Tuesday, December 4, 2012
The Cholesterol Hypothesis on the Beam: Dalcetrapib, PCSK9 inhibitors, and "off-target" effects of statins
I was very pleased to see McConville and Kress' Review article in the NEJM this week (December 6, 2012 issue) regarding weaning patients from the ventilator. I have long been a fan of the University of Chicago crew as well as their textbook and their pioneering study of sedation interruption a decade ago.
In their article, they provide a useful review of the evidence relating to the discontinuation of mechanical ventilation (aka weaning , liberation, and various other buzz words used to describe this process.) Yet at the end of the article, in describing their approach to discontinuation of mechanical ventilation, they provide a look into the crystal ball that I think and hope shows what the future may hold in this area. In a nutshell, they push the envelope and try to extubate patients as quickly as they can, ignoring inconvenient conventional parameters that may impede this approach in select instances.
Much of the research in this field has been dedicated to trying to predict the result of extubating a patient. (In the case of the most widely cited study, by Yang and Tobin, the research involves predicting the result of a predictor of the ultimate result of interest. This reminds me of Cervantes' Quijote - a story within a story within a story....but I digress.) And this is a curious state of affairs. What other endeavor do we undertake in critical care medicine where we wring our hands and so helplessly and wantonly try to predict what is going to happen? Don't we usually just do something and see what happens, making corrections along the way, in silent acknowledgment that predicting the future is often a fool's errand? What makes extubation so different? Why the preoccupation with prediction when it comes to extubation? Why not "Just Do It" and see what happens?