Hypokalemia is one of the most commonly encountered electrolyte abnormalities in critically ill patients, and perhaps the most commonly intervened upon abnormality. Although this is mundane, it behooves us to understand it fully and treat it optimally. Even minor nuances in treatment could potentially have significant impact, given how commonly hypokalemia is managed. The IBCC […]
PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
The management of generalized convulsive status epilepticus remains in perpetual status controversius. There is consensus that the front-line agent should be a benzodiazepine, but little agreement beyond that. The much-awaited ESETT trial is a multi-center RCT comparing three anti-epileptic agents for ongoing status epilepticus (levetiracetam, fosphenytoin, and valproate). This trial will be the highest-quality evidence […]
IBCC chapter & cast – Brain death
Brain death determination and support of a potential organ donor are core topics in critical care. These topics aren’t particularly uplifting or glamorous, so they often are overlooked. Consultants who don’t spend a lot amount of time in the ICU may be uncomfortable with them. This makes it even more important that we have a […]
PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea
I’ve been yearning to use oral urea for euvolemic hyponatremia for years (e.g. see a post from 2015 here). Urea has been used in Europe for decades, but until very recently it was unavailable in the United States. It has numerous advantages compared to the vaptans (which are extremely expensive and potentially dangerous). Recently, an […]
IBCC chapter & cast: Hypothermia
Hypothermia is a heterogeneous topic. At one end of the spectrum are previously healthy people who suffer from cold exposure (for whom the rewarming is the primary focus of therapy). At the other end of the spectrum are patients with mild secondary hypothermia (e.g. due to sepsis), for whom the primary focus is investigation and […]
IBCC chapter & cast: Bupropion intoxication
Most books give bupropion a couple paragraphs, but it arguably deserves its own chapter. With a decrease in the use of tricyclics and increasing use of bupropion XR for depression, bupropion is becoming the most common cause of life-threatening antidepressant overdose. Bupropion has a uniquely dangerous property of blocking gap junctions between cardiomyocytes at high […]
PulmCrit Wee – Prophylactic antibiotics after cardiac arrest?
background Pneumonia after cardiac arrest is problematic for several reasons: Many patients aspirate during cardiac arrest. Patients are intubated and mechanically ventilated, usually with poor mental status – conditions which do not promote secretion clearance. Early diagnosis of pneumonia is impossible for many reasons (inability to measure a fever due to therapeutic temperature monitoring, inability […]
IBCC chapter & cast – Acalculous cholecystitis
Acalculous cholecystitis is a slippery beast. It’s pretty uncommon, lurking among the myriad of sick ICU patients with moderately abnormal gallbladders. It is likely both under-diagonsed and over-diagonsed at various times. Indeed, since surgical cholecystectomy is currently rare, it is frequently unclear whether a patient ever had acalculous cholecystitis! (For example, if a cholecystostomy drain […]
PulmCrit – Correlation confounded by timing: One reason we believe bad therapies are awesome
example 1: anti-emetics Let’s get started with a RCT comparing droperidol versus ondansetron for the treatment of nausea in the emergency department. Meek et. al randomized 144 nauseated patients to receive either droperidol or ondansetron.1 The rates of symptom improvement were indistinguishable (75% vs 80%). So, you might conclude that these drugs are equally efficacious. […]
IBCC chapter & cast – Carbon monoxide poisoning
In the northern hemisphere, Winter is Coming. Folks are firing up their furnaces – some of which may have an inadequate oxygen supply, thereby generating carbon monoxide. Unfortunately, the diagnosis of carbon monoxide poisoning is extremely hard to make, mimicking many different conditions. In particular, carbon monoxide poisoning can mimimic influenza – which is also […]
IBCC chapter & cast: Post-MI complications
Myocardial infarction patients are complex. Unfortunately, this complexity can grow over time. Delayed deterioration in the patient recovering from MI may result from a host of different problems (e.g. medication effect, procedural complications, or merely the natural history of the disease). This chapter explores some problems that we should be on the lookout for in […]
PulmCrit- Metoprolol causes harm in COPD?? Déjà vu all over again
We’ve been all over the road with beta-blockers and COPD. For a long time, there was a belief that beta-blockers were contraindicated in COPD. Eventually that concept fell out of favor. Subsequently, some correlative data suggested that beta-blockers might be beneficial in COPD. This led to the current BLOCK-COPD trial which (spoiler alert) shows that […]
PulmCrit Wee: Do fluid boluses before intubation help? (PREPARE trial)
I’m afraid she will tank after intubation, could you start some fluid? I brought a liter of fluid, just in case the blood pressure falls after intubation. He is decompensating! Run the fluid wide open! We’ve all probably heard and spoken those phrases. Crystalloid is a traditional therapy in efforts to either prevent or mitigate […]
PulmCrit- Commentary on the new pneumonia guidelines using GIFs & some mini-rants
So, the new IDSA guidelines for community acquired pneumonia (CAP) are here. This post will walk us through the guidelines, focusing primarily on issues that relate to critically ill patients. Guidelines can get dull, I’ve added in GIFs to illustrate my feelings about each recommendation & kept things pretty informal. Come for the GIFs, stay […]
IBCC chapter & cast – Methemoglobinemia
Methemoglobinemia is one of my favorite toxicology diagnoses. The diagnosis can often be made at the bedside based on history and physical examination, which is a satisfying bit of detective work. Once the diagnosis is made, patients generally respond promptly to a specific antidote (methylene blue). And this isn’t just a parlor trick – diagnosis […]
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