His Pacing

I am posting this webinar in follow up to a case previously posted in the EKG pages ( RV apical pacing leading to acute MR and APE). I did not report the NT-pro BNP post RV apical pacing but it was 38,421 pg/ml.
With 4 L diuresis  in 24 hours,the patient improved but is sill not optimal and will need His spacing or BiV pacing/CRT-P

Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients with Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis.

Study: Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients with Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis. Khan et al. CHEST 2019.

Clinical question: In patients with sepsis and septic shock who have co-morbid conditions of CHF, ESRD and Cirrhosis, is the full 30 cc/kg IVF bolus associated with higher rates of intubation?

Methods:

Single center, retrospective study

Included patients with CHF (HFrEF, HFpEF), ESRD and Cirrhosis

Sepsis identified through APACHE database, ICD9 and 10 codes followed by trained clinician review based on a published clinical sepsis surveillance definition

Calculated IVF given as bolus fluids in the first 6 hours of hospital arrival; did not include maintenance fluids given in first 6 hours, also did not include fluids given by EMS personnel prior to hospitalization

Primary outcome: Intubation within 72 hours from fluid bolus

Secondary outcomes:

-          Time to intubation

-          Change in oxygen requirement

-          Alive ICU free days

-          Ventilator days

-          Hospital mortality

Included patients assigned to 1 of 2 cohorts:

-          > 30 cc/kg IVF (standard group)

-          < 30 cc/kg IVF (restricted group)

Results:

286 patients included, 208 matched patients (104 standard resuscitation, 104 restrictive group)

No statistical differences between patient characteristics and clinical variables between groups except for:

-          Fluid volume in first 6 hours 1.39 +/- 700 L (restricted) vs 3.38 +/- 1.06 L (standard) (p < 0.001)

-          Fluid volume in first 24 hours 2.38 +/- 1.35 L vs 4.38 +/- 1.61 L (p < 0.01)

-          Fluid balance at 72 hours approached a significant difference 3.17 L vs 4.20 L (p = 0.054)

-          DNI status 3% (restricted) vs 11% (standard)

Notably, there were no differences in vasopressor or diuretic use in the first 72 hours or differences in rates of non-invasive ventilation.

There were no differences in the primary or secondary study outcomes:

After adjustment for APACHE III score, lactate level, steroid use, change in oxygen requirement from baseline, noninvasive ventilation use, fluid balance at 72 h, DNI status, and presence of CHF, cirrhosis, or ESRD with multivariable generalized estimating equation, administration of > 30 mL/kg fluid resuscitation (standard resuscitation) was not independently associated with intubation (P = .34).

Strengths:

-          This trial asks an important question. Early and aggressive IVF resuscitation is a mainstay in the treatment of patients with sepsis and septic shock and is recommended by the Surviving Sepsis Campaign. Clinicians often site the presence of the co-morbid conditions studied in this paper as justification to not order the recommended 30 cc/kg IVF bolus.

-          The findings in this paper correspond with two prior publications which come to mind suggesting the optimal dosing of IVF for patients sepsis patients is around 30 cc/kg IVF:

o    Liu et al. Ann Am Thorac Soc Vol 10, No 5, pp 466–473, Oct 2013 , demonstrates a “J-Shaped” curve for IVF administration and mortality with inflection points occurring at < 7.5 cc/kg and > 45 cc/kg.

-          Leisman et al. Crit Care Med 2018; 46:189–198 demonstrated that > 50% of patients with CHF and ESRD were “fluid responsive” to an initial fluid bolus in the ER.

Weaknesses:

-          Retrospective study. Can not determine causation.

-          Relatively small number of patients, wide confidence interval for intubation in 72 hours (C.I. = 0.41-1.36)

-          Did not risk stratify patients within disease categories, for example, patients with EF 5% vs 40%

-          Did not include maintenance fluid volume or fluid given by EMS personnel

-          Does not offer explanation as to why some patients received full 30 cc/kg IVF bolus while others did not

Conclusion: The 30 cc/kg IVF bolus recommended by the Surviving Sepsis Campaign does not appear to be associated with higher rates of intubation in high risk patients with sepsis. The presence of co-morbid conditions such as CHF, ESRD and Cirrhosis alone should not dissuade clinicians from ordering the full dose bolus. Clinicians should continue to use additional data points such as point of care ultrasound, laboratory and hemodynamic markers of perfusion to aid in decision making. 

