How should we evaluate for myocardial ischemia in a critically ill patient admitted for some other problem (e.g. pneumonia)? What does it mean if their troponin is elevated?
PulmCrit- Sepsis Research Rant: More fake news, less real news
The following rant focuses on sepsis research, but these principles are universal. I apologize for the agitated nature of this post, but I just can’t hold it in any longer. If I read one more correlational study which tries to imply causation, I might just explode. In order to prevent burnout, I’m going to journal these thoughts instead. So, hang on to your hats, because things are going to get a bit heated.
IBCC chapter & cast: Anatomy of a DKA resuscitation
Welcome to the inaugural IBCC chapter! The IBCC chapter on DKA is located here. The podcast & comments are below. Follow us on iTunes
Announcement: Launching the Internet Book of Critical Care (IBCC)
Several years ago a mentor suggested that I write a book. I nearly laughed at her. A book?? Inconceivable! Who would buy it? Would they actually read it? Would it be there at 3 AM when they needed it? How could it be updated? A physical book didn’t seem compatible with the breakneck speed of critical care or our internet-based culture.
PulmCrit- The hidden fragility of meta-analyses: case study of the IOTA trial
Meta-analyses are widely assumed to be robust, without any attempt to test their fragility. This post describes two techniques to evaluate the fragility of a meta-analysis
PulmCrit: A-lines in septic shock: the wrist versus the groin
Historically, emphasis has rested on the distinction between noninvasive versus invasive BP (e.g., cuff pressure vs. radial arterial pressure). Attention focused on whether noninvasive oscillometric BP monitoring is adequate. Meanwhile, it has been assumed that all invasive BP measurement sites are created equal.
PulmCrit- Can we fix a broken circadian clock with melatonin?
Circadian rhythms and melatonin are best known for their relationship to sleep. However, they have a much broader range of functions. Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).
PulmCrit- Could the Furosemide Stress Test clarify resuscitative goals?
Imagine that you admit a patient with septic shock. You resuscitate the patient as best you can with inopressors, fluids, and antibiotics. An adequate blood pressure is achieved. A reasonable amount of fluid is administered. Despite all these measures, the urine output remains minimal. What should you do next?
PulmCrit- A better approach to Torsade de Pointes
A common approach to TdP is shown above. The initial episode is controlled with magnesium and perhaps defibrillation. The patient is sent to ICU for close observation. Usually the patient will be fine, but sometimes TdP does recur. Recurrence triggers second-tier therapies, often including overdrive pacing.
PulmCrit: pH-guided fluid resuscitation & BICAR-ICU
The use of bicarbonate is a source of eternal disagreement. Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest). This has impugned its reputation, giving it an aura of ignorance and failure. Consequently, bicarbonate is underutilized in some situations where it might actually help.
PulmCrit- Should we monitor fibrinogen during full- & half-dose PE thrombolysis?
No high-quality evidence exists on fibrinogen monitoring in PE. Most practitioners don’t check fibrinogen levels for patients getting TPA for PE. This is a bit paradoxical, because fibrinogen is usually monitored in patients receiving catheter-directed thrombolysis – a procedure involving lower doses of TPA with a markedly lower risk of intracranial hemorrhage.
PulmCrit- High dose vasopressors: Never surrender
Every hospital and pharmacopeia have their own “maximum dose” of vasopressors. Which one is correct?
PulmCrit- Ten dubious beliefs in neurocritical care
Recently Geert Meyfroidt published an article in Intensive Care Medicine describing ten false beliefs in neurocritical care shown here: It’s a great article, but I think they could have been more aggressive about challenging neurocritical care dogmas (1). In response, here is a list of ten dubious beliefs that goes farther to challenge the status quo. […]
PulmCrit- Montreal Hospitalist & Resuscitationist Conference FOAMed
I recently got back from the inaugural Hospitalist & Resuscitationist conference, a fantastic FOAMy conference in Montreal organized by Phillipe Rola (@ThinkingCC). It was inspiring to participate alongside fantastic folks including Rory Speigel (@EMNerd), Jon-Emile Kenny (@heart_lung), Kylie Baker (@kyliebaker88), Lawrence Lynn(@PatientStormDoc), Andre Denault, and Segun Olusanya (@iceman_ex). Screencasts of my talks, audio clips, some videos […]
PulmCrit- Drowned Airway Algorithm: Cut to the chase
The literature describes various techniques for the drowned airway. However, there doesn’t appear to be any airway algorithm which integrates these into a coherent strategy. A collection of airway tricks without any plan is a formula for disaster.
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