Intensive Care Medicine
@yourICM
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International peer-reviewed medical journal for all involved in Intensive Care #FOAMed #FOAMcc 🖋 Write 📨 Submit
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Albumin, 10 myths
1️⃣leaks into interstitium
2️⃣ ⬇️volume expansion vs artificial colloids
3️⃣ ⬇️AKI
4️⃣ sepsis: ⬆️survival
5️⃣ ⬆️diuretics effects
6️⃣RRT: ⬆️ fluid removal
7️⃣cirrhosis: ⬇️mortality
8️⃣TBI: ⬆️mortality
9️⃣correcting hypoalb ⬇️mortality
🔟 ⬆️NaCl
📎
17
410
1K
Reflections/lessons from a life in
#ICU
:
1⃣work with people you like/love
2⃣take sabbaticals to recharge
3⃣prioritize family = those you love most
4⃣live every day as having terminal disease: focus on what most important
@JRandallCurtis1
#ICMfromtheInside
20
433
925
Invasive arterial pressure
🌊monitoring
🌊SBP
🌊DBP
🌊MAP
🌊pulse pressure
🌊arterial waveform
Knowledge & application of different signals allow to understand/interpret hemodynamic derangements in
#ICU
guiding
#resuscitation
using simple bedside tools.
📎
14
292
910
Vasopressors in
#ICU
1️⃣set MAP/DBP goals
2️⃣individualize
3️⃣may⬇️+ve fluid balance
4️⃣reassess fluid status/CO
5️⃣change mechanism as 2 line
6️⃣high doses?? hydrocortisone
7️⃣vasopressin in RV failure
8️⃣no MAX dose
9️⃣EN can be initiated
🔟can be safe in PVC
🖇
2
286
764
Fluid administration among most common interventions in
#ICU
... but high potential for harm! Here everything you need to know about deresuscitation
☔️ Why deresuscitation?
☔️ What is it?
☔️ When to start/stop?
☔️ How to deresuscitate?
☔️ So what's next?
🖇️
3
282
635
Coagulopathies severe/frequent complication in
#ICU
: how to manage??
🩸 hemorrhagic coagulopathies: non‑malignant & malignant
🩸 thrombotic c.: sepsis‑induced & solid cancer‑associated
🩸 managing hemorrhagic c.
🩸(preventing &) managing thrombotic c.
🖇️
6
223
610
🏆 Here some of our TOP
@altmetric
score articles for 2022...
#FOAMcc
on
@yourICM
☔️ Deresuscitation
🥚 Myths on albumin
🩸 Invasive BP monitoring in
#ICU
, beyond MAP
🍬 Managing DKA
1
214
601
Management of moderate to severe TBI
⏳ first hours: initial
#resuscitation
targets
🩸💧 in
#ICU
, ⬇️ secondary insults after trauma: ICP, CPP, hemodynamics
👁 multimodality monitoring targets & management
🫁 extracranial complications
🧠 long‐term outcome
2
241
579
Diabetic ketoacidosis? address 3 main issues
💉insulin to resolve at its root cause (glucagon-to-insulin ratio)!)
💧fluids vs hypovolemia (if present) & TBW
🧂 electrolyte replacement, with attention to life-threatening shifts in K+
& beware its myths!
🖇️
10
203
550
📣 Surviving sepsis campaign: international guidelines for management of
#sepsis
& septic shock 2021 out!
➡️screening & early treatment
➡️infection
➡️hemodynamic management
➡️ventilation
➡️additional therapies
#LIVES2021
@ESICM
📣Open
#FOAMcc
@yourICM
🔗
6
328
535
Vasopressors in critically ill pts with shock:
➡️summary of evidence & pivotal trials
➡️relevant pathophysiology of vasodilatory shock
➡️when & what vasopressor(s) to administer? agents & receptor/effect(s), dose, additional benefits
➡️monitoring
➡️weaning
3
264
532
Direct oral anticoagulants, 10 things to know
1️⃣ indications
2️⃣ types
3️⃣ half‑life & elimination
4️⃣ organ failure
5️⃣ ⬇️ absorption & enterohepatic recirculation
6️⃣ monitoring
7️⃣ reversal
8️⃣ management of major bleeding
9️⃣ DOACs in
#ICU
🔟 resuming DOACs
📎
2
206
508
Driving pressure at the bedside:
🛌 how to measure?
🛌 how to control driving pressure in spontaneously breathing patients?
🛌 limitations
One single Vt does not fit all: ΔP may help to titrate Vt according to lungs size, potentially improving outcomes.
