Does protocolised care decrease mortality?

As per the Rivers E et al. study, EGDT decreased short term mortality and many non randomized before and after studies reported survival benefit despite its incomplete or partial implementation. In 2004 the Surviving Sepsis Campaign guidelines endorsed EGDT.

However recently three large multicentre RCTs' the ARISE, ProCESS and ProMISe failed to demonstrate any decrease in mortality following EGDT. 

This was studied in "A systematic review and meta-analysis of EGDT for Septic Shock: the ARISE, ProCESS and ProMISe investigators" by D C Angus et al. 

This group has concluded that EGDT is not superior to usual care for ED patients with septic shock and in fact increases utilization of ICU resources in the form of increased ICU admissions and vasopressor use.

The authors do not support the use of EGDT in management of all patients of septic shock or its inclusion in Surviving Sepsis Campaign.

To read more on this please follow the link below:

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators

The Double Line Sign

Ultrasound Visualization of the Endotracheal tube

The Endotracheal tube (ETT) is generally not clearly visualized in the trachea due to air artifacts . However when visualized it is seen as a double line. This has been termed as Kannapur's "Double Line Sign"(parallel lines close together, posterior margin not visualized).

Visualization is done with the help of a vascular ultrasound probe (13-6 mHz) that is placed along the length of the trachea. To ensure better visualization the cuff of the endotracheal tube is filled with 5 to 8 ml of saline.

Utility of the Double Line Sign
1. To visualize the endotracheal tube in the trachea after intubation
2. To accurately re-position the endotracheal tube prior to trachestomy so as to avoid cuff puncture,  abutment of the needle against the ETT, and passage of the guidewire into the Murphy’s eye of the ETT.
3. To position the tube after intubation so as to achieve bilaterally equal ventilation.

Reference 
Kannapur Anand Shankar, Nakra Monish, R. Ramprasad, Srivastava Vikas: Ultrasound imaging of saline-filled endotracheal tube cuff for accurate repositioning of tube during percutaneous dilational tracheostomy. Intensive care Medicine, Jan 2016 (Online First).

To read more please follow the link: USG visualization of endotracheal tube

Targeted Temperature Management

There has been discussion about pyrexia (>37.6°C) and therapeutic hypothermia after Return of Spontaneous Circulation (ROSC) following a cardiac arrest.

What was known as "Therapeutic hypothermia" has been largely replaced by "Targeted Temperature management (TTM)" also known as "temperature control".

The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation made several treatment recommendations on targeted temperature management and these are reflected in various guidelines.

The summary or bottom line is that "Targeted temperature management"is important but now target a temperature of 36°C rather than that of the previously recommended 32–34°C.


To read more about this please follow the link:  http://icmjournal.esicm.org/journals/abstract.html?v=41&j=134&i=12&a=4051_10.1007_s00134-015-4051-3&doi=