pulmcrit – EMCrit https://emcrit.org Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Mon, 22 May 2017 22:39:22 +0000 en-US hourly 1 https://wordpress.org/?v=4.7.5 http://emcrit.org/feed/podcast/ Help me fill in the blanks of the practice of ED Critical Care. In this podcast, we discuss all things related to the crashing, critically ill patient in the Emergency Department. Find the show notes at emcrit.org. Scott D. Weingart, MD clean Scott D. Weingart, MD spambin55@gmail.com spambin55@gmail.com (Scott D. Weingart, MD) 2009- Online Medical Education on Emergency Department (ED) Critical Care, Trauma, & Resuscitation pulmcrit – EMCrit http://emcrit.org/wp-content/uploads/powerpress/3000x3000-emcrit.jpg https://emcrit.org/category/pulmcrit/ PulmCrit- Liberating the patient with no cuff leak https://emcrit.org/pulmcrit/cuff-leak/ https://emcrit.org/pulmcrit/cuff-leak/#comments Mon, 22 May 2017 11:01:54 +0000 https://emcrit.org/?p=440988 A new joint practice guideline by the ATS and ACCP addresses how to approach cuff leaks. This guideline recommends a clever compromise between these extremes, which is the basis of the algorithm below. This provides a streamlined, evidence-based pathway to extubate patients without a cuff leak.

EMCrit by Josh Farkas.

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PulmCrit- Resuscitationist’s guide to status epilepticus https://emcrit.org/pulmcrit/status-epilepticus-2/ https://emcrit.org/pulmcrit/status-epilepticus-2/#comments Mon, 08 May 2017 11:02:27 +0000 https://emcrit.org/?p=440806 In 2014 I wrote a post suggesting an aggressive, streamlined approach to status epilepticus involving early intubation.  The fundamentals of that post remain valid.  However, much has changed over the last few years.  This post aims to refresh and extend the prior post.  It will also serve as a reference to explain my algorithm for […]

EMCrit by Josh Farkas.

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PulmCrit- Rocketamine vs. keturonium for rapid sequence intubation https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/ https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/#comments Mon, 24 Apr 2017 11:01:35 +0000 https://emcrit.org/?p=440483 Background:  Devil in the details Airway management is a detail-oriented sport.  Minor nuances of patient positioning can be essential.  Or gentle laryngeal manipulation.  Apneic oxygenation can improve first-pass success.  Placing the pulse oximeter on the same arm as the blood pressure cuff can cause real headache.  Failure to recognize and remove dentures is an enormous […]

EMCrit by Josh Farkas.

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PulmCrit- Submassive PE 2017: Getting ’em off the cliff https://emcrit.org/pulmcrit/submassive-pe-peitho/ https://emcrit.org/pulmcrit/submassive-pe-peitho/#comments Mon, 10 Apr 2017 11:01:57 +0000 https://emcrit.org/?p=440066 Follow-up data from the PEITHO trial shows that thrombolytics don't affect long-term morbidity.  This simplifies management substantially. PEITHO trial & long-term follow up The PEITHO trial was a multi-center RCT investigating the effect of thrombolysis in submassive PE.  Tenecteplase caused an increase in intracranial hemorrhage and a reduction in hemodynamic collapse.  Overall there was a […]

EMCrit by Josh Farkas.

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PulmCrit- Metabolic sepsis resuscitation: the evidence behind Vitamin C https://emcrit.org/pulmcrit/metabolic-sepsis-resuscitation/ https://emcrit.org/pulmcrit/metabolic-sepsis-resuscitation/#comments Mon, 27 Mar 2017 11:01:15 +0000 https://emcrit.org/?p=439192 The Metabolic Resus of Sepsis

EMCrit by Josh Farkas.

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PulmCrit Wee: MDCalc for the perfect tape-measure intubation https://emcrit.org/pulmcrit/tape-measure-intubation/ https://emcrit.org/pulmcrit/tape-measure-intubation/#comments Wed, 22 Mar 2017 11:05:29 +0000 https://emcrit.org/?p=439545 Imagine you went to buy an expensive piece of clothing.  Rather than measuring your size, the store owner simply said “well, on average most folks require a medium, so let's try that on, we can always re-size it later.”  You would be irritated that they were wasting your time.  When you go clothes shopping, you […]

EMCrit by Josh Farkas.

