Prasad Nadendla @ventwhisperer.bsky.social · 15/04/2026Was just talking about this with a Co fellow. ESC is so simple to use without needing to constantly reference the guidelines. 000
Prasad Nadendla @ventwhisperer.bsky.social · 02/04/2026Yeah there is definitely a signal towards that. That's one of my issues with using complicated composite scores. 110
Prasad Nadendla @ventwhisperer.bsky.social · 02/04/2026💡 My Takeaway: CDT is likely not contributing any benefit in HI-PEITHO, just the lower dose of lytic. We need more research on the optimal thrombolytic dose. We are seeing positive outcomes with doses much lower then full dose lytics. 📚 Full protocols & Summaries in my ICU Cheat Sheet 👇docs.google.comLandmark Studies in Critical Care MedicineLandmark Studies in Critical Care Medicine 🫁 Pulmonary & Respiratory Medicine Acute Respiratory Distress Syndrome (ARDS) ARMA (Ventilation with Lower Tidal Volumes - 2000): Showed a significant mortal... 140
Prasad Nadendla @ventwhisperer.bsky.social · 02/04/2026🤔 But does the delivery method matter? The STRATIFY trial (2026) compared 20mg of Alteplase via ultrasound-catheter (USCDT) vs. a simple peripheral IV. Result: ZERO difference in clot reduction or outcomes. The expensive hardware didn't add any benefit. 110
Prasad Nadendla @ventwhisperer.bsky.social · 02/04/2026📊 HI-PEITHO showed that low-dose lysis + heparin is superior to heparin alone, reducing hemodynamic collapse from 10.3% to 4%. Additionally there was 0% intracranial hemorrhage in the lysis arm. Low-dose lysis seems safe and effective. 110
Prasad Nadendla @ventwhisperer.bsky.social · 02/04/2026🚨 Follow up post to my review of HI-PEITHO. Does catheter directed Thrombolysis actually work? STRATIFY Trial suggests CDT doesn't work. 🧵👇 #MedSky #CritCare #FOAMed #emimcc 131
Prasad Nadendla @ventwhisperer.bsky.social · 01/04/2026Yeah I was planning to do a follow up post on that article. 010
Prasad Nadendla @ventwhisperer.bsky.social · 01/04/2026Sorry if that last post in the thread is confusing. I'm saying that the catheter directed approach doesn't seem to provide any additional benefit. Peripheral lytics work just as well but the protocol used in this study does seem effective and with low risk of intracranial bleeding. 020
Prasad Nadendla @ventwhisperer.bsky.social · 31/03/2026💡 My Takeaway: 18mg of Alteplase is a viable strategy for treating intermediate high risk PE with anticoagulation unrelated to catheter directed approach. 📚 I’ve added the full protocol & Josh Farkas's review to my open-access ICU Cheat Sheet. Get it here 👇docs.google.comLandmark Studies in Critical Care MedicineLandmark Studies in Critical Care Medicine 🫁 Pulmonary & Respiratory Medicine Acute Respiratory Distress Syndrome (ARDS) ARMA (Ventilation with Lower Tidal Volumes - 2000): Showed a significant mortal... 142
Prasad Nadendla @ventwhisperer.bsky.social · 31/03/2026🤔 The Safety: Systemic lytics usually carry a ~2% ICH risk. In HI-PEITHO? 0% intracranial hemorrhage in the USCDT arm. Major bleeding was higher (6.4% vs 1.1%), but mostly at the access site. A huge safety win for lytics. 120
Prasad Nadendla @ventwhisperer.bsky.social · 31/03/2026📊 The Trial: USCDT (EKOS) + Heparin vs Heparin alone. Primary outcome (PE-death/collapse/recurrence) reduced from 10.3% to 4.0%. A 61% reduction in bad outcomes, driven by a massive drop in hemodynamic collapse. 100
Prasad Nadendla @ventwhisperer.bsky.social · 31/03/2026🚨 Intermediate-high risk PE: RV strain + troponin. Stable for now, but will they crash? HI-PEITHO (NEJM 2026) finally gives us RCT data for Catheter-Directed Lysis (USCDT). Is this the new standard for the "sickest of the stable"? 🧵👇 #MedSky #CritCare #FOAMed #emimcc 110
Reposted by Prasad NadendlaKathleen Bachynski @bachynski.bsky.social · 31/03/2026I showed this graph in class yesterday on how measles cases in the United States plummeted dramatically after the vaccine was licensed in 1963. It’s not subtle and I could not resist observing: “This stunning design in measles cases was not thanks to vitamin A. It was not due to beef tallow.” 1678212538
Prasad Nadendla @ventwhisperer.bsky.social · 27/03/2026I could see some CCM people having different practices from PCCM because some CCM folks don't come from medicine (EM and Anesthesia). 210
Prasad Nadendla @ventwhisperer.bsky.social · 27/03/2026Do you find that in those cases it's due to when people did training? 100
