Archive for June, 2012

The objective of this study was to better quantify the well-known ‘problem’ of the change in interpretation of spirometry, as a consequence of the change from the other commonly used reference standards (Morris, Kory, Crapo, Knudson 1976, and Knudson 1983) to NHANES III.



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Controlling MRSA

Risk factors

While anyone can contract MRSA, the following risk factors predispose LTC residents to infection:

  • invasive devices such as tracheotomies, gastrostomy tubes, intravenous catheters, or indwelling urinary catheters
  • chronic conditions such as dementia, diabetes, and peripheral vascular disease
  • prior long-term hospitalization
  • prior transport in an emergency/­non-emergency vehicle, such as facility shuttle van or car from a hospital, nursing home, etc.
  • the presence of decubiti or open sores upon admission
  • prior antimicrobial therapy such as chemotherapeutic agents that either kill microbes or otherwise interfere with microbial growth
  • close proximity to a patient/resident colonized or infected with MRSA.

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Tissue damage in lungs following high tidal volume mechanical ventilation Tissue sections of the lungs 

In the multivariate analysis, high and traditional tidal volumes were independent risk factors for organ failure, multiple organ failure, and prolonged stay in the intensive care unit. Organ failures were associated with increased intensive care unit stay, hospital mortality, and long-term mortality.

Conclusion: Tidal volumes of more than 10 ml/kg are risk factors for organ failure and prolonged intensive care unit stay after cardiac surgery. Women and obese patients are particularly at risk of being ventilated with injurious tidal volumes.

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A panel of experts came together in Berlin last year and worked to make  an ARDS definition that was more specific.  ALI no longer exists.  Now there is mild, moderate and severe ARDS defined by the PF ratios.

The ARDS Conceptual Model. The panel agreed that ARDS is a type of acute dif- fuse, inflammatory lung injury, lead- ing to increased pulmonary vascular permeability,increasedlungweight,and loss of aerated lung tissue. The clini- cal hallmarks are hypoxemia and bilat- eral radiographic opacities, associated with increased venous admixture, in- creased physiological dead space, and decreased lung compliance. The mor- phologicalhallmarkoftheacutephase is diffuse alveolar damage (ie, edema, inflammation, hyaline membrane, or hemorrhage).29


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jama.2012.Berlin ARDS


Tracheal intubation (TI) is a routine procedure in the intensive care unit (ICU), and is often life saving. However, life-threatening complications occur in a significant proportion of procedures, making TI perhaps one the most common but underappreciated airway emergencies in the ICU. In contrast to the controlled conditions in the operating room (OR), the unstable physiologic state of critically ill patients along with underevaluation of the airways and suboptimal response to pre-oxygenation are the major factors for the high incidence of life-threatening complications like severe hypoxaemia and cardiovascular collapse in the ICU.


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Tracheal intubation in the ICU- Life saving or life threatening?”

As described by author:

Resus.ME exists to help you keep up to date in all aspects of life-saving medicine, from acute medicine and paediatrics, to emergency and critical care medicine, and even pre-hospital care!

I believe we have a responsibility to stay at the cutting edge of resuscitation, and I want to share what I learn. No more relying on what you learned in Advanced Life Support Courses! This is for the specialist in resuscitation.

I scan over 40 journals as well as sources of national and international guidelines so I don’t miss out on what I need to know to save lives!

There’s no guarantee I’ll pick up everything but I’ll do my best not to miss the big stuff. There is inevitably a bias towards the things that interest me: refuting dogma and going beyond basic guidelines. I do not critically appraise all articles quoted and cannot attest to the validity of the findings reported. I endeavour to blog several articles per week but I do work full time in clinical practice in pre-hospital and retrieval medicine and emergency medicine and restrict the blogging to my own time. Any opinions expressed are entirely my own and do not reflect those of my employers. No non-consented identifiable patient details are ever posted.

Enjoy the updates which I offer as a free service to colleagues who are co-combatants in the war against critical illness and injury!



NAP4: Audit Pack

Original audit pack sent to NHS hospitals participating in the 4th National Audit Project (NAP4): Major complications of airway management in the United Kingdom


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Points that came out of the show

  • Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
  • Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
  • Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
  • Awake intubation was not used when it was indicated
  • Junior resident anesthesiologists were often responding to the ED and ICU
  • There was a failure to plan for failure
  • Obesity figured into a large percentage of the airway disasters


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