Intensive Care Medicine - Science topic

This particular child presented with viral myocarditis with HFrEF which was non-responsive to dobutamine. Milrinone was added and dobutamine was tapered and stopped. With inotropic support, BP was maintained between 5-50th centile. In your opinion, what score should be given to this patient? Should it still be 4 as this does not fit into catecholamine-resistant shock as per the ACCCM algorithm?

Could you please share the link to the online pediatric SOFA calculator that takes milrinone into consideration?

Fluid management is a very complex issue.

There are many confounding factors including co-morbidities such as heart failure, liver disease and renal impairment.

It is important that management is individualised on a case by case basis.

Yet to be developed

Different methods available for recruitment most commonly employed are...

1.High PEEP

2.Prone ventilation

The clinical significance of the selected parameters is related to the initial condition of the patient and the disease. Any sustained positive dynamics should be considered clinically significant.

Thats really kind of you - thanks a lot

You can see on North American Association of Neurology and Neurosurgery Guidelines

Currently I am living in Bolivia and most of the Hospital don´t count with those services in ICU.

In Brazil there is a law that determine the presence of some of those professional (PT for example) 24/7. But that doesn´t translate into practice.

Interesting..

A good clinical study to explore, possibly by comparing pre and post implementation data, but also keeping in mind some other factors that may impact the outcome.

Thank you Rainer. Looking forward to any feedback!

Dear Spiros,

thank you for sharing with us your research. Our project is not yet aimed at providing direct clinical recommendations, but rather at developing a technology to quantify lung aeration with MRI similarly to what is done with quantitative analysis of CT scans, but without ionising radiation exposure.

We are open to new collaborations and in case you are interested in assessing the possibility to join our efforts feel free to contact me in private.

Thanks again for your interest,

Lorenzo Ball

I am sorry to hear that this has happened to your mother. Hoping that she  will be better in near future. 

For the ARDS:

Ventilator aspects: recruitment maneuver, prone position ventilation, high PEEP

Drugs: diuretics, hormones, etc.

Extracorporeal Life Support: ECMO

Treatment of etiology: control of primary disease is very important.

"Although aspirin increased the incidence of bleeding by 50%, it did not increase the severity or perioperative morbidity/mortality, except in intracranial surgery and, possibly, transurethral prostatectomy".(Burger W, et al.  meta-analysis. J Intern Med 2005; 257: 399–414.)

The limitations of the TISS-28 is it is based on how we provided critical care 20 years ago. A great deal of nursing care has changed since then that are not captured in the TISS-28. For example we keep patients more awake, promote more mobilization than before yet these items are not captured in the TISS-28.  I would argue, because it misses important advances in critical care, it has a tendency to underscore workload. 

Saying that, this tool does have a lot of validity and reliability evidence in ICUs around the world. 

Regarding the elderly patients there are some kind of problems in my opinion:

Among European nation there are some different ethical problem regarding end-of-life decision, religious and economic issue. Therefore there is an organizational problem, it is different when patient is admitted to ICU in an University Hospital or in a Community one. Then there are clinical issues elderly patients admitted to ICU after elective surgery have a better early and long term outcome than elderly admitted for unplanned surgery or medical problems. So, maybe, would be necessary a sort of score which can help physicians to chose for admitting elderly patients in ICU.

It depends if the patient is mechanically ventilated or spontaneously breathing. Beside the clinical signs of dehydration, leg raise test associated with change in pulse pressure or cardiac output (by CO monitor or echo) is a good test. Most studies define fluid responsiveness as increase in CO/SV by 10-15%.

In mechanically ventilated patients, we use the heart-lung interaction and positive pressure ventilation, either by IVC assessment by echo (collapse more than 12%) or stroke volume variation (LIDCO). PICCO also is of great help.

Fluid responsiveness is a dynamic test and should be repeated through the management till the shock state had been resolved.

you may try the comparison of the ROC of the two groups you want to compare, but they may appear quite similar according to the lower 95%CI. Bonferroni correction is not required for a comparison of two populations.

Dear Muralidharan R.s.,

It is really a very sad story.

Since the topic is so interesting I have copied some important text to shed light on this kind of illness:

Acute febrile illness is the medical term used to describe a sudden fever or elevation in body temperature. This happens when the body is invaded by a pathogen and the immune system is activated to fight it off. Read more to learn about the symptoms and treatment options.

When the body is invaded by a foreign pathogen like a virus or bacteria, the immune system kicks into gear and tries to fight the infection before it has a chance to spread. When this happens, the body's temperature is elevated to try to kill off the pathogen, and this results in what we call a fever. Acute febrile illness is when a fever develops suddenly; specifically, the body temperature rises above 37.5 degrees Celsius (99.5 degrees Fahrenheit).

