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#hellomynameis Segun
@iceman_ex
, 11 tweets, 6 min read Read on Twitter
Just in case you guys don’t know who Sheldon Magder is...

mcgill.ca/physiology/dir…

A GOD among intensivists and physiologists #hrmed19
On the topic of blood pressure ncbi.nlm.nih.gov/m/pubmed/30305…

#Hrmed19

Pressure is not equivalent to blood flow...
Sheldon has a great chapter in this amazing book springer.com/gb/book/978331…

Featuring lots of legends of ICU physiology #hrmed19
Gravity has a significant influence on blood pressure

When lying supine all your BPs are the same

When standing there’s an 88mmHg difference between your heart and your feet

Which results in a head MaP of 51 and a foot MAP of 180

#Hrmed19
Determinants of arterial pressure

LV ejection
Aortic elasticity
Reflected wave

That gives you your pressure trace

#Hrmed19
For a given SV, BP varies with
Position
Age
Disease

Diastolic pressure may or may not matter

sciencedirect.com/science/articl…

#Hrmed19
BP does not determine cardiac output #hrmed19

Regional blood flow is determined by regional resistance

This is the challenge with pure vasoconstrictors in shock- they will normalise BP but not increase flow as all they’ve done is boost resistance
If you want to improve flow you need to constrict the “filling” side and dilate the “emptying” side

Thereby maintaining the appropriate proportion of resistances

This is why some people with a testing MaP of 60 are fine. Regional flow is normal #hrmed19
Does changing MAP affect outcomes?

Arterial blood pressure in early Sepsis and outcomes ncbi.nlm.nih.gov/m/pubmed/19189…

High vs low MAP in Sepsis thebottomline.org.uk/summaries/icm/…

#Hrmed19
MAP is independently associated with mortality in Sepsis ncbi.nlm.nih.gov/pubmed/1597352…

And myocardial injury post op ncbi.nlm.nih.gov/m/pubmed/26540…

#Hrmed19
Should kidneys be a target of BP management?

Dunno

@khaycock2’s thoughts on targeting using RI are interesting #hrmed19

Also catecholamines are not benign- you might be sacrificing perfusion of other beds to try and maintain renal flow #hrmed19
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#hellomynameis Segun
@iceman_ex
Now @Manu_Malbrain arguing for the retirement of the surviving Sepsis guidelines #lives2018
The fall in Sepsis mortality hasn’t coincided with the introduction of the guidelines #lives2018 🤔
Is the pro-con debate of the surviving Sepsis guidelines nothing more than a liberal vs restrictive fluid argument? #Lives2018
Read 23 tweets
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#hellomynameis Segun
@iceman_ex
So what about albumin in the critically ill? Yasser Sakr talks us through it

It might be good- especially in Sepsis #lives2018

It’s also the colloid with the highest safety margin...
And as if by magic in a parallel stream... #lives2018
However albumin may be bad too #lives2018
Read 4 tweets
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#hellomynameis Segun
@iceman_ex
Good morning everyone! For my first session of day 2, I’ve decided to come and learn all about vasculitis in the ICU - being presented by Marlies Ostermann from @GSTT_ICU #lives2018
Marlies starts with a couple of case histories:

Middle aged women, presenting with undifferentiated pulmonary and renal failure, raised inflammatory markers, Nonspecific chest X-ray changes...

But which one has vasculitis? #lives2018
The answers are surprising...

(And it looks like you should #POCUS everyone with suspected vasculitis 😁😜) #lives2018
Read 22 tweets

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Justin Caouette
@JustinCaouette
Overdose on placebos? Apparently it’s a thing:

In 2006, a 26-year old male suffering from depression arrived at an emergency room. He said he had taken all the experimental antidepressants that were given to him as a part of his clinical trial. 1/4
His blood pressure had dropped to 80/40 requiring intravenous introduction of saline. Blood pressure rose but dropped again when the infusion slowed. Doctors determined that he had ingested a bottle of placebos. 2/4
Within 15 minutes of learning the news, his blood pressure returned to his baseline 126/80. He was characterized as having overdosed on placebos. 3/4
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🌱Sin: Typo Bunyip🌱
@quollhorreur
So, I’m going to follow up on this with some of the peer reviewed evidence based research that Glinner apparently hasn’t seen.

You know, just to have it out there.
1. Cornell University did a systematic review of available literature 1991-2017 (59 studies), looking at the effect of transition on wellbeing.

whatweknow.inequality.cornell.edu/topics/lgbt-eq…
These are their major findings.

Just to note - NONE of the studies they reviewed concluded that transition causes overall harm btw.
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Dr Elisabeth Poorman
@DrPoorman
Here are my #clinicalpearls from #IM2019. #meded #medtwitter #WomeninMedicine Share yours! 1/
The oral bioavailability of bumetinide and torsemide is 80-100% vs 10-100% for furosemide. If patients aren’t responding to furosemide orally, consider switching.

#IM2019 #clinicalpearls 2/
Vascular atrial fibrillation=mitral stenosis or mechanical valve. Vitamin K antagonists preferred over NOACs.

#clinicalpearls #IM2019 3/
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Avon Healthcare
@AVONHMO
Every now and then, the debate stirs about whether noodles are healthy or not. Debates on diet aren't bad; what's problematic is the various conflicting information shared with very little credible backing.

We hope this #thread helps.
Instant noodles are popular all over the world and why not: they're convenient, inexpensive and easy to prepare.

However, because they contain few nutrients and high amounts of sodium and MSG, the health effects always spark some controversy.
Let's take a look at the ingredients. Noodles typically contain flour, salt and palm oil. The flavouring packets generally contain salt, seasoning and monosodium glutamate (MSG).

Fun fact: Instant noodles are pre-cooked noodles that have been steamed and dried.
Read 20 tweets
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george davey smith
@mendel_random
1/n A webinar from @CDC_Genomics on Mendelian randomization (MR) highlights some under-appreciated aspects of MR; this thread outlines these
2/n The key interpretive assumption in MR is of gene-environment equivalence: that perturbations caused by genotype have the same downstream effects as if they were caused by modifiable exposures (at 7 mins 40 seconds)
3/n Thus if LDL cholesterol is low due to genotype this will have the same downstream effects (e.g. on coronary heart disease, CHD) as LDL cholesterol will have if it is low due to diet or taking statins (or other cholesterol lowering drugs)
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CORE IM
@COREIMpodcast
@CrispyCoca @tony_breu @j9knudsen 1/ Long-term data, though conflicting, that suggests acetaminophen use may modestly increase population risks of GI bleed and even cause modest increases in blood pressure. ncbi.nlm.nih.gov/pubmed/25732175
@CrispyCoca @tony_breu @j9knudsen 2/ "if a clinician is starting paracetamol for chronic use it might be advisable to discuss these SE. Esp, an incr. risk of GI bleeding and a small (~4 mmHg) increase in SBP are adverse effects for which the evidence is strong, and which show a degree of dose dependence."
@CrispyCoca @tony_breu @j9knudsen 3/ That was from this clinical pharmacology article: ncbi.nlm.nih.gov/pubmed/29863746
Read 3 tweets

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