there's been LOTS of back-and-forth about vaso in sepsis (e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO) TLDR: there is no simple answer; personalize tx 🌌 my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC

Fresh IBCC: POCIT (Point-of-care infrared thermography) This is basically where POCUS was 1995-2005 Technology & evidence-basis are improving Early adopters may be interested IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good emcrit.org/ibcc/pocit/ #EMIMCC

this is an ID fellowship, so the answer isn’t sarcoidosis 😳

1/ 👋 there #neurotwitter #neurosky #neurocritcare, as part of my @neurocritcarej #SoMeAmbassador role, today we will be breaking down the following article: link.springer.com/ar...

Nothing normal about “normal” saline -0.9% NaCl: 154 mEq Na + 154 mEq Cl. pH ~ 5.6 -Human/animal data shows it's proinflammatory -SALT-ED (PMID:29485926) + SMART (PMID:29485925) show incr kidney injury w/ 0.9% NaCl vs balanced solutions -LR more physiologic youtube.com/shorts/XcV7R... #EMIMCC

IMHO the best strategy for occasional intubators (e.g., pulm/crit) is: -Preox with BiPAP (PREOXY trial) -Paralyze with roc/ketamine -Intubate with hyperangulated VL + rigid stylet This has a very sharp learning curve Fellows can do this ~50 times and provide reproducibly safe intubations #EMIMCC

I'm revising the IBCC septic shock chapter based on ANDROMEDA-SHOCK II would love any feedback & critique on this ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler. & maybe it's time to push for IR thermography 😍 emcrit.org/ibcc/sepsis/... #EMIMCC

your daily reminder: ☕️ coffee is great ☕️ caffeine-free diets for hospitalized patients are silly & cause misery due to caffeine withdrawal #EMIMCC

this is really excellent. I was drafting a blog post on ANDROMEDA-SHOCK-2 but this really covers what I was going to say, so I don't have to now. I am still working on a simplified, pragmatic approach to apply this at the bedside... stay tuned. #EMIMCC

I'm updating the septic shock chapter to try to create a coherent & practical approach that incorporates Andromeda-2 Any great reviews, studies, or key points I should include? (Especially stuff that has come out within the past year)

my pressor strategy hepatorenal syndrome in the ICU: #1) start with NE gtt for immediate BP target acquisition #2) once pt is improving, use PO midodrine to accelerate weaning off NE midodrine can be helpful to help liberate patients from ICU but as initial therapy, midodrine is some weak sauce

#idboardreview 40 M presents w/ N, V, severe epigastric pain. SH:smoker, drinks 18 beers/day, monogamous with wife, bit by his dog 3d ago, dental cleaning 7d ago, recently installed air conditioning system. Bandemia, AKI. Diffuse blanching rash & mottling. Dx? #medEd #idmeded #idsky

Reminder to discontinue A-lines when they are no longer needed. Risk of infection is lower than with central lines (since A-lines usually stop working and get pulled relatively soon), but infection risk is real.

Incr safe apneic time important in improving 1st pass success -Preox w/ NIV: Incr PaO2, recruit alveoli -Oxygenate + intubate in Bed Up, Head Elevated -Apneic O2 w/ flush rate NC -Use rocuronium instead of succinylcholine (up to 45 sec more safe apneic time) youtube.com/shorts/-3MFR... #EMIMCC

🌟 ABX Pearl of the Day: ❓ Q: Should I add vancomycin for severe mucositis in my patient with persistent neutropenic fever (NF) of unknown etiology? 🤔 Currently on cefepime & stable. Let’s dive in! 👇 #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

lung ultrasonography for nephrologists: bilateral B-lines ➡️ keep spinning the dialysis machine thingy A-lines & big pleural effusion ➡️ more fluid removal won’t immediately resolve the dyspnea (sometimes these are largely *uremic* effusions so aggressive volume removal can cause hypovolemia)

This was a great case and discussion. @pulmcrit.bsky.social your recent post also made me think of the case (where an MRI was indeed indicated, but not available for some time).

EMCrit Wee - @AndromedaShock 2 Explosion - An amazing discussion with the Lead Investigators. This conversation was educational and so enjoyable. Find out the intricacies of the study [#FOAMed for now] emcrit.org/as2-investi... #edu_kattan

#idboardreview 50 F recent dental infection presents 4d of fever, R headache, L weakness. MRI ring enhancing lesion & aspirate w/ GPC ‘balls of yarn’ 🧶 diagnosis? #medEd #idmedEd #IDsky

History lesson: Neurology and neurologists predated the MRI scan. It is possible to provide neurological care without getting an MRI on every single patient.

Zarbock is a strange guy - he’s done a lot of positive kidney trials which others have not been able to replicate I don’t believe any work if it only comes from that group And the amino acid story is so implausible 🤷🏽‍♂️

Endovasc Stroke Tx + Airway -High risk airway decomp: High NIHSS, AMS or Posterior Stroke -Etomidate a great agent: HD stable -Avoid hypocarbia (cerebral vasoconstriction) -After intubation, lie patient flat. Studies (PMID: 40465238) show improved outcomes youtube.com/shorts/LChtQ... #EMIMCC

asking for a friend: could we apply weight-based dosing to the cafeteria serving size?

our therapy dog posing as a lion wins halloween, thanks for playing everyone

Inspired by @pulmcrit.bsky.social’s recent post on PCN allergies! Thought I’d repost a skeetorial on PCN allergies to add to the great discussion. Link below: bsky.app/profile/alau... #medsky #pharmsky #EMsky #RNsky #GPsky #FOAMed #EMIMCC #IDsky

updated the IBCC section on alcoholic hepatitis. AGA 2024 guidelines seem sensible & useful (picture below) Key points: 🍺Steroid recommended for MELD>20 🍺Aggressive multiorgan support PRN (may have hepatorenal syndrome, sepsis, etc) 🍺Consider acetylcysteine emcrit.org/ibcc/aclf/#a... #EMIMCC