If you've ever been sick, you've probably experienced having a fever, and you know how hard it can be to determine the underlying cause. Acute febrile illness can occur whenever the body is invaded by some type of infectious disease, but it is especially worrisome in tropical and sub-tropical regions where serious diseases loom. These can include malaria, dengue, typhoid, chikungunya, Leptospirosis, scrub typhus, influenza, encephalitis, histoplasmosis, enteric fever, rickettsiosis, Hantavirus, and many, many others. Specifically, the hypothalamus is the part of the brain responsible for regulating body temperature, and it may 'decide' to elevate body temperature in response to an infection.

In addition to causing elevated body temperature, acute febrile illness can be accompanied by headaches, dizziness, sweats, chills, muscle pain, joint pain, and weakness. Sometimes it's also affiliated with respiratory symptoms like coughing or wheezing. A fever in itself isn't necessarily cause for alarm; however, it becomes problematic when the body temperature gets too high or lasts for an extended amount of time.

In infants or very young children, fever may be accompanied by seizures (called febrile seizures). These are generally harmless (although they can be very scary to witness), though it's recommended to take children to the doctor the first time they experience a febrile seizure. They can be recurring, so it's best to make sure they aren't indicative of a more serious cause.

Rafik

The above links are two examples of studies conducted in Australia to determine the effectiveness of an organised response to clinically deteriorating patients in hospitals.  They may add something to your inquiry.

PC protects from high airway pressure. Lung damage comes from high trans-alveolar pressure, which may happen if there is a large inspiratory effort (ie, Pmus adds to Paw). We are talking about simple, set-point targeting of PC modes. You could choose to use adaptive targeting in PC (eg, PRVC or VC+ modes). It all depends on what your goal is. There are only 3 goals of ventilation, safety (gas exchange and lung protection), comfort (patient-ventilator synchrony), and liberation (minimize time on vent). The choice of mode, not just PC vs VC depends on your assessment of the patient's need and hence your clinical goal. There is a rational approach to selecting modes. See attached paper.

see attached

thanks a lot for your generous response Dr Dimitrios and Dr Stany.

we are using betadene scrub bath for the purpose

While correct in concluding that Bland-Altman is not appropriate, I'm still not sure your reasoning in strictly correct.  Even "theoretically", the 3 compartments will probably not be in equilibrium. You might want to review your respiratory physiology notes, particularly the notion of ventilation-perfusion (VQ) mismatch. Imagine a blocked alveolus, which sees no gaseous isolflourane (V = ventilation = 0). There is still arterial blood flow (Q = flow  > 0), but it will not equilibrate with the inspired isoflourane. This happens to lesser degrees even in normal lungs, where VQ mismatch results in blood that is not equilibrated with inspired O2  return to the left heart via the pulmonary veins, which will now have a lower concentration than the alveolar gas. Depending on the gas (oxygen, CO2) and the corresponding solubility of the alveolar-capillary barrier, it may also contribute to lack of equilibrium. But in any case, you can't test for equality between them, since they are fundamentally different quantities. If you only had two variables, you would use some form of correlation coefficient for continuous variables. In fact, with only 3 variables, you might simply report pair-wise correlations (arterial with inspired, venous with inspired, arterial with venous), as long as you adjust for multiple comparisons. 

But I suggest you pick up a good text on the biostatistics and read about inter-rater agreement when the > 2 outcomes are continuous numeric. The 2005 Encyclopedia of Biostatistics (Wiley) has a brief (14 pages) chapter by Shoukri on "Agreement, Measurement of" that states:

The "class" in this case is the subject being studied and the "clinicians" or "raters" are the 3 different measurements (this is a bit confusing, since we're not really looking at agreement here, but the analogy should be clear :). In your reading, you will discover that there are actually 6 different types of ICC depending on your specific experimental design. I think it would be good for you to try to understand which best applies to your trial before asking this list. The distinctions are important, and you will be able to ask a better question if you first understand your experiment. 

Atul

————————————————

Atul Sharma MD, MSc, FRCPC, M.Stat

Senior Consultant | Biostatistics Group | Data Science Platform

George & Fay Yee Centre for Healthcare Innovation

University of Manitoba

Despite the already excellent and thorough  responses to your relevant question I would like to add some comments. 

Transition to spontaneous breathing in ARDS patients is one of the most difficult parts of their ventilatory treatment and the point in time to do so is still under debate. 

