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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]

Apr 222016
 
ICU Physiology in 1,000 Words: ARDS - Part 1

Jon-Emile S. Kenny [@heart_lung] “Often, as new knowledge progresses, old knowledge is abandoned or forgotten.” -Luciano Gattinoni In a succinct and current treatise, Gattinoni and Quintel outline the modern management of the acute respiratory distress syndrome [ARDS] [1].  It is imperative, they reason, that treatment of ARDS minimizes firstly, the mechanical power applied to the [… read more]

Mar 182016
 
The Physiologically Difficult Airway – Part 2

In part 2, I continue my commentary on this excellent review; part 1 may be found here.  In this post I will consider patients with severe metabolic acidosis and those with right ventricular [RV] dysfunction and/or failure. Severe Metabolic Acidosis In patients with severe metabolic acidosis, alveolar ventilation tends to be maximal as a compensatory mechanism.  [… read more]

Mar 112016
 
The Physiologically Difficult Airway – Part 1

To celebrate the birthday of Dr. Erin Hennessey [@ErinH_MD] – my former co-fellow and current Stanford intensivist-anesthesiologist – I will interpret a relatively recent and terrifically high-yield overview of physiologically challenging intubations.  In this must-read survey, the authors highlight particularly troublesome intubations not from the classic, anatomical perspective, but from the standpoint of the – [… read more]

Mar 012016
 
An Expected or Maladaptive Response to Infection?  Sepsis Reconsidered

“A man may take to drink because he feels himself to be a failure, and then fail all the more completely because he drinks … English … becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts.” George Orwell reminds us [… read more]

Feb 172016
 
Recruitment Maneuvers & PEEP in the Morbidly Obese

A recent study of applied respiratory physiology in the mechanically-ventilated, obese patient was published.  The ubiquitous focus on lung protective ventilation with “low” [physiological] lung volumes, and low plateau pressure may leave the obese patient susceptible to untoward respiratory embarrassment.  Excess abdominal and chest wall weight affect each of the following: reduction in lung volume, [… read more]