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.
Background Information: Central venous catheterization is a common procedure performed in the ICU for the purposes of drug administration and resuscitation. The subclavian vein is the more preferred access site given its fixed puncture location, ease for nursing access and low incidence of infections.1 Landmark guided catheterization has a widely variable success rate and has been shown to increase the risk of complications such as hematoma formation and pneumothoraxes.2,3 The use of real-time ultrasound guidance has thus led to more central lines being placed in the internal jugular and femoral lines, however there is substantial debate regarding its use in subclavian vein catheterization.4,5 The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture.
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.
Physicians have and continue to heavily contribute to the current opioid epidemic in the United States and Canada.1 Although much of the focus has been opioid prescriptions given to patients in the emergency department,2,3 not much attention has been paid to critically ill patients who survive to hospital discharge. The long-term sequelae of these opioids is concerningly overlooked especially when physicians utilize these medications as part of an “analgesia first” approach to sedating critically ill patients for the purposes of invasive mechanical ventilation (IMV).4 Previous observational studies in Canada found that approximately 85% of critically ill patients receiving IMV were exposed to opioids.1 Furthermore, the average daily opioid dosing for 2-7 days was 63 milligrams of morphine equivalent (MME), increasing to 106 MME per day for patients receiving IMV for greater than 7 days. The authors of this study performed a retrospective chart review of population-based data from Ontario Canada to investigate the frequency of new opioid initiation and persistent opioid use among critically ill patients who received mechanical ventilation. They compared this to patients who were hospitalized but not critically ill.
Background: Stress related gastrointestinal mucosal damage is a commonly encountered problem in the critically ill patients admitted to the intensive care unit. The incidence ranges from 0.6-7% and is decreasing partly due to aggressive resuscitation strategies and focus on early enteral feeding1. Damage to the mucosal integrity occurs in conditions associated with increased inflammation and reduced mucosal perfusion 2. Despite its decreasing incidence, stress related GI bleed remains a major challenge for the intensivist with many studies showing increase in mortality and ICU length of stay in these patients3.
Stress ulcer prophylaxis is recommended for critically ill patients at risk for GI bleed; the major risk factors include need for prolonged mechanical ventilation, coagulopathy, hepatic and renal failure. There is high quality evidence supporting the use of H2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in these patients. Many international surveys show that PPIs are currently preferred for acid suppression4. Though many randomized controlled trials support the use of PPI over other acid suppressants, there is clearly no recommendation regarding benefits of one group over the other. Alhazzani et al5recently published a network meta-analysis of 57 trials enrolling over 7000 patients that showed moderate quality evidence that PPIs are more effective than H2 blockers, sucralfate or placebo in preventing clinically significant GI bleed though there is a possible increase in risk for pneumonia with similar mortality. Another meta-analysis by Alshamsi et al showed that PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding and overt GI bleeding without a significant increase in risk for pneumonia, mortality and ICU length of stay6
Furthermore, there is growing concern that acid suppression predisposes patients to increased risk for nosocomial infections like pneumonia and Clostridium difficile as well as cardiovascular events. This was demonstrated in a few randomized clinical trials as well as a few observational studies7,8. The authors of the current study aimed to evaluate the benefits and adverse events associated with the use of pantoprazole for stress ulcer prophylaxis in patients at risk for gastrointestinal bleeding9...Read More