IMCrit
@IM_Crit_
Followers
46,097
Following
749
Media
1,444
Statuses
9,385
Intensivist I Internal Medicine | ☕️, 🍩, 🥐, 🍫 addict
Joined April 2020
Don't wanna be here?
Send us removal request.
Explore trending content on Musk Viewer
Rio Grande do Sul
• 171361 Tweets
Tottenham
• 70807 Tweets
Spurs
• 62842 Tweets
Bardella
• 61842 Tweets
Palmer
• 52272 Tweets
Leverkusen
• 49612 Tweets
#CHETOT
• 46878 Tweets
#debatBFMTV
• 32850 Tweets
Hayer
• 29683 Tweets
bruno mars
• 25763 Tweets
Boris Johnson
• 25706 Tweets
Ange
• 25606 Tweets
Aston Villa
• 24655 Tweets
Kaizer Chiefs
• 15438 Tweets
$AAPL
• 14926 Tweets
Cucurella
• 14499 Tweets
Chalobah
• 14105 Tweets
Mudryk
• 13816 Tweets
Wirtz
• 13084 Tweets
Caicedo
• 10885 Tweets
Last Seen Profiles
An hour ago, I placed another chest tube in a COVID-19 patient who developed tension pneumothorax. He was diagnosed 7 weeks ago and has already tracheostomy and PEG. In our hospital's electronic health records, he is not even listed as a COVID patient... 🤦♂️
57
648
3K
ICU Pharmacology Secrets:
Some drug side effects, even if relatively rare, are well entrenched in our memory. For example, most intensivists & hospitalists are aware of cefepime-induced neurotoxicity or clindamycin’s association w C difficile infection (or even the seemingly
49
435
2K
ICU Extubation Tips:
Let’s admit it. As intensivists, we will never be as good in airway management as our Anesthesia or Emergency Medicine colleagues are. They intubate many more pts than we do & some of them under very suboptimal conditions. So, we can never match their skills
59
421
2K
A young ICU nurse resigned this week & will work in an outpatient Plastic Surgery center. Same pay but NO nights/weekends
Our most experienced nurse aide, a pillar of our ICU w whom I did MANY night shifts, is retiring early. He told me: "I had enough"
MD/DOs are leaving too
31
334
2K
ICU Pharmacology Secrets:
This is another random collection of pharmacology pearls that I witnessed & wrote down during the last two months.
And so it begins:
1. Hydralazine (H) is a widely used arterial vasodilator; especially in 🇺🇸, it is mostly used to treat
28
428
2K
ICU stories (from the trenches): It's been a bit more than 2 hrs in your night shift & you are checking some labs signed out to you to be followed on. A rapid response is called for "agitation" in Rm 666; in less than a minute the operator calls for a "Code Blue" in the same room
50
318
2K
ICU stories (a boring one…): If you work in a general ICU of a community hospital in United States, one of the common admissions you will get is the unfortunate resident of a nursing home or rehabilitation center that lives there for several decades & at some point becomes
51
277
2K
Refresher on Hemodynamics:
From: Cardiovascular Hemodynamics. An Introductory Guide. Arman T. Askari, Adrian W. Messerli. Springer International Publishing; 2019
13
473
2K
New guidelines for the management of severe community-acquired pneumonia:
8
416
2K
Friendly reminder (two cases this month):
If a patient is actively bleeding & is hypotensive, we don’t have to (and we should NOT) wait for hemoglobin to fall below 7.0 g/dl
I just saw a patient that received 4 liters of NS but no blood…
I think we have scared people a lot
41
152
1K
Nobody has pointed this out, so I have to play devil’s advocate here:
If you have read the recently published ACORN RCT 👇
15
240
1K
ICU Hemodynamics:
Nice graphs from two excellent and recently published editorials
1. Cardiovascular effects of norepinephrine:
7
261
1K
ICU stories (a brief one): One hour before the end of the am shift, u walk around in the ICU to make sure thinks look OK before u type your sign-out note. You spot the resp therapist & the nurse bagging the pt in Rm 306. From the hallway, u see the monitor: HR 160, RR/45, Sat 70%
28
282
1K
I don't know who has to hear this but if the pt is receiving 30 ml/h from sedatives, 30 ml/h from paralytic, 60 ml/h from pressor drips, 20 ml/h from "carriers", etc, s/he probably does not need another 80 ml/h from maintenance fluids. If anything, s/he needs maintenance diuresis
53
146
1K
ICU stories: Diabetic ketoacidosis (DKA) is another "bread-and-butter" ICU case. The typical scenario is one of a patient who presents to the ED w nausea/vomiting/weakness, receives a few liters of iv fluids & insulin drip overnight (according to a protocol), & the next day he is
15
292
1K
ICU pearls: I don't know who has to hear this but if the patient is in cardiac arrest and you have no reliable iv access, it's perfectly fine to use his dialysis catheter... 🤷♂️ It's also fine to place a peripheral iv catheter in the arm ipsilateral to prior breast cancer surgery.
