Issue #1: The Latest in Critical Care, 5/8/23

High Impact:

Rapid sequence intubation: neuromuscular blockade vs remifentanil. The ultra-short-acting opioid remifentanil could theoretically be a safer induction agent with less risk of aspiration than neuromuscular blockers like succinylcholine or rocuronium. Neuromuscular blockers relax lower esophageal sphincter tone, increasing the risk for reflux and aspiration. Among 1150 patients considered high risk for aspiration at 15 French hospitals, those randomized to receive remifentanil had a higher rate of severe complications of intubation (aspiration, hypoxemia, hypotension, arrhythmia, cardiac arrest, or anaphylaxis), compared to those receiving neuromuscular blockade. This was a noninferiority trial; remifentanil fell below the prespecified threshold for inferiority, though with a wide confidence interval. Read in JAMA

Endovascular thrombectomy for large ischemic stroke came to prominence based on limited data showing its efficacy in patients with smaller strokes; large strokes were excluded. The SELECT2 randomized trial enrolling 178 patients with large ischemic strokes was stopped early for efficacy after an impressive 20% of patients achieved functional independence after thrombectomy, compared to 7% after receiving medical care. Mortality was similar between groups, but thrombectomy resulted in a significant number of vascular complications (including cerebral vessel perforation in 7 patients). Read in NEJM ; accompanying editorial

4-factor prothrombin complex concentrate (PCC) for trauma (PROCOAG trial). 4-factor PCC rapidly replaces blood clotting proteins which are absent from transfused blood. PCC could therefore be helpful when co-administered with packed red blood cells in large volume transfusions. Among 324 patients with trauma and life-threatening bleeding at 12 French hospitals who were randomized to receive 1ml/kg PCC or placebo, there was no reduction observed in 24-hour blood transfusion needs in the PCC group. PCC was associated with a significantly higher risk for thromboembolic complications (35% vs 24%). Read in JAMA

Functional outcomes after survival from critical illness, and the constellation of disabilities and dysfunction now termed post-ICU syndrome, are finally getting more attention. This increasing population represent both critical care’s increased success at preventing death, and the unexpected, sometimes devastating consequences. A landmark paper in NEJM by Herridge et al provides a vital window into the depth and breadth of problems patients experience after the ICU — information that many physicians don’t know, and some may not want to. Read in NEJM

Oxygen saturation during mechanical ventilation: is there an ideal target? Among 2541 patients enrolled in a complicated pragmatic cluster-crossover design at a single academic center, there was no difference in any meaningful outcome (death, ventilator-free days, or severe complications) between patients randomized to an oxygen saturation target of 90%, 94%, or 98%. Read in NEJM

Subdural hematoma’s surgical treatments compared. After a neurosurgeon cuts a bone flap and evacuates a traumatic acute subdural hematoma, it’s unclear whether it’s better to replace the flap (craniotomy) or to leave it off temporarily (decompressive craniectomy). In the RESCUE-ASDH trial enrolling 450 patients, both approaches led to similar outcomes (about 30% one-year mortality, with ~20-25% return to good functional recovery). More patients treated with craniotomy required later surgery, while more craniectomy patients had wound complications. Read in NEJM with editorial

Nursing home patients with metastatic cancer are slightly more likely (not less) to get aggressive care at the end of life, according to a study in Jama Network Open. Among 146,000 patients included in the database study, roughly equal proportions of nursing home patients (~21%) were admitted to the ICU as were community-dwellers. Nursing home patients were no more likely to enter hospice after hospitalization than their community dwelling counterparts. About 19% of nursing home patients with metastatic cancer received chemotherapy or other cancer treatments—about half the rate of community dwellers. Read in JAMA Network Open and in NYT

The rise of mega-journals: In 2022, 55 medical journals published over 300,000 articles—almost a quarter of all medical literature that year. These so-called “mega-journals” are rapidly expanding their output, often charging high publication fees to authors, with lower peer review and publication standards than traditional established journals. Articles from mega-journals may feature high in search results, and their dubious scientific quality may not be obvious. Physicians need to be aware of mega-journals and the opportunities and risks they pose, argue Ioannidis et al in an editorial. Read in JAMA

A pediatric critical care physician loses his daughter, Ceci, to an inexplicable illness, and shares his grief in a heart-crushing essay. Read in JAMA

In The News

Uber for Nurses? Nurses quit in droves during and after the Covid-19 pandemic, while many shifted to part-time or more-lucrative travel nursing. To fill their strained schedules, hospitals are turning to the gig economy. Apps like CareRev and ShiftKey allow hospitals to fill gaps as short as 4 hours on demand for rates over $100/hour. This feels like a bad sign. Read in WSJ

Kaiser Permanente to acquire Geisinger. KP has not been able to successfully replicate its California-based model elsewhere in the U.S., where it holds minimal market share. If regulators approve the deal, KP will fold Geisinger into a new nonprofit to be called Risant Health, which will seek to provide community care more widely in the U.S. while incorporating aspects of the Kaiser and Geisinger models. Read in NYT

Who’s “ready” to die? A palliative care physician delves into the complexity of human psychology around death — the patient’s, and also the care team members’. Read in NYT

From the Blogs

When guidelines disagree, how should physicians prognosticate neurologic outcome after cardiac arrest? Read on PulmCrit

How to teach and learn intubation: Podcast on EMCrit

Managing alcoholic ketoacidosis: Podcast on RebelEM