Shock is the next-door neighbor of death. Shock can present in a myriad of different forms, making early recognition challenging. However, early diagnosis is essential. Shock can be caused by a broad differential of serious illnesses. Unlike most differential diagnosis lists, every item on this differential is life-threatening. Fortunately, many causes of shock are reversible […]
PulmCrit- Vancomycin pharmacokinetics: Make vanco great again
Traditionally, vancomycin doses have been adjusted to target a specific trough level. However, it is increasingly clear that the trough level is an inadequate measurement of vancomycin exposure. Furthermore, the practice of waiting until the fourth dose to measure the trough level may expose the patient to days of suboptimal therapy.
PulmCrit- Acute infection & myocardial infarction: How afraid should we be?
Occasionally, the NEJM publishes a scary article that gets a lot of press, but doesn’t pan out to be valid. The recent example is the PESIT study, which seemed to imply that everyone admitted with syncope had PE (don’t worry- they don’t). It looks like NEJM might be at it again, with this week’s review article on the relationship between acute infection and MI.
IBCC chapter & cast: Severe influenza
Initially I wasn’t planning to write a chapter on influenza, because there is precious little evidence regarding ICU management. However, even in the absence of solid evidence, we will be called upon to treat these patients. Currently flu season is afoot, and it looks like it might be a bad one (with a predominance of […]
IBCC chapter & cast: Acute Kidney Injury
The importance of avoiding and treating renal failure cannot be overstated. The kidneys are delicate organs, often the first to be injured by systemic hypoperfusion or other insults. Severe renal dysfunction leads to a cascade of badness, promoting the failure of other organs and eventual spiraling into multi-organ failure.1 Alternatively, if we are can defend […]
PulmCrit- Antibiotics for abscesses, white walkers, and the inherent myopia of science
There are a number of reasons that an idea may be impossible to test scientifically. Perhaps the disease state that the idea applies to is extremely rare. Perhaps it is logistically impossible to test the idea, due to issues with blinding or time constraints. This post will focus on an insidious reason that ideas are thrown beyond the wall: the timeframe and study size required to test them are unachievable.
IBCC chapter & cast: Community-acquired urosepsis
Urosepsis is one of my favorite ICU diagnoses. In almost all cases, patients will improve dramatically within 12-24 hours and leave the ICU with minimal sequelae. But that shouldn’t lull us into a false sense of security: careful antibiotic selection, aggressive resuscitation, and (in some cases) emergent drainage may be required for a good outcome.
IBCC chapter & cast- Immune-related adverse events from checkpoint inhibitors
If you haven’t started seeing these yet, you will soon. Checkpoint inhibitors are a form of immunotherapy being used for an increasingly broad range of malignancies. They cause a diverse range of adverse events, due to releasing uncontrolled autoimmune hyperactivity. Clinically this can mimic just about any rheumatologic condition. Fortunately these events are quite treatable. However, a high index of suspicion and prompt therapy is important.
PulmCrit- Rant: Antimicrobial exposure and risk of delirium
This paper slipped across my twitter feed over the weekend. It was a bit disquieting to see that it was getting a lot of attention, despite being a methodological train wreck (seriously, MedTwitter, where’s the skepticism??). This post will briefly walk through some of the main flaws. There will be a bit of pharmacology, a modicum of methodology, and a lot of ranting.
IBCC chapter & cast- Adrenal crisis
Adrenal crisis is a can’t-miss diagnosis. Prompt identification and proper management will generally lead to rapid improvement. The most important aspect is maintaining a high index of suspicion. When in doubt, start empiric therapy first and ask questions later. The IBCC chapter is located here. The podcast & comments are below. Follow us on iTunes
IBCC chapter & cast: Post-cardiac arrest management
Post-cardiac arrest management has undergone substantial revisions within the past several years, particularly with regards to temperature management. This remains an area of active controversy and investigation, with the TTM-2 trial currently underway. Although equipoise still exists, this chapter describes a streamlined 36C approach which is based on evidence, guidelines, and experience with various strategies. […]
PulmCrit- Alpha-2 agonists: clonidine, guanfacine, lofexidine, and KetaDex
Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion. It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients). The main drawbacks of dexmedetomidine are logistic: it is expensive and can be administered only as an IV infusion within an ED or ICU. Oral clonidine offers some similar benefits compared to dexmedetomidine, without these logistic constraints.
IBCC chapter & cast: Meningitis and encephalitis
Severe CNS infections are a bit of an orphan disease in critical care. Unlike more common neurologic disorders (e.g. stroke), CNS infections are too rare to recruit lots of patients into RCTs. Consequently, conventional treatment of these disorders lags decades behind other neurologic disorders (e.g. in terms of optimizing cerebral perfusion pressure). Principles of neurocritical […]
IBCC chapter & cast: Torsades de Pointes
Torsades de pointes is an uncommon cause of cardiac arrest. It is generally quite treatable, but if treated inadequately it will often recur (in some cases leading to repeated salvos of ventricular tachycardia, one form an electrical storm). A structured approach incorporating a pre-emptive protocoled magnesium infusion is generally quite effective. The IBCC chapter is […]
IBCC: Guide to supportive care in critical illness
This chapter gives an overview of how to provide high-quality supportive care to the sickest patients. It summarizes about a dozen chapters within the IBCC. This is intended as a quick guide for folks who don’t work full-time in an ICU (e.g. residents rotating through the unit).
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