It' doesn’t look good for the "metabolic cure” 5/6 negative for 1° endpoints; ORANGES found ⬇️ pressor use 5/6 with no mortality Δ; CITRIS did, but mortality was 1 of 46 2° endpoints 1/
This is a great time to do some meta-analysis.
As you can see from my quick/simple analysis, neither vitamin C either alone or in combination with hydrocortisone and steroids reduced in mortality in people with sepsis: 2/
What about other endpoints? It doesn't look much better for vitamin C: 4/6 found no ΔSOFA scores.
Also, while ΔSOFA scores and duration of vasopressors are important, I would argue that mortality is a more meaningful (and more patient centered) endpoint. 3/
Bottom Line:
I've been excited but skeptical since the Marik paper.
Since 2017, there have been several RCTs that have failed to replicate those results.
Now I’m pretty sure #VitaminC doesn’t work.
In the ICU as in life, when something seems too good to be true it probably is
4/
Methods:
This is a binary random effects model looking at 28 or 30-day mortality using #OpenMetaAnalyst and the MetaFor package in #Rstats version 3.6.2
For those interested in doing your own analysis you can download my data here: dropbox.com/s/a2k83j3a09ps…
5/
Damn. Under Trump the White House Medical Unit was a pill-mill. Thousands of ambien & provigil per month.
Worse, for a clinic that doesn’t typically do procedures w/ moderate sedation they sure are they ordering prodigious quantities of morphine, fentanyl, versed, & ketamine…?
Honestly, this reminds me of Norman Ohler’s Blitzed.
The AG report was largely concerned with the enormous cost of prescribing these non-genetic meds.
It’s worth pointing out that dispensing prescription meds without documentation is malpractice. In the case of controlled substances it’s also likely a crime.
The long awaited #COVIDOUT RCT is now in @TheLancet:
- high risk adults randomized to either metformin (MET), ivermectin (IVM), fluvoxamine (FLV) or placebo.
- MET reduced the risk of long COVID (6.3% vs 10.4%; NNT = 24)
- no benefit with IVM or FLV
Pulmonary teaching case: you are called to the bedside of a 60yo man who was admitted for pneumonia a week ago. You were called because “he coughed and now his chest is PULSATING!”
This is what you see at the site of a previously removed chest drain:
EN is a rare complication of an infected pleural effusion where purulent fluid “escapes” the pleura and erodes into the chest wall, causing an extrapleural fluid collection that communicates with the pleural space.
Because Empyema necessitans communicates with the pleural space, fluid can move back & forth with respiration, as seen here:
With inspiration, negative intra-thoracic pressure pulls the fluid into the chest. With expiration, positive intra-thoracic pressure pushes fluid out. 3/ twitter.com/i/web/status/1…
Interesting RCT in @NEJM about platelet transfusions prior to CVC placement in people w/ thrombocytopenia (Plt 10-50k):
- higher rate of grade 2-4 bleeding w/o Plt transfusion: 11.9% vs 4.9%
- difference driven by much more bleeding w/ subclavian lines nejm.org/doi/full/10.10… 1/
This trial enrolled n=338 hospitalized people in 🇳🇱 with platelets between 10-50k, INR <1.5 (changed to 3.0). 57% were heme/onc patients & 43% were ICU patients.
Median Plt count was 30k
Most were getting a CVC for chemoTx. (Most weren’t exactly your “typical” ICU patient.) 2/
Importantly they placed the CVC within 1 hour or randomization. This means they probably didn’t transfuse then place a line, more like placed a line while transfusing.
(IMO this difference matters in situations where platelets are dysfunctional, like uremia) 3/