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 […]
Double-coverage of gram negatives with a fluoroquinolone?
0 Introduction 0 The benefit of empirically using two antibiotics to cover gram negative bacilli is a perpetual controversy. For patients in septic shock, failure to provide effective initial antimicrobial therapy correlates with increased mortality. Using two drugs may increase the likelihood of an including at least one antibiotic which covers the pathogen. This […]
What does it mean if a patient is “allergic” to haloperidol?
0 Introduction with a case 0 Once upon a time at Genius General Hospital, a 25-year old man was admitted to the ICU for agitation. After exclusion of an acute medical or neurologic process, it became clear that he was suffering from schizophrenia with medication nonadherence. Unfortunately, his electronic medical record indicated that he had […]
The myth of large-volume resuscitation in acute pancreatitis
Introduction 0 Severe pancreatitis causes fluid extravasation from the vasculature, sometimes causing shock. Traditionally this has been managed by administration of large volumes of crystalloid. For example, the 2013 American College of Gastroenterology Guideline recommended providing 250-500 ml/hour of crystalloid for the first 12-24 hours of hospitalization. They recommended targeting fluid resuscitation to achieve dilution […]
The fallacy of time-to-intervention studies
0 Time and tide wait for no intervention – Geoffrey Chaucer 0 We are barraged by time-to-intervention studies (door-to-balloon time, time-to-antibiotics, door-to-needle, etc.). However, it must be kept in mind that these studies are purely correlational in design. Such studies cannot […]
Could estrogen-receptor antagonists treat Ebola?
Disclaimer: In light of the ongoing epidemic this post is intended to spark interest and invoke discussion about unconventional therapies. Introduction It is widely believed that there is no specific therapy for Ebolavirus. However, this is only partially true. Some experimental therapies exist, including convalescent serum and interferon, but the ability to deploy these to […]
Two EKG patterns of pulmonary embolism which mimic MI
Introduction with a case 0 A 45-year old man presented to the hospital with chest pain and dyspnea. His troponin was positive, and EKG showed T-wave inversions in the inferior leads and V1-V4. He was pale, diaphoretic, tachycardic, and borderline hypotensive with a systolic blood pressure ranging from 85-110mm. He was taken urgently for cardiac […]
Secondary Bacterial Peritonitis
0 Introduction with a case 0 A patient with advanced alcoholic cirrhosis presents to the hospital with fever and altered mental status. Examination is notable for abdominal distention with rebound tenderness. Bedside ultrasound reveals a large amount of ascites, which is carefully sampled revealing a cloudy fluid with 15,000 neutrophils/uL and a differential of 90% neutrophils (a […]
High-flow nasal cannula to prevent post-extubation respiratory failure
0 Background: Post-extubation failure and noninvasive ventilation (NIV) 0 Post-extubation respiratory failure requiring re-intubation is a major setback for any critically ill patient. Current evidence mainly involves the pre-emptive use of NIV to reduce post-extubation failure, particularly in hypercapnic COPD patients. However, in practice this is difficult to implement widely. Except for the sickest COPD […]
Eight pearls for the crashing patient with massive PE
0 Introduction 0 Literature on massive PE focuses mostly on how to deal with the clot while less attention is spent on other aspects of management. This post will focus on such aspects, especially hemodynamic resuscitation of massive PE. There is nearly no clinical data, forcing us to extrapolate between limited data, hemodynamic theory, and […]
Preoxygenation & apneic oxygenation using a nasal cannula
0 Starting Point: We do a bad job at preoxygenation 0 We could do better at preoxygenating patients before emergent intubations. In my experience the most commonly used device for preoxygenation is a bag-valve mask, which has many pitfalls. We often accept a poor mask seal in efforts to remain gentle with awake patients. […]
Dexmedetomidine to facilitate noninvasive ventilation
Introduction 0 Noninvasive ventilation (NIV) has recently emerged as a fundamental treatment for patients with acute exacerbation of obstructive lung disease or cardiogenic pulmonary edema, often avoiding intubation. However, some patients have difficulty tolerating this therapy due to anxiety. Dexmedetomidine (PRECEDEX) is an attractive sedative to manage this problem, since it may be titrated and […]
