Tom Sewatsky, MD
Several drugs have been investigated in patients with ARDS, including epoprostenol, nitric oxide, statins, and methylprednisolone, but have not improved survival. Meduri et al. performed an RCT demonstrating that methylprednisolone was associated with a reduction in lung injury score and duration of mechanical ventilation. While not powered to evaluate mortality, this trial raised interest in the use of corticosteroid to mitigate inflammatory lung injury. The 2017 Guidelines from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) recommend steroids for treatment of ARDS based on a meta-analysis of nine randomized controlled trials demonstrating reduction in markers of inflammation and duration of mechanical ventilation, although many of the trials had a small sample size and some were performed without lung protective ventilation. In March 2020, Villar et al. published the largest randomized control trial of corticosteroid therapy for moderate to severe ARDS investigating the impact of dexamethasone on survival and duration of mechanical ventilation.
You admitted a 72 year old male to the ICU for septic shock from community acquired pneumonia. He required intubation and mechanical ventilation for failure to improve oxygenation with NIPPV and encephalopathy. He received broad spectrum antibiotics and a 30 cc/kg crystalloid bolus. His MAP was persistently in the 50s despite adequate fluid resuscitation and based on your exam he does not appear hypovolemic. Norepinephrine is started and despite adequate MAP he is oliguric. His only medical history is he was a previous smoker with COPD, HTN, HLD but normal renal function with a Cr of 0.8 two months prior. His Cr on admission is 2.2 and a foley is placed and his UA shows granular casts. He is not acidotic and his electrolytes are normal.
You are concerned this patient is heading towards renal replacement therapy. He is adequately fluid resuscitated and has a MAP above 65 on a vasopressor but is still not making urine and has signs of ATN on urinalysis. Renal replacement therapy is an invasive procedure and has associated risks. If a patient has a chance to have renal recovery with a more conservative approach then this should be considered. You wonder if there is a diagnostic test which can be used to assess the potential for renal recovery.
A 68 year old male with a history of a right ankle ORIF three weeks ago is transferred to your ICU for management of a pulmonary embolism. He developed acute dyspnea while at physical therapy and was taken to an ED where he was found to have bilateral pulmonary emboli extending into both segmental and subsegmental pulmonary arteries on CTPE. His workup included elevated troponins and an echocardiogram that showed a dilated RV with hypokinesis of the RV free wall and reduced tricuspid valve annular systolic excursion. He was started on a heparin infusion prior to transport and was hemodynamically stable when you took the transfer call. When he arrived to your facility he was mentating well but his BP was 85/50 with a HR of 115 and an spO2 of 96% on 2L NC. How will you address his hypotension?
EMS brings in a 67 year old male in a PEA arrest. ROSC is obtained after twenty minutes of downtime. He was intubated by EMS during transport. A colleague talks to the family and she lets you know that he was complaining of shortness of breath and chest pain for an hour before he had a witnessed cardiac arrest and that his PMH includes HLD and HTN. The respiratory therapist is asking for the ventilator settings.
You have a patient in cardiac arrest getting high quality CPR with an initial rhythm of pulseless VT that has been defibrillated three times and received a total of 3 mg of epinephrine and a loading dose of 300 mg of amiodarone. As you continue ACLS, the patient remains in VT. Are there alternative treatments to consider?