There is currently an outbreak of vaping associated pulmonary injury spanning several states, which is under intense investigation by the Centers for Disease Control. We will certainly be learning more about this in the coming weeks to months. However, for now, how should we manage patients who present in respiratory distress following vaping? This chapter […]
IBCC chapter & cast: hypomagnesemia & hypermagnesemia
Magnesium might be the darling ion of critical care. It has an interesting array of therapeutic applications ranging from asthma to Torsade de Pointes to preeclampsia. This pair of chapters discusses the evaluation of both hypomagnesemia and hypermagnesemia. IBCC chapter on hypomagnesemia is located here. IBCC chapter on hypermagnesemia is located here. The podcast & comments […]
PulmCrit- Large volume thora: Can we drain ‘em dry?
How much fluid can safely be removed from a pleural effusion during a thoracentesis? Much has been written about this, but solid evidence remains elusive.
IBCC chapter & cast – Septic Shock
Septic shock is perhaps the defining illness of medical intensive care. As such it is an enormously broad and controversial topic. This chapter attempts to provide a unified and straight-forward approach. However, every physicians has a different approach to septic shock, so it’s impossible to claim that this is the best approach. There will doubtless […]
IBCC chapter & cast – Angioedema
Like so many things in critical care, angioedema is difficult to research since it is uncommon, heterogeneous, and emergent. As such, we have relatively little high-quality evidence regarding this disease (and the high-quality evidence that we do have is largely restricted to pharma-sponsored trials of new and insanely expensive pharmaceuticals). This chapter attempts to create […]
PulmCrit Wee: Reconceptualizing bradykinin-mediated angioedema as a universal vicious spiral
In 2015 I wrote this post on ACEi-induced angioedema. I still think it was a pretty good post (particularly for 2015), but it’s become increasingly clear recently that the post was fundamentally flawed. Let’s try to straighten this out. old model of bradykinin-mediated angioedema This is a conceptual model of how bradykinin-mediated angioedema occurs. Several […]
PulmCrit – Early basal insulin in DKA
The timing of basal insulin administration in DKA has been controversial for years. I posted the following poll on twitter recently to get a sense of current opinion on this: So, it seems that the majority of people are using traditional management (wait for the anion gap to close, give basal insulin, then shut off […]
IBCC chapter & cast – Severe hemoptysis
Severe hemoptysis is a true challenge. Due to the rarity of this condition, there is little high-quality data on it. So you can’t become a hemoptysis whisperer by reading books. Unfortunately, due to the rarity of the condition it’s also difficult to accumulate clinical experience.
IBCC chapter & cast – Hyperthermia & heat stroke
Since it looks like the United States is about to go into total meltdown from a heat wave, I dusted off the hyperthermia chapter. This is a bit of an impromptu post, so we don’t have a podcast to go along with it (we will record one eventually – Adam has more experience with the […]
IBCC chapter & cast – Alcohol Withdrawal
Below is a card from one of the first patients I treated for alcohol withdrawal. He lingered in the hospital for days on various benzodiazepine regimens (including a lorazepam infusion), and eventually limped home on an oral chlordiazepoxide taper. He wrote me a thank-you card days after leaving the hospital, but as you can see […]
Pulmcrit- Evidence Update: Phenobarbital in Alcohol Withdrawal
Over the past year, the five papers below were published regarding the use of phenobarbital in alcohol withdrawal. These studies aren’t massive, glittering multicenter RCTs (and, realistically, it’s dubious whether such a study will happen). However, these papers bring some unique and interesting perspectives to the table. This post will summarize them briefly – a bit like a sampler flight of beers (figure above).
IBCC chapter & cast: Ascending cholangitis & calculus cholecystitis (community-acquired biliary sepsis)
Biliary infection is a fairly common cause of septic shock (especially ascending cholangitis). Evidence isn’t terrific regarding exactly when and how interventions should be done to obtain source control (particularly among cholecystitis). This chapter attempts to reach some clarity on the topic but honestly, it remains a bit murky.
IBCC chapter & cast – Clostridioides Difficile
Clostridioides (previously clostridium) difficile is an inescapable problem within the critical care arena. This may arise as a nosocomial complication, in which case it is usually diagnosed early and treated successfully. It may also be the primary cause of admission to the ICU, in which case it is generally more severe.
PulmCrit- Rigorous vs. lenient spontaneous breathing trials: The answer at last?
background There has long been debate about exactly how to design a spontaneous breathing trial. If the trial is made too easy, then patients would be extubated before being ready (leading to re-intubation). Alternatively, if the trial is too hard, that would prolong mechanical ventilation beyond the point of being beneficial. The figure above shows […]
IBCC chapter & cast – Fluid selection & pH-guided fluid resuscitation
Based on this polling data, 42% of you will hate this chapter. It’s a good thing I’m not running for president. Seriously though, fluid selection remains controversial. This chapter presents an approach which makes sense physiologically and is supported by a substantial amount of animal and human data.
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