@IM_Crit_ @imcrit.bsky.social · 03/10/2026🔟 The core ICU rule. Treat the physiology, not the monitor prompt. "Suction" tells us what the machine is feeling. It is our job is to figure out what is happening. #emimcc #foamed #foamcc 110
@IM_Crit_ @imcrit.bsky.social · 03/10/20269️⃣ CPR can displace the Impella Chest compressions, coughing, movement, and patient repositioning can displace the catheter. Every single time we get ROSC or complete a code, we have to re-confirm depth and orientation with echocardiography or fluoroscopy before trusting our numbers. 120
@IM_Crit_ @imcrit.bsky.social · 03/10/20268️⃣ Is the flow lower than expected? Walk through the sequence: Position → Preload → Afterload → Mechanical hardware Don't jump straight to device escalation when the afterload is sky-high or the inlet is displaced. 111
@IM_Crit_ @imcrit.bsky.social · 03/10/20267️⃣ Still in shock despite Impella? Step back and ask: ① Is the pump actually delivering effective cardiac output? ② Is there unaddressed vasoplegia or sepsis riding along? ③ Are we over-pumping a dry LV? Cranking up the P-level isn't a fix for vasoplegia. 110
@IM_Crit_ @imcrit.bsky.social · 03/10/20266️⃣ Suction + dark urine? Think hemolysis. We have to check plasma-free hemoglobin and the rest of the hemolysis markers. But besides staring at the labs, we have to look for malposition, a small underfilled LV, excessive pump speed, or mechanical obstruction. Find the cause of the shear. 121
@IM_Crit_ @imcrit.bsky.social · 03/10/20265️⃣ Read the suction pattern Diastolic suction can be a clue to inadequate LV filling but it Is also associated with RV dysfunction. Continuous suction will have to make us think: Loading → Position → Anatomy → Device The waveform gives us clues, but we have to interpret the context 110
@IM_Crit_ @imcrit.bsky.social · 03/10/20264️⃣ Don't forget the RV. The LV can only receive and eject what the right heart delivers. RV failure reduces LV preload, lowers Impella flow, and can trigger suction. Sometimes the “Impella problem” is really an "RV problem". 110
@IM_Crit_ @imcrit.bsky.social · 03/10/20263️⃣ Low preload ≠ "give fluid". Hypovolemia? Fluid may help. Severe RV failure? More fluid may dilate the RV, shift the septum to the L, and make LV filling -and suction- worse. Tamponade? Fluid is only a bridge to what the patient actually needs: drainage. 110
@IM_Crit_ @imcrit.bsky.social · 03/10/2026A spinning impeller parked in the wrong spot won't work well, no matter how much volume we give. 110
@IM_Crit_ @imcrit.bsky.social · 03/10/2026?Malposition ?True hypovolemia ?RV failure ?Tamponade ?Excessive support ?Structural obstruction/clot 2️⃣ Check Impella position immediately. Get the probe on the chest early. Is the inlet free in the LV cavity? Is it tangled in the mitral apparatus, grabbing chordae, or hugging the septum? 120
@IM_Crit_ @imcrit.bsky.social · 03/10/2026Here is a step-by-step approach to troubleshooting Impella at the bedside: 1️⃣ Suction is a clue, not a diagnosis Before starting iv fluids, we have to ⬇️ the P-level while we figure out what happened. Then we should build the differential: 110
@IM_Crit_ @imcrit.bsky.social · 03/10/2026#Impella troubleshooting: 10 high-yield ICU pearls The Impella monitor flashes “Suction”. Our knee-jerk reflex says: give 1 L of NS. But what if volume isn't the problem? The exact same alarm can stem from different mechanics meaning that treating the alarm instead of the patient can backfire 140
@IM_Crit_ @imcrit.bsky.social · 01/10/2026As a physician, I have a hard time reading about IV access, drug protocols and physiologic endpoints when the endpoint we're discussing is deliberately killing someone. Whatever your views on capital punishment, this case deserves a very close look. 041
@IM_Crit_ @imcrit.bsky.social · 01/10/2026What we do know is that the protocol didn't work. The governor has now stopped Tennessee's remaining execution scheduled for this year and ordered a review. 121
@IM_Crit_ @imcrit.bsky.social · 01/10/2026Tennessee says that "every step of the protocol was followed". So what happened? IV access? Drug delivery? Preparation? Pharmacokinetics? We don't know. 110