57
111
1K
ICU/ED pearls: I don't know who has to hear this, but if a patient presents with a Na of 107 and has nausea/vomiting, it is very likely that these symptoms represent early cerebral edema and not GI illness. Be careful...
26
111
1K
ICU Airways Secrets:
"Hats and caps" guide to capnography traces on intensive care:
3
276
1K
British Thoracic Society recently published a must-read Statement on pleural procedures. It is 26 pages long & is accompanied by 13 online supplementary appendices
14
319
1K
Early this am and upon entering the ICU, I had a run of V tach after seeing this... 🙄
86
97
1K
For those of use who work in the ICU and, unlike our ED colleagues, rarely see a myocardial infarction (MI) on presentation, these are some important electrocardiographic (ECG) patterns to consider as life-threatening STEMI equivalents:
9
282
1K
ICU stories: "Urosepsis" is one of the "bread & butter" ICU cases. The usual scenario is one of an old lady who is admitted febrile/hypotensive w "dirty urine" & after an overnight ICU stay w ivf/pressors/antibiotics is ready to leave the ICU next am. Let's see how this one went:
28
193
1K
Shock is not about hypotension, shock is about hypoperfusion!
Useful reminder:
Patients with hypoperfusion in the absence of hypotension are at higher risk of dying than patients with hypotension and preserved perfusion
(Jentzer JC, et al. Circ Heart Fail 2021; 14(1): e007678)
#FOAMed
#FOAMcc
#MedEd
#MedTwitter
#MedStudentTwitter
10
131
694
14
179
981
ICU Facts:
I am neither a nephrologist not a hepatologist but I don't think I am too far from truth if I say that hepatorenal syndrome (HRS) is one of the most misused & misunderstood diagnoses in the ICU
19
108
969
ICU Hemodynamics Tips - Swan-Ganz catheters:
This will not be a comprehensive thread. Just happened to place a couple of Swan-Ganz (SG) catheters this week, so it is a good time to emphasize few basic points/steps. I have made a mistake (more than once) in each one of them…
8
227
963
10 in 10
(Random collection of) ICU Pharmacy Pearls (or: Pet Peeves):
I witnessed all of them the last month & decided to write them down. You may disagree with many of them but there we go:
1. If the patient is on warfarin, presents to the ED w massive upper GI bleeding &
14
184
932
ICU Nightshift Secrets:
This will sound a lot as as cookbook medicine but bear w me. The 2 drugs that I use more than anything else whenever I'm on a nightshift are: furosemide & dexmedetomidine. If u don't use any of them, u are probably missing something
Case from last night:
28
104
945
ICU pearls: This is the monthly reminder that “maximum dose pressors” is a stupid concept...🤐 I took care of a patient last night that needed up to 0.55 mcg/kg/min of norepinephrine for several hours & this morning she is almost off pressors. For many years, there was a “max” of
51
144
948
I admitted 2 ds ago a 51 yo pt, unvaxed, w severe COVID-19 ARDS. Tried the usual: steroids, toci, paralysis, proning, APRV, inhaled epoprostenol. Still on FIO2 100% PEEP 16. PF ratio 50-60 with Ppl 35-40. He is not an ECMO candidate per our regional ECMO centers. He is too old...
68
158
918
Friendly reminder that many patients with cardiogenic pulmonary edema are euvolemic (let's not start about what "euvolemia" means)! So, the immediate goal of treatment may not be fluid removal, but fluid redistribution...
NIV + NTG > Lasix (and this comes from a Lasix fanatic!)
28
136
907
ICU pearls: I don't know who has to hear this but if a patient with a chest tube connected to Pleur-evac develops resp distress, the first thing to do is not to start bagging him, not even auscultate him (and definitely not search for US). Make sure that the tube is not clamped.
26
98
886
This is so me when the hospitalist calls me to accept in the ICU an unfortunate 90 yo patient in multiorgan failure (NIV 100%, anuric, hypotensive) because "he is full code", "family wants everything done" and "the floor staff is uncomfortable".
