Controversies in ICU

Blood pressure management in Aneurysmal Subarachnoid Haemorrhage prior to exclusion from circulation

Todd Fraser on 2009-12-23 10:23:00

This is one of those topics I can never get a handle on. What blood pressure is best for unclipped aneurysms? On the one hand, you don't want to exacerbate bleeding. On the ot...



Do you filter for severe sepsis?

Todd Fraser on 2010-01-10 12:43:00

Its been part of our mantra for treating severe sepsis for 10 years or more now, to institute early aggressive haemofiltration in a patient with severe sepsis, with or without over...



Is this the end of Dopamine?

Todd Fraser on 2010-03-07 10:27:00

The March 4 edition of the New England Journal of Medicine features a study comparing Dopamine and Noradrenaline in the treatment of 1600 patients with shock. Patients with cardio...



Endpoints of resuscitation

Todd Fraser on 2010-04-05 20:44:00

Intensive care practice is built around the prompt resuscitation of patients with critical illness. It has long been recongnised that clinical parameters are poor indicators of ad...



Setting the ideal PEEP

Todd Fraser on 2010-05-15 18:38:00

Setting PEEP has to be one of the most confusing things I do. There are some pretty clear therapeutic benefits to PEEP - improved oxygenation and improved cardiac performance to n...



H1N1 - what have we learned?

Todd Fraser on 2010-05-26 13:53:00

As the Southern Hemisphere influenza season rolls around again, it is appropriate to take stock of what we know and what we do not know about Pandemic 2009 H1N1 Influenza. Swine...



Chest versus head

Todd Fraser on 2010-02-04 16:45:00

So here's the patient - a young man is involved in a motor vehicle accident. He has significant pulmonary contusions and segmental lung collapse, and has a small haemopneumothorax...



Dosing renal replacement therapy

Todd Fraser on 2010-06-20 19:51:00

The College of Intensive Care Medicine recently staged its annual Scientific Meeting. The theme for this year was Nephrology and among the many fascinating subjects covered, one o...



Optimal Timing of Tracheostomy

Todd Fraser on 2010-07-26 10:22:00

This week's blog was suggested by Shailesh Bihari, and relates to the timing of tracheostomy. Its clear that there is considerable variation in timing between units and indeed bet...



ICU delirium - what to do?

Todd Fraser on 2010-07-28 17:13:00

We're implementing a new sedation-agitation protocol in our unit. Its been a very interesting exercise in evidence based medicine. While delirium, as defined by the CAM-ICU sco...



Competency to make decisions

Todd Fraser on 2010-08-18 09:06:00

The issue of consent is a regular bugbear for many of us in ICU. The concept seems pretty clear - patients should have a right to refuse health care interventions, though there ...



CPR - to breathe or not to breathe, that is the question

Todd Fraser on 2010-08-25 20:34:00

Recently 2 further studies have been released which appear to justify adopting Compression only CPR. Current guidelines however are yet to be modified in accordance with these fin...



Why don't we SDD?

Todd Fraser on 2010-08-28 20:02:00

Its been a rotten couple of years for evidence based ICU medicine. It seems that we've systematically knocked down the pillars that support our practice. Just think - tight glyca...



Recruitment Manoeuvers

Todd Fraser on 2010-10-25 12:25:00

I'm impressed that I can even spell Manoeuvers... In September 2010, Critical Care and Resuscitation published a small randomised controlled trial examining the pulmonary and no...



Factor VIIa

Todd Fraser on 2010-12-09 15:56:00

Over the last few years a number of very useful interventions in ICU have gone from evidence based to obselete - Steroids in severe sepsis, Activated Protein C, tight glycaemic con...



The Case for Etomidate

Todd Fraser on 2010-12-15 18:39:00

The haemodynamic perils of induction of anaesthesia in severely compromised patients has long been recognised. Few anaesthetic agents can be used in this setting without the poten...



Intensive Insulin Therapy

Neil Orford on 2011-02-03 17:51:00

Anthony Tzannes comments regarding IIT A few comments from my reading of the study: 1. A concern with the protocol of the study: namely that if hypoglycaemia was found on tes...



Are the days of the MacIntosh blade numbered?

Todd Fraser on 2011-02-12 15:21:00

An paper by Di Marco et al in the January 2011 edition of Anesthesia and Analgesia compares novice aquisition of intubation skill when comparing traditional intubation using a Maci...



Two rabbits in a snow storm

Todd Fraser on 2011-03-11 19:44:00

Recently I've added a data interpretation question on a topic it turns out I know little about. Lung ultrasonography has been around for years, but a bit like cardiac echo, its ...



Tranexamic acid - are you doin' it?

Todd Fraser on 2011-02-25 11:52:00

Major trauma is one of the most common admission diagnoses in intensive care practice. Early deaths from uncontrolled bleeding are a significant contributor to overall mortality. ...



ICU : an open and shut case?

