Hanine AlMubayedh, PharmD, BCPS, BCCCP

🚨 Hot off the press! 🚨 Introducing the PRoMPT BOLUS study results — a landmark trial evaluating the safety & efficacy of normal saline vs. balanced fluids in suspected pediatric septic shock 🌍 9,000+ children 🏥 47 sites 🌎 5 countries And the winner is… 👇 nejm.org/doi/full/10.10… @nkuppermann @franbalamuth

MAP > 65 is a myth Lactate isn’t intrinsically bad 30 ml/kg fluid bolus was invented by a shadow government

Looking for the evidence for the 30 ml/kg bolus in sepsis

Comparison of 8.4% Sodium Bicarbonate vs. 3% Sodium Chloride in Severe Hyponatremia: A Retrospective Cohort Study onlinelibrary.wiley.com/doi/10.1111/ac…

We’re proud to announce the centers competing in the SIPHA Clinical Skills Competition for Residency Programs at #SIPHA26 🏆 Where the journey begins.. and clinical excellence takes the spotlight!

🫁 Why I always ask for paired blood gases! CO2 and hemodynamics 🧪 For years, we have relied on: ▪️ Lactate ▪️ ScvO₂ / SvO₂ ▪️ Clinical perfusion But all of them share a critical limitation: 👉 They do not reliably detect ongoing tissue hypoperfusion ⚠️ The problem You can have: ✔️ Normal ScvO₂ ✔️ Decreasing lactate ✔️ “Stable” hemodynamics …and still have microcirculatory failure 👉 This is where CO₂ enters the game 🧠 The physiology in short CO₂ behaves differently from oxygen: ➡️ ~20x more diffusible than O₂ ➡️ Accumulates when flow is insufficient ➡️ Reflects flow adequacy, not just oxygenation 👉 Pv-aCO₂ ≈ inverse of cardiac output 🔥 What the CO₂ gap really tells you 🟢 Pv–aCO₂ < 6 mmHg → Likely adequate flow 🔴 Pv–aCO₂ ≥ 6 mmHg → Suggests low flow / impaired perfusion BUT: ❗ It is NOT a marker of hypoxia alone ❗ It is a marker of flow–metabolism mismatch ⚡ The real upgrade: the CO₂/O₂ ratio 👉 Pv-aCO₂ / Ca-vO₂ This is the missing piece. ✔️ Approximates respiratory quotient ✔️ Detects anaerobic metabolism ✔️ Reacts faster than lactate 📈 >1 = ongoing anaerobic metabolism 🚨 Clinical implications 🩸 Septic shock High CO₂ gap despite ScvO₂ >70% → hidden hypoperfusion Persistent Pv–aCO₂ ≥6 mmHg → ↑ mortality 🫀 Fluid responsiveness ↓ Pv–aCO₂ after fluids → likely responder 🫁 Weaning failure ↑ CO₂ gap during SBT → inadequate DO₂ vs VO₂ 🏥 Post-op patients Elevated CO₂ gap predicts complications better than lactate ❌ Common mistakes ❌ Using lactate alone ❌ Ignoring normal ScvO₂ “false reassurance” ❌ Interpreting CO₂ gap without context (pH, Hb, ventilation) ❌ Treating numbers instead of physiology 🚀 Modern hemodynamic approach We should integrate: 1. Macrocirculation → MAP, CO 2. Oxygen markers → ScvO₂ 3. Metabolic markers → Lactate 4. Flow markers → Pv–aCO₂ 5. Anaerobic markers → Pv–aCO₂ / Ca–vO₂ 👉 Not one variable 👉 A physiology-driven bundle 🎯 Take-home CO₂ is not a waste product. 👉 It is a real-time marker of perfusion adequacy 👉 It detects what oxygen variables miss 👉 It bridges macro and microcirculation 📚 Mallat J et al. (2025) Annals of Intensive Care DOI: 10.1186/s13613-025-01569-2

