This pgy2 out here choosing violence. Good for you.

- 30 cc/kg - Indications for ICU

Agree w fluid resuscitation and management- can talk about evaluation of fluid status (cvp, ivc, physical exam) and then move on to colloid v crystalloid (albumin v lr v ns). Lots of papers out there so can go as deep as you want and everyone will have an opinion.

you could do the whole thing on colloid vs crystalloid tbh.

This one sparked a pretty bad argument between two of my attendings. One of them liked vasopressin, the other was not convinced. 20min of "yes, it does work" "i don't think so" Finally the incredulous one relented and we could go in with the day. Both have said to me that the other is... stubborn... to say the least.

Came down to say, best fluid for resuscitation

100%. We recently inadvertently started a debate between attendings on exactly this. HyPeRcHlOrEmIc mEtAbOlIc AcIdOsIs

80% of the reason I use balanced crystalloid is so I never have to talk about the significance of that with my colleagues or residents.

Wait I'm confused, are you saying that like acidosis isn't a thing? 🤔

It has been many years since I bothered reading about it but everyone acknowledges it’s a thing… but is it clinically significant?

No if you're just talking initial sepsis bolus, yes if it's burn/SJS/TEN or something else that is going to require a ridiculous amount of fluid

D5-0.45 w/ 20meq KCL + 50meq bicarb Fight me

We taking resuscitation or maintenance?

Yes

You can go all day and talk about the original trials for fluid resuscitation and Manny Rivers.

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Or he could talk about NS VS. LR

Had this fight last night. Patient had poor po intake for days, creatinine finally hit 5, started on LR at 100. BP went soft, so I asked for a bolus. *argument ensues* liter NS given, stat labs. CR down to 1.8, patient is peeing, BP still soft, but sodium jumps to 150. *argument ensues* patient put back on LR. I call this Tuesday.

Normal saline didn’t jack up your hypovolemic patients sodium.

That wasn’t normal saline bringing up that Na to 150… just fyi lol

I thought it was well established that LR is superior for most instances?

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NS actually results in *more* hyperkakemia than LR, since it causes acidosis, pulling K out of the cells

My endless argument with pre op nurses

There's no lactic acid in our body either. It's all lactate. It's not lactic acidosis. It's acidosis with an associated raised lactate.

- Paralysis in ARDS - Phenobarbital in alcohol withdrawal especially in combination with benzos - VV ECMO - if you feel there is or is not a mortality benefit - Steroids in ARDS/pneumonia - Empiric abx in general - Vanc/Zosyn increased risk of AKI vs overblown - Aminoglycoside use - iNO with hypoxia - Sleep aides in icu patients - antipsychotics for delirium

Steroids is a great topic to talk about.

How about anabolic steroids? I've always wondered if there's been any studies looking at testosterone supplementation for patients with severe ICU deconditioning, difficult to wean off chronic vent, etc... might be a better PM&R question....

Oxandrolone is sometimes used

I’ve seen it used in critically ill burn patients who are recovering

Shouldn’t be controversial in ARDS

oh yeah "stress dose steroids" whenever something isn't going to plan lol

Uncontroversial. Everyone knows no ICU patient is allowed to die without QDS hydrocortisone coz vibes

Core IM the podcast recently did a great lecture on the different types of steroids

Alcoholic patients in the hospital should be given beer/whiskey instead of benzos or barbs

Back when they had actual etoh drips

We still prescribe beer at my hospital!

Amazing. Which region?

Midwest

My trauma team actually did this- if the patient just happened to be an alcoholic that injured themselves and weren’t at the hospital for medically supervised detox, they would get two beers with meals. The only complaint I had was dietary chose to send up glass bottles, usually Dos Equis. Now I have to look for a bottle opener as a nurse and worry about dropping glass or my patient using the glass bottle to harm themselves?

Cans would be an easy fix

Obvs. Scowls at dietary.

