The Society of Critical Care Medicine published over 1,800 abstracts to go along with their latest conference. I sifted through them to come up with my favorite 20. Kudos to all the authors on creating diverse and thoughtful work – the future of critical care is indeed bright! The abstracts are divided into six groups: […]
IBCC chapter & cast – Vasopressors
Vasopressor use is an everyday exercise in critical care. Unfortunately, high-level evidence regarding these agents is often lacking. Furthermore, patients may react in unique ways. This chapter attempts to clarify some vasopressor basics, but beware – all of your patients will not read the book. The IBCC chapter is located here. The podcast & comments […]
PulmCrit – It’s insane to keep using mortality as a primary endpoint in critical care trials
There, I’ve said it. That’s a bit of a bold statement, but it seems to be supported by the evidence. failure to prove mortality benefit A post in 2018 explored the difficulty of proving mortality benefit from any intervention. To summarize, there are many barriers to proving all-cause mortality benefit: Mortality is decreasing over time […]
PulmCrit – The 65 trial: Is 60 the new 65?
The 65 trial compares MAP targets of >65 mm to >60 mm in treating vasodilatory hypotension. This trial challenges decades of protocols which have targeted a MAP >65 mm. As such, it is a courageous and practice-changing study. However, we need to be realistic about the study’s limitations. trial overview This multi-center RCT was […]
IBCC chapter & cast – Anaphylaxis
Anaphylaxis is a somewhat unique emergency, as one of the few conditions which can kill an otherwise healthy person within a matter of minutes. This is very treatable, so immediate and definitive management is paramount. To make matters worse, different patients will manifest with a variety of diverse presentations, so a high index of suspicion […]
PulmCrit – Steroid for ARDS? The DEXA-ARDS trial
A fresh trial shows considerable efficacy of dexamethasone in ARDS. This may come as a bit of a surprise, but it’s actually entirely consistent with prior evidence. To understand the study, we need to start with previous data… Part I: Background: The Rabbit hole of ARDS, pneumonia, and septic shock We often think about ARDS, […]
PulmCrit Wee: The Yale experience with hyperdiuresis
Hyperdiuresis involves combining hypertonic saline with a loop diuretic for management of diuretic-resistant volume overload. This may seem a bit counter-intuitive, but there are several reasons why it might work: Hypochloremia promotes sodium retention; this could be reversed with hypertonic saline. Hypertonic saline could osmotically pull fluid into the intravascular space, thereby promoting diuresis without […]
IBCC chapter & cast – Status epilepticus
Status epilepticus is one of the true neurologic emergencies, where minutes may actually count. Prompt and definitive treatment often yields excellent outcomes, whereas sluggish or inappropriate treatment can have severe consequences. Management has changed substantially over the past decade including a new definition of convulsive status epilepticus (>5 minutes of seizing, rather than >30 minutes) […]
PulmCrit- WHO guidelines regarding fluid administration for coronarvirus are dangerously misguided
The Surviving Sepsis Campaign is a blight on modern, evidence-based medicine.1 It’s been clear for some years that its fundamentals were flawed (centering around rapid, large-volume fluid resuscitation). Rather than adapt guidelines to modern evidence, the campaign recently doubled down on immediate administration of fluid and antibiotics within one hour. This provoked widespread protest, including […]
IBCC chapter & cast – Hypocalcemia
Hypocalcemia in the ICU is one of the more confusing electrolyte abnormalities, because it’s frankly unclear exactly what to do with it. Most patients in ICU are hypocalcemic, but there is little evidence that trying to “replete” hypocalcemia back to euboxia is beneficial (or even feasible). Of course, there are some patients who have severe […]
PulmCrit- The Rothman Index: Artificial intelligence or merely a symptom of a broken healthcare system?
We are constantly hunting for newer and better sources of information. This leads to a perpetual generation of newer lab tests, different hemodynamic gizmos, and fresh decision tools. Some of these pan out. Most don’t. Why are these new sources of information generally disappointing? The answer is simple: we’re already doing pretty well. In order […]
IBCC chapter & cast – Toxic Alcohols
The diagnosis of toxic alcohols is a particularly controversial topic, based on recent evidence that the osmolal gap has a fairly awful sensitivity and specificity. This chapter describes an approach to toxic alcohol diagnosis which doesn’t depend on the osmolal gap. Although this may seem radical, this strategy has been previously recommended by other authors […]
PulmCrit – An alternative view of the PEPTIC trial
The PEPTIC multi-center RCT compared histamine-2 receptor blockers (H2RBs) versus proton pump inhibitors (PPIs) for stress ulcer prophylaxis among ventilated ICU patients.1 It’s a landmark trial of unprecedented size and statistical power. PEPTIC was presented at the Critical Care Reviews meeting in Ireland and live-cast around the world (available here). This presentation and the editorials […]
PulmCrit- Metabolic Resuscitation: Was the answer inside us all along?
Now that VITAMINS is published, it’s worth trying to look at the big picture of sepsis treatment with hydrocortisone, ascorbate, and thiamine (HAT). Marik et al. 2017: The beginning HAT therapy began with a single-center, before/after study.1 There was a stark mortality reduction following the routine adoption of HAT therapy in septic shock (figure below, […]
IBCC chapter & cast – Central line infection
Prevention and treatment of central line infections is a core competency in critical care. Prevention is the true key here. Achieving zero central line infections is an unreachable goal, but with diligence the rate can be pushed close to zero. The IBCC chapter is located here. The podcast & comments are below. Follow us on […]
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