Critical Care Wizard

Outgunned. Outmanned. Still Standing. Help Ukraine Apparel T-Shirt Outgunned. Outmanned. Still Standing. Help Ukraine Apparel T-Shirt

I have watched this a few times and every time it breaks my heart into a thousand pieces. I occasionally work in a relatively small COVID floor but the gut-wrenching scenario is awfully and hauntingly familiar. For those who have doubts as to the devastating effects of the 'Rona, may this enlighten you. My deep respect to those of my co-nurses who are in the thick of the pandemic. Kudos to all of you!

COVIDLAND: A Film About Survival and Hope in the ICU "The people that survive this keep giving me hope." A critical care physician allows a filmmaker to shadow her in the COVID ward of the ICU. Watch now.

Why Is Saline So Acidic (and Does It Really Matter?)

Commercial 0.9% saline solution for infusion has a pH around 5.5. There are many reasons for this acidity, some of them still obscure. It is also true that infusion of normal saline can lead to metabolic acidaemia, yet the link between the acidity of saline solution and the acidaemia it can engender is not straightforward. This commentary draws together the known and putative sources of acidity in saline solutions: it turns out that the acidity of saline solution is essentially unrelated to the acidaemia complicating saline infusion. read more...

http://www.medsci.org/v10p0747.htm

Why Is Saline So Acidic (and Does It Really Matter?) Consultant, Intensive Care Unit, Royal Adelaide Hospital; Clinical Senior Lecturer, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.

Surviving sepsis: going beyond the guidelines

Abstract

The Surviving Sepsis Campaign is a global effort to improve the care of patients with severe sepsis and septic shock. The first Surviving Sepsis Campaign Guidelines were published in 2004 with an updated version published in 2008. These guidelines have been endorsed by many professional organizations throughout the world and come regarded as the standard of care for the management of patients with severe sepsis. Unfortunately, most of the recommendations of these guidelines are not evidence-based. Furthermore, the major components of the 6-hour bundle are based on a single-center study whose validity has been recently under increasing scrutiny. This paper reviews the validity of the Surviving Sepsis Campaign 6-hour bundle and provides a more evidence-based approach to the initial resuscitation of patients with severe sepsis. read more...
http://www.annalsofintensivecare.com/content/1/1/17

Surviving sepsis: going beyond the guidelines The Surviving Sepsis Campaign is a global effort to improve the care of patients with severe sepsis and septic shock. The first Surviving Sepsis Campaign Guidelines were published in 2004 with an updated version published in 2008. These guidelines have been endorsed by many professional organization...

The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care

Importance Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified read more...
archinte.jamanetwork.com/article.aspx?articleid=1735897

JAMA Network | JAMA Internal Medicine | The Frequency and Cost of Treatment Perceived to Be... Importance Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified.

The Future of Antibiotics and Resistance

In its recent annual report on global risks, the World Economic Forum (WEF) concluded that “arguably the greatest risk . . . to human health comes in the form of antibiotic-resistant bacteria. We live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far behind the curve we allow ourselves to fall.”1

Traditional practices in infection control, antibiotic stewardship, and new antibiotic development are cornerstones of society's approach to combating resistance and must be continued. But the WEF report underscores the facts that antibiotic resistance and the collapse of the antibiotic research-and-development pipeline continue to worsen despite our ongoing efforts on all these fronts. If we're to develop countermeasures that have lasting effects, new ideas that complement traditional approaches will be needed.
http://www.nejm.org/doi/full/10.1056/NEJMp1215093

The Future of Antibiotics and Resistance — NEJM Perspective from The New England Journal of Medicine — The Future of Antibiotics and Resistance

Breaking the cycle of medication overuse headache

When patients who have frequent, disabling migraines take medications to relieve their symptoms, they run the risk that the attacks will increase in frequency to daily or near-daily as a rebound effect comes into play. This pattern, called medication overuse headache, is more likely to happen with butalbital and opioids than with migraine-specific drugs, as partial responses lead to recurrence, repeat dosing, and, eventually, overuse. Breaking the cycle involves weaning the patient from the overused medications, setting up a preventive regimen, and setting strict limits on the use of medications to relieve acute symptoms. read more...
http://www.ccjm.org/content/77/4/236.full

Breaking the cycle of medication overuse headache EDUCATIONAL OBJECTIVE: Readers will recognize the risk of developing medication overuse headache with increasing use of medications to treat acute migraine

Critical Review of the Ankle Brachial Index

Ankle brachial index (ABI) has been utilized in the management of peripheral arterial disease (PAD).ABI is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. Even so, this critical test is underutilized. The purpose of this review is to summarize available evidence associated with ABI methodology variances, ABI usage in the treatment of PAD, and ABI efficacy in predicting cardiovascular disease. This review further evaluates how ABI is used in the prognosis and follow-up of lower extremity arterial disease.We reviewed the most current American College of Cardiology guidelines for the management of PAD, the Trans Atlantic Intersociety Consensus (TASC) working group recommendations, and searched the Medline for the following words: ankle brachial index, ABI sensitivity and specificity, and peripheral arterial disease.