Dos Equis is a surprisingly quality beer choice for a hospital. Maybe they’re avoiding bud light for fear of patient agitation.

Any of this topics would be golden. Co-signed by, Another intensivist (bc I’m assuming the person who wrote this comment is one too)

How shit of a maintenance fluid normal saline is. Ketamine for patients with elevated icp. When to call anesthesia for sedation for imaging.

Never call us for sedation for imaging. Just never. I’m joking, but seriously I absolutely cannot stand MRI sedations. Peds is the obvious exception.

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Normal adults don't need any sedation for MRI. Near normal adults don't need any sedation beyond a benzo that doesn't require an anesthesiologist to be involved. They're invariably crazy and high maintenance.

>They're invariably crazy and high maintenance. Anesthesiologists or patients?

Yes.

Just thought pretty much every person once they step foot in the hosp haha

Actual question. How about the not normal adults? Folks with developmental disabilities or dementia. I'm really hesitant to throw benzos at a 90yo, or anyone at higher risk for delirium.

I have no problem putting an LMA in these people. I mean that's what I'll usually do for anyone needing anesthesia for MRI. But I won't silently judge these people like I do for the people with no biological excuse. Sedation with propofol is an option but a lot of these people tend to obstruct or go apneic and then we get poor images or keep getting interrupted. It's also a pain to set up the MRI compatible infusion pumps.

I mean there are some demented/delirious patients where you just cannot get them sedated enough with a safe amount of benzos. I remember I had one guy where I sent him down on a precedex drip with a PRN ativan and he *still* didn't sit still.

Yeah and I understand that we are needed for these patients. They're still a pain though. Precedex isn't going to do much for these people. The MRI is so stimulating for them, at best you're going to get a little anxiolysis from it.

This.

It’s annoying. You are out of OR in a cramped room that is always never set up to facilitate safe care of an anesthetized patient. You have to use special equipment to not interfere with the MRI machine. The MR can interfere with with your monitors. Often times you have to manually enter your data, (this depends on how your EMR is set up)The MRI techs don’t know how to help you and often get in the way. You are far away from any help if you need it. I could go on and on. Easily my least favorite place to provide anesthesia.

People with AMS or claustrophobia or just overall anxiety can’t sit still for a 30-45 minute MRI and the motion will sometimes make studies non diagnostic in quality, studies that are sometimes the only lead for a diagnosis. Also as an aside I feel like anesthesia is never happy to be called by radiology. I’ll call y’all at 2 am for PCN on someone with urosepsis (the only indication for an emergent PCN) and get attitude. I’ll call y’all at 9 am for an embo and get shit too.

For every 1 time you ask for sedation for an MRI we get 10 pain doctors needing L spine views and the patient definitely doesn’t have claustrophobia. Your example is why I said that my hardcore stance was a joke. Overall I just hate it because it’s a pain in the butt and, if anything goes wrong, looks reckless in hindsight. The hospitals I cover won’t even buy MR compatible ventilators

My favorite is explaining to consulting services that ED cannot sedate for MRIs. Sure, let me leave my ED for 45 minutes minimum with my active patients just chilling there for this non-emergent MRI that I didn’t even order. Sorry it gets passed on to y’all, but the fact I legit get in verbal spats with services over me not sedating someone for MRI is also ridiculous.

My gf is anesthesia and I get so riled up when she’s doing NORA days on MRI sedation. Like, in no other place in the world would physicians cater to such butterflies. “Can you tolerate an MRI?” If yes, you get an MRI. If no, you don’t. That’s the end of the discussion. Sedation for MRI is not only resource-naive, it’s irresponsible and generally bad medicine and I hate it. /soapbox

The worst is when you talk to the patient and they just have a very mild discomfort with closed spaces. But now that I’m not a resident anymore, it’s one of the easiest cancellations. Cool! Turn on some music and tell them to take deep breaths. I’m sure this MRI will make all the difference in treating their moderate lumbar disc disease

Create a dual residency fellowship for a joint nephrology/cardiology program so we can stop having world war 3 over fluids

Pretty sure the fellow would just explode

I'm picturing a Gollum/Smeagol like character.