43
62
885
ICU Infectious Disease Pearls and Pet Peeves: I love ID (or at least I did until COVID-19 came into our lives…) and for quite some time I wanted to write a relevant thread. These are some of the simple things that I always try to keep in mind and discuss/apply during rounds:
19
213
872
ICU stories (a common one):
Patient found unresponsive by police, taken to 🏥 ER. Was febrile, tachycardic. BP 100/60. Sat 99%. Labs: Hb 6.3 g/dl (MCV 78), WBC 5k (poly: 90%, lymph: 2%), PLT 30k, INR 1.5, PTT 38, fibrinogen 135, D-dimer 15,000 ng/ml, BUN/creat 163/3.3, Na 126,
23
141
872
There is a special place in heaven for those - friends - anesthesiologists who after taking emergent cases from the ED to the OR, then they deliver them to the ICU with a central venous catheter and an arterial line... 🙏
22
71
864
Does this happen only in the ICU I work or you have a room in your ICU too that is haunted and whoever is admitted there has high mortality risk and high risk for complications?
135
81
856
10 in 10
(Random collection of) ICU-Pharmacy Pearls (or: Pet Peeves):
I am guilty of the same sins. You may disagree with many of them but there we go:
1. The loading dose of vancomycin is not 1 gram for every septic patient. It is ~ 20+ mg/kg
2. Many hospitals’ vancomycin
8
172
817
(Not only...) ICU pearl: when a patient has urinary retention with 1 liter of urine in the bladder scan, the placement of Foley catheter is an excellent antihypertensive intervention
37
46
810
ICU Infectious Disease Pearls and Pet Peeves – Part2: These are some additional points and random thoughts regarding commonly used antimicrobial agents and frequently encountered ID clinical scenarios in the ICU. Comments from my ID and Pharm friends are welcome. Here it goes:
26
234
800
ICU stories (a boring one...)
This is a story that everybody working in an ICU will see several times/month. It's so common it deserves a separate textbook chapter. Its title: "The elderly/obese patient w multiple comorbidities, now w resp failure/drowsiness, who needs ICU care"
29
146
809
Several of my colleagues living/working outside the United States are surprised to learn that:
1. Many US hospitals have intensive care units but no intensivists. This is unimaginable in many European countries
39
158
786
ICU secrets: I see people dialing "999" in the infusion pump in order to give fluids fast. This actually SLOWS DOWN the infusion rate to ONLY 999 ml/hour while using a pressure bag or even manually squeezing a bag can generate flow rates of 1 liter in 5-10 min
31
84
769
ICU/hospital fact:
If you manage a very sick/crashing patient & you can send ONLY one blood specimen, just send an ABG (could be VBG, no big difference…). You will have in a few min information about many potentially lethal pathologies: acidosis/hyperkalemia/hyperlactatemia etc
21
119
775
ICU Pharmacology Pearls:
Norepinephrine is a "broad-spectrum" pressor agent. It may not be the best drug in EVERY clinical scenario of hypotension BUT it is the BEST bet in most of them.
11
76
750
Being an intensivist, I have to work with many different specialties. I respect all of them but I have the utmost respect for Emergency Medicine. Why? Because for both of us, nobody is too unstable to be helped. We jump into the fire without second thoughts. To my EM mates:
26
60
745
ICU hemodynamics secrets:
There is no way you will read a post or attend a lecture from a hemodynamics aficionado without coming across a pressure-volume (PV) loop.
Fun fact: you will see as many PV loops as aficionados (not many but each one with a personality of its own...)
9
181
746
ICU stories: Elderly pt w HTN/diastolic HF came to the ICU post-op CABG x3 + mitral valve repair. When I arrived for my night shift 3 h later, pt was on IABP and norepi 0.35/vaso 0.06/neo 1.0/epi 0.05. It's always good to know what you are dealing with. POCUS revealed this 4-ch:
24
181
721
Algorithm for initiation of diuretic titration in patients with acute decompensated heart failure (doi:10.3949/ccjm.89a.22016)
ICU (Nephrology) Secrets:
I don't know who has to hear this:
If the pt does not "respond well" to furosemide (Lasix), we don't have to start a continuous infusion of bumetanide (Bumex) & add scheduled albumin. We can simply increase the dose of Lasix & combine w other diuretics
10
35
372
9
207
712
Useful reminder:
Patients with hypoperfusion in the absence of hypotension are at higher risk of dying than patients with hypotension and preserved perfusion
(Jentzer JC, et al. Circ Heart Fail 2021; 14(1): e007678)
#FOAMed
#FOAMcc
#MedEd
#MedTwitter
#MedStudentTwitter
10
131
694
ICU Pharmacology Secrets - Etoh withdrawal:
I heard today from a resident (when I asked if a pt had received phenobarbital): "my attending prefers Precedex (dexmedetomidine) for etoh withdrawal"
Friendly reminder: Dexme is not etiologic treatment for etoh withdrawal. The real
23
108
697
ICU Hemodynamics:
The weekly reminder of the left ventricular (LV) pressure-volume loop and the concept of ventriculo-arterial coupling:
7
149
689
ICU pearls: if you respond to a cardiac arrest & your team manages to achieve return of spontaneous circulation(ROSC) with good BP, don't hastingly declare victory; it's quite likely that -after the epi effect wanes- the next BP will be 70/40. Have a vasopressor drip ready to go!
