Metformin poisoning and lactic acidosis has always been murky. For years there was debate about whether metformin-induced lactic acidosis exists (short answer: it obviously does). However, for an individual patient, it can still be confusing sorting out the contribution of metformin to their critical illness. A recent re-definition of the condition clarifies things a bit, but substantial confusion persists regarding how to diagnose and treat these patients.
PulmCrit- Extracorporeal CO2 removal: Putting the cart ahead of the horse?
Recently the concept of extracorporeal CO2 removal has become somewhat popular, with a goal of facilitating ultra low-tidal volume ventilation. Might there be other means to achieve the same goal? Let’s start with some basic concepts of mechanical ventilation… Fundamental unanswered questions Permissive hypercapnia refers to the concept of allowing the pCO2 level to increase […]
IBCC chapter & cast: Allergies to beta-lactam antibiotics
Emerging evidence shows that there is no such thing as a “penicillin allergy” or “cephalosporin allergy.” Instead, cross-allergic reactions are restricted to much smaller groups of antibiotics that share greater structural similarity. This opens the door to using beta-lactam antibiotics safely in patients who have had an allergic reaction to one or more of these drugs.
IBCC chapter & cast: Preeclampsia & HELLP syndrome
Preeclampsia is among the most commonly encountered obstetric emergencies. Definitions and optimal therapies have changed significantly over the past few years. Although specialists in Obstetrics will invariably be involved in these cases, all resuscitationists need to have a firm grasp of this topic. The optimal therapies for preeclampsia remain controversial. For example, the International Society […]
PulmCrit- Nucleic acid microarrays streamline bacteremia management
Verigene is a nucleic acid micro-array which can be used to provide rapid information about positive blood cultures. The array detects genetic information which may reveal the genus/species of bacteria and the presence of various resistance genes.
IBCC chapter & cast: Hypertensive emergencies
Hypertensive emergency is a fairly common cause of ICU admission. Surprisingly little high-quality data is available to guide our management of these patients (e.g. optimal Bp target? ideal rate of reduction? need for arterial line?). This chapter describes a reasonable strategy to these patients, focusing on the pharmacokinetics of various antihypertensives.
IBCC chapter & cast: Abdominal Compartment Syndrome
Abdominal compartment syndrome can result from primary abdominal pathology (e.g. bowel obstruction), but it can also occur due to systemic inflammation combined with large-volume resuscitation. As such, abdominal compartment syndrome is probably more frequent than generally perceived, functioning as an occult driver of multi-organ failure. Treatment is based upon physiological properties, involving many therapies aside from simply opening the abdomen.
PulmCrit- DEXACET: Four grams of acetaminophen a day keeps the delirium away?
For decades, acetaminophen has been regarded as the first rung of the analgesic ladder. It has a nearly unparalleled risk/benefit profile when dosed correctly (it’s not tremendously effective, but it is extraordinarily safe). Theoretically, acetaminophen should be used very broadly among critically ill patients with pain.However, this isn’t the case.
IBCC chapter & cast: Myasthenic Crisis
Myasthenic crisis along the fault-line between neurology and critical care medicine. This creates a potentially dangerous situation, wherein nobody is fully informed or wholly responsible for the patient.
IBCC chapter & cast: Acetaminophen toxicity
Acetaminophen is in everyone’s medicine cabinet. This makes it one of the more common intoxications. At first blush, this might seem like an easy topic: apply the nomogram, then give acetylcysteine. Unfortunately, it’s not quite that simple. There are a variety of different presentations (e.g. acute, chronic, delayed), many of which will confound the nomogram. […]
PulmCrit wee- Five ways to improve live-tweeting at conferences
For generalists such as myself, there’s almost always a conference of interest going on somewhere in the world. In the normal course of events, I would miss 99.9% of them. However, twitter makes it possible for me to gain some insight from all of them. However, conference tweeting is far from perfect. A large conference […]
IBCC chapter & cast: Hypernatremia
Treating hypernatremia in the ICU isn’t exciting or particularly difficult. However, it’s enormously important to provide patients with comfort. We talk a lot on treating pain, but usually forget about the discomfort caused by thirst. Remember: when you intubate a patient and take control of their airway, you’re also taking responsibility to provide them with water.
PulmCrit: Is pure RSI a failed paradigm in critical illness? The primacy of pressure
Why do some patients’ saturation crash during laryngoscopy, whereas other patients are fine? What can we do to prevent this?
IBCC chapter: Salicylate intoxication
Of all intoxications, salicylates is one of the most important to understand. These cases can unravel rapidly, with fatal outcome. However, with prompt management most patients will do fine. Treatment depends on a solid grasp of the underlying chemistry and renal physiology.
PulmCrit: The surviving sepsis campaign 1-hour bundle is… back?
The surviving sepsis campaign (SSC) has had substantial problems dating back to its inception. The original backbone of the guidelines was a single-center trial by Rivers, which has largely been debunked.1–4 Initially the SSC was slow to let go of invasive early goal-directed therapy. The SSC has finally started eliminating older dogma (e.g., superior vena cava […]
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