Critical Care Archives - PulmCCM
Advertisement


Critical Care Articles

Feb 232017
 
The Normalization Fallacy: why much of "critical care" may be neither

By Scott Aberegg, MD, MPH Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient. On my first MICU rotation in 1997, I was so swept [… read more]

Feb 222017
 
Simple qSOFA score predicts sepsis as well as anything else

Sepsis is sneaky. Physicians, nurses, and epidemiologists struggle to accurately identify patients with sepsis in the emergency department, hospital ward, and in data sets. The so-called SIRS criteria were abandoned as insensitive and nonspecific in the most recent iteration of sepsis care. Sepsis is instead now defined as “life-threatening organ dysfunction caused by a dysregulated [… read more]

Feb 152017
 
Oxygen saturation in critical illness: could low-normal be best?

Oxygen is essential for life, but by forming superoxides and free radicals, supplemental oxygen can also inflict damage on lung and other body tissues. The sweet spot for oxygen delivery in critically ill patients is unknown, but increasing evidence suggests that when it comes to blood oxygen saturation during critical illness, “normal” levels might actually [… read more]

Feb 142017
 
A Primer on the Perils of Intravenous Fluids – Part 2

Jon-Emile S. Kenny [@heart_lung] Read part 1 here Fluids and the Glycocaylx Critically-ill patients all likely have endothelial dysfunction to some degree.  This perturbation in microvascular physiology may be underpinned by abnormal glycocalyx structure and function.  Sepsis, trauma, surgery and ischemic insults are all known to disrupt the glycocalyx which will increase vascular fluid capacitance.  [… read more]

Feb 132017
 
A Primer on the Perils of Intravenous Fluids – Part 1

Jon-Emile S. Kenny [@heart_lung] “To every (wo)man is given the key to the gates of heaven. The same key opens the gates of hell.  And so it is with science.” -Richard Feynman A rich, frosty wind etherizes my face; this cool gust rips through the medieval, labyrinthine passageways of Old Stockholm like frayed edges of [… read more]

Feb 082017
 
Early renal replacement therapy in critical illness did not improve outcomes (AKIKI)

When is the optimal time to initiate renal-replacement therapy in the ICU? Patients with acute renal failure (a.k.a. acute kidney injury or AKI) in the ICU experience worse outcomes than patients who do not. As the kidneys shut down, toxic electrolytes and metabolic waste products build up in the blood. Intuition says — screams, really [… read more]

Feb 022017
 
CDC Releases Ventilator-Associated Events Criteria

A new term has been coined by the Centers for Disease Control and Prevention, ventilator-associated events (VAEs)¹. In 2011, the CDC convened a working group composed of members of several stakeholder organizations to address the limitations of the definition of ventilator-associated pneumonia (VAP) definition². The organizations represented in the Working Group include: the Critical Care [… read more]

Feb 012017
 
Passive leg raise test: helpful maneuver, or ICU parlor trick?

Patients who arrive at the hospital with hypotension will almost all receive intravenous fluid resuscitation (one hopes). When signs of hypoperfusion occur later in a patient’s hospital course, it can be much harder to decide if additional fluid will be helpful. Physical exam is unreliable, and no available technology can accurately identify how much water is [… read more]

Jan 242017
 
2016 Surviving Sepsis Guidelines: A Review and Analysis

By Jon-Emile S. Kenny [@heart_lung] PulmCCM is not affiliated with or endorsed by the Society of Critical Care Medicine or the Surviving Sepsis Campaign. Click here to read the Surviving Sepsis Guidelines. “I am at the moment writing a lengthy indictment against our century.  When my brain begins to reel from my literary labors, I make [… read more]

Jan 112017
 
ICU Physiology in 1000 Words: Hidden Hemodynamics in Respiratory Mechanics

Jon-Emile S. Kenny MD [@heart_lung] Hemodynamic assessment, by any means, demands a shrewd familiarity with mechanical heart-lung interaction.  The two ventricles communicate in series and in parallel; each ventricle’s pressure-volume characteristics and loading conditions pulsate between systole and diastole.  And around the heart and pericardium lies the respiratory pump – the lungs within the thorax [… read more]

