Selective Digestive Decontamination decreases MODS

About 10 years ago we were doing SDD on all our ventilated patients, but we stopped because of a lack of good evidence of efficacy and the fear of developing bacterial resistance. A new Critical Care Medicine systematic review shows that SDD decreases MODS but not mortality.

It's not enough to change our practice, but it's still interesting nonetheless how the same stuff keeps coming up.

Proton pump inhibitors increase the risk of clostridial infection

Patients who were treated with PPI while being treated for clostridial infection had a 42% increased risk of recurrence
http://archinte.ama-assn.org/cgi/content/full/170/9/772

High dose intravenous magnesium drip may help patients with aneurysmal SAH

There was a significant decrease in delayed ischemic infarction in the group that was treated with a high dose magnesium drip to keep the serum magnesium level between 2 and 2.5. There was no statistically significant difference in mortality or GCS, although there was a suggestion to that effect. The morbidity of giving magnesium was nil, and it may help.

Make sure the patient is comfortable at night and can sleep

What happens to you if you’re awoken every 10 minutes? That’s what happens to an ICU patient. If a patient is up all night, they’ll be tired the next day when the time comes to try to extubate. Also, make sure that at night they have adequate ventilator support. Don’t try to wean someone when they’re sleeping.

Always try to allow a patient to say "Good bye" and "I love you"

Often in critically ill patients we are concentrating on stabilizing a patient. If they’re in respiratory distress our priority is getting them intubated. But remember that there will be times that this may be the last time they ever get to speak to their loved ones. So if you can, make sure that you get their family in there so the patient can say “Good bye” and “I love you.”

Endotracheal tube removal requires ability to protect airway

Is a gag reflex present?

Can the patient cough?  (Consider using a "white card" test.  Disconnect the patient from the ventilator, place a white index card in front of the patient, and if they can hock a loogie onto the card, they have an adequate cough)

Are the patients secretions managable?

Can they protect the airway?  (They do NOT need to be completely alert to do this)

Treatment of Septic Shock is all a guideline

I went to a talk by one of the authors of the Surviving Sepsis Campaign. He went through all the points in the SSC. His major point is that the endpoints, such as CVP 8-12, SVO2 >70, MAP>65 are all starting points. You need to use some clinical judgment. For example, let’s say you have a young patient who has a good vascular system. You get the MAP to 60, and the patient starts to pee. Should you push the pressor just to get the MAP to 65? Not necessarily. On the other hand, if you have an elderly patient with atherosclerosis, you may need a higher MAP