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PulmCrit- Hypertriglyceridemic pancreatitis: Can we defuse the bomb? https://emcrit.org/pulmcrit/hypertriglyceridemic-pancreatitis/ https://emcrit.org/pulmcrit/hypertriglyceridemic-pancreatitis/#comments Mon, 13 Mar 2017 11:00:35 +0000 https://emcrit.org/?p=439196 Hypertriglyceridemia causes ~9% of pancreatitis, the third most common cause after alcohol and gallstones.  It is a risk factor for severe pancreatitis, making it more frequent among ICU patients with pancreatitis.  I see this a few times each year.  Nonetheless, it has low penetration into educational curricula or our collective awareness. The treatment of hypertriglyceridemic […]

EMCrit by Josh Farkas.

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PulmCrit- Killer resuscitation: Abdominal hypertension as an occult driver of multiorgan failure  https://emcrit.org/pulmcrit/abdominal-hypertension/ https://emcrit.org/pulmcrit/abdominal-hypertension/#comments Mon, 27 Feb 2017 11:14:56 +0000 https://emcrit.org/?p=438963 Introduction with a clinical conundrum A 66-year-old man is transferred from an outside hospital due to inability to be liberated from the ventilator.  He presented a week earlier with pneumonia and sepsis.  He received six liters of fluid initially, and has been running net positive 1-2 liters daily since then (for a total of about […]

EMCrit by Josh Farkas.

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PulmCrit- Epinephrine vs. atropine for bradycardic periarrest https://emcrit.org/pulmcrit/epinephrine-atropine-bradycardia/ https://emcrit.org/pulmcrit/epinephrine-atropine-bradycardia/#comments Mon, 13 Feb 2017 12:35:55 +0000 https://emcrit.org/?p=438239 Introduction with a case An elderly woman is admitted with atrial fibrillation and fast ventricular rate.  She is asymptomatic, with a heart rate of 160 b/m.  She is treated with a 20 mg diltiazem bolus followed by an infusion at 15 mg/hour for several hours.  Her heart rate slows to 110 b/m. She is then […]

EMCrit by Josh Farkas.

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PulmCrit- Six myths promoted by the new surviving sepsis guidelines https://emcrit.org/pulmcrit/sepsis-myths/ https://emcrit.org/pulmcrit/sepsis-myths/#comments Mon, 30 Jan 2017 13:09:14 +0000 http://emcrit.org/?p=438040 Early Goal-Directed Therapy:  A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy.  This is basically the NINDS trial of the critical care world:  a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline.  The […]

EMCrit by Josh Farkas.

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PulmCrit- How to convert a VBG into an ABG https://emcrit.org/pulmcrit/vbg-abg/ https://emcrit.org/pulmcrit/vbg-abg/#comments Mon, 16 Jan 2017 11:49:22 +0000 http://emcrit.org/?p=437588 This post is about a research project I did as a pulmonary critical care fellow in 2011. To understand it, you need to know a bit of the story behind it.

EMCrit by Josh Farkas.

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PulmCrit- Sedation update: IV olanzapine & combo vs. monotherapy https://emcrit.org/pulmcrit/iv-olanzapine/ https://emcrit.org/pulmcrit/iv-olanzapine/#comments Wed, 11 Jan 2017 14:03:18 +0000 http://emcrit.org/?p=423754 The potential role for IV olanzapine was examined in a post last year.  The following conclusions were reached: IV olanzapine appears to be safe. IV olanzapine has equal potency compared to IV droperidol and about twice the potency of IV haloperidol. Olanzapine doesn't affect QT interval or cause torsade de pointes. Two articles were just […]

EMCrit by Josh Farkas.

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PulmCrit- Dogmalysis of PCI for NSTEMI patients with a history of CABG https://emcrit.org/pulmcrit/pci-nstemi-cabg/ https://emcrit.org/pulmcrit/pci-nstemi-cabg/#comments Mon, 02 Jan 2017 11:50:45 +0000 http://emcrit.org/?p=387511 Many patients with prior CABG probably benefit from catheterization and repeat revascularization (PCI or a repeat CABG). However, this cannot be assumed to be universally true. In particular, patients with smaller infarcts and advanced renal failure could be harmed.

