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?
PulmCrit: What is the fragility index of the NINDS trial?
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.
PulmCrit: We should engineer a new crystalloid
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.
PulmCrit: Fighting refractory ARDS with physiologic jujitsu
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.
PulmCrit- Sepsis 4.0: Understanding sepsis-HLH overlap syndrome
Since the 1980s it has been recognized that some patients with sepsis also develop hemophagocytic lymphocytosis. For decades this was believed to be extremely rare. However, currently there is increasing recognition that this combination might represent a significant fraction of sepsis patients.
PulmCrit- Overcoming occult diuretic resistance: Achieving diuresis without dehydration
Critically ill patients often strongly retain sodium. This may cause diuresis attempts to fail, if patients excrete dilute urine leading to a loss of water without loss of sodium. Such patients may seem to respond to diuresis, but in fact they are merely becoming progressively dehydrated and hypernatremic (occult diuresis resistance).
Pulmcrit Wee: My graduation speech – why we resuscitate
Below is my graduation speech. It is about why we are in medicine. As all resuscitationists know – whether nurse, physician, pharmacist, PA, or paramedic – resuscitation is hard work. We all could have chosen easier, safer paths to follow. Ten years down the track I have no regrets. I appreciate the great privilege of being here. Still, though, it’s good to take a moment to remember how we got here, and why it is that we do what we do.
PulmCrit- Fentanyl infusions for sedation: The opioid pendulum swings astray?
I’ve been using fentanyl infusions as the backbone of my sedative strategy, in keeping with the 2013 SCCM guidelines. This generally works well for patients who can be extubated quickly. However, for patients who remain on the ventilator for longer periods of time, it often leads to problems involving tolerance and withdrawal.
PulmCrit Wee: Ultrasound-guided blakemore tube placement
The most widely feared complication of placing a Blakemore tube is complete inflation of the gastric balloon while it is not in the stomach. If the gastric balloon is fully inflated anywhere outside the stomach (i.e. esophagus, trachea, bronchus, duodenum), this may cause visceral perforation.
PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines
A 55-year-old woman was admitted with toxic shock syndrome. Her norepinephrine requirement was labile, fluctuating between 15 mcg/min and 30 mcg/min. Bedside echocardiogram showed a dilated inferior vena cava without respiratory variability, and a normal ejection fraction. On examination her extremities were cool and her urine output was marginal.
PulmCrit Wee- Extubating the agitated patient: dexmedetomidine vs. cowboy-style?
Dexmedetomidine decreased the duration of ventilation among agitated patients in a recent RCT in JAMA. But did these patients actually require intubation and dexmedetomidine? Or did they merely require extubation?
PulmCrit- Why we fail at hemodynamics: The flaw of averages & the swan’s curse
With a resurgence of the Swan, a resident recently asked me: why don’t we use the Swan to guide sepsis resuscitation? Answering this question forced me to recognize that many problems with the Swan continue to haunt us today when using our new darling, bedside echocardiography.
PulmCrit Wee- Communicating airway difficulty via the allergy list
Intubation is often required urgently. Unfortunately, information about a patient’s airway anatomy is often scattered around the chart and impossible to retrieve rapidly.
PulmCrit- Oral vasopressor to accelerate liberation from the ICU
Midodrine is an oral agent which functions as an alpha-1 agonist. It has been used in a variety of situations including autonomic dysfunction, hepatorenal syndrome, and dialysis-induced hypotension. Over the past few years there has been increasing interest in using midodrine to facilitate weaning off vasopressors.
PulmCrit- Update on post-extubation high-flow nasal cannula to reduce reintubation
Post-extubation HFNC has helped us aggressively liberate patients from mechanical ventilation while simultaneously reducing our reintubation rate. One remaining question is determining which patients benefit from this. My practice has generally been to use HFNC in patients felt to be at higher risk for reintubation. A fresh RCT in JAMA will revise this.
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