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Jun 19, 2023 14 tweets 5 min read Read on X
Randomised clinical trials in cardiogenic shock in the PCI era Image
Treatment considerations for patients with AMI-cardiogenic shock Image
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65) ImageImage
Determination of the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage using the revised SCAI Shock Classification Image
Conceptual model showing the overlap between
different states of hemodynamic compromise. Shock is defined by presence of hypoperfusion; most, but NOT ALL, patients will also be hypotensive. Pts w hemodynamic instability who do not meet criteria for shock are labeled as pre-shock Image
Management algorithm for patients with or at risk for cardiogenic shock (CS) tailored to the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage Image
Framework of clinical parameters to follow in patients with heart failure-related cardiogenic shock in the critical care unit Image
Considerations for invasive hemodynamic assessment in HF-CS Image
Classification and management of HF-CS Image
It seems that the most controversial issue is the use of short-term mechanical circulatory support for cardiogenic shock. So, a very recent publication deals with this: Image
Proposed overview of selection of patients to pVAD based on SCAI shock class A-E Image
Flowchart to identify and handle potential need for escalation of mechanical circulatory support in patients supported by axial flow pump (AFP) Image
Flowchart to identify and handle potential need for venting during V-A ECMO support Image

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More from @IM_Crit_

Jul 31
ICU Snapshots:

Elderly 👴 w interstitial🫁disease was admitted -on NIV- from the ED to StepDown unit w "pneumonia": bil infiltrates/low-grade fever. PF ratio 140. Since I was in the ICU, I asked how he looked. Reply: needs high FiO2 but pulls good tidal volumes

When I saw him: Image
This is not an uncommon scenario: a "low" expired tidal volumes (Vt) makes the staff worried during NIV initiated for hypoxemic respiratory failure but a "high" Vt (even if accurately measured) is left unabated...
In fact, high Vt during NIV has been associated with NIV failure and poor outcomes
Read 9 tweets
Jul 21
The American Thoracic Society (ATS) updated its recommendations on some aspects of the diagnosis and management of community-acquired pneumonia (CAP) Image
This guideline update focuses only on immunocompetent adult patients with a standard diagnosis of CAP

It addresses four clinically relevant questions: Image
The guideline underwent peer review by 16 experts (4 from ATS; 11 from Infectious Diseases Society of America (IDSA). It Is not clear to me why IDSA did not approve it. I copy from the supplement: "The IDSA chose to withdraw rather than approve the final version of the guideline"
Read 15 tweets
May 17
ICU/ED Pharmacology/ID Secrets:

Have you ever managed a septic patient & ordered antibiotics to be given stat only to discover hours later that they were still infusing? If yes, stay tuned

Among several controversies in sepsis management, the early administration of antibiotics Image
Image
is one of the least debatable ones. Time is life in sepsis!

Even though it's hard to believe that every hr of delay in antibiotics ⬆️ mortality by 8% (this is a different topic...), it's one of my pet peeves when it takes for ever to give antibiotics to a septic shock patient
The most commonly ordered combination in 🇺🇸 hospitals (EDs/ICUs) is piperacillin-tazobactam (Zosyn in 🇺🇸) + vancomycin (V). If the usual practice is followed, giving a dose of Zosyn & a dose of vanco can take close to 3 hours. This should not be the case!
Read 14 tweets
May 3
ICU Upper GI Bleeding (UGIB) Secrets:

Is there anything regarding UGIB that has not been already done, studied or tweeted about? Not much, but all of the following are things I witnessed happening (or not happening…) in two UGIB cases I recently saw in the ICU

Here it begins:
1. If a patient does not have an obvious UGIB as in the clip above, she has just presented with melena & it is still unclear if this is due to upper or lower GIB, a quick & dirty trick is to check the blood urea nitrogen/creatinine (BUN/creat) ratio. There are various published
cut-offs in the literature (don’t sweat about them…) but, in general, a ratio of >30 suggests UGIB. This is due to the small bowel absorption/digestion of blood protein which is subsequently metabolized to urea. There are confounding factors, but the trick usually works well
Read 21 tweets
Apr 28
The patient whose ECG/POCUS clips I posted yesterday has remained hemodynamically stable & neurologically intact

This was the #ECG today; still looking angry: Image
I repeated #POCUS; no significant changes:
If you a #VEXUS friend, these are bonus images; no venous congestion:

PS: @MynephCC @NephroP will kill me for not having ECG tracing but we don't have an ECG cable in the trenches... 🤷‍♂️ Image
Image
Image
Read 5 tweets
Apr 27
ICU Stories:

Walking from room to room in the ICU on a Sunday morning while hoping to have a quiet shift, you notice this 👇 on a patient's monitor (60 yo, admitted, intubated for COPD exacerbation + pneumonia 3 days ago, now sedated/hemodynamically stable) Image
It's unfortunately hard to pretend you didn't see it, so you get an ECG praying that it will not show what you saw on the monitor... 😊

Of note, admission ECG was "ok"

Well, it actually looks more impressive on the 12-lead ECG: Image
Now, what are you concerned about?
Read 11 tweets

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