. 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 […]
Does central line position matter? Can we use ultrasonography to confirm line position?
. Introduction . Suppose you just placed the central line shown above. Does it need to be repositioned? . I was trained that the tip of the central line must lie in the lower portion of the superior vena cava. If the line was in the right atrium, it would cause cardiac perforation. If the […]
Myth-busting: Azithromycin does not cause torsade de pointes or increase mortality
. Introduction . In 2012 a NEJM article by Ray et al. reported a correlation between azithromycin and cardiovascular death. This received extensive press and ultimately led the FDA to issue a drug safety communication warning about the risk of QT prolongation and torsade de pointes. Subsequent studies have failed to replicate this result. Nonetheless, […]
Accelerated Goal Directed Therapy for Septic Shock
. . Introduction . The Surviving Sepsis Campaign has raised awareness that septic shock is a medical emergency. However, these guidelines recommend a stepwise approach to resuscitation, which commonly results in a gradual escalation of treatment intensity. Additional therapies are added over several hours if the patient fails to reach treatment goals. For some patients, […]
Steroids in septic shock: Four misconceptions and one truth
Introduction 0 The utility of steroids in sepsis has been debated passionately for decades. There is hope that steroids might improve mortality, but also fear that they could increase infectious complications. Practice varies widely. What does the data truly indicate? 0 Four misconceptions and one truth 0 Misconception #1: Stress-dose steroids decrease mortality 0 This […]
Understanding lactate in sepsis & Using it to our advantage
Introduction with a case 0 Once upon a time a 60-year-old man was transferred from the oncology ward to the ICU for treatment of neutropenic septic shock. Over the course of the morning he started rigoring and dropped his blood pressure from 140/70 to 70/40 within a few hours, refractory to four liters of crystalloid. […]
CT angiography for lower GI bleed: the University of Pennsylvania Experience
Introduction 0 A post two months ago explored the use of CT angiography instead of tagged RBC scans for the evaluation of lower GI bleeding (here). The algorithm below was developed based on evidence regarding the speed and performance of various tests. However, there was no direct evidence validating this algorithm. A new study from […]
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