🖇️
3
215
509
☢️ IV contrast in patients
#AKI
? NOT associated with either persistent AKI at hospital discharge or initiation of dialysis. Current ACR-NKF consensus recommendations for use of IV CM in pts with stable renal disease may be applied if pre-existing AKI.
📎
3
214
489
Acute pulmonary edema in
#ICU
:
1⃣what is it?
2⃣pathophysiology
3⃣actors of organ cross talk
4⃣how to recognise
5⃣management goals
6⃣ensure adequate oxygenation
7⃣loop diuretics
8⃣role of vasodilators
9⃣multidisciplinary teams needed?
🔟avoiding readmission
2
187
475
Prone position in
#ARDS
➡️ effects: chest wall/lung mechanics, ventilation, perfusion, gas exchange
➡️ hemodynamics
➡️ whom & when? indications/contraindications
➡️ ventilator settings
➡️ how to perform bedside
➡️ impact on outcomes
➡️ unanswered questions
3
209
457
Etomidate (0.2–0.3 mg/kg) vs ketamine (1–2 mg/kg) for emergency endotracheal intubation, RCT
💉801 critically ill pts
💉day 7 survival significantly lower with etomidate
💉no significantly different day 28 survival
Full results
#FOAMcc
⬇️ Visual abstracts
3
184
445
Thoracic (lung & pleural)
#POCUS
in critical care:
➡️technique
Evaluating & managing
➡️pneumothorax
➡️pleural effusion
➡️acute dyspnea
➡️pulmonary edema vs
#ARDS
➡️pulmonary embolism
➡️interstitial processes
➡️MV support
Narrative review
#FOAMus
#echofirst
2
219
436
Bleeding leading preventable cause of death in trauma: understand, detect, treat trauma-induced coagulopathy pivotal to improve outcomes
🩸pathophysiology
🩸diagnosis
🩸management
🩸knowledge gaps/future development
DON'T miss supplementary file
#FOAMcc
🖇
4
165
440
Assessing hemodynamics to assess volume status?
💧volume status & fluid therapy, physiological concepts
💧monitoring
💧indications for fluid
#resuscitation
💧how to predict fluid responsiveness & perform fluid challenge?
💧strategy for fluid management
🖇️
6
184
439
Basic
#ultrasound
skills in
#ICU
& NCCU,
@ESICM
consensus & expert recommendations:
➡️brain
➡️lung
➡️heart
➡️abdomen
➡️vascular
#FOAMcc
#FOAMus
#echofirst
#POCUS
🖇️
DO NOT miss supplementary files including additional figures & links to video description!
5
222
417
Ventilating obese pts in
#ICU
?
➡️ NIV to prevent/treat ARF + vs re-intubation
➡️ airways: evaluate, pre-oxygenate, choose devices
➡️ careful RM (case-by-case)
➡️ (moderate to high) PEEP vs collapse
➡️ low Vt (PBW!) in non-ARDS/ARDS
➡️ proning (severe ARDS)
1
195
413
Ventilator induced lung injury
🫁 mechanical ventilation & VILI
🫁 conceptual and mechanistic evolution of VILI: barotrauma, volutrauma, atelectrauma, biotrauma, ergotrauma
🫁 VILI pathogenesis
🫁 VILI assessment
🫁 clinical approach
Free to read
#FOAMcc
🔓
1
154
414
🫁 Let’s protect lung & its circulation to improve prognosis! Besides limiting VILI/improving oxygenation, proning protects pulmonary circulation, unloads RV, improves hemodynamics, maybe partly explaining its beneficial effect especially if RV failure.
🖇️
4
157
411
Coagulation & perioperative bleeding
🩸fibrinogen source/dose/time
🩸Ca++: just vs citrated blood products?
🩸PCCs/factor concentrates
🩸TXA
🩸plasma: volume or coagulation?
🩸PLTs as primary components
🩸RBCs not just DO2
🩸targeted coagulation support
🖇️
1
145
404
Intensive Care Medicine joins the condolences for the lost of Jordi Mancebo, who, in addition to being an exceptional intensive care doctor, teacher & researcher, was an excellent Editor and supporter of
@yourICM
We will continue to honour your legacy in our editorial activities.
