The edition · Emergency & Critical Care
Sudden painless vision loss, one in five septic shocks refractory, and where the transfusion threshold sits in infarction
A joint position paper separates the two forms of ischaemic optic neuropathy; consensus criteria put a number on refractory septic shock; and MINT's ICU subgroup declines to carve out an exception.
The edition in brief
Anterior ischaemic optic neuropathy is a leading cause of sudden, painless, one-eyed vision loss after 50, and a joint Spanish internal medicine and retina society position paper sets out the split that governs everything: the arteritic form, usually giant cell arteritis, is an emergency in which delay costs the other eye, while the far commoner non-arteritic form has no specific effective treatment. The recommendations are explicitly expert consensus where evidence is thin. Applying newly agreed consensus criteria for refractory septic shock — noradrenaline equivalent above 0.5 micrograms per kilogram per minute together with lactate above 2 mmol/L — to 15,732 patients with septic shock in a US health system, 21.8% met them, and their hospital mortality was 64.4%, with risk-adjusted odds of death 4.87 times higher than those who did not. The FDA has approved a supplement to an abbreviated application for generic buprenorphine and naloxone from one manufacturer, an administrative action affecting supply rather than any change in indication or safety. The practice-changer is a subanalysis of the MINT trial in 3,504 patients with myocardial infarction and anaemia, 47.9% of whom were in intensive care at randomisation: a restrictive transfusion strategy was associated with non-significantly higher death and death or reinfarction in both groups, with no interaction by critical illness. The overall MINT result, which favours a liberal threshold in infarction, applies to ICU patients too.
Two diseases wearing the same presentation
In sudden painless monocular visual loss over 50, separate arteritic from non-arteritic before anything else — and act on suspicion of the arteritic form rather than waiting for proof.
One in five septic shocks meets the refractory definition, and two-thirds of those die
When a septic shock patient crosses 0.5 mcg/kg/min of noradrenaline equivalent with a lactate above 2, treat that as the trigger for senior review and a family conversation, not as a number to keep titrating past.
FDA clears a supplement for a generic buprenorphine-naloxone product
Nothing clinical changes — but if your department initiates buprenorphine-naloxone, confirm the patient can actually obtain it before they leave.
Start the steroid before the biopsy is booked
Suspected giant cell arteritis with visual loss gets the steroid before the biopsy — and the reasoning written down so nobody stops it.
No separate transfusion threshold for the critically ill patient with infarction
Stop applying a separate restrictive threshold to the critically ill patient with myocardial infarction and anaemia — MINT's answer covers them too.
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