PulmCrit (EMCrit)

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?

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.

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.

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.

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.