It is impossible to set fixed rules but was has been discussed so far are all good advices. It is important to have the precipitating cause of ARDS under good clinical control and to have witnessed an improvement in lung function such as less needs for FiO2, increasing compliance, decreased PEEP needs to maintain the same ventilation targets. It is very difficult to give general threshold values  as this vary from patient to patient. This improvement is generally seen after 2 - 3 days of controlled lung protective mechanical ventilation. 

The transition to spontaneous breathing has to be smooth as the lung is still  very susceptible to suffer from mechanical stress and it is essential to prevent a second hit mechanism at this stage. 

So independently of when it is decided to transit the patient to spontaneous breathing the following must be taken into account: 

Avoid patient-ventilator asynchrony by choosing modes or settings that enhance synchrony. 

Check for increased work of breathing. Prevent the patients from vigorous inspiratory efforts or high respiratory drive as this may cause large transpulmonary pressure changes in different regions of the lung. If this cannot be controlled it might be too soon to transition the patient to spontaneous breathing.   

Controlling tidal volumes is difficult as patients are contributing with their own Pmus Compliance is hard to interpret as the ventilator does not "see" the patient's contribution. In this circumstance a smooth breathing pattern and a low driving pressure may be the best indicators of an appropriate spontaneous breathing. 

What is this going on sir? These really don't suits you to you guys .You both have given lots of things for our anaesthesiology. Please don't ....

Glutamine is the most abundant free amino acid in the body, but its stores are rapidly depleted during critical illness or injury, including burns. Critically ill patients often have decreased glutamine level on ICU admission, and low plasma glutamine levels are associated with increased mortality.

However, the recent REDOXS trial showed a dramatic increase in mortality rates with high doses of enteral and parenteral glutamine (0.6 g/kg per day). Even though there were more patients with three or more organ systems (including renal failure) failing in the glutamine group than in the control group, a strong trend toward increased mortality with glutamine remained after adjustment for this. In another study (van Zanten ARH et al. JAMA, 2014), high-protein enteral nutrition enriched with glutamine and ‘immune-modulating nutrients’ did not reduce infectious complications or improve other clinical endpoints versus standard high-protein enteral nutrition and may have been harmful as suggested by an increased adjusted mortality at 6 months. Therefore, it's necessary caution untill the mechanisms behind the harmful effects reported in the REDOXS study are better understood.

Please check out the landmark article by Cook et Al in NEJM. It looked at the risk of developing stress ulcer in critically ill patient. In multivariate only two conditions increased the risk of stress ulcers mechanical ventilation greater than 48 hours and coaguloapthy.

The American Society of Health System Pharmacist publish the most widely accepted guidelines for stress ulcer prophylaxis. New guidelines are expected soon. 

Finally, please see the article H2RA vs PPI in JAMA 2014 By MacLaren and colleagues that found higher incidence of hemorrhage, pneumonia and CDI with PPI over H2RA. 

As a side note considering administration- PPI cannot be crushed and given via an NG tube. Special formulations must be used or IV. H2RA, however, can be crused. Using the oral formulation via NG tube can offer a significant cost savings. For example, oral famotidine is ~1/50th the cost of IV pantoprazole. 

I work in a residential facility with individuals who have dual diagnosis (MR and other diagnoses, i.e., CP; ASD; Blind; Deaf; Deafblind; Nonverbal, etc.) and I am the chair of the Dysphagia team.

The standard in our facility is to ensure oral hygiene twice daily (morning and night).  I, of course, do not feel that this is adequate; especially for those who have or are at risk for aspiration and aspiration pneumonia.  Our team directs that all individuals who are under the care of the Dysphagia team receive mouth care pre and post-oral consumption with pre-consumption mouth care being defined as "checking mouth for any foreign matter and clearing mouth of all debris as well as providing a sip of a cool fluid to ensure that the mouth is not too dry to consume" and post-consumption mouth care as full hygiene including tooth brushing.

I believe that a lot more needs to be done in the area of oral hygiene--people tend to forget that the mouth is one of the best places to start in decreasing the risk of aspiration pneumonia (as well as allowing a free water protocol to be put in place which I would not feel comfortable beginning until I knew that appropriate mouth care is being provided to all who reside in this facility).

Lancet. 2005 Jun 18-24;365(9477):2091-7.

Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial

This study probably describes not how to do it. The event rate in many of the smaller hospitals was too low which dramatically reduced the studies power to detect any effect of ICU led rapid response teams.

As a Trauma Surgeon there are ample data that support the early administration  of plasma and platelets  for the critically injured trauma patient.  This may not be relevant to the critically ill medicine patients.

