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]
Procalcitonin Test: Overview Procalcitonin (PCT) is the precursor of the hormone calcitonin and is mainly produced by the thyroid. Procalcitonin is a so-called acute phase reactant, rising in response to tissue inflammation and injury. Outside the thyroid, PCT is secreted by the lungs, intestines and other tissues in increasing amounts in response to bacterial endotoxin [… read more]
Sepsis may contribute to far more hospital readmissions than previously recognized — more than any other monitored condition. Recognition of this by federal and private payers could result in increased intensity of oversight of health teams’ care delivery for patients with sepsis. Hospital readmissions are squarely in the sights of the Centers for Medicare and Medicaid [… read more]
A document that looks like an unsigned, unpublished letter to the Wall Street Journal was posted on Scott Weingart’s EMCrit blog. It is signed only “The Department of Emergency Medicine – Henry Ford Hospital” and responds to the 2008 WSJ piece that suggested irregularities or mishandling of the data in the seminal 2001 trial on EGDT for sepsis. Scott’s [… read more]
Three large, well-conducted randomized trials around the world (ProCESS, ARISE, and ProMISe) all agreed: use of early goal-directed therapy (EGDT) for sepsis does not improve mortality or any other important clinical outcome. The Big Three sepsis trials were a death knell for the formerly ubiquitous “sepsis bundles,” protocols based on the single-center 2001 trial of EGDT [… read more]
After hundreds of trials failing to show benefit of drug treatments for sepsis, could a simple, cheap and effective treatment — high-dose vitamin C — be hiding in plain sight? A respected leader in critical care medicine thinks so, and his hospital system is all in. Vitamin C (ascorbic acid) is depleted during sepsis. That might be bad, [… read more]
In 2008 hospitals were informed they would no longer be paid for treating hospital acquired infections like ventilator associated pneumonia. Miraculously, the rates of VAP (self-reported by hospitals to the Centers for Disease Control and Prevention) fell dramatically by 60 to 70% between 2006 and 2012, to less than one VAP per 1,000 ventilator days [… read more]
By Scott Aberegg, MD, MPH Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient. On my first MICU rotation in 1997, I was so swept [… read more]
Sepsis is sneaky. Physicians, nurses, and epidemiologists struggle to accurately identify patients with sepsis in the emergency department, hospital ward, and in data sets. The so-called SIRS criteria were abandoned as insensitive and nonspecific in the most recent iteration of sepsis care. Sepsis is instead now defined as “life-threatening organ dysfunction caused by a dysregulated [… read more]
Jon-Emile S. Kenny [@heart_lung] Read part 1 here Fluids and the Glycocaylx Critically-ill patients all likely have endothelial dysfunction to some degree. This perturbation in microvascular physiology may be underpinned by abnormal glycocalyx structure and function. Sepsis, trauma, surgery and ischemic insults are all known to disrupt the glycocalyx which will increase vascular fluid capacitance. [… read more]
Jon-Emile S. Kenny [@heart_lung] “To every (wo)man is given the key to the gates of heaven. The same key opens the gates of hell. And so it is with science.” -Richard Feynman A rich, frosty wind etherizes my face; this cool gust rips through the medieval, labyrinthine passageways of Old Stockholm like frayed edges of [… read more]
When is the optimal time to initiate renal-replacement therapy in the ICU? Patients with acute renal failure (a.k.a. acute kidney injury or AKI) in the ICU experience worse outcomes than patients who do not. As the kidneys shut down, toxic electrolytes and metabolic waste products build up in the blood. Intuition says — screams, really [… read more]
Patients who arrive at the hospital with hypotension will almost all receive intravenous fluid resuscitation (one hopes). When signs of hypoperfusion occur later in a patient’s hospital course, it can be much harder to decide if additional fluid will be helpful. Physical exam is unreliable, and no available technology can accurately identify how much water is [… read more]
By Jon-Emile S. Kenny [@heart_lung] PulmCCM is not affiliated with or endorsed by the Society of Critical Care Medicine or the Surviving Sepsis Campaign. Click here to read the Surviving Sepsis Guidelines. “I am at the moment writing a lengthy indictment against our century. When my brain begins to reel from my literary labors, I make [… read more]
By Jon-Emile S. Kenny [@heart_lung] “New York is cold, but I like where I’m living … There’s music on Clinton Street all through the evening.” -Leonard Cohen It’s the end of December; we collectively reflect on the year that was and try to find our footing for the next. In the short winter days of 2016, it [… read more]
By Jon-Emile S. Kenny [@heart_lung] “I want to be your medicine, I want to feed the sparrow in your heart …” -Kristian Matsson Case A 39 year old woman is admitted to the intensive care unit for hypotension, anuria and altered mentation despite 3 litres of intravenous lactated ringers infusion. She is febrile and found to [… read more]
The idea that augmenting cortisol levels to normal or supranormal levels must be somehow beneficial in septic shock has a compelling basis in physiology and intuition. For physicians, injecting powerful synthetic hormones to restore homeostasis to save a dying patient is a seductive fulfillment of the scientist-savior fantasy. So intensivists were primed to believe the results of [… read more]
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]
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]
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]
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