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Is hydrocortisone for septic shock best used alone or in combination with fludrocortisone? This Concise Critical Appraisal explores a retrospective cohort study that found that treatment with hydrocortisone plus fludrocortisone led to lower rates of mortality or discharge to hospice, hospital deaths, and fewer days on vasopressors than treatment with hydrocortisone alone.
Is there an association between balanced versus unbalanced fluids and endothelial glycocalyx integrity in children with sepsis? This Concise Critical Appraisal offers insight into the vascular dysfunction that occurs in pediatric patients with sepsis or septic shock after receiving either balanced or unbalanced fluids.
With the advancement and increasing popularity of artificial intelligence (AI) systems, researchers have begun studying how to apply the technical capabilities of AI to the intensive care unit (ICU). This Concise Critical Appraisal explores how ICU AI systems could replace traditional monitoring systems and clinical risk assessment tools with computers that use multidimensional and multidomain data patterns to enhance patient care, predict outcomes, and seamlessly extract and interpret clinical information.
This Concise Critical Appraisal explores a meta-analysis showing that prone positioning is beneficial for patients meeting criteria for venovenous extracorporeal membrane oxygenation (ECMO), especially when initiated within five days after ECMO initiation. When initiated within five days, patients had lower intensive care unit (ICU) mortality rates, higher likelihood of being discharged alive, shorter ECMO duration, and cumulative 90-day probability of being discharged from the ICU.
Is there an association between fluid accumulation (FA) and adverse outcomes in critically ill pediatric patients, and is there a threshold FA associated with these outcomes? This Concise Critical Appraisal explores a retrospective cohort study of PICU patients over a 5-year period that found that FA was common among critically ill mechanically ventilated children within the first 7 days of admittance. Higher FA was associated with adverse outcomes; however; only greater than 20% FA was associated with worse outcomes.
Early active mobilization has been shown to mitigate ICU-acquired weakness, reduce disability and, most importantly, reduce mortality. This Concise Critical Appraisal describes a recent article published in the New England Journal of Medicine about mobilization during mechanical ventilation that reevaluates the effects of sedation minimization and daily physiotherapy on serious adverse events and mortality at 180 days.
Common causes of death in hospitals, such as sepsis and respiratory failure, are treatable and benefit from early intervention. Machine learning algorithms or early warning scores can be used for early identification and recognition to potentially help accelerate interventions and limit morbidity and mortality. This Concise Critical Appraisal explores an article published in Critical Care Medicine that looked at the impact of one of these early warning scores—electronic cardiac arrest risk triage (eCART)—on mortality for elevated-risk adult inpatients.
This Concise Critical Appraisal describes two articles that illuminate the associations among the COVID-19 pandemic, clinician well-being, and burnout—an article on the perceptions of critical care shortages, resource use, and clinician well-being and an article comparing the effects of the pandemic among critical care professions.
Can arginine supplements improve the hemodynamics of children with severe pain or acute chest syndrome (ACS) related to sickle cell anemia? Although mortality rates in children with sickle cell disease (SCD) have improved over the past decade, ACS and vasoocclusive episodes (VOE) remain relatively common diagnoses in pediatric ICUs. This Concise Critical Appraisal explores an article in which Onalo et al completed the second phase of their work determining the role that L-arginine treatment may play in the cardiopulmonary status of children with SCD and VOE, with or without ACS. In the first phase of their work, the authors demonstrated decreased hospitalization time, decreased opioid use, and the absence of serious adverse events in children with SCD after receiving L-arginine therapy.
The COVID-19 pandemic created a new challenging environment in which healthcare workers must survive. Before the pandemic, healthcare workers experienced burnout due to resource allocation and shortages, mental anguish, and long work hours. The pandemic further exacerbated this situation, creating a new crisis within our already frayed healthcare system. This Concise Critical Appraisal dives into an article published in Critical Care Medicine that reviewed the causes of burnout and the correlation between the COVID-19 pandemic and workplace burnout.
