. 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 […]
Hypocaloric Nutrition: Theory, Evidence, Nuts, and Bolts
0 Introduction 0 Until recently there has been little evidence regarding the caloric target for feeding critically ill patients. In the absence of evidence, it has been assumed that we should aim to meet 100% of predicted energy needs. New multicenter RCTs challenge this dogma, particularly the PERMIT trial by Arabi et al. 0 Theory […]
Flash cigarette burns: To intubate or not to intubate?
0 Getting warmed up with a multiple-choice question 0 A 70-year-old man with oxygen-dependent COPD is admitted following a flash burn. He started smoking with his oxygen running, and the cigarette “exploded” in his face. Currently he is in the emergency department on four liters nasal cannula (twice his chronic oxygen prescription). He is mentating […]
Dear NEJM: We both know that conflicts of interest matter.
0 Introduction 0 Recently the New England Journal of Medicine launched a media campaign challenging the negative perception of industry conflicts of interests (COI). This was surprising, because it is the opposite of what editors of the NEJM have previously reported (see above books by former NEJM editors, published in 2004 and 2005). Big pharma […]
Pneumonia, BiPAP, secretions, and HFNC: New lessons from FLORALI
Introduction 0 Pneumonia is extremely common. Nonetheless, there is surprisingly little evidence about supporting pneumonia patients using bi-level positive airway pressure (BiPAP) or high-flow nasal cannula (HFNC). The recent FLORALI study offers new insight into this. This post will explore how BiPAP and HFNC compare for pneumonia patients, prior evidence, and the FLORALI study. 0 […]
Top 10 reasons to stop cooling to 33C
Introduction 0 Following the Nielsen study, many hospitals developed two protocols for temperature management after cardiac arrest (33C or 36C). For example, the 36C protocol could be used for patients with contraindications to hypothermia (33C). With ongoing evidence emerging about hypothermia, many hospitals are abandoning their 33C protocols and using 36C for all post-arrest patients. […]
Apneic ventilation using pressure-limited ventilation
⚠️AN UPDATE ON THIS TECHNIQUE WAS POSTED IN 2024 HERE. Introduction 0 Noninvasive ventilation (i.e. BiPAP) is arguably the most powerful approach to optimize oxygenation and ventilation before intubation, given its ability to provide 100% FiO2, PEEP, and ventilatory support. The only way to improve upon this is to extend the administration of positive pressure […]
What is the evidence behind the IVC filter?
Introduction 0 Until recently, recommendations regarding IVC filters have been based predominantly on a singleRCT (PREPIC-1). Last week, a second RCT was released in JAMA (PREPIC-2). This post will review both studies. What is the evidence basis for using IVC filters? 0 PREPIC-1 (Decousus et al. A clinical trial of vena caval filters in the […]
Cognitive approach to shock diagnosis using ultrasonography
0 Recently I coauthored an article about the bedside evaluation of shock using ultrasonography. It’s a reasonable article, albeit conventional. Below is a summary of the key points. 0 Many textbooks recommend line-box algorithms for approaching a patient with shock, for example the ACES algorithm below. These algorithms allow the operator to reach a diagnosis based […]
Apneic oxygenation and high-flow nasal cannula don’t prevent desaturation during intubation?
0 0 Introduction 0 Recently there has been increased interest in the use of high-flow nasal cannula (HFNC) to provide preoxygenation and apneic oxygenation during endotracheal intubation. Previous posts have discussed the basic physiology and some evidence behind this. Vourc’h et al. just published a RCT showing no benefit from HFNC in this situation (1). […]
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