Critical Care

Feb 092020
 
Vitamin C didn't improve septic shock in VITAMINS trial

A new randomized trial showed no benefit from intravenous vitamin C in patients with sepsis, but delays in treatment baked into the trial design will keep hope alive for true believers in the novel therapy. Vitamin C, hydrocortisone, and thiamine have been promoted as a lifesaving adjunctive therapy for septic shock, based on anecdotal data [… read more]

Feb 092020
 
The ‘Lacto-Bolo Reflex’

Jon-Emile S. Kenny MD [@heart_lung] “Sich regen bringt Segen” -German proverb Background It is an overcast day in Bern, Switzerland.  I have recently left Zermatt, having had the honour and pleasure of speaking at ‘The Big Sick’ conference.  I spent the day roaming the narrowed passages of this old, beautiful city.  In the midst of my [… read more]

Jan 202020
 
Adding Vitamin D no help in critical illness, even in deficient patients

Vitamin D supplementation brought no measurable benefits to vitamin D-deficient critically ill patients, in a large randomized trial published in the New England Journal of Medicine. Vitamin D supplementation has long been hoped for as a potential lifesaving therapy in critical illness. Many critically ill patients are vitamin D deficient, and deficiency increases the risk [… read more]

Jan 062020
 
ICU Physiology in 1000 Words: Shorthand Equations for Respiratory System Power

Jon-Emile S. Kenny MD [@heart_lung] Background This synopsis will address the basic geometric calculation of respiratory system work for a single breath [in joules] and power [i.e. joules/seconds or watts] which is work multiplied by the respiratory rate.  This geometric approach will then be used to explain two shorthand equations – the second of which was [… read more]

Dec 272019
 
The PHARLAP Trial: Recruitment Maneuvers Buy Stairway to Heaven?

Jon-Emile S. Kenny MD [@heart_lung] “Dying is a wild night and a new road.” -Emily Dickinson Background In 2006, a recruitment maneuver to achieve an ‘open lung’ was circulated; it has since been dubbed ‘stairway recruitment’ given its stepwise upthrusts in airway pressure [see figure 1]: Plodding up this ladder of airway pressure was meant to [… read more]

Dec 212019
 
ICU Physiology in 1000 Words: Asthmatic Mechanics

Jon-Emile S. Kenny MD [@heart_lung] Recently, Josh Farkas and Scott Weingart gave a series of engrossing posts and podcasts on asthma.  I especially liked their deliberations on mechanical ventilation which inspired me – no pun intended – to create a vodcast of my own and, like a novice troubleshooting a ventilator alarm, poke and prod at [… read more]

Dec 052019
 
Intubating robots are coming for your job (someday)

Undergraduate biomedical engineering students have developed the first prototype of a laryngoscope blade whose future iterations could allow novices or robots to intubate patients as well as expert humans. The new laryngoscope blade has embedded force sensors that calculate its location in the airway. The sensors were trained using machine learning, with tactile patterns generated [… read more]

Nov 302019
 
ICU Physiology in 1000 Words: Pulmonary Embolism & Right Ventricular Ischemia

Jon-Emile S. Kenny MD [@heart_lung] Commonly, we are sold that acute pulmonary thromboembolism [PE] burns the right ventricular [RV] candle at both ends.  This is because perfusion of the right coronary artery [RCA] is mediated by both its upstream mean arterial pressure [MAP] and downstream right ventricular end-diastolic pressure [RVEDP].  Given that a PE may decrease [… read more]

Nov 242019
 
ICU Physiology in 1000 Words: Pulmonary Embolism & Pulmonary Vascular Resistance

Jon-Emile S. Kenny MD [@heart_lung] What if I told you that in acute pulmonary thromboembolism [PE] that the initiation of intravenous norepinephrine [NE] decreases the calculated pulmonary vascular resistance [cPVR]?  Would you believe me?  Certainly, you would trust that an infusion of a thrombolytic does so.  Of great interest, both NE and thrombolytics decrease the cPVR [… read more]

