Very nice overview of the current state of affairs in cardiogenic shock (published this week in @TheLancet): Classification systems and key risk factors for cardiogenic shock:

Mixed cardiogenic shock (CS) -herein classified as CS with at least 1 additional contributing cause of shock state- is common (& usually quite challenging to treat...)

20% of all shock patients admitted to contemporary cardiac ICUs have mixed CS

Besides this old-school approach It's good to keep in mind the proposed "normal" hemodynamic compensation & criteria for mixed cardiac-vasodilatory shock:

ICU/ED ECG Secrets:

New fear unlocked:

40 yo male, previously healthy, referred to the ED post-CPR after documented ventricular fibrillation
(VF). Vitals & physical exam: OK. No family history of sudden death. No drugs.

Any concern from this 12-lead electrocardiogram (ECG)? What do you think the most likely concern/explanation is?

ICU (Central Venous/Arterial) Line Secrets - Part 3:

Following from where I stopped last week & if you are not already bored by parts 1 & 2, there are some additional points that may be worth noting

Here the (probably) final part begins: 41. If you think that the patient will need dialysis or right heart catheterization in the next few hours, consider placing a dialysis catheter or an introducer sheath from the beginning

ICU (Central Venous/Arterial) Line Secrets - Part 2:

Following from where I stopped last week (that's why I keep same numbering) & without hoping to a provide tutorial about how to place lines, there are some additional points that I find worth mentioning

https://x.com/IM_Crit_/status/1845053731743621346

Here the (more specific) part begins:

21. Femoral vein (FV) catheters have been demonized. A recently published study of 55,663 CVCs showed no difference of catheter-related bloodstream infection incidence rates between the three insertion sites (). IMHO,doi.org/10.1007/s00134…

ECG Secrets:

50 yo ♂︎ with no significant medical history presented to the ED after acute onset of sharp chest pain. No family hx of heart disease, & no tobacco or illicit drug use. Episode lasted ~30 min before pt arrived to the ED. He was pain-free with normal vitals. ECG: Physical exam: no acute distress, & normal heart-lung exam. Labs sent & were all normal: CK, 193; CK-MB, 3.0; troponin T, 0.03. Patient remained pain-free for the next hour

What would you do next?

ECG Secrets:

Do you know this flag? How is it related to ECG interpretation? This is the South African flag pattern with ST elevation in the leads V2 and aVL, with inferior reciprocal ST depression. It is found in first diagonal occlusion

ICU Ventilator Waveforms Secrets:

I am reading an interesting article about patient-ventilator asynchrony in non-invasive ventilation

From top to bottom, waveforms of airway pressure (Paw), flow, and electrical activity of the diaphragm (EAdi) are depicted

In this figure: please focus on the waveforms in the middle column

Do you think there is an asynchrony?

ICU (Central Venous/Arterial) Line Secrets - Part 1:

An ICU where the patients have no central lines & are not connected to ventilators is not a real ICU. This may be a controversial statement but in my humble opinion not far from truth There are so many textbook chapters, online videos & conference courses dedicated to line placement. Is there really anything left to be said about lines that has not already been said?

ICU Secrets:

We are moving away from massive fluid resuscitation & we become less familiar with its metabolic effects

In this study, 2 groups of 12 pts each who underwent major gynecologic surgery were assigned randomly to receive 0.9% saline or lactated Ringer's @ 30 ml/kg/h! Each patient received approximately 6 liters of crystalloids...

ICU Hemodynamics:

Swan-Ganz refresher from 40 years ago: The pulmonary artery occlusion pressure (PAoP) may not adequately reflect the left ventricular end-diastolic pressure (LVEDP) & the LVEDP may bear little relationship to the left ventricular end-diastolic volume (LVEDV)

This is the weekly refresher on basic hemodynamic monitoring:

Hemodynamic variables determining perfusion pressure and oxygen delivery: Dynamic response of the arterial pressure measurement system:

ICU Nephrology Secrets:

1. The definition of insanity* is to give bolus iv 40 mg of Lasix (furosemide) without seeing any effect and then starting Lasix drip at 10 mg/hr hoping for a brisk diuretic response... 🤷‍♂️

#foamed #foamcc #meded #medtwitter #medstudent Along the same lines:

2. Switching the ineffective Lasix drip to Bumex (bumetanide) drip at 1 mg/hr and keep hoping to see this:

ICU studies:

What do you think the mean blood pressure is just before terminal cardiovascular collapse (TCC)? 20? 30? 40?

TCC defined as the abrupt (< 5min) & exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest

Good to know, right? ...

ICU Stories:

While walking around the ICU at the beginning of your night shift, you notice that the respiratory therapist increased the FiO2 from 90 to 100% in a mechanically ventilated patient. Bedside monitor shows O2 sat 90%. You decide to read a bit more about the patient: This is a 50 yo pt with hx of atrial fibrillation / diastolic HF / HTN / COPD / morbid obesity (190 kg; BMI 55) who presented 3 days earlier with dyspnea & atrial fibrillation with rapid ventricular response

ICU mini-cases:

80 yo pt w HTN/HLD/CKD (creat ~ 3.0 mg/dl) underwent off-pump CABG (LIMA>LAD). Came to ICU intubated.
Surgeon's sign-out: "easy case"
Anesthesiologist's sign-out: "good LV/RV, mild-moderate MR, needed pressors"
What don't u like from what u see on the monitor? When pt was first seen in the ICU, he was on norepi 1.0 mcg/kg/min. Intra-operatively had also received ~500 mcg of phenylephrine boluses, 7 boluses of epi (10 mcg each) & 15 u of vasopressin (in 1-2 u boluses). No Swan-Ganz in place. Did I mention he was on FiO2 100% w PaO2 65?

ICU scenarios (and pet peeves):

- Hey doc, this patient with ileus in bed 6 has a blood pressure of 186/68. What do you want me to give?
- Any worrisome symptoms with this BP?
- No, I am just worried she will stroke out
- Don't give anything
- No hydralazine then?
- No, please This is one of the most common management discussions/topics in the wards or in the ICU. This study tried to shed some light:

ICU Hemodynamics Secrets:

Actually, these are not secrets at all; they reflect common, basic knowledge. But the word “secrets” is more clickbait-y!

Here it begins:

1. You don’t have to check for fluid responsiveness (FR) if the patient is bleeding to death… 2. Preload challenges (eg, end-expiratory occlusion test or tidal volume challenge) are preferable to fluid challenges

Noninvasive ventilation (NIV) has been standard of care treatment for acute exacerbation of COPD (AECOPD) for > 30 years. In this article, the authors describe an evidence-based algorithm of the initiation, titration, monitoring, and weaning of NIV in AECOPD NIV initiation:

An interesting study was recently published in @yourICM and the authors made some sensible - IMHO - suggestions about how to use echocardiography to guide fluid management in critically ill patients

They recognized 3 scenarios where echo can predict fluid responsiveness (FR): 1. Do NOT fill

2. Fill

3. Optional fill

I tried to tabulate their scenarios and recommendations/limitations extracting only information from their paper and not adding any thoughts of mine

Here is begins:

ICU ID Secrets (following up on my post* from last week):

Ten things to remember about methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nasal swabs: 1. The MRSA nasal PCR is mostly helpful in patients with pneumonia or at least high suspicion of it since nasal colonization correlates with MRSA presence in the rest of the respiratory tract