Nov 072019
 
In sepsis, antibiotics reduced yield of blood cultures by almost 40%

by Molly Walker, Associate Editor, MedPage Today If you want an accurate reading from sepsis patients’ blood cultures, don’t start antibiotics until you’ve drawn the blood samples, a new study suggested. Among patients with severe sepsis, blood cultures taken prior to antibiotic therapy were positive for one or more microbial pathogens in 31.4% of patients [… read more]

Oct 312019
 
Vitamin C reduces mortality from sepsis with ARDS in CITRIS-ALI randomized trial ... ?

Vitamin C infusion has generated tremendous interest as an adjunctive treatment for patients with sepsis, since a widely publicized cohort study claimed vitamin C dramatically reduced sepsis-related mortality at a single institution. The publicity, the plausible pathophysiologic mechanism, and the lack of any therapy for sepsis have led many intensivists to prescribe the so-called Marik [… read more]

Oct 302019
 
Vaping-Associated Lung Injury – Part 2

Jon-Emile S. Kenny MD [@heart_lung] “There are sadistic scientists who hurry to hunt down errors instead of establishing the truth.” -Marie Curie In part 1 of Vaping-Associated Lung Injury, the very basics of electronic nicotine delivery systems [ENDS] were covered as well as highlights on clinical presentation, radiology and pathology.  In this second part, flurries of [… read more]

Oct 292019
 
Vaping-Associated Lung Injury – Part 1

Jon-Emile S. Kenny MD [@heart_lung] with illustration by Carla M. Canepa MD [@_carlemd_] “Inside the word ‘emergency’ is ‘emerge’; from an emergency, new things come forth.” -Rebecca Solnit Case A 32-year-old man is admitted with three days of fevers, chills, malaise, dyspnea and productive cough.  He works in a stressful job in the heart of Manhattan [… read more]

Oct 212019
 
2019 IDSA Guidelines for Community Acquired Pneumonia in Adults: To HCAP, we just say fare thee well

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD [@_carlemd_] “Better never means better for everyone… It always means worse, for some.” -Margaret Atwood Case A 73-year-old woman with a history of severe chronic bronchitis, ESRD receiving thrice-weekly hemodialysis and heart failure with a preserved ejection fraction is admitted from home with fevers, [… read more]

Oct 182019
 
Prolonged hypothermia improved neurologic outcomes after non-shockable cardiac arrests (HYPERION, CRICS-TRIGGERSEP)

Targeted temperature management (TTM, or therapeutic hypothermia) has become standard therapy after cardiac arrest, especially for ventricular tachycardia and fibrillation–so called shockable rhythms. A new randomized trial has shown that deep, prolonged cooling after cardiac arrest from non-shockable rhythms (PEA and asystole) improved neurologic outcomes. But how robust were the results, and should they change [… read more]

Oct 112019
 
Major asthma guideline update: ICS-LABA as-needed replaces albuterol

In their first major update in 30 years, newly published asthma guidelines recommend significant changes to the way physicians treat millions of patients diagnosed with asthma. The Global Initiative for Asthma (GINA) now advises that, in general: Most people with asthma can now be prescribed just one inhaler: an inhaled corticosteroid-and-long-acting beta agonist (ICS-LABA) combination [… read more]

Sep 062019
 
Prophylactic IVC filters prevent PE in high-risk trauma patients, but were often unnecessary

Inferior vena cava filters placed prophylactically in patients hospitalized for trauma prevented symptomatic pulmonary embolism in those patients with persistent contraindications to anticoagulation, in a significant randomized trial. However, prophylactic IVC filter placement for all post-trauma patients did not improve outcomes generally. Trauma teams have always faced a difficult dilemma in the prevention and treatment [… read more]

Sep 032019
 
Advisory from CDC re: Severe Pulmonary Disease Associated with Using E-Cigarette Products

From the Centers for Disease Control and Prevention (CDC) and distributed here in the interest of the public health. PulmCCM is not affiliated with the CDC. Distributed via the CDC Health Alert Network August 30, 2019, 0935 AM ET (9:35 AM ET) CDCHAN-00421 The Centers for Disease Control and Prevention (CDC) is providing: 1) background [… read more]

Sep 022019
 

Update 9/6/19: we removed the video at Jon’s request.  Frequent PulmCCM contributor Jon-Emile Kenny is also a co-founder of the medical device start-up Flosonics Medical who (as I understand it) are working to develop and market a wearable ultrasound patch that would help direct fluid resuscitation and vasopressor use in patients in shock. PulmCCM has [… read more]

Aug 302019
 
New Definition for Pulmonary Hypertension in Left Heart Disease: Haunted by how we measure the wedge?

