Is It Better to Have Seen and Failed or Never to Have Seen At All?

UPDATE:  The manuscript of the MACMAN study was simultaneously published in JAMA and presented at SCCM (Lascarrou JB, et al. JAMA. Published Online Jan 24, 2017).  While the peer reviewed primary results are unchanged, demonstrating that videolaryngoscopy improves the glottic view but does not improve the ability to pass the endotracheal tube compared to direct laryngoscopy, one of the secondary results deserves some mention.  It wasn’t presented in the brief late-breaker presentation at ESICM, so I hadn’t discussed it previously.  Lascarrou and colleagues also found a higher rate of severe life-threatening complications with videolaryngoscopy, namely severe hypoxemia, hypotension, and cardiac arrest.  While I am not entirely sure what to make of this finding, I do think it should cause us some pause.  If this is true (and it may just be a type 1 error that secondary analyses are prone to), then not only should we not use VL as the primary intubating device for all our intubations in the ICU, but we should think carefully about which ones we do use it for (and be selective in whom we use it in).  And, while these most recent studies have been informative on the risks and benefits of both VL and DL, there remain unanswered questions.  These studies do not include patients who the clinician believes they have to use VL for intubation, nor do they look exclusively at high risk populations such as morbid obesity or high Mallampati or MACHOCA scores.  I suspect additional studies will be forthcoming in the future and that this field will continue to evolve.  However, in the meantime, both of these most recent well-designed and conducted randomized controlled trials, make it apparent that we should not be using VL as the default intubation device in all our critically ill patients.

 

October 4, 2016;  08:55

In the last couple of decades, some of the biggest advances in medicine have involved technology.  The videolaryngoscopy represents one of these technological advances for assisting with endotracheal intubation.  FDA approval of devices simply requires demonstration that the device does what it claims to do, but does not require demonstration of improved outcomes or any clinical benefit. While there are a number of different videolaryngoscopes, they are all designed with a camera on the end of a laryngoscope connected to some form of a screen that displays the image the camera projects.  Numerous studies have demonstrated that videolaryngoscopes improve the view of the glottis and vocal cords (Cormack Lehane Glottic View Grade) over direct laryngoscopy during endotracheal intubation.  Some of these studies suggest that time to intubation may also be shorter using videolaryngoscope.  These data (probably combined with some allure of new technology) resulted in many opining that the videolaryngoscopy should be the standard of care for intubation in critically ill patients, and should be used in all intubations in the ICU, especially by inexperienced operators.  However, the studies providing the data supporting these recommendations were conducted in the operating room on patients undergoing intubation for surgical procedures.  And most of them studied experienced anesthesiologists as the operators.

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Pulmonary “Steal” Syndrome

I wanted to share this fascinating and incredibly educational case – one where I learned an enormous amount about critical care medicine, pulmonary physiology, and ventilator management.

24 y.o. previously healthy female transferred from an OSH with ARDS.  She developed nausea and vomiting three days after sinus surgery with subsequent shortness of breath.  At presentation, had RLL infiltrate which progressed to diffuse bilateral infiltrates with some cavitary lesions, worse on the right.  Sputum culture grew MRSA – she is on vancomycin.  She also has developed a pneumothorax on the right and has a chest tube in place, although it was clamped during her medical flight to our hospital and she has developed lots of subcutaneous emphysema.  The sq emphysema slowly resolves over a couple of days with chest tube on -20 cm of water suction, but she continues to have a persistent air leak of moderate volume (about 30% of her tidal volume) consistent with a bronchopleural fistula (BPF).

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IV Fluids in Critically Ill Patients: Business as “Normal” or Do We Need More Balance?

First, let me apologize for the long delay between posts.  We had a bit of a snafu in the blog, but things should be better now.

On to a discussion about isotonic crystalloids in our critically ill patients.  Administration of intravenous fluids represents the single most common intervention in critically ill patients.  And most of that iv fluids is given in the form of isotonic crystalloids.  So we are all on the same page, isotonic crystalloids include 0.9% NaCl (i.e. Normal Saline), Lactated Ringer’s solution, and Plasmalyte.  The use of one of these fluids is almost ubiquitous in our care of patients.

Intravenous fluids were first developed in the 1830’s for the treatment of Cholera.  They were refined in the 1880’s when Ringer’s solution was developed to bathe cardiac muscle ex vivo for physiology studies and 0.9% NaCl was found to avoid RBC lysis in vitro.  Use in patients began shortly thereafter and the argument about which iv fluid was best began.

