COVID-19 patients seem to behave in a somewhat unique fashion, compared to other patients with ARDS. This isn’t based on high-level data, but it seems to be a theme emerging from a variety of centers (including my experience with one patient). Some salient points are: Low driving pressures are seen among ventilated patients. Thus, it […]
PulmCrit – Splitting ventilators to provide titrated support to a large group of patients
COVID-19 might out-strip the number of mechanical ventilators available to us. This has led to interest in using a single ventilator to support multiple patients. This post will review the theory and evidence regarding this (with the admission that I don’t have experience with this). basic principles Bedrock principle: Patient-Ventilator Independence Normally, we adjust the […]
PulmCrit – Preview of Lopinavir/Ritonavir efficacy in COVID-19?
background Lopinavir/Ritonavir (tradename KALETRA) is a combination of protease inhibitors typically used in HIV, including post-exposure prophylaxis (lopinavir is the actual antiviral agent, with ritonavir functioning to inhibit metabolism of lopinavir, thereby boosting levels of lopinavir). In vitro, Lopinavir/Ritonavir has activity against SARS-CoV-1 and functions synergistically with ribavirin (the addition of ribavirin increases Lopinavir’s potency […]
IBCC: COVID-19
Friends, As COVID-19 has exploded, so has the amount of information about COVID-19. There are currently over 700 publications regarding coronavirus listed in PubMed within the past few months. More are being released daily. Many haven’t been catalogued on PubMed yet. This chapter will attempt to synthesize the latest and most important information on COVID-19. […]
PulmCrit- Nonsedation in ventilated patients: Two dueling RCTs
A new study in NEJM compared nonsedation with light sedation in ventilated ICU patients. This is a follow-up study, aimed at clarifying the results of a prior trial at the same center. To best understand the current study, we need to start with the first trial… Strom et al. 2010: A protocol of no sedation […]
PulmCrit- My favorite 20 abstracts from SCCM
The Society of Critical Care Medicine published over 1,800 abstracts to go along with their latest conference. I sifted through them to come up with my favorite 20. Kudos to all the authors on creating diverse and thoughtful work – the future of critical care is indeed bright! The abstracts are divided into six groups: […]
IBCC chapter & cast – Vasopressors
Vasopressor use is an everyday exercise in critical care. Unfortunately, high-level evidence regarding these agents is often lacking. Furthermore, patients may react in unique ways. This chapter attempts to clarify some vasopressor basics, but beware – all of your patients will not read the book. The IBCC chapter is located here. The podcast & comments […]
PulmCrit – It’s insane to keep using mortality as a primary endpoint in critical care trials
There, I’ve said it. That’s a bit of a bold statement, but it seems to be supported by the evidence. failure to prove mortality benefit A post in 2018 explored the difficulty of proving mortality benefit from any intervention. To summarize, there are many barriers to proving all-cause mortality benefit: Mortality is decreasing over time […]
PulmCrit – The 65 trial: Is 60 the new 65?
The 65 trial compares MAP targets of >65 mm to >60 mm in treating vasodilatory hypotension. This trial challenges decades of protocols which have targeted a MAP >65 mm. As such, it is a courageous and practice-changing study. However, we need to be realistic about the study’s limitations. trial overview This multi-center RCT was […]
IBCC chapter & cast – Anaphylaxis
Anaphylaxis is a somewhat unique emergency, as one of the few conditions which can kill an otherwise healthy person within a matter of minutes. This is very treatable, so immediate and definitive management is paramount. To make matters worse, different patients will manifest with a variety of diverse presentations, so a high index of suspicion […]
PulmCrit – Steroid for ARDS? The DEXA-ARDS trial
A fresh trial shows considerable efficacy of dexamethasone in ARDS. This may come as a bit of a surprise, but it’s actually entirely consistent with prior evidence. To understand the study, we need to start with previous data… Part I: Background: The Rabbit hole of ARDS, pneumonia, and septic shock We often think about ARDS, […]
PulmCrit Wee: The Yale experience with hyperdiuresis
Hyperdiuresis involves combining hypertonic saline with a loop diuretic for management of diuretic-resistant volume overload. This may seem a bit counter-intuitive, but there are several reasons why it might work: Hypochloremia promotes sodium retention; this could be reversed with hypertonic saline. Hypertonic saline could osmotically pull fluid into the intravascular space, thereby promoting diuresis without […]
IBCC chapter & cast – Status epilepticus
Status epilepticus is one of the true neurologic emergencies, where minutes may actually count. Prompt and definitive treatment often yields excellent outcomes, whereas sluggish or inappropriate treatment can have severe consequences. Management has changed substantially over the past decade including a new definition of convulsive status epilepticus (>5 minutes of seizing, rather than >30 minutes) […]
PulmCrit- WHO guidelines regarding fluid administration for coronarvirus are dangerously misguided
The Surviving Sepsis Campaign is a blight on modern, evidence-based medicine.1 It’s been clear for some years that its fundamentals were flawed (centering around rapid, large-volume fluid resuscitation). Rather than adapt guidelines to modern evidence, the campaign recently doubled down on immediate administration of fluid and antibiotics within one hour. This provoked widespread protest, including […]
IBCC chapter & cast – Hypocalcemia
Hypocalcemia in the ICU is one of the more confusing electrolyte abnormalities, because it’s frankly unclear exactly what to do with it. Most patients in ICU are hypocalcemic, but there is little evidence that trying to “replete” hypocalcemia back to euboxia is beneficial (or even feasible). Of course, there are some patients who have severe […]
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