This piece eloquently articulates my own thoughts on WLST. Current practice leads to avoidable harm, probably for many patients but definitely for their loved ones. We can and have a duty to do better, and should be brave enough to challenge current practice link.springer.com/article/10.1...

Palliative General Anesthesia at Terminal Extubation: “Go Gentle into that Good Night” - Neurocritical Care

Withdrawal of life-sustaining treatments in the intensive care unit most often culminates into the discontinuation of mechanical ventilation and removal of the endotracheal tube or “terminal extubatio...

link.springer.com

This is such a cool illustration of how the Mercator map distorts the size of Greenland, which looks as big as the whole continent of Africa on that map but is actually the size of Mexico.

These may well be the best years of your life, but I’m just saying 6.30-8.30am aren’t the best hours of those best years 🫠

I’m not big on conspiracy theories but this one rings true… #CritcalClosingCriticalSchmosing

In patients with cardiovascular disease and an implantable cardioverter–defibrillator, increasing potassium levels to the high-normal range reduced the risk of arrhythmia events, hospitalizations, and death. Full POTCAST trial results and Research Summary: nej.md/4oQtHTN #MedSky

The doses of bicarb used were aggressive Interquartile range for total cumulative dose was 500-1000 ml of 4.2% bicarbonate That's equivalent to 5-10 amps (50 ml vials) of 8.4% in the USA You can use a LOT of bicarb if you have to (titrated to effect; also look at Na levels & avoid hyperNa) #4/4

a woman in a red dress is saying we go hard bravo

ALT: a woman in a red dress is saying we go hard bravo

media.tenor.com

In honor of spooky month, share a 4 word horror story only someone in your profession would understand “Remember that patient you…”

Shai@shaiuk.bsky.social · 10mo ago

In honor of spooky month, share a 4 word horror story only someone in your profession would understand “They’re for FULL escalation”

normal mentation *doesn't* indicate adequate systemic perfusion especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

Sad Sad Bean GIF

ALT: Sad Sad Bean GIF

media.tenor.com

Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial #AnSky doi.org/10.1111/anae...

The fact the furosemide stress test does well at predicting who will need to commence/continue RRT is great (& unsurprising) but it doesn’t help us at the bedside. The real question is does earlier initiation/re-continuation of RRT help this cohort? 1/ ccforum.biomedcentral.com/articles/10....

Spontaneous diuresis in combination with furosemide stress test (SD-FST) as predictor for successful liberation from kidney replacement therapy: a prospective observational study - Critical Care

Background The optimal time for initiating kidney replacement therapy (KRT) in acute kidney injury (AKI) has been extensively studied in recent years. In contrast, there are currently insufficient dat...

ccforum.biomedcentral.com

😱

Saskia Middeldorp@middeldorps.bsky.social · last yr.

This is what we were waiting for. A direct comparison between apixaban and rivaroxaban for the treatment of acute VTE. Apixaban reduces bleeding risk in the first 3 months by >50%! Practice changing investigator-initiated RCT. #ISTH2025

A normal CT head ≠ a low risk of raised ICP/herniation after LP in meningitis❗️ “80% of pts with ABM who herniate have no CT abnormalities” 🔑 Take-away: Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP journals.sagepub.com/doi/epub/10....

🆕 New RCT in JAMA: Sedation in mechanically ventilated ICU patients—Dexmedetomidine vs Clonidine vs Propofol 📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.

Procalcitonin- the more we learn, the less we love it 💔 ▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT ▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️ “Pct in pts with AKI/ESRD should not be measured” #EMIMCC ccforum.biomedcentral.com/articles/10....

Procalcitonin levels in septic and nonseptic subjects with AKI and ESKD prior to and during continuous kidney replacement therapy (CKRT) - Critical Care

Background Procalcitonin is a 14.5 kDa protein used clinically as a marker of sepsis and therapeutic response to antibiotic therapy. However, its utility in critically ill patients with either acute k...

ccforum.biomedcentral.com

Assessing fluid responsiveness in spontaneously breathing MV patients is tough, so this work on SIGH35 by Messina et al. is really 👌 ▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir Simples. 1/ ccforum.biomedcentral.com/articles/10....

SIGH35 and end-expiratory occlusion test for assessing fluid responsiveness in critically ill patients undergoing pressure support ventilation - Critical Care

Background Assessing fluid responsiveness is problematic for critically ill patients with spontaneous breathing activity, such as during Pressure Support Ventilation (PSV), since spontaneous breathing...

ccforum.biomedcentral.com

Sometimes checking an ScvO2 feels pointless, but other times it’s 23% P.S. a CO2 gap of 2.3 (17mmHg) must take some beating?

