Four contestants went head-to-head on various critical care topics in a session full of playful banter and controversies.
Pardon the Interruption 2020: Controversies in Critical Care, Part 1, hosted by David Schulman, MD, MPH, FCCP, on Sunday, October 18, posed controversial critical care questions to participants David Bowton, MD, FCCP, of Wake Forest University School of Medicine; Kristin Burkhart, MD, MS, FCCP, of Columbia University School of Medicine; Steven Hollenberg, MD, FCCP, of Hackensack Meridian School of Medicine at Seton Hall University; and Amy Morris, MD, FCCP, of University of Washington School of Medicine. The session is available for viewing on the virtual CHEST 2020 meeting platform through February 1, for registered attendees.
Dr. Schulman judged each contestant’s answers on volume, humor, and accuracy. Points were awarded for data, sass, and whether or not it entertained or annoyed Dr. Schulman. In a close fight, Dr. Burkhart came out as the winner.
The first question posed: What is the current role of glucocorticoids in the management of community acquired pneumonia (CAP)? Dr. Bowton said there was no mortality benefit of the steroids, citing the ESCAPe trial, while Dr. Hollenberg said it was a “toss up,” and it’s “never going to be one way or another.”
Dr. Morris argued that it depends on the pneumonia. If someone is super sick on a bunch of pressors, she’d consider them. Dr. Burkhart said there’s a slight mortality benefit of steroids for severe pneumonia, per the Cochrane Review, and said routine use “no,” but maybe in another indication such as sepsis.
The next question: Antibiotics within one hour or thoughtful consideration to avoid overuse?
“I don’t buy, entirely, the thought that mortality goes up linearly with every hour that patients don’t get antibiotics for a couple reasons,” Dr. Morris said. “It’s all retrospective data, heavily statistically adjusted by very smart people, but the challenge is, when you assign a fixed number to that, I think people stop thinking and start doing. And there’s a lot of pressure … to abide by the guidelines instead of maybe doing the right thing and thinking more carefully. … But I think the key thing in the discussion is recognizing that we need to tailor and stop early when we know what is actually causing the problem.”
Dr. Burkhart had a slightly different answer.
“Aim for under one hour,” she said. “In septic shock, you have to go big or go home. … There’s a great risk of death if you don’t appropriately initiate antibiotics in a time-sensitive manner.”
Dr. Hollenberg chimed in and said the issue isn’t when to start, it’s not stopping once administered.
“Within one hour, antibiotics don’t make a difference unless it’s septic shock,” Dr. Bowton added.
Up next: Should we use daily or continuous renal replacement therapy (RRT) for acute kidney injury in the ICU?
“From a cardiology point of view, continuous RRT is better tolerated in cardiac patients,” Dr. Hollenberg said. “It’s just logistically easier for an intensivist in an ICU to be able to manage the continuous RRT rather than strain the resources of the renal service.”
Dr. Morris chimed in saying “you use what you have and have the resources for.”
When asked about targeted temperature management: 33 or 36 degrees?, Dr. Burkhart said the evidence suggests 36 degrees, and when asked “Should septic patients with chronic hypertension have a goal MAP of 80 mm HG in the ICU?”, Dr. Bowton said “No, probably.” Dr. Burkhart agreed with Dr. Bowdon.
Other questions discussed included:
- Should ultrasound be used to guide fluid management in sepsis?
- Should NIPPV noninvasive positive pressure ventilation be used in managing acute hypoxemic respiratory failure from ALI?
- What is the role for Vitamin C and thiamine for sepsis?
- COVID-19 speed round—Empiric CAP therapy for patients admitted with coronavirus?