The Latest in Critical Care, 4/8/24 (Issue #37)
Immediate extubation vs delayed weaning at end-of-life; Anticoagulation for new-onset atrial fibrillation from sepsis; Lifesaving potential of decolonization for MDROs
Immediate extubation vs. gradual ventilator weaning in comfort care
No good data exist to guide the process of withdrawal of invasive mechanical ventilation just prior to the end of life–variously known as “terminal extubation,” “compassionate withdrawal,” “extubation to comfort care,” et al. At most centers, once the decision is made by the patient or family, an opioid infusion is initiated, all non-palliative medicati…
New-onset atrial fibrillation provoked by sepsis: anticoagulate or not?
Your elderly patient with sepsis develops new-onset atrial fibrillation that spontaneously converts to normal sinus rhythm. Should long-term anticoagulation be prescribed at discharge? No good data exist to guide this decision, but a vignette in NEJM provides a closer look at the arguments for and against initiation of a direct oral anticoagulant (DOAC)…
Systematic decolonization of nursing home patients reduced hospitalizations and infections (SHIELD-OC)
About half of nursing home residents and 80% of patients in long term acute care hospital (LTACH) patients are colonized with multidrug resistant organisms (MDROs). The rate is 10-15% in most acute care hospitals. The spread of MDROs through health care environments seems like an unstoppable force, but a new study provides encouraging proof the tide can…
I think that the spike of brain activity prior to death (which is fairly proven with near death studies) speaks to the need for opiates and speedy palliative extubation. Certainly if these patients become more alert just before death, they could experience pain and fear, as well as more pleasant emotions. Our job is to be sure that these patients don't suffer when their family makes a difficult decision to focus on comfort oriented care.