We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines. If you believe that our septic patients deserve more evidence-based guidelines, please stand with us.
PulmCrit- Shrug Technique for US-guided subclavian lines
The CDC guidelines recommend placing subclavian lines to reduce the risk of catheter-related bloodstream infections. Meanwhile, mounting evidence suggests that we should probably be placing lines with ultrasound guidance. Unfortunately, the ultrasound-guided subclavian can be tricky. This post describes a slight modification that could make the technique easier and safer.
PulmCrit- .050 shades of grey in p-value cutoffs
We have a love-hate relationship with the p-value cutoff of <0.05. A p-value right below this cutoff (say, p=0.04) actually constitutes a surprisingly weak level of evidence (1). Thus, the idea of lowering the p-value cutoff has been around for a while. Unfortunately, this wouldn't really fix our problems with p-values.
PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?
ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint. They reached opposite conclusions: steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS. Why?
PulmCrit Wee- Secondary endpoints: Can we separate the wheat from the chaff?
This post will attempt to create a rough framework for analyzing secondary endpoints. This is primarily intended as a springboard for debate, rather than a final answer to this thorny issue (one which has remained unresolved for decades).
PulmCrit- Chasing mortality endpoints is a fool’s errand
“There is no mortality benefit for that.” How many times have you heard that? The implication is usually the same: that intervention is a waste of time. A smart, evidence-based clinician wouldn’t bother with it. But, what does it actually mean if there is no proven mortality benefit?
PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation
Saline vs. balanced solutions has been a topic of ongoing debate. Two fresh studies will illuminate this: the SMART and SALT-ED trials. This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1. There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]
PulmCrit- Mastering the dark arts of BiPAP & HFNC
Skillful use of BiPAP and high-flow nasal cannula (HFNC) can avoid intubation and improve outcomes. However, there isn’t comprehensive evidence about the nitty-gritty details of these techniques. In this post I will use my opinions to fill some gaps in the evidence. Noninvasive respiratory support remains more of an art than a science, perhaps a dark art at that.
PulmCrit- Metabolic sepsis resuscitation: Strike hard, strike fast, no remorse
Escalation-deescalation There are roughly two strategies for adjusting the intensity of treatment: Titrated strategy: Treatment intensity is adjusted to match the severity of the disease. Escalation-deescalation strategy: Treatment intensity is increased rapidly to exceed disease severity and gain control of the disease. After the patient improves, treatment intensity is reduced. The best strategy depends on […]
PulmCrit: ARDS vs. pseudoARDS – Failure of the Berlin definition.
Did this woman have ARDS? According to the Berlin Definition shown below, she had moderately severe ARDS while on conventional low tidal-volume ventilation (P/F ratio of 166). However, she didn’t meet the definition of ARDS while she was APRV, a few hours earlier (P/F ratio 475). Her overall clinical course with prompt recovery and weaning off oxygen is inconsistent with the natural history of ARDS.
PulmCrit- Angiotensin II: five cautions & three comparisons
Upon first reading the ATHOS-3 trial, I was pleasantly optimistic. Who wouldn’t be interested in a shiny new vasopressor? The trial didn’t prove much, but it was intriguing. However, it was alarming to hear that the FDA has approved angiotensin II for use based on it. Precious little evidence is available about this drug. With angiotensin II arriving at hospitals soon, some cautions are in order.
PulmCrit – Treatment of massive insulin poisoning refractory to glucose
Severe insulin overdose usually occurs as a suicide attempt, but can also result from medication error. Conventional therapy focuses on giving tons of intravenous glucose. This generally works, but it can get messy.
PulmCrit- Phenobarbital monotherapy for alcohol withdrawal: Reloaded
Currently there is a lorazepam shortage in the United States. This caused a surge of interest into using phenobarbital for alcohol withdrawal. I’ve received several e-mails over the past few weeks about this. It’s been two years since my last post about phenobarbital, so here’s an update focusing on lessons learned in the interim.
PulmCrit – Optimizing the respiratory drive to avoid failure
Scott Weingart just posted a podcast about management of the hypercapneic, obtunded COPD patient who is failing BiPAP. Do we need to intubate these patients, or could we somehow clear their CO2 noninvasively? This post will start off by exploring respiratory drive as a mediator of disease. With that groundwork, we’ll explore the obtunded COPD patient.
PulmCrit- APRV: Resurrection of the open-lung strategy?
APRV is often used in surgical ICUs, but not medical ICUs. APRV may be viewed as a “new” technique by medical intensivists, whereas it’s been used for decades in surgical ICUs with great results. A fresh RCT may help resolve this.
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