iiinova — where your digital self keeps evolving

josh farkas 💊 @pulmcrit.bsky.social · 02/09/2026

Fresh IBCC chapter on airway management: 🤿 Systematic pre-intubation evaluation, optimization, & checklist 🤿 BiPAP preoxygenation 🤿 HOB up, sniffing position 🤿 1st attempt with hyperangulated VL 🤿 Pulmonologist-style bronch for awake intubation emcrit.org/ibcc/tube/

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josh farkas 💊 @pulmcrit.bsky.social · 06/08/2026

Fresh Blog: Why I think hyperangulated VL should be the default for ICU intubations: 📹 People actually use the tool correctly 📹 Master one technique for easy & hard airways 📹 Compatible with steep bed angulation 📹 The fresh COVALENT MC-RCT 😁 #EMIMCC blog: emcrit.org/pulmcrit/hab...

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josh farkas 💊 @pulmcrit.bsky.social · 21/06/2026

Is oseltamivir killing ICU patients? The p-value for these results is NOT significant by traditional Frequentist benchmarks (p>0.05). But Bayesian statistics yield strongly positive results! Where does the truth lie? See what you think. Fresh blog: emcrit.org/pulmcrit/rem...

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josh farkas 💊 @pulmcrit.bsky.social · 21/06/2026

Fresh Blog: Is oseltamivir assassinating ICU patients? ☠️ The REMAP-CAP trial has concluded with >98% certainty that oseltamivir is killing patients. ☠️ This is an extraordinary claim that requires extraordinary evidence. #1/2... #EMIMCC

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Reposted by josh farkas 💊

Anand Swaminathan @emswami.bsky.social · 10/06/2026

Nicardipine: great for htn emergency but, can see transient hypotension even w/ slow titration -Key is to load + drip -Start 5 mg/hr + titrate up 2.5 mg/hr q5 min -When reach target BP, drop dose back to 5 mg/hr + retitrate infusion until get to steady state youtube.com/shorts/2F0-1... #EMIMCC

youtube.com

Nicardipine Titration #emergencymedicine #criticalcare

YouTube video by EMSwami

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josh farkas 💊 @pulmcrit.bsky.social · 05/06/2026

💯💯 people freak out about the pH, but its the dyskalemia that is really dangerous

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josh farkas 💊 @pulmcrit.bsky.social · 25/05/2026

Stop using IGRA to test for active pulmonary TB! this keeps coming up, so I summarized my take-home messages on this (with a link to the BlueSky discussion) in hospitals that lack deep experience with TB, I think the best heuristic is simply not to use an IGRA to look for active pulmonary TB

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josh farkas 💊 @pulmcrit.bsky.social · 21/05/2026

I'll start- the neutrophil/lymphocyte ratio (NLR) substantially outperforms the WBC for detection of infection Using WBC as an indicator of infection made sense 50 years ago It's 2026, we have better lab instruments, & its time to move on from the WBC more on NLR here: emcrit.org/pulmcrit/nlr/

emcrit.org

PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC

introduction The neutrophil/lymphocyte ratio (NLR) has been gaining increasing attention across many fields of medicine within the past five years.

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josh farkas 💊 @pulmcrit.bsky.social · 21/05/2026

what is your best pearl, or most useful reference, about interpreting a complete blood count with differential? The blood count is one of the most commonly ordered tests in clinical medicine, but its subtleties are woefully overlooked. #EMIMCC

static.klipy.com

Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

ALT: Inception: We Need To Go Deeper Meme with Leonardo DiCaprio

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josh farkas 💊 @pulmcrit.bsky.social · 14/05/2026

we’ve integrated the PREOXI trial into our practice so well that there’s an entire cabinet in our ICU dedicated to it 😁 this improves intubation success & safety. I’vd wanted to do this for a decade but the RCT provided EBM backing to push it forward more here emcrit.org/pulmcrit/bsi/

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josh farkas 💊 @pulmcrit.bsky.social · 09/05/2026

CBC is trivially cheaper than CBC with diff so theoretically, across millions of CBCs we are "wasting" money if we get CBC w/ diff BUT there's no actual real-life cost difference, it's only a slight difference in the facility charge to insurance I don't think this cost difference is meaningful

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josh farkas 💊 @pulmcrit.bsky.social · 09/05/2026

Proposal: for complex patients (eg ICU) we should *always* get CBC w/ differential (not a plain CBC) - Same amount of blood - Run by the same machine (it usually CHECKS the differential & just dumps the data!) - Trivial cost difference - Can be helpful (eg Eos 2/2 drug, NLR) #EMIMCC

static.klipy.com

Beelzebub's Interesting Proposal (Good Omens)

ALT: Beelzebub's Interesting Proposal (Good Omens)

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josh farkas 💊 @pulmcrit.bsky.social · 06/05/2026

my key advice on bupropion XR intoxication: if you intubate a patient for seizures, place a gastric tube & start whole bowel irrigation immediately don't debate, just do it irrigation reduces ongoing drug absorption, minimizing deterioration more emcrit.org/ibcc/bupropi...

