Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “I’ve never known any trouble than an hour’s reading didn’t assuage.” -Schopenhauer The last few decades have infamously boasted numerous failed therapies for sepsis and septic shock. Because sepsis represents an explosive and chaotic cacophony of pro and anti-inflammatory mediators – treatments which [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In a recent and excellent open-access review, Gattinoni, Quintel and Marini ask which is worse, volutrauma or atelectrauma [1]? This concise review is an absolute must-read and forms the fabric from which this short article assembles. Last spring – in Montreal – I was asked a few questions about volutrauma [… read more]
Oral Anticoagulants in the ICU: A summary of the evidence for efficacy in atrial fibrillation, venous thromboembolism, and unique clinical cases Direct oral anticoagulants (DOACs) are recommended as the preferred treatment for venous thromboembolism (VTE) and as a first-line option for stroke prevention in nonvalvular atrial fibrillation (NVAF), but warfarin may be preferred in certain [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “My reputation’s never been worse, so …” -Taylor Swift Case A 54 year old woman with lupus nephritis – treated with mycophenolate mofetil and prednisone – is admitted with pancytopenia and worsening confusion. She was recently discharged after receiving levofloxacin and clindamycin [… read more]
As the use of chest CT-angiograms in emergency departments and medical wards has risen by more than tenfold, so has the discovery of small pulmonary emboli of unclear clinical significance. These PEs are often isolated to distal (subsegmental) branches of the pulmonary artery, without concurrent deep venous thrombosis (DVT). Small distal PEs may be incidentally [… read more]
By Thomas C. Neal, PharmD According to a meta-analysis of randomized trials, prolonged infusions of antipseudomonal beta-lactam antibiotics could save lives. However, obstacles to implementing pharmacodynamically optimized administration practices have slowed the adoption of this practice in most ICUs:1 The requirement for IV pumps, preferably smart IV pumps, is potentially problematic in resource-limited settings or on wards [… read more]
In Europe, patients with asthma have long been advised to take more puffs of their combination inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) inhaler during periods of increased asthma symptoms. In the U.S., patients are instead advised to use albuterol as their rescue inhaler, and stick firmly to the usual maintenance dose of ICS-LABA regardless of symptom severity. [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’m learnin’ to fly … but I ain’t got wings … comin’ down … is the hardest thing.” -Tom Petty Common Events Continued … Abdominal Pain Like chest pain, abdominal pain carries a wide differential diagnosis. Abdominal pain comprises 4% of all in-flight events and 10% of all diversions. An [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “If I could only fly … if I could only fly … I’d bid this place goodbye … to come and be with you.” -Blaze Foley Case ‘If there is a physician on board, can you identify yourself to the cabin crew?’ You are nearly 4 hours into a trans-Atlantic [… read more]
by Nicole Lou, Contributing Writer, MedPage Today Researchers concluded from a large retrospective study that pulmonary embolism is unlikely to cause syncope that results in a trip to the emergency room. Fewer than 1% of nearly 1.7 million patients treated at emergency departments for syncope had pulmonary embolism, according to databases from Canada, Denmark, Italy, and the [… read more]
The new generation of oral anticoagulants have revolutionized management of venous thromboembolism and atrial fibrillation. The changes in clinical practice have also created new questions and confusion around management of bleeding associated with these newer anticoagulants. The American College of Cardiology issued an expert consensus document in December 2017 to help guide physicians on the [… 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]
by Salynn Boyles, Contributing Writer, MedPage Today Cardiovascular event risk may increase in smokers who start using the cessation-assist drug varenicline (Chantix), according to findings from an observational study. The retrospective analysis of medical records for close to 57,000 new users of varenicline living in Ontario, Canada, showed a statistically significant 34% increased risk for [… 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]
Procalcitonin (PCT) levels can be useful (although limited) in deciding whether and when to start, de-escalate, and stop antibiotic therapy in patients with suspected infection. Physicians’ use of procalcitonin in antibiotic decisions has exploded since the FDA approval of a PCT assay whose manufacturer provides specific (albeit oversimplified) cut-off values at which to consider infection [… 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]
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]
People with chronic obstructive pulmonary disease (COPD) had an increased rate of heart attacks and strokes in the first month after starting long-acting inhaled bronchodilators. That’s the conclusion of an observational study from Taiwan, published in JAMA Internal Medicine. Researchers analyzed data on 284,220 Taiwanese adults with COPD who had never used bronchodilators, and were started on [… 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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