iiinova — where your digital self keeps evolving

@IM_Crit_ @imcrit.bsky.social · 01/10/2026

News: Yesterday, Tennessee tried to execute #ChristaPike. She survived. Until recently, Tennessee used three drugs for lethal injection: midazolam for sedation, vecuronium for paralysis, and potassium chloride to stop the heart. In 2024, Tennessee switched to pentobarbital alone.

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@IM_Crit_ @imcrit.bsky.social · 21/09/2026

There are now two #RSIs that worry me. One can rapidly take away a patient's ability to breathe. The other could give an #AI system the ability to recursively improve beyond humanity's ability to reliably control it. Rapid Sequence Intubation. Recursive Self-Improvement.

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@IM_Crit_ @imcrit.bsky.social · 20/09/2026

"A picture is worth a thousand words"

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@IM_Crit_ @imcrit.bsky.social · 07/09/2026

I decided to refresh my memory on cardiac surgery "stuff" and honestly I don't get what surgeons / anesthesiologists / CRNAs / perfusionists complain about. It’s literally just blue tube out, red tube in... #foamed #emimcc

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@IM_Crit_ @imcrit.bsky.social · 07/09/2026

POCUS refresher: detecting tamponade A small but important machine-setting pearl: slow down the sweep speed Slower sweep = more time displayed on the same screen → more consecutive cardiac/respiratory cycles to compare This can make respiratory variation in mitral/tricuspid inflow velocities much

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@IM_Crit_ @imcrit.bsky.social · 04/09/2026

ICU Physiology Secrets: There is no such thing as a "normal" cardiac output value Sure, a CO of 1 L/min for a 19 yo college athlete is obviously terrible but context is everything What's "adequate" for a resting 80 yo on beta-blockers will look completely different for a septic patient in her 20s

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@IM_Crit_ @imcrit.bsky.social · 03/09/2026

I watched an excellent #ESICM webinar discussing the 2026 SSC Guidelines on hemodynamics Interesting talks, but two points I feel strongly about: 1. Stop repeating fluid boluses in persistently hypotensive pts, even if still hypoperfused and dynamic measures show fluid responsiveness

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@IM_Crit_ @imcrit.bsky.social · 01/09/2026

Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 1987; 59(7): 23C-30C

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@IM_Crit_ @imcrit.bsky.social · 01/09/2026

Ischemic cascade: According to the original description 40 years ago, symptoms are a late feature of #ischemia, and #echo can detect changes prior to this point By the time a patient has developed symptoms, some echo abnormalities are expected to be seen by #POCUS #foamed

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@IM_Crit_ @imcrit.bsky.social · 25/08/2026

Medical news: Finally, a robot that wants your blood! 🤖🩸 FDA just cleared "Aletta," an autonomous blood-drawing device that uses near-infrared light and Doppler ultrasound so you never have to be treated like a human pincushion...

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@IM_Crit_ @imcrit.bsky.social · 24/08/2026

Quick reminder: this is a masterclass in how *not* to perform CPR 🫀

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@IM_Crit_ @imcrit.bsky.social · 20/08/2026

ICU Snapshots: It's the start of your night shift, and all eyes are on the monitor... What is going on with patient #4? 👀👇

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@IM_Crit_ @imcrit.bsky.social · 17/08/2026

Exclusive: Unedited footage from the multidisciplinary Heart Team meeting (interventional cardiologists versus cardiac surgeons):

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@IM_Crit_ @imcrit.bsky.social · 08/08/2026

I have never noticed dexmedetomidine associated with tachycardia:

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@IM_Crit_ @imcrit.bsky.social · 07/08/2026

Key applications in Critical Care: 1. Differentiating shock phenotypes 2. Assessing hemodynamics & preload responsiveness 3. Evaluating hypoxemia You may find useful the proposed algorithms for the evaluation of patients with hypotension and/or hypoxemia:

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@IM_Crit_ @imcrit.bsky.social · 07/08/2026

Take-home points: *POCUS expanded from simple bedside "rule-in/rule-out" exam into a comprehensive diagnostic approach **"POCUS Pyramid": Effective hemodynamic evaluation relies on integrating 3 pillars rather than evaluating an organ in isolation: echo+lung US+systemic venous assessment (VEXUS)

