The discovery of prone positioning in ARDS
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Prone positioning was discovered by a woman.
She was a nurse.
This should surprise no one.
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Emily Damuth, MD
Essential resources for COVID-19
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Everyone knows more about COVID-19 than me! Where do I find the highest yield, evidence-based information about the coronavirus disease 2019?
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Goldilocks in the ICU: Oxygenation targets for mechanical ventilation
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Like all medical therapies, we have learned that treatment with oxygen comes at a cost. The medical literature is replete with the detriments of hyperoxia in the management of myocardial infarction, acute stroke, cardiac arrest and septic shock. What is the optimal oxygenation target for critically ill patients requiring mechanical ventilation? Three landmark trials can guide us: Oxygen-ICU, ICU-ROX and LOCO2. The end to the oxygenation fairytale remains to be told, but perhaps Goldilocks is “just right.”
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Mastering mechanical ventilation: what is mechanical power?
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Over the last three decades since the introduction of the term ventilator-induced lung injury (VILI), we have recognized that positive pressure mechanical ventilation can injure the lungs. It is widely recognized that the cornerstone of lung protective ventilation requires control of tidal volume and transpulmonary pressure. On the other hand, there has been considerably less focus on the impact of respiratory rate and flow on VILI. Mechanical power unites the causes of ventilator-induced lung injury in a single variable that incorporates both the elastic and resistive load of the positive pressure breath.6 In other words, mechanical power quantifies the energy delivered to the lung during each positive pressure breath by assessing the relative contribution of pressure, volume, flow and respiratory rate.
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Venous thrombosis after VV ECMO: What is the true prevalence?
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Venous thromboembolism is considered one of the most preventable causes of in-hospital death. Venovenous extracorporeal membrane oxygenation (VV ECMO) utilization for severe respiratory failure has increased in the decade following the 2009 influenza A H1N1 pandemic and the publication of the CESAR trial.1 The interaction between a patient’s blood and the ECMO circuit produces an inflammatory response that can provoke both thrombotic and bleeding complications. In a systematic review of patients with H1N1 treated with VV ECMO published in 2013, the incidence of cannula-associated deep venous thrombosis (CaDVT) was estimated to be as low as 10 percent; however, more recent data suggests the incidence of venous thrombosis after decannulation is much higher. Additionally, a significant proportion of CaDVT are distal thrombi located in the vena cava, which would be missed with a traditional ultrasound diagnostic approach after decannulation from VV ECMO.
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A Novel Coronavirus (2019-nCoV)
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While most coronaviruses cause mild respiratory illness consistent with the common cold, two lethal coronaviruses have been previously identified, including the acute respiratory syndrome coronavirus (SARS-CoV) in 2002 demonstrating 10% mortality and the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 producing 37% mortality. In December 2019, a novel coronavirus (2019-nCoV) was isolated from a cluster of patients with pneumonia in Wuhan, China. As reported in the Lancet last week, two thirds of the affected patients in a case series had a history of exposure to the Huanan seafood market.
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Preventing ventilator-induce lung injury (VILI): Optimizing PEEP titration in ARDS
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Lung-protective mechanical ventilation with low tidal volume and restricted plateau pressure improves survival in ARDS. However, the optimal approach to PEEP titration to minimize VILI is still debated. Should oxygenation, lung compliance, driving pressure or transpulmonary pressure guide adjustment of PEEP in ARDS?
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Critical Care Controversies
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Enteral nutrition in critically ill
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Leave the sedation alone! Diagnosis and management of patient-ventilator asynchrony
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Patient-ventilator asynchrony is underrecognized yet associated with increased mortality, ICU length of stay and duration of mechanical ventilation in critical illness. How do you diagnose and treat it? Hint: the answer is rarely deep sedation or paralysis!
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Management of status epilepticus
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A 72-year-old man develops generalized tonic-clonic activity at home. He receives lorazepam 4 mg intravenously during the 7-minute transport to the ED. He continues to have witnessed convulsions on your examination. Point-of-care glucose is normal. After supporting his airway, breathing and circulation, what medication should be administered second line for status epilepticus (SE)?
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