PulmCrit (EMCrit)

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 […]

introduction Bilevel Sequence Intubation (BSI) refers to initiation of noninvasive bilevel positive pressure ventilation with a backup rate prior to intubation (either using a BiPAP machine or a full-featured mechanical ventilator). BSI is distinct from traditional rapid sequence intubation (RSI), since BSI involves the delivery of machine-initiated, pressure-controlled breaths following administration of sedation and paralytics. […]

intro: the challenge of procedural sedation in critical illness Procedural sedation for critically ill patients is a minefield for several reasons: Patients are already physiologically unstable. Procedures are emergent (a factor widely associated with greater complications). Time constraints often prevent a complete pre-anesthetic evaluation (e.g., medical history and laboratory studies may be unknown). A single […]

Piperacillin-tazobactam is an antibiotic that a lot of people love to hate. Combine this with the conservatism that often (rightfully) surrounds drug safety, and it creates a lot of volatility. Before going further, we should review some recent history regarding piptazo. In the early 2010’s, a series of retrospective correlational studies found that patients treated […]

A razor is a rule of thumb that is helpful, although it isn’t always correct. In medicine we’re familiar with Occam’s razor (the rule of parsimony). The cutoff razor states: if a continuous variable is dichotomized using a cutoff, then values near the cutoff provide little information. A simple illustration of the cutoff razor is […]

(A blogitorial is like a tweetorial in blog form, so folks on different platforms can see it). Our approach to risk stratification and management of (sub)massive PE tends to be dominated by CT scan and echocardiography (eye-candy modalities). And these are great. But I think there are situations where ECG can be really helpful – […]

Eyelid opening apraxia refers to a specific inability to open the eyelids. This may result from non-dominant hemispheric strokes. On superficial examination it will mimic unconsciousness, but upon further examination the patient is awake and able to respond to stimuli with their extremities. I’ve seen a similar phenomenon of eyelid opening apraxia a few times […]

People on twitter absolutely hate the concept of using a central line to resuscitate a GI bleeder. This comes up a couple times per year. I think the source of this hatred is largely three-fold: A central line alone is garbage (without a Level-1 or Belmont infuser). I’ll admit that.  So if you’re working in […]