Sadly none of the instruments/laboratory assays provide an adequate real-time picture of the patient's coagulation status.  Even from TEG and ROTEM have issues related to patients with depleted fibrinogen stores and more importantly cold patients.  Many critical care physicians failed to recognize that when a battery of coagulation tests  are drawn and sent to the laboratory the laboratory warms the sample to 37°C.  Trauma patients owe as much as 50% of the coagulopathy to hypothermia.

Consequently, the answer is clinical judgment.  As a clinician you must take into account the injuries with their estimated blood loss and the patient's temperature and premorbid complicating medical conditions to determine when to give plasma.  As a rule sooner is better than later and warmed is better than cold.

On a separate note we are currently using type A plasma in addition to AB plasma.   The safety of this has now been documented but originally stems from the use of uncrossed matched platelets which carry with them a significant plasma store.  I'm curious how many facilities have liberalize their use of type A plasma to expand the store of fresh plasma for their trauma patients?

Respectfully

John

Thank you for the reply. I am doing a research on number of days neonatal infants received Albuterol treatments while placed on conventional vent versus high frequency oscillator.  If the mode of ventilation does play a role on these infants that require bronchodilator therapy. 

Flexible Fiberoptic specially awake intubation (if applicable) is the safest.

Hi,

very nice reviews from Vinh, Lancet Infect Dis 11; Kuhns, DB, NEJM 2010 and Falcone Curr Opin Infect Dis 12. Watch out mainly from Gram (+) indeed but also mold infections and especially breakthrough fungi since those patients are under long-term antifungals.

See u,

Medical diagnosis is something more complicated than just to takeoff. Checklist are appropriate for repetitive situation requesting a stereotyped verification. Safe surgery checklist is a good example of it. You can find specialysed checklists addressing specific diagnostic situations: if you collect all of them, you'll have a big textbook in your pocket. A different approach is to focus on the situation leading to error and on the cognitive bias that can favorize errors. Mark Graber proposed a very simple checklist that can alarm you if you are in a situation at risk:  Graber ML, Sorensen AV, Biswas J, et al. Developing checklists to prevent diagnostic error in Emergency Room settings. Diagnosis 2014;1:223-31.

"Depth, Rate of Chest Compressions During CPR Impact Survival in Cardiac Arrest" -  Febbraio 6, 2015

DALLAS, Tex -- February 6, 2015 -- The depth of chest compressions and the rate at which they were applied make a significant impact on survival and recovery of patients, according to 2 studies published in Circulation and Critical Care Medicine.

Contrary to popular belief, the studies showed that cardiopulmonary resuscitation (CPR) compressions deeper than 5.5 cm resulted in decreased survival, possibly because of collateral damage to other internal organs.

Previously, investigations and guidelines indicated that deeper compressions were better. The American Heart Association's (AHA) 2010 CPR guidelines recommend compressing the chest at least 5 cm without providing any upper limit.

“Most people do not recognise that it takes quite a bit of thrust to compress the chest 2 inches,” said Ahamed Idris, MD, by UT Southwestern Medical Center, Dallas, Texas. “About 60 pounds [27 kg] of pressure are required to reach this depth, but in some cases a burly fireman or well-intended volunteer can go way past that amount, which can harm the patient.”

The researchers also found that the rate at which chest compression was applied was most important. Compression rates of 100 to 120 per minute were optimal for survival when other factors were considered.

“Survival depends on the quality of the CPR,” said Dr. Idris. “Both the depth of chest compressions and the rate at which they are applied can have important results for patients in the first moments of cardiac arrest.”

About half of responders are giving chest compressions too fast, with about a third above 120 compressions per minute, and 20% above 140 per minute, said Dr. Idris.

The researchers will continue to oversee innovative clinical trials to test the early delivery of interventions for serious trauma and cardiac arrest as part of a federally funded consortium aimed at advancing prehospital emergency care.

The Resuscitation Outcomes Consortium (ROC) has enrolled tens of thousands of patients to test prehospital interventions to improve outcomes in severely ill or injured patients before they are transported to a hospital.

I know your question was human based, but in vet medicine, we also use dexmedetominie for boththe sedative effcts as well as the analgesic effect. We recently have started suing very low doses of alfaxalone (alfaxlone in cyclodextrine) which seems to be better than propofol in termes of resp depression. In terms of pain in particular, we tend to use lignocaine and ketamine infusion, in addition (or not0 to opioids. Do you do similarly in human?

For those of you who maybe interested in holistic medicine, some anaesthetist use in animal an acupuncture point which, apparently may help with ventilation: GV 24...but it seems they use to stimulate breathing during recovery from anaesthesia, while weaning from the ventilator...not sure it will halp in terms of increasing ventilation in an alrady breathing aptient.

