Critical Care

The Furosemide Stress Test

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.

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Prone positioning in pregnant patients with ARDS due to COVID-19: Yes or no?

A 34-year-old woman at 32 weeks gestation presents to the emergency department with cough, dyspnea and hypoxemia. She rapidly progresses to severe ARDS despite lung protective ventilation, paralysis and inhaled epoprostenol. P/F ratio is 99 mm Hg. Is prone positioning safe to perform in pregnant patients with severe ARDS? If so, are modifications necessary to offload the abdomen and monitor the fetus? A recently published review in Obstetrics and Gynecology discusses this important topic. 

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NIPPV in Hypoxic Respiratory Failure

A 56 year old male comes to the ED via EMS after noting progressive dyspnea and fever.  In the field, the EMS team notes the patient is hypoxic with an SPO2 of 85%.  Despite the low oxygen saturation, he is only using minimal accessory muscles and he is alert and oriented.  His chest X-ray shows a right lobar pneumonia and he is requiring 6LNC oxygen to maintain a saturation greater than 90%. You know there is significant guideline evidence to support the use of non-invasive positive pressure ventilation (NIPPV) for COPD and CHF exacerbations, but what about patients with other causes of hypoxia such as pneumonia?

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Nephron vs. Neuron: Diagnosis and management of diabetes insipidus in the critically ill

50-year-old man requires intubation for encephalopathy. His urine output is > 400 cc/hr and serum Na returns at 179 mEq/L. What is the most likely cause of his polyuria? 

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BVM v. ETT in Cardiac Arrest and Pneumonia

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.

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Deflated? Esophageal pressure monitoring in ARDS

Lung protective ventilation limiting tidal volume and plateau pressure improves survival in ARDS. The application of positive end-expiratory pressure (PEEP) further stabilizes the lung by preventing alveolar collapse during expiration, thereby reducing cyclic atelectasis. However, the optimal approach to PEEP titration to minimize ventilator-induced lung injury (VILI) has not been delineated. The EPVent-1 trial demonstrated that esophageal pressure-guided PEEP titration was feasible and safe with a trend toward increased survival and improved oxygenation in mild to moderate ARDS. However, interest in esophageal manometry in ARDS was deflated by the more recent EPVent-2 trial demonstrating no improvement in a composite outcome incorporating mortality and ventilator-free days in patients with moderate to severe ARDS. A new randomized control trial published last week by Wang et al. examined the role of esophageal manometry-guided PEEP titration in a novel subset of severe ARDS patients treated with VV ECMO. 

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Updates in anaphylaxis

A 46 year old woman arrives at the ED with hives, hypotension, difficulty breathing, and stridor after eating dinner with her family.  She is allergic to shrimp, and thought she had avoided it when she ordered from her favorite restaurant.  However, shrimp dishes are on the menu and she wonders if there was cross contamination.  Unfortunately, she couldn’t find her epinephrine auto-injector at home so her family drove her to the ED.  Immediately recognizing anaphylaxis, you give her a dose of IM epinephrine and she improves within several minutes.  After seeing she has stabilized, you wonder how long should she be observed and what the evidence is behind the use of antihistamine and glucocorticoid therapy.

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