I remember a young pt with HLH 2/2 connective tissue dz
we treated the HLH & everything was getting better but the EF dropped from ~45 to ~35
her EF fell b/c the HLH-induced vasodilation had been afterload-reducing her
falling EF reflected systemic recovery
eventually she fully recovered #EMIMCC
Skytorial: Ketamine use for conscious sedation in bronchoscopy!
A new study in CHEST just came out on this 😀
I've thought about this a lot & tried it a few times.
Despite being a huge ketamine fanboy I don't recommend this for three reasons...(#1/4) #EMIMCC
ICU Studies - Refresher:
Are you using the IVC diameter to "predict" if an ICU patient is "fluid responsive" (FR)?
This was an important multi-center descriptive study conducted during a 2-yr period in 5 French ICUs
540 ventilated patients w shock of various origins underwent
ICU Stories:
Middle-aged patient w multiple co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/atrial fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/ hypotension. Urine was purulent. CT showed hydronephrosis & bladder wall thickening:
One of my favorite @criticalcaretime.bsky.social infographics: Comparison of vasodilator scavengers.
When to choose
🟦 Methylene Blue
🟥 Hydroxocobalamin (Cyanokit)
For more discussion you can read here:
onepagericu.com/blog/mini-le...
Crit care docs, how commonly methylene blue and/or cyanokit get used in your personal refractory shock algorithm?
I got more familiar with them during fellowship but my previous training institution hardly ever used it at all. Still defining this aspect of my practice.
#Medsky
#Criticalcare
important thread 👇
{norepi + vaso} can often induce a state of *normotensive* vasoconstrictive shock
this is why I dislike blind algorithms that start with NE, then pile on vaso on without considering global hemodynamics
for experts, there is no such thing as a “1st/2nd/3rd line” pressor #EMIMCC
If the LV of the patient with sepsis is «hyperdynamic» when on noradrenaline, then EF dropps and the LV looks poorly when vasopressin is added, but recovers to normal with dobutamine, you likely haven’t «uncovered hidden LV dysfunction» or septic cardiomyopathy. #emimcc #pocus #echofirst 1/
One thing is to acknowledge the great intra- and interindividual variation in dose response with noradrenaline. Fixed thresholds for adding vaso or other adjuncts like at 0.25 μg/kg/min makes no physiological sense at all.
For anyone interested in learning more about angiography, check out my introductory guide!
You’ll find a lot of nice annotated diagrams like this one.
intuitivecardiology.notion.site/angiography
1/
Back to the basics today: let's talk about common pitfalls in obtaining cardiac #POCUS images ❤️
Here are some very common image acquisition errors in basic views, as well as the simple moves to correct them ✅
🧵
#emimcc #POCUSky #echosky #MedSky
A thread 🧵 on trials I think have changed or will change ICU practice (at least my own). #emimcc
the Hospitalists and Resuscitationist workshop 2025 early bird pricing ends in a week, see photo to see who will be teaching--dream list imo. plz scroll to bottom area to see all the topics covered!
thinkingcriticalcare.com/2024/06/05/h...
I’d love to hear from the rest of #pocusky and #emimcc. Do you use curvilinear probes for procedures?
A table describing the stability of new betalactams at different temperatures. Source: https://www.mdpi.com/1999-4923/15/12/2705
A summary table with the route of administration of new and upcoming antibiotics against Gram-negative bacilli. Source: https://www.who.int/observatories/global-observatory-on-health-research-and-development/monitoring/antibacterial-products-in-clinical-development-for-priority-pathogens
We lack oral options for most MDR-GNB among current or upcoming antibiotics, so ambulatory care for these patients will relay largely on #OPAT.
The good news: most new agents are stable to be administered via infusion bags or elastomeric pumps 👉 www.mdpi.com/1999-4923/15...
#AMSsky #IDsky
Septic shock requiring three or more vasopressors was associated with 57.6% in-hospital mortality. (That's it?!?!? - seems low)... 342 ICUs. Free article.
#emimcc #FOAMed
pubmed.ncbi.nlm.nih.gov/39529908/
Very nice overview of the current state of affairs in cardiogenic shock (published this week in @TheLancet):
one cause of hypernatremia in ICU = recovery from AKI!
[1] urea *accumulates* while kidney is failing…
[2] kidney recovers➡️ clearance of accumulated urea obligates the excretion of H2O
(similar to using oral urea to tx hypoNa)
so hypernatremia can be a sign of renal recovery 🤯
#EMIMCC #nephsky
#TLM24 #LiverSky #IDsky
MTE #3: HCV and Coinfections with Other Types of Viral Hepatitis
➡️ Management of HBsAg+ persons prior to HCV DAA
Reminders :
- HBsAg+ ❌ simplified Tx
- HBV reactivation = 24% if HBsAg+ and ALT ⬆️ 9%
- Risk of HBV DNA ⬆️ isolated anti-HBc is low (1.4%) & ALT ⬆️ ~0%.
#VEXUS cheat sheet by Sonosite
VEXUS is mainstream...
#EMIMCC #POCUS
Should you avoid IV iron in an iron deficient pt who was recently transfused?
Many fear iron overload, as 1U RBC transfusion contains ~200mg iron (primarily within RBCs). Is this a problem?
1/X #medsky #ansky #emimcc #hemesky #irondeficiency
I just heard a phrase I never want to hear again - “homeopathically vaccinated for tetanus”.
#IDSky
#vaccinate
Sometimes, when on call, I get consults for labs signaling a lower-than-normal creatinine.... If 2 am when this happens, I tend to be dismissive
However, here is a nice overview of ⬇️ creatinine causes
#NephSky #MedSky
🔗 karger.com/bpu/article/...
📢 The @ASCO released updated living guidelines for treating stage IV #NSCLC with driver alterations! ascopubs.org/doi/10.1200/....
This is no easy feat, but it was an honor to work alongside exceptional experts dedicated to providing the most up-to-date, evidence-based guidance.
#LCSM #LCAM
obviously the most recent explosion in growth is linked to the election but the enthusiastic level of engagement makes me think people are pretty hungry to interact with users who act like people instead of bots
Transcranial Ultrasound is a bit of a dark art to some
Profs Aarti Sarwal and Chiara Rona are having a wonderful discussion on it at #lives2024 in Barcelona
Here’s a lovely recorded talk from Aarti last year to whet your whistle
youtu.be/KcV7johoDBs?...
Bluesky, I want to share with you one of my favourite papers:
First paper to share here
Delightful to have been part of the all new UK guidelines on the diagnosis of and management of eosinophilia!
www.journalofinfection.com/article/S016...
The most effective pharmacological and hemodynamic intervention for the treatment of hepatorenal syndrome #HRS is a substantial MAP raise, as illustrated in this case example