13
57
674
ICU Hemodynamics:
The regular Swan-Ganz catheter refresher post based on this article:
3
136
668
ICU stories:
Young pt w hx of anxiety-depression/HTN/obesity/ presented to the ED w weakness & "near loss of consciousness" ~4 pm. Also reported being dizzy & sweaty. She stated that she ate very early in the morning & had not had anything else to eat since then other than ice.
18
111
651
ICU stories:
A picture is worth 1,000 words, so 2 pictures... Do the math!
50yo, massive GI bleed, already 3 u of blood for hemorrhagic shock, on the vent, on pressors/sedation etc
Me: Is he "lined"?
Colleague: No, but is OK, has plenty of access, has 3 peripheral ivs
Patient:👇
112
67
646
Fresh study:
In adult medical inpatients receiving ceftriaxone treatment, is concomitant lansoprazole compared with other proton pump inhibitors (PPIs) associated with increased risk of ventricular arrhythmia or cardiac arrest and death?
12
159
621
ICU snippets:
70 yo. Out-of-hospital cardiac arrest. Intubated. Re-arrested many times. Eventually made it to the ICU.
ICU Nurse: What maintenance iv fluids do you need, doc?
👨⚕️: I don't think we need any maintenance iv fluids...
28
56
614
ICU facts:
Acute pulmonary embolism cannot be ruled out with echocardiography
20
55
599
The magic world of “publish or perish”:
We live in interesting times…
37
115
595
During the last week I placed more chest tubes than central lines. The last 1.5 pandemic years I have placed more chest tubes than the previous 5 years...
5
71
578
lCU Neurology Secrets:
If you have not taken a look at the 2023 American Association of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guidelines, now it's a good time:
1
128
595
Critical Care (and others): "It gets easier, but it never gets easy"...
6
183
568
ICU stories: 50 yo male patient w hx of DM / DVT was brought to to the ED due to "altered mental status" & was found to be in diabetic ketoacidosis (DKA) (pH < 7.0 / HCO3: 2) & acute kidney injury:
19
102
557
ICU Hepatology Update:
If you feel a bit queasy - I feel the same! - whenever you admit a patient with cirrhosis/acute-on-chronic liver failure (ACLF), you will find useful this excellent document from the American Association for the Study of Liver Diseases (AASLD):
6
116
567
Fluid management pearl (case from last night): if a patient has already received 7 liters of crystalloids and 1 liter of albumin, I doubt that the 9th liter of fluids will miraculously fix his hemodynamics...
37
36
557
In my humble opinion, Emergency Medicine is the most difficult specialty...
Cheers,
An IM/CCM doc
PS: If you have never watched the medical tv series "ER", you should...
