Background: As I walk to the bedside to re-examine my patient with refractory hypotension, I start thinking what else can I do? My patient came into the hospital with septic shock secondary community acquired pneumonia requiring me to intubate her due to impending respiratory failure. I subsequently placed a central venous catheter and an arterial line as I carefully volume resuscitated her. I turned up her tidal volume momentarily on the ventilator to assess for pulse pressure and stroke volume variation, did a bedside echo, and attempted a passive leg raise, but it appears that she is volume replete. I started a norepinephrine infusion, and as the dose escalated, I added a vasopressin infusion, but she still remains hypotensive even after giving her stress dose steroids. As I contemplate my next move I am haunted by her bedside monitor alarming; MAP 50 mm Hg. What’s my next move? Read more →
Author Archive for: srrezaie
Background: One of the most feared complications associated with rapid sequence intubation (RSI) is hypoxemia ultimately leading to cardiac arrest. The FELLOW Trial, a recent randomized controlled trial demonstrated no difference in hypoxemia rates between patients that received apneic oxygenation and those that did not (i.e. “usual practice”) in the ICU. What many forget about this trial is 1/3 of the patients were pre-oxygenated with a bag valve mask and another 1/3 of the patients with a BIPAP device, meaning that 2/3rds of these patients were not truly apneic during the period that induction medications were pushed up to laryngoscopy. Currently, there is a lack of high quality research on the use of apneic oxygenation in the ED setting. Many still use the intervention as it is cheap, easy to do, with no increase in patient harm, but there are still naysayers that do not feel the intervention is warranted in standard RSI practice. Read more →
Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement. Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients. Read more →
Background: Fluid resuscitation with crystalloid is one of the most basic initial management approaches to adult and pediatric patients with severe sepsis and septic shock. However, which fluid should we be giving, and does it matter? Should we give an unbalanced, chloride rich solution such as normal saline or a balanced, chloride restrictive fluid, such as lactated ringers, Plasma-Lyte, or Normasol? Interestingly, the 2016 Surviving Sepsis Guidelines, added resuscitation with balanced fluids into the guidelines, although a weak recommendation with low quality of evidence.
This recommendation was based on some growing adult data, albeit retrospective, showing that resuscitation strategies using normal saline may be harmful and associated with increased risk of AKI (1), need for CRRT (1) and increased mortality (2-3). The effects of balanced fluids however, have not been studied in the resuscitation of children in severe sepsis and septic shock. Read more →
Background: Sore throat is a common presentation to the emergency department as well as primary care clinics. Corticosteroids inhibit transcription of pro-inflammatory mediators in airway endothelial cells responsible for pharyngeal inflammation and symptoms of pain. They have been used in other upper respiratory tract infections such as acute sinusitis and croup. In adults, previous studies with dexamethasone are in combination with antibiotics but studies of children have included dexamethasone without antibiotics. This study is unique as it is evaluating the benefits of oral corticosteroids for acute sore throat in primary care in the absence of antibiotics Read more →