Upon first reading the ATHOS-3 trial, I was pleasantly optimistic. Who wouldn’t be interested in a shiny new vasopressor? The trial didn’t prove much, but it was intriguing. However, it was alarming to hear that the FDA has approved angiotensin II for use based on it. Precious little evidence is available about this drug. With angiotensin II arriving at hospitals soon, some cautions are in order.
PulmCrit – Treatment of massive insulin poisoning refractory to glucose
Severe insulin overdose usually occurs as a suicide attempt, but can also result from medication error. Conventional therapy focuses on giving tons of intravenous glucose. This generally works, but it can get messy.
PulmCrit- Phenobarbital monotherapy for alcohol withdrawal: Reloaded
Currently there is a lorazepam shortage in the United States. This caused a surge of interest into using phenobarbital for alcohol withdrawal. I’ve received several e-mails over the past few weeks about this. It’s been two years since my last post about phenobarbital, so here’s an update focusing on lessons learned in the interim.
PulmCrit – Optimizing the respiratory drive to avoid failure
Scott Weingart just posted a podcast about management of the hypercapneic, obtunded COPD patient who is failing BiPAP. Do we need to intubate these patients, or could we somehow clear their CO2 noninvasively? This post will start off by exploring respiratory drive as a mediator of disease. With that groundwork, we’ll explore the obtunded COPD patient.
PulmCrit- APRV: Resurrection of the open-lung strategy?
APRV is often used in surgical ICUs, but not medical ICUs. APRV may be viewed as a “new” technique by medical intensivists, whereas it’s been used for decades in surgical ICUs with great results. A fresh RCT may help resolve this.
PulmCrit- Ranking antibiotics in order of allergenicity
Our current approach to allergy is primarily patient-based. This focuses on the patient’s prior history of reaction: how severe was it, when was it, how certain are we that it was truly allergic? This strategy has been proven to be inaccurate. For example, ~90% of patients who report a penicillin allergy are not allergic when skin-tested.
PulmCrit- Who needs empiric coverage for HSV encephalitis?
There is significant practice variation regarding whether to give empiric acyclovir while awaiting PCR results. The goal of this post is to search for an evidence-based approach to this issue.
PulmCrit: Algorithm for diagnosing ICP elevation with ocular sonography
Introduction with a clinical question A young woman is transferred to the ICU from an outside hospital due to severely depressed mental status, thought due to intoxication. You evaluate her intracranial pressure using ocular ultrasonography. Evaluation of the optic disc diameter in both eyes and in both orientations yields four measurements: 5.5 mm and 6.0 […]
PulmCrit: Large-bore suction for intubation: strategies & devices
The ideal suction tool for intubations is debatable, but it seems clear that the Yankauer is a poor choice. Persistent use of the Yankauer suction catheter for airway management represents a profession-wide failure in our ability to manage large-volume regurgitation.
PulmCrit: The ketamine-tolerant patient
The ketamine-tolerant patient presents a quandary to clinicians who aren’t familiar with this phenomenon. The first time I encountered this, I was baffled and aborted the procedure after giving 200 mg ketamine. Eventually I realized that the drug isn’t “failing” to work, but rather we are failing to administer a sufficiently high dose.
Service update: Bleeding Edge Series
Effective, rapid peer review allows for the creation of a new series of posts. These posts will cover material which isn’t supported by much evidence nor experience. In the past, I wouldn’t have felt comfortable posting this material to the blog.
PulmCrit- Brain death, mimics, and flow scans
As with many uncommon situations that are unique to critical illness, we cannot always rely on specialist consultation. Critical care practitioners must develop a firm grasp of this diagnosis. This post will explore some diagnostic conundrums in brain death diagnosis. The radionuclide flow scan is emphasized because it is the most commonly used tool to sort out difficult cases.
PulmCrit- Toxicology dogmalysis: the osmolal gap
I’ve been checking the serum osmolal gap on patients with toxic ingestion for years. However, the osmolal gap has yet to crack a case for me. There have been lots of patients with elevated osmolal gaps due to uremia or ketoacidosis. Meanwhile, the cases of ethylene glycol or methanol intoxication which I have encountered have […]
PulmCrit – Central venous oxygen saturation: signal or noise?
Recently a few cases at Genius General have arisen where cvO2% was misleading. Specifically, the cvO2% was elevated despite cardiogenic or hemorrhagic shock. This post will attempt to explore why this might occur.
PulmCrit- The gag reflex shouldn’t be tested in living patients
As a medical student I rotated through an elite hospital where it was believed that every patient admitted to the medicine service needed a rectal exam. The rationale was to avoid ever missing a case of rectal or prostate cancer. Eventually, the utility of digital rectal examination as a cancer-screening tool was debunked. Thankfully, this practice has fallen out of favor.
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