A post a few weeks ago calculated the fragility index of the NINDS trial (which turned out to be only three). Very briefly, the fragility index tests how many events would need to be changed for the p-value to increase above 0.05, rendering the study “statistically insignificant.” Ryan Radecki commented that he was concerned that the fragility index was married to the p-value, thereby inheriting the flaws of frequentist statistics. Perhaps we should ditch the p-value and the fragility index, switching instead to a purely Bayesian approach to statistics?
Pulmcrit – Renoresuscitation, vasopressin, vepinephrine, and VANISH
My goals during sepsis resuscitation focus largely on preservation of renal function and maintence of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypoperfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too. In this context, any beneficial effect of vasopressin on renal function could be helpful.
PulmCrit – Six reasons to avoid fluoroquinolones in the critically ill
As an internal medicine resident and pulmonary/critical care fellow, I loved fluoroquinolones. The were effective, easy to prescribe, and they had 100% oral bioavailability. However, working full-time in the ICU has forced me to realize that these drugs aren’t so wonderful for the critically ill.
PulmCrit Wee – Pragmatic comparison of 33C vs. 36C after cardiac arrest
A post last year discussed the top 10 reasons to stop cooling to 33C. It was based largely on the Nielsen trial, which showed similar outcomes between therapeutic hypothermia (TH33) and therapeutic temperature management (TTM36). However, this trial left some questions about how these protocols would perform outside the context of a RCT (external validity). Last year’s post speculated that since TTM36 is easier to achieve, it would out-perform TH33 in real-world conditions.
PulmCrit: Which patients admitted for pneumonia need MRSA coverage?
Let’s be honest, our decisions to cover MRSA among patients admitted to the hospital with pneumonia are haphazard. It’s not our fault. The guidelines are contradictory. For example, the MRSA guidelines by the Infectious Disease Society of America recommend coverage for everyone admitted to the ICU with pneumonia. However, pneumonia guidelines by the same society recommend coverage only for patients with specific risk factors. Fortunately, new evidence and diagnostic tools may allow us to properly treat MRSA, without drowning the entire hospital in vancomycin.
PulmCrit Wee: Is piperacillin-tazobactam nephrotoxic?
A recent series of articles suggest that the combination of vancomycin and piperacillin-tazobactam are synergistically nephrotoxic. Is piperacillin-tazobactam truly nephrotoxic, or is this merely pseudo-nephrotoxicity?
PulmCrit: What is the fragility index of the NINDS trial?
Medicine continues to be plagued by poorly reproducible studies. The storyline is familiar. First, a very positive study is released in a major medical journal, with great fanfare. This leads to widespread changes in practice. Decades later, it becomes clear that the study was incorrect. Recently a new tool was developed to help understand the reproducibility of clinical studies: the fragility index. This post will analyze the NINDS trial from the perspective of its fragility index.
PulmCrit: We should engineer a new crystalloid
Considering the importance of crystalloid in critical care, one might expect crystalloid composition to be meticulously engineered and updated. However, our crystalloid choices remain archaic. Normal saline and Lactated Ringers (LR) were developed in the 1800s, whereas Plasmalyte and Normosol emerged in the 1970s.
PulmCrit: Fighting refractory ARDS with physiologic jujitsu
Jui-jitsu is a Japanese martial art based on flexibility and technique, rather than a directly confronting an opponent with force. In the spirit of jui-jitsu, this post explores how to support ARDS patients without directly confronting lung dysfunction. This is useful in refractory ARDS, when frontal assault has failed.
PulmCrit- Sepsis 4.0: Understanding sepsis-HLH overlap syndrome
Since the 1980s it has been recognized that some patients with sepsis also develop hemophagocytic lymphocytosis. For decades this was believed to be extremely rare. However, currently there is increasing recognition that this combination might represent a significant fraction of sepsis patients.
PulmCrit- Overcoming occult diuretic resistance: Achieving diuresis without dehydration
Critically ill patients often strongly retain sodium. This may cause diuresis attempts to fail, if patients excrete dilute urine leading to a loss of water without loss of sodium. Such patients may seem to respond to diuresis, but in fact they are merely becoming progressively dehydrated and hypernatremic (occult diuresis resistance).
Pulmcrit Wee: My graduation speech – why we resuscitate
Below is my graduation speech. It is about why we are in medicine. As all resuscitationists know – whether nurse, physician, pharmacist, PA, or paramedic – resuscitation is hard work. We all could have chosen easier, safer paths to follow. Ten years down the track I have no regrets. I appreciate the great privilege of being here. Still, though, it’s good to take a moment to remember how we got here, and why it is that we do what we do.
PulmCrit- Fentanyl infusions for sedation: The opioid pendulum swings astray?
I’ve been using fentanyl infusions as the backbone of my sedative strategy, in keeping with the 2013 SCCM guidelines. This generally works well for patients who can be extubated quickly. However, for patients who remain on the ventilator for longer periods of time, it often leads to problems involving tolerance and withdrawal.
PulmCrit Wee: Ultrasound-guided blakemore tube placement
The most widely feared complication of placing a Blakemore tube is complete inflation of the gastric balloon while it is not in the stomach. If the gastric balloon is fully inflated anywhere outside the stomach (i.e. esophagus, trachea, bronchus, duodenum), this may cause visceral perforation.
PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines
A 55-year-old woman was admitted with toxic shock syndrome. Her norepinephrine requirement was labile, fluctuating between 15 mcg/min and 30 mcg/min. Bedside echocardiogram showed a dilated inferior vena cava without respiratory variability, and a normal ejection fraction. On examination her extremities were cool and her urine output was marginal.
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