My primer on Critical Care

I’m in San Francisco for the next several days for the Society of Critical Care Medicine (SCCM) Clinical Congress.  I intend to go home with some great new clinical blog topics for you all, but as a segué to whatever I learn here I wanted to get some key references out there for those who are newer to the world of critical care.  Secondary gain:  It makes a great resource for my students and residents.

This list is by no means comprehensive, and studies placed here are here based upon my opinions.  I’ve essentially selected one seminal or one “hot off the presses” publication for several organ systems.

Neuro:  Delirium is obviously one of our nemeses in the ICU, and we want to minimize the risks for it in our patients who require sedation.  Although it’s now 8 years old, a game-changer for me was Pandharipande’s study showing that lorazepam is an independent risk factor for delirium in the ICU.  Our pharmacist had the graph from the study taped to her laptop for over a year, and any time we started discussing sedation strategies I would point at it.  Related: Last January, SCCM released new evidence-based guidelines for the management of pain, agitation, and delirium in the ICU.  The guidelines are very helpful, but they also show many areas in which we still have significant knowledge deficits.

Cardiovascular:  I remember when I started my residency that levophed was typically referred to as “Leave ’em Dead.”  In hindsight, I suspect that this was simply because we weren’t using it optimally, and therefore our patient outcomes were impaired.  In contrast, I now often find myself trying to convince referring MDs that use of dopamine is probably not a best choice, even in refractory hypotension, because of the increased number of adverse events associated with its use.

Pulmonary:  Yes, it’s now 14 years old, but ARDSnet remains our standard of care for our patients with ARDS.  We may not always agree on PEEP or mode of ventilation, but low-stretch remains the standard of care.

Endocrine:  During my residency, we all got VERY excited about tight glycemic control in the ICU based upon the van den Berghe study.  Subsequently, we’ve found that tight control increases the risk of hypoglycemia, which in turn increases the risk for neuroglycopenia (which is bad) and mortality (which is worse than bad).

Nutrition:  The Canadian Critical Care group continues to lead the way in development of evidence-based guidelines.  These were most recently updated in April, 2013 (link is to the summary).

Heme:  The TRICC trial.  I’m eagerly awaiting our findings from the analogous burn study that is still enrolling patients.

Infectious Disease:  How many days of treatment are required for a ventilator associated pneumonia?  Less may be more.  Also, no learner should get through an ICU rotation without knowing about the Surviving Sepsis guidelines and being able to implement them in care of a patient.


  • The New England Journal of Medicine initiated a truly terrific case-based series of reviews on critical care last year.  These are highly recommended for practitioners new and old.
  • SCCM has a series of clinical practice guidelines, of which I have only highlighted a couple.  They are an excellent resource.
  • Again, these references are a starting point for core readings in critical care.  If I have committed a glaring omission, please let me know so I can addend.