@IM_Crit_

I’ve always thought emergency medicine is the most difficult specialty. Not just to train for, but to practice. No appointment, no history, no time, and every gap in the healthcare system eventually walks through your door at 2:00 am. www.linkedin.com/feed/update/...

Dr Graham Walker just announced he’s leaving the bedside after 20 years. His essay, “Always Open. Already Full,” explains why. The ER is the only part of healthcare that can’t say no, so it absorbs everything upstream, and the people working there absorb the rest.

#ICU Evidence #001-002: Two septic shock trials. Two different drugs. One missing piece #Dobutamine improved kidney outcomes Earlier #vasopressin changed practice, but not mortality But who actually needed the drug? Maybe the next trial should start somewhere else:

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

One final thought: I wish we had more participation from Chinese clinicians/researchers on social media. China produces important clinical research; discussions like this would be better if the investigators themselves could join us. We are missing valuable perspectives. #emimcc #FOAMed #FOAMcc

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

My take: Interesting physiology, a striking AKI signal, and potentially reassuring short-term arrhythmia data. But this does not yet convince me to routinely add dobutamine without knowing the hemodynamic phenotype I'm treating.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

Perhaps not. Conversely, preventing kidney injury during a particularly vulnerable period could still have meaningful clinical consequences.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

A personal note: I don't think it is realistic to expect every critical care trial to demonstrate a mortality benefit. Mortality has too many determinants, and adequately powering every ICU trial for mortality would often be impractical.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

Perhaps we sometimes overestimate dobutamine's arrhythmogenic contribution in septic shock? Or perhaps the underlying illness, concurrent norepinephrine exposure, & lower NE requirements with dobutamine matter more than we appreciate.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

My point is not that vasopressin would necessarily have been better. It is that improving a renal endpoint with a vasoactive drug does not necessarily tell us which hemodynamic abnormality we corrected or whether that abnormality was present in the first place.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

And here is a thought experiment: what if, instead of routinely adding dobutamine, we added a fixed dose of vasopressin? Could we also produce a favorable renal signal through an entirely different hemodynamic mechanism? Possibly.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

So dobutamine clearly did something physiologically. But here is my problem: only 82/584 pts (14%) underwent advanced hemodynamic monitoring. Among those w paired measurements, cardiac index changed +0.5 vs −0.2 L/min/m² from baseline to the end of surgery (between-group difference +0.72 L/min/m²).

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

A substantial part of the AKI separation came from urine-output-defined AKI. That doesn't invalidate the finding, but it is particularly interesting when the intervention is a hemodynamically active drug that may influence renal perfusion and urine output.

#ICU Evidence #001: Dobutamine during (mostly) abdominal surgery for septic shock: who actually needs it? A new multicenter RCT from China randomized 584 pts w septic shock undergoing surgical source control, mosttly abdominal, to intraoperative dobutamine + norepinephrine (NE) vs NE alone

ICU Hot Takes: About once a month, I get that call from the ED. The patient has an Hb of 4 g/dL, and the hospitalist, the ED attending, or both aren't "comfortable" admitting them outside the ICU. I get the concern. A hemoglobin of 4 gets everyone's attention.

But can we agree on something? We admit patients to the ICU based on their physiology, not a lab value in isolation. In fact, when I'm told that a patient w a very low Hb is hemodynamically stable, my first thought is that the anemia probably developed gradually, even if blood loss is the cause.

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

9️⃣ CPR can displace the Impella Chest compressions, coughing, movement, and patient repositioning can displace the catheter. Every single time we get ROSC or complete a code, we have to re-confirm depth and orientation with echocardiography or fluoroscopy before trusting our numbers.

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

7️⃣ Still in shock despite Impella? Step back and ask: ① Is the pump actually delivering effective cardiac output? ② Is there unaddressed vasoplegia or sepsis riding along? ③ Are we over-pumping a dry LV? Cranking up the P-level isn't a fix for vasoplegia.

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

5️⃣ Read the suction pattern Diastolic suction can be a clue to inadequate LV filling but it Is also associated with RV dysfunction. Continuous suction will have to make us think: Loading → Position → Anatomy → Device The waveform gives us clues, but we have to interpret the context

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

Same alarm. Completely different physiology.

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

A spinning impeller parked in the wrong spot won't work well, no matter how much volume we give.

#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire

Here is a step-by-step approach to troubleshooting Impella at the bedside: 1️⃣ Suction is a clue, not a diagnosis Before starting iv fluids, we have to ⬇️ the P-level while we figure out what happened. Then we should build the differential:

News: Yesterday, Tennessee tried to execute #ChristaPike. She survived. Until recently, Tennessee used three drugs for lethal injection: midazolam for sedation, vecuronium for paralysis, and potassium chloride to stop the heart. In 2024, Tennessee switched to pentobarbital alone.

What we do know is that the protocol didn't work. The governor has now stopped Tennessee's remaining execution scheduled for this year and ordered a review.

News: Yesterday, Tennessee tried to execute #ChristaPike. She survived. Until recently, Tennessee used three drugs for lethal injection: midazolam for sedation, vecuronium for paralysis, and potassium chloride to stop the heart. In 2024, Tennessee switched to pentobarbital alone.

The new protocol has a backup plan: if the first set of pentobarbital doesn't work, give a second. Pike received both. More than an hour after the execution started, witnesses could reportedly still hear her breathing and snoring. She was eventually taken to a hospital.