Nov 172019
 
Vitamin E acetate in THC liquid is major cause of vaping lung injury, says CDC

The CDC has concluded that vitamin E acetate in vaping oils containing THC (tetrahydrocannabinol) is responsible for many cases of vaping-related lung injury. There have been over 2,051 confirmed and probable cases of e-cigarette or vaping-associated lung injury (EVALI), with 39 deaths. CDC made its advisement based on the consistent presence of vitamin E acetate [… read more]

Nov 112019
 
ICU Physiology in 1000 Words: Pulmonary Embolism & Syncope

Jon-Emile S. Kenny MD [@heart_lung] The transient and reversible loss of consciousness that may accompany pulmonary embolism [PE] is well-documented [1-7].  This brief post will not address the controversy regarding the prevalence of PE in ‘unexplained’ syncope; rather, it will focus on pathomechanisms and serve as the foundation for a few forthcoming entries on pulmonary thromboembolism [… read more]

Nov 072019
 
In sepsis, antibiotics reduced yield of blood cultures by almost 40%

by Molly Walker, Associate Editor, MedPage Today If you want an accurate reading from sepsis patients’ blood cultures, don’t start antibiotics until you’ve drawn the blood samples, a new study suggested. Among patients with severe sepsis, blood cultures taken prior to antibiotic therapy were positive for one or more microbial pathogens in 31.4% of patients [… read more]

Oct 312019
 
Vitamin C reduces mortality from sepsis with ARDS in CITRIS-ALI randomized trial ... ?

Vitamin C infusion has generated tremendous interest as an adjunctive treatment for patients with sepsis, since a widely publicized cohort study claimed vitamin C dramatically reduced sepsis-related mortality at a single institution. The publicity, the plausible pathophysiologic mechanism, and the lack of any therapy for sepsis have led many intensivists to prescribe the so-called Marik [… read more]

Oct 302019
 
Vaping-Associated Lung Injury – Part 2

Jon-Emile S. Kenny MD [@heart_lung] “There are sadistic scientists who hurry to hunt down errors instead of establishing the truth.” -Marie Curie In part 1 of Vaping-Associated Lung Injury, the very basics of electronic nicotine delivery systems [ENDS] were covered as well as highlights on clinical presentation, radiology and pathology.  In this second part, flurries of [… read more]

Oct 292019
 
Vaping-Associated Lung Injury – Part 1

Jon-Emile S. Kenny MD [@heart_lung] with illustration by Carla M. Canepa MD [@_carlemd_] “Inside the word ‘emergency’ is ‘emerge’; from an emergency, new things come forth.” -Rebecca Solnit Case A 32-year-old man is admitted with three days of fevers, chills, malaise, dyspnea and productive cough.  He works in a stressful job in the heart of Manhattan [… read more]

Oct 182019
 
Prolonged hypothermia improved neurologic outcomes after non-shockable cardiac arrests (HYPERION, CRICS-TRIGGERSEP)

Targeted temperature management (TTM, or therapeutic hypothermia) has become standard therapy after cardiac arrest, especially for ventricular tachycardia and fibrillation–so called shockable rhythms. A new randomized trial has shown that deep, prolonged cooling after cardiac arrest from non-shockable rhythms (PEA and asystole) improved neurologic outcomes. But how robust were the results, and should they change [… read more]

Sep 062019
 
Prophylactic IVC filters prevent PE in high-risk trauma patients, but were often unnecessary

Inferior vena cava filters placed prophylactically in patients hospitalized for trauma prevented symptomatic pulmonary embolism in those patients with persistent contraindications to anticoagulation, in a significant randomized trial. However, prophylactic IVC filter placement for all post-trauma patients did not improve outcomes generally. Trauma teams have always faced a difficult dilemma in the prevention and treatment [… read more]

Sep 032019
 
Advisory from CDC re: Severe Pulmonary Disease Associated with Using E-Cigarette Products

From the Centers for Disease Control and Prevention (CDC) and distributed here in the interest of the public health. PulmCCM is not affiliated with the CDC. Distributed via the CDC Health Alert Network August 30, 2019, 0935 AM ET (9:35 AM ET) CDCHAN-00421 The Centers for Disease Control and Prevention (CDC) is providing: 1) background [… read more]