An intensivist on a learning frenzy. Caring for the critically ill using evidence-based medicine.
In patients who need IV fluids, we can either provide "normal saline" or balanced salt solutions.Balanced salt solutions include Lactated Ringer's and Plasmalyte.There have been several trials trying to answer this question. The data hasn't been as rock solid as we'd like to convince our biases.The BaSICS trial is a recent landmark trial.As always, I …
Continue reading BaSICS Trial: Plasmalyte vs. 0.9% NaCl in the Critically Ill
As much as I am not a huge fan of bombarding septic shock patients with IV fluids, I understand there is a role for fluid resuscitation.When our patients get better, though, it is time to get rid of these fluids.That is what we call deresuscitation.It is part of the 4 D's in fluid therapy: drug, …
Continue reading How Strong Is Your Deresuscitation Game in Sepsis Patients?
With a close to 50% mortality rate for cardiogenic shock, we all need a do a better job of caring for these patients. A cardiogenic shock classification would help identify who needs the most help.This is created for anyone caring for cardiogenic shock including physicians, APPs and nurses.We are all in this together. The earlier …
Continue reading Cardiogenic Shock: SCAI Stage Classification
When patients present to the ED in DKA, should we resuscitate them with 0.9% sodium chloride (saline) or balanced salt solutions such as plasma-lyte or lactated ringers?Many DKA order sets use 0.9% sodium chloride "aka normal saline" as their initial fluid of choice.We know these patients are dry when they arrive to the ED.They need …
Continue reading Saline or Lactated Ringers/Plasma-lyte for DKA Resuscitation?
Which should be the first-line vasopressor between norepinephrine and epinephrine in cardiogenic shock?Your patient had an MI and is now in cardiogenic shock.They are hypotensive and need a vasopressor.To clarify, The Crit Doc of Tik Tok aka CriticalCareNow aka Haney Mallemat likes epinephrine as an inotrope, not a vasopressor.This was a pilot study, meaning that …
Continue reading Norepinephrine or Epinephrine in Cardiogenic Shock: Is One Better?
A patient has a cardiac arrest and ROSC was achieved.They present to the ER or ICU.Suspicion is high that this was a cardiac insult.The EKG, though, does not show a STEMI.Troponins are elevated. The patient has a cardiac history.Have you ever wondered why intensivists never ask cardiology to take the patient to the cath lab …
Continue reading When to Take Cardiac Arrest Patients to the Cath Lab
SARS-CoV-2 is a virus that kicks off an inflammatory disorder in certain individuals. That's what data says and that's what most of us have seen. Inflammatory markers through the roof on the sicker patients, those who end up in my ICU. We start glucocorticoid therapy such as dexamethasone or methylprednisolone and the inflammatory markers drop, …
Continue reading Rethinking Corticosteroid/Glucocorticoid Dosing in COVID-19
Mortality for patients in cardiogenic shock is finally improving to be less than 50%. It had been hovering at 50% for decades. Would floating a Swan Ganz catheter, also known as a Pulmonary Artery Catheter improve outcomes in Cardiogenic Shock? The ESCAPE trial took the winds out of the sails of the Swan-Ganz enthusiasts in …
Continue reading Cardiogenic Shock & Swan-Ganz/Pulmonary Artery Catheters
To not fly blind in patients with advanced heart failure or cardiogenic shock, certain equations exist to help us manage our patients. This allows us to identify who is not doing well and act on their deterioration before it really hits the fan. We use cardiac power output (CPO), which I have dissected in THIS …
Continue reading Pulmonary Artery Pulsatility Index (PAPi): Principles & Calculation
This is a one minute journal club. This is not medical advice. The full breakdown in below this snippet.Read the data for yourself.Should we provide our DKA patients with sodium bicarbonate (bicarb) to improve their pH?We want to make the numbers pretty.We want to fix the acidosis faster, but does this work?The first thing people …
Continue reading Bicarb in Diabetic Ketoacidosis (DKA): One Minute Journal Club