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]
“Nihilist” is one of the harshest insults that can be lobbed at a physician. Even while one knows intellectually that every patient can’t be saved, it’s considered odious to openly acknowledge that actuarial reality. Accepting the truth that some patients will inevitably die despite our best efforts is seen by some as the threshold of [… read more]
Jon-Emile S. Kenny MD [@heart_lung] The mechanical power applied to the lung is a risk factor for ventilator or ventilation-induced lung injury [VILI] [1-4]. But can the work done to the lung over time be homogenized into a single value? Could different components of the power equation carry different VILI risk beyond their mathematical inequalities [… read more]
Jon-Emile S. Kenny MD [@heart_lung] A few years ago I was intrigued by a new concept in Ventilator-Induced Lung Injury [VILI] – the mechanical power. I employed this paradigm, introduced by Gattinoni’s group, as an opening for the ‘ARDS Trilogy.’ Since then, I have also discussed this ‘ergotrauma’ in the context of helium-oxygen physiology and [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Why is blood pressure measured by units of length [i.e. millimeters of mercury – mmHg]? What decides systolic and diastolic pressure? What are the determinants of tissue perfusion and what are the clinical implications of this physiology? Can we deceive ourselves into thinking a particular mean arterial pressure [MAP] is [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’m burnin’ through the sky, yeah Two hundred degrees, That’s why they call me Mister Fahrenheit” -Freddie Mercury Part 1 gave a brief overview of the mechanisms of atrial fibrillation [AF] as well as pertinent features of rate controlling agents and anticoagulation. In this brief second part, nuanced features of ventricular [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “The habit of writing for my eye is good practice. It loosens the ligaments.” ― Virginia Woolf Case A 28 year old woman with known severe mitral stenosis from rheumatic heart disease presents with acute onset shortness of breath. Her acute dyspnea began while [… read more]
by Salynn Boyles, Contributing Writer, MedPage Today Vitamin D supplements reduced moderate to severe COPD exacerbations in patients with low circulating levels of its 25-hydroxyvitamin D (25-OH-D) metabolite at baseline, a meta-analysis indicated. But no such effect was seen for patients with at least normal 25-OH-D levels (at least 25 nmol/L) prior to supplementation, according to Adrian [… read more]
Best of 2018: Prone positioning for severe ARDS advised by major societies 2018 Update to Surviving Sepsis Guidelines: Cue Backlash Management of Ground Glass and Subsolid Pulmonary Nodules: Review Vasopressors and Inotropes for Shock Syndromes: Review Prophylactic Precedex prevented delirium in ICU patients Corticosteroids do help [… read more]
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]
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