Archive for June 2009

ND versus NG feeds in the ICU

In this trial of 121 MICU patients, they were randomized to ND versus NG feeds. The ND group experiencedfewer vomiting and VAP episodes, and achieved higher calories and earlier target rate, than the NG group. However, there were no significant differences in clinically significant outcome measures (bacteremia, ICU days, ventilator days, LOS, or death). The debate continues in determining the benefit of ND versus NG feeds, but ND does appear to be a better option in those at risk for vomiting (gastroparesis, dysmotility, GERD) (abstract).

Start HAART after opportunistic infections

In HIV patients who present with an opportunistic infection (OI), it is unknown if there is an advantage to early initiation of HAART. In this trial of 282 patients with HIV and an OI, they were randomized to early HAART (within 14 days of OI treatment) or delayed HAART (started after OI treatment was completed). At 48 weeks, progression of AIDS or death was significantly lower in the early group (14% vs 24%). This adds to the mounting evidence of benefit of early HAART (abstract).

STEMI: Need early PCI after fibrinolytics

In centers without available cath labs, it is unclear how quickly patients need to be transferred for PCI after fibrinolysis. In this trial of 1059 patients with STEMI, after fibrinolysis, they were randomized to immediate transfer for PCI (in <6 hours) or standard therapy (transfer for rescue PCI or angiography >24 hours). Most patients received catheterization (98% of the transfer group and 89% of the standard therapy group) at a median time of 3 and 32 hours, respectively. There was a significant reduction of the 30 day primary outcome (death, reinfarction, recurrent ischemia, or new/worse CHF) in the early treatment group (11% versus 17%). Every effort should be made to transfer patients for catheterization after fibrinolysis in STEMI (abstract).

Severe Cdiff? May try tigecycline

In this small case series of 4 patients in shock due to Cdiff (refractory to metronidazole and vancomycin), all had clinical and microbiologic cure (without recurrence) after treatment with tigecycline. Tigecycline does not induce proliferation of the Cdiff organism or the toxin production. Although premature for widespread use, it may be a reasonable alternative for septic patients that have failed traditional treatment options, and are headed for colectomy (abstract).

First degree AV block? Not so benign after all.

In this prospective cohort from the Framingham Heart Study, researchers determined long term outcomes of patients with a first degree AV block. Patients with first degree AV block had higher risk of atrial fibrillation (HR 2.06), pacemaker placement (HR 2.89), and all cause mortality (HR 1.4). Seemingly benign, first degree AV block is associated with worse long term outcomes (abstract).