@IM_Crit_ @imcrit.bsky.social · 01/10/2026The new protocol has a backup plan: if the first set of pentobarbital doesn't work, give a second. Pike received both. More than an hour after the execution started, witnesses could reportedly still hear her breathing and snoring. She was eventually taken to a hospital. 110
@IM_Crit_ @imcrit.bsky.social · 01/10/2026News: 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. 120
@IM_Crit_ @imcrit.bsky.social · 01/10/2026Maybe Merck has a better explanation. I’d genuinely like to hear it. Antibiotic resistance is accelerating. Our antibiotic business model is moving in the opposite direction. #medsky #idsky #emimcc 110
@IM_Crit_ @imcrit.bsky.social · 01/10/2026Will this leave us defenseless? No. Other agents cover many of the same resistant bugs The point is what happens when we finally develop another weapon against MDR bacteria and discover that the economics reward selling antibiotics often, while stewardship requires us to use them rarely. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026One important detail: This does not appear to be a global withdrawal. Recarbrio remains authorized in Europe. So, this appears primarily to be a U.S. market exit. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026So the better we steward the antibiotic, the less frequently we use it. And the less frequently we use it, the smaller its commercial market. **That is the antibiotic paradox.** We need new antibiotics to be valuable enough to develop but rarely used enough to preserve their effectiveness. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026Recarbrio launched at roughly $268/vial, summing up to roughly $10,000 for a 10-day course. More recently, wholesale list pricing reached approximately $8,141 for 25 vials, or about $326/vial. Hospitals are supposed to reserve antibiotics like this for patients who truly need them. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026And here is where the story gets interesting. Drugs like this are supposed to be used **selectively**. That's good antimicrobial stewardship. But it creates a difficult economic model. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026In 2020, it was approved for hospital- & vent-associated bacterial pneumonia. In 2025, its indication expanded to children ≥ 2kg Why did we need it? Because relebactam inhibits β-lactamases -including KPC and AmpC- helping restore imipenem activity against extremely difficult Gram(-) infections 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026And that should make every intensivist, ID physician, and pharmacist uncomfortable. Recarbrio is the trade name of imipenem/cilastatin + relebactam. The FDA approved it in 2019 for complicated infections in adults with limited or no alternatives. 100
@IM_Crit_ @imcrit.bsky.social · 01/10/2026#ICU News: Recarbrio is disappearing from the U.S. market. Not because it failed. Not because of a safety signal. Not because resistant bacteria disappeared. Merck is discontinuing it as part of a portfolio decision. I guess “portfolio decision” is the code name for “not profitable drug”. 110
@IM_Crit_ @imcrit.bsky.social · 28/09/2026ICU hot take: A white-out lung is not, by itself, an indication for intubation and bronchoscopy. Intubating someone for a “therapeutic bronch” without first putting an ultrasound probe on the chest should be a federal crime. #POCUS #FOAMcc 160
@IM_Crit_ @imcrit.bsky.social · 26/09/2026Different viruses. Same basic return-to-work framework. There are exceptions, and your hospital's Occupational Health policy may be more restrictive. Now I just need to follow my own advice and stop treating “I feel like crap” as an indication to go to work anyway... 110
@IM_Crit_ @imcrit.bsky.social · 26/09/2026Wear a well-fitting mask or respirator through at least Day 5 after your last exposure and monitor for symptoms for at least 5 days. Also worth noting: CDC doesn't consider simply walking past someone with a cold in the hallway an “exposure.” Proximity, duration, PPE and ventilation matter. 110
