Ivor Popovich

@inthehm01 @CoffeeBlackMD There has never been a trial of albumin vs no-albumin in HRS. I suspect in the ICU where we can give vasopressors easily it makes absolutely no difference

@InternSupp @CoffeeBlackMD Hepatorenal syndrome comes to mind for one

I think there are clear cases where albumin helps. And believe me I understand the studies. I’ve been beat over the head with them. In an ICU it’s not something you just give to everyone. But also. We will replace everything else when it’s low. Except albumin. F*ck albumin?

@argulian Complete heart block

An elderly hospitalized patient with irregular heart beat. The team is considering Afib. Mitral inflow PW Doppler is shown. What is the likely explanation?

@AndrewZywiecMD Practically nothing you’ve said is correct

Ok, I'm going to explain this simply. Tylenol reduces glutathione. Glutathione is an antioxidant that highly mitigates inflammatory damage. If a mother has an illness during pregnancy, something called maternal immune activation (MIA) can occur in response. This is known to cause deleterious effects to fetal development. This is all well documented and not controversial. If she takes Tylenol during this inflammation to reduce symptoms, it can also cause a reduction in the ability to mitigate the inflammation, which can exacerbate any potential fetal damage. There is a risk to benefit ratio in every medication. In this instance, the risk is fetal damage, and the benefit is reduction in symptoms. The risk outweighs the benefit. Vaccines cause inflammation. That is, in fact, the goal. Create inflammation to generate an immune response. So pregnant women are given vaccines, which causes inflammation, and cause MIA, which potentially harms fetal development, and then are given Tylenol, which simply exacerbates the situation. I really wish people would just look at these things from an empirical perspective and stop politicizing everything. Feel free to look up anything I just said. It's all textbook medical knowledge. For decades, doctors implored pregnant women to take extra care of themselves, avoid all drugs, toxic foods, get adequate rest, reduce workload, etc, because a developing fetal is exceptionally vulnerable. Please stop spreading incorrect information that harms patients.

@ross_prager If anything the effusion is protective

Patient with shock, what is driving their hemodynamic collapse more, the RV or the pericardial effusion? 👇

@DocPriyamMD Hypoxic drive doesn’t exist. Deadspace actually improves when HPV is released and the Haldane effect is minor. I suspect most cases of “O2 induced hypercapnia” is someone not paying attention to the patients ventilation on presentation and only addressing hypoxia

The night shift was quiet until my intern yelled... "Sir, the COPD patient in Bed 2 came in gasping with an O2 saturation of 82%! I fixed it, but now he won't wake up!" The Catch: The intern had put him on a 15-Liter Non-Rebreather mask. The monitor now showed an SpO2 of 100%, but the patient was unarousable, breathing shallowly and bounding pulses. The intern was confused: "His saturation is perfect now! Why is his GCS dropping?" A classic ward tragedy. Med-X, what did the intern just do, and how do we fix it?

@aribindi @ThinkingCC @fersaurin A swan doesn’t tell you if your failing RV will benefit from fluid or not

@ThinkingCC @fersaurin It is better for the average doc in practice to focus on getting good with interpreting and using swan numbers than relying on pocus. In this scenario, a high cvp and low papi off the swan will easily tell you you are going into RV failure.

It is terrifying that 33% gave fluid to a struggling RV with an underfilled LV. Terrifying.

@IM_Crit_ Inotrope is best choice. Pulmonary dilator unlikely to help and difficult in non ventilated pt. Fluid bolus will make patient worse if diastolic septal flattening already exists. GTN is malpractice

Please explain 👆 #foamed #foamcc #meded #medtwitter #POCUS

ICU - Board Review Qs: 60 yo pt admitted to the ICU because of inferior STEMI. Emergency cath: 100% proximal RCA occlusion treated successfully with stenting One hour post-PCI: dyspnea/anxiety - BP: 94/70, HR: 60/min (sinus). Phys exam: JVD (+), clear lungs, cool extremities

@rbarbosa91 Or they could just stand not off centre? I’ve never had to contort to place a right handed line anywhere

When placing lines, I often see residents twisting and contorting themselves into awkward positions in order to be able to poke with their R hand. Instead: Learn to use your LEFT hand when it's easier. Learning to poke L handed🤚is easier than you think. You'll be 😀 later .