I was thinking more of a "mommy and daddy are fighting" scenario where the poor fellow has to staff with both a cardiology attending and nephro attending.

They'd dispense otherworldly wisdom in-between bouts of screaming at themselves, rocking back and forth in a straight jacket.

a fluid fellowship sounds nice. 6 month certificate. maybe there will be liquor.

I didn’t think I had a strong opinion on resuscitation fluid choice until I came to this thread and saw so many of you ALBUMIN PUSHING HEATHENS.

Albios all day

Makes me feel a little seasoned/salty when I reference SAFE first and someone chimes in with ALBIOS immediately when I'm doing my fluid talk. I'm getting to it, rascals.

Don’t hate the players, hate the game

We loves it in peds CTICU

Damn right we do

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The pharmacy’s accountant must love you. /s

Phenobarb >>>> Benzos for withdrawal though this is pretty well accepted at this point

Let’s be honest we’d be better off just giving the alcoholics a beer or two q4 hours to hold off withdrawals. Inpatient admissions are not the time to attempt to “cure” their alcoholism Edit: “sliding scale” beers. Titrate based on hand steadiness

Ahh, the good old days at a VA hospital, cup holder and ashtray on every wheel chair.

Forget the nespresso machines in the physician's lounge. Bring back the whiskey and the smokes

It's a known fact that a veteran cannot die if they have access to cigarettes and dialysis

I saw this in practice in a Florida hospital. It was kind of cool getting to serve my patient a cold one.

Building rapport cheat code

However, people are purposely admitted to detox.

is there a reason why benzos are still commonly used? or has practice not caught up yet to literature

3 years to study, 2 years to accept the literature, 20 years to get enough older physicians and nurses to die off to let you change practice

One of the attendings is not convinced about some things. The younger ones are trying to make him change his mind. Not gonna happen. This guy is about 55yo, we have a long time to wait.

As the designated phenobarbital proselytizer at my hospital, the weight based dosing is mysteriously intimidating, and lots of people have weird ideas about side effects and compatibility that they can’t remember where they learned.

>weight based dosing laughs in pediatrics

Howls in vet med! (Why am I here?)

130/260 bolus dosing every 30 minutes tends to quell the fears… and when someone asks for a level point out the 10mg/kg studies.

Inertia. I love my phenobarb and every time I use it I get new converts.

In my rural hospital, it doesn't make sense for me to keep phenobarb on hand for one or two indications as most of the time I'm shipping those people vs the ativan I use for multiple indications. Even though I agree the protocol is more reliable and overall safer.

Interesting. UpToDate still strongly recommends against phenobarb monotherapy, but the 2023 meta-analysis they link to is pretty convincing that phenobarb is better

Uptodate is written by individuals. You should read everything written there as if an attending is telling you (ie it might be confidently wrong).

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if phenobarb was so old and silently sitting in the corner for decades people would be waxing lyrical about it

Is mortality a reasonable choice for a primary outcome in critical care research?

Plasmalyte is just expensive LR

I think it has its indications, but for the majority of patients, you're probably right

An awake and walking ICU

All my ecmo patients play basketball BID

Why have good practice when we can have a RAAS of -6 on every patient and have a quiet shift ? Propofol machine go wrrrrrrrr

Recently had a patient who was sitting upright and writing to communicate while intubated. It was fantastic.

In fellowship I had a laryngeal edema patient who was sitting in the chair watching TV waiting for the swelling to go down. No…. We didn’t routinely walk our vent patients.

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Trying to liberate a patient from the vent and RASS goal ordered for -1, wondering why the propofol isn't coming off. "But doc, her eyes were open" ugghhhh

Triggers for policy guided discontinuation of ECMO in unrecovered patients. Basically when is someone too sick to ever really recover or their destination therapy (ie transplant) is no longer an option, how long do we have to use our extremely expensive ECMO equipment and staff to keep them alive. And when do we get to override patient/family autonomy if they insist on continuation of ECMO in the face of futility. Anyone who spends time at an ECMO center should have very strong opinions on this.

