TOPICS

• airway & procedures
• cardiology
• endocrinology
• gastroenterology
• hematology/oncology
• infectious diseases
• nephrology
• neurology
• pulmonology
• rheumatology
• toxicology
• methodology & miscellaneous

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airway & procedures

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Airway pharmacology

• Medication sequence: rocketamine vs. keturonium
• Ketamine-tolerant patient
• Catastrophic complications, ROC vs. SUX

Arterial lines:  wrist versus the groin?

Cricothyrotomy in asphyxial cardiac arrest

Difficult airway communication via allergy list

Drowned airway

• Large-bore suction strategies & devices
• Drowned airway algorithm: cut to the chase

ETT depth calculator

• Endotracheal tube depth
• Online calculator

Laryngoscopy

• Pearls from Levitan Airway Course
• Facial hair & airway management

Preoxygenation, apneic oxygenation, apneic ventilation

• High-flow nasal cannula
  • 1: preoxygenation using a nasal cannula
  • 2: physiology of apneic oxyventilation
  • 3: disagree with RCT by Vourc'h et al. 4/15
• Apneic ventilation using pressure-limited ventilation
• The primacy of pressure:  is RSI a failed paradigm?

Vascular access

• Dirty Double:  Immediate femoral arterial & venous access
• Central line positioning & ultrasound line confirmation
  • Update on ultrasonography for line confirmation 10/16
• Rapid sequence intubation & procedurization
• Shrug technique for US-guided subclavian lines

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cardiology

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Atrial fibrillation

• Magnesium infusions for AF & TdP
• Approaching new-onset AF in critical illness
• Cardiogenic shock after cardioversion of atrial flutter
• Approach to shocky AF patient

Bradycardic periarrest: atropine vs. epinephrine

Hemodynamics

• 2016 series
  • #1: Alternative viewpoint on phenylephrine infusions
  • #2: Oral vasopressors to accelerate liberation from ICU
  • #3: Why we fail at hemodynamics: cognitive errors
  • #4: Epinephrine responsiveness & challenge 
• Phenylephrine & epinephrine can be infused peripherally
• Empty IVC & LV doesn't prove volume depletion
• Central venous oxygen saturation = noise
• Killer resuscitation: abdominal compartment syndrome
• Fluid boluses
  • Myth-busting the fluid bolus
  • Fluid boluses before intubation?  PREPARE trial
• more below: Infectious diseases / Sepsis / Vasopressors

MI

• Over-diagnosis & over-treatment of MI
• Heparin is nonbeneficial for noninvasive tx
• PCI unhelpful status post CABG
• EKG patterns of PE that mimic MI
• Acute infection & MI:  How scared should we be?

Post-cardiac arrest care

• 33 vs. 36
  • Top 10 reasons to stop cooling to 33C
  • Pragmatic comparison 33C vs. 36C
• VSE (vasopressin / steroid / epinephrine)

Shock, undifferentiated

• Approaching cardiopulmonary failure: which tests are useful?
• Cognitive approach to shock diagnosis with POCUS

Torsade de Pointes: a better approach

⇒ more cardiology at iBookCC

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endocrinology

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DKA

• DKA pearls
• Dominating the acidosis in DKA
• ABG/VBG unhelpful in DKA
• Early basal insulin in DKA (local data)

Insulin poisoning refractory to glucose

⇒ more endocrinology at iBookCC

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gastroenterology

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Abdominal compartment syndrome & fluid overload

Cirrhosis

• Coagulopathy management in cirrhosis
• Secondary bacterial peritonitis
• Ultrasound-guided blakemore tube placement

Hematochezia

• CT angiogram for evaluation of hematochezia
• New evidence: Jacovides et al 5/15

Nutrition

• New guidelines simplify ICU nutrition
• Hypocaloric feeding & tube feed cheat sheet

Pancreatitis

• Please stop the drowning
• Hypertriglyceridemic pancreatitis

Stress ulcer prophylaxis (SUP-ICU)

