COVID-19: Don’t order an unnecessary nebulization!!

Colleagues, I know that lots of us have knee-jerk tendencies to order nebulizations on everyone who is on a ventilator, NIV, or any type of shortness of breath under the sun because it makes us feel warm and fuzzy inside where we say "I did something". This behavior needs to stop. We are potentially aerosolizing …

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Upcoming Lectures

The following are places where I am going to be doing my lectures in the upcoming months:2020April 4: Ponte Vedra Beach, FL: Link to ProgramInnovations in Cerebrovascular Science Conference: Topic "Pulmonary Disorders in Acute Neurological Injury"Cancelled. May 14: West Palm Beach, FL: Link to Program Topics: Fluids and Metabolic Resuscitation, Lactic Acidosis, NIV and HFNCCancelled.May 25-29: Maui, …

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Early Vasopressors in Septic Shock?

This is a question that is often asked. Do we give fluids until the patient no longer "responds to fluids" or start vasopressors early? Should we start early vasopressors in septic shock or wait until fluids resuscitation is complete?Here's my bias: I dislike arbitrarily pounding patients with fluids. It causes harm. We know this. I …

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Dexamethasone in ARDS: DEXA-ARDS Trial Improved Outcomes

This is a big impactful study looking at administering Dexamethasone to patients with ARDS. I'm happy it came out, really happy. To start off a big hat tip to my colleagues in España who put this together. ARDS sucks. It's a b-word to treat and patients spend a frustratingly long time to come off of …

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Non-Invasive Ventilation (NIV/BPAP/BiPAP) Algorithm.

Not every patient reads the textbook, but you and I have to know where to start when managing our patients who have hypercapnic respiratory failure that we want to treat with non-invasive ventilation (or what you and I frequently call BiPAP). This NIV algorithm is taken from the British Thoracic Society/Intensive Care Society Acute Hypercapnic …

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Cortisol Levels: Check prior to SDS in Septic Shock?

Your patient is in septic shock. They've gotten the correct source control, antibiotics, fluids, vasopressors. They remain hypotensive. Getting worse, actually. Could they have relative adrenal insufficiency or one of these fancy-termed conditions such as "critical illness-related corticosteroid insufficiency" (CIRCI)? Some clinicians insist on checking cortisol levels in patients who are in septic shock.  Should …

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IV Vitamin C in Sepsis: It Should Decrease Vasopressor Dose & Duration

The VITAMINS trial looking at IV Vitamin C didn’t pan out was not a positive study as it was conducted. It was surprising as intravenous (IV) Vitamin C in sepsis should help decrease vasopressor dose and duration. My contention with that study is that they took too long to initiate the study drug. A median …

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