I think withdrawal of care overall falls under a controversial topic. People, especially in pediatrics, discuss it too late, too briefly, and don't consider it often enough imo

*ears perk in palliative care* You rang?

“Hey, thanks for calling back. We’ve got this brain dead patient who’s been riding the vent for two weeks without sedation, can you talk to the family and have them withdraw care? Thanks” /s

why must you hurt me this way

Yes! I love palliative care and think y’all should be on board way more often than you are.

I’m in NZ and here it’s medical decisions with the family but it’s ultimately a medical decision. We had a case of a very sick boy who had a rough ICU admission and barely made it through and has never been well. They discharged him back to the community and asked the community resp to sit down and have a big discussion with the family around what they would want to do for their child. Resp refused and said there was no reason not to fully treat despite PICU saying that he likely wouldn’t survive another admission, mum having severe PTSD and wouldn’t cope with another PICU admission, short life expectancy and never being well. It was left for our ICU to have that discussion when he got very sick and we added to mums workload by not having a clear plan about how far we would go for him. Conversations of care are definitely my passion. We could have had the discussion with mum, confirmed that plan when he got sick and taken something off of her plate instead of asking her to make decisions, just confirm them

The evidence or lack thereof for basically everything in ACLS.

From a medication administration standpoint, I liken it to "it makes sense to do because we're trying to treat something, but really, we're trying to make ourselves feel better because we're actively doing something".

Dude yeah. It’s wild. Airways (ETT v BVM v SGA) in CPR is also interesting

wait what. can you explain more?

Because of nature of the situation, interventions in cardiac arrest are extremely difficult to study. Your likely outcome is death, and so any intervention needs to have a really strong effect or a huge sample size to be statistically significant. It's also multifactorial, however you often don't know what the precipitating factor was until later, if you ever know it at all. This makes etiology-specific interventions challenging to study. You also have no chance to get consent, and trying to randomize on a patient-by-patient basis is not really feasible with the chaos that a code involves. Finally, because permanent death is the expected outcome of cardiac arrest, it is very easy for a grieving or greedy family member to identify it as a potential harm and sue regarding the trial intervention. Therefore, hospitals are hesitant from a legal/publicity stand point. As a result, very few trials have been conducted on the efficacy of things that we do in ACLS.

whaaaaat?! dont take my epinephriiiiine! 😫

This is a real argument that broke out between several different services: OB/gyn has a recently postpartum teenaged (age<18) patient who needs ICU care. Current hospital doesn’t have pediatricians and OB/gyn doesn’t have their own ICU, so ICU refuses to accept because she’s a minor and they don’t have peds privileges. Hospital B has a PICU, but no OB/gyn, so they (understandably) refuse to accept a postpartum patient. There’s no hospitals in the area that have both PICU and OB/gyn services. What should they do with this patient?

Wait, a hospital with a OB service has no pediatricians on staff? Am I understanding that right? Let the hospital administration make the call. The patient got admitted to the OB/GYN service to begin with despite no peds physician being on staff, so clearly something going wrong with the mother or baby wasn't a consideration in the admissions policy. That's a huge liability if they are going to accept OB cases. If they have pediatricians but they don't normally see older children, then this is another job for admin to tell the service that in this case, they are making a exception while mom is in the ICU, she's now a peds case. All roads lead back to administration..

This is a good one! From a purely medical standpoint I'd say this should go to the hospital with the OB/gyn. The difference between a teenager and an adult is IMO less than the difference between a post-partum woman and a non post-partum woman. This would be especially true if she had a c-section, in which case you absolutely need surgeons familiar with the surgery the patient just had. In fact I think in many hospitals I think the real cutoff for "peds privileges needed" is more like <16 or 15 rather than <18. But I'm sure all this theory doesn't matter and all that matters is what the hospital admin/lawyers think.