⇒ more gastroenterology at iBookCC

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heme/onc

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Coagulation & TEG

• 1) Coagulopathy management in the bleeding cirrhotic – fundamentals
• 2) Validation of TEG to guide coagulation management in cirrhosis

WBC count vs. NLR

• NLR:  Free upgrade to your WBC
• CBC to diagnose septic shock

Sepsis-associated DIC

TXA

• CRASH3:  Tranexamic acid for traumatic brain injury

 

⇒ more heme/onc at iBookCC

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infectious diseases

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Antibiotic allergy

• PCN allergy: strategy
• Ranking antibiotics in order of allergenicity
• Validation of test-dose strategy for beta-lactam allergy

Antibiotics – specific drugs

• Azithromycin
  • Azithromycin doesn't cause torsade or cardiac death
  • Brief rant: still no evidence azithro increases mortality
• Double-coverage?
  • Fluoroquinolone not helpful for double-coverage
  • Double-coverage unnecessary for VAP
• Fluoroquinolones unhelpful in ICU
• Piperacillin-tazobactam isn't nephrotoxic
• Vancomycin pharmacokinetics:  Making vanco great again
• Antibiotics & delirium (brief rant)

Bacteremia

• Microarray technology & antibiotic algorithms for bacteremia

Pneumonia

• Community-onset PNA
  • MRSA coverage: when needed?
  • Treatment overview of severe CAP
  • Ultrasonographic patterns of CAP
  • Comments on new CAP guidelines 2019
• Influenza PNA: triple therapy?
• Metabolic resuscitation for severe pneumonia?
• Ventilator-associated PNA
  • Double-coverage for VAP unnecessary

Sepsis

• Definitions & guidelines
  • Sepsis 3.0
    • 10 problems with sepsis 3.0 definitions
    • qSOFA fails validation
  • Sepsis 4.0: sepsis-HLH overlap syndrome
  • Mythbusting the Surviving Sepsis 2016 guidelines
  • Petition to retire the surviving sepsis guidelines
  • The Surviving Sepsis 1-hour guidelines are… back?
• Overview
  • Concept: Renoresuscitation & avoidance of chronic sepsis
  • Strategy: Accelerated goal directed therapy
• Fluids
  • Myth-busting the fluid bolus
• Steroids & metabolic sepsis resus
  • Stress-dose steroids: overview 7/15
  • VANISH trial: no effect from steroid?
  • Metabolic sepsis resuscitation: evidence for ascorbate
  • ADRENAL trial & implications for metabolic resus
  • APROCCHSS vs. ADRENAL: really discordant?
  • Metabolic resuscitation for severe pneumonia?
  • Checkpoint inhibitors… for septic shock?
  • CITRIS-ALI:  Can a secondary endpoint stage a coup d'etat?
• Vasopressors
  • Angiotensin-II:  caveat emptor
  • Epinephrine
    • Epinephrine & significance of lactate
    • Epinephrine challenge in sepsis
  • High-dose vasopressors: never surrender
  • Norepinephrine…early to stabilize MAP
  • Peripheral infusions of phenylephrine, epinephrine
  • Vasopressin
    • Vasopressin… & renal microvascular hemodynamics
    • Vasopressin, vepinephrine, & VANISH
    • VANCS trial: vasopressin for post-CABG shock

Toxic shock syndrome

• Diagnosis
• Treatment

⇒ more infectious diseases at iBookCC

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nephrology

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Acid-base status & fluid selection

• pH-guided resuscitation  & re-boot after BICAR-ICU
• Is correcting hyperchloremic acidosis beneficial?
• Plasmalyte/normosol vs. LR
• SPLIT trial: internal vs external validity
• We should engineer a new crystalloid
• Get SMART: 9 reasons to quit using normal saline
• Don't correct the anion gap for albumin
• Some acid base discussion questions

Contrast nephropathy: does it still exist?

