Sepsis 3.0 replaced the SIRS criteria with a new risk-stratification tool, qSOFA. qSOFA was initially developed within the Sepsis-3 publication itself. Until now, qSOFA has never been validated. The value of qSOFA vs. SIRS remains controversial.
Management of acidosis in DKA is an ongoing source of confusion. There isn’t much high-quality evidence, nor will there ever be. However, a clear understanding of the physiology of DKA can help us treat this rationally and effectively.
From the pulmonary standpoint, supine positioning may be the worst possible position. Supine positioning may promote aspiration, as gravity tends to pull oral secretions towards the larynx. Supine positioning promotes atelectasis of the posterior lung segments (which are larger and more important than the anterior segments). Among obese patients, abdominal contents compress the diaphragm when supine, further promoting atelectasis. Finally, expectoration is difficult in a supine position, as the patient must expel secretions against gravity.
What should intensivists do at night? Should they sleep at home or remain dutifully in the hospital? Should they extubate patients or just maintain the status quo until 7 AM?
A patient with chronic asymptomatic hyperlithemia is tolerating their current lithium level well. If they have adequate renal function, their lithium level is very likely to decrease over time with hydration (and unlikely to increase). Why dialyze such a patient? It is impossible to improve a patient’s condition if the patient is already asymptomatic.