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CT angiography for lower GI bleed: the University of Pennsylvania Experience
IntroductionA post two months ago explored the use of CT angiography instead of tagged RBC scans for the evaluation of lower GI bleeding (here). The algorithm below was developed based on evidence...
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Understanding lactate in sepsis & Using it to our advantage
Introduction with a caseOnce upon a time a 60-year-old man was transferred from the oncology ward to the ICU for treatment of neutropenic septic shock. Over the course of the morning he started...
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Steroids in septic shock: Four misconceptions and one truth
IntroductionThe utility of steroids in sepsis has been debated passionately for decades. There is hope that steroids might improve mortality, but also fear that they could increase infectious...
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Accelerated Goal Directed Therapy for Septic Shock
IntroductionThe Surviving Sepsis Campaign has raised awareness that septic shock is a medical emergency. However, these guidelines recommend a stepwise approach to resuscitation, which commonly...
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Myth-busting: Azithromycin does not cause torsade de pointes or increase...
IntroductionIn 2012 a NEJM article by Ray et al. reported a correlation between azithromycin and cardiovascular death. This received extensive press and ultimately led the FDA to issue a drug safety...
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Does central line position matter? Can we use ultrasonography to confirm line...
IntroductionSuppose you just placed the central line shown above. Does it need to be repositioned? I was trained that the tip of the central line must lie in the lower portion of the superior vena...
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Proposal: Most community acquired pneumonias with extensive ultrasonographic...
Introduction with a caseA 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia. His chest radiograph is shown above. Chest ultrasonography showed extensive...
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Evidence-based treatment for severe community-acquired pneumonia
IntroductionCommunity-acquired pneumonia (CAP) remains the leading cause of infectious disease death in developed countries. Described by Sir William Osler as "captain of the men of death," it dates...
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Pneumonia, BiPAP, secretions, and HFNC: New lessons from FLORALI
IntroductionPneumonia is extremely common. Nonetheless, there is surprisingly little evidence about supporting pneumonia patients using bi-level positive airway pressure (BiPAP) or high-flow nasal...
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Dear NEJM: We both know that conflicts of interest matter.
IntroductionRecently the New England Journal of Medicine launched a media campaign challenging the negative perception of industry conflicts of interests (COI). This was surprising, because it is the...
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Flash cigarette burns: To intubate or not to intubate?
Getting warmed up with a multiple-choice questionA 70-year-old man with oxygen-dependent COPD is admitted following a flash burn. He started smoking with his oxygen running, and the cigarette...
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Hypocaloric Nutrition: Theory, Evidence, Nuts, and Bolts
IntroductionUntil recently there has been little evidence regarding the caloric target for feeding critically ill patients. In the absence of evidence, it has been assumed that we should aim to meet...
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Proposal: Early ventilator weaning to HFNC in hypoxemic respiratory failure
Case exampleA previously healthy 45-year-old man was transferred to the Genius General Hospital ICU for management of pneumonia. He was intubated prior to transfer due to hypoxemia (details...
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The tale of six blind physicians and the elephant
An elderly man was admitted to the ICU and evaluated by six blind physicians.The blind cardiologist noted that the patient had a malignant pericardial effusion with tamponade. She recommended an...
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Emergent treatment of hyponatremia or elevated ICP with bicarb ampules
Introductory caseA young 70-kg man was transferred to the Genius GeneralICU for management of stupor. He had been diagnosed with aortic valve endocarditis due to heroin abuse two weeks earlier, but...
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Taking control of severe hyponatremia with DDAVP
Introduction with a caseImagine an elderly patient presenting with hypovolemic hyponatremia (sodium of 115 mM) and moderate confusion. How would you treat this patient?The typical approach might be a...
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Unconventional therapies for hyponatremia: Thinking outside the collecting duct
Case: An unusual ICU referralSome years ago at Genius General Hospital, the ICU was asked to accept a patient from the medicine ward with cirrhosis, confusion, and hyponatremia (Na 125 mM) for...
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Recognizing and managing paradoxical reactions from benzodiazepines & propofol
A perplexing caseA young man with a history of seizures and alcoholism presented with a generalized seizure. His seizure responded to lorazepam, but he was intubated for airway protection and was...
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The SPLIT trial: Internal vs. external validity
IntroductionResuscitation with large volumes of normal saline (NS) causes hyperchloremic metabolic acidosis. Some evidence suggests that hyperchloremic metabolic acidosis may impair renal function,...
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Phenobarbital monotherapy for alcohol withdrawal: Simplicity and power
Case example A middle-aged man was admitted to the ICU for refractory alcohol withdrawal. Prior to arriving in the ICU he had been treated aggressively with an escalating regimen of IV diazepam,...
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2015 ACLS Guidelines: What happened to VSE?
IntroductionIn 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest. However, other...
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Magnesium infusions for atrial fibrillation & torsade
Introduction: Perpetual controversyThe use of magnesium for AF has been a controversial topic for decades. Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile....
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Treatment of hemodynamically stable new-onset AF in critical illness
Introduction with a clinical questionA 50-year-old woman with no prior medical problems was admitted to Genius General Hospital with severe influenza pneumonia and acute kidney injury. She was...
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Investigation Bias: The freakonomics of when industry choses to sponsor a...
Background: Publication biasOver the last several years, publication bias has received a considerable amount of attention. In its most blatant form, this is when a drug company sponsors several...
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Brief rant: Still no evidence that azithromycin increases mortality
IntroductionIt has long been known that some macrolides (e.g. erythromycin) cause torsade de pointes. However, azithromycin has a much lower affinity for cardiac potassium channels than erythromycin,...
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