Van Eaton’s Lucky 13:

Neuro:

Used to be that we snowed everyone on the vent. Nowadays, we make everyone wake up and breathe on their own, so they’ll extubate sooner. Here is the “ABC Trial.”

1. Girard TD. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-34.

Pulmonary:

ARDSNet: low lung volumes are better in ARDS, and probably ALI, too. Make sure you know how to diagnose ARDS & ALI.

2. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-8.

VAP guidelines – just read the executive summary and skim the main parts. Know these things: (1) the diagnostic criteria for VAP, HAP, CAP. (2) the clinical pulmonary infection score, & how to use it.

3. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.

Duration of antibiotics for VAP: 8 days is enough, unless you have resistant Gram negatives.

4. Chastre J, Wolff M, Fagon J, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588-98.

CV:

Early goal-directed therapy should go under sepsis, but this article focuses on maintaining perfusion more than treating the underlying cause.

5. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-77.

Here’s a resuscitation paper for trauma that reviews measurements for end-points. (Good for HMC TSICU rotation)

6. Bilkovski RN, Rivers EP, Horst HM. Targeted resuscitation strategies after injury. Curr Opin Crit Care. 2004;10(6):529-38.

GI:

Who needs stress ulcer prophylaxis in the ICU? *Not everyone.* Plus- what kind to give?

7. Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors and strategies to prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002;30(6 Suppl):S362-4.

GU:

Here is the famous “FACTT” paper. This is for patients with ARDS or ALI – should we run them wet or dry? Don’t try to apply these results in hypovolemic trauma patients.

8. Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-75.

Heme:

This is the “TRICC trial” that you’ll be asked about on rounds whenever you attempt to transfuse a patient. People do better if you let their Hct remain low and avoid transfusion risks. Unless they have a bad heart and a few other things.

9. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-17.

Here’s the upshot on Epo in the ICU: Corwin published in 2002 that it decreases transfusion, but said it needed more study to determine other outcomes. So when he repeated the study in 2007 guess what? The transfusion difference was gone, and maybe a trend toward increased survival. Cost is high risk of thrombosis, so that’s why you don’t see much Epo used in our chronically anemic trauma patients.

10. Corwin HL, Gettinger A, Fabian TC, et al. Efficacy and safety of epoetin alfa in critically ill patients. N Engl J Med. 2007;357(10):965-76.

ID:

Conventional wisdom: “Steroids really help save people who are in septic shock…”

The paper that was supposed to prove that, instead changed it to “uh, sort of.” Then it turns out that steroids only help shorten the duration of shock in patients that ended up recovering from shock anyway… Huh? This is the “CORTICUS” trial.

11. Sprung CL. Hydrocortisone therapy for patients with septic shock. NEJM 2008;358:111-24.

Endo:

Tight blood sugar control. Maybe not such a good idea after all. This one’s hot off the presses, conveniently called the “NICE-SUGAR” study.

12. Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97.

MSK:

OK, here’s the Cochrane Review for steroids in acute spinal cord injury. It’s huge. Just read the results section (p 4-5), and for entertainment, read the feedback section (p 5-7). Clearly a large argument still rages in the neurosurgical community. This is a good topic to know at HMC.

13. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2002;(3):CD001046.