I should do a formal retrospective cohort study on this, but I don’t have time. Fortunately, the ICU group at Northshore/Long Island Jewish has done exactly that.
IBCC chapter & cast: Bradycardia
Bradycardia emergencies are uncommon, but these cases can go sideways fast. An appropriately aggressive approach is needed to avoid cardiac arrest. Sometimes the answer is as simple as the appropriate epinephrine dose.
IBCC chapter & cast: community-onset pneumonia
Sir William Osler called pneumonia “the captain of the men of death.” Over a century later, pneumonia remains the leading cause of infectious death in the developed world.
PulmCrit- Solving the OPTALYSE PE riddle: We’re dosing tPA wrong
Occasionally in science we encounter a truly bizarre result. Our natural inclination is to ignore the bizarre result. It’s jarring. It creates cognitive dissonance, challenging our understanding of the world. However, struggling to understand the bizarre result can reset our perspective. It’s often the bizarre, unexpected result that changes everything.
IBCC Chapter & Cast: GI Hemorrhage
GI bleeding is bread and butter critical care. However, there are a lot of nuances – especially regarding variceal bleeding and new approaches to hematochezia.
IBCC chapter & cast: Troponin elevation in non-cardiac critical illness
How should we evaluate for myocardial ischemia in a critically ill patient admitted for some other problem (e.g. pneumonia)? What does it mean if their troponin is elevated?
PulmCrit- Sepsis Research Rant: More fake news, less real news
The following rant focuses on sepsis research, but these principles are universal. I apologize for the agitated nature of this post, but I just can’t hold it in any longer. If I read one more correlational study which tries to imply causation, I might just explode. In order to prevent burnout, I’m going to journal these thoughts instead. So, hang on to your hats, because things are going to get a bit heated.
IBCC chapter & cast: Anatomy of a DKA resuscitation
Welcome to the inaugural IBCC chapter! The IBCC chapter on DKA is located here. The podcast & comments are below. Follow us on iTunes
Announcement: Launching the Internet Book of Critical Care (IBCC)
Several years ago a mentor suggested that I write a book. I nearly laughed at her. A book?? Inconceivable! Who would buy it? Would they actually read it? Would it be there at 3 AM when they needed it? How could it be updated? A physical book didn’t seem compatible with the breakneck speed of critical care or our internet-based culture.
PulmCrit- The hidden fragility of meta-analyses: case study of the IOTA trial
Meta-analyses are widely assumed to be robust, without any attempt to test their fragility. This post describes two techniques to evaluate the fragility of a meta-analysis
PulmCrit: A-lines in septic shock: the wrist versus the groin
Historically, emphasis has rested on the distinction between noninvasive versus invasive BP (e.g., cuff pressure vs. radial arterial pressure). Attention focused on whether noninvasive oscillometric BP monitoring is adequate. Meanwhile, it has been assumed that all invasive BP measurement sites are created equal.
PulmCrit- Can we fix a broken circadian clock with melatonin?
Circadian rhythms and melatonin are best known for their relationship to sleep. However, they have a much broader range of functions. Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).
PulmCrit- Could the Furosemide Stress Test clarify resuscitative goals?
Imagine that you admit a patient with septic shock. You resuscitate the patient as best you can with inopressors, fluids, and antibiotics. An adequate blood pressure is achieved. A reasonable amount of fluid is administered. Despite all these measures, the urine output remains minimal. What should you do next?
PulmCrit- A better approach to Torsade de Pointes
A common approach to TdP is shown above. The initial episode is controlled with magnesium and perhaps defibrillation. The patient is sent to ICU for close observation. Usually the patient will be fine, but sometimes TdP does recur. Recurrence triggers second-tier therapies, often including overdrive pacing.
PulmCrit: pH-guided fluid resuscitation & BICAR-ICU
The use of bicarbonate is a source of eternal disagreement. Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest). This has impugned its reputation, giving it an aura of ignorance and failure. Consequently, bicarbonate is underutilized in some situations where it might actually help.
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