By Jon-Emile S. Kenny [@heart_lung] “The only way to get rid of temptation is to yield to it.” -Oscar Wilde The Case A 76 year old woman without known medical comorbidity is ambulating along 7th avenue, rounding the corner where St. Vincent’s Hospital once operated. It is an exceptionally humid August afternoon and she has not [… read more]
By Jon-Emile S. Kenny [@heart_lung] “Half of the time we’re gone but we don’t know where, and we don’t know where …” -Paul Simon The Case A 42 year old man is admitted with fever, right upper-quadrant pain and jaundice. Over the last few hours he has become progressively confused and hypotensive. He has normal renal [… read more]
Jon-Emile S. Kenny [@heart_lung] “Rather than love, than money, than fame, give me truth.” -Thoreau The Case A 56 year old man with non-ischemic cardiomyopathy [LVEF 40% and mitral regurgitation] is admitted with severe sepsis due to appendicitis. One month prior to admission, his outpatient cardiologist saw him and noted a dry weight of 88 kg. [… read more]
Jon-Emile S. Kenny [@heart_lung] “Truth is like the sun, its value wholly depends upon our being at a correct distance away from it.” -Hjalmar Söderberg The evening is invigorating; the Stockholm Marathon has been run and cobblestoned cafés, concealed within winding, narrowed side-streets are in the throes of summer’s end. I take a coffee and [… read more]
Jon-Emile S. Kenny [@heart_lung] “We do not live in a privileged frame of reference.” -Carl Sagan It is a common human experience to feel that one is the exception. Indeed, the study of cosmology has demoted our – once privileged – place in the cosmos. We have fallen from the center of the universe to [… read more]
Jon-Emile S. Kenny [@heart_lung] 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 [… read more]
Jon-Emile S. Kenny [@heart_lung] “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 [… read more]
Jon-Emile S. Kenny [@heart_lung] “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 [… read more]
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]
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