Manpreet

J & J JITESH & JOSH Joy & Jubilation ✨ #RCBvRR #IPL2025 #RoyalChallengersBengaluru @RCBTweets

💧 DKA resuscitation: Normal Saline vs Ringer’s Lactate, does it really matter? For decades, 0.9% NaCl has been the default fluid in diabetic ketoacidosis. But… is it still the best choice? 🧪 New randomized ICU data (2025-2026) 👉 88 patients with severe DKA 👉 Ringer’s Lactate (RL) vs Normal Saline (NS) 👉 Same insulin protocol 📊 Primary outcome: DKA resolution at 48h ➡️ No difference • RL: 56.5% • NS: 50% (p = 0.66) ⚖️ So… clinically equivalent? Not exactly. The physiology tells a different story 👇 🧠 What RL does better Compared to NS: ✔️ Higher bicarbonate early ✔️ Better potassium levels ✔️ Lower chloride at 48h ➡️ Translation: • Less hyperchloremic metabolic acidosis • Lower risk of hypokalemia • More physiologic acid-base recovery ⚠️ What NS still does ❗ Same DKA resolution speed ❗ Same ICU stay ❗ Same mortality ➡️ So endpoints look “equal”… …but physiology is not. 🚨 Why this matters in real ICU practice Hyperchloremia is not benign: • Worsens metabolic acidosis • Increases respiratory workload • Promotes renal vasoconstriction • Delays recovery And hypokalemia? • Arrhythmias • Insulin resistance • Delayed metabolic correction 🧬 Clinical interpretation This is not about: ❌ “Which fluid resolves DKA faster?” This is about: ➡️ Which fluid creates a better internal environment for recovery 🔥 Take-home message 👉 NS is acceptable 👉 RL is physiologically smarter ➡️ Especially in: • Severe acidosis • High chloride states • Patients at risk of hypokalemia 📚 Trifi A. et al. (2025) Medicina Intensiva doi.org/10.1016/j.medi…

SCREENING FOR LATENT TB BEFORE BIOLOGIC THERAPY

🫁 New classification of DPLDs

Insulin tolerance test is the gold standard for adrenal insufficiency.

⚠️ Vasopressor weaning in septic shock: the blind spot in current guidelines We talk a lot about starting vasopressors. We rarely talk about how to stop them safely. And that may be a problem. 📌 The gap The 2026 Surviving Sepsis Campaign provides: ✔️ Clear guidance on initiation ✔️ Clear escalation strategies ❌ But no guidance on de-escalation 👉 Yet this is one of the most frequent bedside challenges 🧠 Key clinical dilemma Which should be stopped first? • Norepinephrine? • Vasopressin? The answer is… unclear. 📊 Conflicting evidence 👉 Observational studies: • Higher hypotension when vasopressin is stopped first 👉 Randomized trials (DOVSS, RENOVA): • Higher hypotension when norepinephrine is stopped first ➡️ Completely opposite conclusions 💡 Why this contradiction exists It’s not just what you stop. It’s how you stop it. 👉 Abrupt discontinuation vs titrated reduction ✔️ Most RCTs used protocolized titration ❌ Observational studies often used abrupt withdrawal ➡️ Method matters as much as sequence 🧬 Physiology you should not ignore • Endogenous vasopressin rises early • Then drops within ~48h ➡️ Leading to relative vasopressin deficiency 👉 Removing vasopressin at this point may trigger hypotension 🧪 Potential future tool 👉 Copeptin (vasopressin surrogate) • May predict hypotension after withdrawal • Not yet ready for routine decision-making 🚨 Clinical reality There is: ❌ No standardized weaning protocol ❌ No strong guideline recommendation ❌ Limited RCT evidence But: 👉 This is a daily ICU decision 🔥 Take-home message Vasopressor weaning is not a passive step. It is an active hemodynamic intervention. And currently: 👉 We are navigating it with incomplete evidence 📚 Mallmann C. et al. (2026) Intensive Care Medicine doi.org/10.1007/s00134…

Management algorithm of encephalitis Link: pn.bmj.com/content/practn…

What do these 4 cases have in common? 🫁 #Radiology #chestrad #radres #FOAMrad #MedTwitter

