PulmCrit (EMCrit)

Historically, emphasis has rested on the distinction between noninvasive versus invasive BP (e.g., cuff pressure vs. radial arterial pressure).  Attention focused on whether noninvasive oscillometric BP monitoring is adequate. Meanwhile, it has been assumed that all invasive BP measurement sites are created equal.

Circadian rhythms and melatonin are best known for their relationship to sleep.  However, they have a much broader range of functions.  Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).  

Metabolic resuscitation for sepsis is currently quite controversial.  Marik et al. published a before-after study in 2017 describing the combination of hydrocortisone, ascorbate, and thiamine for septic shock. That study incited a media storm of surprising intensity.  Currently, several multi-center RCTs are underway to answer this question more definitively.  In the interim, some additional before/after trials may emerge.  These studies likely won’t answer the question, but they may provide us with some clues about whether metabolic resuscitation is on the right track.

Imagine that you admit a patient with septic shock.  You resuscitate the patient as best you can with inopressors, fluids, and antibiotics. An adequate blood pressure is achieved.  A reasonable amount of fluid is administered.  Despite all these measures, the urine output remains minimal.  What should you do next?

A common approach to TdP is shown above.  The initial episode is controlled with magnesium and perhaps defibrillation.  The patient is sent to ICU for close observation.  Usually the patient will be fine, but sometimes TdP does recur.  Recurrence triggers second-tier therapies, often including overdrive pacing.