Likelihood ratios may be more useful clinically, but sensitivity and specificity are more widely reported. Therefore, it is useful to gain a general understanding of how sensitivity and specificity translate into likelihood ratios.
PulmCrit- Reengineering the analgesic ladder for critically ill patients
We all want to alleviate pain and suffering. Most critically ill patients are treated with opioids for this reason. Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation. Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression. This post explores the optimal use of systemic medications to control pain while minimizing complications.
PulmCrit- Liberating the patient with no cuff leak
A new joint practice guideline by the ATS and ACCP addresses how to approach cuff leaks. This guideline recommends a clever compromise between these extremes, which is the basis of the algorithm below. This provides a streamlined, evidence-based pathway to extubate patients without a cuff leak.
PulmCrit- Resuscitationist’s guide to status epilepticus
In 2014 I wrote a post suggesting an aggressive, streamlined approach to status epilepticus involving early intubation. The fundamentals of that post remain valid. However, much has changed over the last few years. This post aims to refresh and extend the prior post. It will also serve as a reference to explain my algorithm for […]
PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation
Background: Devil in the details Airway management is a detail-oriented sport. Minor nuances of patient positioning can be essential. Or gentle laryngeal manipulation. Apneic oxygenation can improve first-pass success. Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache. Failure to recognize and remove dentures is an enormous […]
PulmCrit- Submassive PE 2017: Getting ’em off the cliff
Follow-up data from the PEITHO trial shows that thrombolytics don’t affect long-term morbidity. This simplifies management substantially. PEITHO trial & long-term follow up The PEITHO trial was a multi-center RCT investigating the effect of thrombolysis in submassive PE. Tenecteplase caused an increase in intracranial hemorrhage and a reduction in hemodynamic collapse. Overall there was a […]
PulmCrit Wee: MDCalc for the perfect tape-measure intubation
Imagine you went to buy an expensive piece of clothing. Rather than measuring your size, the store owner simply said “well, on average most folks require a medium, so let’s try that on, we can always re-size it later.” You would be irritated that they were wasting your time. When you go clothes shopping, you […]
PulmCrit- Hypertriglyceridemic pancreatitis: Can we defuse the bomb?
Hypertriglyceridemia causes ~9% of pancreatitis, the third most common cause after alcohol and gallstones. It is a risk factor for severe pancreatitis, making it more frequent among ICU patients with pancreatitis. I see this a few times each year. Nonetheless, it has low penetration into educational curricula or our collective awareness. The treatment of hypertriglyceridemic […]
PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure
Introduction with a clinical conundrum A 66-year-old man is transferred from an outside hospital due to inability to be liberated from the ventilator. He presented a week earlier with pneumonia and sepsis. He received six liters of fluid initially, and has been running net positive 1-2 liters daily since then (for a total of about […]
PulmCrit- Epinephrine vs. atropine for bradycardic periarrest
Introduction with a case An elderly woman is admitted with atrial fibrillation and fast ventricular rate. She is asymptomatic, with a heart rate of 160 b/m. She is treated with a 20 mg diltiazem bolus followed by an infusion at 15 mg/hour for several hours. Her heart rate slows to 110 b/m. She is then […]
PulmCrit- Six myths promoted by the new surviving sepsis guidelines
Early Goal-Directed Therapy: A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy. This is basically the NINDS trial of the critical care world: a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline. The […]
PulmCrit- How to convert a VBG into an ABG
This post is about a research project I did as a pulmonary critical care fellow in 2011. To understand it, you need to know a bit of the story behind it.
PulmCrit- Sedation update: IV olanzapine & combo vs. monotherapy
The potential role for IV olanzapine was examined in a post last year. The following conclusions were reached: IV olanzapine appears to be safe. IV olanzapine has equal potency compared to IV droperidol and about twice the potency of IV haloperidol. Olanzapine doesn’t affect QT interval or cause torsade de pointes. Two articles were just […]
PulmCrit- Dogmalysis of PCI for NSTEMI patients with a history of CABG
Many patients with prior CABG probably benefit from catheterization and repeat revascularization (PCI or a repeat CABG). However, this cannot be assumed to be universally true. In particular, patients with smaller infarcts and advanced renal failure could be harmed.
PulmCrit- Triple therapy for influenza with naproxen, clarithromycin, and oseltamavir?
Flu seasons is upon us again. A recent paper in CHEST provides some tantalizing evidence about possible treatment. Will this pan out, or is it just another fairy tale?
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