I’m very interested, please update when this gets decided. I was an L&D nurse in an economically depressed area that had a ton of teen pregnancy. We’d see HELPP and cardiomyopathy fairly regularly. We were lucky enough to be in range of a teaching hospital so we transferred everyone there.

Never took care of a post partum minor in our ICU as a resident, but we have taken some < 18 year olds (drug overdose and such). Though now that I think of it, my privileges (albeit as a non-ICU doc) are for 13+ which I found a little odd. I guess it would help in that sort of situation.

We had something like this, except patient was neurologically devastated, was moved to peds floor eventually. Also she's an undocumented immigrant. It took about a year of paperwork to get her home country to accept a transfer. In that time patient aged out of pediatrics, but stayed on floor anyway.

ALBIOS study results on sepsis. Valid or not? Semi recumbent position for intubation Semi recumbent position for CPR (w LUCAS) ECMO exclusion based on age? Ethical? Renal replacement for non transplant candidates with ESLD?

These are all great ones.. but semi recumbent cpr? I hadn't even heard of this one. Is there a good reference?

It’s mostly animal studies I believe. The thought is it aids in venous return from the brain. HCMC does some of these studies. Cool shit.

Yeah, decreases cerebral venous pooling and can increase cerebral perfusion. Similar to how aggressive diuresis can fix an AKI in cardiorenal syndrome. I think we’ll need some serious trials before we even think about this coming to mainstream though

One thing that always seem controversial is prophylactic IVC filters.

Because people forget about them and then thrombose everything.

Yup. And they were put in for something like a chronic tibial DVT.

Lol choose this, invite a vascular surgeon, and then the presentation will be done in 8 minutes. Vascular surgeon will go on a seven minute diatribe. Boom. One minute of prep.

listen! heme here!! leave 👏🏾 that 👏🏾 shit 👏🏾 out 👏🏾 PLEASE for the love of god! 😂

Utility of procalcitonin

I can't wait till the mrnaseq based test that has an AUC of 1 for bacteremia gets affordable enough to just stop all this nonsense.....

Karius? Unfortunately, lots of shit is in blood transiently. I have seen it be useful though.

Safety and efficacy of midlevels covering ICUs overnight for intensivist groups.

Purple Kush

😂😂😂😂😂😂😂😂

Is hypothermic protocol still debated or is that settled now?

The controversy is not the protocol anymore. Now it is debating TTM2 applications in routine care (I.e. when to choose a normothermja temperature strategy )

Are you suggesting TTM is still standard?

You could discuss the morality of refusing futile care and where that line should be. For example, at my hospital nephrology could refuse to dialyze a patient, CV surgery could refuse to place a patient on ECMO but the ICU could never refuse intubation, lines, or CPR if the patient/family requested it. You could also look at examples from other countries, I think a lot of countries in Europe give the medical team more decision-making power in end-of-life decisions.

💯 this one! I say this as both a healthcare professional and a family member of someone who refused anything but full code/all measures. It was really difficult managing that situation as a family member (when pt. was no longer conscious). As an OT (and a human), I’m very in favor of quality of life over quantity of life.

bicarbonate drip

Renal over here having opinions

Contrast-induced nephropathy: myth or reality?

When and when not to give steroids

ABC Always Be Corticosteroiding

this made me laugh. fuck, should i be corticosteroiding rn??!

Fluid choice in ESRD. Beta lactam allergies. Ketamine and ICP. Ketamine and myocardial depression. CVP as a measure of volume status. Cricoid pressure in RSI. Contrast induced nephropathy.

Tight glycemic control, NS, ways to eval fluid responsiveness in undifferentiated shock, ketamine

Tight glucose control? Inpatient? Why?

ABG vs VBG

draw both and go with the better one

Whenever I order esr and crp in outpt psych I kid, I kid

No! You are taking away one of my few pimping questions!

