June 27, 2019

Acute respiratory failure has many causes which can affect the ability to either take up oxygen (hypoxemic), eliminate carbon dioxide (hypercapnia), or both. Acute respiratory failure has many possible causes and in this post/video we will name the causes of acute respiratory failure and describe lung shunt physiology.

June 24, 2019

Shock is one of the most important problems with which physicians will contend with.  The magnitude of the problem is illustrated by the high mortality associated with shock.  Assessment of perfusion is independent of arterial pressure, in that hypotension does not always need to be present to define shock.  Emphasis in defining shock is based on tissue perfusion in relation to cellular function. In this post, the basics of shock, we will define shock, discuss the causes of lactate elevation, and review the main categories of shock.

June 17, 2019

Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics of mechanical ventilation. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial.

June 6, 2019

Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics of mechanical ventilation. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial.

January 7, 2019

Background: Stress related gastrointestinal mucosal damage is a commonly encountered problem in the critically ill patients admitted to the intensive care unit. The incidence ranges from 0.6-7% and is decreasing partly due to aggressive resuscitation strategies and focus on early enteral feeding1. Damage to the mucosal integrity occurs in conditions associated with increased inflammation and reduced mucosal perfusion 2. Despite its decreasing incidence, stress related GI bleed remains a major challenge for the intensivist with many studies showing increase in mortality and ICU length of stay in these patients3. Stress ulcer prophylaxis is recommended for critically ill patients at risk for GI bleed; the major risk factors include need for prolonged mechanical ventilation, coagulopathy, hepatic and renal failure. There is high quality evidence supporting the use of H2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in these patients. Many international surveys show that PPIs are currently preferred for acid suppression4. Though many randomized controlled trials support the use of PPI over other acid suppressants, there is clearly no recommendation regarding benefits of one group over the other. Alhazzani et al5recently published a network meta-analysis of 57 trials enrolling over 7000 patients that showed moderate quality evidence that PPIs are more effective than H2 blockers, sucralfate or placebo in preventing clinically significant GI bleed though there is a possible increase in risk for pneumonia with similar mortality. Another meta-analysis by Alshamsi et al showed that PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding and overt GI bleeding without a significant increase in risk for pneumonia, mortality and ICU length of stay6 Furthermore, there is growing concern that acid suppression predisposes patients to increased risk for nosocomial infections like pneumonia and Clostridium difficile as well as cardiovascular events. This was demonstrated in a few randomized clinical trials as well as a few observational studies7,8. The authors of the current study aimed to evaluate the benefits and adverse events associated with the use of pantoprazole for stress ulcer prophylaxis in patients at risk for gastrointestinal bleeding9
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