PulmCrit (EMCrit)

The ESICM and AHA both just released new guidelines on post-arrest care. It’s always interesting when two professionals produce “evidence-based” guidelines on the same topic, based on the same evidence. If these guidelines were truly evidence-based, they should be identical. But of course, they’re not. Having conflicting guidelines can be frustrating, but I actually find […]

Theodore Warkentin, a leading world expert on HIT, recently visited Vermont and delivered a talk on emerging concepts in HIT.  During his talk, he lamented that it takes ten years for a new idea to make it into Harrison’s textbook of internal medicine. Within the next day, I read several of his articles, as well […]

Let’s talk quickly about Nalbuphine, the Diet Coke of opioids. mechanism Most opioids are basic. They’re pure μ-opioid and kappa-opioid agonists. Nalbuphine is more complex: [#1] Partial agonism at μ-opioid receptors: Nalbuphine functions as a partial μ-agonist, similar to buprenorphine. Compared to buprenorphine, nalbuphine seems to stimulate the μ-opioid receptors less strongly. For patients who […]

We’ve all heard a lot about using large language models (LLMs) in medicine, but it’s generally in the abstract. I’d like to explore concretely how to apply these models to answer a specific medical question. I make no claim to be an expert in this topic, but rather I would like to propose an approach […]

The American Thoracic Society has just released a new guideline on CAP. It’s also been a while since I last updated the IBCC chapter on CAP (10/22), so I’m revising the chapter and incorporating the new guidelines. Here are some of my thoughts on the latest developments in severe CAP. ATS and IDSA are… breaking […]

Family meetings are often necessary to communicate with families and determine the next steps in caring for patients. For most of these family meetings, the patient may be too ill to participate. Furthermore, the ICU team often has never met the patient before the onset of severe illness. This creates a situation where the patient’s […]

I’m writing a letter to the editor in response to a recent article in the Journal of Hospital Medicine.  I’m posting it here rather than submitting it to the journal to avoid burying it behind a paywall (and because I have the attention span of an intensivist hopped up on lots of coffee). First, I […]

Let’s talk about starting patients on milrinone. Milrinone is part of a group of medications that I would regard as quasi-titratable. They have an awkward half-life of roughly ~0.5-3 hours. Other medications in this group might include diltiazem, labetalol, and perhaps nicardipine. These drugs can be given as a continuous infusion, but they’re not easy […]

I’ve seen the following sequence of events several times. I can’t prove the exact causality, but I have a strong suspicion about what is going on here. You can be the judge. clinical presentation A patient presents for management of a pleural effusion. A pigtail chest drain is inserted without difficulty or complication. The drain […]

I think ICU docs may have developed a bit of an RCT problem; not an addiction, but perhaps a dependency. It all started off fine at first. RCTs are the apex trial design, the only trial capable of proving causality. But we’ve taken it too far. Currently, a cluster-randomized trial is underway to study whether […]

I discussed the reasons for migrating to BlueSky here. I’ve received positive feedback from several FOAMed expats who migrated to Bluesky and enjoy it there. I’ve also received some questions about getting started on BlueSky, so here is a brief guide to moving into MedSky.   [1] Set up your account & profile This is essentially […]

Medtwitter was great. We met amazing people and exchanged ideas. There were endless arguments about electrolytes and intubation. But the strength of Medtwitter was never the platform – it was the people. Twitter has been deteriorating for years. For example, the algorithm is horrific, the blocking feature has been largely removed, posts from paid users […]

We often joke that the right ventricle is the “forgotten ventricle,” but there is a sad truth behind this joke.  Recently, there has been increased recognition of the importance of right ventricle failure and systemic congestion within some circles (e.g., nephrologists and resuscitationists). However, overall the right ventricular failure continues to be commonly overlooked. A […]

Sometimes I encounter basic pharmacokinetic questions that don’t seem to be readily answered in the immediately available literature.  I’ve found FOAMed to be a useful way to make sure I’m doing this right (e.g., see a prior discussion of the appropriate loading dose based on intermittent maintenance dosing and half-life here). Today I want to […]

REVISE is the latest multicenter RCT on the use of PPIs for GI prophylaxis in critical illness. I would view this as the triquel following SUP-ICU and PEPTIC. In order to understand REVISE in context, let’s briefly review SUP-ICU and PEPTIC trials, before discussing REVISE. Part I: SUP-ICU (2018) This was a large multicenter RCT […]