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 […]
IBCC chapter: Buprenorphine & opioid use disorder
In critical care, we’ve been treating patients with opioid use disorder for a long time. If they’re intubated for intoxication, we extubate them and send them home. If they’re septic with endocarditis, we treat their sepsis. Unfortunately, this isn’t enough. We’re treating the complications of opioid use disorder, without addressing the underlying problem. Recently, medication-assisted […]
IBCC chapter: Thyroid storm
Thyroid storm is a bit of a zebra. It can mimic a variety of common conditions (e.g. sepsis, delirium, heart failure). Unfortunately, if you’re not looking for it, you probably won’t find it. Once identified, an organized multimodal treatment regimen will generally get the job done. But be careful – these patients may have varying physiology, so blindly following the same rubric for every single patient isn’t the answer.
IBCC chapter & cast: thrombocytopenia & HITT
Thrombocytopenia is extremely common in critical illness. It’s generally a consequence rather than a cause of illness, predicting increased mortality. However, we must remain alert for cases where serious hematologic disease is afoot. The major concern here is the ever-looming possibility of heparin-induced thrombocytopenia and thrombosis (HITT). This chapter explores thrombocytopenia and provides an evidence-based […]
PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?
The use of an inhaled pulmonary vasodilator is a logical strategy for stabilization of PE patients (especially nitric oxide, which may be depleted in this situation). Previously inhaled nitric oxide has only been supported by case series.
IBCC chapter: Antibiotics for the critically ill patient
We spend a lot of time obsessing over the finer details of critical care: which fluid is best? which vasopressor is best? will another liter of fluid help? These details are important, but for a septic patient something more important than any of these details is choosing the right antibiotic(s). In septic shock, source control and […]
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