This piece eloquently articulates my own thoughts on WLST. Current practice leads to avoidable harm, probably for many patients but definitely for their loved ones. We can and have a duty to do better, and should be brave enough to challenge current practice link.springer.com/article/10.1...

This is such a cool illustration of how the Mercator map distorts the size of Greenland, which looks as big as the whole continent of Africa on that map but is actually the size of Mexico.

These may well be the best years of your life, but I’m just saying 6.30-8.30am aren’t the best hours of those best years 🫠

I’m not big on conspiracy theories but this one rings true… #CritcalClosingCriticalSchmosing

In patients with cardiovascular disease and an implantable cardioverter–defibrillator, increasing potassium levels to the high-normal range reduced the risk of arrhythmia events, hospitalizations, and death. Full POTCAST trial results and Research Summary: nej.md/4oQtHTN #MedSky

The doses of bicarb used were aggressive Interquartile range for total cumulative dose was 500-1000 ml of 4.2% bicarbonate That's equivalent to 5-10 amps (50 ml vials) of 8.4% in the USA You can use a LOT of bicarb if you have to (titrated to effect; also look at Na levels & avoid hyperNa) #4/4

In honor of spooky month, share a 4 word horror story only someone in your profession would understand “Remember that patient you…”

normal mentation *doesn't* indicate adequate systemic perfusion especially in cardiogenic shock, people can mentate well despite terrible CO & systemic perfusion poor mentation is sometimes an early sign of *septic* shock, but often a very late indicator of other shock states #EMIMCC

Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial #AnSky doi.org/10.1111/anae...

The fact the furosemide stress test does well at predicting who will need to commence/continue RRT is great (& unsurprising) but it doesn’t help us at the bedside. The real question is does earlier initiation/re-continuation of RRT help this cohort? 1/ ccforum.biomedcentral.com/articles/10....

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A normal CT head ≠ a low risk of raised ICP/herniation after LP in meningitis❗️ “80% of pts with ABM who herniate have no CT abnormalities” 🔑 Take-away: Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP journals.sagepub.com/doi/epub/10....

🆕 New RCT in JAMA: Sedation in mechanically ventilated ICU patients—Dexmedetomidine vs Clonidine vs Propofol 📕 Main takeaway: In critically ill patients, neither dexmedetomidine nor clonidine shortened time to successful extubation compared to propofol.

Procalcitonin- the more we learn, the less we love it 💔 ▪️94% of non-septic AKI pts had a Pct >0.5 prior to commencing CRRT ▪️Even using a threshold of >3.2 the specificity was only 38% 🗑️ “Pct in pts with AKI/ESRD should not be measured” #EMIMCC ccforum.biomedcentral.com/articles/10....

Assessing fluid responsiveness in spontaneously breathing MV patients is tough, so this work on SIGH35 by Messina et al. is really 👌 ▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir Simples. 1/ ccforum.biomedcentral.com/articles/10....

Sometimes checking an ScvO2 feels pointless, but other times it’s 23% P.S. a CO2 gap of 2.3 (17mmHg) must take some beating?

Does the over rapid correction of hypernatraemia really cause cerebral oedema in adults❓ Most guidelines suggest a rate of correction < 10mmol/L per day, and whilst there is evidence of risk in children (with tighter, more vulnerable brains) the evidence of risk in adults is scant 1/

Basilar artery occlusion accounts for ≈10% of nontraumatic causes of coma Unconscious without a good explanation? CT head WITH ANGIOGRAPHY is a must❗️ www.sciencedirect.com/science/arti... #EMIMCC

The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤 Is this a 🇬🇧 thing? Curious to hear other people’s experience… #EMIMCC academic.oup.com/bjs/article/...

📢 This bares emphasis 📢 If you’ve started vasopressin for septic shock & the BPs stable/improved but the skin is mottling, you’ve almost certainly made things worse. VA uncoupling with septic cardiomyopathy is a legit silent 🥷 Pressure ≠ perfusion

Time to dump my shares in Sedaconda! Inhaled Sevoflurane led to increased 90d mortality compared to propofol (52.9% v 44.3%) in pts with ARDS (Also median duration of NMB use of 5 days in both groups seems wild 🫤) jamanetwork.com/journals/jam... #MedSky #EMIMCC

A great opportunity to recite this 💎: 1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps That initial 3L resus = 69 bags worth‼️ It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵‍💫🧂

Adolescence on Netflix is fucking astonishing, urgent, vital and it hurts your heart. Incredible cast, direction and writing. You must watch it. You just must.

Having discontinued Melatonin on numerous occasions (murmuring Pro-MEDIC to any poor soul who’ll listen) the rec FOR melatonin is quite triggering… Now to decide if I’ve got the humility to question my assertions & revisit the issue or just go full ‘Marik’ mode 💡 Ivermectin for delirium ⁉️

brief skytorial on the latest SCCM PADIS guideline update. this is a nice, useful, & concise statement that will change my practice. there are basically two take-home messages... (🧵 #1/3) journals.lww.com/ccmjournal/a... #EMIMCC

📝 ▫️Clonidine should be carefully considered as there is a paucity of evidence around its use ▫️ Consider Haloperidol (first line) for psychomotor symptoms My colleagues will be gutted, but I’m all for the #VitaminH ❤️

An excellent (albeit a little scary) retrospective study of arterial injury after CVC insertion. A National Audit Project looking at CVCs is a fantastic idea, & would hopefully help us answer additional questions (i.e. optimal insertion site, routine line changes, fixation device) #EMIMCC

Thoughts and prayers to the poor centurion who got put on VA-ECMO 🥺 #Zentensivsim link.springer.com/article/10.1...

