The REMAP-CAP trial recently detected mortality benefit from tocilizumab in patients with COVID-19. However, several other RCTs have failed to find substantial benefit from tocilizumab. This begs the question: Has REMAP-CAP discovered a uniquely beneficial way to use tocilizumab, or is this simply a statistical outlier? evidence roundup: RCTs on tocilizumab Let’s review the trials. […]
IBCC – Purpura Fulminans
Purpura fulminans is a rare form of disseminated intravascular coagulation which requires specific management. Most commonly it is seen as a complication of septic shock with multi-organ failure. Unfortunately, purpura fulminans is often treated simply with a generic approach for septic shock. The IBCC chapter is located 👉 here. The podcast & comments are below. […]
PulmCrit – Baricitinib for COVID-19: The rise of the jakinibs
Background: JAK-inhibitors (jakinibs) in the greater context Much of the harm from infections is mediated by hyperactive inflammatory reactions. To date, most research has focused on two classes of medications to treat this: Corticosteroids have the advantage of being cheap, widely available, and often effective. The disadvantage is that corticosteroids modulate innumerable molecular pathways, thereby […]
PulmCrit – Dismantling the systemic racism of pulse oximetry
Oximetry is fundamental to critical care. Consequently, even small biases in pulse oximetry measurements could have real clinical impact (especially when leveraged across innumerable measurements among thousands of patients). Racial bias in pulse oximetry was the subject of two studies in 2005 and 2007. The topic was then largely ignored over the past 13 years. […]
PulmCrit – I’m upset about the RELAX trial
Some studies have reported a gradual upwards trend in the PEEP being used for intubated patients without ARDS (e.g., from 5 cm to 7 cm). Is this good or bad? That is the question which the RELAX trial embarked upon answering. It’s a complex question which probably doesn’t have a binary answer… but never mind – let’s get to the study.
IBCC chapter & cast – Massive Transfusion Protocol (MTP)
Massive Transfusion Protocols have attracted substantial attention over the past several years, so most folks will be familiar with the general concepts. This chapter reviews a variety of details which may be essential to the success of an MTP – yet can easily get lost in the chaos. The IBCC chapter is located 👉 here. […]
PulmCrit – Does Remdesivir reduce length of stay? SOLIDARITY vs. ACTT-1.
With the publication of the SOLIDARITY trial, there is increasing consensus that remdesivir doesn’t affect mortality. However, there continues to be debate about whether remdesivir affects hospital length of stay. Let’s dig into the data here to try to reconcile differences between ACTT-1 and SOLIDARITY. Did ACTT-1 actually show that remdesivir reduces the hospital length […]
PulmCrit – Want to help stop COVID? Be quiet.
The closed mouth catches no flies Benjamin Franklin, Poor Richard’s Almanac, 1742 We’re hopefully nearing the end of the COVID pandemic, with vaccines coming soon. Unfortunately, vaccines won’t be able to bail us out this winter. Neither will fancy designer pharmaceuticals. The main interventions necessary to keep us safe for now are basic public health […]
PulmCrit – I’m so confused about bamlanivimab
2020 has been a weird year by any standard. So, I shouldn’t be surprised that the bamlanivimab story is so weird. But still. Anyhow, if you’re ready to go down the rabbit hole, here we go… derivation and early testing The story begins with Eli Lilly designing a monoclonal anti-spike antibody to neutralize COVID-19. The […]
PulmCrit – Oscar awards for the best COVID prognostic models
We are continually tasked with triaging COVID patients, a situation which will become more complex as the numbers continue to rise. This involves making educated guesses about which patients are most likely to deteriorate, and which patients may benefit most from critical care. That’s enormously difficult. At this point, we’re quite familiar with individual risk […]
PulmCrit – Heparin resistance in COVID & implications for DVT prophylaxis
background: what is heparin resistance? Heparin works by binding to antithrombin III and thereby activating antithrombin III, an endogenous anticoagulant which inhibits clotting factors (especially Xa). Heparin + Anti-thrombin III → [Heparin-Antithrombin-III complex] → Inhibition of Xa activity Heparin resistance refers to situations where unusually large doses of heparin are required to achieve anticoagulation. This […]
PulmCrit: Why the DAMASK trial is a futile diversion – The limitations of RCTs
When I saw the infographic for the DAMASK trial (below), it was immediately clear to me that the trial was inconclusive (not positive, not negative – inconclusive). According to this study, masks might be totally worthless. Or masks might reduce infection by ~40%. This is an inconclusive study. It yields no answer.
IBCC chapter & cast – Toxic Shock Syndrome
Not all septic shock is created equal. Toxic shock syndrome is one of the most fulminant and dangerous forms of septic shock. It is one of the few infectious diseases capable of rapidly killing previously healthy young people. Most importantly, toxic shock syndrome requires targeted therapy – it often fails to respond to conventional therapy […]
IBCC chapter & cast – Ventilator Associated Pneumonia (VAP)
VAP is a perennial riddle in the intensive care unit. There are numerous murky diagnostic tests, but no single gold-standard diagnostic test. Consequently, we are usually left wondering whether or not the patient truly has a VAP. This makes VAP an unsatisfying diagnosis, as we are continually walking a blurred line between undertreatment and overtreatment. […]
IBCC chapter & cast – Sedation for the intubated patient
Sedation is one of the details of ICU care which seems unimportant… until it’s not. Over the past decade we’ve seen a burgeoning repertoire of agents used for sedation and agitated delirium. Unfortunately, the number of medications has out-stripped available Level-I evidence regarding how exactly to use them. This chapter attempts to create a framework […]
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