26
56
555
ICU stories: You start your night shift and while walking in and out each patient’s room, you see this 👇 on one ventilator's screen:
13
162
545
Very important topic since up to 60% of patients with sepsis develop acute kidney injury (AKI). This 👇 is a nice review on sepsis-associated AKI (with interesting diagrams/tables), even though some points can be debatable:
7
133
548
ICU pearls:
I don't know who has to hear this but if the patient is on "lung-protective" ventilation with a prescribed tidal volume of 6 mg/kg & at the same time is “double triggering” the ventilator due to acidosis & air hunger, then s/he is NOT really "protected"... 🤷♂️
13
60
532
ICU secrets (from this week in the ICU) - Pleural space infections:
1. Anaerobic coverage is generally advisable contrary to the community-acquired pneumonia guidelines by American Thoracic Society & Infectious Disease Society of America
6
67
522
ICU stories (sorry for the non-traditional presentation; I will tell you how the case unfolded): A rapid response team (RRT) is called at 2:00 am for an 80 yo pt in the medical floor. 5 min later you are called to assess the pt at the bedside because he looks “bad”. When u enter
16
91
523
10 waveforms (besides electrocardiogram) every intensivist should be familiar with:
1. Arterial line waveform
Obviously, we need an arterial line. Besides the SBP/DBP/MAP/HR data, there is a ton of info to be obtained regarding tamponade, LVOTO, fluid responsiveness etc
4
143
520
I have recently seen SEVERAL hospital admissions, COVID(+), that were started on steroids by their PCPs EARLY when the PCR came +. Please note that the RECOVERY trial showed NO benefit for patients not receiving O2, and in fact a possibility of HARM could not be excluded
12
59
518
In the ICU we had to create a "chest tube cart" mimicking our "line cart". It was a necessity given the number of chest tubes we have to place
3
38
500
ICU stories: Middle-aged pt with cirrhosis presented to the ED with abd pain and underwent Hartmann's procedure (colectomy - end-colostomy). Next am, pt was hypotensive on rising levo gtt (0.24 from 0.1) and lactate (3.4 -> 6.7). S/he was positive 8 liters in 12 hours
16
117
508
ICU pearls:
The most common cause of a lower GI bleed is an upper one
7
40
504
Alcohol withdrawal syndrome: I don’t know if u have a similar experience in other countries (or other places in the States) but I've recently seen a big spike in alcohol abuse-related disorders, especially alcohol withdrawal syndrome (AWS). I'm obviously referring to severe AWS
24
97
505
ICU Cheat Sheet for Management of Acute-on-Chronic Heart Failure Complicated by Cardiogenic Shock:
7
129
505
ICU pearls:
In a crashing/tubed pt w massive PE who receives the still recommended by several textbooks 500ml NS fluid bolus, if u notice (worse) pulse pressure variation, do not interpret it as sign of volume responsiveness & trigger for more fluid boluses. Quite the opposite!
15
99
493
I was checking again today about DKA/HHS in a very modern & easy to read textbook and I saw this about the Na correction:
11
131
484
Take-home messages:
1. You cannot practice Critical Care without good iv access
2. When you step into a disaster outside the ICU, you have to decide fast if you will stay and play (and pray) or scoop and run
3. Know your resources and use them
4. The dose of vasopressin for
3
28
466
ICU/ED pearls: If you manage a pt with a Na of 107 w hypertonic saline (HTS), please follow the urine output very closely. IMHO, this may be even more important than the frequent Na checks. The main risk for hypoNa overcorrection is usually not the use of HTS per se but...
13
95
447
ICU stories: Middle-aged pt w remote hx of seizures had grand-mal sz at home & in the ambulance. Intubated for airway protection in ED; transferred to ICU. Placed on propofol. Overnight received 5 l NS & norepi gtt @ 0.1 & (ABx + steroids) for septic shock due to aspiration PNA.
11
108
444
Take-home messages:
1. We should be careful when we manage "boring" cases
2. Pts, especially the ones that come to the ICU, can have more than 2 life-threatening diagnoses at the same time
3. Old microbiological date should be thoroughly reviewed in order
2
23
447
Many people celebrate being tobacco-free or alcohol-free or carb-free for a month. And I truly applaud them for this.
But I will also have to brag about myself being albumin-use free for more than 2 months. If you are an intensivist, you know that this is not an easy feat!
12
17
431
ICU stories: You get a call from outside 🏥 to accept a middle-aged pt w DM2/HTN/HLD/some type of solid Ca on chemo/obesity who presented to their ED w weakness/anxiety/"feeling cold". Vitals: BP 80-100, HR 130s (sinus tach), afebrile, Sat 100% on room air. Labs: WBC 13K, ...
10
103
432
Mechanical ventilation mode nomenclature secrets:
SIMV = sometimes I may ventilate
#FOAMed
#FOAMcc
#MedEd
#MedTwitter
#Medstudent
4
74
438
ICU Hemodynamic Secrets:
“Norepinephrine is the worst vasopressor, except for all the others”
- Winston Churchill
11
51
435
ICU stories: Walking to the ICU early am & before getting sign-out from the nocturnist covering the ICU, I'm greeted by the nurse of the pt in room 428
– Can u take a look at this pt? I keep going up on levo, now @ 0.15. Middle-age pt w hx of ESRD on HD/afib/CHF/cirrhosis etc etc
7
102
431
New SCCM guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU. They are focusing on infectious disease, peri-transplant, gastrointestinal, and neurologic issues
4
109
428