Critical Care
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An International Survey of Ventilator Weaning Practices
A cross-sectional, multinational survey of adult intensivists revealed significant regional variation in several weaning practices, including screening, weaning modes, techniques to conduct spontaneous breathing trials, the use of written directives, and use of non-invasive ventilation in the peri-extubation period.
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ICU Bed Availability: Does It Make a Difference?
Nationwide, the volume of ICU admissions from the ED has increased significantly over recent years (by 50% from 2001 to 2009). When demand exceeds bed availability, complex decisions regarding ICU must be made. Does bed availability affect triage decisions? If many beds are available, patients who are too ill or too well to benefit from the ICU may be admitted. Conversely, if too few beds are available, ICU admission may be denied to patients who may benefit. In prior studies, ICU denial has been associated with increased hospital mortality.
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Is There a Role for Steroids in ARDS Management?
Mortality rates from acute respiratory distress syndrome (ARDS) remain high, even as therapy has improved over the last decade. Recent guidelines for management center on mechanical ventilation, with initial therapy beginning upon identification and treatment of the underlying cause of the ARDS. There is reasonable consensus regarding the use of lung-protective strategies, such as low tidal volume ventilation, prone positioning for those meeting criteria for severe ARDS, and restrictive fluid management after the initial resuscitation. However, for patients with the most severe disease, these treatments often are not completely effective, and we look for other therapies that might help.
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Routine Chest Radiographs After Ultrasound-guided Central Line Placement May Be Unnecessary
Catheter misplacement and pneumothorax after routine ultrasound-guided catheter placement are rare, and routine post-procedural chest radiographs may not be cost-effective.
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Real-time Tracking of Influenza-related ICU Use
Surrogate markers of influenza severity, specifically trends in ICU use, were collected and revealed differences from current influenza reporting.
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Management of Catheter-related Bloodstream Infections
Catheter-related bloodstream infections (CRBSIs) remain one of the more common nosocomial infections today, with an estimated 250,000 CRBSIs occurring in the United States annually, of which approximately 80,000 are associated with an ICU stay. The science behind current practices has reduced the CRBSI rate by 50% between 2008 and 2014. However, the rate of infection is far from zero, and rates remain significantly different between states, suggesting that there is room for improvement.
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Mammalian Bites
Bites, whether dog, cat, or human, are a common reason for emergency department visits.This article reviews the complexities of different types of bites ED providers may encounter and issues regarding closure and antibiotic prophylaxis, in addition to vaccination concerns.
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ECMO vs. Prone Position in ARDS: The Curious Rejection of Evidence-based Practice
Despite credible evidence from a large, randomized, controlled trial and numerous meta-analyses demonstrating improved outcomes, prone position is seldom attempted prior to initiating extracorporeal membrane oxygenation to treat severe acute respiratory distress syndrome.
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Critical Illness-related Corticosteroid Insufficiency: What’s New?
For critically ill patients with sepsis, septic shock, acute respiratory distress syndrome, and major trauma, a multispecialty task force of 16 international experts developed evidence-based recommendations for the diagnosis of corticosteroid insufficiency and use of corticosteroids in the ICU.
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A Perspective on PEEP at 50 Years
Fifty years ago, positive end-expiratory pressure (PEEP) was introduced as an effective technique for improving oxygenation in patients with large intrapulmonary shunt, the hallmark of acute respiratory distress syndrome (ARDS). Although PEEP remains the primary means for stabilizing oxygenation in ARDS, consensus on how to approach setting it remains elusive. This is a narrative review on how our understanding and approach to PEEP has evolved over the past half century.