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josh farkas 💊 @pulmcrit.bsky.social · 06/05/2026

everyone learns about TCA overdose in med school, but not bupropion XR overdose time to level up bupropion XR overdose is increasingly common & VERY dangerous ongoing drug absorption creates a "toxin bomb" wherein patients look OK initially, but deteriorate later on... (#1/2) #EMIMCC

static.klipy.com

CS:GO Bomb Defuse Timer Countdown Animation

ALT: CS:GO Bomb Defuse Timer Countdown Animation

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josh farkas 💊 @pulmcrit.bsky.social · 22/04/2026

one fun thing about using phenobarbital for seizures in ICU is that you can be as precise as you want (PK is predictable & levels turnaround fast) high precision usually isn't needed but if the neuro team wants me to hit a specific phenobarbital level in brittle SE, I'm on it 🫡. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 19/04/2026

I’m a little skeptical that antibiotics do a whole heck of a lot for sinusitis at all 🤷‍♂️ the latest Cochrane review says maybe it accelerates recovery but it’s not like people are dying from untreated sinusitis

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josh farkas 💊 @pulmcrit.bsky.social · 18/04/2026

tough to say but yeah, there may be an expanded role here for keeping pts, supporting temporarily with pulmonary vasodilators and using variable dosing strategies for tPA reminds me of the time before we had catheter-directed embolectomy used more tPA & overall our outcomes were probably similar 😆

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josh farkas 💊 @pulmcrit.bsky.social · 18/04/2026

avoid truly fetotoxic meds (e.g., valproic acid), but these are uncommon mostly focus on providing excellent & usual care (doing the basics well) IBCC chapter on status epilepticus: emcrit.org/ibcc/sz/#top IBCC section on status in pregnancy: emcrit.org/ibcc/ob/#sei...

media.tenor.com

a little girl wearing sunglasses is standing in a doorway and says `` good luck ! love you you got this gogg ! ''

ALT: a little girl wearing sunglasses is standing in a doorway and says `` good luck ! love you you got this gogg ! ''

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josh farkas 💊 @pulmcrit.bsky.social · 18/04/2026

medicine of the PITT: status epilepticus in pregnancy if you're using levetiracetam as your go-to antiseizure med (as most folks are), then the treatment is essentially the same as usual add Mg, but Mg prevents sz recurrence (rather than lysing active sz) #1/2 #EMIMCC

media.tenor.com

a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

ALT: a man with a stethoscope around his neck is sitting in front of a sign that says " only time will tell "

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josh farkas 💊 @pulmcrit.bsky.social · 14/04/2026

PS- updated the critical asthma chapter tough to write (opinions >>> data) I've boiled it down & made it more prescriptive (cannot cover every treatment style/option) lotta ways to skin the asthma cat, this is my general preference, adapt to the patient in front of you emcrit.org/ibcc/asthma/

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josh farkas 💊 @pulmcrit.bsky.social · 14/04/2026

You're basically correct, but there are some exceptions, so 99% figure may be too high. [1] Some patients don't respond to lysis (old rubbery clot) [2] There is a group of high-risk submassives at risk of ICH who benefit from catheter thrombectomy. Likely smaller than we used to think, maybe ~5%.

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josh farkas 💊 @pulmcrit.bsky.social · 14/04/2026

is there a reason that we don't use more IV glycopyrrolate for status asthmaticus? admittedly minimal direct evidentiary support, but makes sense & indirect evidence seems more benign than various alternative treatments (eg intubation, ECMO, extracorporeal CO2 removal). #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 12/04/2026

I’m a proud brand ambassador for generic hospital scrubs™️ Hospital scrubs are laundered at higher temperatures than your home washer, making them cleaner. Hospital scrubs: ✅ Easy ✅ Clean ✅ Make your body look like a human blimp

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josh farkas 💊 @pulmcrit.bsky.social · 03/04/2026

It's wild that a single company managed to brainwash the entire specialty of neurocritical care into believing that NPi is the be-all and end-all of pupillometry. It's not. eg: for predicting DCI after SAH, trending CV is better 👇 More on NPi: emcrit.org/pulmcrit/npi/

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josh farkas 💊 @pulmcrit.bsky.social · 03/04/2026

Pet peeve: Research on pupillometry that only reports the neural pupil index (NPi) is worthless & will wind up in the ash heap of history. NPi is *proprietary* & calculated with a *secret* formula by *one* company's product. Does this seem like ideal scientific practice?...#1/2 #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 02/04/2026

meh, these things come and go… i’m hoping everyone will forget about it soon

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josh farkas 💊 @pulmcrit.bsky.social · 31/03/2026

note to self: use more IV nalbuphine it's supported by robust theoretical & clinical evidence I'm pretty sure the only reason we don't use it more often is due to our training and habits (habit-based practice, not evidence-based practice) esp. useful in patients with tenuous respiratory drive

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josh farkas 💊 @pulmcrit.bsky.social · 31/03/2026

PS - Due to some feedback on X and Bluesky, I updated the section on functional endpoints to clarify my thoughts on this. This is admittedly murky and not the primary reason to perform thrombolysis.

