An 80-year-old man was admitted with sepsis due to liver abscess. Over the first two hospital days his platelet count decreased from 122 to 39. Prophylactic heparin was held due to concerns about bleeding risk. Additional coagulation studies showed a D-dimer of 1221 ng/ml, a fibrinogen of 672 mg/dL, and the following thromboelastograph:
Pulmcrit Wee- Vasopressin vs. norepinephrine for vasoplegic shock after cardiac surgery
Patients in the VANISH trial treated with vasopressin had a lower incidence of renal failure requiring hemodialysis. However, this was a secondary endpoint which seemed to contradict the primary endpoint (defined as a milder degree of kidney injury). New data may clarify this controversy.
PulmCrit- Devil in the details: Endotracheal tube depth
According to Napoleon, “the moment of greatest vulnerability is the instant immediately after victory.” In airway management, this instant occurs immediately after placement of the endotracheal tube. There is a risk of relaxing and overlooking critical details. Meanwhile, this is often the point when the patient’s blood pressure and saturation nadir. Introduction with a rare but […]
PulmCrit- New guidelines simplify ICU nutrition
Introduction to nutritional dogma Everyone has strong opinions about food. We all feel that we have some special, intuitive understanding of nutrition. Nonsense. Such intuitions have historically created a wide array of dogma regarding nutrition, complicating matters immensely. Fortunately, the 2016 SCCM/ASPEN guidelines have stripped away much of the nonsense involved in nutritional support. This […]
PulmCrit- Top 10 reasons pulse oximetry beats ABG for assessing oxygenation
What does it mean if PaO2 and oxygen saturation seem to disagree? Do we need to measure an ABG if the oxygen saturation waveform is adequate? What is the best way to measure oxygenation?
PulmCrit mythbusting- Anaphylaxis to penicillins isn’t a contraindication to meropenem
An unconscious septic patient rolls in wearing a “PCN anaphylaxis” medic-alert bracelet. What is the best broad-spectrum antibiotic for this patient? There is no agreement between allergy guidelines, infectious disease society guidelines, or individual infectious disease experts.
PulmCrit Wee- Oxygen-ICU trial: 100% isn’t an A+
Among intubated patients, we can often control the pO2, pCO2, and pH. Sounds great. Unfortunately, we also have no idea which numbers we should be targeting. Should we target a normal pH, or permissive hypercapnia? Should we shoot for a normoxia, try to maximize the oxygen delivery (hyperoxia), or allow for permissive hypoxemia? Nobody knows. We check ABGs and tweak the ventilator, but it’s often dubious whether this helps our patients.
PulmCrit- Power, the forgotten error, and inconclusive trials
The new HYPRESS trial tests whether steroid could prevent deterioration from sepsis into septic shock. The study found no significant benefit from steroid, but I thought it was underpowered. However, an accompanying editorial in JAMA didn’t even mention power. This raises some questions: How can we measure type-2 error? How should it be reported? What is an acceptable level of type-2 error?
PulmCrit – Bad news for sepsis-3.0: qSOFA fails validation
Sepsis 3.0 replaced the SIRS criteria with a new risk-stratification tool, qSOFA. qSOFA was initially developed within the Sepsis-3 publication itself. Until now, qSOFA has never been validated. The value of qSOFA vs. SIRS remains controversial.
PulmCrit- Dominating the acidosis in DKA
Management of acidosis in DKA is an ongoing source of confusion. There isn’t much high-quality evidence, nor will there ever be. However, a clear understanding of the physiology of DKA can help us treat this rationally and effectively.
PulmCrit Wee- Proning the non-intubated patient
From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.
PulmCrit Wee – The meaning of nocturnal extubation is 42
What should intensivists do at night? Should they sleep at home or remain dutifully in the hospital? Should they extubate patients or just maintain the status quo until 7 AM?
PulmCrit- Why dialyze patients with chronic, asymptomatic hyperlithemia?
A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient’s condition if the patient is already asymptomatic.
PulmCrit- Do phenylephrine and epinephrine require central access?
Until recently I believed that prolonged vasopressor administration requires a central line, to avoid extravasation. I lumped together all vasopressors, treating them all as equal. I used the occurrence of an extravasation reaction from one vasopressor as evidence that all vasopressors could cause extravasation reactions (the fallacy of inappropriate generalization). Upon closer examination, these beliefs aren’t supported by evidence.
PulmCrit- The siren’s call: Double-coverage for ventilator associated PNA
Some theories are so attractive that they are nearly irresistible. No matter how many times they are disproven, these theories still seem compelling. One example is double-coverage for pseudomonas. Recently, the IDSA recommended this for ventilator-associated PNA (VAP), despite openly admitting that RCTs found it to be ineffective.
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