May 24, 2021

Background: It’s no surprise that unplanned, emergency intubations are significantly different from intubations in the operating room (OR). Unplanned intubations on the floors and in the ED and ICU settings are highly unlikely to be “physiologically optimized:” they have underlying shock, respiratory failure, metabolic acidosis, as well as other pathophysiological changes that can substantially increase the risks of adverse peri-intubation events.  Historically, we focused more on the anatomically challenging airway instead of the physiologically challenging airways. Fortunately for our patients, this has changed in recent years. There is increased attention on physiologic challenges including hypotension, hypoxemia, and metabolic acidosis.  Taking care of critically ill patients that require intubation can be a high stress situation with very little room for error.  Having a large evaluation of routine clinical practice and occurrence of adverse events could help establish which high-priority interventions could reduce risk in this already risky situation.

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 3, 2021

Background: In 2019 the World Health Organization listed “Antimicrobial Resistance” as a top 10 threat to global health. This was echoed in a 2021 document. [WHO 2019, WHO 2021] The classic medical teaching regarding antimicrobial therapy pushed for longer treatment courses. There was a commonly held myth that premature cessation or prescription of a short course of antibiotics could select for more virulent pathogens thereby re-exacerbating and intensifying illness as well as hastening the development of antibiotic resistance. However, microbial stewardship is of paramount importance and we should embrace shorter courses of antibiotics when clinically appropriate.

April 15, 2021

Background: In patients requiring mechanical ventilation, sedative medications are used for patient comfort and safety.  However, these medications can also lead to brain dysfunction (i.e. delirium or coma) and long-term cognitive impairment. Currently, the Society of Critical Are Medicine [2] recommends sedation with either dexmedetomidine or propofol targeted to light levels of sedation in adult patients receiving mechanical ventilation. The evidence for which agent to use thus far with respect to acute brain dysfunction or cognitive impairment after critical illness have been unclear in determining which agent should be used. In fact, the Society of Critical Care Medicine’s 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS Guidelines) recommends the use of either propofol or dexmedetomidine to target light sedation.

April 5, 2021

Background Information:

The use of corticosteroids in patients with pneumonia secondary to COVID-19 has been a controversially hot topic, particularly early on in the pandemic. Prior evidence seen in Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome have led some to argue against their use due to delayed viral clearance.1 More recent evidence related to SARS-Cov-2 has specifically shown reduced mortality and reduced need for mechanical ventilation with corticosteroids.2-4 More recently, the RECOVERY Trial showed an improvement in 28-day mortality among patients on oxygen therapy who received Dexamethasone.5 Little information exists in the literature about patients with moderate to severe disease who do not warrant ICU level of care but require hospital admission due to the extent of their illness. The authors of this study designed and conducted a pragmatic, partially randomized control trial to evaluate the possible benefit of methylprednisolone in hospitalized patients with moderate to severe COVID-19 pneumonia.
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