Post-cardiac arrest management has undergone substantial revisions within the past several years, particularly with regards to temperature management. This remains an area of active controversy and investigation, with the TTM-2 trial currently underway. Although equipoise still exists, this chapter describes a streamlined 36C approach which is based on evidence, guidelines, and experience with various strategies. […]
PulmCrit- Alpha-2 agonists: clonidine, guanfacine, lofexidine, and KetaDex
Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion. It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients). The main drawbacks of dexmedetomidine are logistic: it is expensive and can be administered only as an IV infusion within an ED or ICU. Oral clonidine offers some similar benefits compared to dexmedetomidine, without these logistic constraints.
IBCC chapter & cast: Meningitis and encephalitis
Severe CNS infections are a bit of an orphan disease in critical care. Unlike more common neurologic disorders (e.g. stroke), CNS infections are too rare to recruit lots of patients into RCTs. Consequently, conventional treatment of these disorders lags decades behind other neurologic disorders (e.g. in terms of optimizing cerebral perfusion pressure). Principles of neurocritical […]
IBCC chapter & cast: Torsades de Pointes
Torsades de pointes is an uncommon cause of cardiac arrest. It is generally quite treatable, but if treated inadequately it will often recur (in some cases leading to repeated salvos of ventricular tachycardia, one form an electrical storm). A structured approach incorporating a pre-emptive protocoled magnesium infusion is generally quite effective. The IBCC chapter is […]
IBCC: Guide to supportive care in critical illness
This chapter gives an overview of how to provide high-quality supportive care to the sickest patients. It summarizes about a dozen chapters within the IBCC. This is intended as a quick guide for folks who don’t work full-time in an ICU (e.g. residents rotating through the unit).
IBCC chapter & cast: Hyperkalemia
Hyperkalemia is bread and butter critical care medicine. However, the therapeutic approach has changed substantially within the past 5 years. Myths about kayexalate and normal saline have been exposed, allowing more effective therapies to take their place.
IBCC chapter & cast: Delirium
Delirium occurs in about half of critically ill patients. Some fairly simple measures may reduce the risk of delirium. When it occurs, delirium is a diagnostic challenge because occasionally it can be a sign of undiagnosed underlying illness. Treatment is challenging, with little evidence to support most of the standard therapies.
PulmCrit: No more antipsychotics for delirium? Not so fast!
Recently the MINDS-USA trial evaluated the use of haloperidol or ziprasidone for delirium in critical illness. Before jumping into the results of this study, it will help to establish a couple of foundational principles.
PulmCrit- Does the HIGH trial debunk high-flow nasal cannula?
High-flow nasal cannula (HFNC) has become popular for the hypoxemic respiratory failure, driven partially by the FLORALI trial.1 Recently, the HIGH trial evaluated the ability of HFNC to reduce mortality among immunocompromised patients with acute hypoxemic respiratory failure.2 HFNC failed to improve mortality or significantly reduce intubation rates. Popular narrative about this trial A common […]
IBCC chapter & cast: Anemia & transfusion targets
Most patients in the ICU will become anemic. This chapter explores prevention, evaluation, and treatment of anemia in the ICU. Causes of new-onset anemia in the ICU are distinct from the causes of anemia seen in the outpatient clinic, so the approach should be appropriately tailored to the critical care environment.
PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be?
SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed. However, the study still provides a wealth of information about SUP in the ICU.
IBCC chapter & cast: Acute pancreatitis
Management of severe pancreatitis has remained in a state of controlled chaos and persistent debate for years (mirroring evolution in our treatment of septic shock). This confusion shows no signs of abating in the near future. This chapter explores a reasonable approach to pancreatitis, with the caveat that there is very little evidence available to guide our combat against this challenging foe.
PulmCrit- Ketamine for alcohol withdrawal?
Recent publications have explored the role of ketamine in alcohol withdrawal. Ketamine undoubtedly has some outstanding properties, which make it well suited for this task. The challenge is integrating ketamine into a unified, coherent treatment strategy.
IBCC chapter & cast: severe heart failure & cardiogenic shock
Management of severe heart failure and cardiogenic shock is difficult. There is a notable lack of high-quality evidence regarding the sickest patients. Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.
IBCC chapter & cast – Hypoglycemia
Severe hypoglycemia can be scary, especially when the patient isn’t responding to front-line therapies (e.g. IV dextrose). However, some unconventional tools and an organized approach can make this extremely manageable.
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