No high-quality evidence exists on fibrinogen monitoring in PE. Most practitioners don’t check fibrinogen levels for patients getting TPA for PE. This is a bit paradoxical, because fibrinogen is usually monitored in patients receiving catheter-directed thrombolysis – a procedure involving lower doses of TPA with a markedly lower risk of intracranial hemorrhage.
PulmCrit- High dose vasopressors: Never surrender
Every hospital and pharmacopeia have their own “maximum dose” of vasopressors. Which one is correct?
PulmCrit- Ten dubious beliefs in neurocritical care
Recently Geert Meyfroidt published an article in Intensive Care Medicine describing ten false beliefs in neurocritical care shown here: It’s a great article, but I think they could have been more aggressive about challenging neurocritical care dogmas (1). In response, here is a list of ten dubious beliefs that goes farther to challenge the status quo. […]
PulmCrit- Montreal Hospitalist & Resuscitationist Conference FOAMed
I recently got back from the inaugural Hospitalist & Resuscitationist conference, a fantastic FOAMy conference in Montreal organized by Phillipe Rola (@ThinkingCC). It was inspiring to participate alongside fantastic folks including Rory Speigel (@EMNerd), Jon-Emile Kenny (@heart_lung), Kylie Baker (@kyliebaker88), Lawrence Lynn(@PatientStormDoc), Andre Denault, and Segun Olusanya (@iceman_ex). Screencasts of my talks, audio clips, some videos […]
PulmCrit- Drowned Airway Algorithm: Cut to the chase
The literature describes various techniques for the drowned airway. However, there doesn’t appear to be any airway algorithm which integrates these into a coherent strategy. A collection of airway tricks without any plan is a formula for disaster.
Petition to retire the surviving sepsis campaign guidelines
We are disseminating an international petition that will allow clinicians to express their displeasure and concern over these guidelines. If you believe that our septic patients deserve more evidence-based guidelines, please stand with us.
PulmCrit- Shrug Technique for US-guided subclavian lines
The CDC guidelines recommend placing subclavian lines to reduce the risk of catheter-related bloodstream infections. Meanwhile, mounting evidence suggests that we should probably be placing lines with ultrasound guidance. Unfortunately, the ultrasound-guided subclavian can be tricky. This post describes a slight modification that could make the technique easier and safer.
PulmCrit- .050 shades of grey in p-value cutoffs
We have a love-hate relationship with the p-value cutoff of <0.05. A p-value right below this cutoff (say, p=0.04) actually constitutes a surprisingly weak level of evidence (1). Thus, the idea of lowering the p-value cutoff has been around for a while. Unfortunately, this wouldn't really fix our problems with p-values.
PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?
ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint. They reached opposite conclusions: steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS. Why?
PulmCrit Wee- Secondary endpoints: Can we separate the wheat from the chaff?
This post will attempt to create a rough framework for analyzing secondary endpoints. This is primarily intended as a springboard for debate, rather than a final answer to this thorny issue (one which has remained unresolved for decades).
PulmCrit- Chasing mortality endpoints is a fool’s errand
“There is no mortality benefit for that.” How many times have you heard that? The implication is usually the same: that intervention is a waste of time. A smart, evidence-based clinician wouldn’t bother with it. But, what does it actually mean if there is no proven mortality benefit?
PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation
Saline vs. balanced solutions has been a topic of ongoing debate. Two fresh studies will illuminate this: the SMART and SALT-ED trials. This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1. There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]
PulmCrit- Mastering the dark arts of BiPAP & HFNC
Skillful use of BiPAP and high-flow nasal cannula (HFNC) can avoid intubation and improve outcomes. However, there isn’t comprehensive evidence about the nitty-gritty details of these techniques. In this post I will use my opinions to fill some gaps in the evidence. Noninvasive respiratory support remains more of an art than a science, perhaps a dark art at that.
PulmCrit- Metabolic sepsis resuscitation: Strike hard, strike fast, no remorse
Escalation-deescalation There are roughly two strategies for adjusting the intensity of treatment: Titrated strategy: Treatment intensity is adjusted to match the severity of the disease. Escalation-deescalation strategy: Treatment intensity is increased rapidly to exceed disease severity and gain control of the disease. After the patient improves, treatment intensity is reduced. The best strategy depends on […]
PulmCrit: ARDS vs. pseudoARDS – Failure of the Berlin definition.
Did this woman have ARDS? According to the Berlin Definition shown below, she had moderately severe ARDS while on conventional low tidal-volume ventilation (P/F ratio of 166). However, she didn’t meet the definition of ARDS while she was APRV, a few hours earlier (P/F ratio 475). Her overall clinical course with prompt recovery and weaning off oxygen is inconsistent with the natural history of ARDS.
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