This would be a very informative case report (and it’s true and unexaggerated), but I anticipate staunch editorial resistance (even sans puns), so I’ll describe it here and have some fun with it. Background: The author has anecdotally observed for many years that so-called “septic shock” follows rather than precedes intubation and sedation. This raises [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In the last few weeks I have been contacted by curious clinical physiologists craving my conceptions of ‘venous excess’ [1]. These words will address this model, concisely and – I pray – clearly. The Myth of Venous Return The roots of venous excess took hold within the fertile soil of [… read more]
The antifungal micafungin is often given empirically to patients in ICUs with sepsis who are also at high risk for invasive fungal infections. IDSA guidelines endorse the use of empiric antifungals for patients with unresolving ICU-acquired sepsis, but any benefits of this are unknown. A randomized trial published in JAMA sheds light on the practice. French [… read more]
Treating Pain in Mechanically Ventilated Patients Adult patients in the intensive care unit (ICU) frequently experience pain, resulting from acute and chronic illness as well the positioning and interventions standard to ICU care.1,2 Besides being ethical and humane, adequately treating pain prevents agitation and delirium in mechanically ventilated patients. There are also many physiologic responses to [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD Pilots of high-performance, tactical fighter jets each have continuous positive airway pressure [i.e. CPAP] masks as a part of their flight suit. Strikingly, beyond the clinically-commonplace airway pressure of 5-15 cm of H2O, a fighter pilot may endure a mask-applied pressure of 90 [… read more]
The FDA is warning physicians not to provide other enterally-absorbed drugs within 3 hours before or after giving sodium polystyrene sulfonate (Kayexalate, Concordia Pharmaceuticals) for hyperkalemia. In testing performed 59 years after its launch, it was discovered that Kayexalate can bind to many prescription drugs, potentially rendering them ineffective. For patients with gastroparesis or ileus, FDA [… read more]
U.S. medical centers vary widely in the average shelf life of the blood in their blood banks. Trauma and high-volume surgical centers receive the oldest blood from the Red Cross, on the premise that they’ll be likely to transfuse it. All blood banks tend to dispense the oldest units first. This reduces waste of donated [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “To believe in medicine would be the height of folly, if not to believe in it were not a greater folly still.” -Proust A 32 year old man with no past medical history save for a BMI of 51 is admitted with severe acute pancreatitis following a large intake of [… read more]
In 2013, New York’s state government began regulating the care of sepsis. The state has since required its hospitals (and thus its doctors) to adhere to some version of a sepsis protocol that included a “bundle” to be delivered within 3 hours after sepsis recognition: blood cultures before antibiotics; lactate measurement; broad-spectrum antibiotics The Empire [… read more]
Jon-Emile S. Kenny MD [@heart_lung] That high flow oxygen applied via nasal cannula lends itself to treating hypoxemic respiratory failure may be obvious. With adequate heat and humidification, oxygen can be employed relatively comfortably at very high flow rates – upwards of 60 L/min – to the nares. At such rates, the effort of the [… read more]
Physicians may soon have another vasopressor to add to their toolkit in treating patients with septic shock and other vasodilatory shock. Angiotensin II infusions improved blood pressure in critically ill patients with vasodilatory shock who remained hypotensive on high doses of conventional vasopressors, in the phase III ATHOS-3 trial. Patients with hypotension despite catecholamine infusions [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD “Our life consists partly in madness, partly in wisdom: whoever writes about it merely respectfully and by rule leaves more than half of it behind.” -Montaigne Marking the 50 year anniversary of the first description of the adult respiratory distress syndrome – later [… read more]
In acute respiratory distress syndrome (ARDS), anyone with the keys to a ventilator knows low tidal volume ventilation (~6 mL/kg ideal body weight) is standard care. Low tidal volume ventilation can prevent or ameliorate ventilator-associated lung injury ; if early clinical trials represent current reality, one in 11 people with ARDS treated by low tidal volume ventilation could have their [… read more]
Iodinated IV contrast has long been considered a significant contributor to acute kidney injury in hospitalized patients. But so-called contrast induced nephropathy is hard to accurately identify in real clinical circumstances. Acute kidney injury (AKI) can happen from a variety of causes, or their combination, during acute illness. And no randomized trial has established the risk [… read more]
HIT Overview Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin exposure. In HIT, the body creates an autoantibody against the complex of platelet factor 4 bound to heparin. The anti-PF4 autoantibodies can activate platelets and cause life- and limb-threatening thrombosis in arteries and veins. Platelets generally fall by more than 50% five to ten [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Please read part 1 and view the vodcast on inferior vena cava collapse prior to reading below; this post seeks to explain the interesting findings of Juhl-Olsen & colleagues [1] as well as provide a physiological rationale to Dr. Marik’s comments on my vodcast; there is a new explanatory animation [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Three years ago I wanted to share my physiology website heart-lung.org; I needed a topic to stoke some interest, so I sent a brief essay to Matt here at pulmccm.org. In it, I briefly described inspiratory IVC collapse and its relationship to volume status and volume responsiveness. With this, the [… read more]
“Stop chest compressions for a minute while I intubate this patient!” That refrain must have been heard tens of thousands of times during CPR after cardiac arrest before 2010, when the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS) guidelines advised resuscitation teams not to interrupt chest compressions to place advanced airways, unless a patient [… read more]
Will “therapeutic” hypothermia someday need to be renamed? After a rush of optimism surrounding small trials showing large benefits from hypothermia to 33° after out-of-hospital cardiac arrest, hospitals and intensivists flocked to provide hypothermia to all victims of cardiac arrest (in- or out-of-hospital). When the much more powerful TTM trial showed no benefit of deep cooling [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Briefly, part 1 of this reflection on the mean systemic filling pressure [Pmsf] considered an analogy for volume status as the vastness of an ocean beyond the hull of a leaking ship; I argue that looking only inside the hull of the ship cannot tell you the volume of the [… read more]
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