Large-volume diuresis is a topic that isn’t discussed much in critical care curricula or textbooks. Nonetheless, this is a daily reality for intensivists, especially those living in the United States (where patients continue to be empirically treated with 30 cc/kg fluid as initial fluid bolus, for a broad variety of complaints). This chapter attempts to […]
PulmCrit- Sepsis special edition & CBC to diagnose septic shock
The Journal of Thoracic Diseases is about to release a special edition on sepsis, edited by Paul Marik (open access). It’s deliciously rebellious – just look at the table of contents 👇 My article on using the complete blood count to diagnose sepsis is already available, so I’ll summarize it here (yes, I know, you […]
IBCC chapter & cast – Myxedema coma (decompensated hypothyroidism)
Myxedema coma is a misleading misnomer. Most patients don’t have non-pitting edema (myxedema), nor are they frankly comatose. The best way to think about this disease is simply decompensated hypothyroidism. Patients with under-treated or untreated hypothyroidism have no metabolic reserve. Stressors may easily push them into multi-organ failure. Myxedema coma is easily missed, because it […]
IBCC chapter & cast – Noninvasive respiratory support (BiPAP & HFNC)
Noninvasive respiratory support is among the greatest recent advances in critical care. When used properly, these techniques may facilitate avoidance of intubation, reduced length of stay, and better outcomes. Unfortunately, our knowledge of exactly how to use these devices remains woefully incomplete. In particular, there are rather few RCTs directly comparing BiPAP versus HFNC. In […]
PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?
Recently Sara Crager released a video on EM-RAP recommending inhaled milrinone or nitroglycerin as an emergency therapy for massive pulmonary embolism (in case you don’t have access to EM-RAP, an audio clip from the video is below). This is the first that I’ve heard of using inhaled nitroglycerin. It seems like a pretty neat idea, […]
IBCC chapter & cast – Acute promyelocytic leukemia
Acute promyelocytic leukemia (APL) is a unique leukemia, with particular importance to resuscitationists. Unlike most leukemias, the highest rate of mortality occurs at the time of diagnosis (a phenomenon known as “early deaths”). If patients are able to survive the initial phase of illness, the cure rate is extremely high (>90%). Aggressive support in the […]
Pulmcrit Wee- Rare catastrophic complications, heparin, and succinylcholine: Sometimes excellent is the enemy of perfect.
A multi-center RCT was released yesterday comparing rocuronium versus succinylcholine. It’s a thoroughly uninformative study, so at first I wasn’t planning to write about it. But then I realized that the study, in its very myopia, is a good illustration of our problem with rare catastrophic complications. warmup: heparin infusions and rare catastrophic complications A […]
PulmCrit- Furosemide failure: should we add metolazone, IV chlorothiazide, or… tolvaptan?!? (3T trial)
Diuretics are a bit like vasopressors. We use them all the time, so we feel that we know them pretty well. However, the amount of RCT-level evidence on them is shockingly low. So, whenever a RCT on diuretics shows up, it’s worth careful examination. the 3T trial: basics This is a single-center, double-blind trial involving […]
IBCC chapter & cast – Hyponatremia
Since finishing my training, I’ve learned three new techniques for the management of hyponatremia: the DDAVP clamp, use of hypertonic bicarbonate, and oral urea. Meanwhile, I’ve removed the use of vaptans from my practice and grown more comfortable using 3% saline. The confluence of these factors has transformed hyponatremia from something scary to something which […]
PulmCrit- Hyperdiuresis: Using hypertonic saline to facilitate diuresis
Using hypertonic saline to facilitate diuresis seems counterintuitive, paradoxical even. Volume overloaded patients have excess sodium. Why should we give them more? Let’s start by trying to understand the underlying physiology. hypochloremia may cause renal sodium retention We generally don’t pay much attention to serum chloride levels. Chloride is often viewed as a leftover, an […]
IBCC chapter & cast – Hypokalemia
Hypokalemia is one of the most commonly encountered electrolyte abnormalities in critically ill patients, and perhaps the most commonly intervened upon abnormality. Although this is mundane, it behooves us to understand it fully and treat it optimally. Even minor nuances in treatment could potentially have significant impact, given how commonly hypokalemia is managed. The IBCC […]
PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
The management of generalized convulsive status epilepticus remains in perpetual status controversius. There is consensus that the front-line agent should be a benzodiazepine, but little agreement beyond that. The much-awaited ESETT trial is a multi-center RCT comparing three anti-epileptic agents for ongoing status epilepticus (levetiracetam, fosphenytoin, and valproate). This trial will be the highest-quality evidence […]
IBCC chapter & cast – Brain death
Brain death determination and support of a potential organ donor are core topics in critical care. These topics aren’t particularly uplifting or glamorous, so they often are overlooked. Consultants who don’t spend a lot amount of time in the ICU may be uncomfortable with them. This makes it even more important that we have a […]
PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea
I’ve been yearning to use oral urea for euvolemic hyponatremia for years (e.g. see a post from 2015 here). Urea has been used in Europe for decades, but until very recently it was unavailable in the United States. It has numerous advantages compared to the vaptans (which are extremely expensive and potentially dangerous). Recently, an […]
IBCC chapter & cast: Hypothermia
Hypothermia is a heterogeneous topic. At one end of the spectrum are previously healthy people who suffer from cold exposure (for whom the rewarming is the primary focus of therapy). At the other end of the spectrum are patients with mild secondary hypothermia (e.g. due to sepsis), for whom the primary focus is investigation and […]
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