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@IM_Crit_ @imcrit.bsky.social · 07/08/2026

Nice review article examining the evolution, physiological principles, and clinical applications of point-of-care ultrasound (POCUS) and Critical Care Echocardiography (CCE)

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@IM_Crit_ @imcrit.bsky.social · 26/07/2026

ICU (Night) Stories: 90-year-old admitted to the ICU at 8 pm with complete heart block. Cardiology had semi-emergently placed a temporary transvenous pacemaker just before ICU admission. At 3 am, we found her delirious but triumphantly holding this in her raised right hand:

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@IM_Crit_ @imcrit.bsky.social · 19/07/2026

If you have a little bit more time, a cooperative patient, and the necessary expertise: The “clean duo”: 1 axillary/subclavian venous line + 1 arterial line Different patients. Different circumstances. Different priorities

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@IM_Crit_ @imcrit.bsky.social · 19/07/2026

When the patient is crashing and/or exsanguinating, speed and access come first The “dirty duo”: 2 femoral lines side-by-side in the groin (typically one venous and one arterial) The “dirty trio”: 3 femoral lines (1 arterial + 2 venous: triple lumen and introducer or dialysis catheter)

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@IM_Crit_ @imcrit.bsky.social · 18/07/2026

Unpopular ICU opinion: Switching from a radial to a femoral arterial catheter often reveals adequate pressure and allows for de-escalation of vasopressors. The opposite can happen too... 😩 Welcome to my life!

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@IM_Crit_ @imcrit.bsky.social · 18/07/2026

"It is difficult to make predictions, especially about the future" -Yogi Berra

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@IM_Crit_ @imcrit.bsky.social · 12/07/2026

Good iv access. Bonus: well secured...

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@IM_Crit_ @imcrit.bsky.social · 08/07/2026

2026 has reached the point where "Cannibalism is bad for your health" required scientific confirmation

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@IM_Crit_ @imcrit.bsky.social · 02/07/2026

Some fortunate ICUs have that one aide who knows everything: where every piece of equipment is kept, from gauze to 9Fr catheters to pacing wires; what needs to be reordered; and, just as important, when something should not be reordered at all! They know how to move patients safely, how to calm

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@IM_Crit_ @imcrit.bsky.social · 29/06/2026

In the past, when diuretics were given outside the ICU, creatinine increased and diuresis was held. Creatinine increased from 1.2 to 1.7 while patient was in the ICU but we didn't care and didn't stop diuresis...

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@IM_Crit_ @imcrit.bsky.social · 29/06/2026

Urine output the last 24 hours:

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@IM_Crit_ @imcrit.bsky.social · 29/06/2026

ICU stories: Middle-age pt w known cardiomyopathy comes to the ICU from the ward w "fluid overload" after AICD fired once. BP 95/70, HR 90, on 6 l/m O2 (nasal cannula). Anasarca: + Cards asked us to "optimize" fluid status before heart cath. In 2 days, > 22l of urine & >20l (-) fluid balance

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@IM_Crit_ @imcrit.bsky.social · 22/06/2026

The same individuals whose feedback is being solicited have paid substantial fees to participate in the USMLE process. For 2026, the published application fees are $695 for Step 1, $695 for Step 2, and $955 for Step 3, before considering other possible costs such as preparation materials, travel etc

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@IM_Crit_ @imcrit.bsky.social · 22/06/2026

The United States Medical Licensing Examination (USMLE) is co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). The USMLE program is inviting physicians to participate in a practice analysis survey that is expected to take ~45 min

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@IM_Crit_ @imcrit.bsky.social · 21/06/2026

Yann Le Cun, former chief AI scientist at Meta before co-founding Advanced Machine Intelligence Labs in Dec 2025 Large language model (LLM) versus a 4 yo child:

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@IM_Crit_ @imcrit.bsky.social · 11/06/2026

Our usual reaction to any new study is either “I don’t believe it” or “I knew it”...... A NEJM trial in ICU pts w acute resp failure found that mucolytics (carbocisteine & hypertonic saline) don’t help. My ICU rounds line “mucolytics are useless” may need an update: “and possibly harmful”

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@IM_Crit_ @imcrit.bsky.social · 30/05/2026

I want to shake everyone’s hand here, but I don’t want my hands getting bruised 🤝 Btw, has anybody heard about senile purpura? Or my Internal Medicine background is acting up?

