Critical Care Wizard

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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