The edition · Emergency & Critical Care
Daily sedation interruption probably reduces deaths in ventilated patients, an updated Cochrane review finds
Twenty-three trials link a daily pause in sedation to fewer deaths, shorter stays and fewer tracheostomies; cephalosporin generation made no difference in discharged pyelonephritis; and 4 in 10 paramedic STEMI calls were something else.
The edition in brief
An updated Cochrane review of 23 randomised trials (nearly 6,000 ventilated adults and children) found daily sedation interruption probably reduces mortality (RR 0.88, 95% CI 0.77 to 0.99, moderate certainty), ICU stay and hospital stay by about 11%, and tracheostomy (RR 0.68), and may shorten ventilation by about 14% at low certainty. Accidental extubation did not clearly rise; opioid doses probably rose slightly. In a US multicentre cohort of 1,147 adults discharged from the emergency department with pyelonephritis on an oral cephalosporin, 14-day treatment failure was similar whether first-, second- or third-generation agents were used, about 18% to 20%, though the study was observational. In a Victorian ambulance registry of 7,205 paramedic-suspected STEMI patients with a recorded diagnosis, 60% had confirmed STEMI and 8.5% a non-cardiac diagnosis, the group with the highest long-term mortality. The FDA lists an ongoing Class II recall of one premixed vasopressin infusion for manufacturing-practice deviations. The pearl: a patient on an SGLT2 inhibitor can be in ketoacidosis with a near-normal glucose, so check ketones in anyone unwell.
Paramedic-suspected STEMI: 60% confirmed, and the non-cardiac minority fares worst
On arrival, actively reassess paramedic-activated STEMI patients for serious alternative diagnoses without delaying reperfusion for those who need it.
Outpatient pyelonephritis: cephalosporin generation did not change 14-day failure
For outpatient pyelonephritis, choose an oral antibiotic by local susceptibility and culture, not by cephalosporin generation.
FDA lists a Class II recall of one premixed vasopressin infusion
Ask pharmacy to check imported premixed vasopressin stock against the FDA recall and have a vial-based alternative ready.
SGLT2 inhibitor and unwell: check ketones whatever the glucose
In any unwell patient on an SGLT2 inhibitor, check ketones and a venous gas even when glucose is normal.
Daily sedation interruption: probably fewer deaths, shorter stays, fewer tracheostomies
Use a daily sedation interruption with a safety screen for ventilated patients; it probably reduces mortality and length of stay.
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