Mucolytics did nothing for ventilated patients, and both caused harm

The edition in brief

The emergency and critical care desk opens with MARCH, a 2-by-2 factorial trial in 1,956 mechanically ventilated patients with difficult-to-clear secretions. Neither enteral carbocisteine nor nebulised hypertonic saline shortened mechanical ventilation — median 186.1 against 172.7 hours and 184.5 against 174.3 hours respectively — and each carried harm: clinically important upper gastrointestinal bleeding in 1.4% versus 0.2% with carbocisteine, and hypoxaemia during nebulisation in 4.1% versus 0.3% with hypertonic saline. A meta-analysis of 34 studies of machine learning sepsis prediction reports a pooled AUROC of 0.913 but a 95% prediction interval from 0.660 to 0.983, with many studies reusing the same public datasets. A Dutch post hoc analysis of 18,798 patients found that the association between emergency-department-to-ICU transfer time and mortality ran in opposite directions in academic and non-academic hospitals for out-of-hospital cardiac arrest, and was absent for sepsis, pneumonia, overdose, respiratory failure and intracranial haemorrhage. The AZ-SWED trial of azithromycin in 840 preschoolers with moderate-to-severe wheezing in the emergency department was stopped for futility despite the antibiotic clearing bacteria in 58.7% against 11.4%. A pearl covers the agitated patient who cannot be examined. The edition closes with a 1,194-patient trial showing intranasal and subcutaneous ketamine are clinically equivalent for acute musculoskeletal pain.