The LITFL Critical Care Compendium is my ongoing obsession, a living resource that covers the spectrum of critical care, including the knowledge base for the FCICM and much, much more. There are now over 1,500 entries built into the LITFL backend
- If the bougie is my first love, the Aintree catheter is close second. Other airway exchange catheters are discussed here too: when and how to use them, tips, tricks and complications. Good videos too!
Can I call it hysteria? The FOAMcc world (especially) seems convinced that chloride is a poison. I still have equipoise, the evidence that normal saline fluid therapy causes clinically significant harm is very, very weak. The much heralded Yunos et al, 2012 study in JAMA is critically flawed – as the authors themselves acknowledged in the paper (it can be viewed as a study of harms from “gelofusine-rich” fluid as much as a study of “chloride rich” fluids). Paul Young spoke about this topic at SMACC Chicago and we are all eagerly awaiting the publication of his SPLIT trial: plasmalyte versus normal saline for fluid therapy in ICU. Churchill would no doubt say that chloride is a riddle, wrapped in a mystery, inside an enigma… I’d agree with him.
Positive fluid balance is decidedly negative if you’re an ICU patient (though how much of fluid excess is confounded by chloride excess…? Now, there’s a thought). Paul Marik has a delicious term for this, ‘iatrogenic salt water drowning’ – though as he said at SMACC Chicago, he doesn’t have a strong opinion on the matter. If fluid excess is the question, then ‘de-resuscitation’ is the answer – it is perhaps one of the dark arts of intensive care medicine. Do I sense a ‘Mind of the De-resuscitationist’ podcast in the works?
John Myburgh said that Kath Maitland should get the Nobel Prize for FEAST. Who am I to disagree with John Myburgh? (even if #myburghcanthandlethetruth was briefly trending at SMACC Chicago). FEAST is a mind-blowing trial – in its conception, its execution and in its findings. Is it time for an adult FEAST?
Is there any therapy more ubiquitous in the arsenal of the resucitationist? As you’d expect for such a sacrosanct intervention there is a mountain of evidence supporting its use and a bullet proof physiological rationale (especially in sepsis). Incidentally, I heard an American attendee at SMACC say to Karim Brohi after he apparently gave a talk rubbishing tranexamic acid in trauma, “you realise that Americans don’t get irony?”… Read into that what you will.
There is so much to love about this. It sounds exotic – anyone else have visions of a Perrier drinking Lemur? The causative organism sounds seriously badass: Fusobacterium necrophorum. Anyone who diagnoses it gets to be king for a day. The disease itself – thrombophlebitis of the internal jugular (IJ) vein and bacteraemia caused by primarily anaerobic organisms, following a recent oropharyngeal infection – we could all do without.
Transpulmonary pressure (TPP) is the net distending pressure applied to the lung by contraction of the inspiratory muscles or by positive-pressure ventilation. Perhaps we should be using oesophageal manometers in mechanically ventilated patients so that we can measure TPP. Perhaps not…
Sometimes things don’t always go to plan… sometimes this is good, sometimes not so good. Risk factors, prevention, management and complications. It is all here.