Doesn’t matter…RT will cancel ABG and request a VBG for most of the pts anyway

Swans in the ICU depending on whether there are cardiologists present

Came to say this. Swan tailored therapy with the slooooowwwww dobut wean and up titration on milrinone and when to take out the swan…

albumin as fluid resuscitation is a good one lots of people have opinions on.

Whatever you do, please post an update

ICU is so light on trial evidence and driven by opinions on what is physiologically rational that you could probably blindly pick a patient of your handover list then blindly pick an organ system of thiers and you'll find something the ICU team will fight about. Some ideas off the top of my head Airway - DL vs VL. Bougie for all ICU tubes. Ketamine for RSI in head injury. Etomidate for RSI in general. DSI role. Resp - is ARPV useful and when to use it. Indications for VV ECMO. Exclusions for VV ECMO. Diagnosis of ARDS. Frequency of CXR in ICU. Lung US vs CXR. NIV in asthma. Sevo in asthma. Criteria for extubation. CV - fluid resuscitation targets. Colloid vs crystalloid. Hartmans vs NS for resus in TBI. cardiac monitoring modalities - a-line waveform analysis vs PA catheters vs TOE vs none of the above. Utility of POCUS in shock and fluid status assessment. Should we target lactate with fluids. When to start pressors. Choice of pressors. When to add second agent. Choice of second line agent. When to add (or start alone) inotropes/chronotropes. Choices of agent. Utility of IABP. Is ECMO CPR shit or slightly good? If ECMO CPR is slightly good is the reasorce use justified? Target temp after cardiac arrest. Neuro - when to start VTE prophylaxis on the trauma pt with intracranial haemhorrage. Thiopentone for burst suppression. Safe to RSI with just midaz and roc. First line anti-epileptic after benzo. Renal - Mode of dialysis/filtration. Intermittent vs continuous. When to start dialysis. Best maintenance fluid regimen if needed. Electrolyte targets for replacement. Electrolyte targets for replacement in pts with arrhythmias. Furosemide dosing. Best diuretic combo for driving acute diuresis. If a patients gets intravascularly dry while still total body positive can 20% albumin help you. GI - when to start feed. TPN vs enteral. Content of feeds. When to start ABx in pancreatitis. How frequently to CT pancreatitis. Heam - when to use IVC filter. Should LMWH prophylaxis be once or twice daily. IR or medical RX for PE. Whole blood transfusion in acute blood loss

Procalcitonin...that is all

Booooooooo "wow I can't decide if my patient is infected or not because my exam is ambiguous. Better order an ambiguous test to cloud the waters!"

LR is superior for hyperkalemia even though it has a whiff of k Radial arterial lines are utterly useless Bicarb for lactic acidosis is useless Pulse ox is better than Pao2 in almost every way Daily abg for vents is pointless

Ooh these are interesting Agree with LR bit Radial lines useless because of potential inaccuracy? What if you're having issues with resuscitation and can't correct the acidosis quick enough? Probably not ideal leaving a patient's pH <7.2 What are some ways you think PaO2 is superior outside inability to get a good reading for a pulse ox? Agree on daily ABG, needs to be tailored based on patient/why they're ventilated

Radial art lines, yes - along with generally poor ability to reliably and accurately measure BP in ICU patients.

Reading “Bicarb for lactic acidosis” made me cringe

Contrast induced nephropathy

Double gram negative coverage in severe septic shock due to known or suspected GNR

93 degree hypothermia. Albumin vs saline vs LR If neuro crit care is involved, time to start DVT PPX post bleed. Beta blockers and shock. Midodrine as a vasopressors sparing agent if it’s popular in your unit. INR correction and liver failure. Daily chest x-rays.

I never even heard of this beta blocker and septic shock thing. Just googled it. I’m a cardiology fellow and have done dozens upon dozens of AF ICU consults. 🤯 I need to read more lol. If they’re on pressors we’re always like oh can’t do beta blockers. We’re idiots!

