Pulmonary and Critical Care

Updated guidelines from surviving sepsis campaign

The Surviving Sepsis Campaign guidelines have been updated. Some of the highlights include (abstract): Initial fluids with crystalloids at 30cc/kg, with goal in first 6 hours of CVP 8-12mmHg, MAP>65 mmHg, and urine output >0.5cc/kg/hr; Antibiotics within 1 hour No steroids unless refractory shock and no RBC transfusions unless Hb<7 Vasopressor of choice is norepinephrine with epinephrine added if needed, phenylephrine only with arrhythmias, if cardiac output is high with low BP, or as salvage therapy, and dobutamine for myocardial dysfunction or continued hypoperfusion.

Noninvasive ventilation for acute COPD

In this large retrospective analysis of patients hospitalized with acute COPD exacerbations with respiratory failure, the use of noninvasive ventilation increased from 14% to 16% from 2006 to 2008, but variation in use between hospitals was great (ranging from 0 to 100%, with a median of 11%). Noninvasive ventilation was associated with better outcomes than invasive ventilation, including lower inpatient mortality (risk ratio 0.54, CI 0.50 to 0.59), shorter LOS (-3.2 days, CI -3.4 to -2.9), lower hospital charges (-$35,012, CI -$36,848 to -$33,176), and fewer iatrogenic pneumothorax (0.05% vs 0.5%, p<0.001). Noninvasive ventilation is probably underutilized, and associated with better outcomes compared to invasive ventilation, in patients with acute COPD with respiratory failure (abstract).

Evidence of benefit for antibiotics in acute COPD

This large retrospective analysis of patients hospitalized with COPD found those that received antibiotics had lower mortality (1% vs 1.8%), and fewer 30 day readmissions (5.4% vs 6.8%), but longer LOS and cost, compared to those that did not receive antibiotics (after propensity scoring adjustment). Overall there appears to be a benefit for the use of antibiotics in patients hospitalized with COPD (abstract).

Daily chlorhexidine bathing in ICU reduces infections

In this large randomized trial of ICU patients, they were randomized to daily bathing with or without chlorhexidine; those in the chlorhexidine group had a 23% lower risk of the acquisition of any MDROs, and 28% lower risk of hospital acquired bloodstream infections during their hospital stay. This should become the standard of care for all ICU patients (abstract).
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