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ESICM – Hot Topics

Today was a big day at the European Society of Intensive Care Medicine (ESICM) International Conference.  Today was the Hot Topics session with the results from a number of studies being presented, many of which were published online simultaneously with the presentations.  I would like to take the opportunity to highlight four such trials presented in this Hot Topics session today:  1) The EMPIRICUS Trial (Empiric Micafungin in critically ill septic patients colonized with candida and with multiple organ dysfunction); 2) The OXYGEN-ICU Trial (Conservative vs. conventional oxygen therapy in ICU patients); 3) LeoPARDS Trial (Levosimendan in Septic Shock); and 4) High Flow Nasal Cannula vs Non-Invasive Ventilation Post-Extubation in High Risk Patients.

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ESICM ICU Clinical Trials (Part 2)

Yesterday, I blogged about the first group of clinical trials with results presented at European Society of Intensive Care Medicine International Conference (ESICM Update #1).  This blog will try to summarize some of the trials presented in the session on Tuesday, October 4.  The four studies from this session that I will briefly discuss include: Long-term outcomes of the TRISS randomized trial, the GRAVITY-VAP trial (lateral trendelenberg vs semirecumbent position to prevent VAP), the CLASSIC trial (restricting resuscitation fluid in patients with septic shock), and the OPERA trial (post-operative high flow nasal cannula vs conventional oxygen in patients after major abdominal surgery).

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Update from ESICM – ICU Clinical Trials

The European Society of Intensive Care Medicine (ESICM) is conducting its international conference this week.  This conference has traditionally been a hotbed for breaking results from clinical trials.  In this post, I would like to briefly highlight four clinical trials whose results were presented during the President’s Session of Clinical Trials in Intensive Care yesterday.  Specifically, this post will briefly summarize the HYPRESS trial (Hydrocortisone for Prevention of Septic Shock), the DESIRE trial (Dexmedetomidine for ventilated septic patients in ICU), NAVA versus Pressure Support Ventilation, and the MACMAN trial (McGrath VL versus Macintosh DL for orotracheal intubation in intensive care patients).

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Update on Early Mobility: New Data. New Thoughts?

For those of you who have been following the blog, you might remember that I recently detailed some new studies investigating early mobility in critically ill patients (See blog post here:  Is Early Mobility in the ICU at a Standstill?).  This week, another new study was published, this one in The Lancet (Schaller SJ, et al. Lancet. 2016;388(10052):1377-1388).  This randomized study found benefit from early mobilization in critically ill surgical patients enrolled from 5 international ICUs (3 in US, 1 in Austria, 1 in Germany).  I’d like to use this opportunity to discuss the methodology and results of this study and my current thoughts on early mobility in critically ill patients. Continue reading “Update on Early Mobility: New Data. New Thoughts?”

Fight Fire with Fire? Should We Be Using Probiotics in Critically Ill Patients

Fight fire with fire.  What does this mean?  Some of you may think this is a song by Metallica (others may think it is a song by Kansas).  While that is true, I am not referencing Metallica when I use it in the title for this blog post.  Instead, I am referencing the definition which suggests you treat something with its likeness, or respond to something with more of that same thing.  You treat aggressiveness with more aggression.  In ecological terms, it might be viewed as a controlled burn – using fire to burn out areas in a controlled manner ahead of a forest fire to halt its progression.

The use of probiotics is a bit akin to this.  The definition of probiotics is “living organisms that have a beneficial effect in the prevention and treatment of disease.”  The purpose of probiotics is to replenish (or maintain) the natural flora of the human body, especially the gastrointestinal tract.  Research has demonstrated that a significant portion of illness comes from bacteria in the intestinal tract – more than just Clostridium dificile infections, although they clearly result in disease in the intestinal tract.  Bacterial translocation across the GI tract and into the bloodstream has been implicated in numerous conditions, especially in critical illness.

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Forecast for Targeted Temperature Management: Partly Cloudy and a Bit Warmer

Modern CPR began a little over a half century ago when clinicians started performing chest compressions in patients who had in-hospital cardiac arrest.  It improved survival from none to slightly more than none.  Since that time, continued research in cardiopulmonary resuscitation has resulted in ACLS courses, mainstream use of defibrillators, and most importantly, slowly, but steadily improving survival rates.  Unfortunately, brain injury begins within minutes of cardiac arrest, and survival with good neurological recovery remains unacceptably low.  Many who survive are alive but with devastating neurological dysfunction. Continue reading “Forecast for Targeted Temperature Management: Partly Cloudy and a Bit Warmer”