For renal transplant recipients, we use Epidural Anesthesia and use fentanil with ropivacaine 0,2% In PCA post operatively. For donor, we use thoracic epidural in conjuction with GA.

Dear Paulo:

ICC, CCC and Bland-Altman are methods to assess reliability with continuous data.

CCC is identical to some ICC.

ICC has several advantages: global assessment of reliability since it combines both bias error and random variation into a single coefficient; besides that, it is possible to evaluate the agreement when there are more than 2 raters.

The main disadvantage: ICC is quite affected by the heterogeneity of the sample and commonly shows very high values that may be biased (In a recent study, we found ICC values of 0.58 -first tertile-, 0.28 -second tertile- and 0.46 -third tertile-, whereas ICC on the complete series was 0.90!!)

The Bland-Altman plot is a good method to know the distribution of differences, the heterokedasticity, limits of agreement and repeteability coefficient.

My suggestion is the use of both the ICC and the Bland-Altman method.

Regards.

We do not have such a small age of Chiari malformation undergoing surgery but we do perform about a dozen cases from 1994 in our hospital, often with correction of scoliosis. Smallest age is 13 y.o.. No particular attention for us, anesthesiologist, although a theorical difficult airway and M.H. incidence...thanks God we do not encounter although I remember one of them has a combined Klippel Feil and Sprengel deformity. None of them have CV abnormalities. Complications encountered are: CSF leak, meningitis but no fatal outcome..   

You should specify which patient are you talking about (i.e. neurologic, septic, etc.). In general, there is no need for endocrine tests unless history and the clinical condition suggests a specific deficiency. Even in septic shock, low dose steroid treatment can be initiated without the need to test for adrenal insufficiency (see FunkD. et al. Low-Dose Corticosteroid Treatment in Septic Shock: A Propensity-Matching Study. Crit Care Med 2014; 42:2333–2341).

Thank you Ali for your input on this subject, I will read them with interest.

Have never used it, coz this is the place where it can be carried to CNS and its vital tissues directly. However, in the epidural route and peripheral blocks the absorption characteristics are variable. But free accessibility of this drug to CNS structures while floating in CSF has not been studied extensively and mainly Indian studies are available only. Even the dose calculation is little weird when it is used intrathecally. Concerns from FDA are likely to come up soon regarding its intrathecal use.

I think, central pumping has its own merits and demerits. Especially for critically ill patients, therapeutic approach is individualized and as such setting central pumps will prove very costly particularly in ICU. Can be considered in general wards but sill i think initial cost will be very high and their potential utility in long run also depends upon so many clinical and economical factors which can prove to be limitation for such a costly set-up

 Not so dificult,.In our depatrement anesthesiologist to do percutaneous tracheostomy. I agree- 5-10 supervised is enough to independently work.

The debate about feeding and haemodynamic stability is totally superfluous. Most often when patients are unstable, we are concerned with resuscitating them and often the gut is forgotten! We only think about the gut as a 'secondary organ system' and when we have 'resuscitated' the patient and can step back, do we think of nutrition! But what is resuscitation? Is it a set haemodynamic end points? Is it normalisation of acid-base status, normal or near normal pulmonary gas exchange (i.e. a near normal PO2) or return of urine out put? So, in my view the debate should not take place at all. Sick patients (as we see them in ICU) are more often than not nutritionally challenged as they may not have eaten for a few days (at home) or not been fed on the hospital floor before ICU admission. Either way, feeding (high fibre or not) IS PART OF HOLISTIC RESUSCITATION of the patient!

We have been using citrate (first, homemade concentration of 30%) for more than 10 years (right now citrate 4%for compliance with european regulations purposes) with efficacy and security, provided nurses and junior doctors receive prior teaching. Heparin systemic administration is parallelled only in specific cases (ECMO..).

Be glad to help. Let me know.

Allen

The question is Mannitol versus Glycerol?

Why not Hypertonic saline ??

The benefit of Glycerol on acute stroke is not well established, its benefit on acute brain traumatism injury remains questionable, however some have recommended it’s orally use after a mannitol challenge.

In contrast to Glycerol, Mannitol benefits are evident, and thus WAS CONSDERED as the gold standard.

Recently, its detrimental effect of on mortality when compared to Hypertonic saline has been highlighted (Cochrane 2013), thus we may prefer sodium lactate (Ichai C et al ICM 2009)

Il mio piacere!

Normothermia 36ºC should be the end point after cardiac arrest based on the most precise RCT performed till nowadays (TTM trial).

N Engl J Med 2013;369:2197-206.

The question could be...should we cool all our patients after cardiac arrest or only those whom present temperature above 37ºC...?

