. Background: Publication bias . Over the last several years, publication bias has received a considerable amount of attention. In its most blatant form, this is when a drug company sponsors several trials, but only publishes the trials which yeild positive results. Growing awareness of this problem has led to the development of trial registries, […]
PulmCrit – Treatment of hemodynamically stable new-onset AF in critical illness
. Introduction with a clinical question . A 50-year-old woman with no prior medical problems was admitted to Genius General Hospital with severe influenza pneumonia and acute kidney injury. She was transferred to the ICU and treated with high-flow nasal cannula oxygen support. Over time she gradually improved with decreasing oxygen requirements and improving renal […]
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PulmCrit – Magnesium infusions for atrial fibrillation & torsade
. Introduction: Perpetual controversy . The use of magnesium for AF has been a controversial topic for decades. Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile. Ironically, this is also magnesium’s Achilles heel, because this has caused the pharmaceutical industry to have no interest in it. This leaves […]
2015 ACLS Guidelines: What happened to VSE?
. Introduction . In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest. However, other studies investigating the addition of vasopressin alone to epinephrine have been negative. Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation […]
Phenobarbital monotherapy for alcohol withdrawal: Simplicity and power
[PLEASE NOTE: For the most complete & updated material on alcohol withdrawal, please see the Internet Book of Critical Care Chapter on this topic here] Case example . A middle-aged man was admitted to the ICU for refractory alcohol withdrawal. Prior to arriving in the ICU he had been treated aggressively with an escalating […]
The SPLIT trial: Internal vs. external validity
. Introduction . Resuscitation with large volumes of normal saline (NS) causes hyperchloremic metabolic acidosis. Some evidence suggests that hyperchloremic metabolic acidosis may impair renal function, but the clinical relevance of this remains unclear. If hyperchloremic metabolic acidosis is truly detrimental, this would be one argument to use balanced crystalloids rather than NS. . . […]
Recognizing and managing paradoxical reactions from benzodiazepines & propofol
. A perplexing case . A young man with a history of seizures and alcoholism presented with a generalized seizure. His seizure responded to lorazepam, but he was intubated for airway protection and was transferred to the Genius General ICU. He was also loaded with levtiracetam to prevent further seizures. . Overnight he developed agitation. Despite […]
Unconventional therapies for hyponatremia: Thinking outside the collecting duct
. Case: An unusual ICU referral . Some years ago at Genius General Hospital, the ICU was asked to accept a patient from the medicine ward with cirrhosis, confusion, and hyponatremia (Na 125 mM) for hypertonic saline therapy. There was concern that the patient’s confusion was due to his hyponatremia. . Chart review showed […]
Taking control of severe hyponatremia with DDAVP
. Introduction with a case . Imagine an elderly patient presenting with hypovolemic hyponatremia (sodium of 115 mM) and moderate confusion. How would you treat this patient? . The typical approach might be a slow infusion of 3% sodium chloride. The presence of neurologic symptoms supports the use of hypertonic saline. However, patients with hypovolemic […]
Emergent treatment of hyponatremia or elevated ICP with bicarb ampules
. Introductory case . A young 70-kg man was transferred to the Genius GeneralICU for management of stupor. He had been diagnosed with aortic valve endocarditis due to heroin abuse two weeks earlier, but left the hospital against medical advice. Shortly after admission to Genius General, the lab called with a critical sodium value of […]
The tale of six blind physicians and the elephant
. An elderly man was admitted to the ICU and evaluated by six blind physicians. . The blind cardiologist noted that the patient had a malignant pericardial effusion with tamponade. She recommended an immediate pericardial drain followed by intra-pericardial chemotherapy. . The blind oncologist noted that the patient had stage IV lung cancer. He recommended […]
Proposal: Early ventilator weaning to HFNC in hypoxemic respiratory failure
. Case example . A previously healthy 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia. He was intubated prior to transfer due to hypoxemia (details unavailable). His chest radiograph showed dense right lower lobe consolidation, which was confirmed with ultrasonography. He was treated with a regimen of dexamethasone, […]
Evidence-based treatment for severe community-acquired pneumonia
Introduction . Community-acquired pneumonia (CAP) remains the leading cause of infectious disease death in developed countries. Described by Sir William Osler as “captain of the men of death,” it dates back to antiquity. However, we are only beginning to understand the best ways to treat it. . Part 1: The Pneumococcal meningitis story . Ceftriaxone […]
Proposal: Most community acquired pneumonias with extensive ultrasonographic consolidation are pneumococcus
Introduction with a case . A 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia. His chest radiograph is shown above. Chest ultrasonography showed extensive consolidation of the entire right lower lobe with dynamic air bronchograms (video below). He was treated with ceftriaxone and azithromycin. . Extensive lobar consolidation with […]
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