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 […]
Search Results for: acid base
Hypokalemia
CONTENTS Rapid Reference 🚀 Physiology: Potassium pharmacokinetics Diagnosis Clinical significance Causes Workup Risk stratification Treatment Target potassium level? Enteral route generally preferred Intravenous potassium Magnesium repletion Other measures Podcast Questions & discussion Pitfalls consider risk factors for arrhythmia 📖 EKG changes (especially QT prolongation). Digoxin. Myocardial ischemia. Medications that prolong QT interval and promote torsade […]
PulmCrit- Tranexamic acid for traumatic brain injury (CRASH3)
preamble CRASH-3 is the latest massive, pragmatic multi-center RCT brought to us by the London School of Hygiene and Tropical Medicine Trials Unit. These investigators have created an extensive network of hospitals throughout the world with the capability of performing truly impressive trials. Especially in the critical care arena, these trials have uniquely high power […]
APRV Guideline
general philosophy Let’s admit it, nobody knows exactly how to set APRV. Numerous protocols and articles recommend different approaches. There has never been a human trial comparing two different APRV protocols, so it’s impossible to dogmatically say whether any protocol is better than any other protocol. The most successful clinical trial of APRV to date […]
Valproic Acid Intoxication
CONTENTS Rapid Reference 🚀 Pharmacology & pathophysiology Clinical manifestations Laboratory tests Imaging Treatment General supportive measures Gastrointestinal decontamination Naloxone Carnitine Hemodialysis Carbapenems Additional treatments for hyperammonemia Serial re-assessment For patients on valproate to manage epilepsy Podcast Questions & discussion Pitfalls formulations and absorption Valproic acid is available in immediate-release, delayed-release (q12-hr administration) or extended-release (q24-hr […]
PulmCrit- Dominating the acidosis in DKA
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.
COVID 19 ICU/stepdown management
CONTENTS: Management of COVID-19 patients admitted to stepdown or ICU Link to full chapter here (more complete – but longer). Preamble & caveats Initial tests to guide management Organ support Cardiovascular Respiratory Noninvasive respiratory support Invasive mechanical ventilation Infectious disease – antibiotics Renal Hematology Neurology Immunomodulation Steroid Tocilizumab Baricitinib Things that don’t work Remdesivir Convalescent […]
PulmCrit – Four DKA Pearls
Introduction I have a confession to make: I love treating DKA. It’s satisfying to take a patient from severe acidosis, electrolytic disarray, and hypovolemia to normal physiology during an ICU shift. Although it’s usually straightforward, there are some pitfalls and a few tricks that may help your patients improve faster.0 Pearl #1: Avoid normal saline […]
PulmCrit- Hypertriglyceridemic pancreatitis: Can we defuse the bomb?
Hypertriglyceridemia causes ~9% of pancreatitis, the third most common cause after alcohol and gallstones. It is a risk factor for severe pancreatitis, making it more frequent among ICU patients with pancreatitis. I see this a few times each year. Nonetheless, it has low penetration into educational curricula or our collective awareness. The treatment of hypertriglyceridemic […]
Tumor Lysis Syndrome
CONTENTS Rapid Reference 🚀 Clinically relevant physiology Epidemiology & risk factors Signs & symptoms Diagnosis Prevention Treatment Podcast Questions & discussion Pitfalls simplified Cairo definition of tumor lysis syndrome: (more) Malignancy plus at least two of the following: K >6 mEq/L. Phosphate >4.5 mg/dL (>1.45 mM). Uric acid >8 mg/dL (>476 uM). Calcium <7 mg/dL […]
PulmCrit- Metabolic Resuscitation: Was the answer inside us all along?
Now that VITAMINS is published, it’s worth trying to look at the big picture of sepsis treatment with hydrocortisone, ascorbate, and thiamine (HAT). Marik et al. 2017: The beginning HAT therapy began with a single-center, before/after study.1 There was a stark mortality reduction following the routine adoption of HAT therapy in septic shock (figure below, […]
PulmCrit- Extracorporeal CO2 removal: Putting the cart ahead of the horse?
Recently the concept of extracorporeal CO2 removal has become somewhat popular, with a goal of facilitating ultra low-tidal volume ventilation. Might there be other means to achieve the same goal? Let’s start with some basic concepts of mechanical ventilation… Fundamental unanswered questions Permissive hypercapnia refers to the concept of allowing the pCO2 level to increase […]
Angioedema
CONTENTS Rapid reference 🚀 Overview Diagnosis of angioedema Histamine-mediated vs bradykinin-mediated angioedema Airway management Histamine-mediated angioedema Bradykinin-mediated angioedema Pathophysiology Differential diagnosis Evaluation Treatment Extubating the angioedema patient Podcast Questions & discussion Pitfalls allergic vs. bradykinin-mediated angioedema: approach to angioedema: Angioedema is a common indication for critical care admission. An allergist usually won’t be immediately available, […]
PulmCrit- Montreal Hospitalist & Resuscitationist Conference FOAMed
I recently got back from the inaugural Hospitalist & Resuscitationist conference, a fantastic FOAMy conference in Montreal organized by Phillipe Rola (@ThinkingCC). It was inspiring to participate alongside fantastic folks including Rory Speigel (@EMNerd), Jon-Emile Kenny (@heart_lung), Kylie Baker (@kyliebaker88), Lawrence Lynn(@PatientStormDoc), Andre Denault, and Segun Olusanya (@iceman_ex). Screencasts of my talks, audio clips, some videos […]
Management of severe hyperkalemia in the post-Kayexalate era
0 Introduction 0 There is increasing recognition that sodium polystyrene sulfonate (Kayexalate) is ineffective for the immediate management of severe hyperkalemia (Kamel 2012). With Kayexalate gone, there seems to be a gap in our treatment regimen. I often encounter residents who know that Kayexalate isn’t helpful, but aren’t sure exactly how to treat hyperkalemia without […]
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