-by John Kazianis, MD , Medical Director AICU

Current Management of HFpEF- ESC

ID Things to Be Grateful For, 2019 Edition

• An Ebola vaccine works! In perhaps no other disease will a vaccine play such a critical role in getting control of an outbreak. This is wonderful, very welcome progress!
• U = U (undetectable equals untransmittable) continues to hold up. Perhaps the most transformative finding in the history of HIV medicine — that people on successful HIV treatment don’t pass the virus on to others sexually — remains a rock-solid fact. I’ve included U = U here before several times, but why not continue to celebrate it?
• HIV incidence in many urban regions in the USA drops. In New York City, for example, 1,917 people were diagnosed in 2018, a 67 percent decline from 2001. Treatment as prevention and PrEP are yielding these impressive results.
• Zika is all but gone. Remember how crazy things were in 2016? Especially for couples who wanted to have children? And for us ID doctors (and primary care and OBs) trying to advise them? Yes, Zika could come back (and likely one day will), but let’s be grateful for our current situation compared to that insane period.
• New antibiotics, some with new mechanisms of action, expand our treatment options. No, they’re not perfect, and some are only incremental advances, or targeted at rare clinical situations — but great anyway to have lefamulin, pretomanid, omadacycline, eravacycline, meropenem-vaborbactam, imipenem-relebactam, cefiderocol (with some confusing data on this last one, still to be sorted out). Now let’s try to fix the economics of antibiotic drug development!
• Additional studies continue to demonstrate the clinical benefit of ID consultation on outcomes. Just a few recent examples — candidemia, sepsis, and long-term outcomes in Staph aureus bacteremia. The parade goes on and on!
• A “Shorter is Better” philosophy about duration of antibiotic therapy moves into clinical practice. And with this updated super list from Dr. Shorter-is-Better himself, Brad Spellberg (https://www.bradspellberg.com/)

• Pragmatic clinical trials in ID give us important new strategies for therapy. The most notable examples in the past year are the POET and OVIVA trials, demonstrating the noninferiority of oral to IV therapy for endocarditis and osteomyelitis. More of these, please!
• The “Ask the Experts” section on the Immunization Action Coalition remains a gold mine of useful information.  I’ve mentioned it before, but that doesn’t mean I can’t still be grateful! Barely a week goes by without my consulting this site.
• Shorter treatment courses for latent TB gain traction. Drug interactions aside, who doesn’t prefer 4 months of rifampin to 9 months of INH? Can 1 month of isoniazid/rifapentine be far behind?
• New guidelines for diagnosis and treatment of Lyme Disease are imminent. The draft guidelines have already been released — final version expected soon.
• Dolutegravir-based regimens are increasingly available globally. In many settings that previously had only efavirenz (first-line) and lopinavir/ritonavir (second line), dolutegravir represents major progress — for both treatment-naive and treatment-experienced patients. It will be important to see how this big change in strategy works out, which is the primary goal of this observational study.

                                                                             by Paul E. Sax, MD-Journal Watch

Precision Therapy in the ICU

An excellent presentation, highlighting the limitations of guidelines:one fits all. This is the main problem of RCT's also (which we base the guidelines on), a heterogeneous population = no external validity .

Strain Imaging ASE

10 Things ICU Specialists Need to Know about New Valvular Procedures in Interventional Cardiology

Many invasive procedures are now performed for valve replacement or repair.  Of significant importance are transcatheter aortic valve replacement (TAVR), transseptal procedures including transcatheter mitral valve repair (TMVR) and transcatheter tricuspid valve repair (TTVR).

Following complications are encountered with these procedures [see article for details]

1.  Rhythm disorders
2.  Pericardial tamponade
3.  Cerebrovascular events
4.  Vascular complications
5.  Myocardial ischemia
6.  Paravalvular leak
7.  Postoperative delirium
8.  Device embolization or clip detachments
9.  Renal failure
10.  Early onset prostatic valve endocarditis