Stress hyperglycaemia and lactataemia

  • July 17, 2014

Lactate glucoseAustralian lactate enthusiasts have taken a huge dataset and discovered high sugar is not an independent risk factor when the lactate is also high. Given they both take part in the Cori cycle and glycolysis maybe this shouldn’t be a surprise but maybe it also explains NICE-SUGAR and should reassure us that semi-tight control is right. Increasingly clear we still don’t really know how to interpret lactate levels?

Chlorhexidine dressings do work for CLABSI prevention

  • July 17, 2014

CLABSI and chlorhexSafdar et al have combined 9 studies and found an NNT of 77 which may not seem fantastic but where the complication is a quality indicator…

Time to add them to the line pack for non-tunnelled catheters at least? The varied but often high background CLABSI rate may make you hesitate though.

Prone who, when and for how long? Are we clear now?

  • July 13, 2014

prone sud forrestProning in ICU is 40 years old now. Meta-analyse 11 high-quality studies in a thorough manner (including blinding to authors!) and it appears strikingly good, with an NNT of 11 – definitely better than protective ventilation alone.  Do it in the severely hypoxic (P/F <100 mmHg), do it early (within 72 hours), do it for more than 16 hours and expect some excess skin pressure damage and the odd airway panic. Is it safe and ‘externally valid’ to apply this in units that prone only occasionally? How about practice sessions to keep up team proning skills?

More power to the probe – lung US for pneumonia

  • July 8, 2014

Chavez Lung US Chavezconfirms the great predictive value of ultrasound in detecting pneumonia. We know more than 80% of pneumonia patients have disease extending to the pleura so this is no real surprise. How well trained do you need to be though? Pneumonia lung US

Blood boosting no good in TBI

  • July 7, 2014

TBI transfusionThis 2 by 2 study looking at both Epo and transfusion triggers in closed TBI makes interesting reading and re-reading. Although large outcome benefit levels were sought (20%) there was no difference in neurological outcome (or mortality, ARDS, infection rate) between Epo and placebo or between a transfusion trigger of 7 and 10. Nor did Epo seem to work convincingly. Part of the reason for trying Epo was an apparent animal experiment neuro-protective effect, clearly not very evident here. There was even potential harm from the higher transfusion target in the form of higher thromboembolic events (20 ‘v’ 8%) and from Epo in the form of (predominantly arm) DVT incidence. Maybe they should have looked for smaller benefit?

Recruit and protect in theatre too?

  • July 3, 2014

PEEP theatre3 (fairly) recent studies (IMPROVE, PROVHILO, Defresne) show mixed benefit of using protective lung ventilation strategy with or without recruitment manoeuvres. Unimpressive results even in the obese. We know lungs de-recruit quickly under anaesthesia and that simple PEEP alone doesn’t help on radiological studies.

Dignified death on the ICU

  • July 3, 2014

Dying considerationThe ABCD approach to holistic care in the patient who is dying on the ICU. We know it’s not all about opiate but it’s useful to acknowledge that death needs managing as well as any other stage in a disease process.

Use NEWS in A&E

  • June 25, 2014

NEWS mortalityIn this Scottish national audit project a single NEWS score of >8 in the presence of sepsis predicted a >30% chance of ICU admission or dying within 30 days. Interesting from a triage perspective but how about adding the power of a single lactate of more than 2.0 to decide who with sepsis you really should take very seriously in the emergency department?