Follow-up data from the PEITHO trial shows that thrombolytics don’t affect long-term morbidity. This simplifies management substantially. PEITHO trial & long-term follow up The PEITHO trial was a multi-center RCT investigating the effect of thrombolysis in submassive PE. Tenecteplase caused an increase in intracranial hemorrhage and a reduction in hemodynamic collapse. Overall there was a […]
PulmCrit Wee: MDCalc for the perfect tape-measure intubation
Imagine you went to buy an expensive piece of clothing. Rather than measuring your size, the store owner simply said “well, on average most folks require a medium, so let’s try that on, we can always re-size it later.” You would be irritated that they were wasting your time. When you go clothes shopping, you […]
PulmCrit- Hypertriglyceridemic pancreatitis: Can we defuse the bomb?
Hypertriglyceridemia causes ~9% of pancreatitis, the third most common cause after alcohol and gallstones. It is a risk factor for severe pancreatitis, making it more frequent among ICU patients with pancreatitis. I see this a few times each year. Nonetheless, it has low penetration into educational curricula or our collective awareness. The treatment of hypertriglyceridemic […]
PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure
Introduction with a clinical conundrum A 66-year-old man is transferred from an outside hospital due to inability to be liberated from the ventilator. He presented a week earlier with pneumonia and sepsis. He received six liters of fluid initially, and has been running net positive 1-2 liters daily since then (for a total of about […]
PulmCrit- Epinephrine vs. atropine for bradycardic periarrest
Introduction with a case An elderly woman is admitted with atrial fibrillation and fast ventricular rate. She is asymptomatic, with a heart rate of 160 b/m. She is treated with a 20 mg diltiazem bolus followed by an infusion at 15 mg/hour for several hours. Her heart rate slows to 110 b/m. She is then […]
PulmCrit- Six myths promoted by the new surviving sepsis guidelines
Early Goal-Directed Therapy: A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy. This is basically the NINDS trial of the critical care world: a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline. The […]
PulmCrit- How to convert a VBG into an ABG
This post is about a research project I did as a pulmonary critical care fellow in 2011. To understand it, you need to know a bit of the story behind it.
PulmCrit- Sedation update: IV olanzapine & combo vs. monotherapy
The potential role for IV olanzapine was examined in a post last year. The following conclusions were reached: IV olanzapine appears to be safe. IV olanzapine has equal potency compared to IV droperidol and about twice the potency of IV haloperidol. Olanzapine doesn’t affect QT interval or cause torsade de pointes. Two articles were just […]
PulmCrit- Dogmalysis of PCI for NSTEMI patients with a history of CABG
Many patients with prior CABG probably benefit from catheterization and repeat revascularization (PCI or a repeat CABG). However, this cannot be assumed to be universally true. In particular, patients with smaller infarcts and advanced renal failure could be harmed.
PulmCrit- Triple therapy for influenza with naproxen, clarithromycin, and oseltamavir?
Flu seasons is upon us again. A recent paper in CHEST provides some tantalizing evidence about possible treatment. Will this pan out, or is it just another fairy tale?
PulmCrit- Coagulation balance in sepsis-associated DIC
An 80-year-old man was admitted with sepsis due to liver abscess. Over the first two hospital days his platelet count decreased from 122 to 39. Prophylactic heparin was held due to concerns about bleeding risk. Additional coagulation studies showed a D-dimer of 1221 ng/ml, a fibrinogen of 672 mg/dL, and the following thromboelastograph:
Pulmcrit Wee- Vasopressin vs. norepinephrine for vasoplegic shock after cardiac surgery
Patients in the VANISH trial treated with vasopressin had a lower incidence of renal failure requiring hemodialysis. However, this was a secondary endpoint which seemed to contradict the primary endpoint (defined as a milder degree of kidney injury). New data may clarify this controversy.
PulmCrit- Devil in the details: Endotracheal tube depth
According to Napoleon, “the moment of greatest vulnerability is the instant immediately after victory.” In airway management, this instant occurs immediately after placement of the endotracheal tube. There is a risk of relaxing and overlooking critical details. Meanwhile, this is often the point when the patient’s blood pressure and saturation nadir. Introduction with a rare but […]
PulmCrit- New guidelines simplify ICU nutrition
Introduction to nutritional dogma Everyone has strong opinions about food. We all feel that we have some special, intuitive understanding of nutrition. Nonsense. Such intuitions have historically created a wide array of dogma regarding nutrition, complicating matters immensely. Fortunately, the 2016 SCCM/ASPEN guidelines have stripped away much of the nonsense involved in nutritional support. This […]
PulmCrit- Top 10 reasons pulse oximetry beats ABG for assessing oxygenation
What does it mean if PaO2 and oxygen saturation seem to disagree? Do we need to measure an ABG if the oxygen saturation waveform is adequate? What is the best way to measure oxygenation?
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