We are constantly hunting for newer and better sources of information. This leads to a perpetual generation of newer lab tests, different hemodynamic gizmos, and fresh decision tools. Some of these pan out. Most don’t. Why are these new sources of information generally disappointing? The answer is simple: we’re already doing pretty well. In order […]
IBCC chapter & cast – Toxic Alcohols
The diagnosis of toxic alcohols is a particularly controversial topic, based on recent evidence that the osmolal gap has a fairly awful sensitivity and specificity. This chapter describes an approach to toxic alcohol diagnosis which doesn’t depend on the osmolal gap. Although this may seem radical, this strategy has been previously recommended by other authors […]
PulmCrit – An alternative view of the PEPTIC trial
The PEPTIC multi-center RCT compared histamine-2 receptor blockers (H2RBs) versus proton pump inhibitors (PPIs) for stress ulcer prophylaxis among ventilated ICU patients.1 It’s a landmark trial of unprecedented size and statistical power. PEPTIC was presented at the Critical Care Reviews meeting in Ireland and live-cast around the world (available here). This presentation and the editorials […]
PulmCrit- Metabolic Resuscitation: Was the answer inside us all along?
Now that VITAMINS is published, it’s worth trying to look at the big picture of sepsis treatment with hydrocortisone, ascorbate, and thiamine (HAT). Marik et al. 2017: The beginning HAT therapy began with a single-center, before/after study.1 There was a stark mortality reduction following the routine adoption of HAT therapy in septic shock (figure below, […]
IBCC chapter & cast – Central line infection
Prevention and treatment of central line infections is a core competency in critical care. Prevention is the true key here. Achieving zero central line infections is an unreachable goal, but with diligence the rate can be pushed close to zero. The IBCC chapter is located here. The podcast & comments are below. Follow us on […]
IBCC chapter & cast – Deresuscitation (Dominating the Diuresis)
Large-volume diuresis is a topic that isn’t discussed much in critical care curricula or textbooks. Nonetheless, this is a daily reality for intensivists, especially those living in the United States (where patients continue to be empirically treated with 30 cc/kg fluid as initial fluid bolus, for a broad variety of complaints). This chapter attempts to […]
PulmCrit- Sepsis special edition & CBC to diagnose septic shock
The Journal of Thoracic Diseases is about to release a special edition on sepsis, edited by Paul Marik (open access). It’s deliciously rebellious – just look at the table of contents 👇 My article on using the complete blood count to diagnose sepsis is already available, so I’ll summarize it here (yes, I know, you […]
IBCC chapter & cast – Myxedema coma (decompensated hypothyroidism)
Myxedema coma is a misleading misnomer. Most patients don’t have non-pitting edema (myxedema), nor are they frankly comatose. The best way to think about this disease is simply decompensated hypothyroidism. Patients with under-treated or untreated hypothyroidism have no metabolic reserve. Stressors may easily push them into multi-organ failure. Myxedema coma is easily missed, because it […]
IBCC chapter & cast – Noninvasive respiratory support (BiPAP & HFNC)
Noninvasive respiratory support is among the greatest recent advances in critical care. When used properly, these techniques may facilitate avoidance of intubation, reduced length of stay, and better outcomes. Unfortunately, our knowledge of exactly how to use these devices remains woefully incomplete. In particular, there are rather few RCTs directly comparing BiPAP versus HFNC. In […]
PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?
Recently Sara Crager released a video on EM-RAP recommending inhaled milrinone or nitroglycerin as an emergency therapy for massive pulmonary embolism (in case you don’t have access to EM-RAP, an audio clip from the video is below). This is the first that I’ve heard of using inhaled nitroglycerin. It seems like a pretty neat idea, […]
IBCC chapter & cast – Acute promyelocytic leukemia
Acute promyelocytic leukemia (APL) is a unique leukemia, with particular importance to resuscitationists. Unlike most leukemias, the highest rate of mortality occurs at the time of diagnosis (a phenomenon known as “early deaths”). If patients are able to survive the initial phase of illness, the cure rate is extremely high (>90%). Aggressive support in the […]
Pulmcrit Wee- Rare catastrophic complications, heparin, and succinylcholine: Sometimes excellent is the enemy of perfect.
A multi-center RCT was released yesterday comparing rocuronium versus succinylcholine. It’s a thoroughly uninformative study, so at first I wasn’t planning to write about it. But then I realized that the study, in its very myopia, is a good illustration of our problem with rare catastrophic complications. warmup: heparin infusions and rare catastrophic complications A […]
PulmCrit- Furosemide failure: should we add metolazone, IV chlorothiazide, or… tolvaptan?!? (3T trial)
Diuretics are a bit like vasopressors. We use them all the time, so we feel that we know them pretty well. However, the amount of RCT-level evidence on them is shockingly low. So, whenever a RCT on diuretics shows up, it’s worth careful examination. the 3T trial: basics This is a single-center, double-blind trial involving […]
IBCC chapter & cast – Hyponatremia
Since finishing my training, I’ve learned three new techniques for the management of hyponatremia: the DDAVP clamp, use of hypertonic bicarbonate, and oral urea. Meanwhile, I’ve removed the use of vaptans from my practice and grown more comfortable using 3% saline. The confluence of these factors has transformed hyponatremia from something scary to something which […]
PulmCrit- Hyperdiuresis: Using hypertonic saline to facilitate diuresis
Using hypertonic saline to facilitate diuresis seems counterintuitive, paradoxical even. Volume overloaded patients have excess sodium. Why should we give them more? Let’s start by trying to understand the underlying physiology. hypochloremia may cause renal sodium retention We generally don’t pay much attention to serum chloride levels. Chloride is often viewed as a leftover, an […]
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