Jon-Emile S. Kenny [@heart_lung] “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 [… read more]
Jon-Emile S. Kenny [@heart_lung] “A rising tide lifts all boats.” -John F. Kennedy Two years ago, heart-lung.org went live – a project borne out of my deep interest of the inter-connectedness of the cardiovascular and respiratory pumps. I have been truly amazed and deeply appreciative of the kind words which I have received from around [… read more]
Jon-Emile S. Kenny [@heart_lung] “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 [… read more]
Jon-Emile S. Kenny [@heart_lung] “… 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 [… read more]
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]
Jon-Emile S. Kenny [@heart_lung] How might you answer this oral board examination question? Describe the systemic effect on pH following 2 litres infusion of each of the following solutions: A. normal saline with a pH of 7.0 B. normal saline with a pH of 5.6 C. normal saline with a pH of 4.6. Pick [… read more]
Jon-Emile S. Kenny [@heart_lung] 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 [… read more]
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]
Jon-Emile S. Kenny [@heart_lung] In memory of a kind and gentle soul, I would like to share this brief and basic overview of the genetics of cystic fibrosis [CF]. While CF had been known to be an autosomal recessive gene since 1949 – given its inheritance pattern – it was in 1989 when researchers at [… read more]
Jon-Emile S. Kenny [@heart_lung] A 66 year old man presents to the emergency department with sudden-onset fevers, chills, and scant hemoptysis. He is hypoxemic, tachypneic and noted to have egophony with focal crackles and wheezing across his right, anterior chest. Further, he is found to be in acute kidney injury and his chest x-ray reveals [… read more]
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]
Jon-Emile S. Kenny [@heart_lung] 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 [… read more]
Jon-Emile S. Kenny [@heart_lung] I didn’t know Paul Kalanithi, but I knew of him; we shared patients. It was in January of my final year of fellowship, sitting in Tressider Union, when I received a link to his New York Times article from a colleague. Alone I sat, reading his reflection on being diagnosed with [… read more]
Jon-Emile S. Kenny [@heart_lung] 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 [… read more]
Jon-Emile S. Kenny [@heart_lung] “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.” [… read more]
Jon-Emile S. Kenny [@heart_lung] 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: [… read more]
By Jon-Emile S. Kenny [@heart_lung] The problem with the lung in the acute respiratory distress syndrome [ARDS] is not that it is stiff, but rather, that it is small [1]. In the 1980s, CT scans of the lungs of patients with ARDS revealed that the functional lung was attenuated in size and that dependent densities [… read more]
Jon-Emile S. Kenny [@heart_lung] 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. [… read more]
Jon-Emile S. Kenny [@heart_lung] 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 [… read more]
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]
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