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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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Demystifying the p-value
IntroductionThe limitations of p-values for null hypothesis testing has been debated since their invention in the 1920s. Unfortunately, statistics textbooks typically whitewash this controversy,...
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Apneic oxygenation and high-flow nasal cannula don’t prevent desaturation...
IntroductionRecently there has been increased interest in the use of high-flow nasal cannula (HFNC) to provide preoxygenation and apneic oxygenation during endotracheal intubation. Previous posts have...
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Cognitive approach to shock diagnosis using ultrasonography
Recently I coauthored an articleabout the bedside evaluation of shock using ultrasonography. It's a reasonable article, albeit conventional. Below is a summary of the key points. Many textbooks...
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What is the evidence behind the IVC filter?
IntroductionUntil recently, recommendations regarding IVC filters have been based predominantly on a singleRCT (PREPIC-1). Last week, a second RCT was released in JAMA (PREPIC-2). This post will...
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Apneic ventilation using pressure-limited ventilation
IntroductionNoninvasive ventilation (i.e. BiPAP) is arguably the most powerful approach to optimize oxygenation and ventilation before intubation, given its ability to provide 100% FiO2, PEEP, and...
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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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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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