Comparative Effectiveness of Vancomycin and Metronidazole

Among patients with severe disease, 30-day all-cause mortality was significantly lower for those who were treated with oral vancomycin than for those who were treated with metronidazole (15% vs. 20%); 30-day mortality did not differ significantly among patients with mild-to-moderate disease. Also, CDI relapse rates did not differ between treatment groups in either stratum of disease severity.

Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With Clostridium difficile Infection


Real life data show that metronidazole is still given frequently in patients with severe disease.


Here is a risk calculator for moderate- severe disease requiring oral vancomycin

NOACs in Surgery

This a video from the European Society of Intensive  Care Medicine on monitoring , time of holding and restarting of NOACs in relation to surgery and treatment/reversal  with various degrees of bleeding. A couple of important points:

1) Apixaban does not affect coagulation parameters, as all other NOAC's do to a variable extend (but never correlate with degree of anticoagulant effect) . dTT and PT/PTT will only tell you if there is treatment effect if elevated, but it says nothing about the actual levels of the drug . A normal PT/PPT and TT in a patient taking an unknown NOAC , can have significant elevated drug levels and be coagulopathic when the drug was apixaban.
2) There is no role for a FFP during bleeding with any of these drugs ....you will have to give liters and liters and deplete the bloodbank in the process
3) Thromboelastograms will become more and more important, especially now that rivaroxiban is approved in conjunction with DAPT in ACS
4) Be very careful with NOACs in Stage D HFrEF patients, as they often have wide swings in renal function and a large number of them have cardio-renal syndrome class II. I still prefer VKA as drug of choice. Moreover, these patients were not studied in the various trials
5) Although not mentioned in this Webinar: NOAC's are contraindicated in patients with mechanical valves ( until further trials available)  !

Attached is also an article from JACC on the relation of NOAC's and coagulation parameters.

Laboratory Measurement of the Anticoagulant Activity of the Non–Vitamin K Oral Anticoagulants

Webinar 2016 Sepsis Guidelines ESICM

Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants

Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants https://t.co/oTvhHIDTbJ pic.twitter.com/0VQ3S22orA

— Critical Care (@Crit_Care) February 15, 2017

Link of the article to my ReadCube

Should We Intubate During In -Hospital Cardiopulmonary Resuscitation: Conventional Wisdom vs Big Data

Intubation during arrest was associated with worse outcomes.

The 2015 American Heart Association Advanced Cardiovascular Life Support guidelines deemphasize advanced airway placement as a component of initial resuscitation. Out-of-hospital–arrest data suggest lower survival among patients who are intubated in the field (NEJM JW Emerg Med Feb 2013 and JAMA 2013; 309:257). To determine whether this applies to in patients, investigators examined resuscitations of more done 108,000 patients in a US registry.

Seventy percent of patients were intubated during their code events; most (95%) of these intubations occurred within 15 minutes of resuscitation. Patients with initial nonshockable rhythms (i.e., pulseless electrical activity [PEA] or asystole) were more likely to be intubated than were those with ventricular fibrillation or tachycardia (69% vs. 53%).

In a time-matched propensity analysis, patients who were intubated during resuscitation were significantly less likely to survive to discharge than those who were not (16% vs. 19%) and were less likely to be discharged with good functional status (11% vs. 14%). In subgroup analyses, associations between intubation and these outcomes were not seen in patients who had preexisting respiratory insufficiency but were more pronounced for patients with initial shockable rhythms.

Comment by Patricia Kritek, MD. , American College of Chest Physicians (Critical Care Board Review Course):

This observational study raises important questions about an established practice: Attempt at intubation can interrupt chest compressions or slow defibrillation, potentially delaying these life-saving interventions, particularly for patients with ventricular fibrillation or tachycardia.  However the results still could be confounded by underlying differences between the intubated and non-intubated groups that were not captured by the statistical technique of propensity matching.  Therefore, I am not ready to abandon efforts to intubate patients with in-house arrest, especially those with PEA or asystole moreover, when respiratory failure is the cause of an arrest, early advanced airway management is important as a potential remedy to the underlying pathophysiology.

The accompanying editorial in JAMA  is enlightening and highlights the pitfalls, but also the strengths of this analysis.

Is There Any Benefit at all to Hypothermia in In-Hospital Cardiac Arrest

Data from a large cohort examining the the benefit of hypothermia in adult in- hospital arrest found no benefit. As a matter of TTM( targeted temperature management) was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of a favorable neurological outcome in both shockable and non- shockable rhythms . An RCT is certainly warranted in this group. The data are consistent with a prospective study in the pediatric population ( the latter did have a major flaw of initiating TTM on average 5 hours after ROSC )

Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest

No Benefit from Therapeutic Cooling After Pediatric In-Hospital Cardiac Arrest

One-year outcomes were similar with therapeutic hypothermia or therapeutic normothermia.

The efficacy of therapeutic hypothermia (target temperature, 33.0°C) versus therapeutic normothermia (target temp 36.8°C) in improving outcomes after out-of-hospital cardiac arrest in children is similar in clinical trials. To compare the efficacy of these interventions after in-hospital pediatric cardiac arrest, researchers randomized 329 children aged 48 hours to 18 years to either intervention (maintained for 120 hours) after in-hospital arrest.

The primary outcome was 12-month survival with favorable neurobehavioral outcomes. All participants had previously normal neurobehavioral assessment, received chest compressions for at least 2 minutes, and remained dependent on mechanical ventilation after return of circulation.

There were no between-group differences in the primary outcome, and the rates of survival at 12 months between the hypothermia and normothermia groups were also similar (49% and 46%, respectively). The trial was stopped after a review of interim efficacy results due to an assessment of futility.

COMMENT

Despite these authors' valiant attempt to control the therapeutic interventions, some variables might have affected the outcomes. For example, it took approximately 5 hours to initiate the interventions after the return of circulation. Would outcomes have been different if the interventions had been carried out more quickly? Are these target temperatures the correct ones? 

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children

Lower Oxygen Saturation Goals Are Safe in Mechanically Ventilated Patients

Targeting to 88%–92% did not cause harm.

The optimal oxygenation goal for patients who are receiving invasive mechanical ventilation remains unclear. Clinicians usually target resolution of hypoxemia and pay little attention to weaning levels of oxygen once 100% saturation has been achieved. However, harms caused by hyperoxia, including effects on cardiac function and lung parenchyma, are of concern.

To assess the safety of a lower oxygenation target, investigators randomized 104 patients who were receiving invasive mechanical ventilation to either a conservative strategy (peripheral oxygen saturation, 88%–92%) or a liberal strategy (peripheral oxygen saturation, >95%) for the duration of ventilator support. Positive end expiratory pressure (PEEP) levels were determined by treating physicians who were not blinded to the intervention. Three quarters of enrolled patients had medical diagnoses. Mean fraction of inspired oxygen (FiO2) at randomization was 0.44.

No differences were detected between groups in organ dysfunction or mortality. Mean saturation in the conservative arm was 93.4% (vs. 97.0% for the liberal arm), and more arterial blood gases were drawn. These two findings suggest some clinician discomfort with targeting lower oxygen saturation levels. Patients in the conservative arm were more likely to have episodes of severe desaturation, although these events were rare in both groups.

This study reassures us that a lower oxygen saturation target is not harmful. Whether this practice confers benefit is unclear, but these results should allow researchers to comfortably conduct larger randomized, controlled trials with lower oxygen saturation goals.

Conservative versus Liberal Oxygenation Targets for Mechanically Ventilated Patients. A Pilot Multicenter Randomized Controlled Tria