Critical Care

Apr 042018
 
Are balanced crystalloids better than saline? SMART Talk with Dr. Michael Pinksy

Jon-Emile S. Kenny MD [@heart_lung] “Each time new experiments are observed to agree with the predictions, the theory survives and our confidence in it is increased; but if ever new observation is found to disagree, we have to abandon or modify the theory.” — Stephen Hawking A 47 year old man with fever, right upper [… read more]

Mar 242018
 
High-Flow Nasal Cannula, Work of Breathing & Mechanical Power: is there benefit?

Jon-Emile S. Kenny MD [@heart_lung] “I grow old … I grow old … I shall wear the bottoms of my trousers rolled.” -T. S. Eliot Background While it is tempting to isolate nasal high flow [NHF] into one’s cognitive schema for hypoxemia, NHF rightly deserves an esteemed position within one’s cerebral scaffolds for both hypercapnia [… read more]

Mar 122018
 
Is There Synergy between PEEP & Prone Position in ARDS?

Jon-Emile S. Kenny MD [@heart_lung] “… when you walk around a kitchen, you will say to yourself, this is interesting, this is grand, this is beautiful like Chardin.” -Marcel Proust Background Titration of positive end-expiratory pressure [PEEP] in the acute respiratory distress syndrome [ARDS] is achieved by a diverse assortment of practices undergirded by equally [… read more]

Mar 092018
 
Does Piperacillin-Tazobactam Cause Renal Failure?

The combination of the antibiotics piperacillin-tazobactam and vancomycin is so often used as empirical antibiotic coverage for severe infections in hospitalized patients that it’s been dubbed “Vosyn.” Vancomycin’s nephrotoxicity is well-known, requiring close monitoring of serum levels; pip-tazo has been seen to prolong increased creatinine levels (without significant known direct nephrotoxicity).  Reports have surfaced in [… read more]

Mar 082018
 
Hydrocortisone plus fludrocortisone improved survival from septic shock (APROCCHSS trial)

Patients with septic shock who received hydrocortisone and fludrocortisone together had improved survival compared to patients receiving placebo, according to a large randomized trial (APROCCHSS) published in the New England Journal of Medicine. From 2008-2015, investigators enrolled 1,241 patients in France with septic shock for less than 24 hours to receive either hydrocortisone 50 mg [… read more]

Mar 022018
 
Corticosteroids do help in sepsis: ADRENAL trial

Stress-dose corticosteroids appear safe and generally beneficial in patients with septic shock undergoing mechanical ventilation, without improving survival. That’s the takeaway from the ADRENAL trial recently published in the New England Journal of Medicine. Investigators (led by the famed ANZICS collaborative) randomized 3,800 patients with septic shock requiring mechanical ventilation in 69 medical-surgical ICUs around the [… read more]

Feb 222018
 
The Great Lactate Debate Part 2: can we ‘myth-bust’ the strong ion approach?

Jon-Emile S. Kenny MD [@heart_lung] “The truth is rarely pure and never simple.” -Oscar Wilde In part 1, the crux of this ‘Great Lactate Debate’ was distilled into the unclear origin of the proton in the setting of ‘lactic acidosis.’  Is the [H+] secondary to biochemical work and ATP hydrolysis or is the proton from [… read more]

Feb 192018
 
The Great Lactate Debate Part 1: should we be counting protons or strong ions?

Jon-Emile S. Kenny MD [@heart_lung] “….  She was here on earth to grasp the meaning of its wild enchantment and to call each thing by its right name …” -Boris Pasternak Background Over the last half-decade, there has been a distinct shift in the approach to lactate elevation.  The long-held belief that elevated serum lactate [… read more]

Feb 112018
 
Vasopressors and Inotropes for Shock Syndromes: Review

Overview Vasopressors and inotropes are cornerstones in the management of shock syndromes. Understanding vasopressors’ receptor activity and resultant pharmacological response enables clinicians to select the ideal vasopressor(s) for a patient suffering from shock. The following table outlines common vasopressors/inotropes and their general receptor activity profiles.1,2 Drug Dose α1 ß1 ß2 DA V1 V2 cAMP Norepinephrine [… read more]