EMCrit by Josh Farkas.

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PulmCrit- Triple therapy for influenza with naproxen, clarithromycin, and oseltamavir? https://emcrit.org/pulmcrit/influenza_naproxen_clarithromycin/ https://emcrit.org/pulmcrit/influenza_naproxen_clarithromycin/#comments Mon, 19 Dec 2016 13:20:15 +0000 http://emcrit.org/?p=387077 Flu seasons is upon us again. A recent paper in CHEST provides some tantalizing evidence about possible treatment. Will this pan out, or is it just another fairy tale?

EMCrit by Josh Farkas.

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PulmCrit- Coagulation balance in sepsis-associated DIC https://emcrit.org/pulmcrit/sepsis-dic/ https://emcrit.org/pulmcrit/sepsis-dic/#comments Mon, 05 Dec 2016 13:07:41 +0000 http://emcrit.org/?p=386158 An 80-year-old man was admitted with sepsis due to liver abscess. Over the first two hospital days his platelet count decreased from 122 to 39. Prophylactic heparin was held due to concerns about bleeding risk. Additional coagulation studies showed a D-dimer of 1221 ng/ml, a fibrinogen of 672 mg/dL, and the following thromboelastograph:

EMCrit by Josh Farkas.

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Pulmcrit Wee- Vasopressin vs. norepinephrine for vasoplegic shock after cardiac surgery https://emcrit.org/pulmcrit/vasopressin-vancs/ https://emcrit.org/pulmcrit/vasopressin-vancs/#comments Wed, 23 Nov 2016 13:05:10 +0000 http://emcrit.org/?p=383284 Patients in the VANISH trial treated with vasopressin had a lower incidence of renal failure requiring hemodialysis. However, this was a secondary endpoint which seemed to contradict the primary endpoint (defined as a milder degree of kidney injury). New data may clarify this controversy.

EMCrit by Josh Farkas.

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PulmCrit- Devil in the details: Endotracheal tube depth https://emcrit.org/pulmcrit/endotracheal-tube-depth/ https://emcrit.org/pulmcrit/endotracheal-tube-depth/#comments Mon, 21 Nov 2016 12:39:02 +0000 http://emcrit.org/?p=365709 According to Napoleon, “the moment of greatest vulnerability is the instant immediately after victory.”  In airway management, this instant occurs immediately after placement of the endotracheal tube.  There is a risk of relaxing and overlooking critical details.  Meanwhile, this is often the point when the patient's blood pressure and saturation nadir. Introduction with a rare but […]

EMCrit by Josh Farkas.

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PulmCrit- New guidelines simplify ICU nutrition https://emcrit.org/pulmcrit/enteral-nutrition-intubated/ https://emcrit.org/pulmcrit/enteral-nutrition-intubated/#comments Mon, 07 Nov 2016 11:09:31 +0000 http://emcrit.org/?p=361032 Introduction to nutritional dogma Everyone has strong opinions about food.  We all feel that we have some special, intuitive understanding of nutrition.  Nonsense.  Such intuitions have historically created a wide array of dogma regarding nutrition, complicating matters immensely. Fortunately, the 2016 SCCM/ASPEN guidelines have stripped away much of the nonsense involved in nutritional support.  This […]

EMCrit by Josh Farkas.

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PulmCrit- Top 10 reasons pulse oximetry beats ABG for assessing oxygenation https://emcrit.org/pulmcrit/pulse-oximetry/ https://emcrit.org/pulmcrit/pulse-oximetry/#comments Wed, 02 Nov 2016 11:43:18 +0000 http://emcrit.org/?p=336882 What does it mean if PaO2 and oxygen saturation seem to disagree? Do we need to measure an ABG if the oxygen saturation waveform is adequate? What is the best way to measure oxygenation?

EMCrit by Josh Farkas.

