Jon-Emile S. Kenny MD [@heart_lung] “The truth is balance, but the opposite of truth, which is unbalance, may not be a lie.” -Susan Sontag Case A 49 year old man presents with two days of hemoptysis, right-sided pleuritic chest pain and a few hours of ‘confusion’ according to his teammate in a pick-up hockey league. One [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Nolite te bastardes carborundorum” -Margaret Atwood Case An 86 year old woman presents with two days of decreased intake by mouth and 3 days of melena and vomiting. She is followed closely by her internist and cardiologist for hypertension, severe mitral regurgitation, pulmonary venous hypertension and right ventricular dysfunction with co-morbid [… read more]
After a review of reported adverse events, the U.S. FDA is warning physicians that fluoroquinolone antibiotics may increase the occurrence of aortic dissections, resulting in aortic rupture and death. FDA used unusually direct language in advising, “Fluoroquinolones should not be used in patients at increased risk unless there are no other treatment options available.” Patients [… read more]
Pressing fingers against the cricoid cartilage (the Sellick maneuver) during rapid sequence intubation compresses the esophagus beneath the firmer trachea. It has long been espoused that this prevents aspiration (emesis or reflux of gastric contents into the supraglottic space and airway, obscuring the operator’s view and harming the patient). The Sellick maneuver is believed to [… read more]
Tennessee law enforcement agents announced they had arrested and charged a nurse with reckless homicide and patient abuse for a fatal medication error she allegedly committed while working at Vanderbilt University Medical Center in December 2017. The charges allege that the nurse intended to provide an ordered dose of midazolam (Versed) to an anxious patient [… read more]
A large proportion of patients who remain in ICUs for more than a few days develop hospital-acquired infections, including bloodstream infections. Indwelling urinary or venous catheters, gut translocation, aspiration and impaired host defenses can all be causative. Bloodstream infection incidence has been reduced over time, but remains persistently ineradicable. One enticing method of prevention has been [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Why is blood pressure measured by units of length [i.e. millimeters of mercury – mmHg]? What decides systolic and diastolic pressure? What are the determinants of tissue perfusion and what are the clinical implications of this physiology? Can we deceive ourselves into thinking a particular mean arterial pressure [MAP] is [… read more]
By Nicholas Mark, MD During the 1940s, many Melanesian cultures were profoundly altered as the Second World War was waged in the Pacific around them. Western soldiers constructed airstrips out of the jungles and the natives witnessed vast wealth in the form of manufactured goods literally rain down from the skies on parachutes or carried [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’m burnin’ through the sky, yeah Two hundred degrees, That’s why they call me Mister Fahrenheit” -Freddie Mercury Part 1 gave a brief overview of the mechanisms of atrial fibrillation [AF] as well as pertinent features of rate controlling agents and anticoagulation. In this brief second part, nuanced features of ventricular [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “The habit of writing for my eye is good practice. It loosens the ligaments.” ― Virginia Woolf Case A 28 year old woman with known severe mitral stenosis from rheumatic heart disease presents with acute onset shortness of breath. Her acute dyspnea began while [… read more]
In an unusual turn, the Society for Critical Care Medicine (SCCM) is advising against implementation of the one-hour sepsis bundle originally advocated in Spring 2018 by committee members of its Surviving Sepsis Campaign. SCCM and American College of Emergency Physicians (ACEP) issued a joint statement in which they acknowledged “concerns expressed about the recently released Surviving [… read more]
For acutely ill patients, oxygen saturation should not exceed 96%, an international panel recommended. A multidisciplinary team of clinicians was brought together by The BMJ as part of the Rapid Recommendation initiative to focus on the most effective approach to oxygen therapy for patients with acute medical illness. The team used findings from an April 2018 systematic [… read more]
Best of 2018: Prone positioning for severe ARDS advised by major societies 2018 Update to Surviving Sepsis Guidelines: Cue Backlash Management of Ground Glass and Subsolid Pulmonary Nodules: Review Vasopressors and Inotropes for Shock Syndromes: Review Prophylactic Precedex prevented delirium in ICU patients Corticosteroids do help [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Remarkably, non-invasive cardiology did not begin with ultrasound but rather as investigations into systolic time [1]. Indeed, studies on the duration of systole began in 1875 with Garrod who showed that the left ventricular ejection time [LVET] – the time that the aortic valve is open and ejecting blood – varies [… read more]
More than 60% of patients receiving mechanical ventilation have continued to receive daily chest x-rays since the publication of guidelines recommending against the practice. The findings came from a database review of hundreds of thousands of patients and were published in JAMA Network Open. The American College of Radiology once recommended daily chest films in [… read more]
Obese people are significantly more likely to survive severe illness due to infections, as compared to people with normal weights, according to analyses of three large data sets presented at a European conference. Among more than 1.5 million hospitalizations for pneumonia in the U.S. between 2013-2014, obese patients (BMI > 30) were 29% more likely [… read more]
Another large study suggests that there is no benefit to early initiation of renal replacement therapy (RRT) in patients with severe sepsis with septic shock and acute kidney injury (AKI). And many patients whose renal replacement was delayed recovered sufficient kidney function to avoid dialysis entirely. Because AKI is associated with worse outcomes in critical [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “I’ve never known any trouble than an hour’s reading didn’t assuage.” -Schopenhauer The last few decades have infamously boasted numerous failed therapies for sepsis and septic shock. Because sepsis represents an explosive and chaotic cacophony of pro and anti-inflammatory mediators – treatments which [… read more]
Severe hyponatremia (often defined as a serum sodium < 120 mEq/L) occurs most often in people with pituitary or lung tumors, those taking antipsychotic or other neuroleptic drugs, heavy beer drinkers, or the elderly. Usually sodium levels decline slowly over weeks or months prior to detection, allowing time for the brain to compensate, with only [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In a recent and excellent open-access review, Gattinoni, Quintel and Marini ask which is worse, volutrauma or atelectrauma [1]? This concise review is an absolute must-read and forms the fabric from which this short article assembles. Last spring – in Montreal – I was asked a few questions about volutrauma [… read more]
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