Pulmonary and Critical Care

What are we thinking? Part 1

My patient was a 69 year old lady with metastatic small cell lung cancer. She was on experimental chemotherapy and was admitted from clinic with worsening lower extremity edema and a new oxygen requirement.  She underwent a chest and abdominal CT that revealed new pulmonary masses, tumor and a mass invading her right pulmonary artery, a new loculated pleural effusion, and acute thrombus in the IVC that was occluding her hepatic veins as well as extending into her iliac veins bilaterally.  She was tachycardic and tachypneic.  Every time she moved, despite supplemental oxygen, she desaturated into the 60 percent range. OK, pop quiz:  What is the answer to this patient management problem? If you have answered the word "hospice," you are right. I spoke with the outpatient oncologist, the palliative care team,  and had a meeting with the patient and her daughter explaining the lack of clear therapeutic options. They…

Universal MRSA decolonization in ICUs

The large multi-center ICU trial randomized ICUs to 1 of 3 strategies: MRSA screening/isolation, MRSA screening/isolation/decolonization, or global decolonization (5 days BID nasal mupiricin and daily chlorhexidine bathing). The hazard ratios for MRSA isolates in the 3 groups were 0.92, 0.75, 0.63 respectively. The hazard ratios for any bloodstream infection in the 3 groups were 0.99, 0.78, and 0.56 respectively. Global decolonization of ICU patients results in lower MRSA acquisition and bloodstream infections compared to targeted decolonization based on screening (abstract).

No benefit to intensivist staffing overnight in academic ICUs

This trial found no difference in patient outcomes (mortality or LOS) if admitted during a time of 24/7 intensivist coverage, or during a time with only daytime intensivist coverage (with home call at night) in a medical ICU. This study does not show a patient benefit to a 24/7 intensivist staffing model in an academic medical ICU (abstract).

Prone best for severe ARDS

This trial of patients with severe ARDS randomized them to prone (at least 16 hours a day) or supine positioning. Those in the prone position had significantly lower 28 day mortality (16% vs 33%), and 90 day mortality (24% vs 41%) with no difference in complications (abstract).

Music for ICU patients

This study of patients intubated in the ICU randomized them to patient-initiated/directed music, noise canceling headsets, or usual care. Those in the music group had significantly lower anxiety scores and use of sedatives compared to usual care. Those in the music group also had lower sedation frequency (but not sedation intensity or anxiety scores) compared to the noise canceling headset group. Both noise canceling headsets and music therapy can be beneficial in intubated ICU patients (abstract).