josh farkas 💊

agree the study is weak...TBH I find the case reports on TMP-SMX-induced ARDS to be more persuasive

very rare but the case reports are BRUTAL (kid takes TMP/SMX for acne, gets ARDS)

mostly a reminder to avoid giving >1wk of TMP-SMX (which we probably shouldn't be doing anyway for most indications)

Trimethoprim-sulfamethoxazole carries a very low (but real) risk of causing ARDS.

Duration of therapy is a risk factor (>7 days).

Could likely be minimized by avoiding unnecessarily long courses.

TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC

“I have been using a combination of cap refill and MAP since the original ANDROMEDA SHOCK paper”

Justin explores the many limitations of this trial but then admits that he does use CRT as a resus target.

I fundamentally agree.

Implementing imperfect data into practice is complicated. #EMIMCC

New study design:

Multiply a small & uncertain number with a big number and you get a big number

The final big number looks, well, really big

This grabs headlines & gets cited

It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything

Mathematically rigorous clickbait

I’d propose a formal framework for reaching a “probable HRS-AKI” diagnosis.

A probable HRS-AKI dx could be reached without delay (based on H&P, chart review, and POCUS evaluation of heart & kidney)

This would allow immediate treatment in parallel with ongoing investigation.

#EMIMCC

a close up of a man 's face with a beard looking at the camera . ALT: a close up of a man 's face with a beard looking at the camera .

ADQI/ICA guidelines finally scrapped the 48-hour mandatory albumin infusion before formally diagnosing HRS-AKI

I’ve argued against this for years (it delays tx for 3 days & you miss optimal window for intervention)

HRS-AKI carries a massive ~30% in-hospital mortality, its an emergency…

💯💯

my favorite is when a consultant recommends “admit to ICU” in the chart without talking to us 🙄

patients w/ hepatic encephalopathy sometimes develop a spontaneous portosystemic shunt (their body essentially creates a TIPS) that exacerbates encephalopathy

if they are healthy enough to tolerate closure (MELD <11), IR ligation of the shunt improves encephalopathy

this case👇 is extremely unusual

I’ve never heard if this before… just when you thought you’d heard of every dumb idea…

it’s pretty wild that they managed to get IRBs to approve an RCT of terlipressin vs placebo (CONFIRM trial)

yeah of course it worked, probably dopamine would be better than placebo 🤷‍♂️

In terms of osm, you dont need to worry about what the cations are doing because the anions will balance them out

I think if you did the math the actual amount of H+ liberated would be minimal.

Yes, they are super into terlipressin.

As an ICU person, I must admit I don't see the attraction to terli.

(Full disclosure: my center doesn't have terlipressin, regardless, but for any ICU patient, norepinephrine seems easier to use, equally as effective, and lower risk of pulmonary edema)

I read a lot of guidelines. I've never seen a guideline ever that specified exactly how to titrate norepinephrine in this way. This isn't normal.

https://pubmed.ncbi.nlm.nih.gov/38527522/

a fancy nephrology guideline trying to describe how to titrate a norepi gtt is sending me 🤣

adjust q4hr??

the whole point of a NE gtt in HRS-AKI is immediate BP control

tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great

(and peripheral IV is fine)

The Na+ can't be blown off.

Some dissolved CO2 may be blown off but the quantative amount is small and the tonicity is determined by the sodium concentration (active osmole) so I don't think this CO2 loss will affect tonicity shifts.

yes, I've seen a fair number of these patients with low lactate who respond well to epinephrine with an elevation in their lactate and shock resolution... consistent with your paper!

Brain Death/Death by Neurologic Criteria Guidance on Communication, Objections, Pregnancy, and Public Trust | Neurology This position statement provides updated member guidance from the American Academy of Neurology (AAN) regarding (1) communication with surrogate decision makers about brain death/death by neurologic c...

Ethical review of brain death in the context of familial objections or pregnancy.

This is largely intuitive and common sense, but it's useful to have a guideline if needed for reference. #EMIMCC

www.neurology.org/doi/pdf/10.1...

cosign: isotonic bicarb is great for the renal failure patient with hyperkalemia & acidemia

even if the kidneys take 24-48 hrs to start working, isotonic bicarb resus can often drop the K & improve pH enough to avoid needing dialysis (buys time for renal recovery)

agree, in the USA osteopaths are equivalent to MDs. many of my colleagues are DOs. its confusing.

this would be really easy to misdiagnose as Lofgren syndrome 2/2 sarcoidosis 😬 #PulmSky

Nursing is no longer counted as a 'professional degree' by Trump admin The Department of Education has excluded nursing as a "professional degree" program as it implements various changes to student loans.

According to the Trump admin, nursing isn’t a profession so they won’t qualify for student loans 🤬

We’re barely recovering from the last RN shortage and they want to create another one 😫

Literally zero patients survive the ICU without outstanding RN care.

www.newsweek.com/nursing-not-...

Understanding lactate in sepsis & Using it to our advantage Introduction with a case 0 Once upon a time a 60-year-old man was transferred from the oncology ward to the ICU for treatment of neutropenic septic

super sick patients who should mount a lactic acidosis but dont often have autonomic dysfunction with inability to produce endogenous epinephrine; they may respond well to exogenous epinephrine

emcrit.org/pulmcrit/und...

Roon: Welcome to our exclusionary doctors' lounge.

Me: Meh, I'd rather hang out at the nursing station in the ICU eating chicken nuggets, gossiping, and smacktalking about antibiotics and pressors I don't like.

#EMIMCC

YouTube video by EMSwami Promotility Agents in UGIB #criticalcare #emergencymedicine #resuscitation

Priorities in UGIB management: blood, ceftriaxone (if varices suspected), GI to bedside + consider intubation
Finer point: administration of metaclopramide + erythromycin
Promotility agents which help empty the stomach of blood, improve the view for endoscopist

youtube.com/shorts/ae98W...
#EMIMCC

Roon is launching a social media site for USA doctors only

Looks lame

The strength of MedTwitter has always been diversity (geographic & training - docs, RNs, PAs, pharmacists etc)

Further fractionating our community isn't the way forward

I think Bluesky is ideal; we just need more people here

stan marsh from south park is holding a cup and saying wow that sucks dude ALT: stan marsh from south park is holding a cup and saying wow that sucks dude

💯💯

there is no way a MedTwitter clone can survive with USA docs alone

it’s totally doomed

i think they seriously miscalculated the importance of fancy USA doctor credentials

woah, Tay-tay is vanco? A mildly toxic agent that is problematic to dose, adds little to pipazo, and is generally unnecessary and stopped within <48 hours?

I feel like she deserves to be the beta-lactam backbone since she has greater versatility and influence.

Finished updating the IBCC chapter on septic shock

This algorithm is where I ended up 👇

Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)

Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC

I joined Roon but it doesnt look good, doubt I will use it much.

I think you may need to be a USA physician to join ???

A major strength of MedSky is multidisiplinary discussions… so excluding RNs, PAs, pharmacists, RTs etc destroys that.

TBH we just need more people here, this place is nice