Has the rate of venous thromboembolism (VTE) in children changed over time? A 2009 study reported a 70% increase in VTE in acutely and chronically ill children. The reasons for this increase were not clear but were postulated to be related to improved survival of critically ill children, increased use of central venous catheters, and increased prevalence of adolescent obesity. This Concise Critical Appraisal dives into a 2022 article that sought to determine whether the rate of VTE continued to increase between 2008 and 2019.
Recently published guidelines have replaced the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). This Concise Critical Appraisal examines the previously reported recommendations and evidence, reviews the ERC-ESICM updated recommendations, and highlights the areas that still lack investigation and clarity.
Does your hospital use a checklist or bundle to minimize risk factors for delirium? Delirium is common in surgical and medical intensive care units (ICUs) and has shown to be associated with longer mechanical ventilation duration and longer ICU and hospital lengths of stay. This Concise Critical Appraisal explores a study that evaluated a multicomponent nonpharmacologic quality improvement intervention aimed at the sleep-wake cycle for reducing delirium in critically ill patients in the surgical critical care setting.
This Concise Critical Appraisal highlights an article in Pediatric Critical Care Medicine that sought to determine the association between invasive mechanical ventilation—a known predictor of adverse outcomes in children—and subsequent new neurodevelopmental and psychiatric disorders after pediatric intensive care unit hospitalization by reviewing Texas Medicaid Analytic eXtract data.
Tracheal intubation is a high-risk procedure that is frequently performed in the emergency department and intensive care unit. Failure of first-pass success (FPS) when intubating has been shown to be associated with major adverse events, so maximizing FPS is paramount for improving patient outcomes. This Concise Critical Appraisal explores a study published in JAMA that sought to determine the effect of using a bougie (tracheal tube introducer) versus an endotracheal tube with stylet when intubating.
Although several trials have examined in-hospital cardiac arrest (IHCA), only two trials in the past decade have examined the use of vasopressin and glucocorticoids for IHCA. Both trials found improved survival and favorable neurologic outcome with a vasopressin-epinephrine-methylprednisolone combination. Because of a lack of additional supporting evidence, neither the American nor European international guidelines have recommended this combination for IHCA. This Concise Critical Appraisal examines an article by Andersen et al that attempted to validate the results of these trials.
This Concise Critical Appraisal explores an article published in Critical Care Medicine on a program at Cooper University Hospital in Camden, New Jersey, USA, that implemented a previously published successful ECMO model, in which ECMO cannulation primarily performed by cardiothoracic surgeons is transitioned to medical intensivist-led cannulation. This article is significant in advancing the role of the medical intensivist in the cannulation of patients who require ECMO.
The average annual incidence of pediatric in-hospital cardiac arrest (IHCA) has recently been estimated at more than 15,000 cases.1 Survival rates for pediatric patients who have had pulseless cardiac arrest have remained below 50% for the past decade.2,3 The American Heart Association currently recommends epinephrine, the cornerstone medication for cardiac arrest, dosed every 3 to 5 minutes in adult and pediatric cardiac arrest, although there is conflicting evidence about whether this is the best interval.4,5 Epinephrine is believed to acutely increase coronary perfusion pressure by increasing diastolic blood pressure (DBP).
This Concise Critical Appraisal explores an article in The Lancet Respiratory Medicine that evaluated the efficacy of awake prone positioning to prevent intubation or death in patients with severe COVID-19. This meta-trial used a new study design that allowed for the combination of six simultaneous national randomized, controlled, open-label trials.
Clostrididioides difficile infection (CDI) occurs in about 4% of ICU patients, causing fulminant colitis and death in nearly 60% of symptomatic critically ill patients, so it is imperative for ICU professionals to stay abreast of the evidence-based advancements of CDI management. In June 2021, the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America updated their recommendations on the management of CDI in adults. This Concise Critical Appraisal offers a review of the updated guidelines.
Invasive bedside procedures (IBPs) require a high degree of familiarity and skillful expertise. Yet effective and thorough bedside training can be haphazard or unattainable. Chest published a systematic review and meta-analysis that highlights gaps in research on IBP training in critical care. The study included four focus groups of pulmonary and critical care medicine faculty and fellows from four U.S. medical centers. The focus groups identified traits, behaviors, and context as common themes of effective teachers. This Concise Critical Appraisal takes a deep dive into the study and the takeaways for experts and novices seeking to improve procedural knowledge and increase patient safety.
