Jan 082021
 
Kambô Intoxication for the Intensivist – Part 2

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]

Jan 072021
 
Kambô Intoxication for the Intensivist – Part 1

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]

Dec 312020
 
Epinephrine and Cerebral Blood Flow in Cardiac Arrest

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]

Nov 112020
 
ICU Physiology in 1000 Words: Pulmonary Vascular Resistance & Linear Assumptions

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]

Oct 302020
 
ICU Physiology in 1000 Words: On Venous Capacitance and the U.S. Election

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]

Oct 102020
 
ICU Physiology in 1000 Words: The Diastolic Shock Index & Subendocardial Perfusion

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]

Sep 122020
 
More on Corticosteroids in COVID-19 – Part 2: REACT meta-analysis

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]

Sep 102020
 
Prone Position in COVID-19 Studied with 3-Dimensional Trans-esophageal Echocardiography

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]

Sep 102020
 
More on Corticosteroids in COVID-19 – Part 1: REMAP-CAP, CAPE-COVID & CoDEX trials

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]

Sep 062020
 
Vitamin C, steroids, thiamine for septic shock: no benefit in ACTS trial

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]

Aug 182020
 
ICU Physiology in 1000 Words: Cardiothoracic Uncoupling & Venous Ergotrauma

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]

Jul 302020
 
ICU Physiology in 1000 Words: Patient Self-Inflicted Lung Injury – Part 2

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]

Jul 302020
 
ICU Physiology in 1000 Words: Patient Self-Inflicted Lung Injury – Part 1

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]

Jun 302020
 
A Brief Overview of Corticosteroids in COVID-19

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]

Jun 282020
 
A Brief Update on Angiotensin & Aldosterone Inhibition in COVID-19

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]

May 302020
 
COVID-19 Associated Coagulopathy: a contentious conundrum

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]

May 242020
 
Does the 65 Trial Dial Down the Mean Arterial Pressure in Sepsis?

Jon-Emile S. Kenny MD [@heart_lung] “This whole thing is not about heroism.  It’s about decency.  It may seem a ridiculous idea, but the only way to fight the plague is with decency.” -Albert Camus Background In 2013, Dünser and colleagues communicated a rogue viewpoint in shock resuscitation – let us do away with strict macro-hemodynamic goals [… read more]

Apr 302020
 
COVID-19 Associated ARDS: ‘CARDS’ & the L-Phenotype

Jon-Emile S. Kenny MD [@heart_lung] “No facts are to me sacred; none are profane; I simply experiment, an endless seeker with no Past at my back.” -Ralph Waldo Emerson Background  When Drs. Marini and Gattinoni author a letter describing a new phenotype of the acute respiratory distress syndrome [ARDS] encountered in patients infected with SARS-CoV-2, we [… read more]