July 2017

The cure for cholesterol could be the key to delirium?!

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  • These results do not support the hypothesis that simvastatin modifies duration of delirium and coma in critically ill patients.

 

Focussed scan, whenever you can!

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  • Focused echocardiography using the Focused Intensive Care Echo protocol is feasible and clinically useful in a high proportion of ICU patients.
  • However, many still require additional expert echocardiographic assessment.
  • Focused echocardiography delivered by non-experts is clinically useful in this setting but its limitations must be understood and access to expert assessment should be available.

 

So 24 or 48h…that’s the question?!

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  • In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours.
  • However, the study may have had limited power to detect clinically important differences, and further research may be warranted.

 

The gut, when it’s unhappy, could just be trying to tell you something!

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  • The AGI grading scheme is useful for identifying the severity of GI dysfunction and could be used as a predictor of impaired outcomes.
  • In addition, these results support the hypothesis that persistent FI within the first week of ICU stay is an independent determinant for mortality.

 

Nitric Oxide was out in sepsis…but is it reappearing?

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  • In patients with sepsis, plasma hArg concentrations are decreased and ADMA concentrations are increased.
  • Both metabolites affect NO metabolism and our findings suggest reduced NO bioavailability in sepsis.
  • In addition, reduced expression of DDAH2 in immune cells was observed and may not only contribute to blunted NO signaling but also to subsequent impaired pathogen defense.

 

High flow nasal cannulas….are they all everyone says they are!?

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  • Compared to COT, HFNC reduced the rate of intubation, mechanical ventilation and the escalation of respiratory support.
  • When compared to NIV, HFNC showed no better outcomes.
  • Large-scale randomized controlled trials are necessary to prove our findings.

 

More on the microcirculation!

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  • Techniques that allow direct viewing of the microcirculation are not completely disseminated, nor are they incorporated into the clinical management of patients in shock.
  • The numerous techniques developed for microcirculation assessment include clinical assessment (e.g., peripheral perfusion index and temperature gradient), laser Doppler flowmetry, tissue oxygen assessment electrodes, videomicroscopy (orthogonal polarization spectral imaging, sidestream dark field imaging or incident dark field illumination) and near infrared spectroscopy.
  • In the near future, the monitoring and optimization of tissue perfusion by direct viewing and microcirculation assessment may become a goal to be achieved in the hemodynamic resuscitation of critically ill patients.

A legend writes on the damage we do!

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  • Therefore, a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator is needed to improve future care.
  • Knowledge of functional lung size would allow the quantitative estimation of strain.
  • The determination of lung inhomogeneity/stress raisers would help assess local stresses; the measurement of lung recruitability would guide PEEP selection to optimize lung size and homogeneity.
  • Finding a safety threshold for mechanical power, normalized to functional lung volume and tissue heterogeneity, may help precisely define the safety limits of ventilating the individual in question.
  • When a mechanical ventilation set cannot be found to avoid an excessive risk of VILI, alternative methods (such as the artificial lung) should be considered.

 

Carefully does it! PEEP titration…

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  • In patients with severe respiratory failure, titrating positive end-expiratory pressure against the severity of hypoxemia, or providing it in a decremental fashion after a recruitment maneuver, is recommended.
  • If high plateau, driving or mean airway pressures are observed, prone positioning or ultraprotective ventilation may be indicated to improve oxygenation without additional stress and strain in the lung.

 

Make sure you ‘Prone Safe’

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  • The use of the checklist when performing the prone maneuver increased the safety and reliability of the procedure.
  • The team’s understanding of the tool’s importance to patient safety and training in its use are necessary for its success.

 

Just below the delirium spectrum….

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SSD occurs in one-third of the ICU patients and has limited impact on the outcomes. The current literature concerning SSD is composed of small-sample studies with methodological differences, impairing a clear conclusion about the association between SSD and progression to delirium or worse ICU clinical outcomes.

Steroids good for shock…bad for infections!

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In this population-based cohort study, baseline steroid use was associated with increased long-term risks of community-acquired infections and sepsis.

 

Diastolic dysfunction…we need to look at this more!

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A reduction in septal e′/s′ may indicate diastolic dysfunction in patients with severe sepsis and septic shock who have normal systolic function. As opposed to limited traditional measures of diastolic dysfunction, it is applicable in those with hyperdynamic systolic function.

 

So IgG isn’t the solution to sepsis either then!

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In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality. (Continued on next page)

 

More plugs for procalcitonin!

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The combined use of PCT and BDG could be helpful in the diagnostic workflow for critically ill patients with suspected candidaemia.

 

Are you genetically more susceptible then?

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The rs11666254 polymorphism in the FPR2/ALX gene is a functional SNP that increases sepsis susceptibility in patients after traumatic injury.

 

Too many Vents…which is best?

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The above is in response to an interesting paper on usability of certain ventilators on ITU. Click below to read the 2016 paper:

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This study provides empirical evidence of how four ventilators from market leaders compare and highlights the importance of medical technology design. Within the boundaries of this study, we can infer that SERVO-U demonstrated the highest levels of use safety and user experience, followed by G5. Based on qualitative data, differences in outcomes could be explained by interaction design, quality of hardware components used in manufacturing, and influence of consumer product technology on users’ expectations.

 

Let’s stimulate….it might help your NIV patients

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Compared to both PSP and NAVA, PSN improved comfort and patient-ventilator interaction during NIV by facial mask. PSN also improved synchrony, as opposed to PSP only.