How can clinical information gleaned from focused cardiac ultrasound (FCU) be used to augment clinical assessments in children with suspected septic shock? This month’s Concise Critical Appraisal analyzes a study published in Pediatric Critical Care Medicine that sought to show how often a clinician’s hemodynamic characterization of a child with septic shock was altered by FCU and to further validate an expert-developed algorithm for these assessments.
Bedside echocardiography has become increasingly widespread among physicians caring for critically ill patients. The Examination of Special Competence in Critical Care Echocardiography (CCEeXAM) was administered for the first time in 2019 to 524 physicians from multiple specialties. The examination was designed for physicians to demonstrate an objective competence and obtain certification in advanced critical care echocardiography (CCE).
The updated Surviving Sepsis Campaign (SSC) COVID-19 guidelines are now available, reflecting the learnings from the latest major studies. This month’s Concise Critical Appraisal dives into the update to outline the changes and new recommendations made by the international panel and discusses limitations of the available data.
The medical community has faced many challenges as a result of the COVID-19 pandemic, including ensuring continued medical education in the face of social distancing guidelines and the increased workloads of faculty and trainees. This Concise Critical Appraisal explores an article published in ATS Scholar that sought to outline distance learning options and develop a practical framework for transitioning content to a virtual platform.
This Concise Critical Appraisal delves into a study published in Pediatric Critical Care Medicine that sought to determine whether early hemostatic intervention can prevent the development of DIC and improve outcomes.
The ARREST Trial compared extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation to advanced cardiac life support (ACLS) treatment in patients with out-of-hospital cardiac arrest (OHCA). This month’s Concise Critical Appraisal takes a deep dive into the trial, published in The Lancet.
Is cardiopulmonary resuscitation (CPR) futile in hospitalized patients with COVID-19 experiencing cardiac arrest? A study recently published in Critical Care Medicine sought to answer this question and provide more data around outcomes of in-hospital cardiac arrest in patients with COVID-19.
Dive into a study that evaluates a standardized process of using rapid exome sequencing to help diagnose critically ill children with suspected genetic diseases in this Concise Critical Appraisal.
This Concise Critical Appraisal offers a look into the results of the RECOVERY trial published in the New England Journal of Medicine, which demonstrated that dexamethasone improved mortality in hospitalized patients with COVID-19.
This Concise Critical Appraisal offers a deep dive into the HALT-IT trial, which investigated whether early use of tranexamic acid to treat acute severe gastrointestinal bleeds would reduce overall mortality while limiting the burden of thromboembolic events.
Can the biomarkers identified in the Pediatric Sepsis Biomarker Risk Model (PERSEVERE II) be used to predict acute kidney injury and renal recovery in pediatric septic shock? This Concise Critical Appraisal explores a study in which Stanski et al (Am J Respir Crit Care Med. 2020;201:848-855) sought to answer this question.
This Concise Critical Appraisal explores a Lancet Respiratory Medicine article by Ramanathan et al, which outlines how to plan for extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress syndrome (ARDS) related to COVID-19. ECMO is a complex therapy usually restricted to specialized centers. World Health Organization guidelines suggest that carefully selected patients with ARDS may benefit. The authors explore how good planning can help during outbreaks of emerging infectious diseases.
What is the benefit of early versus late nutrition in critically ill children? In this Concise Critical Appraisal, Daniel E. Sloniewsky, MD, FCCM, offers a deep dive on this Pediatric Critical Care Medicine article by Srinivasan et al, which sought to answer this question using data from the Heart and Lung Failure-Pediatric Insulin Titration (HALF-PINT) study.
Villar et al (Lancet Respir Med. 2020;8:267-276) attempted to demonstrate the effect of steroids in patients with moderate to severe acute respiratory distress syndrome (ARDS) along with modern standard ICU practices, including lung-protective mechanical ventilation.