💧 Albumin in the ICU: life-saving drug… or expensive myth? We’ve been using it since the 1940s. Yet in 2026 we still don’t fully agree when it actually helps. 🧠 First principle Albumin is NOT just a volume expander. It does much more: ▪️ Maintains oncotic pressure ▪️ Protects endothelium & glycocalyx ▪️ Modulates inflammation ▪️ Alters drug pharmacokinetics ➡️ It’s a biologically active molecule, not “fancy saline” ⚠️ The uncomfortable truth 👉 50-70% of albumin use is inappropriate 👉 In some studies: >90% misuse Yes… even in modern ICUs 🔥 Where albumin actually WORKS ✔️ Hepatorenal syndrome (HRS) → Albumin + terlipressin = better renal outcomes ✔️ Spontaneous bacterial peritonitis (SBP) → ↓ AKI + ↓ mortality ✔️ Large-volume paracentesis → Prevents circulatory collapse ⚖️ Where evidence is… mixed 🟡 Septic shock → No mortality benefit vs crystalloids → BUT better hemodynamics in some patients 🟡 ARDS → Improves oxygenation (if hypoalbuminemic) → No survival benefit 🟡 Major surgery → ↓ fluids, ↓ complications → BUT watch renal risk (especially 20%) 🚫 Where you should think twice ❌ Traumatic brain injury → ↑ ICP → ↑ mortality ➡️ Albumin crosses disrupted BBB → worsens edema 💡 Key ICU insight Albumin is NOT about: ❌ “giving protein” ❌ “correcting labs” It’s about: ✔️ hemodynamics ✔️ endothelial integrity ✔️ patient selection 📉 Hypoalbuminemia matters Every ↓10 g/L: ▪️ ↑ mortality ▪️ ↑ complications ▪️ ↑ length of stay ➡️ But correction ≠ automatic benefit 🎯 Clinical decision rule Use albumin when: ✔️ Cirrhosis-related complications ✔️ Refractory shock after crystalloids ✔️ Severe hypoalbuminemia with instability Avoid when: ❌ Routine resuscitation ❌ TBI ❌ “just low albumin” 🧠 Take-home ➡️ The question is NOT “Does albumin work?” ➡️ The real question is “In which patient, at which moment?” 📚 Rubio-Baines I et al. (2026) Journal of Clinical Medicine DOI: 10.3390/jcm15051981

@ohsnapimginger @SCCM @SCCM_CPP @SCCM_EM Congrats, Kevin! Well deserved! 🎉

Honored to be inducted as a Fellow of the American College of Critical Care Medicine #FCCM at #SCCM2026. Grateful to be part of a field that continues to push what pharmacists can do in critical illness and emergency care. The work continues! @SCCM @SCCM_CPP @SCCM_EM #EMPharmD

@nickmmark @omarkandah @austincamp @doc_BLocke @PulmCrit even midodrine 😔

@omarkandah @austincamp @doc_BLocke @PulmCrit Yeah. It’s weird. For comparison, they aren’t recommending methylene blue even though the data for that is stronger.

Not a single PharmD author? 🧐 journals.lww.com/ccmjournal/ful…

@BradSpellberg @ABsteward @DrToddLee @jasonroberts_pk @PulmCrit Need to get cultures before antibiotics. But wait, you can give antibiotics prehospital, so cultures schmulters. Then give alot of fluids. And after large volume fluids, you can give more large volume fluids. Or small volume fluids. Because....guidelines.

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Sepsis is evolving! We’ve moved past the “one-size-fits-all” approach. Not every patient needs 30 cc/kg. Not every patient is fluid responsive. And even if they are fluid responsive, early pressors should still be considered instead of reflexively ordering more fluids.

@austincamp @DrToddLee @PulmCrit @BradSpellberg Hahhahaahahahhahahaaa

@DrToddLee @PulmCrit @BradSpellberg The Brad signal has been activated!

Surviving Sepsis 2026 is here & it's even more loony tunes than I was expecting. They're promoting pre-hospital ABX & preemptive broad-spectrum IV antibiotics for intubated patients. This insane fever dream is an antimicrobial stewardship nightmare. Embarrassment for SCCM.

يا بلادي عاد عيدك يا بلادي يا مغنّ المجد والتاريخ كلّه #عيّدي_معتزة #وزارة_الدفاع

Checking methodology and statistics when reading an observational study link.springer.com/article/10.100… via @audreydejongMD et al

ACE = “ace” AIDS = “aids” GERD = “gerd” PEEP = “peep” BUN = “omg did you just pronounce it ‘bun’ that’s crazy where did you go to school why are you here omg hey you’ll never guess what this guy just said…”

In an international, randomized trial involving patients with acute venous thromboembolism, the risk of clinically relevant bleeding was significantly lower with apixaban than with rivaroxaban during the 3-month treatment period. Full COBRRA trial results: nejm.org/doi/full/10.10…

رايتنا خضراء، ووطننا أمجاد. #يوم_العلم