Within the past year, two major societies have released guidelines on ARDS: the ATS (American Thoracic Society) and the ESICM (European Society of Intensive Care Medicine). Don’t be fooled by their names – both of these organizations are fundamentally international in scope. Some authors on the ATS document were from Europe, and similarly some authors […]

A loading dose may be used to rapidly achieve steady-state pharmacokinetics. For drugs with a long half-life, this accelerates the attainment of therapeutic levels: For most drugs with single-compartment pharmacokinetics, a loading dose may be calculated using the following formula: (discussed further here) The graph below illustrates how this equation works: If (dosing interval)/(half life) […]

Some folks on twitter asked my thoughts on AMIKINHAL trial, so I thought I’d jot them here. AMIKINHAL is a multi-center RCT that evaluated the ability of inhaled amikacin to prevent VAP (ventilator-associated pneumonia) among patients who had been intubated for three days.  It’s available here at NEJM. It was a positive trial, which is […]

More guidelines!  Today we’ll walk through some interesting bits of the new IDSA/SCCM guideline on evaluation of new fever in the adult ICU patient (available free here). how should temperature be evaluated? This is frankly a mess. Bladder catheter or esophageal probe are best, but usually not used. Rectal temperature is 2nd best, but unwieldy […]

Hello fellow nerds, let’s take a look at the new American Association of Neurology (AAN) brain death guidelines. Instead of a tweetorial, I’ll jot my thoughts here, so they’re accessible to everyone. Disclaimer: the following discussion applies only to adult medicine. Most of these guidelines are consistent with the 2020 World Brain Death Project, so […]

background Today the Van de Bergh group in Belgium released a RCT investigating tight versus liberal glycemic control in the ICU. Before diving into this study, let’s take a walk down memory lane. Major interest in tight glycemic control in the ICU began in 2001 with an RCT by the same group of investigators, also […]

In many countries, pulmonary and critical care are commonly bundled together. Consequently, a single person will often be responsible for both inpatient ICU management as well as inpatient pulmonary consultation. Honestly, I have some doubts about whether this is an ideal system. As both pulmonology and critical care medicine become increasingly complex, it’s becoming impossible […]

My dear pulmonologists, I have some bad news.  Santa Claus isn’t real.  Neither is “ARDS.” “ARDS” has traditionally been conflated with a specific histopathological form of lung injury: diffuse alveolar damage (DAD).  Lectures, chapters, and articles typically juxtapose these two entities, promoting the concept that they’re one and the same. But they aren’t. The ability […]

The precise utilization of ABG, VBG, and pulse oximetry remains controversial. Unfortunately, there is little high-level evidence investigating whether these interventions affect patient outcomes (for example, there is precious little evidence to support most of the target values that we’re chasing after). This chapter attempts to explore the strengths, weaknesses, and indications for various techniques. […]

CAR-T cell therapy is rapidly expanding as a miraculous therapy for numerous malignancies.  However, it also causes a variety of unique and severe side-effects, which frequently cause ICU admission.  This chapter explores current approaches to complications including CRS (cytokine release syndrome), HLH (hemophagocytic lymphohistiocytosis), and ICANS (immune effector cell-associated neurotoxicity syndrome).  Updates will be needed […]

Recently, two sets of guidelines for neuroprognostication following cardiac arrest were released – almost simultaneously. In a perfect world, two evidence-based guidelines based on the same evidence would be the same.  But of course, this isn’t actually the case.  The guidelines differ significantly. The Neurocritical Care Society guidelines recommended this general approach:(36949360)  Meanwhile, the Canadian […]

(Blogitorials are short, informal blogs that are written in the spirit of a tweetorial).  Stress hyperglycemia is an everyday occurrence in the ICU, but we hardly know how to treat it. I’ve been waiting years for this topic to be clarified… but I’ve realized that such clarity will probably never be reached. Why? The traditional […]

Steroid is worthless for pneumonia! Wait, a new study shows it’s beneficial! Hang on, a fresh meta-analysis shows that steroid is useless! And wait, here’s a fresh NEJM study showing mortality benefit!! This feels like a roller coaster. What’s going on here? Several factors may explain this: Steroid is beneficial, but only in a subset […]

This is SIESTA syndrome.  The patient is locked in a cycle of unconsciousness, punctuated with brief episodes of agitation.  Most of the time the patient is sedated to the point of having minimal EEG activity, which may hinder their ability to regain consciousness.  

Historically, many patients admitted with congestion due to heart failure have been treated with furosemide monotherapy.  However, a strategy of furosemide monotherapy has numerous drawbacks:  Furosemide tends to stimulate production of dilute urine, leading to a greater amount of water loss than sodium loss.  Predominant loss of water may cause loss of volume from the […]