The ABI is a simple, noninvasive clinical test that should not only be applied to diagnose PAD, but also to provide important prognostic information about future cardiovascular events. Although the ABI has been employed in clinical practice for some time, our review of various studies reveals a lack of standardization regarding both the method of measuring ABI and the cutoff point for abnormal ABI. It is extremely important that we understand all aspects of this crucial test, as it is now being recommended as part of a patient’s routine health risk assessment. read more...
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779349/

Critical Review of the Ankle Brachial Index Ankle brachial index (ABI) has been utilized in the management of peripheral arterial disease (PAD).ABI is a surrogate marker of atherosclerosis and recent studies indicate its utility as a predictor of future cardiovascular disease and all-cause mortality. Even so, this critical test is underutiliz...

Comparison of the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in patients undergoing cardiac surgery with low cardiac output after anesthetic induction

INTRODUCTION

Ventricular dysfunction can be seen, in different perioperative periods, in patients undergoing cardiac surgery, with the consequent inadequate oxygen supply to body tissues. After adjusting the blood volume, hemodynamic support with varying doses of inotropic drugs and/or vasodilators can contribute for hemodynamic adequacy. When the need of inotropic support in situations of low cardiac output is identified, dobutamine is one of the drugs used more often. More recently, phosphodiesterase inhibitors like milrinone have been indicated for this purpose 1.

In a study comparing the effects of milrinone and dobutamine in patients with low cardiac output after myocardial revascularization, the efficacy of both drugs was observed. However, patients who received dobutamine had a higher increase in cardiac output, heart rate, and mean arterial pressure while in the milrinone group patients had greater reduction in pulmonary wedge pressure 2. As for side effects observed in this study, dobutamine was associated with a higher number of cases of increased blood pressure and atrial fibrillation, while the incidence of sinus bradycardia was higher in patients treated with milrinone. This greater reduction in pulmonary wedge pressure related to milrinone can contribute for faster reduction in pulmonary congestion in patients with congestive heart failure 2,3. However, in other studies with patients with heart failure, significant differences in parameters related to right ventricular function, mortality, need of other vasodilator or inotropic drug, or need of mechanical circulatory support in cardiac transplantation with the isolate use of one of those two drugs were not observed 4,5. read more...
http://www.scielo.br/scielo.php?pid=S0034-70942010000300003&script=sci_arttext&tlng=en

Revista Brasileira de Anestesiologia - Comparison of the effects of dobutamine and milrinone on... Comparison of the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in patients undergoing cardiac surgery with low cardiac output after anesthetic induction

Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure

Introduction:

Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IV hypertensive retinopathy. read more...

Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy amo...

ACC/AHA Clinical Competence in ECG Diagnoses

The following list of ECG diagnoses was derived from a recently published statement of the American College of Cardiology/American Heart Association (ACC/AHA) Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography (J Am Coll Cardiol 2001;38:2091-2100). These diagnoses are considered to be the minimum knowledge necessary for competence in interpreting 12-lead ECGs. Items in the list are linked to topics in the ECG Outline of the Alan E. Lindsay ECG Learning Center or to ECG examples in the Image Index.

http://ecg.utah.edu/acc_aha

ECG Learning Center - An introduction to clinical electrocardiography Short Description Here

Trends in Prescription Drug Abuse: 'Bridging Medications'

The epidemic of unintended prescription drug overdoses continues to spread across the United States. The medications being abused and misused in these tragic events are often opioids and benzodiazepines.

A lesser known phenomenon involves use of other prescription medications to minimize physiologic withdrawal until individuals can obtain their next "chemical high" with their drug of choice. This practice is commonly referred to as "bridging." Traditionally, the term "bridging" has been used in medication-assisted addiction treatment centers while stabilizing patients. Unfortunately, this terminology has gained a new meaning at the street level. Recognizing bridging behaviors may help clinicians identify patients with the disease of addiction or potential medication adverse effects. read more...
http://www.medscape.com/viewarticle/804740

Trends in Prescription Drug Abuse: 'Bridging Medications' Do you know how to identify this new trend of prescription drug abuse in opioid or benzodiazepine addicts?

