Full text link
Your personalized Share Link:
authors.elsevier.com/a/1mfhq8MwDH...
23.02.2026 15:42
👍 0
🔁 0
💬 0
📌 0
Full text link
Your personalized Share Link:
authors.elsevier.com/a/1mfhq8MwDH...
What’s optimal PEEP for your patients with an increased BMI?
Our study showed a simple equation you can use:
PEEP = BMI/3
There’s variability, but BMI/3 approximates the mean optimal PEEP (by esophageal manometry) from BMI 25 to > 40
#EMIMCC #medsky
www.sciencedirect.com/science/arti...
Yes, it will get you closer to the LV than guideline recommended hand
What remains unknown (for now) is would it take away from other important elements of the resuscitation (eg longer pauses) and would localization and hand placement over LV improve rate of ROSC or other outcomes
What’s the best site for chest compressions?
Probably mid-LV
Guideline recommended location overlies the LV in the minority of cases
TTE may be a good tool to better localize mid LV and thus optimal compression location (esp if TEE unavailable)
#foamcc
www.sciencedirect.com/science/arti...
Can you allow a MAP of < 65 in your patients with septic shock?
Yes! Maybe as low as MAP of 50
But you must examine to make sure they are perfused
-capillary refill < 3 seconds, warm extremities without mottling
-adequate urine output
-clearing lactate
#EMIMCC
journals.lww.com/ccmjournal/a...
Yes, I think I see this in the post op cardiovascular surgery population with Nicardipine
Unimpressive atelectasis with out of proportion hypoxemia
Interesting to think is there a titratable infusion that doesn’t cause it?
#emimcc
Setting PEEP by BMI/3 might be a good starting point in patients with an elevated BMI
Understanding it may lead to over or under PEEP for about 2/3 of patients based on our OR population with variable BMIs
Other recent work in this area
pmc.ncbi.nlm.nih.gov/articles/PMC...
The mean of esophageal pressure estimates of optimal PEEP surprisingly approximated the mean of BMI/3 in our >100 patients with BMI <25 to >45
BUT
BMI/3 would only capture about 1/3 of patients esophageal pressure base transpulmonary pressure optimal PEEP (tPP of 0 +\-2)
Individualized PEEP:
Can you estimate optimal PEEP in any BMI with the simple equation of BMI/3?
Maybe!
Our new paper comparing esophageal pressure base transpulmonary pressure estimates of optimal PEEP (tPP of 0 +\-2) vs BMI/3 in OR patients
www.sciencedirect.com/science/arti...
How do you stop hydrocortisone once septic shock has resolved?
I tend to be an abrupt discontinuation kind of person, stop as soon as the pressors are off rather than taper (unless it’s been a prolonged course)
Restrospective evidence 👇
journals.lww.com/ccejournal/f...
Answer: #2 normotensive cardiogenic shock
It’s sneaky, easy to miss but important to identify, diagnose cause, manage and admit to ICU—not the floor tele unit
Occurs in about 12% of CS patients
Mortality 17%
www.jacc.org/doi/10.1016/...
Which has a higher mortality?
1. Patient with EF 30% BP 80/56 with lactic acid 1.8, normal LFTs, and warm extremities
OR
2. Patient with EF 30% BP 100/70 with lactic acid 3.8, elevated LFTs and cool distal extremities
Excited to share our updated review of ECMO for the emergency clinician! Grateful for my excellent co-authors who shared their extensive expertise & time: @skylerlentz.bsky.social, Cameron Upchurch, Jenelle Badulak, Brit Long, and @mgottliebmd.bsky.social
authors.elsevier.com/a/1lFOI2dHVQ...
“the PaO2/FiO2 ratio was significantly lower in the group treated with lower tidal volumes on days 1 and 3” (ARDSnet)
But as we know 28 day mortality was eventually higher in the larger tidal volume group
I wonder what we’re doing now in medicine that is similar?
What in critical care medicine do you think makes the patient look better in the short term but is actually worse in the longer term?
25 yrs ago we might have said look my patient with ARDS and 12 ml/kg tidal volume is oxygenating better, so it must be superior to 6 ml/kg
Intensivists and Respiratory Therapists: 🫁
What’s your go to tidal volume for the patient without ARDS and why?
6 ml/kg PBW
8 ml/kg PBW
10 ml/kg PBW
Something else?
What’s the highest IPAP you’ll use with NIV in a patient with COPD and respiratory failure?
Before this trial I’d stop at ~ 20 cmH20, and think about intubating if not improving
After this trial:
Now up to 30 cmH20 may safely avoid intubation
jamanetwork.com/journals/jam...
What’s the role of the osm gap in identifying toxic alcohol poisoning?
The con: We say it’s limited and all about the history and clinical course
www.sciencedirect.com/science/arti...
What’s the highest temperature you’ve seen in clinical practice and what was the cause?
🫀What happens when epinephrine is given before defibrillation in VT/VF arrest
journals.lww.com/ccmjournal/a...
Failed extubation?
I like to think of it as an intubation vacation