I'm excited to share that I've been extensively updating my OnePagerICU.com site to make it run smoother and add a bunch of highly requested features. For example:
1️⃣ Search 🔎
This should make it easier & much faster to find content! Less scrolling, more learning! 1/
2️⃣ References 📚
The site now includes links to all the references cited in each OnePager. In most cases I try to point out the seminal papers & their findings. Hopefully this makes it easier for learners to find the "key studies" on a topic!
(DM me ones I've missed! 🙏) 2/
3️⃣ Related OnePagers 🖇️
Thumbnails to related OnePagers - for example if you just learned about ECMO Fundamentals perhaps you'd like to see OnePagers about ECMO troubleshooting, LVADs, Balloon Pumps, etc?
Hopefully this makes it easier to find your next topic to learn about! 3/
4️⃣ Links to other sites 🔗
There's a ton of great #FOAMed out there; I've added links to some of my favs! (e.g. @emcrit@LITFLblog@derangedphys@PulmPEEPs etc)
(This is a work in progress; please DM me or @OnePagerICU if you have suggestions for links I should include! 🙏) 4/
5️⃣ Translations! 🌍
The beauty of #OpenSource is it makes it easy to collaborate/translate. Thanks to several amazing volunteers, we now have OnePagers translated into 7 languages! 🇫🇷🇩🇪🇪🇸🇵🇹🇧🇷 & more!
6️⃣ More OnePagers! 📟
There's some new content & I've got about a dozen #OnePagers in the works including some amazing collaborations. Stay tuned for a lot more *content* in the coming weeks! #FOAMed#FOAMcc
If you intubate you need to read the #PREOXI trial!
-n=1301 people requiring intubation in ED/ ICU were randomized to preoxygenation with oxygen mask vs non-invasive ventilation (NIV)
-NIV HALVED the risk of hypoxemia: 9 vs 18%
-NIV reduced mortality: 0.2% vs 1.1%
#CCR24
🧵 1/
Hypoxemia (SpO2 <85%) occurs in 10-20% of ED & ICU intubations.
1-2% of intubations performed in ED/ICU result in cardiac arrest!
This is an exceptionally dangerous procedure and preoxygenation is essential to keep patients safe.
But what’s the *BEST* way to preoxygenate? 2/
Most people use a non-rebreather oxygen mask, but because of its loose fit it often delivers much less than 100% FiO2.
NIV (“BiPAP”) delivers a higher FiO2 because of its tight fit. It also delivers PEEP & achieves a higher mean airway pressure which is theoretically helpful! 3/
Results from #PROTECTION presented #CCR24 & published @NEJM.
- DB RCT of amino acid infusion vs placebo in n=3511 people undergoing cardiac surgery w/ bypass.
- Reduced incidence of AKI (26.9% vs 31.7% NNT=20) & need for RRT (1.4% vs 1.9% NNT=200)
Potential game changer!
🧵 1/
I work in a busy CVICU & I often see AKI following cardiac surgery.
Despite risk stratification & hemodynamic optimization, AKI remains one of the most common complications after cardiac surgery with bypass.
Even a modest reduction in AKI/CRRT would be great for my patients. 2/
During cardiac surgery w/ bypass, renal blood flow (RBF) is reduced dramatically. This causes injury, especially in susceptible individuals.
But what if we could use physiology to protect the kidneys?
Renal blood vessels dilate after a high protein meal increasing RBF & GFR! 3/
77 yo with respiratory distress, RR 30, SpO2 80% on non-rebreather at 15 lpm
CXR & TTE are unrevealing
pH 7.58 / PaCO2 24 / PaO2 >500 / HCO3 22
MetHb 0% CarboxyHb 0%
The ABG looks like this:
The answer is sulfhemoglobinemia.
Sulfhemoglobinemia is a *permanently* modified hemoglobin associated with exposure to TMP/SMX, dapsone, phenazopyridine, & other amino & nitro compounds.
It has an altered oxy-hemoglobin dissociation curve.
2/
Sulfhemoglobinemia is easily confused with methemoglobinemia. Both have very dark colored blood & present with cyanosis. Diagnosis typically requires a specialized lab.
Spoiler: you may have heard that SulfHb is green. It isn’t really. You’re thinking of Vulcans’ blood.
Damn. Under Trump the White House Medical Unit was a pill-mill. Thousands of ambien & provigil per month.
Worse, for a clinic that doesn’t typically do procedures w/ moderate sedation they sure are they ordering prodigious quantities of morphine, fentanyl, versed, & ketamine…?
Honestly, this reminds me of Norman Ohler’s Blitzed.
The AG report was largely concerned with the enormous cost of prescribing these non-genetic meds.
It’s worth pointing out that dispensing prescription meds without documentation is malpractice. In the case of controlled substances it’s also likely a crime.