Rory Spiegel

Can the YEARS Criteria safely rule out PE in cancer patients? The new Hydra trial (JAMA) says yes... but the details tells a more nuanced story about how well YEARS actually risk-stratifies these patients. New post on EM Nerd emcrit.org/emnerd/the-cas…

Can the YEARS Criteria safely rule out PE in cancer patients? The new Hydra trial (JAMA) says yes... but the data underneath tells a more nuanced story about how well YEARS actually risk-stratifies these patients Full Thread on Roon roon.com/doctors/posts/…

Is normal saline harmful in the critically ill? 34,685 patients, one meta-analysis, and four different answers depending on how you ask the question. A thread on BEST-Living and what "probability of benefit" actually means. roon.com/doctors/posts/…

Full thread at roon.com/doctors/posts/…

doi.org/10.1111/anae.7… A 2026 meta-analysis shows PCT-guided antibiotic decreases antibiotics by 2 days in sepsis. But standard care moving towards shorter courses of antibiotics. Is PCT still adding value, or just beating a comparator that's already becoming obsolete?

@PulmCrit The mere fact so many sites in this trial opted out of the no-drug arm because they believed in its benefits so strongly, even with zero prior studies examining its use in this population and its seemingly meager benefits at best in the general influenza population, is troubling

@PulmCrit That being said, the default stance that oseltamivir should be used in the critically ill is concerning.

Fresh Blog: Is oseltamivir assassinating ICU patients? The REMAP-CAP trial has concluded with >98% certainty that oseltamivir is killing patients. This is an extraordinary claim that requires extraordinary evidence. #1/2... (link to blog in 2nd post)

“This post will be mauled by Bayesian statisticians. That's OK, go ahead. I am tired of being gaslit by statisticians saying that Bayesian calculus can somehow convert a p-value of 0.4 into 97% certainty.” Brilliant line!

@AnilMakam Or just random chance. Which given the CIs is a fairly high probability

Good thread And that 4% might very well be worth it for an inexpensive, relatively safe intervention What is unanserable is how much of 4% abs diff is driven by clinician reflexive behavior to make bicarb go up vs clinical need Even if former, bicarb gtt to keep nephrosurrogologists away is a good thing

No. Check for tolerance first. Responsiveness does not equal need, nor benefit. Maximizing output was shown decades ago to not be a viable strategy. Optimize tissue perfusion. Learners, please reconsider a forward-flow-centric approach. Focus on tissue perfusion, and the two do NOT have a linear relationship. Understand hemodynamic interfaces. Ping @icmteaching @khaycock2 @EMNerd_ @edu_kattan @ross_prager

@EM_phile @ThinkingCC

@ThinkingCC @EMNerd_ This will change your life. seriouseats.com/the-best-roast…

SODa-BIC just dropped in NEJM. The large, rigorous RCT examining the use of sodium bicarbonate ICU patients with shock and acidosis. nejm.org/doi/full/10.10…

@DanielJafari Sure but that only holds if you choose to initiate CRRT for a pH< 7.2. If we admit there is no evidence to justify dialysis for a pH alone than it’s not really a relevant endpoint.

@EMNerd_ Sorry but I don't understand the argument. If you don't give bicarb, then you will have to go on circuit. I don't think this present study contradicts that, because the threshold for enrollment was higher. Notice the higher rates of RRT in placebo arm of BICAR ICU2 vs rest.

@DanielJafari If you look at table E5 most of the excess RRT was due to a pH< 7.2.

@EMNerd_ Can't remember the exact triggers for RRT, but I believe it was the same as BICAR ICU 1. I don't think having a third lower odds of going on circuit is not meaningful. But I do agree that the circuit is another mode of bicarb delivery.

@DanielJafari Yes but even than they failed to really demonstrate a meaningful difference

@EMNerd_ It's worth mentioning the different pH thresholds between the two trials. BICAR ICU2 took patients with more severe metabolic acidosis and renal failure.

@AndyDeitch That’s only if you decide to put them on pump due to acidosis. But if acidosis (at least at these levels) doesn’t effect the other outcomes we care about then why bother

@EMNerd_ I’d argue reducing rates of CRRT is a meaningful outcome. One less procedure for the patient. Keeps your nursing ratio at 1:2, less expensive. Eyes wide open - not saving lives or kidneys here.

@EMNerd_ Ok. Tell me more about the potatoes. This seems to be the most useful

@icmteaching Fair point, I'll add this to the Roasties recipe ;)

Very occasionally I’ve given it when there was a hyponatraemic acidosis (narrowed NaCl gap) in a non intubated spontaneously breathing patient when I wanted to reduce their work of breathing to potentially avoid them needing respiratory support but this is a very rare scenario. Your indications are spot on ie mostly non medical 😆

@nickmmark Adding 2 tablespoons of baking soda to water when parboiling the potatoes prior to roasting leads to greater breakdown of the surface of the potato, leading to more surfaces area to crisp up during the roasting process

@EMNerd_ I’m a big believer in bicarb. Tell me more about the potatoes recipe