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PulmCrit mythbusting- Anaphylaxis to penicillins isn’t a contraindication to meropenem https://emcrit.org/pulmcrit/pulmcrit-mythbusting-anaphylaxis-penicillins-isnt-contraindication-meropenem/ https://emcrit.org/pulmcrit/pulmcrit-mythbusting-anaphylaxis-penicillins-isnt-contraindication-meropenem/#comments Mon, 24 Oct 2016 11:16:24 +0000 http://emcrit.org/?p=316875 An unconscious septic patient rolls in wearing a “PCN anaphylaxis” medic-alert bracelet. What is the best broad-spectrum antibiotic for this patient? There is no agreement between allergy guidelines, infectious disease society guidelines, or individual infectious disease experts.

EMCrit by Josh Farkas.

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PulmCrit Wee- Oxygen-ICU trial: 100% isn’t an A+ https://emcrit.org/pulmcrit/icu-oxygen/ https://emcrit.org/pulmcrit/icu-oxygen/#comments Wed, 19 Oct 2016 11:15:31 +0000 http://emcrit.org/?p=292438 Among intubated patients, we can often control the pO2, pCO2, and pH. Sounds great. Unfortunately, we also have no idea which numbers we should be targeting. Should we target a normal pH, or permissive hypercapnia? Should we shoot for a normoxia, try to maximize the oxygen delivery (hyperoxia), or allow for permissive hypoxemia? Nobody knows. We check ABGs and tweak the ventilator, but it's often dubious whether this helps our patients.

EMCrit by Josh Farkas.

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PulmCrit- Power, the forgotten error, and inconclusive trials https://emcrit.org/pulmcrit/relative-power/ https://emcrit.org/pulmcrit/relative-power/#comments Mon, 10 Oct 2016 10:29:41 +0000 http://emcrit.org/?p=273869 The new HYPRESS trial tests whether steroid could prevent deterioration from sepsis into septic shock. The study found no significant benefit from steroid, but I thought it was underpowered. However, an accompanying editorial in JAMA didn’t even mention power. This raises some questions: How can we measure type-2 error? How should it be reported? What is an acceptable level of type-2 error?

EMCrit by Josh Farkas.

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PulmCrit – Bad news for sepsis-3.0: qSOFA fails validation https://emcrit.org/pulmcrit/sepsis-3-sofa-validation-news/ https://emcrit.org/pulmcrit/sepsis-3-sofa-validation-news/#comments Sat, 01 Oct 2016 11:01:42 +0000 http://emcrit.org/?p=235583 Sepsis 3.0 replaced the SIRS criteria with a new risk-stratification tool, qSOFA. qSOFA was initially developed within the Sepsis-3 publication itself. Until now, qSOFA has never been validated. The value of qSOFA vs. SIRS remains controversial.

EMCrit by Josh Farkas.

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PulmCrit- Dominating the acidosis in DKA https://emcrit.org/pulmcrit/bicarbonate-dka/ https://emcrit.org/pulmcrit/bicarbonate-dka/#comments Mon, 26 Sep 2016 10:51:29 +0000 http://emcrit.org/?p=232263 Management of acidosis in DKA is an ongoing source of confusion. There isn’t much high-quality evidence, nor will there ever be. However, a clear understanding of the physiology of DKA can help us treat this rationally and effectively.

EMCrit by Josh Farkas.

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PulmCrit Wee- Proning the non-intubated patient https://emcrit.org/pulmcrit/proning-nonintubated/ https://emcrit.org/pulmcrit/proning-nonintubated/#comments Wed, 21 Sep 2016 11:53:58 +0000 http://emcrit.org/?p=190529 From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.

EMCrit by Josh Farkas.

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PulmCrit Wee – The meaning of nocturnal extubation is 42 https://emcrit.org/pulmcrit/nocturnal-extubation/ https://emcrit.org/pulmcrit/nocturnal-extubation/#respond Thu, 15 Sep 2016 11:00:19 +0000 http://emcrit.org/?p=183709 What should intensivists do at night? Should they sleep at home or remain dutifully in the hospital? Should they extubate patients or just maintain the status quo until 7 AM?

EMCrit by Josh Farkas.

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PulmCrit- Why dialyze patients with chronic, asymptomatic hyperlithemia? https://emcrit.org/pulmcrit/dialysis-asymptomatic-hyperlithemia/ https://emcrit.org/pulmcrit/dialysis-asymptomatic-hyperlithemia/#comments Mon, 12 Sep 2016 11:13:30 +0000 http://emcrit.org/?p=175335 A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient's condition if the patient is already asymptomatic.

