Dexmedetomidine decreased the duration of ventilation among agitated patients in a recent RCT in JAMA. But did these patients actually require intubation and dexmedetomidine? Or did they merely require extubation?
PulmCrit- Why we fail at hemodynamics: The flaw of averages & the swan’s curse
With a resurgence of the Swan, a resident recently asked me: why don’t we use the Swan to guide sepsis resuscitation? Answering this question forced me to recognize that many problems with the Swan continue to haunt us today when using our new darling, bedside echocardiography.
PulmCrit Wee- Communicating airway difficulty via the allergy list
Intubation is often required urgently. Unfortunately, information about a patient’s airway anatomy is often scattered around the chart and impossible to retrieve rapidly.
PulmCrit- Oral vasopressor to accelerate liberation from the ICU
Midodrine is an oral agent which functions as an alpha-1 agonist. It has been used in a variety of situations including autonomic dysfunction, hepatorenal syndrome, and dialysis-induced hypotension. Over the past few years there has been increasing interest in using midodrine to facilitate weaning off vasopressors.
PulmCrit- Update on post-extubation high-flow nasal cannula to reduce reintubation
Post-extubation HFNC has helped us aggressively liberate patients from mechanical ventilation while simultaneously reducing our reintubation rate. One remaining question is determining which patients benefit from this. My practice has generally been to use HFNC in patients felt to be at higher risk for reintubation. A fresh RCT in JAMA will revise this.
Pulmcrit – An alternative viewpoint on phenylephrine infusions
Make no mistake, I’m not very fond of phenlephrine. I rarely use it (mostly for hypotensive atrial fibrillation). However, understanding phenylephrine is a prerequisite to understanding related vasopressors, particularly midodrine and norepinephrine.
PulmCrit- Top ten problems with the new sepsis definition
A satisfactory clinical definition of sepsis has been eluding us since the ancient Greeks first coined the term. Current definitions of sepsis attempt to achieve two goals: to provide a rapid screening test to detect sepsis and to render a definitive diagnosis of sepsis. However, it remains unclear whether any definition can achieve this.
PulmCrit- BRASH syndrome: Bradycardia, Renal failure, Av blocker, Shock, Hyperkalemia
This is one of my favorite diagnoses. When first encountered, it may seem bewildering and difficult to treat (1). Indeed, standard ACLS algorithms often fail with these patients. However, once understood, this disorder is easily treated and patients typically improve rapidly.
PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol?
Is IV olanzapine ready for prime time? This boils down to a choice of the devil that we know (haloperidol) versus the devil that we don’t entirely know (olanzapine). IV olanzapine is newer, so it is possible that additional side effects may emerge over time. However, we already know that there are significant problems with IV haloperidol.
PulmCrit- Controlled thrombolysis of submassive PE?
Controlled thrombolysis using a slow 25-mg alteplase infusion with protocoled monitoring might offer patients the benefit of lytic therapy with an extremely low risk of severe hemorrhage.
PulmCrit- Ultrasound-assisted thrombolysis of PE works. The question is, why?
Ultrasound-assisted catheter-directed thrombolysis is increasingly popular for submassive PE. Unfortunately, the actual mechanism of action of this therapy remains unclear.
PulmCrit- Neurocritical care of the comatose meningitis patient
Early in my training I had a few comatose meningitis patients. They were admitted, given antibiotics, and supported on a ventilator. They died. For a while, I believed that this condition was fairly hopeless. Then I encountered a comatose young man with meningitis due to adjacent mastoiditis. His lumbar puncture opening pressure was ~50cm. Following mastoidectomy and temporary placement of a lumbar drain, he recovered. Since then, I have been increasingly aggressive about managing this. Some patients have responded surprisingly well.
PulmCrit- Coagulopathy management in the bleeding cirrhotic: Seven pearls and one crazy idea
Traditionally, coagulation management in patients with cirrhosis has focused largely on using large volumes of FFP to decrease the INR. However, recent evidence indicates that INR prolongation in these patients is nonspecific and that FFP usually isn’t helpful.
Blood gas measurements in DKA: Are we searching for a unicorn?
Routinely obtaining an ABG or VBG is widely recommended, for example in both American and British guidelines. Why? Is this helping our patients, or is it something that we do out of a sense of habit or obligation?
Brief rant: Still no evidence that azithromycin increases mortality
Introduction . It has long been known that some macrolides (e.g. erythromycin) cause torsade de pointes. However, azithromycin has a much lower affinity for cardiac potassium channels than erythromycin, so it has less effect on the heart. For many years it was believed that azithromycin lacked cardiac toxicity. . Controversy was sparked in 2012 when […]
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