@IM_Crit_ @imcrit.bsky.social · 26/09/2026A well-fitting medical mask meets the source-control requirement. Obviously, that doesn't replace PPE. If the patient's isolation precautions or the procedure require an N95, wear an N95. 🦠 Exposed but feeling fine? Generally, NO work restriction. 110
@IM_Crit_ @imcrit.bsky.social · 26/09/2026😷 When you return: Wear a well-fitting medical mask or respirator through the end of Day 7 and Day 8 is the first possible day without the added masking requirement. And no, you don't automatically need an N95 just because you're returning after an infection. 210
@IM_Crit_ @imcrit.bsky.social · 26/09/2026🤒 If you're sick: Day 0 = symptom onset. You can return Day 4 or later when: 1. At least 3 d have passed since symptoms started 2. You've been fever-free ≥ 24 h without antipyretics 3. Symptoms are improving 4. You feel well enough to work 110
@IM_Crit_ @imcrit.bsky.social · 26/09/2026The return-to-work rules just changed for healthcare workers with respiratory infections The practical change: Day 4 may now be the EARLIEST return to work but ONLY IF you meet ALL the criteria below CDC now uses the SAME framework for COVID-19, influenza, RSV & several other respiratory viruses 311
@IM_Crit_ @imcrit.bsky.social · 21/09/2026Both present an alignment problem. For one, we have an algorithm. For the other, we have a research problem. Be safe. 010
@IM_Crit_ @imcrit.bsky.social · 21/09/2026There 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. 210
@IM_Crit_ @imcrit.bsky.social · 20/09/2026I usually include it in the admission orders for most of my ICU patients along with DVT and GI prophylaxis...! T deficiency behaves less like an obscure vitamin deficiency & more like a potentially reversible form of mitochondrial energy failure. #foamed #foamcc #meded #emimcc 100
@IM_Crit_ @imcrit.bsky.social · 20/09/2026Especially think about it when you see malnutrition/refeeding, alcoholism/cirrhosis, dialysis, polyuria/DKA, chronic diuretics, unexplained encephalopathy, sepsis, or otherwise unexplained persistent hyperlactatemia 100
@IM_Crit_ @imcrit.bsky.social · 20/09/2026 Rule of thumb: “⬆️ lactate + risk factor + no good explanation" → think B1 deficiency” 100
@IM_Crit_ @imcrit.bsky.social · 20/09/202610. The kidney may be an important target organ Renal tubular cells are highly energy dependent. Across secondary analyses, observational data, and meta-analytic evidence, T supplementation -particularly in deficient patients- shows a signal toward less AKI 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20269. 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 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20268. Sepsis data are more nuanced than “T works” or “T doesn't work” T is not expected to improve hard outcomes in the overall septic-shock population. Some subgroup analyses & meta-analyses suggest signals for improved lactate clearance & organ function. I don't consider it a magic drug... 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20267. A plasma thiamine concentration is not a great “rule-out” test Testing is often unavailable/expensive. Blood concentration does not necessarily reflect tissue thiamine status. I don't even remember when I last ordered the test. Just recognize the risk population and consider a therapeutic trial 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20266. Do not wait for the classic Wernicke's triad Altered mental status, ocular abnormalities & gait ataxia are rarely all present together. I think I've seen it only a few times. In an at-risk ICU patient w otherwise unexplained encephalopathy, absence of the complete triad should not reassure you 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20265. 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 100
@IM_Crit_ @imcrit.bsky.social · 20/09/20264. Starting nutrition can unmask the deficiency Glucose administration ⬆️ carbohydrate metabolism & T utilization. A malnourished pt may develop ⬆️ lactate after initiation of par-enteral nutrition. Refeeding syndrome is not simply a Phos/K problem; T deficiency can be central to its pathophysiology 100