Norepinephrine Uptake Mechanisms in Cardiovascular Disease Deserve Our Attention

NOREPINEPHRINE UPTAKE AND NOREPINEPHRINE UPTAKE IS NOT THE SAME

With few exceptions, norepinephrine is the main neurotransmitter released from postganglionic sympathetic neurons in peripheral tissues. Norepinephrine's biological effects are mediated through pre- and postsynaptic adrenoreceptor stimulation. In the periphery, norepinephrine increases heart rate, cardiac contractility, vascular tone, renin–angiotensin system activity, and renal sodium reabsorption. Approximately 80%–90% of the released norepinephrine is taken up again through the neuronal norepinephrine transporter (NET). Norepinephrine reuptake through NET is a secondary active transport process driven by an inwardly directed Na+ gradient. Norepinephrine taken up by NET is either repackaged into vesicles via the vesicular monoamine transporter-2 or degraded by monoamino-oxidase. Neuronal norepinephrine uptake through NET is also referred to as “uptake 1.” A significant albeit smaller proportion of the released norepinephrine is taken up by extraneuronal tissues through the “uptake 2” system and is metabolized by catechol-O-methyltransferase. The organic cation transporter 3 (OCT3) was identified as the transporter mediating extraneuronal norepinephrine uptake.1

Given the important effect of excess norepinephrine on cardiovascular regulation and disease progression, altered norepinephrine uptake could have important clinical implications. Surprisingly, cardiovascular influences of impairments in the NET function have been somewhat neglected by the cardiovascular community. The possibility that extraneuronal norepinephrine uptake through OCT3 could also have a bearing on the cardiovascular system is almost completely ignored. The accompanying article by Solbach et al2 provides an impetus to address these issues, both from a scientific and from a clinical perspective. read more...

Norepinephrine Uptake Mechanisms in Cardiovascular Disease D... : Journal of Cardiovascular Pharmaco An abstract is unavailable.

Cardioprotective Effect of Beta-3 Adrenergic Receptor AgonismRole of Neuronal Nitric Oxide Synthase

There is accumulating evidence that β3-adrenergic receptors (β3-AR) play an important role in the modulation of cardiovascular function in heart failure (1- 3). In contrast to the well-characterized β1/β2-AR, stimulation of β3-AR induces a negative inotropic effect that is associated with nitric oxide (NO) release via nitric oxide synthase (NOS) activation (4). Chronic heart failure is associated with sustained overactivation of the sympathetic nervous system, which initially plays a compensatory role for depressed contractility, but worsens heart function over time. The positive inotropic response to β-AR stimulation is diminished during heart failure due to selective down-regulation and desensitization of β1/β2-AR (5). Conversely, β3-AR is up-regulated in failing hearts in both human and animal models (6- 8). Whether this increase is a protective response to catecholamine overexpression or a contributor to heart failure has been controversial; however, increasing evidence suggests it functions as a “physiological brake” to reduce the effects of sympathetic overstimulation. Belge et al. (9) showed that mice with cardiomyocyte-specific overexpression of β3-AR had attenuated left ventricular (LV) hypertrophy compared with wild-type (WT) mice in response to chronic isoprenaline administration. Our recent work revealed exacerbated pathological remodeling and impaired cardiac functional compensation in mice lacking β3-AR (2,10). These studies support the idea that β3-AR serves a chiefly protective role in maladaptive remodeling and in the development of heart failure read more...

American College of Cardiology Foundation | Journal of the American College of Cardiology | Cardiopr This research was funded by grants from the National Institutes of Health (K08-HL076220), the W.W. Smith Charitable Trust, American Heart Association Beginning Grant-In-Aid, and American Diabetes Association to Dr. Barouch; National Institutes of Health (5T32HL007227) to Dr. Watts; and the China Sch...

