EMCrit Project

Management of acidosis in DKA is an ongoing source of confusion. There isn’t much high-quality evidence, nor will there ever be. However, a clear understanding of the physiology of DKA can help us treat this rationally and effectively.

From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.

What should intensivists do at night? Should they sleep at home or remain dutifully in the hospital? Should they extubate patients or just maintain the status quo until 7 AM?

A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient’s condition if the patient is already asymptomatic.

Until recently I believed that prolonged vasopressor administration requires a central line, to avoid extravasation. I lumped together all vasopressors, treating them all as equal. I used the occurrence of an extravasation reaction from one vasopressor as evidence that all vasopressors could cause extravasation reactions (the fallacy of inappropriate generalization). Upon closer examination, these beliefs aren’t supported by evidence.

Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.

A post a few weeks ago calculated the fragility index of the NINDS trial (which turned out to be only three). Very briefly, the fragility index tests how many events would need to be changed for the p-value to increase above 0.05, rendering the study “statistically insignificant.” Ryan Radecki commented that he was concerned that the fragility index was married to the p-value, thereby inheriting the flaws of frequentist statistics. Perhaps we should ditch the p-value and the fragility index, switching instead to a purely Bayesian approach to statistics?

My goals during sepsis resuscitation focus largely on preservation of renal function and maintence of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypoperfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too. In this context, any beneficial effect of vasopressin on renal function could be helpful.

As an internal medicine resident and pulmonary/critical care fellow, I loved fluoroquinolones. The were effective, easy to prescribe, and they had 100% oral bioavailability. However, working full-time in the ICU has forced me to realize that these drugs aren’t so wonderful for the critically ill.

A post last year discussed the top 10 reasons to stop cooling to 33C. It was based largely on the Nielsen trial, which showed similar outcomes between therapeutic hypothermia (TH33) and therapeutic temperature management (TTM36). However, this trial left some questions about how these protocols would perform outside the context of a RCT (external validity). Last year’s post speculated that since TTM36 is easier to achieve, it would out-perform TH33 in real-world conditions.

Let’s be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It’s not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.

A recent series of articles suggest that the combination of vancomycin and piperacillin-tazobactam are synergistically nephrotoxic. Is piperacillin-tazobactam truly nephrotoxic, or is this merely pseudo-nephrotoxicity?

Medicine continues to be plagued by poorly reproducible studies. The storyline is familiar. First, a very positive study is released in a major medical journal, with great fanfare. This leads to widespread changes in practice. Decades later, it becomes clear that the study was incorrect. Recently a new tool was developed to help understand the reproducibility of clinical studies: the fragility index. This post will analyze the NINDS trial from the perspective of its fragility index.

Considering the importance of crystalloid in critical care, one might expect crystalloid composition to be meticulously engineered and updated. However, our crystalloid choices remain archaic. Normal saline and Lactated Ringers (LR) were developed in the 1800s, whereas Plasmalyte and Normosol emerged in the 1970s.

Jui-jitsu is a Japanese martial art based on flexibility and technique, rather than a directly confronting an opponent with force. In the spirit of jui-jitsu, this post explores how to support ARDS patients without directly confronting lung dysfunction. This is useful in refractory ARDS, when frontal assault has failed.