PulmCCM - All the best in pulmonary & critical care
Oct 282016
Corticosteroids for sepsis didn't prevent progression to 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. Injecting powerful synthetic hormones to restore homeostasis to save a critically ill patient is a perfect fulfillment of the physician-scientist hero myth. So intensivists were primed to believe the [… read more]

Oct 212016
PESIT Investigators: the incidence of PE in those hospitalized following first syncope

“The only way to get rid of temptation is to yield to it.” -Oscar Wilde The Case A 76 year old woman without known medical comorbidity is ambulating along 7th avenue, rounding the corner where St. Vincent’s Hospital once operated.  It is an exceptionally humid August afternoon and she has not been eating well because [… 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]

Oct 142016
Piperacillin-Tazobactam: The Antibiotic You’re Not Administering Correctly

“Half of the time we’re gone but we don’t know where, and we don’t know where …” -Paul Simon The Case A 42 year old man is admitted with fever, right upper-quadrant pain and jaundice.  Over the last few hours he has become progressively confused and hypotensive.  He has normal renal function with adequate urine [… read more]

Sep 252016
Sepsis-Associated AKI – Bellomo Kidney – Implications for Management

“Rather than love, than money, than fame, give me truth.” -Thoreau The Case A 56 year old man with non-ischemic cardiomyopathy [LVEF 40% and mitral regurgitation] is admitted with severe sepsis due to appendicitis.  One month prior to admission, his outpatient cardiologist saw him and noted a dry weight of 88 kg.  On admission to the [… read more]

Sep 102016
Let’s Plan for Extubation in the Morning

“Truth is like the sun, its value wholly depends upon our being at a correct distance away from it.” -Hjalmar Söderberg The evening is invigorating; the Stockholm Marathon has been run and cobblestoned cafés, concealed within winding, narrowed side-streets are in the throes of summer’s end.  I take a coffee and meander about the Grand [… read more]

Aug 312016
Anemia & the Injured Brain

“We do not live in a privileged frame of reference.” -Carl Sagan It is a common human experience to feel that one is the exception.  Indeed, the study of cosmology has demoted our – once privileged – place in the cosmos.  We have fallen from the center of the universe to inhabiting but one planet [… read more]

Aug 262016
Rising Lactate & the Art of Venous Blood Gas Interpretation

A 23 year old woman is admitted with severe abdominal pain following 5 days of profound non-bloody diarrhea and 72 hours of recalcitrant non-bloody emesis.  She has lost 7 pounds in this time frame and has been unable to maintain oral hydration.  Her eyes are sunken and her vital signs are notable for a heart [… read more]

Aug 252016
FAQ: How To Study for the Critical Care Medicine Board Examination?

“Let the wild rumpus start!” -Maurice Sendak Many of you are preparing for the Critical Care Medicine Board Examination; thank you to those who have downloaded my free review notes.  I often receive a question or two about the exam and how germane my notes were, in retrospect.  This is a difficult question to answer [… read more]

Jul 302016
IDSA Guidelines 2016: HAP, VAP & It’s the End of HCAP as We Know It (And I Feel Fine)

“It is important to realize that guidelines cannot always account for individual variation among patients.  They are not intended to supplant physician judgement with respect to particular patients or special clinical situations.” -IDSA/ATS Guidelines 2016 A 73 year old man is admitted from a nursing home for an NSTEMI and is treated on the telemetry [… read more]

Jul 142016
Intra-abdominal Pressure and Renal Function: The Venous Side of the Road

“An’ it ain’t no use in turnin’ on your light, babe, I’m on the dark side of the road …” -Bob Dylan A 44 year old man with cryptogenic cirrhosis is admitted with large ascites and acute kidney injury.  A 50 mL, diagnostic paracentesis reveals 12 PMNs and he is admitted from the emergency department for further [… read more]

Jul 072016
The Revised Starling Principle: Implications for Rational Fluid Therapy

“Doctrine once sown strikes deep its root, and respect for antiquity influences all men.” -William Harvey [1628] The use of hyperoncotic albumin to draw fluid from the interstitial space permeates dark corners of the critical care community.  The ‘pull and push’ of 25% albumin followed by furosemide remains somewhat of a cryptic lore – its [… read more]

Jun 122016
Blood Pressure Goals in Intracerebral Hemorrhage - ATACH II

“… it is a tale.  Told by an idiot, full of sound and fury, signifying nothing.” Macbeth: Act V, Scene V The results of the ATACH II trial are out; we have even more guidance when managing the blood pressure of hypertensive patients with supratentorial, intra-cerebral hemorrhage of less than 60 cm3 in volume.  The question: [… read more]

Jun 112016
ICU Physiology in 1,000 Words: ARDS - Part 3

Jon-Emile S. Kenny [@heart_lung] While parts 1 and 2 of this trilogy considered the mechanical power applied to the lung skeleton and the effects of lung inhomogeneity [i.e. ‘stress raisers’], respectively; this final installment will draw the reader towards the pulmonary vasculature as a key mediator of ventilator induced lung injury [VILI].  That the pulmonary [… read more]

Jun 102016
Call for Abstracts: Pittsburgh-Munich International Lung Conference

Have you submitted your abstract to the 2016 Pittsburgh – Munich International Lung Conference? Concurrent submissions are accepted!  Use the abstracts you have submitted this spring for other national/international conferences (i.e. ATS) for a chance to further showcase your work.  Click on the links below to begin. The 2016 Pittsburgh – Munich International Lung Conference [… read more]

May 282016
The Cerebral Circulation and Sepsis-Associated Delirium

The Journal of Intensive Care has newly published a series of sepsis-related organ dysfunction reviews.  Additionally, a comprehensive yet concise overview of the cerebral circulation was just disseminated.  This summary draws on both of these terrific primary resources as a point-of-departure for discussion of sepsis-associated delirium [SAD]. Cerebral blood flow [CBF] ultimately depends on 1. the [… read more]

May 012016
ICU Physiology in 1,000 Words: ARDS - Part 2

Jon-Emile S. Kenny [@heart_lung] Gattinoni and Quintel have, very recently, outlined their approach to managing the acute respiratory distress syndrome [ARDS] [1].  They argue that treatment of ARDS should minimize firstly, the mechanical power applied to the lungs – as described in part 1.  Secondly, Gattinoni and Quintel note that, in the treatment of ARDS, [… read more]