The U.S. Food and Drug Administration (FDA) warned health care teams about the risk of pneumothorax caused by certain enteral feeding tubes that use technology to guide their insertion, also called enteral access systems (EAS). It issued a safety communication stating, Most reports indicate these pulmonary events required urgent intervention, including needle decompression or chest [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “One of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important.” -Bertrand Russel I read with great interest a recent letter penned by Taylor and Camporota in response to an investigation on airway pressure release ventilation [APRV] by Zhou and colleagues. Their brief [… read more]
Since Marik et al announced exceptional survival rates among patients with septic shock given a cocktail of vitamin C, thiamine, and hydrocortisone, physicians taking care of septic patients have expressed both enthusiasm and skepticism about the cocktail’s reported lifesaving effects. Soon, more rigorous testing from randomized, double-blind placebo-controlled trials should provide harder data about the [… read more]
Bougies are long, stiff plastic wands inserted into the trachea through the glottis during direct laryngoscopy (DL), providing a “guidewire” over which an endotracheal (ET) tube can then be more easily advanced into the trachea. Bougies have traditionally been used after one or more failed intubation attempts with direct laryngoscopy, at which point the airway [… read more]
Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials. Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three [… read more]
Introduction Respiratory failure is a commonly encountered disease process in both the emergency department (ED) and intensive care (ICU) setting. Respiratory failure most frequently results from exacerbations of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), respiratory infections, encephalopathy, or a combination of these etiologies. Obesity, with or without obesity hypoventilation syndrome, reduces [… read more]
Jon-Emile S Kenny MD [@heart_lung] “What is memory but a story about how we have lived?” -Mark Doty During the recent ‘Hospitalist and the Resuscitationist’ conference in Montreal, there were discussions around the hemodynamics of prone positioning as well as using venous Doppler as a hemodynamic metric. Much of this discussion was generated and driven [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Lung Stress in Pulmonary & Extrapulmonary ARDS Initially described in the late 1990s, the distinction between direct pulmonary insults [i.e. pulmonary ARDS] and indirect pulmonary insults [i.e. extra-pulmonary ARDS] is important [1]. Additionally, direct pulmonary injury such as gastric acid aspiration may have a different molecular phenotype from indirect, extra-pulmonary [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In the previous segment, time constants [t] – and their limitations – were described as a lesson in applied respiratory physiology for setting T-Low and prediction of auto-PEEP in airway pressure release ventilation [APRV]. In this brief missive an alternative approach to titrating T-low is described and critiqued. As well, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] While the lung in the throes of acute respiratory distress syndrome [ARDS] is shrunken, edematous and inflamed, a basic management maneuver is to ‘recruit’ lost pulmonary surface area. In other words, unfold alveolar-capillary units with the ventilator like a respirothoracic party horn. One ‘unconventional’ method of maximizing and maintaining lung [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The real process of education should be the process of learning to think through the application of real problems.” -John Dewey On April 18 & 19, 2018, I had the pleasure of participating in the inaugural conference “The Hospitalist and the Resuscitationist” in Montreal. The entirety of this meeting was [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “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 [… read more]
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]
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]
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]
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]
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]
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]
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]
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]
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