EMCrit

Based on the Rivers trial of early goal-directed therapy, central venous oxygen saturation (cvO2%) emerged as a resuscitation target.  This was recommended for over a decade until the PROCESS, PROMISE, and ARISE trials demonstrated that cvO2% monitoring was unnecessary.  Consequently, this has largely fallen by the wayside.However, one niche role of cvO2% in the ICU has … [Read more...]

As a medical student I rotated through an elite hospital where it was believed that every patient admitted to the medicine service needed a rectal exam.  The rationale was to avoid ever missing a case of rectal or prostate cancer.  Eventually, the utility of digital rectal examination as a cancer-screening tool was debunked.  Thankfully, this practice has fallen out of … [Read more...]

Example #1:  Osmolar Gap I'm a bit skeptical of the value of screening toxicology patients by measuring an osmolar gap.  So I looked for literature about the test's performance.  Lynd 2008 found that an elevated osmolar gap had a sensitivity of 90% and a specificity of 22% (1).  That's about what I might have guessed - the test is fairly sensitive and very poorly specific (it … [Read more...]

We all want to alleviate pain and suffering.  Most critically ill patients are treated with opioids for this reason.  Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation.  Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression.  This post explores the optimal use of systemic … [Read more...]

Prior to extubation, the cuff leak is usually checked.  This consists of deflating the cuff of the endotracheal tube to verify that gas is able to move around the tube.  Absence of a cuff leak suggests the presence of airway edema, increasing the risks of post-extubation stridor and reintubation.  However, the test isn't that great.  Absence of cuff leak can also occur due to … [Read more...]