@ArielG_RRT @ventilacionmeca @DocMusician @DrMiguelIbarra1 @emireles_c @critconcepts @IM_Crit_ @Vent_Busters @JVentilation @CCF_PCCM @RespiratorySCCM @SaudiRTs @DrSateeshPCCM First thing I would do is drop the rate way down and increase the volumes and i time. Then peep question depends on the patient… try different levels of peep and see what happens to the peak-plateau difference- often some peep stents the airways and is helpful

Would you set PEEP>0 or PEEP=0 in this case? What is the logic behind it? @ventilacionmeca @DocMusician @DrMiguelIbarra1 @emireles_c @critconcepts @IM_Crit_ @Vent_Busters @JVentilation @CCF_PCCM @RespiratorySCCM @SaudiRTs @DrSateeshPCCM

@ROKeefeMD thats where I disagree. You wont be able to clear all the ketones you produce and have normal anion gap. caveat is what number u consider normal. If baseline AG is 12 and it rises to 18 then that is a gap acidosis even tho still in “normal range” (esp if albumin not considered)

I think the main point is that patients with acidosis from something more chronic like AKA or starvation may present with NAGMA given kidneys are clearing the ketoanions and in turn taking in more chloride. But a NAGMA shouldn't make you think it CAN'T be ketones, so you should still check

Daily Pearl(s): Alcoholic Ketoacidosis and NAGMA Ketoacidosis (from alcohol, diabetes, or starvation) can present as a normal anion gap metabolic acidosis (NAGMA) if renal function is preserved. When renal function is preserved, the kidneys can efficiently excrete the negatively charged keto-anions. To maintain electroneutrality, the renal tubules reabsorb chloride in exchange for the excreted ketones. This anion exchange effectively "closes" the anion gap by replacing the unmeasured keto-anions with the measured chloride anion, resulting in a hyperchloremic, normal anion gap metabolic acidosis. Thus, a calculated anion gap should not be used to rule out ketoacidosis; if clinical suspicion is high based on the history, a direct serum beta-hydroxybutyrate level is the definitive test. Source: CPS - Episode 437 RLR An Abnormal Normal Gap Acidosis

@ROKeefeMD I thought the post was implying that the chloride would somehow “mask” the presence of ketones. Apologies if I misunderstood

@ROKeefeMD It might be we are confused with wording. You would see a NAGMA! It just that your kidneys won’t completely clear ketones from the blood until their production is switched off. So my opposition was to your statement that normal AG doesn’t rule out ketacidosis.

@ROKeefeMD If you have ketoacids the anion gap will be high (adjusted for albumin) and if you don’t it won’t. The hyperchloremia only affects the delta ratio and whether there is a combined nagma/nagma or not.

@ROKeefeMD Not correct. The NAGMA or the presence of Cl ions does not affect the measurement of the anion gap.

@EMNerd_ I always only look at AG. Their concern is based off not understanding acid base. They are worried that the high Cl falsely closes the gap- not realising that this is impossible (because HCO3 falls when chloride rises)

Okay got in a discussion with Endo at work about the management of DKA on following the AG vs the serum Bicarb to assess for resolution. They cited the following guideline which recommends using the serum bicarb because the AG can be affected by the hyperchloremic acidosis.

@msiuba @cardiojaydoc02 A picco is easier and just as accurate

@cardiojaydoc02 100% In skilled hands/teams, it’s a quick and safe procedure

If ones is unsure about the hemodynamics and there are no contraindications, just do the RHC and be done. No guessing, more precision, and possibly better outcomes. #foamed #meded

@TheKoshurDoc Which pressures are recorded in professional weight lifters also. Brief spikes to this level are not harmful

@PulmCrit I think useful if very low but normal- high means nothing

@PulmCrit People ignore the basic physiology… VO2 is not fixed and changes with cardiac output! Plus distributive and low output shock often co-exist.

ScvO2 is so hot right now. About a decade ago we had a patient in shock with terrible echo windows. ScvO2 was high, so the team thought sepsis. Antibiotics failed. Autopsy showed MI. We had an M&M conference. Everyone was confused about why the ScvO2 misled us. … #1/2