EMCrit Project

Convalescent plasma use against epidemic respiratory viruses dates back to the influenza pandemic of 1918.  This intervention has persisted for over a century based on high face-validity, rather than any high-quality evidence.  The COVID epidemic reignited enthusiasm for this therapy, leading to its use in tens of thousands of patients (e.g., an expanded-use program organized […]

Acute liver failure is rare, but when it does occur it requires an organized diagnostic and therapeutic approach.  Success often relies upon aggressive support of other organs (e.g. renal failure and management of intracranial hypertension). The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on iTunes

Spontaneous bacterial peritonitis is an important consideration for any hospitalized patient with substantial ascites.  Patients can have minimal symptoms.  To complicate matters further, in some cases spontaneous bacterial peritonitis may present with failure of other organs (e.g. hepatic encephalopathy, or disseminated intravascular coagulation leading to gastrointestinal hemorrhage). The IBCC chapter is located 👉 here. The […]

Invasive candidiasis is growing more common in the ICU, as our patients are becoming increasingly complex, with longer stays.  However, most isolation of Candida in the ICU represents colonization rather than infection – so there is a major risk of overdiagnosis resulting in unnecessary medication toxicity and antimicrobial resistance. The IBCC chapter is located 👉 here. […]

We’ve been seeing a lot of decompensated liver disease recently, likely related to increases in alcohol intake due to the COVID pandemic.  Over the next month, several chapters on critical care hepatology be released, exploring how to manage these patients.  We start with hepatorenal syndrome and hepatorenal physiology, because this is often the crux of […]

Cirrhosis causes a derangement of all components of coagulopathy.  Fortunately, these derangements tend to balance one another out (so the best approach is often to merely observe).  However, sometimes imbalances may spin out of control and require aggressive management (e.g. causing hyperfibrinolysis with refractory bleeding). The IBCC chapter is located 👉 here. The podcast & […]

Most available data on atrial fibrillation pertains to chronic outpatient management or atrial fibrillation following cardiac surgery.  This data may not apply perfectly to most critically ill patients.  Extrapolation of available data to the management of critically ill patient is challenging, with much left to clinical judgement. The IBCC chapter is located 👉 here. The […]

The MENDS2 trial was intended as a study comparing dexmedetomidine to propofol. However, the doses of these medications used in the study weren’t high enough to be impactful. In retrospect, the study may actually be an investigation of how clinicians approach the agitated intubated patient – potentially revealing an over-reliance on opioid infusions.

Whether or not you have any interest in bamlanivimab, you should read this post as an amusing example of shoddy statistics being published in top journals.  background & general landscape of the two trials The BLAZE-1 trial involved randomizing patients within three days of testing positive for COVID-19 to one of four arms:  placebo, 700 […]

The COVID chapter has been updated, overhauled, and refocused on the management of the sickest COVID patients (those requiring admission to ICU or stepdown units).  The new chapter removes more basic information about COVID that we’re all probably familiar with at this point (but the original, larger chapter is still available here). The goal of […]

Disseminated Intravascular Coagulation (DIC) is like the ARDS of the hematological system.  It’s not really one disorder, but rather a collection of different disorders with some shared features.  The diagnosis and optimal treatment remain elusive. The IBCC chapter is located 👉 here. The podcast & comments are below. Follow us on iTunes  

Passive immunity refers to the infusion of antibodies (either polyclonal antibodies in the form of convalescent plasma, or engineered monoclonal antibodies).  The goal is to neutralize viral particles, reduce viral replication, and thereby improve clinical outcomes.  This is a promising theory, but it requires evidentiary support in the form of randomized controlled trials.  So far, […]

The REMAP-CAP trial recently detected mortality benefit from tocilizumab in patients with COVID-19.  However, several other RCTs have failed to find substantial benefit from tocilizumab.  This begs the question:  Has REMAP-CAP discovered a uniquely beneficial way to use tocilizumab, or is this simply a statistical outlier?   evidence roundup:  RCTs on tocilizumab Let’s review the trials.  […]

Purpura fulminans is a rare form of disseminated intravascular coagulation which requires specific management.  Most commonly it is seen as a complication of septic shock with multi-organ failure.  Unfortunately, purpura fulminans is often treated simply with a generic approach for septic shock. The IBCC chapter is located 👉 here. The podcast & comments are below. […]