8 Mar 2021

March 8, 2021

Written by REBEL Crit
Background: Though oxygen is fundamental for life, supra-physiological levels can be deleterious. Several randomized controlled trials and meta-analyses have been conducted in the critically ill to determine whether a conservative oxygenation approach compared to a liberal oxygenation approach is beneficial. The OXYGEN-ICU trial was one of the first trials to explore this issue in 2016. It was a small, single centered trial with 434 ICU patients that showed a significantly lower ICU mortality in the conservative oxygenation group with an ARR 8.6%1. ICU-ROX (Mechanically ventilated patients) and LOCO2 (ARDS patients) were two more randomized trials that explored critically ill patients in the ICU with conflicting evidence on oxygen targets. There was no mortality benefit or ventilator free days in either study2,3. Although in the LOCO2 trial there was a clinically relevant excess mortality in the conservative group of 14 percentage points higher than in the liberal group at 90 days (not statistically significant) Additionally, the LOCO2 trial found a higher rate of intestinal ischemia in patients with a conservative oxygenation strategy3. Based on these three trials it can be stated that both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided.  An SpO2 of 92 to 96% (PaO2 60 to 90) would be the ideal target in these patients. Until now, there has not been any good data regarding oxygenation parameters in patients with acute hypoxemic respiratory failure.
Medical Categories: Thoracic and Respiratory
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7 Mar 2021

March 7, 2021

Written by REBEL Covid-19, REBEL EM
Background: Early observational studies led to the Emergency Use Authorization (EUA) for convalescent plasma therapy (CPT) in the US in August 2020 for the treatment of COVID-19. Data from the RECOVERY trial, the largest clinical trial on COVID-19 treatments was halted early and was communicated as a press release [2] in January 2021.  The preliminary report was based on data from ≈10,000 patients and indicated no significant association of benefit with CPT in reducing all-cause mortality compared with standard of care. Due to this press release the authors of this paper decided to perform a systematic review and meta-analysis to summarize the current literature on the topic.
Medical Categories: Infectious Disease
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26 Feb 2021

February 26, 2021

Written by REBEL EM
Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical.  It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:
  1. Be as simple and rapid as possible
  2. No special equipment required
  3. High success and low complication rate
Medical Categories: Procedures and Skills
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20 Feb 2021

February 20, 2021

Written by REBEL Covid-19, REBEL EM
Background: COVID-19 typically starts as a mild illness that progresses over several days. Most treatment interventions for COVID-19 are focused on hospitalized patients who have progressed past this mild illness.  Monoclonal antibodies have been heavily touted in this role for patients at high-risk of decompensation but have fallen well short of expectations and are prohibitively expensive and resource intensive. [BLAZE-1] [REGN-COV2]. Easily accessible effective treatments are badly needed for patients with mild COVID-19 not requiring hospitalization. Many reports have shown an under representation of patients with asthma and chronic obstructive pulmonary disease in patients hospitalized with COVID-19. One hypothesis is this may be due to the use of inhaled glucocorticoids in these patients.  Inhaled glucocorticoids have been shown to reduce exacerbations of both asthma and COPD.
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15 Feb 2021

February 15, 2021

Written by REBEL EM
Background: Alteplase has been the accepted thrombolytic for acute ischemic stroke (AIS) for 25 years. However, recent data has emerged regarding tenectaplase as an alternative.  Tenecteplase is a modified form of alteplase, with a lower cost and more favorable pharmacokinetic profile allowing for bolus injection.  Specifically, it has a higher fibrin specificity and lower affinity to plasminogen activator inhibitor (PAI-1) with a slightly longer half-life.
Medical Categories: Neurology
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