So I pose the question..

Without US, how can you determine;

1) the vessels patency

2) the vessels pathway

3) respiratory variation/haemodynamic stability of the vessels

If you had a thrombosed R)IJ, then you would not know until you had already tried the procedure i.e punctured the vessel (on possibly more than 1 attempt, and had a likely failed guidewire feed).

US would allow the clinician to determine the vessels 'state of health' before even commencing the procedure, therefore reducing the risk of possible inadvertent thrombus dislodgement.

hi karen,

interesting question ...

i don't know how detailed you want/need to know this. as far as i remember according to typical physiology books: normal intrathoracic negative pressures during spontaneous respiration are between -5 to -20 cmH2O, and i assume it will be similar in the trachea, however, i do not know the exact pressurue gradient lowering this value in the trachea, apparently it has to be higher than in the alveoli to keep air flowing. however in obstruction maximum numbers such as -140 cmH2O have been observed.

christoph

In our institutional experience, when the biopsy is done for a patient who is in an outpatient setting it usually provides useful information and a therapeutic change for over 50% of the patients. For critically ill and mechanically ventilated patients that require high PEEP and FiO2, perhaps it is too late and surgical intervention not only adds insult to injury but also doesnt change much in terms of therapy. Our mortality rate for outpatients is 0% and for ICU patients jumps to 45%.

I am surprised with your results.! Which persons (nurses, interns, paeditricians or neonatologists) in your NICU staff are responsible for setting UVC? Do you have a control group (infants without UVC)?

Dear Hans

I hope this part be useful for you ...

Many hypothermic patients have severe infections or other life-threatening illnesses. Patients with "uncomplicated" hypothermia (often due purely to cold exposure) have a fairly low mortality rate; patients with significant associated diseases have a much worse prognosis. ln terms of ultimate outcome, the underlying disease process is far more important than the initial temperature or the rewarming method chosen.

Therefore, evaluation and treatment must include a search for associated diseases as well as management of the hypothermia itself.

If asphyxia or near-drowning precedes the development of hypothermia, the prognosis is very poor. If asphyxia has not occurred, the protective effect of hypothermia may have an important influence on prognosis. Decreased oxygen requirements can protect the brain and other organs against anoxic and ischemic damage. This means that the usual criteria indicating death or irreversibility of disease are not valid in the hypothermic patient, who may even survive prolonged cardiac arrest without neurologic sequelae.

Tintinalli's Emergency Medicine(2011), Section16: Environmental Injuries, Chapter203: Hypothermia, Page 1338.

Usually journals want to get the full article at once: the abstract will be a part of the full article. Also, every journal has its own standards for abstrats: is some the length is maximum 100 words, in some, 250 words, some journals want to get a 'structured' abstract (the aim, data, results and implications all separately). So, you still need to find a suitable journal and then read its instructions for authors (every journal has its own instructions, and they can be very different: allowed paper length, the way how to format the list of references etc. can differ a lot). Also, look at the papers published there: what their authors have written in their abstracts.

Foreign body aspiration (FBA) is one of the main causes of accidental death in childhood. Most studies show that fewer than 15% of foreign body aspirations occur among children older than 5 years of age. Boys comprise more than 50% of all cases of foreign body aspiration. It’s largely preventable, and the morbidity and mortality associated with it can be significantly reduced by public education (especially parents, caretakers and families) and legislation.

Educational campaigns carried out through television and radio broadcasts, articles, and interviews in newspapers especially vernacular newspapers and educational programs at pediatric outpatient departments and wards using audio visual aids can increase community awareness about the dangers of FBA.

Most importantly, physicians and health workers can play a significant role in spreading awareness about FBA in the community. Sensitizing the community toward the need of awareness regarding FBA through educational campaigns involving mass media and stricter measures if taken by the primary care givers can drastically reduce the morbidity and mortality associated with FBA.

I am pleased to share this link with you.

As an Emergency Physician i find it a very useful device to have and effective in fluid depleted patient requiring critical resuscitation .

The key is expertise in scanning as always error of judgement is there as it i soperator dependent .

I don't have experience using Niccomo, but I have some using Nicom which is similar. I think that it could be a good monitoring for typically anesthetized patients but not really for septic patients. Indeed, the analysis is based on the amount of fluid in the thoracic cavity, which varies a lot during resuscitation of septic patients. Moreover, I am quite sure that you are inserting arterial and central venous lines to treat your septic patients. So, once you've already inserted those lines, why not use a more invasive monitor like Picco or another thermodilution monitor which is definitely more precise?

To conclude, I think that Nicom or Niccomo are good monitors when you really need a minimally invasive monitor like in the OR.

