Critical Care

Oct 202016
 
Mechanical Circulatory Support Devices: What You Need to Know (Part 1 of 2)

The Rise of Mechanical Circulatory Support Devices What Critical Care Physicians Need to Know Felipe Teran-Merino M.D. Part 1 of 2 (read part 2)   I. The failing pump and hemodynamic rationale for the use of MCS devices The rising field of mechanical circulatory support (MCS) offers a spectrum of therapies and devices with the potential to rescue patients [… read more]

Oct 142016
 
Piperacillin-Tazobactam: The Antibiotic You’re Not Administering Correctly

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]

Sep 252016
 
Sepsis-Associated AKI – Bellomo Kidney – Implications for Management

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]

Sep 102016
 
Let’s Plan for Extubation in the Morning

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]

Aug 262016
 
Rising Lactate & the Art of Venous Blood Gas Interpretation

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]

Jul 142016
 
Intra-abdominal Pressure and Renal Function: The Venous Side of the Road

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]

Jul 072016
 
The Revised Starling Principle: Implications for Rational Fluid Therapy

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]

Jun 122016
 
Blood Pressure Goals in Intracerebral Hemorrhage - ATACH II

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]

Jun 112016
 
ICU Physiology in 1,000 Words: ARDS - Part 3

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]

May 282016
 
The Cerebral Circulation and Sepsis-Associated Delirium

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]

May 012016
 
ICU Physiology in 1,000 Words: ARDS - Part 2

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]

Apr 222016
 
ICU Physiology in 1,000 Words: ARDS - Part 1

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]

Mar 182016
 
The Physiologically Difficult Airway – Part 2

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]

Mar 112016
 
The Physiologically Difficult Airway – Part 1

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]

Mar 012016
 
An Expected or Maladaptive Response to Infection?  Sepsis Reconsidered

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]

Feb 172016
 
Recruitment Maneuvers & PEEP in the Morbidly Obese

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 respiratory embarrassment.  Excess abdominal and chest wall weight affect each of the following: reduction [… read more]

Feb 132016
 
ICU Physiology in 1000 Words: Driving Pressure & Stress Index

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]

Jan 212016
 
That Fallible IVC

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 inferior 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]