On the note of VAP, we've written a review article. More specifically, focusing on the evidence behind strategies to prevent and manage VAP. This link gives 50 days of free access. Hope you all find it useful. #emimcc authors.elsevier.com/a/1lbEr7K3e2...

Insulin gtt + usual management. Oral triglyceride meds going forward.

Nice thread. Well summarised. Thank you. Imho- prone ventilation helps homogenise distribution of mechanical power. If on VV and on “rest” ventilation (whatever that is since no consensus on what rest is whilst ELSo guidelines allude to) then the benefit from proning is v minimal

I think, given that it took many trials with different sample sizes and durations of proning for us to realise its effectiveness in ARDS without ECMO, it would be even harder to prove in patients on ECMO for several reasons. COI: I love to prone 🧵 #emimcc

I don't have strong opinions about APRV, but I think the utility and effectiveness of certain strategies depend heavily on the system within which they work. #EMIMCC

A well written argument cautioning against misinterpreting evidence from clinical trials on angiotensin II. Currently, A-II is not available outside a clinical trial where I work. However, there are efforts to evaluate A-II in other populations (not sepsis). pmc.ncbi.nlm.nih.gov/articles/PMC...

I rather think it’s action bias, easier to do something than to wait and see. People overestimate the risk of deterioration and underestimate bleeding risk.

interesting thread with some great points here 👇 IMHO the key is having an institutional pathway about classification & management that everybody agrees on for patients in whom the treatment pathway is clear, there is no need to involve everybody (eg, if clearly not an IR candidate, why call IR?)

Similar arguments could be made perhaps for “shock” teams 🤔

Could not agree more! The problem with pulmonary embolism is the lack of clear ownership (at least in my part of the world). #emimcc #cardiosky

My unpopular opinion is that I'm skeptical about the effectiveness of PERT. 🧵 #EMIMCC

An interesting issue of ICU Management & Practice. From Sepsis to ARDS. #EMIMCC healthmanagement.org/c/icu/issue/...

Let’s try something different. Does anyone have any questions about acute and critical care echocardiography? If I can’t answer I’ll try to bring in someone who can. #emimcc #cccsky #pocus

I disagree with the conclusion reached here. I have previously written a thread on this, which I have linked below. #emimcc

What I love about echocardiography in critical care is how you can see physiology unfolding before your eyes. This is a case that has stayed with me and shaped how I think about treating acute LVOT obstruction #cccsky #echofirst #pocus #emimcc

Are you interested in #Sustainability in #Anesthesiology and how reusing TIVA lines could help reduce greenhouse gas emissions? Per Werner Moller, originally an expert in #AppliedPhysiology and #VenousReturn, discusses their environmental paper on the #EJA podcast. open.spotify.com/episode/2RCa...

Had a similar case of someone with disproportionate hypoxaemia in the context of an intermediate risk PE. Pt was also hypertensive. #emimcc #pulmsky #medsky

This trial always fascinated me. It's extremely informative and with other evidence (ASTER), makes you wonder about the benefit of PCM/APAP in sepsis. Primary outcome was neutral, but PCM/APAP ⬇️ ICU LOS in survivors and ⬆️ ICU LOS in non-survivors. This can mean one of 2 things (1/7)🧵 #emimcc #medsky

It's unethical not to adjust for a priori important baseline characteristics predictive of the outcome! #stats #medsky #metascience

When interpreting this trial, it is also important to consider the pre-specified adjusted analysis [OR 0.89 (95%CI 0.79 to 0.99)] as adjustment improves statistical efficiency. This article explains the benefits of adjustment quite well. #emimcc jamanetwork.com/journals/jam...

I agree, in a Vt range of 6-8 ml, the main component is dP. However, if you target low/very low dP (12-15) in a patient with poor compliance (very low tidal ventilation) and the increase in respiratory rate becomes relevant, I think. The figure is from the excellent paper you referenced (thanks).

This trial evaluating a driving pressure limiting strategy to standard care in patients with pneumonia and ARDS showed no difference in ventilator-free days. However, I have a few thoughts on it. 🧵

A treasure trove of important trials for ICM trainees to sink their teeth into Nice work @dilipj1.bsky.social 🙌

We are gearing up to offer our online course on Reimagining Global Health in summer 2025 For now, you can access last year's slides & readings here www.teachepi.org/courses/reim...

