The edition · Emergency & Critical Care
Open ICU visiting halved delirium in 13 trials, and the radial line that under-reads on vasopressors
Flexible family presence was linked to less delirium without more infection; one in five patients on vasopressors had a radial pressure more than 11 mmHg below the cuff.
The edition in brief
Today's emergency and critical care edition opens with a multicentre Polish study of 303 ICU patients on vasoactive drugs with radial arterial lines (Critical Care Medicine, 23 October). In 18%, the non-invasive brachial mean pressure exceeded the radial reading by more than 11 mmHg. A large gradient was independently associated with higher vasopressor doses and went with worse illness severity and higher ICU mortality (48% vs 30%). A meta-analysis of nine randomised trials (585 patients) found airway pressure release ventilation improved oxygenation but did not lower mortality (RR 0.95) or clearly change ventilator-free days, with low to very low certainty. A US multicentre cohort of 1,147 adults discharged from the emergency department with pyelonephritis (Annals of Emergency Medicine, 6 October) found 14-day failure similar with first-, second- and third-generation oral cephalosporins, at about 18–20%. The pearl is setting tidal volume from predicted, not actual, body weight. The practice changer is a meta-analysis of 13 randomised trials with 3,861 adult ICU patients (Critical Care Medicine, 15 October): open or flexible family visiting roughly halved delirium (RR 0.48) and slightly shortened ventilation, with no increase in hospital-acquired infection or mortality. Certainty is low and the trials varied, but the intervention is cheap and the main fear about it — infection — was not borne out.
Radial lines under-read the cuff by over 11 mmHg in one in five patients on vasopressors
On high-dose vasopressors, check the radial pressure against a cuff; a large gradient may mean the line under-reads central pressure.
Airway pressure release ventilation improved oxygenation but not survival
APRV improved oxygenation but showed no survival benefit; keep lung-protective conventional ventilation as standard in ARDS.
Cephalosporin generation did not change pyelonephritis failure after ED discharge
Oral cephalosporins of different generations had similar 14-day failure in ED pyelonephritis; let culture and local resistance guide choice.
Set tidal volume from predicted body weight, not actual weight
Calculate tidal volume from height-based predicted body weight, never from actual weight.
Open ICU visiting halved delirium without more infections
Flexible ICU visiting was linked to half the delirium with no rise in infection; consider opening visiting hours.
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