“Thiamine before glucose” is a bedside teaching that started with a sound physiologic concept and slowly hardened into dogma when dealing with patients with alcohol use disorder. Thiamine deficiency underlies Wernicke encephalopathy, a preventable but often missed neurologic emergency most commonly seen in alcohol use disorder, malnutrition, prolonged vomiting, and…
Premature atrial complexes (PACs) are something I’ve explained to trainees and patients for years, but about a week ago, I started having them following a really rough stretch in the CVICU. As a cardiac anesthesiologist and intensivist, I know how common PACs are and how often they are benign, but…
Left ventricular (LV) thrombus is typically a result of stasis from myocardial hypokinesis/akinesis. A segment of myocardium stops moving, blood lingers in the cul-de-sac of an akinetic apex, and the endocardial surface becomes a scaffold for clot. Large anterior infarctions, end-stage heart failure, and dilated ventricles can set the stage…
High altitude pulmonary edema (HAPE) typically shows up in otherwise healthy patients after rapid ascent (e.g., mountain-climbing) with subsequent coughing, tachycardia, hypoxemia, and fatigue. These symptoms are often attributed to overexertion or dehydration, but it’s important to recognize the underlying physiology. At its core, altitude exposes the lung to hypoxia…
Olanzapine (Zyprexa) and quetiapine (Seroquel) are often discussed as if they are interchangeable sedating antipsychotics used to help with addressing facets of delirium (insomnia, emotional lability, etc.). It often feels like dealer’s choice when deciding which one to use. Here are some of my considerations as an intensivist. Olanzapine is…
Andexanet alfa (Andexxa) will leave the US market on December 22, 2025, after AstraZeneca withdrew its biologics license application for commercial reasons. For a drug that costs as much as a car (~$25-50K per dose) and carries meaningful safety concerns… good riddance! Andexanet entered practice as the only FDA-approved reversal…
Middle aortic (“mid-aortic”) syndrome (MAS) refers to a segmental narrowing of the distal thoracic or abdominal aorta, often with associated stenosis of the renal and visceral branches. The result is severe renovascular hypertension in children and young adults who otherwise have “healthy” hearts and no atherosclerotic risk profile. Etiologies range…
Creating a new arteriovenous fistula (AVF) generates a major hemodynamic shift. Connecting a high-resistance artery to a low-resistance vein increases venous return, lowers systemic vascular resistance, and forces the heart to sustain a chronic high-flow load. Many patients adapt, but those with limited reserve can decompensate quickly with dyspnea, edema,…
Candida auris (C. auris) has become a significant challenge in critical care across the country. It spreads across surfaces, equipment, and even skin, allowing outbreaks to take hold long before they are detected. These infections tend to appear in patients with comorbidities like advanced age, diabetes, kidney disease, malignancy, dialysis…
Tramadol (Ultram) is often prescribed for analgesia because it’s easy to write for (especially at hospital discharge); however, its pharmacology makes it unreliable for pain control. The parent compound has only weak affinity for the mu opioid receptor, so most of the meaningful opioid effect comes from its active metabolite…