Blast From the Past: Occult Sepsis, Lactic Acid, and Mortality

Severe sepsis and septic shock affect millions of patients worldwide and have high rates of morbidity and mortality as well as high resource utilization. The way we manage sepsis has changed quite a bit since the Rivers et al randomized controlled trial of early goal-directed therapy (EGDT) ¹ , which had an absolute decrease in mortality from 46% with “usual care” to 31% with EGDT. What we now know is that a proactive approach to septic patients will result in lower mortality rates and better outcomes (i.e. early identification, early intravenous fluids, and early antibiotics). Patients with sepsis are still missed despite the fact that we understand the benefits to morbidity and mortality with early recognition. In this blast from the past study from 2007, Howell et al ² answered the important question of does elevated lactic acid simply reflect a patient’s hemodynamic status or can it independently predict 28 day in-hospital mortality after controlling for other potential confounders in patients with sepsis. (more…)

By Salim Rezaie, MD|2016-11-11T19:37:14-08:00Jun 29, 2015|Critical Care/ Resus, Expert Peer Reviewed (Clinical), Infectious Disease|

AIR Series: Respiratory Part 1 (2015)

We found an enormous amount of posts on respiratory topics and thus have divided the content into two modules. This first module will focus on general respiratory issues with airway and pulmonary embolism covered in the second module. Below we have listed our selection of the 15 highest quality blog posts within the past 12 months (current as of April 2015) related to respiratory, curated and approved for residency training by the AIR Series Board. In this module we have 4 AIRs and 11 Honorable Mentions. We strive for comprehensiveness by selecting from a broad spectrum of blogs from the top 50 listing per the Social Media Index.

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By Andrew Grock, MD|2017-03-05T14:14:15-08:00Jun 17, 2015|Approved Instructional Resources (AIR series), Pulmonary|

Salicylate Toxicity PV card v2: Lessons in post-publication review

I was recently the author of a PV card for management of Salicylate Toxicity, which had some discrepancy with expert opinion. The point of contention was in regards to measurement of urine pH vs serum pH for alkalinization. In preparing the first version of the card, I began with notes from a recent toxicology rotation, and expanded by examining textbooks and review articles. Although there was mention of serum pH measurement, numerous sources emphasized urine alkalinization as the primary endpoint for the treatment of aspirin toxicity. Therefore I choose to include this on the size-limited PV card.

Despite review by numerous peers and colleagues, not long after publication we were met with concern from prominent toxicologists regarding an oversight in mentioning serum alkalinization. Utilizing the strengths of our blog and social media we were immediately able to initiate a discussion with experts on the topic.

Expert Peer Review Comments

Dr. Lewis Nelson of NYU was able to clarify that by prioritizing serum alkalinization, we will avoid the cerebral toxicity that is the primary etiology of mortality. Serum alkalinization should also facilitate urine alkalinization as well as allow time to arrange for hemodialysis. Dr. Bram Dolcourt from Detroit expanded that serum alkalinization and normokalemia alone do not guarantee an optimal urine pH and suggest measurement of both urine and serum. From Twitter, Dr. David Juurlink from Toronto also recommended measurement of both, stating his forthcoming publication will expand on the topic. Our own ALiEM clinical pharmacist Dr. Bryan Hayes also assisted with expert insight as I was revising the PV card.

My Reflections

As the ALiEM-CORD virtual fellow, I have had the challenging task of collaborating with experts in my field, while still very much in a learner role myself. I was fortunate enough to have been featured on a site that has a robust commenting system and pride in peer review, even if it is post-publication. There is certainly content on the web that may be inaccurate or ‘less-accurate’, and consumers of both FOAM and conventional publications, as always, should remain critical and review multiple sources. There is a broad range in teaching and practice based on region, and when we work together we can identify what is truly best practice. Hopefully this conversation and the forthcoming publication on the topic will translate into changes in practice and in the textbooks in the coming years. Luckily, utilizing the strengths of our medium, we are able to publish these corrections today.

PV Card: Acute Salicylate Toxicity

For those curious, here was the original version 1.

By Sam Shaikh, DO|2021-10-05T12:51:20-07:00Jun 15, 2015|ALiEM Cards, Expert Peer Reviewed (Clinical), Medical Education, Social Media & Tech, Tox & Medications|

Tricks of the Trade: Fluorescein application techniques for the eye

Application of fluorescein is a vital part of the workup of ocular complaints. Despite some studies showing questionable support, the typical cited clinical concern for stored fluorescein solutions is contimination with Pseudomonas and risk for iatrogenic infection with associated ulcer formation. ^1–4 Subsequently, single dose sterile strips have become the standard agent stocked in most EDs. Many patients, especially children, can be apprehensive of the application of the physical strip directly to the eye, and are more comfortable with the concept of eye drops. In this post, we review multiple technique to create fluorescein solutions and additional tips for utilization that may be integrated into your practice, depending on the supplies available to you.
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By Sam Shaikh, DO|2019-02-19T18:59:57-08:00Jun 11, 2015|Ophthalmology, Tricks of the Trade|

Trick of the Trade: Eye pH

Your patient presents with an ocular burn after accidentally splashing an industrial acid on his face. You, however, can not seem to find the ever elusive eye pH paper to track her initial and serial pH’s during copious ocular irrigation. Now what?

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By Michelle Lin, MD|2016-10-26T17:04:28-07:00Jun 10, 2015|Ophthalmology, Tricks of the Trade|

Diagnose on Sight: Diffuse Desquamating Dermatitis

Case: An 84 year old female presents with five days of a diffuse rash. She had a seizure and was started on phenytoin 2 weeks ago. Her mouth, labia, and medial canthi are involved. There are scattered areas of desquamation comprising less than a tenth of her total body surface area. She is tachycardic and febrile. Her complete blood count differential is normal. What is the diagnosis?

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By Jeff Riddell, MD|2016-12-22T19:43:02-08:00Jun 8, 2015|Dermatology, Diagnose on Sight|

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