Todd Fraser on 2011-03-26 20:28:00

This week's blog was suggested by Benjamin Moran, raising the intriguing issue of whether or not a closed ICU format, familiar to most intensivists in Australasia, improves patient...



Elderly patients in ICU

Todd Fraser on 2011-04-06 11:34:00

The population distribution in Western Countries is consistenly aging. The likely impacts of this demographic change on ICU resourcing are fairly apparent. It is tempting to su...



Therapeutic hypothermia - who, what, when, where, how?

Todd Fraser on 2011-04-26 12:56:00

Two recent publications raise the issue of therapeutic hypothermia. In march 2011, Dumas et al published a large retrospective review of outcomes from cardiac arrest. While not...



What outcome measures are important?

Todd Fraser on 2011-04-30 10:35:00

This month, the Archives of Surgery published a paper examining the longer term quality of life in patients admitted to a surgical ICU. The results were profound. The authors f...



Journal Club : Permissive hypotension in trauma - does the evidence support the hype?

Todd Fraser on 2011-05-08 13:09:00

Did I just give away my position on this arguement? This month we see the release of an interim analysis by a group from Texas, USA, led by the indefatiguable Ken Mattox. In th...



Diagnosing Ventilator Associated Pneumonia

Todd Fraser on 2011-05-17 10:35:00

Ventilator associated pneumonia is an important cause of acquired morbidity in the ICU. Unlike community acquired pneumonia, the diagnosis is not always straight forward, as many ...



Paediatrics in general ICUs - striking the right balance

Todd Fraser on 2011-07-24 08:42:00

I worked in a small regional ICU for nearly 5 years. In that time I dealt with a number of very sick children, and many who were "not that sick". There was always great pressur...



Cause for concern - is clinical brainstem testing sufficiently specific?

Todd Fraser on 2011-06-12 19:00:00

Ben Moran sent me a horrifying article published in Critical Care Medicine this month. The paper, by Webb and Samuels, describe a case of a 55 year old man who suffered a sudden c...



Measuring lung compliance

Todd Fraser on 2011-06-27 08:01:00

This weeks blog topic was sent in by Ben Tang, who asks : " Just wondering if anyone could help me with a question on compliance? How do we assess lung compliance at the bedside...



Ultrasound for line insertion

Todd Fraser on 2011-07-26 08:30:00

The addition to the literature by Fragou et al this month seemingly adds to the case for ultrasound to be used for all central line insertions, regardless of site. The momentum fo...



On the Dark Side of the Heart

Todd Fraser on 2011-08-07 13:04:00

The right ventricle intrigues me. Everything I seem to do in ICU makes it harder for the RV to function. I use vasoconstrictors - right heart doesn't like it. I let the CO2 go u...



Echo training in ICU

Todd Fraser on 2011-08-28 14:38:00

Echocardiography is becoming increasingly popular in the Intensive Care setting. Access to appropriate equipment is almost universal. The issue now is establishing appropriate cr...



Patient Ventilator Dyssynchrony

Todd Fraser on 2011-08-29 10:47:00

Patients and ventilators just don't get along sometimes. A recent vodcast highlights these issues and can be accessed at, in the vo...



Going through the motions in ICU

Todd Fraser on 2011-10-04 15:53:00

Defecation. Okay, no-one wants to talk about it much. But fundamentally, its one of the most basic functions we have. And if there is one thing ICU is all about, its maintaining ...



Interosseous needles - coming of age?

Todd Fraser on 2011-11-06 07:44:00

Once the domain of paediatric emergency physicians, the humble interosseous needle is seemingly ready for prime time. A paper by Leidel and co-workers published in the September...



The truth about fluids

Todd Fraser on 2011-11-19 16:32:00

I've got a theory that the way we use fluids will completely change in the next 10 years. I can't help but think that we completely over use them. I frequently hear of elderly ...



Responsibility for end of life decision making

Todd Fraser on 2012-01-08 16:50:00

Is it just me? It appears that ICU is relied upon more and more to provide end of life decision making support for ward patients. It seems that fewer ward clinicians are comfor...



Prognosis after cardiac arrest

Todd Fraser on 2012-01-21 14:20:00

This week sees the release of a review of clinical signs and their predictive significance in cardiac arrest in children (see the current paper in the journal club). This paper at...



The Ethical Fabric of ICU

Todd Fraser on 2012-02-08 13:29:00

Crit-IQ has just released a thought provoking podcast with Sharyn Milnes. Sharyn is a medical ethicist and lecturer for the Deakin University School of Medicine in Victoria, Austr...



Helium - useful for more than making your voice sound funny

Todd Fraser on 2012-02-18 10:48:00

A couple of recent papers have focused on the use of Helium-Oxygen mixture in respiratory failure, particularly in infants on nasal CPAP for bronchiolitis, both papers finding it u...