Accordingto the data published by Mascia (JAMA, 2010, 304, 2620),we use volume control ventilation with VT 6 to 8 mL/Kg, PEEP 8 to 10 cm H2O (according to the hemodynamic tolerance and respiratory mecanics (we use the stress index). We use CCS for trachal aspiration and performed the apnea test in CPAP. RM were performed after each disconnection.

I'm a cardiac anesthesiologist and my expertise is in the field of cardiac surgery. My experience with PDE3 inhibitors has been changed over the time. In the early 90' the scenario in our adult and pediatric intensive care units was completely different from the actual one. Patients in those years tipically come out the operating room extremely cold because of the hypotermic arrest with systemic vasoconstriction with very high SVR and low CO. We had the idea that much of the effect of Amrinone or Enoximone on CO was due to their vasodilatory effect. Still then it was possible to note some difference between that drugs being Amrinone much more a vasodilator than an inotrope while the inotropic potential of enoximone was much more evident. However time goes by and fortunately surgery technique has been changed, ECC has been developed and also patients and their preoperative therapies are different from those we had in that time with much more betablokers and ACE inhibitors use. Therefore the scenario has been profoundly changed and now we tipically have to treat patients with normal or low or very low SVR and sometimes low CO. Now I can say that enoximone is really a good inotrope independently by its vasodilatory effect. Nowadays the systemic vasodilator effect of enoximone and the consequent hypotension is quite an adverse effect that we usually have to counterbalance it with vasoconstrictors. In my actual experience norepinephrine is most used to avoid excessive hypotension in an abnormally vasolilated patient, expecially during bolus infusion and is often needed. In conclusion I believe that the effect of Enoximone on CO derives by its own inotropic effect. In vasoconstricted patients however an indirect effect driven by dilation has to be considered. To note that in patiens with isolated right heart failure with high pulmonary vascular resistances PDE-3I have the best effect. In those patients the dilation of the pulmonary vascular bed toghether with the direct inotropic effect on myocardiocyites produces a great improvement of the right cardiac output as it is typically seen by TEE and if the left ventricle is normal or quite normall we usually observe a global improvement in cardiac performance without hypotension.

As Stephen Lapinsky correctly states the contribution of the PEEP to the value of the CVP depends on the compliance of the lungs, and unless further montoring is undertaken this is unknown. Even oesphogeal pressure ( difficult to do and interpret) may not reflect the "global"transmission of PEEP to the venous return.

However if the CVP response to fluid challenges are followed, it is possible to detect the point at which further fluid results in rapid rises in pressure , suggesting the steep part compliance curve have been reached. This pressure differs between patients , over time and with PEEP. A rise of > 5cm H20 ten minutes after a fluid bolus of 500ml suggests further fluid loading will not improve the ability of the Right heart to increase cardiac output .

For me, how often you use it depends very much on the criteria that you use to decide whether the patient is a candidate for awake intubation, in other words - patient selection. Fourth National Audit Project in the UK stated that awake intubation was not used when indicated in a number of cases that ended up as major disasters of airway management (ischemic brain damage, surgical airway, intensive care admission and death).

I agree that it needs to be practiced regularly so I suggest that fibreoptic scope should be used instead of Macintosh laryngoscope for intubation of any patient who is having general anaesthesia and requires tracheal tube placement for their surgery (providing patients have normal airway and are not aspiration risk).

So you would be using fibreoptic laryngoscope instead of Mac for intubation of a regular patient scheduled to have general anaesthesia and intubation. Although, acquired on anaesthetised patient, the skill acquired this way is likely to increase you confidence in using fibreoptic scope. One of the reasons why British anaesthetists don't use awake fibreoptic intubation often enough was to do with confidence in performing this procedure. This often led to more risky airway management options being undertaken with potentially serious consequences.

Can BIS monitoring be used to assess the depth of propofol

anesthesia in the treatment of refractory status epilepticus?

*Tadeusz Musialowicz, yEsa Mervaala, zReetta Ka¨lvia¨inen, *Ari Uusaro,

Epilepsia, 51(8):1580–1586, 2010

doi: 10.1111/j.1528-1167.2009.02514.x

Dear Raoul. ....

Thanks for your answer. We obtained a resolution of the RSE and we use the dose recomendad by Rosati

Actually the children is under ketogenic diet .

Found some good stuff after rooting around a bit. The baseline TIMI remains the same, the new variables (dichotomous) are added as an in patient

Open access article doi: 10.1161/JAHA.112.003269

ASA published only recently their updated airway algorithm (Anesthesiology 2013; 118:251-70). Current algorithms (ASA, DAS) are very useful, but we found some of them difficult to follow in critical airway situations. We developed our own algorithm which starts with mask ventilation - the first measure the anesthesiologist will try if any problem occurs. We also included all the tools that are available at our institution. I attached a translated version of the algorithm. Any critics? Suggestions?