Dec 242016
 
Pneumonia or Atelectasis?  Here's a trick to tell them apart

By Jon-Emile S. Kenny [@heart_lung] “New York is cold, but I like where I’m living … There’s music on Clinton Street all through the evening.” -Leonard Cohen It’s the end of December; we collectively reflect on the year that was and try to find our footing for the next.  In the short winter days of 2016, it [… read more]

Dec 012016
 
ICU Physiology in 1000 Words: The Folly of Pulmonary Vascular Resistance

By Jon-Emile S. Kenny [@heart_lung] When interpreting hemodynamic studies of drugs which – potentially – alter the resistance of the pulmonary vascular tree, we often turn to the calculated pulmonary vascular resistance [cPVR] as our guide.  For instance, a vasopressor determined to increase the cPVR is wholly avoided in a patient with pulmonary arterial hypertension.  We [… read more]

Nov 182016
 
Does intensive rehab and physical therapy in the ICU really help?

Every year, over a million people in the U.S. suffer respiratory failure requiring mechanical ventilation. They experience enormous catabolic stress, extended periods of inactivity, and usually go without their usual caloric intake. It’s no surprise that many are rendered profoundly debilitated by the experience. For many, this weakness and loss of muscle mass represents a second [… read more]

Nov 172016
 
Older transfused blood as good as fresh (INFORM)

What’s the shelf life of human blood? Like the milk in your fridge, stored donated human blood has an expiration date: currently it’s 42 days, set by the FDA. But is fresher blood actually better? As with ordering wine by the glass, should patients about to be transfused blood ask for “whatever was opened most recently”? There’s [… read more]

Nov 112016
 
Methylene Blue: the drug you’ve never used

By Jon-Emile S. Kenny [@heart_lung] “Major Major had been born too late and too mediocre. Some men are born mediocre, some men achieve mediocrity, and some men have mediocrity thrust upon them. With Major Major it had been all three …” -Joseph Heller In my younger days, parked on a bench overlooking Stanley Park, I sought [… read more]

Nov 092016
 
Almost half of intensivists feel severe burnout, report says

Almost half of critical care physicians report symptoms of severe burnout associated with their ICU work, according to a report and “call to action” from the Critical Care Societies Collaborative (CCSC). Symptoms of severe burnout were highest among pediatric critical care specialists, while 45% of intensivists caring for adults acknowledged severe burnout. Burnout symptoms include [… read more]

Nov 052016
 
Levosimendan in Septic Shock: the LeoPARDS study

By Jon-Emile S. Kenny [@heart_lung] “I want to be your medicine, I want to feed the sparrow in your heart …” -Kristian Matsson Case A 39 year old woman is admitted to the intensive care unit for hypotension, anuria and altered mentation despite 3 litres of intravenous lactated ringers infusion.  She is febrile and found to [… read more]

Oct 282016
 
Corticosteroids for sepsis didn't prevent septic shock (HYPRESS trial)

The idea that augmenting cortisol levels to normal or supranormal levels must be somehow beneficial in septic shock has a compelling basis in physiology and intuition. For physicians, injecting powerful synthetic hormones to restore homeostasis to save a dying patient is a seductive fulfillment of the scientist-savior fantasy. So intensivists were primed to believe the results of [… read more]

Oct 202016
 
Mechanical Circulatory Support Devices: What You Need to Know (Part 2 of 2)

The Rise of Mechanical Circulatory Support Devices What Critical Care Physicians Need to Know Felipe Teran-Merino M.D. Part 2 of 2 (read part 1)   II. Main MCS devices used for emergency and short-term support Intra-Aortic Balloon Pump The oldest and simplest mechanical device is the intra-aortic balloon pump (IABP). Introduced in 1968, the IABP is still used as a [… read more]

Oct 202016
 
Mechanical Circulatory Support Devices: What You Need to Know (Part 1 of 2)

The Rise of Mechanical Circulatory Support Devices What Critical Care Physicians Need to Know Felipe Teran-Merino M.D. Part 1 of 2 (read part 2)   I. The failing pump and hemodynamic rationale for the use of MCS devices The rising field of mechanical circulatory support (MCS) offers a spectrum of therapies and devices with the potential to rescue patients [… read more]