Conservative treatment of a left atrial intramural hematoma after left atrial thrombus resection and concomitant mitral valve replacement - case report

Left atrial intramural hematoma is a seldom cause of left atrial mass. It has been described to occur spontaneously, after interventional procedures, after blunt chest trauma, or after aortocoronary bypass surgery. We present a case of mitral valve replacement together with the removal of a large intraatrial space-occupying lesion. Intraoperative transesophageal echocardiography confirmed a successful resection of this mass. Surprisingly, upon admission to ICU, transesophageal and transthoracic echocardiography revealed a recurrence of an intramural lesion, closest matching a hematoma, which was confirmed by contrast-enhanced computed tomography. Surgical intervention was thoroughly discussed but a conservative management was favoured. 3 months after surgery, a reassessed transthoracic echocardiography and computed tomography demonstrated an almost complete resolution of the pre-existing hematoma. read more...
http://www.cardiothoracicsurgery.org/content/6/1/50

Conservative treatment of a left atrial intramural hematoma after left atrial thrombus resection and Left atrial intramural hematoma is a seldom cause of left atrial mass. It has been described to occur spontaneously, after interventional procedures, after blunt chest trauma, or after aortocoronary bypass surgery. We present a case of mitral valve replacement together with the removal of a large in...

The relationship between inotrope exposure, six-hour postoperative physiological variables, hospital mortality and renal dysfunction in patients undergoing cardiac surgery

Low cardiac output syndrome is a common complication in patients undergoing cardiac surgery [1]. The aetiology is multifactorial and is believed to be related to a combination of myocardial ischaemia, reperfusion injury, cardioplegia-induced myocardial dysfunction and preexisting cardiac disease [2]. The administration of fluids and inotropes and the use of ventricular assist devices are common therapies in the management of low cardiac output syndrome. Physiological variables such as cardiac index, mixed venous oxygen saturation, oxygen delivery and lactate levels, obtained either from a cardiac output monitoring device or by measuring oxygen consumption and delivery, are often used to guide therapy. Inotropic agents are frequently used and titrated to achieve certain target levels of these physiological variables [3].

However, there is no consensus regarding low cardiac output syndrome in terms of both the physiological parameters that define it and the interventions used to treat it [2]. The use of inotropes has been described to be both centre- and physician-dependent and as being administered to as few as 5% or to as many as 100% of patients undergoing elective coronary bypass surgery [4-6]. Although inotropes have been demonstrated to improve haemodynamics and measured physiological variables [2], they may be a source of increased mortality and morbidity as they can increase cardiac arrhythmias and ischaemia [7]. Very few randomised, controlled trials comparing the different agents used and their effects on clinical outcomes have been performed in patients who undergo cardiac surgery [2]. In a recent observational study, the receipt of dobutamine perioperatively was associated with increased mortality [8]. In addition, investigators in randomised, controlled trials of inotropes in patients with heart failure and left ventricular dysfunction have reported increased side effects and increased mortality [9]. read more...
http://ccforum.com/content/15/4/R162

The relationship between inotrope exposure, six-hour postoperative physiological variables, hospital Acute haemodynamic complications are common after cardiac surgery and optimal perioperative use of inotropic agents, typically guided by haemodynamic variables, remains controversial. The aim of this study was to examine the relationship of inotrope use to hospital mortality and renal dysfunction.

Combination Therapy to Prevent Cardiovascular Disease

Cardiovascular disease is the major cause of mortality and morbidity globally and affects half of all individuals over their lifetimes.1 The burden of cardiovascular disease in developing countries is increasing substantially, and cardiovascular disease is becoming the leading cause of death.1 The concept of combining antihypertensive drugs, a statin, and aspirin into a single, fixed-dose, combination pill to prevent myocardial infarction and stroke is now a dozen years old, but still no such pill is licensed in most countries.

Only a small proportion—perhaps fewer than 10%—of individuals in the world who have, or are at high risk of developing, cardiovascular disease receive appropriate drugs for preventing future myocardial infarction or stroke.2 Many people at high risk are not identified because of a lack of systematic screening. Of those who are diagnosed, many are not treated because of unavailability or unaffordability of drugs, cumbersome treatment regimens, and lack of well-functioning health systems. Even patients who do receive treatment often have poorly controlled risk factor profiles3 because of an emphasis on treating individual conditions like hypertension or diabetes rather than the overall risk of cardiovascular disease. Moreover, adherence is universally poor, with less than half of those patients who are prescribed antihypertensive, lipid-lowering, or antidiabetic drugs continuing treatment beyond 1 year.4 read more...
http://jama.jamanetwork.com/article.aspx?articleid=1671770

JAMA Network | JAMA | Combination Therapy to Prevent Cardiovascular DiseaseSlow ProgressCombination. Author Affiliations: UnitedHealth Chronic Disease Initiative, London, United Kingdom (Dr Smith); and Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada (Drs McCready and Yusuf).