I’m excited to share the link to Open Critical Care, a new hub providing open access critical care learning tools, COVID-19 treatment guidelines, and loads of other high-quality resources. Funded by USAID and directed by physicians at UCSF, it’s an endeavor worth following. Although their offerings are directed especially toward health care workers in resource-variable [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Booksellers are the most valuable destination for the lonely, given the numbers of books that were written because authors couldn’t find anyone to talk to.” – Alain de Botton Introduction An important reason for treating both tuberculosis and HIV with multiple pharmacological agents is the ability of these infectious scourges to [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “There are poisons that blind you, and poisons that open your eyes.“ – August Strindberg. In the introduction to kambô, or what Esparmer and colleagues called a “fantastic chemical cocktail with potential medical applications, unequaled by any other amphibian,” a superficial overview was offered. This first part included a very basic [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison.” -Paracelsus Background Per one account, many living in the village Kaxinauá were seriously-ill and the shaman could not help them with known herbal medicines. During a ritual involving ayahuasca, the [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I am a necessary part of an important search to which there is no end.” -Keith Haring Background With PARAMEDIC-2, the role of epinephrine in cardiac arrest, and especially its effects on cerebral perfusion and neurological outcome, have been appropriately questioned. Recall that Perkins and colleagues studied epinephrine in out-of-hospital cardiac arrest in a [… read more]
Jon-Emile S. Kenny MD [@heart_lung] A recent review of Paul Wood’s consummate approach to pulmonary hypertension is well-worth a read [1]. In it, the basic physiology of the calculated pulmonary vascular resistance [cPVR] is presented, as it often is, as a linear function. Recall, maybe traumatically, the grade-school equation y = mx + b. With this [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Administering norepinephrine during sepsis resuscitation has a myriad of hemodynamic effects [1]. Importantly, the predominant mechanism probably varies around multiple patient, intervention and time-dependent elements. Most commonly, perhaps, norepinephrine is provided to raise ‘mean arterial pressure’ – an effect driven by its alpha-agonist stimulation of pre-capillary arterioles. While this plays a [… read more]
Jon-Emile S. Kenny MD [@heart_lung] When we model the circulation at the bedside, we resort to generalizations. While these mechanistic heuristics don’t completely capture the complexity of hemodynamics, they do help us think quickly when confronted by clinical urgency. For example, distilling ‘venous return’ into an upstream pressure and downstream pressure separated by a single resistance, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “As human beings, don’t we need questions without answers as well as questions with answers?” -Alan Lightman With the publication of REMAP-CAP, CAPE-COVID and CoDEX, the World Health Organization [WHO] Rapid Evidence Appraisal for COVID-19 Therapies [REACT] Working Group combined these results with 4 other randomized trials of corticosteroids in COVID-19. [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “In that day there’s a moment when it all goes away …” -The Tallest Man on Earth A recent case series reporting experience with 3-dimensional trans-esophageal echocardiography in moderate-to-severe COVID-19 associated lung injury was published in Intensive Care Medicine. With only 9 patients described the findings are, nevertheless, noteworthy because of [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Let us try to assume our fundamental ambiguity.” -Simone de Beauvoir When the pre-peer review RECOVERY trial was released in mid-June of this year, clinicians lost equipoise to enroll hospitalized patients receiving at least oxygen for COVID-19 into trials including a treatment arm without corticosteroids. This brought to an early-halt three [… read more]
A combination of vitamins C and B1 with corticosteroids didn’t prevent organ failure in septic shock, the ACTS trial showed. The intervention improved the Sequential Organ Failure Assessment (SOFA) score 4.7 points compared with a 4.1-point improvement with placebo over the 72 hours after enrollment, which was not significant at P=0.12 for interaction, reported Michael Donnino, [… read more]
Thank you for the warm support regarding this volume. Errata will be listed on this page. Versions downloaded prior to Sept. 16, 2020 included the following error: chapter 2, page 43 incorrect equation 2. The axial pressure difference is directly proportional to both flow and resistance. This equation should match equation 3 in chapter 1, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Pulmonary Elastic Ergotrauma There are hidden hemodynamics in respiratory mechanics, as previously discussed. Recall that these relationships are illustrated by comparing volume-pressure, or compliance curves. Trans-pulmonary pressure, which approximates pulmonary stress, is the pressure in the airway compartment less the pleural pressure [1]. In a passive, mechanically-ventilated patient, the trans-pulmonary pressure [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In part 1, evidence for and against spontaneous breathing effort in acute respiratory distress syndrome [ARDS] was briefly outlined. The mechanisms of patient self-inflicted lung injury [P-SILI] are touched upon herein with reconciliation of the clinical and experimental data. Mechanisms: basics A handful great reviews on spontaneous breathing in ARDS and [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Background In an excellent review from early 2016, Gattinoni and Quintel note that ventilator induced lung injury [VILI] is better considered ventilation induced lung injury because VILI can develop during spontaneous breathing [1]. To support this claim, they reference a classic experimental study from the late 1980s by Mascheroni and colleagues [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “ This is the way the world ends Not with a bang but with a whimper.” -T.S. Eliot As lightly discussed a few months ago, deploying corticosteroids in COVID-19 began, expectedly, with controversy. Russell and colleagues submitted a letter arguing against wholesale administration of corticosteroids in patients infected with SARS-CoV-2. They [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “We’re on a road to nowhere …” -David Byrne Background In early March of this year, Fang and colleagues published a letter noting that patients with diabetes and/or hypertension treated with ACE inhibitors or angiotensin II type-1 receptor blockers [i.e. ARBs] increase their expression of the ACE2 enzyme. Parenthetically, they also stated [… read more]
Tracheostomy in COVID-19: Many opportunities, limited evidence By Andrew DeMaio, M.D. and David Feller-Kopman, M.D. Let’s start with a case – one that unfortunately we have seen way too frequently over the past few months. A 61-year-old man with ESRD on hemodialysis and prior pulmonary embolism was admitted to the ICU for ARDS due to [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Knavery and flattery are blood relations.” -Abraham Lincoln Background SARS-CoV-2 is a positive-sense, single-stranded RNA virus with spiked surface glycoproteins emanating from its viral envelope. It is a member of the Coronaviridae family, similar to the first SARS [SARS-CoV] and the Middle East Respiratory Syndrome [MERS]. SARS-CoV-2 preferentially targets respiratory epithelium, [… read more]
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