PulmCrit (EMCrit)

Critically ill patients often strongly retain sodium. This may cause diuresis attempts to fail, if patients excrete dilute urine leading to a loss of water without loss of sodium. Such patients may seem to respond to diuresis, but in fact they are merely becoming progressively dehydrated and hypernatremic (occult diuresis resistance).

Below is my graduation speech. It is about why we are in medicine. As all resuscitationists know – whether nurse, physician, pharmacist, PA, or paramedic – resuscitation is hard work. We all could have chosen easier, safer paths to follow. Ten years down the track I have no regrets. I appreciate the great privilege of being here. Still, though, it’s good to take a moment to remember how we got here, and why it is that we do what we do.

I’ve been using fentanyl infusions as the backbone of my sedative strategy, in keeping with the 2013 SCCM guidelines. This generally works well for patients who can be extubated quickly. However, for patients who remain on the ventilator for longer periods of time, it often leads to problems involving tolerance and withdrawal.

The most widely feared complication of placing a Blakemore tube is complete inflation of the gastric balloon while it is not in the stomach. If the gastric balloon is fully inflated anywhere outside the stomach (i.e. esophagus, trachea, bronchus, duodenum), this may cause visceral perforation.

A 55-year-old woman was admitted with toxic shock syndrome. Her norepinephrine requirement was labile, fluctuating between 15 mcg/min and 30 mcg/min. Bedside echocardiogram showed a dilated inferior vena cava without respiratory variability, and a normal ejection fraction. On examination her extremities were cool and her urine output was marginal.