Some very challenging interactions with a new surgical colleague this morning #ILookLikeASurgeon 👩‍⚕️ 🥰 🦄

New @accpchest.bsky.social transfusion guidelines out in #journalCHEST!

Latest ACCP guidelines (post-MINT trial) for RBC transfusions in ICU have dropped 🔑 take-away recommendation: ❗️In patients with acute coronary syndrome, a permissive strategy is recommended (Hb >10 g/dL)❗️ #EMIMCC #MedSky journal.chestnet.org/article/S001...

TL;DR ▫️There’s no good evidence mucolytics help (or harm) ventilated ICU pts ▫️Everyone uses them anyway ▫️🤞MARCH trial will give us some answers ▫️Until then, carry on practicing based on shameless personal bias/gestalt Fin/ #EMIMCC #MedSky ccforum.biomedcentral.com/articles/10....

Great to have an another tool in the pocket for assessing fluid responsiveness in patients ventilated with low Vt, although… Currently I just whack the Vt up to 9mls/kg, measure PPV then change them back. Seems a lot less faff 🫤 #EMIMCC ccforum.biomedcentral.com/articles/10....

Prognostication following cardiac arrest care is complex. Myoclonus is observed in about 20-30% of post-arrest patients admitted to ICU, and a frequent dilemma is distinguishing between simple myoclonus and myoclonic status 1/

❓Authors suggest ensuring adequate respiratory drive (e.g. P0.1 >2) prior to US assessment, but presumably in severe diaphragmatic weakness P0.1 will be low. Don’t we really need EAdi measurements to look for neuro-mechanical uncoupling❓ #POCUS #emimcc link.springer.com/article/10.1...

Useful BNF reminder in 🇬🇧 context too. 500mg oral sodium bicarb ≈ 6mmol HCO3 1L of 1.26% sodium bicarb = 150mmol HCO3 Orders of magnitudes difference

Doppler ultrasound for venous congestion - #VEXUS - has truly been game-changing in my clinical #POCUS practice. Here's the TL;DR on the concept of #VEXUS - 🧵 #emimcc

As someone who is a fan of both decremental PEEP trials & monitoring P0.1 this paper is 🫶 Trying to personalise PEEP during PSV is tough, & we don’t all have EIT/oesophageal manometry! Pick the PEEP resulting in lowest P0.1, makes a lot of sense 😬 link.springer.com/article/10.1... #EMIMCC

Medics need to take a leaf out of the surgical playbook: “I’ve booked 78 year old Dorothy an HDU bed. She’s a little muddled and her urea is 8 with patchy consolidation right base. CURB-65 14% 30-d mortality. She’s a NEPA case so I’ll send her right up. No, on room air. BP 140/90”

As I suspected… now don’t go complaining when I send your pre-planned HDU admission straight to the ward from recovery! 😜

🇬🇧 Anaesthetist pals: Trying to educate myself on the role of CPET testing prior to major intra-abdominal surgery. Seems to be good evidence for its ability to predict mortality/morbidity/LOS, but any data to suggest routine HDU admission based on CPET scores actually improves patient outcomes?

Objection your honour! Ethanol is an ineffective osmole, so whilst it does raise measured serum osmolality it won’t cause the water shifts that lead to hypertonic hyponatraemia (unlike glucose/mannitol) jamanetwork.com/journals/jam...

Question for MedSky community: Has anyone seen obstructive shock physiology resulting from dynamic hyperinflation in a ̲𝚜̲̲𝚙̲̲𝚘̲̲𝚗̲̲𝚝̲̲𝚊̲̲𝚗̲̲𝚎̲̲𝚘̲̲𝚞̲̲𝚜̲̲𝚕̲̲𝚢̲ ̲𝚋̲̲𝚛̲̲𝚎̲̲𝚊̲̲𝚝̲̲𝚑̲̲𝚒̲̲𝚗̲̲𝚐̲ patient with a severe COPD/asthma exacerbation? #EMIMCC

If a picture’s worth 1000 words then this cine loop’s a damn novella dedicated to the pathogenesis of hepatic hydrothorax 😍 #EMIMCC #pocus

The same research group reported that kidney transplant recipients were more fearful of going back on dialysis than dying. Think about that #nephjc

In a retrospective cohort of 273 pts with HSV encephalitis: ➖ 4% had an initial -ve HSV PCR ➖ 17% had CSF WCC <5 ‼️ If you have a high clinical suspicion, continue aciclovir & repeat the LP (all false -ve occurred within 4 days of symptom onset) #EMIMCC pubmed.ncbi.nlm.nih.gov/35167501/

🤯 Prehospital Ketamine for BZD/ resistant Status Epilepticus 🔹Seizure termination in 56/57 (98.2%) * ESETT 📄 Levetiracetam terminated seizures in 68/145 (47%) by 20 mins 🔹 Only 2 pts required ventilatory support * ESETT 📄 Levetiracetam group 30/150 (20%) intubated at 60mins #EDIMCC

Another day, another dissection, another excuse for the Drake Meme #EMIMCC

People often talk about the time critical nature of sepsis. But it may surprise you to hear that the evidence to support “early” antibiotics actually isn't a settled debate. Why is that? The key question is “early in relation to what”? 🧵 1/n