A razor is a rule of thumb that is helpful, although it isn’t always correct. In medicine we’re familiar with Occam’s razor (the rule of parsimony). The cutoff razor states: if a continuous variable is dichotomized using a cutoff, then values near the cutoff provide little information. A simple illustration of the cutoff razor is […]
PulmCrit Blogitorial – Use of ECGs for management of (sub)massive PE
(A blogitorial is like a tweetorial in blog form, so folks on different platforms can see it). Our approach to risk stratification and management of (sub)massive PE tends to be dominated by CT scan and echocardiography (eye-candy modalities). And these are great. But I think there are situations where ECG can be really helpful – […]
PulmCrit Wee: Propofol induced eyelid opening apraxia – the struggle is real
Eyelid opening apraxia refers to a specific inability to open the eyelids. This may result from non-dominant hemispheric strokes. On superficial examination it will mimic unconsciousness, but upon further examination the patient is awake and able to respond to stimuli with their extremities. I’ve seen a similar phenomenon of eyelid opening apraxia a few times […]
PulmCrit wee: Why I like central lines for GI bleed resuscitation
People on twitter absolutely hate the concept of using a central line to resuscitate a GI bleeder. This comes up a couple times per year. I think the source of this hatred is largely three-fold: A central line alone is garbage (without a Level-1 or Belmont infuser). I’ll admit that. So if you’re working in […]
PulmCrit wee: Polypharmacy in the ICU – when in doubt, deprescribe
Polypharmacy is technically defined as taking five or more medications on a daily basis. Polypharmacy is increasingly becoming the norm among adults, due to several factors (an aging population, increasing numbers of medical problems, and increasingly complex regimens available to treat chronic disorders such as heart failure). Indeed, the term “polypharmacy” is arguably antiquated now […]
PulmCrit hot take: VAP prophylaxis (PROPHY-VAP trial)
background: ANTHARTIC trial Prophylaxis against VAP (ventilator-associated pneumonia) is already supported by a few studies in the literature, perhaps most notably the ANTHARTIC trial. That was a multicenter RCT evaluating 48 hours of therapy with amoxicillin/clavulanate for patients intubated following cardiac arrest. Antibiotic therapy reduced early-onset VAP, with a trend towards more ventilator-free days (further […]
PulmCrit – Validation of my model for converting VBGs to ABGs
background and general concept My research project in fellowship was the construction of a mathematical model to convert VBG values into ABG values. The fundamental concept for the model was pretty simple: we can approximate the respiratory quotient (RQ) of tissue in the hand as being constant. This indicates that changes in oxygen content and […]
PulmCrit: New ARDS guidelines reveal a shambolic state of affairs
Within the past year, two major societies have released guidelines on ARDS: the ATS (American Thoracic Society) and the ESICM (European Society of Intensive Care Medicine). Don’t be fooled by their names – both of these organizations are fundamentally international in scope. Some authors on the ATS document were from Europe, and similarly some authors […]
PulmCrit wee – Loading dose pharmacokinetics for antibiotics
A loading dose may be used to rapidly achieve steady-state pharmacokinetics. For drugs with a long half-life, this accelerates the attainment of therapeutic levels: For most drugs with single-compartment pharmacokinetics, a loading dose may be calculated using the following formula: (discussed further here) The graph below illustrates how this equation works: If (dosing interval)/(half life) […]
PulmCrit blogitorial: Why I don’t believe the AMIKINHAL trial
Some folks on twitter asked my thoughts on AMIKINHAL trial, so I thought I’d jot them here. AMIKINHAL is a multi-center RCT that evaluated the ability of inhaled amikacin to prevent VAP (ventilator-associated pneumonia) among patients who had been intubated for three days. It’s available here at NEJM. It was a positive trial, which is […]
PulmCrit Blogitorial – New IDSA/SCCM guidelines on fever evaluation in ICU
More guidelines! Today we’ll walk through some interesting bits of the new IDSA/SCCM guideline on evaluation of new fever in the adult ICU patient (available free here). how should temperature be evaluated? This is frankly a mess. Bladder catheter or esophageal probe are best, but usually not used. Rectal temperature is 2nd best, but unwieldy […]
PulmCrit Blogitorial – Why the new brain death guidelines are unacceptable
Hello fellow nerds, let’s take a look at the new American Association of Neurology (AAN) brain death guidelines. Instead of a tweetorial, I’ll jot my thoughts here, so they’re accessible to everyone. Disclaimer: the following discussion applies only to adult medicine. Most of these guidelines are consistent with the 2020 World Brain Death Project, so […]
PulmCrit Hot Take: Aggressive glycemic control is dead (TGC-Fast Trial)
background Today the Van de Bergh group in Belgium released a RCT investigating tight versus liberal glycemic control in the ICU. Before diving into this study, let’s take a walk down memory lane. Major interest in tight glycemic control in the ICU began in 2001 with an RCT by the same group of investigators, also […]
PulmCrit – Introducing the IBHP (Internet Book of Hospital Pulmonology)
In many countries, pulmonary and critical care are commonly bundled together. Consequently, a single person will often be responsible for both inpatient ICU management as well as inpatient pulmonary consultation. Honestly, I have some doubts about whether this is an ideal system. As both pulmonology and critical care medicine become increasingly complex, it’s becoming impossible […]
PulmCrit: “ARDS” is not a real thing
My dear pulmonologists, I have some bad news. Santa Claus isn’t real. Neither is “ARDS.” “ARDS” has traditionally been conflated with a specific histopathological form of lung injury: diffuse alveolar damage (DAD). Lectures, chapters, and articles typically juxtapose these two entities, promoting the concept that they’re one and the same. But they aren’t. The ability […]
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