Janus kinases (JAKs) are named after Janus, the Greek god of beginnings, gates, transitions, and duality. They’re named after Janus because they contain a mirror-image structural element. However, given their role within the immune system as a multi-functional gateway for cytokine systems, the name seems apt. The cytokine storm induced by COVID-19 has received considerable […]
IBCC chapter & cast – Refeeding syndrome
Refeeding syndrome is a slippery topic. It’s probably more common than we recognize, often running underneath the radar (the constellation of electrolyte and clinical abnormalities can easily masquerade as another problem, such as alcohol withdrawal). However, there is essentially no prospective evidence on how to prevent or treat it. Indeed, there is no clear consensus […]
IBCC chapter & cast – Takotsubo’s Cardiomyopathy
Takotsubo’s cardiomyopathy may be perceived as a zebra, but it is extremely common in the ICU (as a secondary consequence of endogenous stress and exogenous catecholamines). With increasing recognition, Takotsubo cardiomyopathy is also noted to underlie ~1-2% of patients presenting with chest pain and a similar fraction of cath lab activations. The IBCC chapter is […]
PulmCrit: Remdesivir 5-day vs. 10-day trial raises some red flags?
So, Gilead’s first RCT on remdesivir was just published, and it’s very interesting.1 Gilead’s, you say? Yep. The study was designed, monitored, analyzed, and written by Gilead: Before getting into the study, let’s take a moment and think about what Gilead’s first RCT could look like. Gilead knows more about remdesivir than anyone (they built […]
IBCC chapter & cast – Parenteral anticoagulants
Anticoagulation is ubiquitous in critical care. Considering the use of DVT prophylaxis, the majority of critically ill patients will receive some form of anticoagulation during their ICU stay. Anticoagulants are potentially high-risk medications, with relatively narrow therapeutic windows. Thus, it’s important to understand the pharmacology of various agents to select and monitor anticoagulation optimally. The […]
PulmCrit – Mythbusting 40 mg enoxaparin daily for DVT prophylaxis in critical illness
The basics often aren’t exciting, but it’s important to get them right. DVT prophylaxis is a good example of this. Most critically ill patients will receive DVT prophylaxis at some point during their ICU stay (that’s 5 million patients per year in the United States alone). Thus, even minor tweaks in the optimal treatment for […]
PulmCrit – Preliminary report on NIAID trial of remdesivir (ACTT-1)
The preliminary report of the Adaptive COVID-19 Treatment Trial (ACTT-1), a multi-center, placebo-controlled RCT on remdesivir is here!1 The one we’ve all been waiting for! Patients Patients were recruited from 60 sites in several countries. Inclusion criteria were patients who were hospitalized due to COVID-19 with evidence of lower respiratory tract infection, defined in terms […]
PulmCrit – Sodium Zirconium Cyclosilicate for urgent treatment of hyperkalemia?
Sodium Zirconium Cyclosilicate (SZC) is a potassium-exchange resin similar in concept to sodium polystyrene sulfonate (Kayexalate). It’s not particularly new, as the original studies were performed around 2015. Accumulating evidence over the last five years supports the drug’s safety. The real question is how effective it may be. Efficacy data for short-term improvement in potassium […]
IBCC chapter & cast – COPD exacerbation
COPD exacerbation is bread and butter critical care. However, familiarity can breed concept. Thus, it’s important to always approach patients labeled with “COPD exacerbation” with fresh eyes, because they can present with other pulmonary pathologies as well. The primary challenge among these patients is usually utilizing noninvasive support devices to avoid intubation, whenever possible. The […]
PulmCrit – Before/after study of short-course steroid in COVID-19
One of the most notable controversies in COVID is when steroid might be beneficial. Since steroid is widely available and inexpensive, this issue has escaped the attention of pharmaceutical companies. Consequently, evidence surrounding this is extremely sparse. Available evidence consists largely of retrospective studies which relate steroid administration to outcome. Such studies are inherently flawed, […]
PulmCrit – Lupus Anticoagulant in COVID-19: Culprit or correlate?
An emerging body of evidence relates lupus anticoagulant to COVID-19. Both of these topics are enormously confusing on their own, so let’s try to ease into this… background on lupus anticoagulant what is lupus anticoagulant? Lupus anticoagulant isn’t any single thing, but instead it refers to a variety of different antibodies which may behave […]
PulmCrit- Virus Wars: Return of Lopinavir/Ritonavir (along with ribavirin and interferon)
Background Where were we with the Lopinavir/Ritonavir story? Let’s backtrack for a moment. Lopinavir/Ritonavir showed some efficacy against SARS, but as triple therapy in combination with ribavirin. A while ago, some studies tested lopinavir/ritonavir alone against COVID-19 and this didn’t work. Consequently, that was set aside for a while. However, there were lingering questions about […]
PulmCrit – High-dose anakinra for COVID-19: The anti-inflammatory trials begin
Over the last several weeks, we have seen a flurry of studies on various anti-viral therapies (lopinavir-ritonavir, hydroxychloroquine, chloroquine, and remdesivir). On the whole, these studies were consistently unimpressive. Perhaps remdesivir works a bit, but overall these studies simplified management by allowing us to ignore several drugs. I’m expecting the anti-inflammatory trials to be the […]
PulmCrit – Thrombosis update in COVID-19: Data from the Mount Sinai system in NYC
One of the most controversial issues regarding management of COVID-19 is the appropriate dosing of anticoagulation. It’s universally agreed upon that patients with COVID-19 should receive some dose of anticoagulation (at least prophylaxis), barring contraindications. However, the optimal dose is unclear. Numerous reports indicate that patients with COVID-19 have high rates of venous thromboembolic disease, […]
PulmCrit – Awake Proning for COVID-19
Recently, many on twitter have been engaged in a furious debate about how to ventilate patients with COVID-19. Is it ARDS or not? High PEEP or low PEEP?… As an intensivist, these issues are near and dear to my heart. However, the truth is that humble methods to keep patients off invasive ventilation altogether are […]
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