Ionised hypocalcaemia after ROSC

Ionised hypocalcaemia has been observed post-cardiac arrest in previous studies. Investigators in Utah induced VF in a swine model and resuscitated them back to spontaneous circulation1. Ionised hypocalcaemia was associated with hypotension and impaired LV function, and its treatment with a calcium infusion resulted in improved mean arterial pressure and left ventricular stroke work.

Although iv calcium is not recommended as a blind treatment in cardiac arrest, in part due to concerns about exacerbating cellular injury, this study reminds us that the treatment of ionised hypocalcaemia is important, and may be necessary after ROSC.

1. Hypocalcemia following resuscitation from cardiac arrest revisited
Resuscitation 2010 Jan;81:117–122

Therapeutic hypothermia with simple measures

Thirty-eight post-cardiac arrest patients were effectively cooled to the target temperature range of 32-34 celsius using intravenous cold saline and ice packs to groin, axillae, and neck. The ice packs were frozen 250 ml saline bags wrapped in pillow cases. If shivering occurred muscle relaxation with rocuronium was used until the target temperature was reached. Interestingly, rebound hyperthermia occurred in 8/34 patients.

Although a small study, these data reassure those of us who induce therapeutic hypothermia without the use of dedicated cooling equipment.

Cold saline infusion and ice packs alone are effective in inducing and
maintaining therapeutic hypothermia after cardiac arrest

Resuscitation 2010;81:15–19

Bulging fontanelle in febrile infants

In a study of febrile infants with a bulging fontanelle, only one out of 153 infants had bacterial meningitis. Other diagnoses included aseptic meningitis (26.7%), upper respiratory tract infection (18.3%), viral disease NOS (15.6%), roseola infantum (8.5%) and acute otitis media (6.5%).

In this study, most infants with fever and a bulging fontanelle had benign and self-limited disease.

Bulging fontanelle in febrile infants: is lumbar puncture mandatory?
Arch Dis Child. 2009 Sep;94(9):690-2

Steroids and insulin in septic shock – more data

In a multicentre RCT of patients with septic shock who were receiving steroids (hydrocortisone) for the septic shock, intensive insulin therapy did not affect outcome but was (once again) associated with a higher incidence of hypoglycaemia. Also, the addition of (enteral) fludrocortisone did not provide benefit compared with hydrocortisone alone.

Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults
JAMA. 2010;303(4):341-348