Hello, and welcome back! Firstly, I must apologise for such a prolonged absence. I can’t quite believe it has been so long since my last blog post but I seem to have managed to keep myself very busy with a number of things. Regardless, we shall crack on with having a look through the different critical care and anaesthesia literature out there that is waiting to be devoured. Given that I have currently just started a block of neuro-critical care, I felt it was a good time to have a look at some of the big studies in this area, especially as there have been a few interesting ones recently. Today I’ve opted to have a look at the RESCUEicp study which came out in September last year. The full text is available at the link below, and I’d definitely recommend having a look at it as well as just reading my rambling thoughts. I’ve also put together a more focused review of the paper here [link] if you want to read a bit more of the details. ​

The RESCUEicp Study
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In last week’s journal club, we turned our gaze back to neuro critical care, with a paper that revisited the question of blood pressure control in acute intracerebral haemorrhage. It’s a scenario that is familiar to many of us; the systolic blood pressures well into the 200s in a patient with a new bleed in their head. Qureshi and colleagues have tried to revisit the question of what is the best way to respond to this through the ATACH2 trial (Antihypertensive Treatment in Acute Cerebral Haemorrhage II). The paper is available to read through the link below:

The ATACH2 Trial

The scene will be familiar to many of us; our patient is leaving the ICU after their brutal clash with sepsis. They were really, REALLY sick when they came in but you and the team have done an amazing job. Aggressive cardiovascular support, meticulous attention to lung protective ventilation, intensive physiotherapy – you’ve done a cracking job in maximising their chances and they’ve pulled through. They are now stepping down to the ward and it’s all smiles, best wishes and high fives around the room. Job well done team!

But wait, one of your junior trainees has pointed out that their 2 year mortality is actually quite affected by this illness, and they’re not out of the woods yet…

The mood darkens slightly. The party hats are taken off. Killjoy! Can’t we celebrate the little victories?

And yet this is where we are in intensive care medicine much of the time. A spell on the unit is hardly a spa weekend that renews your vigour and health – the acute illness process is just the start. This topic is the focus of the paper from our recent journal club, available open-access through the link below. Specifically, it looks at the impact of sepsis on our patients in the long term.

Prescott H et al. Late mortality after sepsis: propensity matched cohort study. BMJ. 2016. 353. i2375

In today’s journal club we analysed an interesting paper looking at the role of a chloride restrictive approach to fluid therapy for minimising the risk of AKI. The authors start by discussing some of the experimental data that suggests the high amounts of chloride in some commonly used fluids impairs renal function with effects such as renal vasoconstriction and reduced urine output. They note that there was little clinical evidence of this harm at the time of the study (published in 2012) and hence embarked on this particular project. The full text is available at the link below (free) but I also advise having a quick look at the supplementary materials and letters.
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Association between a chloride liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults
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Well for various reasons it has been a little while since our last post but we’re back with a review of a paper that was looked at during our more recent local journal club. The paper is entitled ‘Adequate antibiotic admission prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality’ and is freely available via the link below, so definitely worth having a bit of a look at. Sepsis is probably the top condition we face in critical care, and indeed probably for hospital medicine as a whole. There have been big strides forward in the management of this massive killer, though we still seem a little way off understanding this very diverse condition completely. The triad of ARISE, PROMISE and PROCESS have expanded how we think about the resuscitation for the condition, but one of the lynchpins of treatment has always been early antibiotics. Indeed I think some of the numbers from Kumar et al.’s have been extrapolated to every infection through the widespread education of the Sepsis 6 (I don’t think my patient with a simple UTI will have a 7% increase in mortality from an hour delay in antibiotics, but the message is pretty widespread at least). So I was quite interested to see what this particular paper could provide in the way of improved understanding.

Adequate antibiotic admission prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality
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