The golden hour for antibiotics in sepsis, reiterated. Shoot first, ask questions later?

  • August 12, 2014

Antibiotic timingSSC international data from more than 28,000 patients with severe sepsis or septic shock emphasises early source control is paramount  (closely followed by BP management). Get antibiotics in within 1 hour (2 at the very most) – the clock is ticking! Here, this was timed from the moment of triage or, on the wards, the moment the observations met criteria – differing slightly from previous work.

Possible signs in the data suggest it’s particularly those with severe sepsis but no hypotension that action was delayed. Also maybe under-recognition of liver dysfunction as organ failure.

Some concern that having a hair trigger for sepsis may keep antibiotic use high? Early de-escalation needs to remain high on the check-list for post-resuscitation management.

 

 

Recruitment manoeuvres – looking for an evidence base

  • August 9, 2014

recruitment manoeuvreThe PHARLAP open lung approach showed promising short term benefit earlier on in the year in ARDS, but now the evidence for recruitment manoeuvres alone has been meta-analysed by Suzumura. Nearly 1600 patients. No standardized strategy, illness severity or timing. They at least seem safe but outcome gain is less clear. An attempt at isolating the studies with least potential for bias suggests a mortality improvement. An NNT of 17 will encourage enthusiasts but sceptics might pull at the statistics. Evidence strongest in the moderate-severe group. Unclear if previous hints of more help in extra-pulmonary ARDS still stand. Staircase, ramp or 40-at-40, it remains part of the ARDS package, has basic science backing, and doesn’t seem harmful.

Nasal high-flow oxygen prevents re-intubation

  • August 7, 2014

NHF oxygenMaggiore et al have looked at the use of nasal high-flow oxygen in 100-ish pneumonia/trauma patients and found, most significantly, a reduction in re-intubation rate. You also get more sats for your FiO2, and fewer mask-now-on-their-ear moments. We know it gives flow-related 2-5 cmH2O of CPAP and is preferred by claustrophobes, but this small study suggests NHF is now fully-fledged and finding it’s fortes. The re-intubation prevention aspect deserves a closer, bigger look.

Viral haemorrhagic fever guidelines – just in case!

  • August 1, 2014

VHF algorithmIt’s clearly extremely unlikely but, particularly if you work near an airport….

The patient has been hot in the last day, maybe with sore throat, vomiting and diarrhoea, and travelled to affected area in last 21 days, or knows someone who has? Risk assess further with this algorithm. But basically – double protection including FFPP3, discuss with high security ID unit, check for malaria, send EDTA & serum for VHF and follow these guidelines or equivalent. Alarmingly no help on actual therapy! Presumably support, and aggressively attend to coagulapathy.

 

 

More detail from recent reports (at 3/10/14):

Virology

  • 5 subtypes of Ebolavirus – this outbreak is the Zaire group. Possible animal (bat/pig/monkey) reservoir in West Africa.
  • Seemed to start in Gabon or Guinea, then Liberia, Congo, Sierra Leone, Nigeria, Senegal.
  • Transmission by physical contact and, less so, contact with body fluids (not airborne).

Symptoms

  • Approx 80% – fever, fatigue,
  • 40-70% – loss of appetite, vomiting , severe diarrhoea, headache, abdominal pain
  • <10% haemorrhage.
  • 95% are symptomatic within 3 weeks

Mortality

  • Somewhere between 50 and 80%

Management

  • Supportive
  • Transfuse from a survivor
  • ZMapp currently the most highly regarded specific therapy (cocktail of 3 monoclonal antibodies)

Public health tenets

Enable early diagnosis, isolation/quarantine/social distancing, trace contacts asap, immaculate infection control (hygiene, disposal), ensure appropriate burial facilities. Social mobilization measures and community education also crucial. Vaccination not yet available.

Rate of spread

Doubling rates differ between countries (15 to 30 days). Under-reporting is certain. A total of 20,000 reported cases by early November is predicted.

Ethics

New treatments are likely to be scarce and expensive – who gets them? How much can you hurry the drug development process?

 

Read:

Gostin in JAMA

Briand in NEJM

Now a great CDC site on Ebola

WHO Ebola site

Public health England map

UK advisory on dangerous pathogens

ICU echocardiography – fully in focus

  • July 31, 2014

FATEcardThe ILC-FoCUS focused echocardiography recommendations are a product of 4 conferences, 33 experts and a Delphi process, giving a useful set of statements on everything from training to equipment to volume status.

Early tracheostomy? Definitely maybe.

  • July 29, 2014

Early trachy editorialTracman said no, but others have shown benefit. Siempos’ meta-analysis of 13 trials suggests thinking again. Depending on which statistical model you use, it appears that early tracheostomy may reduce 30 day mortality, particularly, or exclusively in patients with high baseline risk of death. Less pneumonia and, unsurprisingly, shorter ICU stay is also suggested. However longer term mortality is not improved. Difficult to know where this leaves us now. Yet another treatment that might give short term without long term benefit.

It also brings home how fragile much of our knowledge is: different but valid statistical methods give a different ‘truth’.

Surely statins are useful for something on the ICU?

  • July 25, 2014

StatinVAPRecent articles on statins for ARDS treatment, VAP treatment and COPD excerbation prevention have all been disappointing. In the lab they are anti-inflammatory, protect coagulation pathways, and inhibit micro-organisms. On the unit there have been suggestions that they prevent the onset of, and reduce mortality in, severe infections and sepsis, but this has been difficult to replicate in larger studies or analyses.

Be balanced when resuscitating sepsis?

  • July 25, 2014

Balanced fluids RadhunathanRaghunathan has used some interesting statistics to try and extract the effects of using Saline or Ringer’s lactate in resuscitating sepsis. Elixhauser comborbidities, 5:1 greedy matching, Generalized Estimating Equation models, and “missing-ness” are just a few of the terms I didn’t understand.

Nevertheless this appears to be a retrospective study that suggests there’s measurable mortality benefit in using balanced resuscitation fluid in the septic adult. The greater the proportion of balanced fluid the better they did.

Hypothesis generated!