Diuresis

• Diuretic resistance & natriuresis
• Furosemide stress test to clarify resuscitative goals
• Furosemide failure:  metolazone vs. IV chlorothiazide (3T trial)
• Hyperdiuresios: Using hypertonic saline to facilitate diuresis

Hyperkalemia

• LR is safe in hyperkalemia
• Management of severe hyperkalemia
• BRASH syndrome: hyperK + AV blocker

Hyponatremia

• Emergent tx with bicarb ampules
• Taking control with DDAVP
• Unconventional tx with lactulose
• Controlled aquaresis:  Oral urea

⇒ more nephrology at iBookCC

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neurology

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10 dubious beliefs in neurocritical care

Analgesia

• Fentanyl infusions vs. ketamine?
• Reengineered analgesic ladder for critical care
• Alpha-2 agnoists: clonidine, guanfacine, and KetaDex
• DEXACET trial:  evidence behind scheduled acetaminophen

Anoxic brain injury & post-arrest management

• 33 vs. 36
  • Top 10 reasons to stop cooling to 33C
  • Pragmatic comparison 33C vs. 36C
  • HYPERION trial:  33C vs… 37C?
• VSE (vasopressin / steroid / epinephrine)
• Prophylactic antibiotics after cardiac arrest?  ANTHARTIC study

Antipsychotics

• Are haloperidol allergies real?
•  Olanzapine
  • Intravenous olanzapine
  • Update: IV olanzapine & combo vs. mono-tx
• No more antipsychotics for delirium?

Brain death & flow scans

CNS infections

• Meningitis can benefit from neurocritical care
• Encephalitis rule-out: who needs acyclovir?

Delirium

• Delirium prevention with melatonin?
• Sleep-protective monitoring

Gag reflex dogmalysis

ICP elevation

• Hypertonic saline infusion: rant
• ICP elevation & ocular sonography

Status epilepticus

• Rapid-sequence termination (2014)
• Resuscitationist's guide to status
• All conventional 2nd line anti-epileptics are equally bad:  ESETT trial

Stroke

• The fragility index of the NINDS trial 
• Thrombectomy + Thrombolysis for ischemic CVA?

⇒ more neurology at iBookCC

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pulmonology

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ABG/VBG

• ABG unhelpful in diagnosis of cardiopulmonary failure
• ABG/VBG unhelpful in DKA
• Oximetry beats PaO2 for assessing oxygenation
• Converting a VBG into an ABG

ARDS & oxygenation

• ARDS physiology: what is our oxygenation goal?
• Definition issues:  ARDS vs. pseudoARDS
• Proning the non-intubated patient
• Oxygen-ICU trial & lower oxygen targets
• APRV: resurrection of the open lung

COPD:  Is metoprolol dangerous?  C'mon…

Extubation

• Cuff leak & extubation 
• Nocturnal extubation is OK
• Dexmedetomidine & extubating the agitated patient
• Rigorous vs. lenient spontaneous breathing trials
• Post-extubation HFNC
  • HFNC to avoid reintubation
  • HFNC for early ventilator weaning
  • Hernandez 2016-I: low-risk patients
  • Hernandez 2016-II: high-risk patients

NIV & high-flow nasal cannula (HFNC)

• Overview:  mastering dark arts of HFNC & BiPAP 
• Dexmedetomidine to facilitate noninvasive ventilation
• Post-extubation HFNC
  • HFNC to avoid reintubation
  • HFNC for early ventilator weaning
  • Hernandez 2016-I: low-risk patients
  • Hernandez 2016-II: high-risk patients
• HFNC for apneic oxyventilation (more about this under Airway above)
• HFNC for hypoxemic respiratory failure
  • HFNC for pneumonia & FLORALI study
  • Does HIGH trial debunk HFNC?

