TheVentilatorWhisperer

Landmark Studies in Critical Care Medicine Landmark Studies in Critical Care Medicine 🫁 Pulmonary & Respiratory Medicine Acute Respiratory Distress Syndrome (ARDS) ARMA (Ventilation with Lower Tidal Volumes - 2000): Showed a significant mortal...

💡 Takeaway: While there may be a signal for delayed RRT, we need a dedicated trial with unconfounded parameters to actually prove it. No ☠️ benefit.

📚 I put the exact protocols & FOAMed links for this & 50+ other trials in a living ICU Cheat Sheet. Access the Google Doc here 👇

My Take:
The protocol mandated RRT if pH ≤ 7.15. Because Bicarb directly raises pH, it's hard for me to view the reduced RRT rate as a definitive clinical win. It feels like we might just be treating the trigger number rather than saving nephrons.

📊 The Trial: BICARICU-2 (The Lancet, 2025)
Evaluated patients with severe metabolic acidemia (pH ≤ 7.20) and Stage 2-3 AKI.

The Abstract: IV bicarb didn't improve 90-day survival, BUT it significantly delayed and reduced the need for Renal Replacement Therapy (RRT) from 50% to 35%.

🚨 Septic shock, AKI, pH 7.15. Do you start a Bicarb drip? Does it save kidneys or just treat a number?

I built an open-access "Landmark ICU Trials" cheat sheet/reference for rounds. Let's look at a new addition: BICARICU-2. 👇
#MedSky #CritCare #Nephrology #FOAMed #MedEd

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…

Just had a patient with this exact thing.

Institution dependent and nursing dependent.

New ESICM guidelines on circulatory shock. www.esicm.org/esicm-guidel...

New RCT: Avoiding A-line in shock didn't affect mortality (trend towards *reduction*) & decreased line complications

They avoided A-lines despite patients requiring pretty substantial doses of vasopressors

Very #zentensivist

Don't need to rush to an A-line

www.nejm.org/doi/full/10.... #EMIMCC

When looking at the secondary endpoints I think it's pretty telling.

Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock This randomized clinical trial examines whether a personalized hemodynamic resuscitation protocol targeting capillary refill time was more effective than usual care in patients with early septic shock...

jamanetwork.com/journals/jam...

Andromeda Shock 2 Trial is out.

I can't find the article on your website. What day is it listed under?

Loss of carbs in diet does not directly equate to weight loss. Caloric deficit leads to weight loss. The assumption in this post is that life style modification has failed and pharmacological or surgical interventions is next.

Decay in Physiologic Knowledge Since Med School Among Critical Care Fellows

1st-yr PCCM/CCM fellows perform worse than med students on assessment of pulmonary physiologic concepts, suggests decay in knowledge during training
@atscommunity.bsky.social #medsky

tinyurl.com/tfwutc76

The vast majority of Christians live in the first world where people tend to achieve higher levels of education. We also know that people who are more educated tend to become less religious. I'd bet that people leaving Christianity happens more in first world countries then third world countries.

A good review of the furosemide stress test.

www.mdpi.com/2077-0383/14...

Management of Acute Right Ventricular Failure in the Intensive Care Unit Right ventricular (RV) failure occurs when the RV fails to maintain enough blood flow through the pulmonary circulation to achieve adequate left ventricular filling. This can occur suddenly in a previ...

Have been learning about hemodynamic coupling, currently reviewing interface IV (RV-PA coupling).

This is a great review article on RV failure.

pmc.ncbi.nlm.nih.gov/articles/PMC...

I linked it in my comment.

Management of Acute Right Ventricular Failure in the Intensive Care Unit Right ventricular (RV) failure occurs when the RV fails to maintain enough blood flow through the pulmonary circulation to achieve adequate left ventricular filling. This can occur suddenly in a previ...

Just read this article. Great review of RV failure.

pmc.ncbi.nlm.nih.gov/articles/PMC...

is contrast nephropathy in the room with us right now?

another article showing that contrast nephropathy isn’t a thing

I wonder how long these articles will keep getting published, since I kinda thought this was settled 🤷‍♂️

https://www.jem-journal.com/article/S0736-4679(24)00372-X/abstract #EMIMCC

It all matters within context. You go to these other instances and it becomes understandable. In Elons case he has openly supported the modern nazi party and know nazis on social media so no, these are not the same thing.

YouTube video by UBC IM POCUS Lung Ultrasound for Interstitial Syndromes

1/
One of the BIGGEST #POCUS misconceptions is that B lines 🟰 pulmonary edema 🤦‍♀️

Did you know that there is actually a wide DDx for B lines?

Check out my latest video about #LungUltrasound for interstitial syndromes 👀; or read on for the highlights 👇 🧵

#emimcc

www.youtube.com/watch?v=eSuA...

I actually find using wrist restraints wrapped around the hand instead, is easier to adjust tightness then using tape.

In M mode that is the parasternal long axis view correct and the arrow is indicating systolic anterior motion of the mitral leaflet?

Completely avoidable.

Additionally if you have a cvp monitor then coronary perfusion pressure goal > 20.

Been doing some reading and listening on advanced resuscitation/hemodynamics. Dr. Per Olav Berve gave a fantastic lecture at the Big Sick in 2018.

Takeaways:
1. Diastolic BP goal > 25 using late diastolic peak on A-line
2. EtCo2 monitoring during code, use the peak alveolar plateau readings.

Large-bore Mechanical Thrombectomy Versus Catheter-directed Thrombolysis in the Management of Intermediate-risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial | Circul... Background: There is a lack of randomized controlled trial (RCT) data comparing outcomes of different catheter-based interventions for intermediate-risk pulmonary embolism (PE). Methods: PEERLESS is a...

How does everyone feel about the Peerless trial?

I like this idea as well. Had we done a more prolonged volume resuscitation I think this would have been the better option to avoid any possible increased lactate production from the bicarb.