Well….ESICM happened! I must trawl the feeds to see what I can pull together for you on it. I wish I could have made it there, as there was a lot released, some brilliant POCUS and many friends were there amongst the masses!

So, here are some bytes of the latest stuff out there at the moment. Hopefully keeping you absolutely, ‘on the ball’, as far as Crit Care is concerned.

To come later…Dan’s next ED bytes and some regional anaesthesia stuff.

It was nice to get out to teach some of the physiotherapists in the art that is chest POCUS last Friday in Nottingham. Well organised course by Simon Hayward @sonophysio, I was privileged to be faculty on. Do check out his site

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Time is ticking to iFAD 2017, where I will be on the SoME panel. Can’t wait and do check out the site….get registered!

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BW

JW

Papers & Reviews

 

Possibly a bit 3rd world…but very important nonetheless!

This study looked at a cohort of Zambian patients presenting with sepsis (most had HIV), and the effect of effectively EGDT protocols for resuscitation Vs standard care. It is evident that they don’t have some of the technologies we do, but this is quite niche and landmark for this neck of the woods!

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So did the above do harm…??

Apart from the Ivory Tower of Rivers, EGDT has thus far demonstrated no overall outcome benefit, although little harm. But, did the EGDT style arm in this 3rd world trial do harm…and why!?

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‘Roids review!

Here is a great review on Critical illness related steroid insufficiency. Worth a peruse as forms the foundations of why we use them in sepsis or septic shock.

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Let’s individualise to optimise and dress to INPRESS!

Look at what your patient’s normal BP is…yes, we have always taught the importance of this. Now it seems that swaying over 10% either side could lead to worse outcomes in major, sick laparotomies. So..this adds fuel to the EGDT trials in early recovery alimentary surgery and protocols therein perhaps?? The study was ever so slightly underpowered and more were recruited to the standard arm than to the individualised trial arm…

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The editorial on “avoid hypoxia and hypotension’ is out…

The editorial on the INPRESS study…as I said on Twitter, just makes you ensure you give a . ‘good anaesthetic’!!

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Its all in the ART then…

So you would expect that very carefully and scientifically guided PEEP titration and recruitment manoeuvres might have improved outcomes in our ARDS patients….wouldn’t you? According tho the results of this…perhaps not. This was one of the studies discussed at LIVES 2017 ESICM just gone. I bring you the ART Trial….

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Check out some of the original papers below:

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Should we slam the door on aggression….well we all should now!

By aggression, I mean heavy recruitment manoeuvres and titrated, possibly excessive PEEP levels. Seems the pendulum could be swinging the other way again. Look at this editorial, fed by the ART trial results.

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So give some of that poison to stroke patients now!

Oh dear, Oh dear! So oxygen seems good for nothing, apart from combustion support. DIdn’t help ischaemic stroke patients out either!

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Following on from ABLE then…

So it seems those left on the shelf a little longer fair you no worse of in critical care than the freshly drawn ones! Very similar findings to the original 2015 ABLE study.

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Oh hell…not a good thing when you get the weight wrong!!

This paper highlights that whet we use as gospel….actually isn’t and could be a huge safety issue!

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The RV…look after it in ARDS!

Here is a great review article by my good friend Vasileos Zochios! A look at RV / LV interdependence and what happens to that relationship in ARDS when it can all go potentially wrong!

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The diaphragm shouldn’t be ignored!

Here is a review article on an area we often completely ignore. We spend a lot of our time focussing in on respiratory muscles as the cause of failure to wean…but then there’s that other muscle!!

Interesting to see that most clinicians find scanning the left chest for a diaphragmatic view a pain! I can vouch for that!

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You’re fat, and you know you are…hang on…know you’ll live longer!?

So this throws what we all thought we know right on it’s head then. This paper needs to be dissected further, but it insinuates it’s carbs that are the pure evil…fats…not os much, clearly.

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Don’t rely on the radial artery folks!

So you want to use it radial artery derived pulse pressure variation to tell you whether your parent is a fluid responder or not…..it doesn’t correlate too well with thermodilution so care needed…although a small case series in the report.

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Quash that thoracotomy pain

More on the efficacy and simplicity of serrates anterior place blocks (the TAP’s of the back) for thoracotomy pain. According to the authors, these are as efficacious as TEA for one of the worst types of pain out there!

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Forthcoming to look out for!

Speakingof brain injury!

We will await the results of the COBI study…we have always talked about hyper-osmolar therapy in various types of neurotrauma / brain injury. Perhaps this trial, approved, will show us the way?

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Manual you must download!

All that is emergency!

Thanks to the Stanford Anaesthesia Cognitive Aid Group for this link. Helps you with all that is CRM / emergency!

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POCUS!

 

Look at the ones you think are a PE!

I am sure we looked at this a while ago, but emultrasound take us through a nice paper looking at POCUS and PE. Not too sensitive though. They looked at:

  • PLAX
  • A4c
  • LV:RV ratio
  • LV length and diameter or qualitative distension of RV apex adjacent to LV apex also assessed
  • RV function (nl vs. hypokinetic), paradoxical septal motion, and presence of McConnell’s sign.

There are more sensitive ways to quantify RV function; TAPSE / TR jets and the 60/60 sign discussed a few weeks ago (click the pic below to look at that post). But, nonetheless…adds to the armamentarium!

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A great look at all the ultrasound resources you could ever want!!

And we appear on here somewhere too!

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This is an article where you quote ‘..just saying’. To those who are POCUS cynics!

Hav

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You have to attack POCUS….to keep the balance!

So an interesting article here regarding the utilisation of POCUS and in particular chest US. Take a look…not all positive…

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Look at that Intra-abdominal fluid!

 

Blogs

 

More on the paranoia that is contrast!!

Another great piece from Salim and the crew at RebelEM on this topic. Are we over paranoid…I am growing more and more certain we are!

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Don’t let that blood pressure get you!

A great byte from the guys at FOAMCast on hypertension and emergencies.

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Getting yourself out of the fire…not into the frying pan!

Here is a lovely piece from the Airway Jedi on basic airway management. There are some beautiful drawings of most manoeuvres that’ll get you out of the sh@t!

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Oxygen’s not good you know!

We all thought there could be no harm in providing supra-normal O2 delivery to most patients. Surely amongst those suffering acute MI…it can’t be bad, as you’re improving myocardial O2 delivery. But….read on, another trial suggesting it could be the devil in these circumstances where patients weren’t hypoxic from the start! Thanks to TBL for this…

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See the results of the original AVOID trial here.

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Best of Twitter!

Ketofolorama!!

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Check out this black pudding!

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What the bleep is this!?

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Jaundice…sweep the liver to see!

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Blocked guts!

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Eyes wide shut!

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Weird PPM code!

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Watch the curtain dance!!!

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Infographic of the week

They call me mellow yellow!

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Remember this!

The good old foetal circulation!

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