Jan 292018
 
ICU Physiology in 1000 Words: Venous Doppler & Volume Tolerance

Jon-Emile S. Kenny MD [@heart_lung] With the birth of ‘fluid responsiveness’ physiology [1], there has been a slow and solemn drumbeat ushering the central venous pressure [CVP] up the squeaking planks of the hemodynamic gallows [2, 3].  Despite this, a few years ago I made a humble defense of the central venous pressure.  Importantly, I was [… read more]

Jan 232018
 
Conference: The Hospitalist & The Resuscitationist April 18-19

The Hospitalist & The Resuscitationist April 18-19, 2018 Two awesome days in Montreal where we focus on basics, but the right basics. The key points, the key pearls, and especially, the key physiological points in managing sick people. Day 1, pretty sick people. Day 2, really sick people. Do one day, do both, whatever fits [… read more]

Jan 202018
 
Prone positioning for severe ARDS advised by major societies

In case you missed it, major professional societies in critical care now strongly recommend prone positioning for patients with severe acute respiratory distress syndrome (ARDS), with a PaO2-to-FiO2 (P/F) ratio of ≤ 100. The recommendation marks a major shift in advised care for ARDS. Prone positioning improves ventilation-perfusion matching (transferring delivered oxygen into the bloodstream more [… read more]

Dec 262017
 
ICU Physiology in 1000 Words: Visualizing Heart-Lung Interaction

Jon-Emile S. Kenny MD [@heart_lung] “Upward, not northward.” -E. A. Abbott A pressure chamber within a pressure chamber; the heart within the thorax.  These are two pumps beating in-and-out of time, varying in physiology and pathophysiology between patients and within any one patient during the arc of an illness.  As such, when we inspect the [… read more]

Dec 182017
 
Esmolol in Sepsis: Microcirculatory Savior or Autoregulation Annihilator?

Jon-Emile S. Kenny MD [@heart_lung] Background If venous pressure were always the downstream pressure of an artery, then when flow is zero, the arterial pressure should equal the venous pressure.  For example, if one were to measure the coronary artery pressure and coronary sinus pressure at zero flow, their pressures should be equal.  Yet, this [… read more]

Dec 142017
 
Sedation interruptions were even more helpful in surgical patients

Most good medical intensive care units have incorporated interruptions in sedation (so-called ‘sedation vacations’) into standard care for patients receiving mechanical ventilation. Avoiding excessive sedation in general is believed to reduce prolonged mechanical ventilation in ICUs. However, there is surprisingly little data about effects of sedation (or over-sedation) on critically ill postoperative patients in the [… read more]

Dec 082017
 
Meropenem-vaborbactam (Vabomere), a new combination antibiotic + inhibitor, now available

Intensivists have another antibiotic combination to treat severe infections caused by gram-negative bacteria with the FDA’s approval of Vabomere (meropenem, combined with the beta-lactamase inhibitor called vaborbactam). FDA approved Vabomere only for the treatment of complicated urinary tract infections (such as pyelonephritis). However, licensed U.S. physicians routinely prescribe FDA-approved antibiotics “off-label” for other indications. Meropenem-vaborbactam [… read more]

Dec 022017
 
A Great Lecture on Applied Respiratory Physiology

Jon-Emile S. Kenny MD [@heart_lung] -What is the world record for longest breath hold? -Why does the diagnosis of brain death require a rise in PaCO2 to at least 60 mmHg? -What minute ventilation can a human achieve? -What’s the difference between an elevated PaCO2 in someone who ‘won’t’ versus ‘can’t’ breathe? I’d like to [… read more]

Dec 012017
 
Should patients watch videos of CPR before code status decisions?

Physicians and patients alike tend to avoid frank discussions about “code status” — whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If [… read more]

Nov 262017
 
Sepsis, Diastolic Dysfunction & Hypernatremia

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “… And you may ask yourself … well, how did I get here? … And you may tell yourself … my God!  What have I done?” -David Byrne A 92 year old woman is transferred to the coronary care unit for treatment of pulmonary edema.  She [… read more]

Nov 192017
 
Should intensivists routinely perform bedside echos in suspected PE?

In pulmonary embolism (PE), right ventricular (RV) strain on transthoracic echocardiography increases the likelihood of shock and mortality. One study showed among patients with PE and normal blood pressure, 10% of those with RV strain on echocardiogram developed shock, and 5% died in hospital. Those without RV strain maintained their blood pressure and survived (but important [… read more]