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IMCrit

@IM_Crit_

Apr 28

ICU stories (a brief one): A 40+ yo pt w hx of bipolar disorder/asthma/GERD/HTN was brought to the ED by EMS after his wife found him lethargic ("altered mental status"). Apparently, he had spent the previous 2 days isolated in his forest cabin. Upon ED arrival, he was obtunded

& was given Narcan with no improvement. Vitals: 140/90, hr 80, rr 22, afebrile, sat 97% on room air. He could respond to simple questions. CT brain was negative. Lab work/up showed Hct of 59%, wbc 11k, PLT 400k and a chemistry panel showed:

A urine drug screen was sent 👇 while patient admitted that he had probably taken more Xanax (alprazolam) pills than he should. However, he denied that he wanted to hurt himself.

Read 18 tweets

IMCrit

@IM_Crit_

Apr 27

ICU "news":

Have you heard about the Doraya catheter? It is percutaneously deployed in the IVC below the level of the renal veins & works as a temporary iv flow regulator -> partially obstructing the venous flow -> ⬇️ cardiac preload & venous congestion

In a very small preliminary study, the catheter was placed in 9 patients (LVEF 24±12%) for a mean duration of 8.5 hours. The catheter deployment led to significant pressure ⬇️ above the device 12.4±4.7 mmHg, when compared to unchanged pressure below the catheter 18.5±6.2 mmHg

Diuresis was 77.1±25 ml/h at baseline, and 200.8±93 ml/h during device deployment with average peak urine output of 294 ± 139 ml/h... Spot urine Na increased from 35 to 101 mmol/l

Reference:
jacc.org/doi/10.1016/j.…

Read 6 tweets

IMCrit

@IM_Crit_

Apr 21

ICU Pharmacy pearls:
If u have not heard the news, there is a national shortage of IV hydrocortisone (HC) ...
ashp.org/drug-shortages…
So, if u are like me & use often HC in septic shock, u need to be aware of other options. If HC (Solu-Cortef®) is not available, consider use of

an alternative parenteral corticosteroid: methylprednisolone (MP) (Solu-Medrol®) or dexamethasone (D)

The "problem" w these two drugs is that they have minimal mineralocorticoid activity, so u may need to supplement them w fludrocortisone (FC)

This should not be a totally unknown practice for intensivists, since the "prototype" of positive steroid trials in septic shock, the Annane trial published 20 years ago in JAMA (jamanetwork.com/journals/jama/…) implemented a 7 day course w iv hydrocortisone AND enteral fludrocortisone

Read 7 tweets

IMCrit

@IM_Crit_

Mar 28

https://twitter.com/IM_Crit_/status/1640097382460272641

Since I (re-)started the albumin debate

https://twitter.com/IM_Crit_/status/1640097382460272641

I have to bring more info to the table:

"Anti-albumin":

"Pro-albumin":

Read 4 tweets

IMCrit

@IM_Crit_

Mar 26

From Critical Care

Fluid therapy in septic shock:

Criteria to customize the fluid strategy at different steps of septic shock:

Means for reducing the cumulative fluid balance depending on the stage of resuscitation of septic shock

Read 9 tweets

IMCrit

@IM_Crit_

Mar 5

ICU stories (a brief one): 60 yo male w lung cancer / CAD / HTN / HLD / status post chemotherapy a month ago presented to the ED w SOB/cough/weakness after failing outpatient tx w azithromycin. CT chest: no PE but positive for bilateral consolidations:

Patient came to the ICU intubated, sedated, on pressors & antibiotics for PNA. Next step: POCUS. PLAX looked "weird", so Doppler and "zoomed" views were recorded:

PSAX & subcostal views:

Read 16 tweets

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