0 [PLEASE NOTE: For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] 0 Introduction 0 Recently the New England Journal published a review article about delirium tremens which is somewhat misguided (see a scathing critique by The Poison Review). The […]
Holiday break & Comic relief
Introduction: Medicine is stressful. Humor helps. Here are some of the funniest medical videos I’ve seen. If there is a video you love that’s not here, drop it in the comments section. Disclaimer: These videos are intended only for healthcare professionals with intact senses of humor. They contain some foul language. Watch them at your […]
Mythbusting: (Empty IVC + hyperkinetic heart) does not equal volume depletion
0 Introduction with an example 0 A 60-year-old woman is admitted with septic shock due to pyelonephritis. Currently she has received two liters of crystalloid. Her mean arterial pressure is now 55 mm, her pulse is 120 b/m, and she is producing very little urine. Bedside ultrasound shows that her IVC is completely empty (sometimes […]
Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications
0 Introduction 0 Over the last few years, I’ve gone through an almost 180-degree change in my conceptualization of septic shock. In a perfect world, this would be irrelevant. Ideally there would be sufficient randomized controlled trials (RCTs) to answer all important questions directly, and my opinions would be irrelevant. Unfortunately not. Reconceptualizing the disease […]
Renal microvascular hemodynamics in sepsis: a new paradigm
Introduction 0 Traditionally it has been thought that during septic shock, renal blood flow decreases leading to pre-renal kidney injury. This implied that if we could improve the cardiac output and renal blood flow, the kidneys would recover. Recent research challenges these concepts, with interesting therapeutic implications. 0 New paradigm of microvascular physiology in renal acute kidney […]
Is correcting hyperchloremic acidosis beneficial?
0 Clinical Question 0 An elderly woman presents with renal failure due to severe dehydration from diarrhea. She has a hyperchloremic acidosis from diarrhea with a chloride of 115 mEq/L, bicarbonate of 15 mEq/L, and a normal anion gap. During her volume resuscitation, should isotonic bicarbonate be used to correct her hyperchloremic acidosis? Does […]
Facial hair, airway management, and Movember
Preamble: Movember 0 Movember is an annual event involving growing a mustache during November to raise awareness and funds to support men’s health issues including prostate cancer. To support Movember, this post is about mustaches… and critical care, of course. 0 Introduction with a Case 0 Once upon a time at Genius General Hospital, there was […]
Hydro-Point: Ultrasound sign of air-fluid level in the pleura
Introduction with a case 0 Hydro-point on thoracic ultrasound is diagnostic of an intrapleural air-fluid level, which may be caused by hydropneumothorax, hemopneumothorax, or pyopneumothorax. This has been described in the literature but is not widely appreciated (Volpicelli 2013). For example, a prominent ultrasound website may have misdiagnosed this. Before going further, watch the video […]
Mythbusting: Correcting the anion gap for albumin is not helpful
0 Introduction 0 In 1998 Figge reported a strong linear relationship between anion gap and albumin concentration, which has led to the widespread recommendation to correct anion gap for albumin. It was proposed that since albumin is an anion, failing to correct for a low albumin level could allow an anion-gap acidosis to go undetected. […]
Mythbusting: Heparin isn’t beneficial for noninvasive management of NSTEMI
Introduction 0 The use of heparin for noninvasive management of non-ST elevation MI (NSTEMI) is one of the most deeply entrenched myths of modern medicine. Although heparin reduces reinfarction, when it is discontinued there is a rebound in infarction rates. Ultimately, short-term treatment with heparin delays reinfarction without having any sustained benefit. Clinical trials which fail […]
10 Pearls from the Levitan Airway Course
0 Introduction 0 Last week I attended Dr. Levitan’s airway course in Baltimore. It was a teriffic course, which I would recommend to anyone looking to improve their airway management skills. For those of you unable to attend the course, here are some points which were particularly interesting to me. 0 Pearl #10. Respect the […]
Early norepinephrine to stabilize MAP in septic shock
0 Introduction 0 With publication of the PROCESS and ARISE trials, many hemodynamic goals are being disproven. There is a growing tide of nihilism. Should we should just give septic patients a couple bags of fluid, some antibiotics, and hope for the best? 0 Probably not. PROCESS and ARISE have showed us what we can […]
Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.
Introduction 0 Several months ago I gave a grand rounds on pH-guided resuscitation which was summarized in this post. This included a discussion that Lactated Ringers (LR) is safe in hyperkalemia. However, myth-busting is hard work. The dogma that LR should be avoided in hyperkalemia continues to replicate, both locally and on twitter. This […]
Large volume thoracentesis: How much can safely be removed?
0 Introduction 0 Completely draining a pleural effusion has many benefits including symptomatic improvement, avoiding multiple procedures, faster disposition home, and imaging the chest with the lung inflated. However, complete drainage is usually avoided to due to fear of re-expansion pulmonary edema. What is the evidence behind this? 0 Traditional model of reexpansion pulmonary edema (RPE) 0 […]
Pneumothorax ex vacuo: Post-thoracentesis pneumothorax in the ultrasound era
CT showing pneumothorax ex vacuo due to trapped lung (Pereyra 2013) 0 Introduction 0 A recent review article by Wilcox in JAMA questions whether ultrasound guidance truly reduces the risk of pneumothorax. Bedside ultrasound reduced pneumothorax (OR = 0.55) but this reduction was statistically insignificant due to a huge confidence interval of 0.06-5.3. Another meta-analysis found […]
