(1/ )Summaries of the average high impact trial by field:
#EBM
#medtwitter
#epitwitter
#FOAMed
#Cardiology
:We enrolled the entire population of Europe in a trial to detect a composite endpoint occurring in 3% of patients. The relative risk reduction was 20%. The NNT is 12,000
People say things like, “are you anesthesia?” and it makes me laugh every time. Like imagine going up to a cardiology fellow like, “Hey, are you diuretics?”
Hyperkalemia is not a contraindication to Ringers
Hyperkalemia is not a contraindication to Ringers
Hyperkalemia is not a contraindication to Ringers
Hyperkalemia is not a contraindication to Ringers
Hyperkalemia is not a contraindication to Ringers
Intern checklist for taking call with a med student:
☑️They take the early admissions
☑️Make sure they eat dinner - you may need to remind them
☑️Make sure they are caffeinated
☑️Pay for their caffeination - you have a salary, they have tuition
☑️Make sure they get some sleep
I guess it's time to share some news:
At the end of next week, I'm leaving the department of anesthesia and transitioning to internal medicine residency at MGH.
It’s come up a lot lately, so I want to talk about large-bore IV (LBIV) access for a sec
A big IV can be the difference between life and death for a bleeding or severely volume-down patient
But what's "good enough"?
Here's some of why LBIVs matter
🧵
Me, signing out post-call in the MICU lately:
“I have no idea what’s going on with half of these people but everyone who needs to be is lined and tubed”
(5/)
#anesthesia
: We asked if gas is good or bad. We are still not sure. Future studies will determine which is cooler: ultrasound or simulation.
#InfectiousDisease
: We did a trial to see if you can shorten the course of abx. We found you can.
I don’t even know where to start with unpacking the layers of chutzpah in
@BrighamWomens
emailing me, an MGH resident, asking me to donate to to their hospital today, in honor of “national doctors day”.
(4/)
#Surgery
: These were my last 85 patients and what happened to them. I combined them with 3 of my friends' patients. Then we asked a statistician to propensity-score match, so this was basically a randomized trial.
#Nephrology
: We tried to do a trial but no one would fund it.
A little late to the party, but can finally share this meta-analysis in
@LancetRespirMed
on cytokines in 1,245 pts w/
#COVID19
vs. sepsis, ARDS, & CAR T CRS.
I could belabor the details, but the bottom-line is simple:
#COVID19
is not a
#CytokineStorm
.
(2/)
#CritCare
: We powered this trial assuming treatment would reduce mortality by 8000%. The primary outcome was not significant (p=0.06). However post hoc analysis of subgroup X was encouraging. A follow up trial but still inadequately powered trial is planned in this group.
(3/)
#Oncology
: We conducted a randomized trial of new drug X. The strengths of this study are BiOpLaUsiBiLitY. It was limited by a short-term surrogate primary outcome and lack of a control group. All authors have COI w/ drug manufacturer. The test article is now FDA approved.
Update: Nine years after realizing this is what I was meant to do with my life, I am finally going to be an ICU doctor.
I’m so excited to start this next part of my training at
@MGH_PCCM
@PCCSM_BIDMC
and immensely grateful to everyone who has helped me along the way to get here.
We are absolutely delighted to welcome this amazing class of new fellows to the MGH/BIDMC Pulmonary and Critical Care Medicine Fellowship in July 2024!
@MGH_PCCM
@PCCSM_BIDMC
Me in college:
“I like numbers because numbers don’t lie.”
Me, after 10 years of clinical and translational research:
“Listen, numbers are straight up the most dishonest, scheming, untrustworthy, duplicitous MFs out there.”
I was just chatting with a new admission on our floor, ICU downgrade in his 30s. The last time I saw him he was in the ICU with COVID ARDS, proned, paralyzed, on iNO and being considered for ECMO. So today is a pretty good day.
There is absolutely no reason to go through and through with an ultrasound guided radial art line and you shouldn’t do it. Thank you for coming to my TED talk.
@coachsadji
Bacterial pneumonia
Post-partum hemorrhage
Tuberculosis
Syphilis
Gallstones
Lyme Disease
Hepatitis C
Malaria
Tension pneumothorax
Hodgkins Lymphoma
Many leukemias
Many breast cancers
Endometrial cancer
Bacterial meningitis
Shall I keep going?
