Welcome to the the 13th CCC Update!
LITFL’s Critical Care Compendium continues to grow and grow, and continues to be updated. It seems to be meeting a need too, with the CCC homepage alone reaching over 90,000 pageviews in 2015. A major driver for behind its maintenance is that it is the core resource for FCICM Part 2 exam preparation at The Alfred ICU, where it has helped over 20% of all of Australasia’s successful candidates in 2015. Of course, it helps to have such awesome trainees too 🙂
Now, before getting stuck into the recent major updates and additions, remember you can search for CCC entries by using search keywords in the CCC table, by googling “litfl ccc searchterm” or by searching GoogleFOAM. Also remember that I crave corrections and constructive criticism… That’s the fuel needed for making the CCC even better… So bring it on!
I met Marcelo Amato in 2014 and was super-impressed; he’s a great speaker and a profound thinker when it comes to mechanical ventilation and ARDS. He was the lead author of a 2015 NEJM paper suggesting that ‘driving pressure’ might be the key ventilatory variable to optimise to prevent ventilator-induced lung injury in patients with ARDS. This page, coauthored by the equally impressive Jack Iwashyna (@iwashyna), explains the concept of driving pressure and the rationale for its use, including a summary of the Amato et al 2015 article. More studies needed of course…
We are all down with the ALS approach to asystole/PEA… However, there are at least 2 problems with this. The ‘Hs and Ts’ approach is clunky and there is the spectre of Pseudo-PEA. In an age of ‘Echo for everyone’ we are realising that PEA is a very heterogenous condition. Some PEA patients are simply severe shock patients that might not even need CPR and with appropriate treatments these ‘mostly dead’ patients may do much better than the other ‘completely dead’ PEA/asystole patients. Read on for all the ins and outs.
If a patient arrives in the ICU after cardiac surgery with an open chest, your antennae should start twitching — you most likely have a very very sick patient in your midst. Read this page for the rationale, indications and pros and cons of delayed sternal closure in the critically ill post-cardiac surgery patient.
After the Sepsis SMACCDOWN in Chicago, many were left wondering if they have any idea what sepsis actually is… never mind how to treat it. In reality, we know what a septic patient is, someone who is properly sick from an infection that has triggered off a deleterious host response. The problem is, current definitions – promoted by the Surviving Sepsis Campaign Guidelines — don’t necessarily reflect this and over-complicate matters. This page gives the current key definitions related to sepsis and highlights the problems with SIRS-based definitions, as well as problems with diagnosing sepsis in general. It also provides a summary of the Kaukonnen et al NEJM 2015 article (et al includes two of my colleagues from the Alfred, Dave Pilcher and Jamie Cooper 😉 ) that debunks the utility of the SIRS critieria in the Australasian ICU population. I also preview the soon-to-be-published “Sepsis 3.0” definition… yes, I will have to update this page again soon! Wouldn’t it be good if there was decent sepsis biomarker we could use?
Don’t hold your breath in anticipation of biomarkers clearing the muddied sepsis waters. This page provides an overview of the different types, highlights some of the more commonly discussed examples and emphasises the generic limitation shared by all current sepsis biomarkers. With nearly 200 sepsis biomarkers in the published medical literature, you’d think it at least one would cut the mustard…
Some would argue that procalcitonin is the sepsis biomarker that comes closest to lacerating hot-tasting yellowish condiments. Procalcitonin was de riguer in other places I’ve worked, but I don’t use it these days. This page reviews the biology of procalcitonin (synthesis, kinetics and functions) and the pros and cons of its use as a sepsis biomarker. There is also a summary of key evidence, namely the 2010 PRORATA study and a systematic review and meta-analysis from 2015. I also provide a summary of how I might use procalcitonin if I was going to use it… (?!?)