Tweet

@ThinkingCC

@NephroP

More from @IM_Crit_

IMCrit

@IM_Crit_

Dec 3

ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes

febrile/“altered” & is sent to the ED for “evaluation”. The course is so predictable that we usually consider these admissions “boring”. This is the case of a middle-aged pt w cerebral palsy/mental retardation/seizures (on valproic)/PEG-chronic Foley in place who was sent to

the ED for fever+hypotension+tachycadia. Labs: WBC 15k, lactate 4.0. UA -as usually- suggestive of UTI (WBC>50, +bacteria, +nitrite, +esterase). CXR “clear” & pt w sat 99% on room air. Received ivf, Abx (pip/tazo + vanco) but due to persistent ⬇️BP, norepinephrine gtt was ordered

Read 25 tweets

IMCrit

@IM_Crit_

Nov 4

Alcohol withdrawal syndrome: I don’t know if u have a similar experience in other countries (or other places in the States) but I've recently seen a big spike in alcohol abuse-related disorders, especially alcohol withdrawal syndrome (AWS). I'm obviously referring to severe AWS

that eventually will need to come to the ICU (if we have a bed available!). There are many fantastic, well-searched reviews on this topic but it may be hopefully interesting for some if I put “my way” out there & also for me to learn from your experience. Even though the focus

will be on the neuropsychiatric component, I believe it is quite important to highlight other parts of AWS management. To this end, I will use the assessment/plan “per organ” approach which is commonly used when we write progress notes here in US. Here it goes:

Read 26 tweets

IMCrit

@IM_Crit_

Oct 30

ICU stories: You get a call from outside 🏥 to accept a middle-aged pt w DM2/HTN/HLD/some type of solid Ca on chemo/obesity who presented to their ED w weakness/anxiety/"feeling cold". Vitals: BP 80-100, HR 130s (sinus tach), afebrile, Sat 100% on room air. Labs: WBC 13K, ...

... Lactate 5.2, creat 1.3. UA w some WBCs/bacteria. CXR clear. Norepi drip ordered but cancelled after BP improved to mid-90s, HR fell to 120s, & lactate ⬇️ to 2.5. What's your next step?

The discussion went like this:
Me: I will be happy to accept but I have no idea what we are treating. If it is sepsis, the source is unclear. And what about PE? Can you pls get a CT before sending?
ED: Sure, will do it. Thanks.
You go home & next am you learn that the CT showed:

Read 21 tweets

IMCrit

@IM_Crit_

Oct 14

ICU stories (from the trenches): It's been a bit more than 2 hrs in your night shift & you are checking some labs signed out to you to be followed on. A rapid response is called for "agitation" in Rm 666; in less than a minute the operator calls for a "Code Blue" in the same room

When u arrive @ the code, u see a very young pt white as a sheet w CPR in progress. Presented to ED 12 h earlier c/o non-bloody emesis & abd pain x 1 wk. Uses daily NSAIDs for chronic pain. Vitals in ED: 125/77, HR 125, Hb 7.9 g/dl. Guaiac(+) stools. Vitals improved w hydration

and EGD was performed that showed "normal esophagus, large amount of food in the stomach, 6 mm non-bleeding antral ulcer & a large non-bleeding duodenal bulb ulcer". Evaluation was thought to be "limited" & plan was to repeat EGD next am. Back to the code, which is a PEA arrest

Read 28 tweets

IMCrit

@IM_Crit_

Sep 23

ICU Infectious Disease Pearls and Pet Peeves-Part3: These are some extra points & random thoughts regarding commonly used antimicrobials & frequently encountered ID scenarios in the ICU. Comments from ID & Pharm friends are welcome as what I post comes from memory. Here it goes:

1. Especially in immunosuppressed patients with severe septic shock, don’t be in a hurry to de-escalate the antibiotics when the Microbiology lab calls you to report a positive blood culture result. In a number of patients, likely close to 5%, the bacteremias can be polymicrobial

2. The role of anaerobes in aspiration pneumonia is probably over-rated. Not much else to say here since the topic is extensively discussed recently. The message is that anaerobic coverage is frequently redundant. In addition, there is a huge debate about...

Read 26 tweets

IMCrit

@IM_Crit_

Sep 16

ICU Infectious Disease Pearls and Pet Peeves – Part2: These are some additional points and random thoughts regarding commonly used antimicrobial agents and frequently encountered ID clinical scenarios in the ICU. Comments from my ID and Pharm friends are welcome. Here it goes:

1. Candida pneumonia is essentially a non-existent entity (except in the presence of SEVERE immunodeficiency). Candida in the sputum is almost always a colonizer. You can use it as a marker of systemic candidiasis in order to justify antifungal coverage but the studies...

...are not supportive of significant clinical benefit

2. If u suspect Candida in a septic pt, echinocandin (not an azole) is the preferred empirical tx. Most people in US start w 100 mg of micafungin but u can easily give 150 or even 200 (if your pharmacist doesn't freak out...)

Read 26 tweets

Share this page!

IMCrit

People who liked this thread also liked...

Try unrolling a thread yourself!

More from @IM_Crit_

IMCrit

IMCrit

IMCrit

IMCrit

IMCrit

IMCrit

Did Thread Reader help you today?

Don't want to be a Premium member but still want to support us?

Send Email!