Pulm/crit attending at U. Vermont 🐄 Zentensivist 🧘♂️ trying to post more about medicine in order to distract myself from doomscrolling 🤦♂️ author of free online critical care textbook emcrit.org/ibcc/toc/ 📖 no conflicts of interest 💰
josh farkas 💊
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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... #EMIMCC
we’ve integrated the PREOXI trial into our practice so well that there’s an entire cabinet in our ICU dedicated to it 😁
this improves intubation success & safety. I’vd wanted to do this for a decade but the RCT provided EBM backing to push it forward
more here emcrit.org/pulmcrit/bsi/
Is oseltamivir killing ICU patients?
The p-value for these results is NOT significant by traditional Frequentist benchmarks (p>0.05).
But Bayesian statistics yield strongly positive results!
Where does the truth lie? See what you think.
Fresh blog: emcrit.org/pulmcrit/rem...
my key advice on bupropion XR intoxication:
if you intubate a patient for seizures, place a gastric tube & start whole bowel irrigation immediately
don't debate, just do it
irrigation reduces ongoing drug absorption, minimizing deterioration
more emcrit.org/ibcc/bupropi...
Stop using IGRA to test for active pulmonary TB!
this keeps coming up, so I summarized my take-home messages on this (with a link to the BlueSky discussion)
in hospitals that lack deep experience with TB, I think the best heuristic is simply not to use an IGRA to look for active pulmonary TB
Proposal: for complex patients (eg ICU) we should *always* get CBC w/ differential (not a plain CBC)
- Same amount of blood
- Run by the same machine (it usually CHECKS the differential & just dumps the data!)
- Trivial cost difference
- Can be helpful (eg Eos 2/2 drug, NLR)
#EMIMCC
I'll start- the neutrophil/lymphocyte ratio (NLR) substantially outperforms the WBC for detection of infection
Using WBC as an indicator of infection made sense 50 years ago
It's 2026, we have better lab instruments, & its time to move on from the WBC
more on NLR here: emcrit.org/pulmcrit/nlr/
what is your best pearl, or most useful reference, about interpreting a complete blood count with differential?
The blood count is one of the most commonly ordered tests in clinical medicine, but its subtleties are woefully overlooked. #EMIMCC
Nicardipine: great for htn emergency but, can see transient hypotension even w/ slow titration
-Key is to load + drip
-Start 5 mg/hr + titrate up 2.5 mg/hr q5 min
-When reach target BP, drop dose back to 5 mg/hr +
retitrate infusion until get to steady state
youtube.com/shorts/2F0-1...
#EMIMCC
josh farkas 💊
josh farkas 💊
josh farkas 💊
josh farkas 💊
josh farkas 💊
josh farkas 💊
josh farkas 💊
everyone learns about TCA overdose in med school, but not bupropion XR overdose
time to level up
bupropion XR overdose is increasingly common & VERY dangerous
ongoing drug absorption creates a "toxin bomb" wherein patients look OK initially, but deteriorate later on... (#1/2) #EMIMCC
josh farkas 💊
Anand Swaminathan
josh farkas 💊
introduction The neutrophil/lymphocyte ratio (NLR) has been gaining increasing attention across many fields of medicine within the past five years.
TB gurus: is there a role for using interferon gamma release assays to diagnose active TB?
guidelines & textbooks *don’t* generally recommend this (eg https://www.tandfonline.com/doi/full/10.1080/24745332.2022.2035638#appendixes)
but in practice I see this done a *lot* 🧐
#IDsky #pulmsky