PE

• Diagnosis: EKG patterns of PE that mimic MI
• IVC filters: where is the evidence?
• Thrombolysis
  • Submassive PE 2014: PEITHO, MOPETT, ULTIMA, TOPCOAT
  • 2016: Controlled thrombolysis I: deconstructing CDT
  • 2016: Controlled thrombolysis II: rationale & protocol
  • 2017: New paradigm: Getting 'em off the cliff
  • Should we monitor fibrinogen during full/half-dose lysis? 
  • OPTALYSE-PE:  We're dosing tPA wrong
  • Contraindication checklist for thrombolysis
• Pulmonary vasodilators
  • Inhaled pulmonary vasodilators: iNope trial
  • Nebulized nitroglycerine:  The stealth pulmonary vasodilator
• Resuscitation: Eight pearls for the crashing PE patient

Pleural disease & thoracentesis

• Post-thoracentesis pneumothorax
• Large volume thora
  • Large-volume thoracentesis #1
  • Large volume thora 2019: yes we can
• Ultrasound diagnosis of hemopneumothorax

Pneumonia

• Community-onset PNA
  • MRSA coverage: when needed?
  • Treatment overview of severe CAP
  • Ultrasonographic patterns of CAP
• Influenza PNA: triple therapy?
• Metabolic resuscitation for severe pneumonia?
• Double-coverage for VAP unnecessary

Respiratory muscle weakness & respiratory drive & hypercapnia

• Extracorporeal CO2 removal:  Putting the cart ahead of the horse
• Respiratory drive!
  • Optimizing respiratory drive to avoid failure
  • The crashing asthmatic with Leo Stemp, Weingart's response, Followup comments
• Tx in Guillain-Barre & Myasthenia

Upper airway disease

• Angioedema due to ACE-inhibitors
• Flash cigarette burns: is early intubation needed?

⇒ more pulmonology at iBookCC

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rheumatology

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Angioedema due to ACE-inhibitors

How to use IV epinephrine for anaphylaxis

⇒ more rheumatology at iBookCC

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toxicology

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Alcohol withdrawal & GABA receptor physiology

• Phenobarbital for EtOH w/d  #1 (12/14)
• Phenobarbital for EtOH #2 (monotherapy, 10/15)
• Phenobarbital for EtOH #3 (monotherapy reloaded, 12/17)
• Phenobarbital for EtOH #4 (one order to sedate them all, 10/18)
• Phenobarbital for EtOH #5 (evidence update 2018-2019)
• Ketamine for alcohol withdrawal?
• Paradoxical reactions due to BZDs & propofol

Insulin poisoning refractory to glucose

Lithium intoxication: dialyze if chronic & asymptomatic?

Osmolal gap dogmalysis

⇒ more cardiology at iBookCC

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methodology & miscellaneous

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Methodology & statistics

• Type-I error
  • Demystifying the P-value
  • Fragility Index & the NINDS trial
  • Interpreting a 2×2 table: P-value, fragility & Bayes
  • 0.050 shades of grey in p-value cutoffs
• Type-II error: Power & inconclusive trials
• Mythbusting sensitivity & specificity
• Timing problems
  • The fallacy of time-to-intervention studies
    • Sepsis research rant:  More fake news
  • Correlation confounded by timing

Bias

• Investigation bias
• Conflicts of interest, guidelines, and review articles

Endpoints

• Chasing mortality endpoints is a fool's errand
• Secondary endpoints: separating wheat vs. chaff
• The inherent myopia of science

Fragility

• The fragility index of the NINDS trial 
• The hidden fragility of meta-analyses

Philosophy of critical care

• Errors of commission vs. omission
• Why most diagnostic procedures aren't beneficial
• The tale of six blind physicians and the elephant
• Graduation speech: why we resuscitate
• Rare catastrophic complications fly under the radar

Conference notes

• Northern New England Crit Care 2017 (Sepsis)
• Montreal Hospitalist & Resuscitationist Conference 2018
• Northern New England Crit Care 2018 (Delirium)

Translation to other languages

• German (translated by Urban Bromberger)
  • Adrenaline vs. atropine in bradycardic periarrest
  • Therapy for hyperkalemia in the post-kayexalate era
  • BRASH syndrome
  • Lactated ringers is safe in hyperkalemia
  • Dominating the pH in DKA
  • Get SMART:  Balanced crystalloids vs. saline
• French
  • Lactated ringers is safe in hyperkalemia (@nfkb)