Shifting a lot of my educational activities over here but will still interact/share papers on what used to be twitter

#Thiamine in the ICU: 10 high-yield pearls 1. Unexplained lactate? Think thiamine. Thiamine is required for pyruvate dehydrogenase. Deficiency blocks conversion of pyruvate to acetyl-CoA, shunting pyruvate toward lactate and impairing mitochondrial aerobic metabolism. Thus, thiamine deficiency belongs in the differential diagnosis for otherwise unexplained lactic acidosis. 2. Thiamine deficiency in the ICU is not rare. ~30-70% of critically ill patients are thiamine-deficient. Many arrive deficient; others develop deficiency during critical illness because of increased metabolic demand, inadequate intake, or losses. 3. The bedside phenotype is more important than waiting for a thiamine level. High-risk situations include malnutrition, alcohol-related liver disease, bariatric surgery, renal replacement therapy, polyuria/DKA, chronic diuretic therapy, unexplained encephalopathy, unexplained lactate elevation, and sepsis. 4. Starting nutrition can unmask the deficiency. Glucose administration increases carbohydrate metabolism and thiamine utilization. A malnourished patient may therefore develop rising lactate after initiation of enteral/parenteral nutrition. Refeeding syndrome is not simply a phosphorus/potassium problem; thiamine deficiency can be central to its pathophysiology. 5. Dialysis and polyuria are major clues. Thiamine can be lost during continuous RRT, hemodialysis, and peritoneal dialysis. Renal losses also rise with polyuria, including the diuretic phase of AKI, post-transplant polyuria, DKA, and chronic diuretic therapy in heart failure. 6. Do not wait for the classic Wernicke's triad. Altered mental status, ocular abnormalities, and gait ataxia are rarely all present together. I think I have seen it only a few times. In an at-risk ICU patient with otherwise unexplained encephalopathy, absence of the complete triad should not reassure you. 7. A plasma thiamine concentration is not a great “rule-out” test. Testing is often unavailable and expensive, and blood concentration does not necessarily reflect tissue thiamine status. I don't even remember when I last ordered the test (if ever...). Erythrocyte transketolase activity is physiologically more informative, but its cutoffs are poorly defined. Just recognize the risk population and consider a therapeutic trial rather than wait for laboratory confirmation. 8. The sepsis data are more nuanced than “thiamine works” or “thiamine doesn't work.” Thiamine is not expected to improve hard outcomes in the overall septic-shock population. Some subgroup analyses and meta-analyses suggest signals for improved lactate clearance and organ function, particularly renal outcomes. I don't consider it a magic drug... 9. Thiamine alone ≠ HAT (hydrocortisone + ascorbic acid +thiamine) therapy. Do not interpret negative trials of HAT as proof that correcting thiamine deficiency is useless. Large HAT RCTs failed to demonstrate the dramatic clinical benefit initially claimed, and a VICTAS secondary analysis raised concerns about longer-term outcomes. That is a different question from replacing thiamine in a patient likely to be deficient. 10. The kidney may be an important target organ. Renal tubular cells are highly energy dependent. Across secondary analyses, observational data, and meta-analytic evidence, thiamine supplementation -particularly in deficient patients- shows a signal toward less AKI progression, better renal recovery, and less need for RRT, although individual RCTs have not consistently demonstrated significant benefit in unselected populations. Rule of thumb: “⬆️ lactate + risk factor + no good explanation" → think B1 deficiency” Especially think about it when you see malnutrition/refeeding, alcoholism/cirrhosis, dialysis, polyuria/DKA, chronic diuretics, unexplained encephalopathy, sepsis, or otherwise unexplained persistent hyperlactatemia. I usually include it in the admission orders for most of my ICU patients along with DVT and GI prophylaxis...! Thiamine deficiency behaves less like an obscure vitamin deficiency and more like a potentially reversible form of mitochondrial energy failure. Or that's how I like to think about it. #foamed #foamcc #meded

Not ‘taking a side’, is taking a side btw.

