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
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 ventilation throughout sedation and paralysis, right up until the moment […]
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). […]
Demystifying the p-value
Introduction 0 The limitations of p-values for null hypothesis testing has been debated since their invention in the 1920s. Unfortunately, statistics textbooks typically whitewash this controversy, presenting null hypothesis testing as the only viable approach to statistics. Recently, the journal of Basic and Applied Social Psychology took this debate a step further, officially banning the […]
Sleep-protective monitoring to reduce ICU delirium
0 Introduction 0 Recently an excellent post on the Trauma Professional’s Blog pointed out that nocturnal vital signs disrupt sleep and may be unnecessary in stable patients (e.g. patients recovering from minor orthopedic surgery). I couldn’t agree more. Allowing restorative sleep is one of the best approaches to prevention of delirium. 0 What about patients […]
CT Angiogram for evaluation of severe hematochezia
Introduction 0 Gastrointestinal hemorrhage is a common reason for ICU admission. The approach to severe upper GI bleeding is relatively straightforward (figure below). A predictable approach facilitates planning ahead, and anticipating who needs to be contacted for help when. 0 0 Unfortunately, the approach to severe hematochezia is often less clear. Below is a description […]
Do CT scans cause contrast nephropathy?
Introduction 0 In April 2013 a series of articles in Radiology debated whether contrast nephropathy still exists using modern contrast dye. Two years later, the controversy remains. This is a daily conundrum when managing critically ill patients: one radiologist will urge us to use contrast, while the next radiologist will caution us against using contrast. […]
Management of severe hyperkalemia in the post-Kayexalate era
0 Introduction 0 There is increasing recognition that sodium polystyrene sulfonate (Kayexalate) is ineffective for the immediate management of severe hyperkalemia (Kamel 2012). With Kayexalate gone, there seems to be a gap in our treatment regimen. I often encounter residents who know that Kayexalate isn’t helpful, but aren’t sure exactly how to treat hyperkalemia without […]
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