Jon-Emile S. Kenny MD [@heart_lung] “What time is this, to trade the handshake for the fist?” -Joni Mitchell Background As remarked by the authors of the recent PLUS trial, a systematic review and meta-analysis of randomized controlled trials comparing balanced resuscitation fluid to 0.9% saline was reported in the New England Journal of Medicine Evidence. This [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The tremendous, Hospitalist and the Resuscitationist [H & R] conference returns this May 18-21st in Montreal, Canada. I am humbled to participate this year and look forward especially since the conference was paused for 2021. I am certain that Dr. Philippe Rola, who has been organizing this meeting since 2018, will [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The world wavered and quivered and threatened to burst into flames.” -Virginia Woolf Background Intravenous fluid therapy is one of the most commonly-performed interventions in all of critical care medicine. Numerous trials over the last 20 years have attempted to identify the ideal fluid for those in the intensive care unit, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “… but prejudices, like odorous bodies, have a double existence, both solid and subtle – solid as the pyramids, subtle as the twentieth echo of an echo, or as the memory of hyacinths which once scented the darkness.” -Mary Ann Evans Background As previously described, the SARS-CoV-2 main protease inhibitor [Mpro] [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “When she smiles without her teeth in place she looks like a witch. But with them in her mouth she’s very pretty.” -Judy Blume Basic Biology The SARS-CoV-2 genome encodes structural proteins [i.e., spike, envelope, membrane, nucleocapsid] and polyproteins [i.e., pp1a and pp1ab]. When the guts of SARS-CoV-2 spew into a [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I find real life challenging enough. If I get to the dry cleaners without having a huge fight, that’s challenging enough.” -Fran Lebowitz Background Quite recently, the BaSICS investigators evaluated the infusion rate of a fluid bolus on patient outcome. As considered, however, contrast should be made between a fluid bolus, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “If you’re afraid of butter, use cream.” -Julia Child Background Early observational studies and the RECOVERY collaborative group initially demonstrated the benefit of corticosteroid therapy in oxygen-requiring, COVID-19-patients; additional randomized studies as well as a meta-analysis of these reports corroborated this. Yet the dosing of corticosteroids across the above studies was [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “It was after this realization that I began trying to find the ‘point’ of California, to locate some message in its history.” -Joan Didion Background A few months ago, I found myself in one of my favourite places – the American Museum of Natural History in New York City. Meandering through [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “… Sartre tells us that man makes himself this lack of being in order that there might be being.” -Simone de Beauvoir Background Like many early, proposed therapies for COVID-19, inhaled corticosteroids [ICS] had suggestive, conflicting evidence. For example, in a very large observational investigation – the OpenSAFELY platform – patients with both [… read more]
Jon-Emile S. Kenny MD [@heart_lung] About a decade ago, a handful of terrific reviews and investigations about phenylephrine – an alpha1 agonist – were published [1-3]. While this vasoactive medication might be thought only to ‘increase afterload,’ phenylephrine’s hemodynamic effects are knotty and noteworthy. Therefore, this dedicated dispatch delineates the difficulties encountered when predicting the hemodynamics [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “In those years, truth was elusive – as was my own faith that I could recognize and contain it.” -Mary Oliver Previously, the very basic underpinnings of fluvoxamine as a pharmacological method to quell cytokine unruliness was outlined. In brief, fluvoxamine is a sigma-1-receptor [S1R] agonist – an effect that opposes [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The left ventricular ejection fraction [LVEF] is a commonly-sought cardiac measure. With the explosion of bedside ultrasound and automated methods to capture LVEF, the ejection fraction will grow in clinical prominence and affect decisions for the acutely-ill. Asked the meaning of the LVEF, many clinicians might describe it as a ‘measure [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The relative simplicity of extending one’s finger onto the tissue overlaying a major artery belies the complicated forces generating an arterial pulse. Descriptions and physiological elucidations have been put forth across the decades, yet even today the machinations relating cardiac contraction to a waxing and waning arterial wall are a bit [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “He walked away across the room, his cowboy boots echoing like pistol shots.” -Sylvia Plath Background Implicit in resuscitation is speed. Throughout training we are zealously instructed that ‘time is tissue’ for all manners of compromised perfusion. We envision spendthrift mitochondria chewing through oxygen without regard to withering supply; as such, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “May I be the tiniest nail in the house of the universe, tiny but useful.” -Mary Oliver Background The use of ‘balanced’ intravenous fluids as compared to 0.9% saline – so-called ‘normal’ saline – has garnered much scientific interest in the last half-decade. Propelling some of this curiosity is a newfound [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “There are hills, rounded, blunt, burned, squeezed up out of chaos, chrome and vermilion painted, aspiring to the snow-line.” -Mary Austin With very basic introductions to heat transfer, the cardiovascular response to heat stress and the distinction between heat exhaustion and heatstroke, this final section addresses fundamental aspects of treating heat-related [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Tell me, what is it you plan to do, with your one wild and precious life?” -Mary Oliver When carbon dioxide retention tickles intensivists’ neurons, clusters of adjacent synapses spark in deep sulci – discharging neural silos of respiratory physiology, alveolar ventilation, pH interpretation and the like. But like flash-bulbs against [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I believe that the very process of looking can make a thing beautiful.” -David Hockney With the basics of temperature, heat and heat transfer described previously, this section turns to some select physiological aspects of heat-related illness. While this is clearly a very broad topic with multiple, intersecting avenues of discussion, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Study hard what interests you the most in the most undisciplined, irreverent and original manner possible.” -Richard Feynman Heat-related illness is a very common form of environmental injury. Like many insults, it may be modelled by ‘diathesis-stress.’ In other words, heat-related illness materializes at the cross-roads of inherent patient characteristics [e.g., [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Apocalypse is played out now on a personal scale; it is not in the sky above us, but in our bed.” -Mark Doty Introduction With a proposed pathway coupling pathogen-associated molecular patterns to the elaboration of pro-inflammatory cytokines, sketched lightly in part 1, this segment ties murine biomolecular theory to human [… read more]
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