Jon-Emile S. Kenny MD [@heart_lung] “I know that character exists from the outside alone.  I know that inside the body there’s just temperature.” -Sheila Heti Background: DPG versus PVR  In 1971, the use of the pulmonary artery diastolic pressure gradient [DPG] was introduced to better refine the hemodynamic definition of pulmonary vascular disease.  What is the [… read more]

Aug 232019
 
APRV and Esophageal Manometry: a new way to titrate T-Low?

Jon-Emile S. Kenny MD [@heart_lung] “I had some dreams, they were clouds in my coffee, clouds in my coffee …” -Carly Simon Background  A recent letter to the editor in Critical Care posed a rather provocative question – ‘Are we really preventing lung collapse with APRV?’  The authors cited a case report of esophageal manometry used in [… read more]

Jul 182019
 
ICU Physiology in 1000 Words: Venous Doppler & Veno-Cardiac Coupling – Part 2

Jon-Emile S. Kenny MD [@heart_lung] In part 1, the basics of ventriculo-arterial coupling [VAC] were described and related to the Guyton Diagram.  In this second part, the notion of cardiac performance [Eh] is explored in relation to venous Doppler velocimetry.  Subsequently, I hypothesize that ‘veno-cardiac uncoupling’ – a concept analogous to VAC – is a [… read more]

Jul 172019
 
ICU Physiology in 1000 Words: Venous Doppler & Veno-Cardiac Coupling – Part 1

Jon-Emile S. Kenny MD [@heart_lung] Background Concepts have been clanging around my head since I participated in Philippe Rola’s [@thinkingCC] sedulous Hospitalist & Resuscitationist Conference in Montreal.  Initially, the abstractions of ventriculo-arterial coupling, Guytonian physiology and venous Doppler seemed insuperably sundered; but the cognitive haranguing recently gave way to harmony. What is ventriculo-arterial coupling and [… read more]

Jun 302019
 
Intravenous Fluids Act as Inotropes in Recent Sepsis Study

Jon-Emile S. Kenny MD [@heart_lung] “I’ve looked at clouds from both sides now …” -Joni Mitchell Background In a recent physiological study – brought to my attention by the erudite and kinetic [@iceman_ex] – the detailed physiological effects of intravenous fluids, norepinephrine and dobutamine were sequentially evaluated in patients with sepsis.  Sepsis was defined as [… read more]

Jun 092019
 
Dexmedetomidine helpful but inadequate alone for sedation (SPICE III)

In a new randomized trial, use of dexmedetomidine (Precedex) as the primary sedative in mechanically ventilated patients in the ICU resulted in no reduction in 90 day mortality. Dexmedetomidine resulted in a small improvement in delirium and ventilator days, but was almost never adequate to sedate patients on its own, and brought a small increase [… read more]

Jun 032019
 
Applied Respiratory Physiology for the Ventilator: A Workshop from the Hospitalist & Resuscitationist Conference

Jon-Emile S. Kenny MD [@heart_lung] “Our deeds determine us, as much as we determine our deeds.” -George Eliot Considering the independent and dependent variables of ventilation marked my final contribution to the “Hospitalist and the Resuscitationist” conference in Montreal, Canada; I gave a workshop on graphical analyses of ventilation.  This began with the basics of [… read more]

May 302019
 
Neuromuscular blockade for ARDS was no help, in supine patients

Continuous neuromuscular blockade for severe ARDS became common practice after the ACURASYS trial (2010) showed it reduced mortality by an absolute 9%. A larger trial, ROSE, now finds no benefit of the therapy over usual care — but leaves lingering questions due to major design differences. The ROSE trial was a multicenter randomized trial in [… read more]

May 282019
 
Pitfalls when using Doppler Ultrasound to Measure Peripheral Flow: A Lecture from the Hospitalist & Resuscitationist Conference

Jon-Emile S. Kenny MD [@heart_lung] “I am fearful, or suspicious of generalizations … they cannot guide me reliably in making decisions about particular individuals.” -Ruth Bader Ginsburg Between the 22nd and 24th of May, I participated in the “Hospitalist and the Resuscitationist” conference in Montreal, Canada.  I spoke on the stanchions of physiology and evidence [… read more]

May 272019
 
Integrating the Evidence and Physiology of IVC Collapse: A Lecture from the Hospitalist & Resuscitationist Conference in Montreal

Jon-Emile S. Kenny MD [@heart_lung] “There is no power for change greater than a community discovering what it cares about.” -Margaret J. Wheatley Between the 22nd and 24th of May, I participated in the galvanic, second-annual “Hospitalist and the Resuscitationist” conference in Montreal, Canada.  The entirety of this meeting was organized by Dr. Philippe Rola [… read more]