Critical Care Round-up
Four articles relevant to the critical care medicine in the emergency department were selected by the critical care medicine section. No formal literature search was performed.
Article 1: Jakob SM, Ruokonen E, Grounds RM, et al; Dexmedetomidine for Long-Term Sedation Investigators. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012 Mar 21;307(11):1151-60
Article 2: Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Restrospective Before-After Study. Chest. 2017 Jun;151(6):1229-1238
Article 3: Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis. 2013 May;13(5):426-35
Article 4: Glajchen M, Lawson R, Homel P, Desandre P, Todd KH. A rapid two-stage screening protocol for palliative care in the emergency department: a quality improvement initiative. J Pain Symptom Manage. 2011 Nov;42(5):657-62.
These two blinded, randomized controlled trials comparing dexmedetomidine with midazolam and propofol demonstrated noninferiority of dexmedetomidine with regards to the proportion of time spent at the desired level of sedation, with a decreased in duration of mechanical ventilation compared to midazolam, but no difference compared to propofol. Imbalances in dosing, resulting in lower levels of sedation among patients receiving dexmedetomidine compared to the standard drugs, and lack of objective criteria for weaning of mechanical ventilation and extubation suggest that there may be issues with both internal and external validity. Additionally, patient-centered outcomes and cost were not assessed in this study, nor was the incidence or degree of delirium.
This single-center, before and after study demonstrated a rather large reduction in morality among patients with severe sepsis and septic shock treated with IV vitamin C, hydrocortisone, and thiamine. The results of this study are quite profound, and hence should be confirmed with additional prospective, randomized controlled trials. If this intervention is truly this beneficial, and truly reduces mortality to less than 10% in this patient population, routine use of this therapy should be initiated immediately.
In this meta-analysis evaluating the diagnostic capability of serum procalcitonin in the differentiation of sepsis from non-infectious SIRS, the reported pooled sensitivity and specificity correspond to positive and negative likelihood ratios of 3.7 and 0.29, which will only result in small changes in disease probability. Therefore, caution will need to be exercised when interpreting test results. Interval likelihood ratios may provide more clinically useful information, but were not provided. If procalcitonin is to become a relevant aspect of sepsis care, additional research will need to identify a particular clinical role with an improvement in patient-oriented outcomes.
This study suggests that an ED protocol to screen elderly patients with functional decline who would benefit from palliative care or hospice is feasible, but highly cost-ineffective. Additional means of implementing this protocol in a way that does not involve hiring additional, full-time staff should be sought and studied.