PulmCrit (EMCrit)

I've been checking the serum osmolal gap on patients with toxic ingestion for years.  However, the osmolal gap has yet to crack a case for me.  There have been lots of patients with elevated osmolal gaps due to uremia or ketoacidosis.  Meanwhile, the cases of ethylene glycol or methanol intoxication which I have encountered have been diagnosed based on other features (e.g., … [Read more...]

Based on the Rivers trial of early goal-directed therapy, central venous oxygen saturation (cvO2%) emerged as a resuscitation target.  This was recommended for over a decade until the PROCESS, PROMISE, and ARISE trials demonstrated that cvO2% monitoring was unnecessary.  Consequently, this has largely fallen by the wayside.However, one niche role of cvO2% in the ICU has … [Read more...]

As a medical student I rotated through an elite hospital where it was believed that every patient admitted to the medicine service needed a rectal exam.  The rationale was to avoid ever missing a case of rectal or prostate cancer.  Eventually, the utility of digital rectal examination as a cancer-screening tool was debunked.  Thankfully, this practice has fallen out of … [Read more...]

Example #1:  Osmolar Gap I'm a bit skeptical of the value of screening toxicology patients by measuring an osmolar gap.  So I looked for literature about the test's performance.  Lynd 2008 found that an elevated osmolar gap had a sensitivity of 90% and a specificity of 22% (1).  That's about what I might have guessed - the test is fairly sensitive and very poorly specific (it … [Read more...]

We all want to alleviate pain and suffering.  Most critically ill patients are treated with opioids for this reason.  Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation.  Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression.  This post explores the optimal use of systemic … [Read more...]