Suppose pt in shock from brisk venous bleed that began 3h ago. They've lost 3L & still bleeding
If IV flows are ideal:
🔴20g barely keeps up w/ losses & won’t fix deficit (or shock)
🔴18g keeps up but takes a long time to restore perfusion
🟢16g or 14g get the job done quickly
Most important thing I’ve learned from anesthesia residency so far: by touching your chin to your chest before you swallow, you can avoid immediately aspirating when eat/drink lying on your couch without having to sit up
Man, I hate “those” codes.
The ones that everyone sees coming a mile away, with the outcome all but certain, and yet there you are chugging away, feeling 90 year old ribs cracking under your compressions, and you walk away sure only that you definitely did not help anyone
I am still ICU bound. The practice and science of critical care medicine are still my life's calling. I am just taking a different road to my destination.
🔑Point 1:
Large bore pIV = 16g or 14g
Here's why -
Access must be sufficient to BOTH keep up w/ ongoing losses AND correct the existing deficit
Max flow rates (to gravity) for different IVs under *ideal conditions*:
20g: 60mL/min
18g: 100mL/min
16g: 210mL/min
14g: 345mL/min
(1/) I want to bounce around a disease model for
#COVID19
. This is hypothesis, some parts are hand-wavy, but I'd like to think a lot is also based on evidence. I'll try to clearly distinguish knowns from assumptions as we go...
#COVID2019
#SARSCoV2
#medtwitter
#FOAMcc
#FOAMed
It's bittersweet. I'm sad to leave the OR community that has been my home this year.
But I am excited to come back to
@mghmedres
and to see what the next chapter will bring.
In internal medicine we say, “the patient aspirated”,
and in anesthesiology we say “the patient had a vagal/sympathetic response”,
when we mean, “I have no idea why they looked so bad for a hot sec there”.
Guys! Did you know a stethoscope can be used for more than checking to see if you mainstemed the endotracheal tube!?
I can’t think of anything specific, (I think I used to know once?), but everyone else in clinic seems to use them all the time
If your takeaway from the INTUBE study was that propofol use is the single biggest predictor of peri-intubation cardiovascular instability, I might encourage you to read this letter by Jay Crowley and I
Don’t blame the drug - pay attention to the patient
I messaged our CA1 group chat about something extra stupid I did this morning and the chat immediately turned into a thread of all the dumb things everyone did today and basically I have the best co-residents
@MGHanesthesia
After a month of cardiac anesthesia and I’ve never been so simultaneously relieved and bummed to finish a rotation
It’s been exhausting, humbling, and challenging, but I’ve never learned so much in such a short time. And my barometer for “sick patient” has totally changed
This was, and still is, a really difficult decision but it's one I know is ultimately right for me. It's been made even harder by how unbelievably supportive everyone in the DACCPM, especially
@DanSaddawi
, has been.
In sum - for bleeding and/or hypovolemic shock:
🩸Yes, you need large bore access
🩸Large bore = 16g or 14g pIV (or a venous sheath)
🩸 20g and 18g don’t cut it
🩸Central lines, PICCs, or other long catheters don’t cut it either
🩸No claves or connectors!
You guys ever think about how blood vessels aren’t rigid pipes, and blood is a colloid with variable viscosity, but we still use hydrodynamics to model the circulatory system anyway?
🔑Point 3: Don’t attach a clave!
Claves work by obstructing flow (pic 1).
Look at what these devices do to flow rates (pic 2). A clave will turn your 16g or 14g back into an 18g, and turn an 18g into a 20g!
Instead, connect IV directly to tubing.
Ref:
Intern year is great.
Like, I’m already exhausted, and I don’t know what day it is, and I feel like an idiot most of the time...but I’ve also had at least 12 other jobs and held one near continuously since I was 14. I‘ve never enjoyed coming to work so much, not even close.
This year has given me immense respect for anesthesiology as a field. I will be forever grateful for what I have learned and the skills I have gained. But I am most grateful for the incredible faculty and co-residents I've been able to work alongside and learn from.
🔑 point 2: Central lines, PICCs, etc. don’t work for volume resuscitation
The distal (brown) port of a standard 16cm TLC is the largest, it’s 16g. But it is 11cm longer than a 16g pIV.
As a result, it only runs 52mL/min. That’s even slower than a 20g pIV
Today’s teaching point:
If you accidentally cannulate a peripheral or femoral artery instead of a vein during a hypotension response, don’t panic, don’t pull the line, hook up pressure tubing and now you have an a-line
@coachsadji
Myopia and hyperopia
Cataracts
Bowel obstruction
Peptic Ulcer Disease
A wide array of traumatic injuries
Osteoarthritis of the hip and knee
Heat stroke & hypothermia
Leprosy
Ascariasis
Strongyloidiasis
Gonnorhea & chlymydia
Chorioamnionitis
My dude, I can do this all day long
🔑 Points:
🩸Large bore = 16g or 14g pIV (or a venous sheath).
