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Jan 212016
 
That Fallible IVC

A 58 year old man with ethanol-related cirrhosis is admitted to the floor with anuria and a rising creatinine.  Over the day, serial ultrasounds of his interior vena cava [IVC] consistently reveal that it is diminutive and collapsing.  He receives many liters of crystalloid without much change in his urine output.  In the middle of [… read more]

Jan 172016
 
Review: Lactate & Sepsis

On this snowy, Stockholm Sunday, I look out from my quarters on the Mälardrottningen across the still, icy waters and I think about a cirrhotic patient for whom I recently cared.  She presented with significant dyspnea as she had stopped taking her diuretics.  Instead, she was using excessive doses of her friend’s albuterol inhaler to treat [… read more]

Sep 172015
 
Overdiagnosis of pulmonary embolism on CT-angiogram by radiologists may be widespread

Contrasted CT-angiography of the chest, often called a “PE protocol CT,” has dramatically improved the diagnosis of pulmonary embolism. When used in conjunction with validated clinical decision tools like modified Wells criteria, CT-angiography is highly sensitive (good at detecting PE when it’s there and ruling it out when it’s not) and specific (generating few false-positive [… read more]

Aug 272015
 
Limited cancer screening seems appropriate after unprovoked PE

Cancers can cause pulmonary embolism, and an unprovoked PE may signal an undiscovered cancer lurking in the body. In older studies, as many as 1 in 10 patients with unprovoked PE were diagnosed with cancer within a year. (The current terminology is that a PE is provoked if associated with a known cancer or another provoking factor, but [… read more]

Aug 252015
 
Dabigatran-induced bleeding: antidote (idarucizumab) on the way

New oral anticoagulants like dabigatran, apixaban and rivaroxaban have advantages over warfarin: not requiring regular monitoring for efficacy; faster onset of action; shorter half-lives. Unlike warfarin, they’ve had the significant disadvantage of having no proven antidote for the bleeding that inevitably occurs when any anticoagulant is given to thousands of people. [lawsuits] Boehringer Ingelheim, makers [… read more]

Aug 252015
 
Are central lines really needed for vasopressor infusions?

image: Wikipedia There’s only one sure way to prevent complications from a central line: don’t place one. Like many invasive interventions, some of central venous catheters’ indications have been called into question in recent years. Monitoring of central venous pressure and central venous oxygen saturation via central IV access — once considered essential to good care [… read more]

Aug 232015
 
2015 ATS Guidelines on Treatment of IPF Released

ATS Releases New Idiopathic Pulmonary Fibrosis Treatment Guidelines Recent Studies Bring New Recommendations by Lekshmi Santhosh, MD This month, the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society and Latin American Thoracic Association released their updated guidelines on the treatment of idiopathic pulmonary fibrosis (IPF). They are free on the ATS website for all to peruse, but [… read more]

Aug 012015
 

ICU Physiology in 1000 Words Veno-Arterial Extra-Corporeal Membrane Oxygenation (VA-ECMO) Jon-Emile S. Kenny M.D. [@heart_lung] Perhaps the most memorable patient of both my pulmonary and critical care fellowships was that of a very young woman who suffered from propofol-related infusion syndrome [PRIS]. As a consequence of PRIS, she endured multiple cardiac arrests and was placed [… read more]

Jul 172015
 
Recurrent PE risk after long-term warfarin therapy remains high (PADIS-PE)

Not long ago, doctors were taught that 6 months of anticoagulation was plenty for patients with unprovoked pulmonary embolism. That standard was never based on long-term outcomes studies. And as longer-range data started to come in — gulp — it was clear that large numbers of people treated with 6-month warfarin courses after unprovoked PE [… read more]

Jul 172015
 
Bridging anticoagulation for procedures after DVT/PE: usually, more harm than help?

“Bridging” anticoagulation — usually, interrupting chronic warfarin therapy, starting injectable or intravenous heparin, stopping just before an invasive procedure, restarting heparin and warfarin after, then stopping heparin — is a cumbersome and common practice in medicine. A new paper in JAMA Internal Medicine suggests that for most patients taking anticoagulation after deep venous thrombosis (DVT) [… read more]

Jul 152015
 
Medicare will pay for death panels, I mean end-of-life counseling

Medicare announced last week it will finally pay doctors for their time spent talking to patients about their end-of-life preferences, among the most important medical decisions most people will make. The decision overcomes years of setbacks brought about by Sarah Palin’s politicizing of the Affordable Care Act’s provision for end-of-life counseling as endorsing “death panels” of [… read more]

Jul 022015
 
Direct thrombin inhibitors associated with heart attack risk in multiple trials

Direct thrombin inhibitors (DTIs) are anticoagulants (blood thinners) most often used as alternatives to heparin and warfarin. DTIs are approved by the FDA for prevention and treatment of venous thromboembolism (deep venous thrombosis and pulmonary embolism) and to prevent blood clots in people with atrial fibrillation. But multiple randomized trials suggest these widely used anticoagulants might cause heart [… read more]

Jul 012015
 
Families stall end of life talks, say doctors. True?

Doctors and nurses said patients and their families created the largest obstacles to end-of-life decision making in the ICU, in a large survey published in JAMA Internal Medicine. About 1,300 staff at 13 academic hospitals in Canada rated barriers to end-of-life goals of care on a 1-7 scale. Doctors and nurses considered the largest barriers [… read more]

Jun 252015
 
PulmCCM Journal Vol. 1, Issue 3 Now Available

Issue #3 of PulmCCM Journal, an open-access, peer-reviewed journal in pulmonary and critical care medicine, is now available online. Click the link, or the “Journal” tab in the menu bar on PulmCCM to read the latest issue of PulmCCM Journal. This issue’s featured concise clinical review is “Who should undergo intracranial pressure monitoring in acute liver failure?” by [… read more]

May 312015
 
SICU Basic Training (Video, Part 2 of 2)

Part 2 of a video lecture by Dr. Richard Savel, director of the surgical intensive care unit (SICU) at Maimonides Medical Center, Albert Einstein College of Medicine. Designed for an audience of SICU house staff, its content is applicable to non-surgical critically ill patients as well. Topics presented include shock; sepsis bundles; acid base status; [… read more]

May 292015
 
FDA approves once-daily tiotropium with olodaterol (Stiolto)

Image: Stuart Fisher The FDA approved Boehringer Ingelheim’s Stiolto, the latest of the new generation of once-daily inhalers for maintenance treatment of COPD. Stiolto contains the long-acting antimuscarinic agent tiotropium (Spiriva) and the long acting beta agonist olodaterol (marketed separately as Striverdi). Stiolto made it to approval based on 2 separate year-long phase III randomized [… read more]