EMCrit Project

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.

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).

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.

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.

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.

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.

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?

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.

Intubation is often required urgently. Unfortunately, information about a patient’s airway anatomy is often scattered around the chart and impossible to retrieve rapidly.

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.

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.

Make no mistake, I’m not very fond of phenlephrine. I rarely use it (mostly for hypotensive atrial fibrillation). However, understanding phenylephrine is a prerequisite to understanding related vasopressors, particularly midodrine and norepinephrine.

A satisfactory clinical definition of sepsis has been eluding us since the ancient Greeks first coined the term. Current definitions of sepsis attempt to achieve two goals: to provide a rapid screening test to detect sepsis and to render a definitive diagnosis of sepsis. However, it remains unclear whether any definition can achieve this.

This is one of my favorite diagnoses. When first encountered, it may seem bewildering and difficult to treat (1). Indeed, standard ACLS algorithms often fail with these patients. However, once understood, this disorder is easily treated and patients typically improve rapidly.

Is IV olanzapine ready for prime time? This boils down to a choice of the devil that we know (haloperidol) versus the devil that we don’t entirely know (olanzapine). IV olanzapine is newer, so it is possible that additional side effects may emerge over time. However, we already know that there are significant problems with IV haloperidol.