Over the past 2 or 3 decades a variety of technologies have been introduced into the clinical care of the brain injured patient – intraventricular ICP monitoring devices,SjVO2, brain tissue oxygen devices, microdialysis, xenon flow scanning, etc. However, compared with general critical care, the evidence base for protocols based on the utilization of these technologies … Continue reading
Anecdotally, the majority of anesthetists withhold ACE inhibitors (angiotensin converting enzyme inhibitors ACEI) on the day of surgery because of concerns regarding hypotension, particularly in operations that may involve sympathectomy (spinal anesthesia) or blood loss. This appears to be a particular problem with angiotensin receptor blockers (here). We already know that withholding beta blockers and … Continue reading
Over the next few months I am sure that the real reasons for the comparatively poor outcomes of Irish patients in the EUSOS study will emerge. In the meantime, we can only guess the reasons. Aside from blaming surgeons for poor patient selection (which is suspiciously convenient), case volume may be a problem, the time … Continue reading
Few issues have been more controversial in the past 20 years than the implementation of the intensivist model. Fundamentally this involves delegation of primary responsibility for critically ill patients to a narrow group of clinicians, whose primary training may be in an entirely different specialty. Hence, surgical patients may be managed by internists, and medical … Continue reading
For years I have been trotting around the world telling everyone that NaCl 0.9% is evil, because each litre delivers 50mmol of HCL and chloride is nephrotoxic. This belief has come from a series of studies in volunteers (reduced GFR, reduced splanchnic perfusion, reduced cortical blood flow) and observations (increased contrast nephropathy with NaCl versus … Continue reading
As a junior doctor how many times were you called to replace an iv catheter on a veinless patient because with was 3 days old (and “hospital policy” and all that). There was no point asking to see the evidence on which this “policy” was based. Whatever! – here is the counter evidence, and it … Continue reading
A couple of weeks ago I announced the imminent death of colloid. Now it’s back with another “Safe” trial (known as CHEST) from our colleagues in Australia and New Zealand (here). The study enrolled a colossal number of patients (7000) to either isotonic saline (IS) or Voluven (R). This is a 130/0.4 tetrastarch in isotonic … Continue reading
You may recall a movie from a few years ago called “Super Size Me” that featured Morgan Spurlock eating nothing but McDonalds food for a month. If offered a super sized meal, he said – yes. He became lethargic, gained weight and developed a fatty liver. The message was that if you ate highly calorific fatty food, you … Continue reading
Alas – another intervention bites the dust. For decades the intra-aortic balloon pump has been heralded as the great savior of the patient with cardiogenic shock. If you have always found these devices confusing (when to use, when to wean, what difference 1:1 versus 1:2 augmentation etc), then worry not: they are heading to the … Continue reading
Colloid lovers are distraught by the publication of the 6S study from Scandanavia, which has demonstrated that hydroxy ethyl starches (HES) were associated with poor outcomes (read here). For many of us, however, colloids are like nicotine, caffeine, carbohydrates and heroin rolled into one: we just believe in them. It’s so hard to stop. This month … Continue reading
