Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis

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Another day, another Vitamin C article. This one came out just two weeks ago, it’s not free, and the results are a bit strange. There are larger trials in the works. If I were part of the group of these authors, I’d be itchy to get my data out ASAP as well. Just 31 patients in each arm of this trial. Heck, even I could replicate this trial in my 20 bed MSICU if I wanted to over 1.5 years. The problem is that my bias admittedly is for the cocktail to work. I am wide openly admitting that, everyone. I have a bias. I want it to work bc I want my patients to live.  

There are numerous parts of this study that seem strange to me. 

1. the ICU mortality of the control arm is 42%. This number should not be quite as high based on the latest data. That could lead the p-value of 0.004 to be perhaps a bit too small. But considering that they used the same strategies to manage septic shock these pts in both arms, it’s still valid for that institution. 

2. The duration of the vasopressors were longer in the experimental arm. This makes NO sense as Vitamin C is a co-factor in the endogenous creation of catecholamines. Heck, even the authors admitted this was strange. 

3. There was no significant difference in hospital mortality. They probably needed a high n to get this to show a difference. The hospital medicine and palliative teams must be great at getting code status’ changed so that people don’t bounce back to the unit. 

4. Pts did not get off of the ventilator faster. Word on the street is that there’s preliminary data suggesting that it helps this process that just isn’t out yet. Stay tuned. 

Lastly, everyone is worried about renal failure. No difference in AKI here, folks. In fact, I am yet to see one report in any of these trials talking about renal calculi secondary to vitamin C in sepsis. 

What are your thoughts on the matter? Is your shop using this yet? Are you a believer or a skeptic?

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Diagnostic accuracy of C-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic CT scan

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When I was in training, I was taught that Procalcitonin helped to differentiate between bacterial and viral infections. That's the reason why it was approved by the FDA and that's the reason why we use it today. I have seen other clinicians and colleagues suspect infection on a patient, order a PCT, see that it's negative, and then feel good about everything going on. On the same token, I've seen patients with an elevated PCT who are completely asymptomatic be kept in the hospital for extra days to be "observed" to see whether they will present themselves with an infection within the next 24 hours. Unfortunately, many people have not read the most recent studies where you have to tease out the fact that a negative PCT does not completely rule out infection and vice versa. This study, with a bunch of limitations within it, opened my eyes to the fact that you can have a patient with community acquired pneumonia and a negative PCT. Game changer. I no longer use it to make me feel better inside. I only use it when it's elevated in the first place and I have a confirmed bacterial infection to help me deescalate antibiotics and I also use it to help me know whether source control has been achieved. 

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Procalcitonin: should you use it to guide antibiotic treatment

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Oh my good friend, #procalcitonin, we are doing you so wrong. Sometimes we ignore you to stop antibiotics, sometimes we use you inappropriately to differentiate between bacterial and viral infections and end up under treating bacterial infections. I plan on clearing up a bunch of confusion within the next few months but this shall be article one on the subject. This is where I do feel that checking procalcitonin levels is actually useful and now there’s additional data to support it. Trending it to see if you can discontinue antibiotics early, much to the chagrin of some of my #infectiousdisease colleagues, is a place where it is definitely useful. The caveat is that it has to be elevated in the first place. I’m sure we’ve all seen septic patients with a negative procal at this stage of our careers, as frustrating as that may be. Those are the nuisances of these tests that, if employed correctly, will make you one of the Masters of the Universe. Sorry, my nerd brain is on full swing this morning. 

-EJ

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Incentive Spirometry: Does it work?

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Let’s talk about something that’s ubiquitous and yet has some poor data behind it. As the title says, I’m referring to the #incentivespirometer. I’ve always shrugged my shoulders when patients refuse to do it as often as they should (you know, the plastic device is over by the windowsill and the patient is on the other side of the room) and perhaps incorrectly so after this study. The sample size seemed a bit small, 80 in each group, and the primary outcome is #radiologist based #correlateclinically. Either way, they were able to show some good secondary outcomes and in a world where we are being evaluated for every single extra day in length of stay, that may be the single biggest finding of this study (at least in my opinion). As mentioned in the study, we spend a billion dollars a year on these things. Guess I need to invest in those companies haha. But seriously, there’s no way we are getting them out of our facilities to save that cash so we might as well use them properly. That was not financial advise, by the way. 

-EJ

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HFNC vs. conventional oxygen after extubatio

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One of the dreaded things in Critical Care is to extubate someone and see that they’re not flying. It makes you question yourself; your judgement, assessments. It makes you self conscious. Will families may lose trust in you, and most importantly: are you causing harm to your patients? I’ve had just 6 reintubations in my 2 years out of training but that is considered too few as the reintubation rate should be 10-15%. Otherwise you’re not being aggressive enough. I don’t even check blood gases before I pull the tube. Needless to say, my kickass RT’s know that for the questionable pts, I want the #BiPAP or #HFNC at the bedside when we pull the tube. Sometimes hooked up and ready to go, sometimes outside the room to “ward off evil spirits”. I have a plan A, B, and C ready to go before I reintubate. My empiric data, otherwise worthless, shows that HFNC does help prevent reintubation. This meta-analysis says different. My bias, admittedly, says the conclusion has some limitations, and if you seek you shall find. This is an issue with meta analyses, the heterogeneity. You’re trying to compare apples and oranges regarding different studies and the authors did the best they could with statistical gymnastics that I don’t quite understand to make apple pie with an orange flavored crust. It just didn’t work out to show certain endpoints bc the included studies were just too different. Does that means that HFNC really doesn’t help avoid reintubations? Nope. It just means we need more data. A big 🎩 tip to the authors. 

