0 Clinical Question 0 An elderly woman presents with renal failure due to severe dehydration from diarrhea. She has a hyperchloremic acidosis from diarrhea with a chloride of 115 mEq/L, bicarbonate of 15 mEq/L, and a normal anion gap. During her volume resuscitation, should isotonic bicarbonate be used to correct her hyperchloremic acidosis? Does […]
Facial hair, airway management, and Movember
Preamble: Movember 0 Movember is an annual event involving growing a mustache during November to raise awareness and funds to support men’s health issues including prostate cancer. To support Movember, this post is about mustaches… and critical care, of course. 0 Introduction with a Case 0 Once upon a time at Genius General Hospital, there was […]
Hydro-Point: Ultrasound sign of air-fluid level in the pleura
Introduction with a case 0 Hydro-point on thoracic ultrasound is diagnostic of an intrapleural air-fluid level, which may be caused by hydropneumothorax, hemopneumothorax, or pyopneumothorax. This has been described in the literature but is not widely appreciated (Volpicelli 2013). For example, a prominent ultrasound website may have misdiagnosed this. Before going further, watch the video […]
Mythbusting: Correcting the anion gap for albumin is not helpful
0 Introduction 0 In 1998 Figge reported a strong linear relationship between anion gap and albumin concentration, which has led to the widespread recommendation to correct anion gap for albumin. It was proposed that since albumin is an anion, failing to correct for a low albumin level could allow an anion-gap acidosis to go undetected. […]
Mythbusting: Heparin isn’t beneficial for noninvasive management of NSTEMI
Introduction 0 The use of heparin for noninvasive management of non-ST elevation MI (NSTEMI) is one of the most deeply entrenched myths of modern medicine. Although heparin reduces reinfarction, when it is discontinued there is a rebound in infarction rates. Ultimately, short-term treatment with heparin delays reinfarction without having any sustained benefit. Clinical trials which fail […]
10 Pearls from the Levitan Airway Course
0 Introduction 0 Last week I attended Dr. Levitan’s airway course in Baltimore. It was a teriffic course, which I would recommend to anyone looking to improve their airway management skills. For those of you unable to attend the course, here are some points which were particularly interesting to me. 0 Pearl #10. Respect the […]
Early norepinephrine to stabilize MAP in septic shock
0 Introduction 0 With publication of the PROCESS and ARISE trials, many hemodynamic goals are being disproven. There is a growing tide of nihilism. Should we should just give septic patients a couple bags of fluid, some antibiotics, and hope for the best? 0 Probably not. PROCESS and ARISE have showed us what we can […]
Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.
Introduction 0 Several months ago I gave a grand rounds on pH-guided resuscitation which was summarized in this post. This included a discussion that Lactated Ringers (LR) is safe in hyperkalemia. However, myth-busting is hard work. The dogma that LR should be avoided in hyperkalemia continues to replicate, both locally and on twitter. This […]
Large volume thoracentesis: How much can safely be removed?
0 Introduction 0 Completely draining a pleural effusion has many benefits including symptomatic improvement, avoiding multiple procedures, faster disposition home, and imaging the chest with the lung inflated. However, complete drainage is usually avoided to due to fear of re-expansion pulmonary edema. What is the evidence behind this? 0 Traditional model of reexpansion pulmonary edema (RPE) 0 […]
Pneumothorax ex vacuo: Post-thoracentesis pneumothorax in the ultrasound era
CT showing pneumothorax ex vacuo due to trapped lung (Pereyra 2013) 0 Introduction 0 A recent review article by Wilcox in JAMA questions whether ultrasound guidance truly reduces the risk of pneumothorax. Bedside ultrasound reduced pneumothorax (OR = 0.55) but this reduction was statistically insignificant due to a huge confidence interval of 0.06-5.3. Another meta-analysis found […]
Double-coverage of gram negatives with a fluoroquinolone?
0 Introduction 0 The benefit of empirically using two antibiotics to cover gram negative bacilli is a perpetual controversy. For patients in septic shock, failure to provide effective initial antimicrobial therapy correlates with increased mortality. Using two drugs may increase the likelihood of an including at least one antibiotic which covers the pathogen. This […]
What does it mean if a patient is “allergic” to haloperidol?
0 Introduction with a case 0 Once upon a time at Genius General Hospital, a 25-year old man was admitted to the ICU for agitation. After exclusion of an acute medical or neurologic process, it became clear that he was suffering from schizophrenia with medication nonadherence. Unfortunately, his electronic medical record indicated that he had […]
The myth of large-volume resuscitation in acute pancreatitis
Introduction 0 Severe pancreatitis causes fluid extravasation from the vasculature, sometimes causing shock. Traditionally this has been managed by administration of large volumes of crystalloid. For example, the 2013 American College of Gastroenterology Guideline recommended providing 250-500 ml/hour of crystalloid for the first 12-24 hours of hospitalization. They recommended targeting fluid resuscitation to achieve dilution […]
The fallacy of time-to-intervention studies
0 Time and tide wait for no intervention – Geoffrey Chaucer 0 We are barraged by time-to-intervention studies (door-to-balloon time, time-to-antibiotics, door-to-needle, etc.). However, it must be kept in mind that these studies are purely correlational in design. Such studies cannot […]
Could estrogen-receptor antagonists treat Ebola?
Disclaimer: In light of the ongoing epidemic this post is intended to spark interest and invoke discussion about unconventional therapies. Introduction It is widely believed that there is no specific therapy for Ebolavirus. However, this is only partially true. Some experimental therapies exist, including convalescent serum and interferon, but the ability to deploy these to […]