Pet peeve: Premature escalation to Impella RP for right ventricular failure without utilizing multimodal medical therapy Multimodal therapy for RV failure in a type III protamine reaction may include the following: 🫁 100% FiO2 (pulmonary vasodilator) 🫁 Combination of two inhaled pulm vasodilators (eg nitric plus epoprostanol, or nitric plus milrinone). Yes, you can use multiple inhaled pulmonary vasodilators. 🫁 Systemic BP support (vasopressin, norepinephrine) 🫁 Inotropic support (epinephrine) 🫁 IV pulmonary vasodilator (tricky but faster and arguably more evidence-based than Impella RP; best data for IV epoprostanol in treating protamine reactions) I realize how hot mechanical support is right now. It's new and exciting and makes beeping noises and gets all your case reports accepted. But please, I'm begging you, don't forget basic physiology and medical/respiratory therapies for RV failure.

Equations and graphs can obscure haemodynamics as much as they reveal it. Go back to fundamental physics. Start with the energy supplied by the heart. The circulation’s properties and current configuration determine what happens next. The flows, pressures and volumes we measure describe the state that results. None is its independent controller. In the series finale, I present a new way of seeing how the blood goes round. The Venous Return Wars end here. thedependentvariable.com/p/e…

If you are sick of all the AI slop and being constantly bombarded with fake imagery, follow Film 20 for a feed of pure reality and in film photography from professional and amateur film photographers from around the world. Reality is beautiful.

The richest 34 Americans now control roughly $2.6 trillion in wealth, equal to a record 12% of U.S. national income, per FT

For every complex (ICU) problem there is an answer that is clear, simple, and wrong. H. L. Mencken

New science🚨! Does fluid restriction improve outcomes in chronic HF?💧 This meta-analysis of 9 RCTs (1,335 pts) found no significant differences in mortality, HFH, congestion, biomarkers or QoL between restrictive & liberal fluid strategies. 🔗 bit.ly/4gYZdxD

Check out our updated Adult Reading List: A list of peer-reviewed articles that cover key and high-yield topics that are up to date, comprehensive and pertinent. Access the Adult Reading List here: bit.ly/4poGD3Y

The feds are reviving a Nixon-era counterterrorism framework that hasn't been used in decades: kenklippenstein.com/p/trump-…

Join the CCF MILU team July 6-7 for Cutting-Edge Critical Care in Liver Failure: From Physiology to Transplantation Options for in-person or virtual attendance! 📣 Registration is still open: ccfcme.org/LiverFailure26 @KapoorA_CC @msiuba @siddharth_dugar @StephanieNBass

Mechanical ventilation doesn’t have to be confusing. I teach a FREE course using real ventilator images. It has 44 videos (5-10min each) covering foundations to advanced topics, like esophageal pressure monitors and dyssynchronies! Sign up here: forms.office.com/r/GNhq7GxPb…

What are you seeing and what is the diagnosis? @SCAI @ACCinTouch @uwashfellows

An American just got sentenced to 30 years in federal prison for moving “Antifa” zines and there’s about 1000x as much media coverage of Trump’s reflecting pool 👍

The shape of the CW Doppler envelope carries important hemodynamic information. For both stenotic and regurgitant lesions, larger orifices generally produce early-peaking, triangular envelopes, whereas smaller orifices generate more rounded, parabolic, later peaking envelopes. Understanding Doppler shape can provide insights beyond velocity and gradients alone. For more concepts and practical examples, read here: academic.oup.com/ehjimp/arti… @echo_batman @EchoSoliman

This tax measure would apply to just 250 total people in California. If Newsom and billionaires block it, 3 MILLION Californians could lose their health care coverage. Pass it on.

Hepato–Cardio–Renal Interactions and Transplant Implications. #POCUS plays a key role in hemodynamic phenotyping and individualizing care. #Nephpearls #Transplantation @AmirKazory 🔗journals.lww.com/transplantj…

Plus scheduled nebs for everybody who is on the vent… 🙃

By conservative estimates Elon Musk probably killed hundreds of thousands by taking a chainsaw to global health programs. He’s not a visionary, he’s a dimwit and a monster.

Two pictures taken on the same ARDS pt shortly apart. What led to the increase in peak pressures? Clue: nothing changed with their respiratory system. This post illustrates the point made by @msiuba, @jeremyeorr & @CV33_CAG last week. Thank you for your contribution!