Acute on Chronic Liver Failure (ACLF) refers to decompensated cirrhosis causing failure of at least two organs (e.g. hepatic encephalopathy, hepatorenal syndrome, shock, or respiratory failure). It may be useful to conceptualize these patients as having ACLF (rather than, for example, hepatic encephalopathy plus hepatorenal syndrome), because this provides a more accurate global understanding of […]
PulmCrit Wee – Therapeutic anticoagulation for COVID ICU patients: Is the heparin vial half empty, or half full?
A fresh preprint reveals the results of combining three trials to evaluate therapeutic anticoagulation among severe COVID patients (defined as patients requiring high flow nasal cannula, noninvasive ventilation, intubation, vasopressors, or inotropes). Patients were randomized to therapeutic anticoagulation versus thromboprophylaxis per usual care guidelines. REMAP-CAP also simultaneously randomized some patients to receive aspirin as well. […]
PulmCrit Wee: High-titer convalescent plasma fails again for hospitalized COVID patients
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 […]
IBCC – Acute Liver Failure
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
IBCC – Spontaneous Bacterial Peritonitis
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 […]
IBCC – Invasive candidiasis
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. […]
IBCC – Hepatorenal Syndrome
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 […]
IBCC – Coagulation management in cirrhosis
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 & […]
PulmCrit – RECOVERY confirms benefit of toci combined with dexamethasone
The RECOVERY trial just released a preprint demonstrating benefit from tocilizumab in COVID-19. As with the prior RECOVERY studies, this is a multicenter, open-label, pragmatic trial. A robust mortality benefit was detected (the fragility index calculates to 17, which isn’t too shabby). Several important secondary endpoints were positive as well (e.g., reduced intubation rate, reduced […]
IBCC chapter & cast – Atrial Fibrillation in critical illness
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 […]
PulmCrit Wee – MENDS2: Fentanyl or fentanyl for sedation in mechanically ventilated adults with sepsis
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.
PulmCrit Wee – Follow-up Bamlanivimab study unmasks statistical chicanery
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 […]
IBCC – Revamped COVID chapter focusing on ICU & stepdown management
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 […]
IBCC chapter – Disseminated Intravascular Coagulation (DIC)
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
PulmCrit- RCTs don’t justify using convalescent plasma or antibody cocktails
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, […]
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