Does the over rapid correction of hypernatraemia really cause cerebral oedema in adults❓ Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant 1/

two cartoon characters with big brains are standing next to each other in front of a brick wall

ALT: two cartoon characters with big brains are standing next to each other in front of a brick wall

media.tenor.com

Basilar artery occlusion accounts for ≈10% of nontraumatic causes of coma Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️ www.sciencedirect.com/science/arti... #EMIMCC

Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma

Nontraumatic impaired consciousness is a common issue in emergency departments with a serious but widely variable prognosis.The aim of this prospectiv…

sciencedirect.com

The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤 Is this a 🇬🇧 thing? Curious to hear other people’s experience… #EMIMCC academic.oup.com/bjs/article/...

📢 This bares emphasis 📢 If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse. VA uncoupling with septic cardiomyopathy is a legit silent 🥷 Pressure ≠ perfusion

josh farkas 💊@pulmcrit.bsky.social · last yr.

Think septic cardiomyopathy when pressors are rapidly escalating & not working. MAP = CO x SVR ↔️ ⬇️ ⬆️ Excess afterload causes the CO to drop. The BP may be relatively stable. Excess pressors are exacerbating the shock. Pts may look cool & poorly perfused with ⬆️ cap refill time.

Time to dump my shares in Sedaconda! Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS (Also median duration of NMB use of 5 days in both groups seems wild 🫤) jamanetwork.com/journals/jam... #MedSky #EMIMCC

Inhaled Sedation in Acute Respiratory Distress Syndrome

This clinical trial compares the efficacy of inhaled sevoflurane vs intravenous propofol for sedation in patients with acute respiratory distress syndrome.

jamanetwork.com

A great opportunity to recite this 💎: 1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps That initial 3L resus = 69 bags worth‼️ It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵‍💫🧂

josh farkas 💊@pulmcrit.bsky.social · last yr.

a liter of isotonic crystalloid contains about 3.5 grams of sodium. anyone bolusing their patient with crystalloid while keeping them on a sodium-restricted diet needs to repeat high school chemistry.

Adolescence on Netflix is fucking astonishing, urgent, vital and it hurts your heart. Incredible cast, direction and writing. You must watch it. You just must.

Having discontinued Melatonin on numerous occasions (murmuring Pro-MEDIC to any poor soul who’ll listen) the rec FOR melatonin is quite triggering… Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode 💡 Ivermectin for delirium ⁉️

josh farkas 💊@pulmcrit.bsky.social · last yr.

brief skytorial on the latest SCCM PADIS guideline update. this is a nice, useful, & concise statement that will change my practice. there are basically two take-home messages... (🧵 #1/3) journals.lww.com/ccmjournal/a... #EMIMCC

brief skytorial on the latest SCCM PADIS guideline update. this is a nice, useful, & concise statement that will change my practice. there are basically two take-home messages... (🧵 #1/3) journals.lww.com/ccmjournal/a... #EMIMCC

📝 ▫️Clonidine should be carefully considered as there is a paucity of evidence around its use ▫️ Consider Haloperidol (first line) for psychomotor symptoms My colleagues will be gutted, but I’m all for the #VitaminH ❤️

Intensive Care Society@ics-updates.bsky.social · last yr.

Delirium in critically ill patients is a serious but often underdiagnosed condition. Our new guidelines offer expert recommendations for early detection, prevention, and management in the ICU. Let's improve outcomes together! Read below now👇 bit.ly/deliriumicsguidance

An excellent (albeit a little scary) retrospective study of arterial injury after CVC insertion. A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device) #EMIMCC

Anaesthesia@anaesjournal.bsky.social · last yr.

Arterial trauma is a rare, but potentially life-threatening complication of central venous catheter insertion. In this interrogation of two national databases of incident reports, outcomes included: • stroke (10%) • death (4%) #AnSky #MedSky https://doi.org/10.1111/anae.16570

Thoughts and prayers to the poor centurion who got put on VA-ECMO 🥺 #Zentensivsim link.springer.com/article/10.1...

Utilization and outcomes of life-supporting interventions in older ICU patients in Japan: a nationwide registry study - Intensive Care Medicine

Purpose The purpose of this study is to describe the implementation of life-supporting interventions and the short-term outcomes of older patients in ICUs in Japan. Methods All adult patients admitted...

link.springer.com

Some very challenging interactions with a new surgical colleague this morning #ILookLikeASurgeon 👩‍⚕️ 🥰 🦄