualising hyperglycaemia management similar to blood pressure management, by targeting the patient’s pre-admission usual glycaemic, is a novel concept and has not been explored before in large RCT. Setting and design The CONROLING study is a multicentric, double-blind, RCT conducted in 12 centres in France. The study included patients from medical, surgical, […]

play_arrow Early Vs Delayed RRT in ICU Dr Swapnil Pawar Blog Written by Dr Jose Chacko 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 more concerning is the perpetuation of damage that may occur due to the hemodynamic instability that often accompanies RRT. The proximal tubules located at the corticomedullary junction are particularly […]

play_arrow Surviving Sepsis Campaign Guidelines Dr Swapnil Pawar Blog Written by Dr Jose Chacko Screening and early treatment Recommendation against qSOFA The qSOFA screening parameters include a systolic BP <100 mm Hg, respiratory rate >22, and a GCS  <15. The presence of 2 or more criteria denotes a positive qSOFA. The SSG make a strong recommendation against the use of qSOFA as a single screening tool, compared to the National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), or the systemic inflammatory response syndrome (SIRS) considering its poor sensitivity for the diagnosis of sepsis. This recommendation is mainly based […]

play_arrow The Role of Hyperventilation in ICP Control Dr Swapnil Pawar Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study Written by – Dr Jose Chacko & Dr Swapnil Pawar Context –  Recent BTF Guidelines suggested the use of Hyperventilation (HV) to target PaCO2 32–35 mmHg for controlling ICP only as a second-tier treatment. These guidelines did not support lower PaCO2 levels and recommended against routine hyperventilation to PaCO2 below 30 mmHg. However, the practices vary across the globe. Objectives –  to assess, in a real-world context, PaCO2 management and […]