6
108
394
Septic shock
#resuscitation
, from current practice:
➡️clinical targets
➡️initial fluids & fluid responsiveness
➡️vasoactive drugs
... to evolving concepts:
➡️new potential targets
➡️fluid resuscitation
➡️vasopressors
➡️refractory shock
Narrative review on
2
177
394
Management of severe community-acquired pneumonia:
@EuroRespSoc
@ESICM
@ESCMID
@ALATorax
international guidelines
➡️ evidence-based recommendations for diagnosis, empirical treatment, ABTs
➡️ current knowledge gaps
➡️ recommendations for future research
🖇️
2
185
384
Less (antibiotics) is more in
#ICU
➡️ use effective short‑course regimens
➡️ de‑escalate if improvement/negative cultures
➡️ optimize according to PK/PD
➡️ targeted/directed ABT: NO combinations if known pathogen/susceptibility
➡️ aggressive source control
5
188
379
Thromboprophylaxis in
#ICU
🩸which pharmacological thromboprophylaxis for critically ill patients? LMWH preferred vs UFH unless severe renal insufficiency
🩸contraindications? mechanical thromboprophylaxis
🩸important considerations & pending questions
🖇️
2
137
376
Major haemorrhage in critical care
🩸pathophysiology of hemorrhagic coagulopathies: trauma, postpartum, chronic liver disease, DIC, uremia, anticoagulation
🔍diagnosis & evaluation
📃protocols
🩸management post bleeding & massive transfusion
🤔 & more
🔓
2
179
376
Main early papers on
#COVID19
& their findings, an overview:
➡️ manifestations of severe disease
➡️ pharmacological therapy
➡️ ventilatory support in pts with
#SARSCoV2
related
#ARDS
➡️ healthcare organization & healthcare worker stress
#FOAMcc
#COVIDFOAM
2
198
371
Vasopressors? Focus on norepinephrine
💉pharmacological properties
💉current dosing strategies
Consensus of definitions needed (ie refractory shock or high-dose vasopressors) as equivalences between drugs (catecholaminergic/non) to facilitate comparisons
🔓
0
151
371
The use of high‑flow nasal oxygen:
💨 acute hypoxemic respiratory failure
💨 acute hypercapnic respiratory failure
💨 weaning from mechanical ventilation
💨 special populations: immunocompromised patients & tracheostomised patients
🖇️
4
147
366
Wean/extubate critically ills
1⃣optimize (⬇️) sedation
2⃣diaphragm-protective MV
3⃣daily screen for SBT
4⃣best SBT?
5⃣weaning strategy
6⃣what if SBT fails
7⃣muscle load/efficiency ratio
8⃣weaning/extubation failure
9⃣post-extubation support
🔟 tracheostomy
6
166
361
How I use
#ultrasound
in cardiac arrest
🫀
#POCUS
to confirm CA & guide management during cardiopulmonary resuscitation
🚨general assessment immediately after ROSC: hemodynamics & circulatory support + non cardiac
🔮 future perspective
#FOAMcc
#FOAMus
🔓
🧵
1
169
360
Etomidate vs ketamine for emergency endotracheal intubation, RCT
💉801 critically ill pts assigned to receive etomidate (0.2–0.3 mg/kg) or ketamine (1–2 mg/kg)
💉day 7 survival significantly lower with etomidate
💉no significantly different day 28 survival
9
151
354
Post-cardiac arrest brain injury, narrative review:
🧠pathophysiology: primary (ischemic) & secondary (reperfusion)
🧠treatment options
🧠outcomes
🧠neuroprognostication
🧠
@ERC_resus
@ESICM
2021 algorithm for prognostication
Open
#FOAMcc
#FOAMres
@yourICM
2
164
351
Lung
#ultrasound
based approach for early diagnosis of
#COVID19
pneumonia:
➡️20 US/European hospitals
➡️1462 pts
Combining
#LUS
patterns of probability + clinical characteristics allow to rapidly rule in/out
#SARSCoV2
pneumonia at bedside w high accuracy!