EMCrit by Josh Farkas.

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PulmCrit- Do phenylephrine and epinephrine require central access? https://emcrit.org/pulmcrit/phenylephrine-epinephrine-central-access/ https://emcrit.org/pulmcrit/phenylephrine-epinephrine-central-access/#comments Wed, 07 Sep 2016 11:29:48 +0000 http://emcrit.org/?p=151968 Until recently I believed that prolonged vasopressor administration requires a central line, to avoid extravasation. I lumped together all vasopressors, treating them all as equal. I used the occurrence of an extravasation reaction from one vasopressor as evidence that all vasopressors could cause extravasation reactions (the fallacy of inappropriate generalization). Upon closer examination, these beliefs aren't supported by evidence.

EMCrit by Josh Farkas.

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PulmCrit- The siren’s call: Double-coverage for ventilator associated PNA https://emcrit.org/pulmcrit/double-coverage-vap/ https://emcrit.org/pulmcrit/double-coverage-vap/#comments Mon, 29 Aug 2016 10:51:22 +0000 http://emcrit.org/?p=120838 Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.

EMCrit by Josh Farkas.

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PulmCrit- Interpreting a 2×2 table using fragility, p-values, and maximal Bayes Factor https://emcrit.org/pulmcrit/2x2-table-maximal-bayes-factor/ https://emcrit.org/pulmcrit/2x2-table-maximal-bayes-factor/#respond Wed, 24 Aug 2016 11:18:35 +0000 http://emcrit.org/?p=103532 A post a few weeks ago calculated the fragility index of the NINDS trial (which turned out to be only three). Very briefly, the fragility index tests how many events would need to be changed for the p-value to increase above 0.05, rendering the study "statistically insignificant." Ryan Radecki commented that he was concerned that the fragility index was married to the p-value, thereby inheriting the flaws of frequentist statistics. Perhaps we should ditch the p-value and the fragility index, switching instead to a purely Bayesian approach to statistics?

EMCrit by Josh Farkas.

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Pulmcrit – Renoresuscitation, vasopressin, vepinephrine, and VANISH https://emcrit.org/pulmcrit/vanish-renoresuscitation-vasopressin-vepinephrine/ https://emcrit.org/pulmcrit/vanish-renoresuscitation-vasopressin-vepinephrine/#comments Mon, 15 Aug 2016 11:43:30 +0000 http://emcrit.org/?p=97106 My goals during sepsis resuscitation focus largely on preservation of renal function and maintence of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypoperfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too. In this context, any beneficial effect of vasopressin on renal function could be helpful.

EMCrit by Josh Farkas.

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PulmCrit – Six reasons to avoid fluoroquinolones in the critically ill https://emcrit.org/pulmcrit/fluoroquinolone-critical-illness/ https://emcrit.org/pulmcrit/fluoroquinolone-critical-illness/#comments Mon, 01 Aug 2016 10:54:11 +0000 http://emcrit.org/?p=72688 As an internal medicine resident and pulmonary/critical care fellow, I loved fluoroquinolones. The were effective, easy to prescribe, and they had 100% oral bioavailability. However, working full-time in the ICU has forced me to realize that these drugs aren't so wonderful for the critically ill.

EMCrit by Josh Farkas.

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PulmCrit Wee – Pragmatic comparison of 33C vs. 36C after cardiac arrest https://emcrit.org/pulmcrit/33c-36c-cardiac-arrest/ https://emcrit.org/pulmcrit/33c-36c-cardiac-arrest/#respond Thu, 28 Jul 2016 11:25:49 +0000 http://emcrit.org/?p=71208 A post last year discussed the top 10 reasons to stop cooling to 33C. It was based largely on the Nielsen trial, which showed similar outcomes between therapeutic hypothermia (TH33) and therapeutic temperature management (TTM36). However, this trial left some questions about how these protocols would perform outside the context of a RCT (external validity). Last year's post speculated that since TTM36 is easier to achieve, it would out-perform TH33 in real-world conditions.

EMCrit by Josh Farkas.

