Its 3am in the ED and you need to call a consult.  What strategies can you use to get great care for your patients and be a good colleague?

It's a typical day in the ED.  You are asked to see your next patient who is a 60 year old male, recently discharged from the hospital after being treated for cellulitis presenting with abdominal pain and diarrhea.  He’s tachycardic and hypotensive to 75/40.  The patient is mentating well.  After taking a more thorough history your differential diagnosis narrows in on intra-abdominal sepsis associated with significant volume losses.  The lactate returns at 6.  On volume assessment by physical exam and POCUS, the patient is significantly volume down.  You know that getting the antibiotics and fluids on board is the cornerstone of treatment, but they will take some time to be given.  You wonder if you should temporize your resuscitation with pressors during the time it takes for the fluids and antibiotics to be administered.

You admitted a 72 year old male to the ICU for septic shock from community acquired pneumonia. He required intubation and mechanical ventilation for failure to improve oxygenation with NIPPV and encephalopathy. He received broad spectrum antibiotics and a 30 cc/kg crystalloid bolus. His MAP was persistently in the 50s despite adequate fluid resuscitation and based on your exam he does not appear hypovolemic. Norepinephrine is started and despite adequate MAP he is oliguric. His only medical history is he was a previous smoker with COPD, HTN, HLD but normal renal function with a Cr of 0.8 two months prior. His Cr on admission is 2.2 and a foley is placed and his UA shows granular casts. He is not acidotic and his electrolytes are normal. 

You are concerned this patient is heading towards renal replacement therapy. He is adequately fluid resuscitated and has a MAP above 65 on a vasopressor but is still not making urine and has signs of ATN on urinalysis. Renal replacement therapy is an invasive procedure and has associated risks. If a patient has a chance to have renal recovery with a more conservative approach then this should be considered.  You wonder if there is a diagnostic test which can be used to assess the potential for renal recovery.

A patient is brought in by ambulance in cardiac arrest.  As is your practice, you start CPR and focus on bag valve mask ventilation (BVM) while the code gets started.  The patient is resuscitated and eventually intubated as they were not conscious after return of spontaneous circulation.  You wonder, if use of BVM is associated with an increased risk of pneumonia given that the airway isn’t defended as well compared to a cuffed endotracheal tube.