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josh farkas 💊 @pulmcrit.bsky.social · 30/03/2026

HI-PEITHO #2/2: 🔊 Select pts benefit (intermediate-high risk, borderline vitals, RV/LV >1) 🔊 Study used a fancy vibrational catheter that delivered tPA directly into the pulmonary artery, which is almost certainly unnecessary & adds procedural risks. blog: emcrit.org/pulmcrit/hip...

media.tenor.com

Vibby Vibby Vibes GIF

ALT: Vibby Vibby Vibes GIF

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josh farkas 💊 @pulmcrit.bsky.social · 30/03/2026

Fresh blog on the HI-PEITHO trial 😁 🔊 ~18 mg alteplase over 7 hrs is safe (no ICH, no difference in bleeding rates) 🔊 Alteplase reduces the risk of cardiopulmonary decompensation and poor functional outcomes #1/2 #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 28/03/2026

will blog about this soon. It's a very useful trial once you realize that the catheter delivery of tPA is equivalent to peripheral tPA. Unfortunately, most people won't realize that. Industry sponsors are trying to hijack the entire research agenda and are largely getting away with it.

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josh farkas 💊 @pulmcrit.bsky.social · 28/03/2026

it's hilarious watching people desperately try to apply the AHA/ACC risk stratification system to the HI-PEITHO trial HI-PEITHO was built off of the ESC risk-stratification system and it's impossible to map these patients onto the AHA/ACC classification. ESC is better. just use it.

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josh farkas 💊 @pulmcrit.bsky.social · 26/03/2026

missing sepsis - bad misdiagnosing another catastrophe as “sepsis” - also bad it almost makes me think that maybe we should specially train people how to identify and differentiate these disease processes and provide personalized care 🤔

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josh farkas 💊 @pulmcrit.bsky.social · 24/03/2026

kudos to ACEP for calling out the Surviving Sepsis Campaign 2026 guidelines and not joining in this madness. ACEP is great at making evidence-based policies that actually *help* provide better patient care. When ACEP is politely burning your guideline, you’re in trouble. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

Yeah, I’m not sure who they’re trying to help but surely not us. Other organizations (eg ACEP) do a much better of creating practice guidelines that don’t box doctors into a medicolegal corner for trying to do the right thing.

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

PS - I'm not going to do a blog on this because I've already done a lot of blogs on the SCC and they don't work. The SCC is just too much of a behemoth to resist. If you're looking for a PulmCrit blog on this theme, this one from 2019 is still good. emcrit.org/pulmcrit/ssc...

emcrit.org

PulmCrit: The surviving sepsis campaign 1-hour bundle is... back?

The surviving sepsis campaign (SSC) has had substantial problems dating back to its inception. The original backbone of the guidelines was a

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

sick patient in the ambulance, and there's a red light at the intersection? VANC ZOSYN

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

It just doesn't make any sense. We spend tons of effort checking procalcitonin and stopping ABX as soon as possible, then the SCCM is just like "hey what if we gave broad-spectrum antibiotics to everyone".

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josh farkas 💊 @pulmcrit.bsky.social · 23/03/2026

Surviving Sepsis 2026 is here & it's even more loony tunes than I was expecting. They're promoting pre-hospital ABX & preemptive broad-spectrum IV antibiotics for intubated patients. This insane fever dream is an antimicrobial stewardship nightmare. Embarrassment for SCCM. #EMIMCC

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josh farkas 💊 @pulmcrit.bsky.social · 22/03/2026

target sat >88% pacer set to 88 b/m LFG

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josh farkas 💊 @pulmcrit.bsky.social · 19/03/2026

sorry, drowning pancreatitis patients is the worst

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josh farkas 💊 @pulmcrit.bsky.social · 19/03/2026

If you missed this, read it before the HI-PEITHO trial comes out on 3/28 I think the STRATIFY trial will be integral to understanding and applying the results of the HI-PEITHO trial 😁🤞

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josh farkas 💊 @pulmcrit.bsky.social · 19/03/2026

someday this will make a funny story. I think the time for change on this BS will be measured in decades, not years. People cling to dogma hardest that is supported by the least data.

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josh farkas 💊 @pulmcrit.bsky.social · 16/03/2026

👁️ Using the NPi hampers the generalizability of research data across different locations that use different pupillometers. 👁️ Superior pupillary index formulations are likely coming soon that will render the NPi obsolete. Fresh blog here: emcrit.org/pulmcrit/npi/

emcrit.org

PulmCrit: Six reasons to stop relying on the NPi (neurological pupil index)

what is the NPi (neurological pupil index)? The pupillary light reflex is one of the most fundamental tests of clinical medicine. Unfortunately,

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josh farkas 💊 @pulmcrit.bsky.social · 16/03/2026

Fresh blog: Six reasons to stop relying on the NPi (neurological pupil index) 👁️ NPi is based on a secret, proprietary formula used by one company 👁️ The neuroICU field was somehow convinced that we're too stupid to understand pupillometry tracings, so we need the NPi...(#1/2) #EMIMCC

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