A thread 🧵 on trials I think have changed or will change ICU practice (at least my own). #emimcc

I think that’s right, but it’s being made worse by a monomanic focus on sepsis through campaigns etc. People are more scared of missing sepsis than misclassifying other kinds of shock as sepsis.

Important to note what “low” really means. In the 65 trial the low arm achieved a MAP around 68.

However 65 trial showed a different direction of effect with reduction in mortality in the permissive group with chronic hypertension (and overall in adjusted mortality analysis). Given that “permissive” in Sepsispam was not all that permissive (actual MAP 70-75) I’m not convinced.

"Notably, no point estimate favored a higher target for mean arterial blood pressure." #emimcc evidence.nejm.org/doi/full/10....

Talking of Bier, @orthopodreg.bsky.social the story of how he developed spinal anaesthesia is pretty wild A story of cocaine, cigars, and German army helmets. #AnSky #MedSky #HistoryMedSky

Here are over 500 accounts to follow here. #Medsky #Ansky #Anaesthesia #Anaesthetist #ICM #ICU #CriticalCare #Intensivist #Anaesthesiologist #PHEM #HEMS Pack 1 go.bsky.app/4N4D7MW Pack 2 go.bsky.app/QEgekcF Pack 3 go.bsky.app/CaeuLtL Pack 4 go.bsky.app/7gHUdmc PHEM go.bsky.app/NWQRhE1

Absolutely- well conducted trial emulation with appropriate correction for confounding is almost certainly going to be more reliable than “we looked at treatments A and B given sporadically”. The million dollar question is, of course, how well the confounders were measured and adjusted for.

When many of these interventions are tested in larger multicentre trials, the estimate of effect is not commonly replicated. ccforum.biomedcentral.com/articles/10.... #emimcc

Single centre trials tend to have a higher rate of falsely positive results for many reasons. Statistically, this paper illustrates this phenomenon quite well www.bjanaesthesia.org.uk/article/S000... #emimcc

ICU Hemodynamics: There is a lot of discussion about the role of methylene blue (MB) in refractory #septicshock. We don't have many RCTs in this topic & I read every new one with interest. This small RCT was recently published:

#PCCMSky Update Up to 95 members Repost so those new to this place can populate their following list with good PCCM people Reply if you are not on this list and should be go.bsky.app/88wg6oG

Most units paralyse and deeply sedate ARDS patients in the prone position. But, small studies have shown spontaneous breathing is feasible in prone patients. #emimcc rc.rcjournal.com/content/66/5...

@benmorton.bsky.social Do you use continuous neuromuscular blockade routinely when you prone patients? Interested in other people's practice as well.

Dexmedetomidine is used quite a lot. However, it’s not that benign an agent. Single centre observational study finds 15% of patients on Dexmed have a fever of >38.5. #emimcc pubmed.ncbi.nlm.nih.gov/33813941/

Critical care intubation hills I’m willing to die on (collating an occasional series from elsewhere). Each hill is based on experience and other people’s research (I claim no other expertise) #EMIMCC #PCCM #AnSky

Advancing extracorporeal carbon dioxide removal technology: bridging basic science and clinical practice CCR Journal Watch criticalcarereviews.com/latest-evide... Get the latest critical care literature every weekend via the CCR Newsletter - subscribe at criticalcarereviews.com/newsletters/...

This 2021 paper "The female medicla workforce" covers the basics of gender bias, and discusses isses relevent to anaesthetists such as menstruation, fertility, pregnancy and menopause associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10....

Review article covering common viral infections in intensive care associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

A great issue of Clinics in Chest Medicine, with the theme of Acute Respiratory Distress Syndrome #ARDS. Excellent articles by experts in the field highlight challenges in the definition, pathology, and management of this syndrome. #ICU #critcaresky www.chestmed.theclinics.com/issue/S0272-...

Morning all! As this place has gained a LOT of momentum this week, and inspired by @emergencybod.bsky.social, I thought I would introduce myself. I am an anaesthetist, and a SAS doctor (I'll tell you all about that), based in the UK. I play bass, bake bread, give talks, take pictures of things.

A great issue of Clinics in Chest Medicine, with the theme of Acute Respiratory Distress Syndrome #ARDS. Excellent articles by experts in the field highlight challenges in the definition, pathology, and management of this syndrome. #ICU #critcaresky www.chestmed.theclinics.com/issue/S0272-...