The way this NEJM study on prostate CA was framed & is being publicised is misleading 13% relative reduction in prostate CA-related mortality is PITIFUL (for comparison, colonoscopy causes ~60% relative reduction) There's obviously no dent in all-cause mortality (maybe higher with screening) #1/2

🌟 ABX Pearl of the Day: ❓ Q: Treating HAP/VAP? 🤔 Can we go shorter than 7 days? 💡A: Yes! While 7 days is the norm, evidence supports shorter courses in specific cases. Let’s break it down! 👇 #IDsky #medsky #meded #pharmsky #skyRX #AMSsky

Augmented renal clearance (ARC) is so important, we all need to think about this more. 👌👌 ARC most commonly comes into play regarding antibiotics, but it can be relevant for any renally cleared drug.

Remembering the most likely mediator of reduced mortality in the original EGDT therapy was the presence of the CI in the intervention arm, the regular attendance of an interested and informed clinician (and skilled ICU nurse) likely has a bigger impact than any single drug or intervention.

Great & important trial that demonstrates safety & efficacy of capillary refill time to guide resus But it's a stretch to claim this shows *superiority* If you need a risk-stratified win ratio to demonstrate superiority at a p=0.04 level, the intervention probably isn't terribly effective #EMIMCC

MASSIVE RCT from Kenya showing that steroids reduce mortality in CAP Mortality benefit easier to demonstrate w/ less resources available to salvage pts Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered) www.nejm.org/doi/pdf/10.1... #EMIMCC

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

The BICAR-ICU-2 trial just dropped! RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia VERY similar conclusions to BICAR-ICU-1 🧵 #1/ jamanetwork.com/journals/jam... #EMIMCC

I continue to be shocked by how PCN allergies are misunderstood This is from UpToDate on neutropenic fever It's wrong With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem The R-chain structure that determines allergy is different emcrit.org/ibcc/penicil... #EMIMCC #IDsky

Largest ever study of peripheral 23.4% NaCl with 863 administrations 😀 Some extravasation did occur, but it *didn't* lead to any major problems (tissue necrosis etc) If someone is having an ICP crisis, you should worry about their BRAIN and not their ARM - their arm will be fine #EMIMCC

The entire IDSA guideline on diabetic foot infection doesn't include the word "cefepime." Not once. It does recommend piperacillin-tazobactam in certain cases. I'm not saying you *can't* use cefepime (you absolutely can and should in some cases), but such therapy isn't guideline-directed. 🤷‍♂️

New blog: Fresh dueling guidelines about post-arrest care from the AHA and ESICM 💔 BP targets 💔 Who needs an emergent cath? 💔 O2 targets 💔 pan-CT scans 💔 temp targets 💔 neuroprognostication Which guideline do I love? 😍 You'll have to read the post to find out. emcrit.org/pulmcrit/202... #EMIMCC

It feels like there has been a sea change in studies on PRBC transfusion, with newer studies often tending to favor more liberal transfusion. I wonder if this might relate to better modern management of volume overload, or improvements in transfusion safety over time? #EMIMCC

interesting an easier way to confirm tracheal intubation is to gently re-introduce the videolaryngoscope and directly re-visualize the ETT going thru the cords one person with DL who claims it went thru the cords = sus everyone in room sees video screen & agrees the tube is thru the cords = solid

Morrison’s Pouch (RUQ view in FAST) -Highest yield for finding free fluid -Must see the liver tip as this is where blood pools first -Increase sensitivity w/ head down + w/ R lateral decub positioing youtube.com/shorts/c1Nid... #EMIMCC

Updated the IBCC chapter on pancreatitis Added fresh, new guidelines from the AGA (meh) and International Association of Pancreatology (very good) Lets talk about some updates… #1/6🧵 (chapter: emcrit.org/ibcc/pancrea...) #EMIMCC

unpopular opinion: if ICP is unequivocally elevated due to cardiac arrest (eg >25mm), that suggests severe brain injury with a poor prognosis, no matter what you do. this explains why trials of higher MAP targets after cardiac arrest (eg BOX trial) are all neutral. #EMIMCC

hard cosign on this👇 Also, for patients at risk of aspiration, it's often wise to intubate in a bolt upright position This was difficult with direct laryngoscopy, but with indirect video-laryngoscopy, it's not hard to intubate patients who are steeply angulated (you may need to stand on a stool)

EMCrit 410 - What PulmToilet Taught Me About Views on SCAPE (Sigh...) In which an instragrammer Sh!tPosts His Way Successfully on to the Podcast and then is too nice for me to feel good about dragging him... emcrit.org/410

Just updated the IBCC chapter on cholecystitis & cholangitis. These patients are often initially triaged to the ICU. Understanding these diseases can help us direct patients to interventions they need. Let’s talk about four pearls 😁 chapter: emcrit.org/ibcc/biliary... #EMIMCC

meanwhile: ceftriaxone+doxy is looking down on all the fluoroquinolones (which all have black-box warnings for neuromuscular side-effects)

hepatitis D is fascinating virologically: it's an incomplete virus that *requires* HBV co-infection in order to replicate I've never seen a case... why? because HBV vaccination has dropped HBV rates - thereby *simultaneously* eliminating HDV 🏆 reminder of how awesome universal HBV vaccination is

Great pro/con editorial about X vs Bluesky One key reason to support BlueSky is that we simply need an effective communications system. For example, the next time a pandemic/epidemic occurs, trying to communicate on X about it won't work. #EMIMCC