Critical Care Roundup
You've just spent a grueling day working in the TCC area of the ED, taking care of several septic patients, intubated patients, and level 1 traumas. Your mind is a whirl with vent settings, antibiograms, and sedative drips. The world seems to have taken on the gray, pixelated appearance of an ultrasound screen, and all you hear are beeping alarms as you crash on your couch and fall into a deep sleep.
In your dreams, you are visited by four ghosts.
The first is a large redheaded man with a deep southern twang. "I am the ghost of the ventilator past," he drawls, tobacco-stained saliva trailing down his chin. "Beware high tidal volumes and plateau pressures."
As you cower deeper into the couch, the ghost fades and disappears. But just as you begin to think you're safe, a second figure appears before you. He has neatly combed hair, a stubbly beard, and wears a long white coat with the words "Welcome to the Holthaus of Pain" written in blood on the chest. He looks at you with cold eyes, whispers a single word—"sepsis"—and disappears.
Before you've had a chance to wipe the sweat from your brow, a new figure emerges from the ether. She has dark skin and brilliant white teeth, her lips pulled back in a welcoming smile. This one seems nice, you think, until she raises her arms and steps forward, wrapping the cord of an ultrasound probe around your throat. Your hands reach reflexively up to your neck, but they find nothing there. The cord, and the
ghost, is gone.
A noise disturbs you. A loud boom from the hallway sends shivers up your spine. It comes again and again, until finally the door slowly creaks open. Standing at the entrance is a tall, thin ghost with a soul patch beneath his bottom lip. When he jumps into the air, you notice with curiosity that he's strapped into a snowboard. The snowboard lands inside with a final thud. The ghost leans forward, his face now
inches away. That's when you notice the syringe in his hand, its contents milky white. With a single deft move, he plunges the needle into the side of your neck. Before you can scream, the propofol has hit your bloodstream, and everything goes black.
Soaked in sweat, you awaken on the couch, alone. Wondering what the dream could mean, thinking perhaps a lack of critical care understanding led your mind to create the ghosts, you head online to find some high-yield articles in the medical literature…
Four articles relevant to the critical care medicine in the emergency department were selected by the critical care medicine in the emergency department were selected by the critical care medicine section. No formal literature search was performed.
Article 1: Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment
reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014 Aug; 42(8):1749-55.
Article 2: Ferrada P, Evans D, Wolfe L, et al. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg. 2014 Jan;76(1):31-7; discussion 37-8.
Article 3: Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation
Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. 2017 Mar 1. pii:S0196-0644(17)30028-8.
Article 4: Tanaka LM, Azevedo LC, Park M, et al; ERICC study investigators.. Early
sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care. 2014 Jul 21;18(4):R156.
In this retrospective study evaluating the association between timing of antibiotic administration and mortality in patients with severe sepsis or septic shock, an incremental increase in adjusted mortality was seen for every hour delay in antibiotic administration. This was, unfortunately, a retrospective analysis of previously collected data rife with potential sources of bias (despite the use of logistic regression to account for known confounders). Despite this limitation, it makes clinical sense to administer antibiotics in as timely a fashion as possible in septic patients, and there is likely to be some association with mortality as demonstrated in this study.
This pseudorandomized trial of the use of limited transthoracic ECHO (LTTE) to direct resuscitation of hypotensive trauma patients demonstrated less fluid administration (1.5 L vs. 2.5 L; p < 0.0001), less time to OR (35.6 vs. 79.1 minutes; p = 0.0006), and higher ICU admission rates (80.4% vs. 67.2%) among those patients undergoing LTTE. There was a trend toward lower mortality in patients in the LTTE
group, but this did not reach statistical significance (RR 0.56, 95% CI 0.28 to 1.11). Given the lack of risk associated with this bedside ultrasound technique, it makes sense to use LTTE to guide resuscitation in such patients. Some methodological flaws may limit the internal validity of the study (pseudorandomization, lack of outcome assessor blinding).
In this before and after study evaluating the effect of implementing a protocol for lung-protective ventilation in the ED, after propensity matching to balance known confounders, there was a significant reduction in the risk of pulmonary complications (adjusted OR 0.47, 95% CI 0.31 to 0.71) and mortality (OR 0.47, 95% CI 0.35 to 0.63). Despite some methodological issues, this study clearly demonstrates both the feasibility and effectiveness of lung-protective ventilation in the ED.
This retrospective study conducted using date from a previously collected database demonstrated longer duration of ventilation among patients with deep vs. light sedation (median 7 days vs. 5 days, p = 0.041), higher tracheostomy rates (38.9% vs. 22%, p = 0.001), and a trend toward higher ICU mortality (RR 1.4, 95% CI 1.0 to 1.9) and hospital mortality (RR 1.3, 95% CI 1.0 to 1.7). The retrospective
nature of this study and lack of balance between groups make it more likely that these differences were due to an association rather than causation, with sicker patients either receiving deeper sedation or being more sedated due to their disease processes. It is impossible to draw any clinically meaningful conclusions from these results.