Another really busy week with various meetings going on around the world. This is a selection offering you an insight into what has been going on out there recently, and do remember that many of the Twitter shots contain clickable links!

Lots of POCUS, as well as lots of new papers and reviews from Critical Care as they celebrate their 20th Anniversary

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We look forward to the 14th Annual Critical Care Symposium in Manchester, click below and hope to see you there.

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A final note…I plan on releasing a piece on the best os ISICEM 17 this week.

 

Twitter

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Youtube-rama!

Malaria

Have look at this fabulous new video from one of our favourite sources! The incubation and lifecycle of Malaria.

Upper Extremity Blocks

Here is a rather nice little discussion of many of the upper extremity blocks we perform in theatre on a regular basis. These are discussed in the context of the ED…interesting!

http://www.ultrasoundpodcast.com/?powerpress_embed=3285-podcast&powerpress_player=html5video

That Immobilised Airway!

Have a look here at this video of VL in action. Clinical video demonstrating a collection of techniques to facilitate elective intubation for a patient with an unstable cervical spinal injury in caliper traction. Note the sideways introduction of the VL blade due to limited space for the VL handle, optimisation of the view (‘Rule of 3’), use of a coude-tipped bougie (introducer), and the 3-part technique to advance the endotracheal tube when it catches on the arytenoid cartilage (pull tube back to disengage, rotate 90 degrees counterclockwise, advance tube).

EM Stuff

Snapshot of Tachyarrhythmias!

Take a look at this fabulous quick differentiation of Tachydysrhythmias.

What’s the Top 10 in EM?

Simon Carley from the fabulous St. Emlyns Blog takes us through the Top 10 EM Papers. We love their site, full of vignettes and Pearls to keep you right on top of what’s current…particularly useful when you have to go down to resuscitation as the ICU physician!

Trache Traumas!

This article by Vibha Gupta discusses the pitfalls and complications of the good old trace tube. Common tracheostomy issues is presented in a clear and concise manner…shows what can and does go wrong!!

More ATLS Bashing!!

Is what ATLS says regarding palpable blood pressures wrong?

Get the ‘Special K’ Out Again…

Ketamine as a first-line treatment for severely agitated emergency department patients.

See EM Topics take on the paper here

Want to reduce agitation in 5 minutes? This observational study pitched Ketamine against equivalent doses of other traditional anxiolytics.

Ketamine 1 mg/kg IV or 3 mg/kg IM was more efficacious than:

  • midazolam 3mg IV
  • Lorazepam 2.2mg IM
  • Lorazepam 2mg IV
  • Haloperidol 2.4mg IM
  • Haloperidol 6mg IM
  • Haloperidol/lorazepam 5mg/2mg

There seemed to be no increase in adverse effects and Ketamine was surprisingly hemodynamically neutral, given its intrinsic sympathomimetic properties. It was likely the agitation reduction and sympathetic stimulation from the drug cancelled out any net effect.

Anticholinergic Toxicity

Have a read of this lovely brief vignette on the subject of Antichloinergic Toxicity.

ICU Papers

Anaemia…are we going a bit too low?!

Anemia and blood transfusion in the critically ill patient with cardiovascular disease

Patients with CVD may benefit from higher transfusion thresholds than patients without CVD. This review suggests there is no difference in 30‐day mortality, but there is an increased risk of ACS in patients with CVD who were randomized to a restrictive transfusion threshold compared with a more liberal threshold. Perhaps then, we should be following a more liberal transfusion threshold (>80 g/l) in this population. But as they say, further trials needed.

Fluid challenge…now it’s Tidal Volume Challenge!

Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

PPV is often used to predict preload responsiveness, it is simple to do and doesn’t require expensive gizmos! But, as the article points out, it can be unreliable during low tidal volume ventilation, which is now widely practiced in ICU patients. But…don’t be too hasty, this is easily overcome by using the ‘tidal volume challenge’ a simple bedside test, following which PPV can reliably predict fluid responsiveness. Whether this test may also have the potential to overcome other limitations associated with the use of PPV needs to be further studied.

Watch your doses!

Medicating patients during extracorporeal membrane oxygenation: the evidence is building

Here is a great paper on the pramacodynamic / kinetic changes we need to be vigilant to when dosing our patients on ECMO.

The muscles are weak…but the diaphragm is where the problem is!

Novel insights in ICU-acquired respiratory muscle dysfunction: implications for clinical care

We are continuously looking at the best ways to liberate our patients from artificial ventilation. Respiratory muscle weakness is the last thing you need! This paper looks at the evidence behind why this is a constant headache, new biomarkers and new techniques too try to combat it. But…do they work?

Get in there early with Amiodarone or lidocaine…or not?!

