Category Archives: critical care

ADRENAL trial – to steroid or not to steroid in septic shock

The original:

http://www.nejm.org/doi/full/10.1056/NEJMoa1705835

An excellent summary:

http://www.thebottomline.org.uk/summaries/icm/adrenal/

Should we still be trying to modify the dysregulated immune response in sepsis? An interesting evolutionary perspective:

https://evolutionmedicine.com

My verdict:

Although not improving (or worsening) mortality, if steroids reduce duration of shock and length of ICU stay then they are probably worth a go, given that the absolute possible increase in risk of noteworthy adverse outcomes is very low, although this must be borne in mind.  Could still argue it either way though. When we can genotype patients we may be able to identify those specific individuals in whom steroid may do significant benefit or harm. Or maybe not!

To drain a pleural effusion found on POCUS?

Suggested indications:

If underlying lung is recruitable (ref?)

Inverted diaphragm 

Specific indications e.g. Surgical, BTS guidelines 

Stalled wean + large effusion. If max distance between diaphragm measures >5cm then almost certainly >800ml and drainge will improve situation (ref?)
High RSB index

Overall nil definitive evidence, so take a pragmatic approach.

From CUSIC day @ICSSeminars