February 24, 2020

Background: Critical illness and ICU admission comes with significant consequences – not just from the primary pathology but also from the secondary effects of therapies that may be begun to correct the abnormal physiology. One of these consequences in ventilated patients is the development of stress ulcers in the gastrointestinal tract, leading to bleeding. Over two-thirds of patients admitted to the ICU will be prescribed some form of stress ulcer prophylaxis, often in the form of either a proton pump inhibitor (PPI) or a histamine-2 receptor blocker (H2RB)1. But which one is better? Are there any risks? The existing evidence of benefit of one over another is limited. Though one systematic review did show a benefit of PPIs, the reviewed data was limited2. Neither drug is without risk either. These include a potential for immunosuppression and increased risk of infections3. More evidence is needed – which is where the Proton Pump Inhibitors vs Histamine-2 Receptor Blockers for Ulcer Prophylaxis Treatment in the Intensive Care Unit (PEPTIC) randomized clinical trial comes in4.

February 20, 2020

The REBELEM Team is proud to provide you with a Critical Care Education Curriculum that can be used for your residents, medical students, advanced providers as well as many other learners during their rotation. We realize now, more than ever, that providers are under high pressure to perform clinically in high stress environments like the Emergency Department and the Intensive Care Unit and provide high quality education at the same time. Our team would like to provide you with a quality resource to help you deliver a fun, dynamic, multimodal curriculum to your learners.

February 17, 2020

Background: In REBEL Cast Episode 73, Anand Swaminathan and I discussed two recent studies on the safety of peripheral vasopressors from two large trials [1][2]. An email from good friend Rory Spiegel brought my attention to yet another trial on this topic [3]. I think we can all agree that in patients with septic shock, or shock in general, the administration of vasopressor agents early, can help to stabilize patients and reverse end-organ hypoperfusion.  Traditionally, this has been done through central venous catheters (CVCs) due to the hypothetical risk of extravasation injury to extremities.  The flip side of this is, that central venous catheters are not without their own risks and time to place them can delay a therapy that may benefit patients.

February 13, 2020

Background: In critically ill patients needing IV access, ultrasound has helped improve gaining access to a set of peripheral veins, located deeper in the arm.  The time it takes to do this however is not insignificant but even more importantly is that once you achieve success, the line can fail due to a short catheter length. Central venous catheters, often seen as a solution to this latter issue, are not without their own risks and complications.  Therefore, a nice alternative option may be a midline catheter. These catheters are not meant for fast, large volume resuscitations because they also take time to place, but also have a longer catheter length which slows down infusion rates. Midline catheters are really about having safe access that is unlikely to be dislodged. This is a great option when you have medications you want to give but not have extravasation occur (i.e. vasopressors, hypertonic saline, calcium chloride, etc.).

February 10, 2020

The use of heated and humidified high flow nasal cannula (HFNC) has become increasingly popular in the treatment of patients with acute respiratory failure through all age groups.  Over the past several years, many studies have come out reviewing the mechanisms of action as well as its use in a variety of conditions.  In this episode, I will summarize how it works and for part 2, I will discuss the main indications for its use in both adult and pediatric patients and practical tips on how to use it.