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]
Jon-Emile S. Kenny [@heart_lung] “It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgement with respect to particular patients or special clinical situations.” -IDSA/ATS Guidelines 2016 A 73 year old man is admitted from a nursing home for an NSTEMI and is [… read more]
Jon-Emile S. Kenny [@heart_lung] The Journal of Intensive Care has newly published a series of sepsis-related organ dysfunction reviews. Additionally, a comprehensive yet concise overview of the cerebral circulation was just disseminated. This summary draws on both of these terrific primary resources as a point-of-departure for discussion of sepsis-associated delirium [SAD]. Cerebral blood flow [CBF] ultimately [… read more]
Jon-Emile S. Kenny [@heart_lung] A 66 year old man presents to the emergency department with sudden-onset fevers, chills, and scant hemoptysis. He is hypoxemic, tachypneic and noted to have egophony with focal crackles and wheezing across his right, anterior chest. Further, he is found to be in acute kidney injury and his chest x-ray reveals [… read more]
Jon-Emile S. Kenny [@heart_lung] “A man may take to drink because he feels himself to be a failure, and then fail all the more completely because he drinks … English … becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts.” [… read more]
Jon-Emile S. Kenny [@heart_lung] On this snowy, Stockholm Sunday, I look out from my quarters on the Mälardrottningen across the still, icy waters and I think about a cirrhotic patient for whom I recently cared. She presented with significant dyspnea as she had stopped taking her diuretics. Instead, she was using excessive doses of her friend’s [… read more]
image: Wikipedia There’s only one sure way to prevent complications from a central line: don’t place one. Like many invasive interventions, some of central venous catheters’ indications have been called into question in recent years. Monitoring of central venous pressure and central venous oxygen saturation via central IV access — once considered essential to good care [… read more]
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