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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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CT Angiogram for evaluation of severe hematochezia
IntroductionGastrointestinal hemorrhage is a common reason for ICU admission. The approach to severe upper GI bleeding is relatively straightforward (figure below). A predictable approach facilitates...
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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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Sleep-protective monitoring to reduce ICU delirium
IntroductionRecently an excellent post on the Trauma Professional's Blog pointed out that nocturnal vital signs disrupt sleep and may be unnecessary in stable patients (e.g. patients recovering from...
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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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Top 10 reasons to stop cooling to 33C
IntroductionFollowing the Nielsen study, many hospitals developed two protocols for temperature management after cardiac arrest (33C or 36C). For example, the 36C protocol could be used for patients...
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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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Five pearls for the dyspneic patient with Guillain-Barre Syndrome or...
IntroductionGuillain-Barre Syndrome (GBS) and Myasthenia Gravis (MG) are common causes of acute weakness. About 25% of these patients may develop respiratory failure requiring intubation, so a major...
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Hemodynamic access for the crashing patient: The dirty double
Introduction with a caseA 75-year-old man presents in transfer to the ICU for management of bradycardia and hyperkalemia. His history is notable for hypertension with chronic use of an ACE-inhibitor....
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High-flow nasal cannula for apneic oxyventilation
IntroductionLast summer I wrote a postabout preoxygenation and apneic oxygenation using high-flow nasal cannula (HFNC). At that point there was no evidence supporting it, so the post was based...
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Management of severe hyperkalemia in the post-Kayexalate era
IntroductionThere is increasing recognition that sodium polystyrene sulfonate (Kayexalate) is ineffective for the immediate management of severe hyperkalemia (Kamel 2012). With Kayexalate gone, there...
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Do CT scans cause contrast nephropathy?
IntroductionIn April 2013 a series of articles in Radiology debated whether contrast nephropathy still exists using modern contrast dye. Two years later, the controversy remains. This is a daily...
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CT Angiogram for evaluation of severe hematochezia
IntroductionGastrointestinal hemorrhage is a common reason for ICU admission. The approach to severe upper GI bleeding is relatively straightforward (figure below). A predictable approach facilitates...
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