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.
PulmCrit- Top ten problems with the new sepsis definition
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.
PulmCrit- BRASH syndrome: Bradycardia, Renal failure, Av blocker, Shock, Hyperkalemia
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.
PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol?
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.
PulmCrit- Controlled thrombolysis of submassive PE?
Controlled thrombolysis using a slow 25-mg alteplase infusion with protocoled monitoring might offer patients the benefit of lytic therapy with an extremely low risk of severe hemorrhage.
PulmCrit- Ultrasound-assisted thrombolysis of PE works. The question is, why?
Ultrasound-assisted catheter-directed thrombolysis is increasingly popular for submassive PE. Unfortunately, the actual mechanism of action of this therapy remains unclear.
PulmCrit- Neurocritical care of the comatose meningitis patient
Early in my training I had a few comatose meningitis patients. They were admitted, given antibiotics, and supported on a ventilator. They died. For a while, I believed that this condition was fairly hopeless. Then I encountered a comatose young man with meningitis due to adjacent mastoiditis. His lumbar puncture opening pressure was ~50cm. Following mastoidectomy and temporary placement of a lumbar drain, he recovered. Since then, I have been increasingly aggressive about managing this. Some patients have responded surprisingly well.
PulmCrit- Coagulopathy management in the bleeding cirrhotic: Seven pearls and one crazy idea
Traditionally, coagulation management in patients with cirrhosis has focused largely on using large volumes of FFP to decrease the INR. However, recent evidence indicates that INR prolongation in these patients is nonspecific and that FFP usually isn’t helpful.
Blood gas measurements in DKA: Are we searching for a unicorn?
Routinely obtaining an ABG or VBG is widely recommended, for example in both American and British guidelines. Why? Is this helping our patients, or is it something that we do out of a sense of habit or obligation?
Brief rant: Still no evidence that azithromycin increases mortality
Introduction . It has long been known that some macrolides (e.g. erythromycin) cause torsade de pointes. However, azithromycin has a much lower affinity for cardiac potassium channels than erythromycin, so it has less effect on the heart. For many years it was believed that azithromycin lacked cardiac toxicity. . Controversy was sparked in 2012 when […]
Investigation Bias: The freakonomics of when industry choses to sponsor a clinical trial
. Background: Publication bias . Over the last several years, publication bias has received a considerable amount of attention. In its most blatant form, this is when a drug company sponsors several trials, but only publishes the trials which yeild positive results. Growing awareness of this problem has led to the development of trial registries, […]
PulmCrit – Treatment of hemodynamically stable new-onset AF in critical illness
. Introduction with a clinical question . A 50-year-old woman with no prior medical problems was admitted to Genius General Hospital with severe influenza pneumonia and acute kidney injury. She was transferred to the ICU and treated with high-flow nasal cannula oxygen support. Over time she gradually improved with decreasing oxygen requirements and improving renal […]
PulmCrit – Magnesium infusions for atrial fibrillation & torsade
. Introduction: Perpetual controversy . The use of magnesium for AF has been a controversial topic for decades. Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile. Ironically, this is also magnesium’s Achilles heel, because this has caused the pharmaceutical industry to have no interest in it. This leaves […]
2015 ACLS Guidelines: What happened to VSE?
. Introduction . In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest. However, other studies investigating the addition of vasopressin alone to epinephrine have been negative. Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation […]
Phenobarbital monotherapy for alcohol withdrawal: Simplicity and power
[PLEASE NOTE: For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] Case example . A middle-aged man was admitted to the ICU for refractory alcohol withdrawal. Prior to arriving in the ICU he had been treated aggressively with an escalating […]
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