An unconscious septic patient rolls in wearing a “PCN anaphylaxis” medic-alert bracelet. What is the best broad-spectrum antibiotic for this patient? There is no agreement between allergy guidelines, infectious disease society guidelines, or individual infectious disease experts.
PulmCrit Wee- Oxygen-ICU trial: 100% isn’t an A+
Among intubated patients, we can often control the pO2, pCO2, and pH. Sounds great. Unfortunately, we also have no idea which numbers we should be targeting. Should we target a normal pH, or permissive hypercapnia? Should we shoot for a normoxia, try to maximize the oxygen delivery (hyperoxia), or allow for permissive hypoxemia? Nobody knows. We check ABGs and tweak the ventilator, but it’s often dubious whether this helps our patients.
PulmCrit- Power, the forgotten error, and inconclusive trials
The new HYPRESS trial tests whether steroid could prevent deterioration from sepsis into septic shock. The study found no significant benefit from steroid, but I thought it was underpowered. However, an accompanying editorial in JAMA didn’t even mention power. This raises some questions: How can we measure type-2 error? How should it be reported? What is an acceptable level of type-2 error?
PulmCrit – Bad news for sepsis-3.0: qSOFA fails validation
Sepsis 3.0 replaced the SIRS criteria with a new risk-stratification tool, qSOFA. qSOFA was initially developed within the Sepsis-3 publication itself. Until now, qSOFA has never been validated. The value of qSOFA vs. SIRS remains controversial.
PulmCrit- Dominating the acidosis in DKA
Management of acidosis in DKA is an ongoing source of confusion. There isn’t much high-quality evidence, nor will there ever be. However, a clear understanding of the physiology of DKA can help us treat this rationally and effectively.
PulmCrit Wee- Proning the non-intubated patient
From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.
PulmCrit Wee – The meaning of nocturnal extubation is 42
What should intensivists do at night? Should they sleep at home or remain dutifully in the hospital? Should they extubate patients or just maintain the status quo until 7 AM?
PulmCrit- Why dialyze patients with chronic, asymptomatic hyperlithemia?
A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient’s condition if the patient is already asymptomatic.
PulmCrit- Do phenylephrine and epinephrine require central access?
Until recently I believed that prolonged vasopressor administration requires a central line, to avoid extravasation. I lumped together all vasopressors, treating them all as equal. I used the occurrence of an extravasation reaction from one vasopressor as evidence that all vasopressors could cause extravasation reactions (the fallacy of inappropriate generalization). Upon closer examination, these beliefs aren’t supported by evidence.
PulmCrit- The siren’s call: Double-coverage for ventilator associated PNA
Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.
PulmCrit- Interpreting a 2×2 table using fragility, p-values, and maximal Bayes Factor
A post a few weeks ago calculated the fragility index of the NINDS trial (which turned out to be only three). Very briefly, the fragility index tests how many events would need to be changed for the p-value to increase above 0.05, rendering the study “statistically insignificant.” Ryan Radecki commented that he was concerned that the fragility index was married to the p-value, thereby inheriting the flaws of frequentist statistics. Perhaps we should ditch the p-value and the fragility index, switching instead to a purely Bayesian approach to statistics?
Pulmcrit – Renoresuscitation, vasopressin, vepinephrine, and VANISH
My goals during sepsis resuscitation focus largely on preservation of renal function and maintence of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypoperfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too. In this context, any beneficial effect of vasopressin on renal function could be helpful.
PulmCrit – Six reasons to avoid fluoroquinolones in the critically ill
As an internal medicine resident and pulmonary/critical care fellow, I loved fluoroquinolones. The were effective, easy to prescribe, and they had 100% oral bioavailability. However, working full-time in the ICU has forced me to realize that these drugs aren’t so wonderful for the critically ill.
PulmCrit Wee – Pragmatic comparison of 33C vs. 36C after cardiac arrest
A post last year discussed the top 10 reasons to stop cooling to 33C. It was based largely on the Nielsen trial, which showed similar outcomes between therapeutic hypothermia (TH33) and therapeutic temperature management (TTM36). However, this trial left some questions about how these protocols would perform outside the context of a RCT (external validity). Last year’s post speculated that since TTM36 is easier to achieve, it would out-perform TH33 in real-world conditions.
PulmCrit: Which patients admitted for pneumonia need MRSA coverage?
Let’s be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It’s not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.
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