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PulmCrit: Which patients admitted for pneumonia need MRSA coverage? https://emcrit.org/pulmcrit/pneumonia-mrsa/ https://emcrit.org/pulmcrit/pneumonia-mrsa/#comments Mon, 18 Jul 2016 10:28:37 +0000 http://emcrit.org/?p=62718 Let's be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It's not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.

EMCrit by Josh Farkas.

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PulmCrit Wee: Is piperacillin-tazobactam nephrotoxic? https://emcrit.org/pulmcrit/piperacillin-tazobactam-nephrotoxic/ https://emcrit.org/pulmcrit/piperacillin-tazobactam-nephrotoxic/#comments Sat, 09 Jul 2016 13:18:06 +0000 http://emcrit.org/?p=60086 A recent series of articles suggest that the combination of vancomycin and piperacillin-tazobactam are synergistically nephrotoxic. Is piperacillin-tazobactam truly nephrotoxic, or is this merely pseudo-nephrotoxicity?

EMCrit by Josh Farkas.

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PulmCrit: What is the fragility index of the NINDS trial? https://emcrit.org/pulmcrit/fragility-index-ninds/ https://emcrit.org/pulmcrit/fragility-index-ninds/#comments Tue, 05 Jul 2016 10:57:38 +0000 http://emcrit.org/?p=59758 Medicine continues to be plagued by poorly reproducible studies. The storyline is familiar. First, a very positive study is released in a major medical journal, with great fanfare. This leads to widespread changes in practice. Decades later, it becomes clear that the study was incorrect. Recently a new tool was developed to help understand the reproducibility of clinical studies: the fragility index. This post will analyze the NINDS trial from the perspective of its fragility index.

EMCrit by Josh Farkas.

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PulmCrit: We should engineer a new crystalloid https://emcrit.org/pulmcrit/crystalloid/ https://emcrit.org/pulmcrit/crystalloid/#comments Wed, 29 Jun 2016 11:05:19 +0000 http://emcrit.org/?p=58546 Considering the importance of crystalloid in critical care, one might expect crystalloid composition to be meticulously engineered and updated. However, our crystalloid choices remain archaic. Normal saline and Lactated Ringers (LR) were developed in the 1800s, whereas Plasmalyte and Normosol emerged in the 1970s.

EMCrit by Josh Farkas.

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PulmCrit: Fighting refractory ARDS with physiologic jujitsu https://emcrit.org/pulmcrit/ards-oxygen-extraction-ratio/ https://emcrit.org/pulmcrit/ards-oxygen-extraction-ratio/#comments Mon, 20 Jun 2016 11:11:27 +0000 http://emcrit.org/?p=55709 Jui-jitsu is a Japanese martial art based on flexibility and technique, rather than a directly confronting an opponent with force. In the spirit of jui-jitsu, this post explores how to support ARDS patients without directly confronting lung dysfunction. This is useful in refractory ARDS, when frontal assault has failed.

EMCrit by Josh Farkas.

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PulmCrit- Sepsis 4.0: Understanding sepsis-HLH overlap syndrome https://emcrit.org/pulmcrit/sepsis-hlh-overlap-syndrome-shlhos/ https://emcrit.org/pulmcrit/sepsis-hlh-overlap-syndrome-shlhos/#comments Mon, 06 Jun 2016 09:35:00 +0000 http://emcrit.org/?p=44075 Since the 1980s it has been recognized that some patients with sepsis also develop hemophagocytic lymphocytosis. For decades this was believed to be extremely rare. However, currently there is increasing recognition that this combination might represent a significant fraction of sepsis patients.

EMCrit by Josh Farkas.

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PulmCrit- Overcoming occult diuretic resistance: Achieving diuresis without dehydration https://emcrit.org/pulmcrit/occult-diuretic-resistance/ https://emcrit.org/pulmcrit/occult-diuretic-resistance/#comments Mon, 23 May 2016 10:59:52 +0000 http://emcrit.org/?p=20875 Critically ill patients often strongly retain sodium. This may cause diuresis attempts to fail, if patients excrete dilute urine leading to a loss of water without loss of sodium. Such patients may seem to respond to diuresis, but in fact they are merely becoming progressively dehydrated and hypernatremic (occult diuresis resistance).

EMCrit by Josh Farkas.

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