CCC Update 014

Updates to the CCC seem to be coming thick and fast these days. Keep the feedback coming on this free guide to Critical Care encompassing over 1650 pages.

This is what has sprung up since CCC Update 013:

Mitchondrial dysfunction and mitochondrial diseases

About 1.5 billion years ago something extremely odd and extremely pivotal happened in our evolution. One cell enveloped another in an endosymbiotic union. The mitochondria were born, and they continue to be passed along by our mothers today. As the energy powerhouses of our cells, it makes sense that if they don’t work, then we are in big trouble. This manifests as various genetic mitochondrial diseases, which are outlined on this page of the CCC. However, another intriguing hypothesis – one espoused by Mervyn Singer among others – is that mitochondrial dysfunction is central to the sine qua non of critical illness, multi-organ dysfunction syndrome (MODS). This page reviews the structure and function of mitochondria in clinically relevant terms, the effects of systemic inflammation on mitochondrial function and the rationale for a mitochondrial explanation for MODS.

Preoxygenation

Though commonplace, denitrogenating the lungs to create an oxygen reservoir prior to intubation is a nifty trick. This page has been throughly rejigged with more info on reasons for preoxygenation failure and extended summaries of different devices for preoxygenation.

Apnoeic oxygenation

The major update is my take on the FELLOW trial – no surprise that apnoeic oxygenation doesn’t have a benefit if you exclude difficult and prolonged intubations or if you ventilate most of the patients so that they are not actually apnoeic… Apnoeic oxygenation, though not in any way a substitute for effective preoxygenation, remains part of the airway arsenal.

Delayed sequence intubation (DSI)

You can’t update Preox and Apox without doing the same for Delayed Sequence Intubation. Reuben Strayer’s “KSI” approach (ketamine DSI with no paralysis) gets a mention and Weingart has had a bit of to and fro in the letters sections of journals. Overall though, not much has changed as far as recommendations go.

Sepsis Overview

This is a new page that links to all the sepsis pages in the LITFL CCC, including…

Initial management of severe sepsis and septic shock

What do you actually do if you are not a disciple of Early Goal Directed Therapy and the Surviving Sepsis Campaign guidelines? Perhaps you work as an intensivist in Australia or New Zealand? This page attempts to synthesise ‘usual care’ in the Australasian setting and the state-of-the-art in sepsis. Controversies abound, but when you’re at the bedside you’ve got to something. Oh, and remember to check your local guidelines.

Neutropaenic sepsis

An overview of the critical care approach to neutropaenic sepsis, with an emphasis on antibiotic choice based on Australian Therapeutic Guidelines.

Septic cardiomyopathy

Common in severe sepsis, this condition has rapid onset, is reversible in survivors and is characterised by a dilated left ventricle. It is hard to know what therapies really benefit these patients, but ultimately we are left with judicious fluid administration and inopressors. It will be interesting to see if a role for beta-blockers or drugs like ivabradine emerges, but these aren’t for prime time just yet (in most circumstances at least). More on the beta-blocker controversy in  Catecholamine excess, Beta Blockade and Critical Illness.

Septic encephalopathy

Up to 70% of patients with sepsis have some degree of encephalopathy and this can have longterm consequences. There’s a few ideas on how it all happens, but the pathophysiology is murky. No specific therapies exist.

Urosepsis

Source control is often a matter of delicate negotiation when it comes to urosepsis, otherwise this overview of the causative bugs, risk factors, assessment and management of urosepsis is pretty straightforward.