The problem with treating ARDS using mechanical ventilation is that treatment starts too late in the disease process. We have recently published two papers in a high fidelity clinically applicable animal model showing that preemptive application of the appropriate ventilation strategy actually PREVENTS ARDS. In our first paper (Roy S et al J Trauma 2012) we tested early application of airway pressure release ventilation (APRV) using very precise settings immediately post injury (peritoneal sepsis plus gut ischemia/reperfusion) and showed that we could prevent the development of ARDS. In the second paper (Roy S et al Shock 2013) we compared preemptive APRV with the standard of care ARDSnet low tidlal volume (Vt) ventilation, which was applied late after injury developed. Again APRV prevented ARDS while the low Vt did not stop disease progression and all animals in the ARDSnet group developed established-ARDS. Our efforts should not be at treating established ARDS because it is refractory to treatment. In the recent ALIEN paper by Villar he showed even with low Vt ventilation mortality is still greater than 40%, clearly showing that low Vt is not very effective. Indeed, nothing is very effective at treating established ARDS therefore we must attempt to prevent the disease from occurring. In the paper by Roy et J Trauma we discuss ARDS being a staged disease similar to cancer and the key to reducing ARDS mortality is application of treatment in an early ARDS stage, similar to reducing mortality for cancer.

I agree with Palanikumar. Most of PDT in our ICU are performed with endoscopic guidance/control to reduce major complications like perforation of the posterior tracheal wall, bleedings, cartilage rupture or tracheal tube misplacement.

My second prefered technique especially in patients with short neck is changing to a laryngeal tube and puncture of the trachea with ultrasound guidance. Nevertheless after tracheostomy a bronchoscopic control is done to exclude above mentioned complications.

Although some groups claim that PDT is safe without bronchscopic guidance it increases patient's safety. If you have it - use it.

You can compare this discussion with the threat about ultrasound guided central venous cath introducing. Landmark guided insertion can be safe in experienced hands but ultrasound can decrease complication rate even more.

There is plenty of evidence suggesting that videolaryngoscipes are more successful at managing difficult airway (when difficulty is defined by limited view at Macintosh laryngoscopy). Choosing the videolaryngoscope that you have some experience in using in normal airways is important point mentioned previously as almost all videolaryngoscopes require some adjustment to your intubation technique.

I would disagree though with ILMA (Fastrach LMA) being selected as suitable device for use in failed intubation. This device has to be used with the guidance of fibreoptic scope if it is to be effective (UK DAS guidelines). A number of surveys in the UK pointed towards limited experience with this device. Blind intubation through the ILMA has a success rate of around 80% - not enough for a failed intubation rescue device. Fibreoptic guided intubation through ILMA has much higher success rate but requires significant amount of training before proficiency is achieved.

I would argue that learning to use a videlaryngoscope is much simpler and easier than learning to intubate through ILMA with fibreoptic guidance.

Use of Airtraq and Pentax AWS in the prehospital setting is now well researched and supports the use of these portable devices that are shock and water resistant to a reasonable degree.

There is no precise limit. Some patients may survive for a long time. By and large the cause of death is infrequently respiratory failure , but MODS (multiple organ failure ) is the culprit. if no success in weaning from the ventilator, a tracheostomy should be performed relatively soon . Patients may remain ventilated for years (home ventilation) as long as no other complications arise

Dear Michael, dear Ingo,

thank you both very much for sharing your experience and your preliminary data. It seems more than important to perform prospective multicenter trials in this context. Regarding the possible confounders (e.g., baseline temperature, length of CPR, ...) it would be interesting to know how your results (Michael) are influenced after adjusting the multivariable analysis.

Once again - thank you for your contributions and best regards

Raoul

Richmond agitation sedation scale ( rass ) is an objectively corroborable and reproducible assessment tool under standarized conditions.

In my opinion, the option to use ECMO when you meet a very unstable patients is very useful. I personally have treated some patients with huge posterior VSD (the worst type) after 6 days of ECMO. The aim is to buy time to remodel the haemorragic site of myocardium and to warrant a good operation with very low risk of residual shunt

Reviewing the termination of life support treatment, would you disconnect a mechanically ventilated conscious or semiconscious patient , probably begging you help? (Most probably this was the withdrawn treatment that killed within 15 minutes) I would like to review the definition of euthanasia according to BBC ethics guide as follow: