Saline vs. balanced solutions has been a topic of ongoing debate. Two fresh studies will illuminate this: the SMART and SALT-ED trials. This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1. There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]
Search Results for: acid base
Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.
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 […]
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 […]
Valproic Acid Intoxication
CONTENTS Rapid Reference 🚀 Pharmacology & pathophysiology Clinical manifestations Laboratory tests Imaging Treatments: Primary therapies General supportive measures Gastrointestinal decontamination Carnitine Hemodialysis Carbapenems Additional treatments: Other potential treatments For patients on valproate to manage epilepsy Podcast Questions & discussion Pitfalls labs to obtain Fingerstick glucose. Electrolytes including Ca/Mg/Phos. Liver function tests. Creatinine kinase Ammonia level. […]
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 […]
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 […]
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- 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 […]
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 […]
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 […]
The Case of the Balanced Solution
Saline-based resuscitation strategies were first proposed as far back as 1831 during the Cholera Epidemic. In an article published in the Lancet in 1831, Dr. O’Shaughnessy suggests the use of injected salts into the venous system as a means of combating the dramatic dehydration seen in patients afflicted with this bacterial infection(1). Saline’s potential harms […]
Neurologic emergencies in pregnancy
CONTENTS General Differential diagnosis Initial approach Specific information about disease states in pregnancy Acute ischemic stroke Intracranial hemorrhage Seizures Cerebral edema Myasthenia Gravis (MG) Metastatic choriocarcinoma Ventriculoperitoneal shunt malfunction Podcast Questions & discussion Pitfalls neurological emergencies encountered in pregnancy 💡 Pregnant women presenting with neurologic emergencies can have several simultaneous neuropathologies (especially preeclampsia, PRES, and […]
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- 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 […]
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