November 28, 2016

The use of therapeutic hypothermia (TH) has become part of the routine care of patients after return of spontaneous circulation (ROSC) from cardiac arrest (Use of the phrase Targeted Temperature Management has become more accepted). It became much more accepted after two separate trials were published in the New England Journal of Medicine in 2002 showing a survival benefit and improved neurologic outcome with use of TH. (1,2) The use of TH has even been given a Level One recommendation by the American Heart Association for comatose post-arrest patients. (3) Uncertainties still remain, however, such as what optimal temperature to use, and most recommendations on specifics related to TH are based on observational studies and expert opinion. So what is the actual evidence behind the use of TH?

October 31, 2016

Background: The most recent surviving sepsis campaign recommends the use of hydrocortisone in patients with refractory septic shock (i.e. vasopressor dependent).  However, the use of hydrocortisone in severe sepsis without shock still remains a very controversial topic. Recommendations for hydrocortisone are mostly based on 2 randomized clinical trials (i.e. Annane et al [2] and CORTICUS [3]), but subsequent meta-analyses had more mixed results.  Shock reversal was consistently improved irrespective of disease severity; however, mortality outcomes were not as consistent.  Therefore, it has been hypothesized that early hydrocortisone administration could prevent shock by attenuating patient’s inflammatory response.

October 3, 2016

  This blog post is the third part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part three of this series we will discuss some useful strategies at the bedside to help us not worsen pre-intubation/peri-intubation metabolic acidosis.

September 29, 2016

  This blog post is the second part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part two of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypoxemia.

September 26, 2016

  This blog post is the first part of a series of 3, on a recent lecture I was asked to give  on Critical Care Updates: Resuscitation Sequence Intubation. This talk was mostly derived from a podcast by Scott Weingart (Twitter: @EMCrit) where he talked about the physiologic killers during preintubation and perintubation. In this podcast, Scott mentions the HOp killers: Hypotension, Hypoxemia, and Metabolic Acidosis (pH) as the physiologic causes of pre-intubation/peri-intubation morbidity and mortality. Taking care of these critically ill patients that require intubation can be a high stress situation, with little room for error.  In part one of this series we will discuss some useful strategies at the bedside to help us reduce pre-intubation/peri-intubation hypotension.