May 13, 2021

Background Information: Over one year into the pandemic many therapies to treat COVID-19 have targeted innumerable aspects of the virus. Most recently, the use of corticosteroids to treat the virus’ excessive inflammatory effects has become the front and center of therapy in patients requiring oxygen therapy.1 The RECOVERY trial showed a mortality benefit when using Dexamethasone in severe cases where oxygen therapy or mechanical ventilation was required.2 Interestingly, compared to other corticosteroids, high doses of Methylprednisolone are actually the preferred agent for anti-inflammation in pulmonary diseases as it achieves a more direct effect on cell membrane associated proteins.3 The authors of the following paper sought to investigate the effectiveness of methylprednisolone compared to Dexamethasone in hypoxemic ICU patients with COVID-19.

May 6, 2021

Background: Hyponatremia is one of the most common electrolyte abnormalities seen in clinical practice. Under-correction could lead to cerebral edema, whereas overcorrection could result in osmotic demyelination syndrome (ODS).  The current recommendation is to use hypertonic saline in small, fixed, intermittent boluses. This approach avoids rapid partial correction of serum sodium, limits risk of overcorrection, and doesn’t require complex calculations. Slow continuous infusions on the other hand, require complex calculations to adjust hypertonic saline infusions to a rate of correction over time based on the rate of serum sodium correction.  Despite these facts, there are limited high-quality trials that have demonstrated if slow continuous infusion (SCI) therapy is as good as or as safe as rapid intermittent bolus (RIB) therapy.

October 10, 2020

From Oct 6th – 8th, 2020, Haney Mallemat (@CriticalCareNow) and his team put on an absolutely amazing online critical care conference called ResusX Rewired.  ResusX is a conference designed by resuscitationists to provide clinicians with the most up to date skills and knowledge to help make a difference in your patients' lives.  Haney and his crew made a combination of short-format, high-yield lectures, and completely customizable small group sessions with procedural demos seem easy.  There were so many high-quality speakers and pearls that I learned from this conference that I wanted to archive them here in one post for reference and to share with our readers/followers.

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.

June 11, 2020

Background: In end-stage renal disease (ESRD) patients on hemodialysis (HD), infection is the second most common cause of mortality after cardiovascular disease (Sarnik 2000). Because of the systemic inflammation and increased capillary permeability, septic patients are at significant risk for fluid imbalances and frequently require large volumes of crystalloids. The Surviving Sepsis Campaign guidelines provide a strong recommendation with low quality of evidence for administering a 30mL/kg fluid bolus within 3 hours of recognition of sepsis-induced hypoperfusion (Rhodes 2016). Further fluid administration should be guided by hemodynamic assessment (bedside echocardiography, passive leg-raise, etc.). In the general population, this early administration of fluids to patients with hypotension or sepsis-induced hypoperfusion has been associated with improved outcomes. However, there is significant confusion regarding the effects of a large 30mL/kg bolus on ESRD patients due to a lack of studies. While these patients may appear, volume overloaded on physical exam, they may be intravascularly volume deplete. Physicians may be hesitant to administer a large fluid bolus in ESRD patients because of the risk of precipitating cardiogenic shock, pulmonary edema, and respiratory failure. In fact, multiple studies show that patients who have ESRD are less likely to receive the full 30mL/kg fluid bolus compared to non-ESRD patients (Lowe 2018, Truong 2019, Dagher 2015). Furthermore, some studies show equivalent outcomes between ESRD patients who receive the full bolus and those who do not. We will review two studies that examined this topic.