Why does Fluconazole increase levels of Warfarin.? 💊🤔

🧠 Uremic Coagulopathy — High-Yield Pearls (Heme Perspective) 🩸 Pathophysiology → platelet dysfunction (NOT factor deficiency) 🧩 Mechanism → impaired platelet adhesion + aggregation 🔬 Key toxins → guanidinosuccinic acid, phenols, PTH ⚠️ vWF interaction ↓ → defective GP Ib–vWF binding 🧪 Platelet count → usually NORMAL 📉 PT/PTT → usually NORMAL 📉 Bleeding time / PFA-100 → PROLONGED 🩺 Clinical picture 🩸 Mucocutaneous bleeding (epistaxis, gingival) 🩸 Easy bruising, petechiae 🩸 GI bleeding common 🩸 Post-procedure bleeding risk ↑ 🚨 Triggers worsening bleeding ❌ Uremia (BUN >60–80 mg/dL) ❌ Anemia (↓ Hct → worsens platelet function) ❌ Concomitant antiplatelets/NSAIDs ❌ Dialysis delay 🧪 Diagnosis (clinical) ✔️ CKD/ESRD context ✔️ Normal coagulation profile ✔️ Platelet dysfunction pattern ✔️ Exclusion of DIC / liver disease 💊 Management (stepwise — guideline-based) 🟢 1. Dialysis = DEFINITIVE ✔️ Rapid improvement within 24–48h ✔️ First-line in active bleeding 🟡 2. DDAVP (Desmopressin) 💉 0.3 mcg/kg IV over 20–30 min ⚡ Onset: 1–2 h ⏳ Duration: 6–8 h ⚠️ Tachyphylaxis after 1–2 doses 🟡 3. Correct anemia 🎯 Target Hb ≥10 g/dL ➡️ RBC transfusion improves platelet interaction 🟡 4. Cryoprecipitate ✔️ If bleeding persists ✔️ Works via ↑ vWF & fibrinogen ⏳ Effect within hours 🟡 5. Conjugated estrogens 💉 0.6 mg/kg IV daily × 5 days ⏳ Delayed onset (6–24 h) 🕐 Longer effect (1–2 weeks) 🔴 Avoid ❌ Platelet transfusion (limited role unless thrombocytopenia) ❌ NSAIDs / aspirin 🧠 Practical procedural prep ✔️ Dialyze pre-procedure ✔️ Give DDAVP 30–60 min before ✔️ Ensure Hb optimized ✔️ Consider cryo if high-risk 📊 Evidence pearls 📌 DDAVP → transient but effective (standard of care for urgent bleeding) 📌 Dialysis → cornerstone (KDIGO CKD guidelines) 📌 Estrogens → useful in recurrent bleeding when dialysis insufficient 🎯 MCQ Patient ESRD + epistaxis + normal PT/PTT → best immediate therapy? A) FFP B) Platelets C) DDAVP ✅ D) Vitamin K 👉 Answer: C (DDAVP) — fastest hemostatic correction 🧪 OSCE scenario 📍 ESRD patient needs central line ➡️ Plan: Dialysis → DDAVP pre-procedure → optimize Hb → avoid NSAIDs #Hematology #Nephrology #Coagulopathy #CKD #KFSHRC

Vagus nerve innervates inferior aspect of the heart, and hence nausea and vomiting can occur in inferior STEMI.

🧵 When you see a "carpet of cysts" on HRCT don't just call it UIP and move on... That macrocystic honeycombing pattern might be telling you something bigger. 👇

Si te interesan los JAKinibs 💊 aquí tienes la súper revisión ✍️ Acceso abierto 🔑 nature.com/articles/s4157…

Her expressions, her voice, her aura 🔥 Pooja Sharma made Draupadi unforgettable 💥

Pooja B sharma as Draupadi is Devine 🪷💯 No one can beat it One of the best performances in ITV Namit Malhotra sir should have considered her for the role of Urmila.. dearest sister of maa Sita #Ramayan @malhotra_namit

the whole monologue part

pooja sharma as draupadi

Why is Captopril causing first-dose hypotension.? 🤔

Why is Levofloxacin associated with tendon rupture? 🤔

Rheumatologic Serologies

🚨🚨🚨ليش مهم تجنب اعطاء Triptans لـ المرضى اللي عندهم مشاكل في القلب؟