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]
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]
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]
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]
Jon-Emile S. Kenny MD [@heart_lung] “I had some dreams, they were clouds in my coffee, clouds in my coffee …” -Carly Simon Background A recent letter to the editor in Critical Care posed a rather provocative question – ‘Are we really preventing lung collapse with APRV?’ The authors cited a case report of esophageal manometry used in [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In part 1, the basics of ventriculo-arterial coupling [VAC] were described and related to the Guyton Diagram. In this second part, the notion of cardiac performance [Eh] is explored in relation to venous Doppler velocimetry. Subsequently, I hypothesize that ‘veno-cardiac uncoupling’ – a concept analogous to VAC – is a [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Background Concepts have been clanging around my head since I participated in Philippe Rola’s [@thinkingCC] sedulous Hospitalist & Resuscitationist Conference in Montreal. Initially, the abstractions of ventriculo-arterial coupling, Guytonian physiology and venous Doppler seemed insuperably sundered; but the cognitive haranguing recently gave way to harmony. What is ventriculo-arterial coupling and [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’ve looked at clouds from both sides now …” -Joni Mitchell Background In a recent physiological study – brought to my attention by the erudite and kinetic [@iceman_ex] – the detailed physiological effects of intravenous fluids, norepinephrine and dobutamine were sequentially evaluated in patients with sepsis. Sepsis was defined as [… read more]
In a new randomized trial, use of dexmedetomidine (Precedex) as the primary sedative in mechanically ventilated patients in the ICU resulted in no reduction in 90 day mortality. Dexmedetomidine resulted in a small improvement in delirium and ventilator days, but was almost never adequate to sedate patients on its own, and brought a small increase [… read more]
Continuous neuromuscular blockade for severe ARDS became common practice after the ACURASYS trial (2010) showed it reduced mortality by an absolute 9%. A larger trial, ROSE, now finds no benefit of the therapy over usual care — but leaves lingering questions due to major design differences. The ROSE trial was a multicenter randomized trial in [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I am fearful, or suspicious of generalizations … they cannot guide me reliably in making decisions about particular individuals.” -Ruth Bader Ginsburg Between the 22nd and 24th of May, I participated in the “Hospitalist and the Resuscitationist” conference in Montreal, Canada. I spoke on the stanchions of physiology and evidence [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “There is no power for change greater than a community discovering what it cares about.” -Margaret J. Wheatley Between the 22nd and 24th of May, I participated in the galvanic, second-annual “Hospitalist and the Resuscitationist” conference in Montreal, Canada. The entirety of this meeting was organized by Dr. Philippe Rola [… read more]
Jon-Emile S. Kenny MD [@heart_lung] More than 20 years ago Amato and colleagues reported a significant mortality reduction in ARDS patients who had their ventilator settings guided by the pressure-volume [PV] curve [1]. The 28-day mortality reduction was profound – 71% versus 38% – in favour of the patients who had their positive end-expiratory pressure [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I am suffocated and lost when I have not the bright feeling of progression” -Margaret Fuller A recent letter and review in Critical Care have called for adoption of the ‘Open Lung Approach’ to patients with severe ARDS. More specifically, in refractory ARDS whilst prone, it is argued that esophageal [… read more]
“Nihilist” is one of the harshest insults that can be lobbed at a physician. Even while one knows intellectually that every patient can’t be saved, it’s considered odious to openly acknowledge that actuarial reality. Accepting the truth that some patients will inevitably die despite our best efforts is seen by some as the threshold of [… read more]
In acute respiratory distress syndrome (ARDS), using pleural pressure to adjust positive end-expiratory pressure (PEEP) has long been considered a cumbersome but theoretically ideal technique to optimize ventilator management. Using esophageal pressure as a surrogate for pleural pressure can allow one to calculate and minimize the transpulmonary pressure gradient, elevations in which are the putative [… read more]
A review of studies comparing 24/7 in-house intensivist physician coverage with less-intensive models (with no intensivist in the ICU overnight) found no clear or consistent benefits associated with in-house intensivist coverage. Authors informally reviewed about 50 previous studies and meta-analyses. They concluded that in-house intensivists overnight might reduce ICU length of stay by a few [… read more]
A randomized trial confirmed what most intensivists have long believed and practiced: in the moments before endotracheal intubation, we should help patients achieve the highest arterial oxygen saturation possible, using bag-mask ventilation (BMV). This seems self evident — why wouldn’t we? Bag-mask ventilation can distend the stomach with air, potentially increasing the risk for vomiting [… read more]
Guidelines advise physicians give large boluses of intravenous crystalloid infusions (two to three liters, generally) to patients with septic shock. Vasopressors are typically begun only if patients’ blood pressure remains low after fluid administration. A vocal minority of researchers have advised against delaying vasopressors in septic shock, arguing that norepinephrine, not intravenous fluid, is the [… read more]
by Nicole Lou, Contributing Writer, MedPage Today HONOLULU — Andexanet alfa (Andexxa), the reversal agent for anticoagulants in the factor Xa inhibitor class, worked for patients who developed acute major bleeding while on one of these agents, the full report of the ANNEXA-4 study confirmed. A bolus of the antidote saw median anti-factor Xa activity drop more [… read more]
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