🩸20g and 18g don’t cut it.
🩸Central lines, PICCs, other long catheters don’t cut it either.
🩸No claves or connectors!
Woke up s/p call to see this blew up. I have nothing to promote other than:
1) Statsitical reasoning is clinical reasoning
2) Be nice to your students and trainees: learning doesn’t always require hazing.
@Poietic_Justice
@rubin_allergy
Sometimes in the “instructions for pharmacy” box on the order - I literally just write “I don’t have any idea how to dose this, please help”
@JamiePrivratsky
Lol rounding 3x in a single stretch of daylight hours sounds like it’d be a great way to comprehensively discuss all the work you don’t have time to get done
Why is this the case?
Hagen-Poiseuille's Law says that increasing the radius of the catheter increases fluid flow by a *power* of 4!
The law also says that an increase in either catheter length or fluid viscosity will reduce flows 8-fold.
Brings us to point 2…
Someone told me this week to remember that when wrestling with a decision, “delaying a decision to the point of not making one is itself a decision” and I feel like that is very true of both clinical medicine and life in general
Our work exploring the dynamics of alveolar, epithelial, & organ injury markers in severe
#COVID19
just published online in
@ATSBlueEditor
(sad that this is even still relevant )
There's a lot to unpack so I'll try to hit some highlights 🧵
Off-service rotations are great not just because of what you learn but also because you get to see how hard another specialty’s job is.
Continually have so much respect for emergency medicine clinicians.
2 week vacation with no travel plans,
Day 1:
“I am going to apply to fellowship, resubmit 2 papers, learn a new programming language, discover the mechanism of anesthetics, and solve the Reimann Hypothesis.”
Day 7:
“Look, at least I finally made it to the gym today.”
I would work 80h/week and give up research for the rest of my career if you if you told me that was the only way I could be an intensivist. (Luckily it isn't, but still). Like I'm bummed about starting a vacation block b/c I can't stay on in the unit. This feels pathologic.
Dear Administrators,
I don’t know of a nice way to say this, so I’ll just say it. If your email is longer than 500 words, there is a near zero percent chance I am going to read it.
Looks like we will be changing up the house wine
Pragmatic RCT finds Zosyn ⬇️ delirium/coma vs Cefepime without ⬆️ adverse renal events (or mortality) = enough to change my practice
But I do wonder if generalizes to (eg, onc) pts w/ baseline cytopenias
My signout this morning was election-themed in that:
-it was incomplete
-key results are pending
-no one really knows what’s going on
-there is no plan
-overnight events bode poorly
-its clear we could and should’ve done a better job
Anesthesia notes will be like:
Number of intubation attempts - 16
Assists Used - Laryngeal manipulation, bougie, cricothyrotomy.
Was the Patient a Difficult Airway - No
An anesthesiologist told me as a med student that a CA1 is the most dangerous intern in the hospital because of how oblivious they can be when they’re close to the edge and I am starting to understand that and frankly agree.
This was a fun one
Post-hoc look at ATHOS-3 trial patients who had ARDS at enrollment
Contrary to what I’d guessed we would find, Ang-II group had significantly improved oxygenation by Hour-48 vs placebo
#anesthesiology
textbooks really be like:
Chapter 1 - Here is some fluffy narrative about the history of
#anesthesia
Chapter 2 - Here is the Newtonian basis for medical gas delivery systems
Last, a fair counterpoint:
“An 18g in the 💪 is >> than a 14g in the ☣️🗑”
AGREE!
If inexperienced w/ LB or tough stick,reasonable to 1st get small IV, then LBIV. Can have 2 ppl work on opposite arms to parallel process
But in true hemorrhage/hypovolemic shock, <16g = too slow
To Indian doctors:
Consider administering CYPROHEPTADINE (PERIACTIN) 8mg TID to patients with severe COVID illness (hypoxemic and tachypneic)
There is good physiologic rationale to support the use of this inexpensive medication 👇
@isccmsociety
(1/ ) Let's do a thread on this. Great question that lets us speak a lot of what is and is not known about
#sepsis
.
Let's start with some of the assumptions in the way this is asked, since some of them may not hold up.
#medtwitter
#FOAMed