PulmCrit (EMCrit)

Enormous attention is committed to the control of pain, with much less being directed to the control of nausea.  However, nausea and vomiting can be even more distressing than pain.  By understanding the receptor pharmacology of various antiemetics, a rational and effective approach is possible. The IBCC chapter is located here. The podcast & comments […]

It’s impossible to get through a single shift in the ICU without encountering several patients experiencing pain.  Controlling pain is easy – but controlling pain while limiting collateral side-effects can be a challenge.  Anesthesiologists have pioneered the best approaches here, which often involve multimodal combinations of various medications carefully titrated to effect.  Although intensivists may […]

Inhaled pulmonary vasodilators are generally quite safe.  They offer a variety of physiologic benefits to patients with cardiopulmonary failure, including improved oxygenation and right ventricular function.  Unfortunately, like so many interventions in critical care, there is a dearth of large, multi-center RCTs proving patient-centered benefit.  This chapter attempts to sift through available evidence, in efforts […]

Hyperosmolar Hyperglycemic State (previously known as “Hyperosmolar Hyperglycemic Nonketotic Syndrome” and, before that, “Hyperosmolar Hyperglycemic Nonketotic Coma”) is a bit of a slippery animal.  Despite being redefined several times, the precise definition remains elusive.  This may cause it to be over-diagnosed in anyone with severe hyperglycemia.  The treatment likewise remains a bit controversial, with different […]

Guillain-Barre Syndrome is the most common cause of acute-onset neuromuscular weakness requiring ICU admission.  COVID-19 appears to be one trigger of Guillain-Barre Syndrome, so this might be even more common in the coming months.  There isn’t much high-quality evidence regarding respiratory support in Guillain-Barre Syndrome, particularly when intubation is indicated.  Consequently, it’s important to use […]

Intracranial hemorrhage is a fairly common problem, which spans the gamut from mild to life-threatening.  Most therapies haven’t been shown to work, so management mostly consists of high-quality neuro-supportive care. The IBCC chapter is located here. The podcast & comments are below. Follow us on iTunes

Catastrophic antiphospholipid syndrome (CAPS) is a truly rare cause of multi-organ failure.  It is usually not considered as a diagnostic possibility, leading it to be mis-diagnosed as septic or cardiogenic shock.  Awareness of this condition and various red flags suggesting its presence might facilitate earlier diagnosis and therapy. The IBCC chapter is located here. The […]

Familiarity breeds contempt.  Fever is so common in the ICU, that we often don’t put much thought into these workups.  Just culture everything, right?  Well, not really.  Excessive cultures frequently lead to false-positive results (representing colonization), which serve only to misdirect attention away from the actual problem.  Meanwhile, inadequate attention to the physical examination and […]

Catheter-associated urinary tract infection (CAUTI) is supposedly one of the most common causes of nosocomial infection.  However, it’s dubious to what extent it is truly a disease.  It’s increasingly clear that the vast majority of cases of “CAUTI” are likely merely asymptomatic bactiuria, which has been mis-diagnosed as infection (leading to unnecessary treatment and iatrogenic […]

Sickle cell disease affects 100,000 people in the United States and far more internationally.  One of the most dangerous manifestations of the disease is acute chest syndrome, which involves a vicious cycle of erythrocyte sickling and respiratory failure.  Acute chest syndrome can be a presenting feature upon hospital admission, it can arise as a complication […]

The hard part about playing chicken is knowing when to flinch – Bart Mancousco, The Hunt for the Red October Epiglottitis is often a game of chicken.  The great majority of adult patients don’t require intubation, so the best management for them is steroid and antibiotic (plus close observation and the ability to intubate if […]

Pneumocystic Jirovicii Pneumonia (previously Pneumocystic Carinii Pneumonia) remains an important opportunistic infection in critical care.  Improved treatment for HIV has reduced the frequency of PJP due to AIDS, but meanwhile the development of increasingly sophisticated immunosuppressive regimens for other patient populations has increased the incidence of non-HIV PJP.  New diagnostic tests are improving our ability […]

Early in the COVID epidemic, it became clear that the virus often causes a cytokine storm, leading to immunopathological organ damage.   The first major study to suggest benefit from steroid in COVID was a retrospective study by Wang et al. released in early March, which found reduced mortality among COVID patients with ARDS who were […]

Vocal cord dysfunction is a masquerader of life-threatening pathologies (most notably asthma and anatomic upper airway obstruction).  Vocal cord dysfunction itself is not dangerous, but if not properly diagnosed it may lead to considerable iatrogenic harm (e.g. multiple unnecessary intubations for “asthma”).  On the flip side, incorrect diagnosis of vocal cord dysfunction is also dangerous, […]

Invasive pulmonary aspergillosis was traditionally conceptualized as a rare infection restricted to profoundly immunocompromised patients.  However, over the past decade, it’s become increasingly clear that invasive aspergillosis can also occur as a nosocomial superinfection among patients who aren’t immunocompromised (especially following influenza).  This opens a can of worms regarding how to sift out colonization versus […]