3
189
348
Ventilation in
#COPD
& asthma
➡️ respiratory mechanics/gas exchange
➡️ heart–lung interactions
➡️ HFNO & NIV
➡️ managing invasive MV from intubation to (early) weaning limiting hyperinflation
➡️ long‑term outcome & role of tracheostomy
➡️ future strategies
1
135
350
Critical care
#ultrasound
goal-directed vs EGDT in septic shock
🩸improved 6h lactate clearance
💧reduced 12 & 24h cumulative fluids
CCUGDT effective to guide hemodynamic management, optimizing organ perfusion/avoiding excess fluid resuscitation
#FOAMus
📖
4
164
347
HFNC as respiratory support, guideline synthesizing best-evidence in 4 recommendations
➡️ hypoxemic resp failure: STRONG
➡️ peri-intubation: NO
➡️ post-extubation: CONDITIONAL
➡️ postop (cardiac or thoracic surgery): CONDITIONAL in high risk &/or obese pts
3
163
339
Early prone position: may reduce mortality in
#COVID19
induced severe hypoxia? in this study, vs non proned pts
significant difference in SpO2/ROX at 10' & SpO2/RR/ROX at 30'
(some) improved CT
56.5 vs 24.3% survival at 90 days
#FOAMcc
#COVIDFOAM
@yourICM
3
187
331
#HFNO
found a role in every aspect of hypoxemic respiratory failure:
➡️ first-line support
➡️ preoxygenation
➡️ post-extubation
Closely monitor, not to delay intubation if needed. Open challenges: improving comfort, potential for even higher flows, weaning
3
194
332
Monitoring cerebral oxygenation to understand brain dysfunction after
#ABI
& individualize management
🧠 pathophysiology of cerebral oxygenation
⚙️ technology of cerebral oxygen measurement
📖 evidence/clinical applications
#FOAMcc
@yourICM
@chiara_robba
📎
2
145
332
As announced, the "Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)" are now online. Thanks for all the efforts to the authors,
@ESICM
,
@SCCM
and
@yourICM
and
@CritCareMed
staff.
4
234
329
#COVID19
induced
#AKI
in critically ills with
#SARSCoV2
#Coronavirus
infection: several mechanisms possibly involved, prevalent, associated with poor outcomes/high mortality rates in
#ICU
&, to date, no specific treatment. Open access
#FOAMcc
#COVIDFOAM
1
189
330
Dexamethasone in
#COVID19
& severe hypoxaemia: with 12 vs 6 mg
💉high probabilities of benefit on all outcomes, including days alive without life support/mortality
💉relatively low probabilities of important harm
COVID STEROID 2 trial bayesian analysis
5
170
329
Fluid de-escalation
☔️ should I withdraw fluids?
☔️ is it right time to attempt fluid withdrawal? Tissue perfusion = adequate + pts must not be preload responsive
☔️ how to proceed?
☔️ when to stop?
☔️ how to react when hemodynamic instability occurs?
🖇️
2
140
327
Pathophysiology of anaphylactic shock captured on CT!
💉post contrast lost of consciousness/cardiac arrest
☢️ early vs late-phase images comparison revealed marked/extensive intestinal edema, IVC collapse, volume-reduced spleen (autotransfusion)
#FOAMcc
🖇️
4
117
326
Breathing effort on ventilator
🫁 monitoring inspiratory effort w Pes
🫁 monitoring respiratory drive & effort w/o Pes
Validated non-invasive tools, allowing bedside detection/quantification of effort are now available: time to start monitoring!
#FOAMcc
🔓
0
118
326
10 things we learned about
#COVID19
1
#SARSCoV2
#Coronavirus
2 The infection
3 Immunity
4 Inflammation
5 Thrombosis
6 Diagnostic tests
7 Clinical aspects
8 Therapy
9 Anti
#SARSCoV2
vaccines
10 Preparedness & further research
Open access
#FOAMcc
#COVIDFOAM
3
205
319
Understanding pathophysiology of hemostasis disorders in critically ill patients with COVID-19.
Free read at
@yourICM
@Dr_Cit
@ClinMedJournals
@ESICM
2
201
318
Best PEEP on MV?? Individual-specific providing oxygenation (SpO2 >90%/no excessive FiO2 + acceptable PaCO2 (<50/55 mmHg) & minimal need for fluids/cardioactives. Start at 10-12 but stay alert to hemodynamic impact & as set, serially asses need/adequacy.
🖇
3
127
313
Balcony of Hope? To be included in
#ICU
design! Outdoor spaces where spend time with family feeling sunlight/breeze are valuable therapeutic backing: well-being of critically ill can positively influence recovery & impact on outcome.
🖋️
#ICMfromtheInside
🪟
13
96
312
Antifungal stewardship in
#ICU
🧪 biomarkers
⬇️ de‑escalation
🍄 other methods to improve AFs use
Empirical AFs commonly used (poor prognosis if inappropriate/delayed): AFS can ⬆️ performance measures/⬇️ AFs consumption, no negative impact on outcome
🖇️
0
116
309
ICP, fundamental physiology & technologies:
📚 history
⚡️ harm from intracranial hypertension & protocols for treatment
🧠 indications for invasive monitoring in
#trauma
& non‑traumatic neuroemergencies
🖥️ invasive/non monitoring techniques + thresholds
📎
5
150
311