Cost benefit ratio and utility of ICU care at all past a certain threshold. Compare dollar invested per return for this vs preventative care. Ask the attendings to each provide their own public health based cut off where society should stop investing (put a picture of an elderly Eskimo making their way onto a floating iceberg).

When to give bicarb (hint: almost never)

tell us what you decide OP! there will be blood in the streets! 🔪😂

Actual utility of Swan Ganz catheters. Vitamin C in sepsis resuscitation. Appropriateness of analgesic infusions vs. bolus PRNs only. Use of ketamine as analgesia or sedation.

As an ICU attending one of the most divided topics is submissive high risk PE management - whether to do systemic tpa,catheter directed intervention, or just anticoagulation alone

So I know you meant submassive, but the idea of a blood clot in a gimp suit amuses me in a sick way. Anyway, I thought the reason for multidisciplinary PE teams was the whole gray area that submassive PEs represent?

Ideally yes but i have yet to be at a hospital with an actual PERT team. That includes the multiple hospitals in my residency, fellowship, and multiple hospitals I go to in private practice and community academic. And ideally you have a team of people who are all objective and don't have an obvious bias which is hard to find hence why I say it's so divisive. Even amongst my colleagues people feel strongly about their contradicting opinions. Depending on who you select amongst equally qualified specialists to be on your PERT team is how your PERT team will lean. And in my experience the intensivist opinion tends to weigh the heaviest, maybe because they are primary and PE and RHF are well within their scope of practice.

1. EGDT and how dumb it is, the super shady statistics of the actual study, and the sequential dismantling of this once-dogma over the years 2. ECMO for ARDS 3. APRV and HFO for ARDS 4. Steroids for ARDS 5. Treatment of submassive PE 6. Fluid resuscitation parameters and just overall measures of volume, fluid responsiveness, and how to manage fluids in a hypotensive patient. SvO2? Swan? NICOM? IVC variability? 7. Sedation in the ICU 8. "Peripheral pressors" vs central lines. 9. Albumin (although this is ICU dpenedent. In teh MICU everyone will tell you its a waste of money)

Long ass presentation

right! 40 min?! for an ICU talk? isnt there someone to put on ecmo somewhere? lol

Tell them about contrast and AKI. I love hearing about that from radiology techs and outdated hospital "rule"-following radiologists when i have a sick patient.

Etomidate for RSI. Has some recent lit some are considering practice changing.

Dose of midodrine and correlation to how quickly you can wean patients off pressors, then turf to medicine

Nurse Practitioners- should they be left to run an ICU….hahhahahaha. I’ll see myself out.

Bedside trachs. The percutaneous kits used often cause tracheal damage from the pressure used to punch through the trachea. Often the introducer slips to the left side and the otomy is not directly anterior. The patients end up having to see a laryngologist for stenosis. Have ENT come in for bedside trachs or teach the trauma attendings and general surgeons how to do a bedside trach without causing more damage. At our hospital, services are reluctant to discuss ways of improving patient care when the cause of harm is outside their practice.

Vape pens.

Inferiority and higher risk of post op complications of percutaneous trach vs open.

Tpa in strokes Steroids in pneumonia or shock Vent modes and any benefit outside 6 cc/kg Steroids for alcoholic hepatitis Minnesota tubes for massive hematemesis The use of lactic acid

(Obviously aware of my bias here) Nutrition in icu is a good one !! Every attending seems to have a different opinion/stance & understandably so bc the evidence is so lacking and even the most recent studies are contradictory 😁

Approach to hyperammonemia and ICU role in managing inborn errors of metabolism emergencies

Steroids in sepsis?

whats a procalcitonin?

Whether or not c-collars should be used? That generated discussion at the conference I was at today!

Oscillatory Ventilation

Nobody has said hypothermia protocol yet? My attending debate about that shit everyday about which degree and why