Antiarrhythmic drugs for out-of-hospital cardiac arrest with refractory ventricular fibrillation

Do amiodarone or lidocaine given for refractory VF/pVT out of hospital cardiac arrests inpmrove outcome? Read on …

Who wants a Nobel Prize….in Anaesthetics?

Anti-inflammatory properties of anesthetic agents

Anaesthetic agents seem to herald new modulatory effects on a daily basis. What do they do to the immune system though? Let’s face it, we don’t even know how volatiles work, but we do know about the IV agents. Read on to discover what has been unearthed.

Obesity…a massive problem with new discoveries!

Mechanical ventilation in obese ICU patients: from intubation to extubation

So, what do we know? It’s a massive problem, takes multiple personnel, bits of kit, time and expense to cope with. Obesity is rife in our population, so we need to get smart in how we treat it. This article discusses many techniques via which we can make the situation less of a problem for these patients. They have enough to deal with as it is, let alone liberation from a ventilator!

Let’s all go Hi-Flow!

High-flow nasal cannula support therapy: new insights and improving performance

Read this fabulous review regarding the recent excitement of HFNC as a bridge to intubation, to avoiding intubation and many other things. Is it the golden gate to avoiding invasive ventilation in high risk patients?

The Holy Grail…or is it?!

Have a read of this fantastic editorial on the shortcomings of Hemodynamic monitoring in the era of evidence-based medicine. Manu Malbrain et al discuss it’s positives and negatives in this snappy editorial.

Do you…or Don’t You??

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

A landmark look at what happens to patients after expeditious intubation. It probably is not the ‘be all and end all’, in immediate resuscitation management. There were a large cohort of cardiac arrest patients looked at here.

Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge

Scan them…don’t just ‘Test’ Them!

Point-of-care ultrasonography and liberation from mechanical ventilation

This demonstrates that you can actually ‘see’ what the diaphragm is, or isn’t up to before you go pulling that ET tube out and watching your patient fall in a heap again! It’s kind of akin to blind fluid resuscitation without echo!

Perhaps Pollution is in the Dilution?!

The Effect of Routine Maintenance Intravenous Therapy on Hemoglobin Concentration and Hematocrit during Anesthesia in Adults

You would be quite surprised what you can do to the rheology of a patient’s circulating volume…without even realising it. This paper eloquently demonstrates we are probably inadvertently haemodiluting many of our patients!

Dump that Cholesterol…a New Way!

The ORION-1 Trial interim analysis results are encouraging for the usage of this new agent to fight the battle against LDL-C.

ORION-1 is a double-blind, placebo-controlled trial of inclisiran, administered by subcutaneous injection in adults with high LDL-C and at high risk of CVD.

For the primary end point, the mean reduction from baseline of LDL-C at day 180 was 27.9% to 41.9% after a single dose of inclisiran, compared with a 2.1% increase for placebo (P<0.001).

See the Press release here.

The Dangers of Dig!

Download the Full Presentation here

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Crit Care Blogs

Clear those triglycerides!

Have a read of this fab blog on hypertriglyceridaemic Pancreatitis, from Pulmcrit. Key points:

  • Hypertriglyceridemic pancreatitis is common among critically ill pancreatitis patients, but receives little attention.

  • Measuring a triglyceride level should be considered in all patients with pancreatitis.

  • The diagnosis of hypertriglyceridemic pancreatitis is based upon an elevated triglyceride level (typically >1,000 mg/dL) and exclusion of other likely causes.

  • In addition to general therapies for pancreatitis, patients with hypertriglyceridemic pancreatitis may also benefit from treatments targeted at reducing triglyceride levels (either plasmapheresis or insulin infusion).

  • Some recent evidence suggests that insulin infusion may be more effective than plasmapheresis clinically. Insulin infusion is also safer and easier to initiate immediately.

VA ECMO – the Solution to Hypoxia?

What is different about hypoxia on VA ECMO? This article offers a brilliant Q&A on this topic. This is a particular favourite for the FFICM exam, as we viva’d people on on the Oxford FFICM course last week.

Podcasts!

Bring on the BLING…again!

Now the BLING-II trial heralded interesting results:

In critically ill patients with severe sepsis, there was no difference in outcomes between β-lactam antibiotic administration by continuous and intermittent infusion. Australian New Zealand Clinical Trials Registry number

However, BLING-III is about to recruit. Have a listen to this interview with the P.I.

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IV fluids…where’s the Balance?!

Have a listen to this podcast where Simon Finfer discusses yet another IV fluid trial idea. The PLUS trial aims to look at the evidence in support of the fact that buffered fluids for resuscitation of ICU patients improves outcomes compared with normal saline.

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Infographics

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And Finally…

Stressed up? Have a read of this fabulous blog on the topic within medicine. Sit down though, its a long one!

Performance Under Pressure

Thanks for reading and your continual support!

JW

21st March 2017