November 19, 2020

Background Information: Central venous catheterization is a common procedure performed in the ICU for the purposes of drug administration and resuscitation. The subclavian vein is the more preferred access site given its fixed puncture location, ease for nursing access and low incidence of infections.1 Landmark guided catheterization has a widely variable success rate and has been shown to increase the risk of complications such as hematoma formation and pneumothoraxes.2,3 The use of real-time ultrasound guidance has thus led to more central lines being placed in the internal jugular and femoral lines, however there is substantial debate regarding its use in subclavian vein catheterization.4,5 The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture.

November 16, 2020

Background Information:

US vs Landmark for Radial Arterial LinesUltrasound guided peripheral and central venous access has become more common while simultaneously decreasing complications and increasing first pass success. Landmark guided palpation has historically been considered the standard of care when placing arterial lines, however the use of ultrasound is challenging that notion as anatomic landmarks are not helpful in 30% of patients.1 Additionally, increasing obesity and hemodynamic instability can make radial arterial line placement even more difficult when using landmark-guided palpation alone. The literature comparing the different methods of arterial line placement is limited to two prospective studies. The first assessed second- and third-year emergency medicine residents while the second study evaluated only four emergency medicine attendings, all with extensive ultrasound training and experience.2,3 The authors of this study sought to compare radial arterial line placement using ultrasound vs landmark guided palpation performed by novice emergency medicine interns with respect to overall success.

October 1, 2020

Background Information: Cannabinoid Hyperemesis Syndrome (CHS) is characterized by the chronic use of cannabis paired with nausea, recurrent vomiting episodes and diffuse abdominal pain.1 The pathophysiology of CHS remains unclear and large systematic reviews of the literature have recommended up to 9 differing mechanisms as to why it occurs.2 The duration of cannabis use in CHS also widely varies with the majority of patients reporting daily use and beginning use early in life.2 In addition to the history of frequent cannabis use, patients’ self-reported relief of symptoms following hot showers or baths helps distinguish CHS from other cyclic vomiting syndromes. Treatment typically involves cessation of cannabis use however the authors of this randomized controlled pilot study wished to investigate the use of topical capsaicin cream when compared to placebo.

August 24, 2020

Background Information:

It is well documented throughout the literature that critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.1–4 Acute kidney injury may be complicated by acidosis, hyperkalemia and other major metabolic disorders and thus the initiation of renal replacement therapy (RRT) is generally considered beneficial in these patients.5 In patients without these complications, the timing of when to initiate RRT remains unclear and is frequently debated. There are three trials to know before getting to this one: ELAIN, IDEAL and AKIKI. The ELAIN trial was the only one of the three to show reduced 90-day mortality with early vs delayed initiation of RRT and was the smallest in sample size.6 The IDEAL trial concluded that early planned initiation of dialysis in stage V chronic kidney disease was not associated with improvement in survival or clinical outcomes.7 Lastly, the AKIKI trial found no significant difference with regard to mortality between an early and delayed strategy of RRT and actually saw an appreciable number of patients avert the need for RRT in a delayed strategy.8 The authors of the following study sought to investigate whether an accelerated strategy for RRT would result in lower risk of death from any cause at 90 days when compared to a standard strategy of RRT initiation.

August 3, 2020

 Background Information:

The care and management of patients with acute respiratory distress syndrome (ARDS) is complex and follows an inciting injury to the lungs. This constellation of symptoms is characterized by hypoxemia, diffuse lung inflammation, decreased lung compliance and noncardiogenic pulmonary edema typically seen as bilateral opacities on radiographical imaging.1  Slow progress has been made in developing effective ARDS treatments, among them are low tidal volumes which have been shown to improve mortality.2 Over time the development of guidelines such as the ARDSnet protocol have also helped provide a stepwise framework to treatment. However, there are a subset of patients who continue to remain hypoxic and refractory hypoxemia accounts for 10-15% of deaths in ARDS patients.3   The therapies typically implemented to correct refractory hypoxia include proning, inhaled pulmonary vasodilators, extracorporeal membranous oxygenation (ECMO), paralysis, recruitment maneuvers, unconventional ventilator modes and more.4–8 The following post and included infographics focus on the following therapies: Proning, Paralytics and (lung) Protection. It is important to note that regardless of the therapy, specializing care on an individual basis with a risk-benefit analysis is required to give patients the best possible chance at survival.