Cervical spine clearance in the intubated patient

Todd Fraser on 2012-03-03 13:54:00

Its an area that continues to cause controversy in ICU. Protocols from the biggest trauma institutions conflict and seem to change on a yearly basis. How do you clear the cervi...



Measuring Performance of an ICU

Todd Fraser on 2012-03-18 10:43:00

An interesting article in a medical news digest recently described the impact of public reporting of hospital patient-centred outcomes. One of the measures used as a risk-adjusted...



Ethical Conundrum

Todd Fraser on 2012-04-15 15:15:00

A while ago I looked after a chap who had tried to kill himself by gassing himself in a car. It turns out he had metastatic bowel cancer - he knew he was dying and was scared of ...



Hypertonic saline

Todd Fraser on 2012-05-09 08:17:00

Hypertonic saline seems to be it and a bit in the world of neurocritical care. It appears in many clinical pathways for the management of intracerebral catastrophes such as trauma...



The artist vs the scientist

Neil Orford on 2012-05-26 17:08:00

The undercurrent argument at the CICM ASM has been based on the tension between the artist and the scientist. It has been good natured, and an interesting topic for reflection. ...



Measuring output - how do you do it?

Todd Fraser on 2012-06-10 11:24:00

One of the interesting by-lines from the recent CICM Annual Scientific Meeting in Melbourne was the regional difference in trend to monitor cardiac output. While the contingent of...



Antibiotics in ICU - do you know what you're doing?

Todd Fraser on 2012-08-31 13:51:12

The more I read about antibiotics in ICU the less I seem to understand them.  An interesting article published earlier this year by the RENAL investigators revealed that up...



Emergency surgical airway access - is there a best way?

Todd Fraser on 2012-09-30 09:46:14

The subject of emergency surgical airway technique is one of the favourite topic of emergency, critical care, anaesthetic and pre-hospital bloggers these days.  So why shou...



Weaning from the ventilator

Todd Fraser on 2012-12-29 14:30:37

It seems that when it comes to weaning long-term patients from a ventilator, there are as many theories on how to do it as there are intensivists.  And probably more.




Not a drop to spare - Jehovah's witnesses in the ICU

Todd Fraser on 2013-01-29 11:19:00

I was sent details of an interesting case that captured my attention recently.


It was a 70 year old man who was a life-long Jehovah's Witness, who had clear...



Critical Care Clinics - do you have one?

Todd Fraser on 2013-02-23 16:22:37

The long term outcomes of ICU patients has gained increasing interest over the last decade.  As mortality in ICU falls worldwide, the impact of therapeutic interventions ha...



Evidence Shmevidence

Todd Fraser on 2013-03-08 19:38:54

So it seems I started a bit of a firestorm this week.


I posted the results of the new OSCILLATE and ...



Under the pump - family and resuscitation

Todd Fraser on 2013-03-15 20:21:13

Neil recently added an interesting paper to the journal club - Family Presence during Cardiopulmonary Resuscitation.  This paper, appearing in the NEJM this month, provokes...



Crisis behaviours

Todd Fraser on 2013-04-06 12:18:07

Recently, a blog post on Australian website "Resus Room Management" challenged the frequently mad...



Decannulation debation

Todd Fraser on 2013-06-16 19:43:52

One of the great areas of "black magic" in ICU surrounds the best method for removing a tracheostomy.


While a decision on whether or not the patient require...



Selective Digestive Decontamination - Right time for prime time?

Todd Fraser on 2013-07-16 09:10:42

Selective Digestive Decontamination, or SDD, remains one of the most maligned therapeutic strategies going around.

Rumour is that a major international multi centre rando...



Interesting Case - Recurrent PE

Todd Fraser on 2013-08-12 09:58:36

Here's another fascinating case to mull over, sent to me from New Zealand this week.


An 85 year old lady, who had been quite well until 5 years ago, is admi...



Targeted Temperature Management - Game changer or just another piece of the jigsaw?

Christopher Poynter on 2013-11-22 10:08:07

There appears to have been a lot of hyperbole surrounding the release of the Read More >>


Fluids in critical care - What does euvolaemia mean anyway?

Chris Poynter on 2013-12-12 19:56:12

Recently, I seem to be learning more and more about how wrong everything that I ever thought about fluids in ICU is.  In fact, I’m way more confused now than I ...



Who's brain dead - us or them?

Chris Poynter on 2014-01-24 10:50:31

There has been some tragic, but enthralling, reading in the press recently surrounding two different cases of “brain death” in America.&n...



ICU Research on Comatose Patients - How does that work?

Chris Poynter on 2014-05-19 14:20:43

Last week there was discussion in the New Zealand press about clinical trials in the setting of ICU (see Read More >>


Much Ado About Tamiflu

Chris Poynter on 2014-06-20 09:46:37

Recently we had a debate amongst our Intensivists about how to proceed with our influenza patients in ICU in light of recent controversy surrounding Tamiflu (Oseltami...





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