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High-Flow Nasal Cannula Therapy in Do-Not-Intubate Patients With Hypoxemic Respiratory Distress

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Transcatheter aortic valve replacement

A special shout out to the author of this article, Melody, who is one of the kick-ass nurses I have the pleasure of working with in the CVICU at my shop.

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Cardiogenic Pulmonary Edema: Does Non-Invasive Ventilation work for this?

Link to the Abstract

This happens every single day at every shop I’ve worked at. Patient comes in with a CHF exacerbation sucking wind. You feel you have a little bit of wiggle room and don’t have to intubate them, while at the same time they’re too sick for nasal cannula or high flow. What do you reach for? The “BiPAP” machine! Now, just for clarification, the nomenclature is all wonky for this machine and its settings which is a different post all in itself. BiPAP is when you have a difference between the IPAP and EPAP settings while CPAP is when the IPAP and EPAP settings are the same. Being a good clinician; #physician or #respiratorytherapist, what you need to do is spend some time at the bedside hanging out with your patient to make sure you find the sweet spot that’s comfortable for them. Sometimes it’s easy, sometimes it’s impossible and they need to be intubated. This meta-analysis shows that pts who get placed on the #CPAP setting do better than those placed on #BiPAP setting with decreased mortality. A 🎩 tip to the authors.

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Bolus intermittent vs. continuous infusion of furosemide in heart failure

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As a critical care doc, a good chunk of the consults I receive for acute hypoxemic respiratory failure are from pulmonary edema. So I do my thing, intubate when necessary, and place these patients on a BiPAP setting that’s comfortable for them. Airway, check! Now it’s time to diurese them to a potato chip. I know there are suggested dosing that you may find in the literature, and the fact the IV vs. PO dosing of #furosemide is different. Clinical practice is always an art, though, as using an exact flow every time can get your patient into trouble. Prior studies as to whether to give #lasix as a bolus or a drop were negative studies, but this one favored providing drip. The bolus arm used q12 dosing which raises my eyebrows, though, as I usually use q8 dosing in my practice. @codyperrigo and I used a drip on a pt the day after this study came out with some phenomenal results! That’s empiric data and is worthless, though 😉. Anyway, a big 🎩 tip to the authors.

-EJ

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Evidence-Based Medicine Pyramid

Link to EBM images.

I am thrilled that my page has gotten a few people turned on to evidence based medicine. I refuse, though, to try to teach statistical analysis, though, as I don’t think I’m very good at it. I am sharing this pyramid which is easy to understand and helps one see why I feel that some studies are better than others and why some studies get published in not-so-good journals and others get published in NEJM and The Lancet. As noted at the bottom of the image, my opinion from practical observation is 💩which is why you should always read data for yourself and not trust what I write and say. I hope I don’t upset the copyright gods bc stealing someone’s image.

-EJ

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The effect of melatonin on delirium in hospitalised patients: A systematic review and meta-analyses with trial sequential analysis

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We are all trying to combat delirium by all possible means. Getting pts their glasses and hearing aides. Keeping the lights on during the day. Having family around to speak to them. We’ve also had recent trials which have been quite disappointing using medications. Could there be a good cheap medication to prevent #delirium? This paper on using #melatonin is a strong meta analysis that looks into this and could potentially change my practice... but not for the reasons on the surface. I’ve even recently heard of using melatonin for sepsis, but that’s a discussion for another day and something else I’m going to dig into. Either way, a 🎩 tip to the authors.

-EJ

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Hyperkalemia in patients with kidney disease: how to manage it

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#hyperkalemia, a daily issue for the #intensivist, #emergencymedicine docs, and #nephrologist. It’s really not that hard to manage once you check your own pulse. This tasty little algorithm definitely puts the adrenaline in check after you see that number called in as a critical from the lab and shows up glowing red on your computer screen telling you to just do something! A 🎩 tip to the authors.

-EJ

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Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis

Link to Abstract. Not a free article. :(

This is a question I would always ask myself as I would check off the boxes on admission orders as a resident, not as a fellow because the residents do it, and sometimes now as an attending. I always thought it was a waste of resources and uncomfortable to the patients to not only inject them with pharmacological DVTs prophylaxis, but also burden them with those SCDs. I’m really grateful for my colleagues in Saudi Arabia for putting together this study and sealing the deal for me as to how to manage this moving forward. A definite 🎩 tip to them

-EJ

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Mortality rate and other clinical features observed in Open vs closed format intensive care units

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Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome

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