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@IM_Crit_ @imcrit.bsky.social · 30/05/2026

I thought that routine daily aspirin is no longer recommended for the primary prevention of heart attacks and strokes Please advise

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@IM_Crit_ @imcrit.bsky.social · 20/05/2026

I may be biased here, as I extubate MANY patients directly to NIV when I "feel" they will benefit, without relying on CO2, age, or cardiorespiratory status. This was a post-hoc analysis of two RCTs, and showed that in high-risk patients without hypercapnia at extubation, prophylactic NIV alternating

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@IM_Crit_ @imcrit.bsky.social · 17/05/2026

"Interesting" screening questions before participating in a medical survey: 🤦‍♂️

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@IM_Crit_ @imcrit.bsky.social · 17/05/2026

What is the highest #glucose value you have managed in a patient? #foamed #foamcc #meded #medsky #emimcc #diabetes

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@IM_Crit_ @imcrit.bsky.social · 13/05/2026

When you love both #ECMO and #Impella but also want to keep things tidy and close #foamed #foamcc #medsky #emimcc

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@IM_Crit_ @imcrit.bsky.social · 08/05/2026

An audit of 2.5 million academic biomedical-science papers identified ~3,000 w fake references;, ones that could not be traced to known publications. There were 12 times more publications w fabricated citations in 2025 compared w 2023. 🤦‍♂️ Topaz et al, Lancet, 407: 1779-81. (2026)

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@IM_Crit_ @imcrit.bsky.social · 04/05/2026

Tell me what you want to prove & I will find you a study! A small study presented at the 🇺🇸 Association for Cancer Research Annual Meeting 2026 suggested that “younger nonsmokers who eat a higher quantity of healthy foods than the general population are more likely to develop lung cancer" #medsky

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@IM_Crit_ @imcrit.bsky.social · 03/05/2026

I am reading this piece in CHEST and thinking that the #COVID-19 pandemic acted as a catalyst for re-evaluating so many aspects of our daily life #foamed #medsky #emimcc

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@IM_Crit_ @imcrit.bsky.social · 18/04/2026

From: Current Anesthesiology Reports (2024) 14: 446-57. doi.org/10.1007/s401... Just one of the personalized peri-intubation resuscitation approaches:

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@IM_Crit_ @imcrit.bsky.social · 18/04/2026

ICU Stories (at the beginning of my night shift): Me: Anybody coming? Morning ICU shift attending: Just a young patient with etoh withdrawal from 2D The patient 👇: Not responsive. SBP in the 80s, HR: 150/min, breathing 60/min. O2 sat 96% on 15 l/m non-rebreather mask. Febrile

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@IM_Crit_ @imcrit.bsky.social · 14/04/2026

If you chose grade 1 CL or POGO >90%, you need to make sure that you were actually looking at the glottis... In this case, the esophageal opening (E) can be confused with the normal glottic opening (G), thus impersonating it:

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@IM_Crit_ @imcrit.bsky.social · 14/04/2026

The POGO score represents the percentage of glottic opening seen, as defined by the linear span from the anterior commissure to the inter-arytenoid notch. A POGO score of 100% is a full view of the glottis & corresponds to the best CL grade 1 view:

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@IM_Crit_ @imcrit.bsky.social · 14/04/2026

The Cormack-Lehane grading system for laryngeal exposure was first described in 1984 for obstetric anesthesia. The original CL grading system consisted of 4 grades:

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@IM_Crit_ @imcrit.bsky.social · 14/04/2026

ICU/ED/OR Airway "Secrets": #foamed #foamcc #meded #medsky #emimcc #airways While you attempt direct laryngoscopy in a hypoxemic patient, you get this view:

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