Prasad Nadendla @ventwhisperer.bsky.social · 27/03/2026It's quite shocking the practice differences between SICU and MICU even for overlapping conditions. 121
Prasad Nadendla @ventwhisperer.bsky.social · 26/03/2026Yeah my takeaway was the progress towards phenotyping septic shock which I do think is the future. 210
Prasad Nadendla @ventwhisperer.bsky.social · 26/03/2026In general I don't like protocol or algorithm driven care. This feels like many patients will unnecessarily get PA catheters which are not without complications. 281
Prasad Nadendla @ventwhisperer.bsky.social · 26/03/2026🚨 New Trial: TIGRIS 🚨 Polymyxin B Hemoadsorption (PMX) in endotoxic septic shock. ✅ 99.4% probability of benefit for 90-day survival. ✅ 15.5% absolute risk reduction in mortality. ✅ NNT of 6.5 Interesting step towards endotyping shock and immune mediated management.🧬 #FOAMed #emimcc #critcarethelancet.comPolymyxin B haemoadsorption in endotoxic septic shock (Tigris): a multicentre, open-label, Bayesian, randomised, controlled, phase 3 trialIn patients with endotoxic septic shock defined by high endotoxin activity and multiorgan failure, polymyxin B haemoadsorption was associated with a high probability of lower mortality at 28 days and ... 241
Prasad Nadendla @ventwhisperer.bsky.social · 17/03/2026But that's more the loss of pulsatility causing the issue and not the device. Since the micro axial device has non pulsatile flow is there not some loss of the Windkessel effect just from the device? 100
Prasad Nadendla @ventwhisperer.bsky.social · 16/03/2026Just wanted to follow up. I had already been working on a big presentation about hemodynamic targeted CPR and this was a phenomenal lecture with great resource. Will be listening to part II. Appreciate your recommendation. 001
Prasad Nadendla @ventwhisperer.bsky.social · 16/03/2026Patient with cardiogenic shock, EF <10%. Micro axial flow device is placed. Is there loss of the Windkessel effect due to the micro axial device? #emimcc #critcare #FOAMed #Physiology 310
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026I will say that presence of cuff leak is contextual. If intubated for airway edema then I think it matters or they may even need visualization of the airway prior to extubation. On the other hand if they were intubated with a large tube 8.0 or bigger then they may not get a leak regardless. 000
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026I like the Cleveland Clinic SEVA method for liberation. They basically have a set of parameters that must be met before a true SBT is performed. I'd share the image here but it was a payed course and am not sure they would appreciate me sharing their material. 111
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026Great thought, Josh! In a beating heart, I completely agree. But during CPR, isn't the systolic peak (and thus PP) mostly an artifact of the mechanical compression force rather than intrinsic contractility? I lean toward DBP since it is the pure driver of coronary perfusion. 100
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026Thanks for sharing this. I'll give it a listen. 000
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026To round out the HD-CPR thread: read the curves, not just the digital numbers! EMCrit has two perfect deep-dives on this. One on targeting A-line DBP > 35, and another on reading true 'Pre-Tidal' EtCO2 curves during compressions. #FOAMed emcrit.org/emcrit/dbp-c... emcrit.org/emcrit/preti...emcrit.orgEMCrit 244 - Incredibly Important Wrinkles to Titrated Vasopressors during CPR in Cardiac Arrest with PO BerveWe've been doing it all wrong--mysteries solved thanks to PO Berve 010
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026Following up on the HD-CPR post: here is Per Olav Berve at Big Sick 2018 explaining exactly why monitors lie to us during mechanical CPR. If you want to understand "pre-tidal" CO2 and true diastolic pressure, watch this. #CritCare #FOAMed #emimccyoutu.beHemodynamics during mechanical CPR | Per Olav Berve | Big Sick 2018YouTube video by scanFOAM 252
Prasad Nadendla @ventwhisperer.bsky.social · 15/03/2026Yeah in situations where there is vfib or vtach I think epi may do more harm then good and if they are maintaining diastolic pressures >35 you could argue holding the epi pushes. 010
Prasad Nadendla @ventwhisperer.bsky.social · 14/03/2026Good suggestions! Where I work <8cc/kg is pretty standard practice now. I think Prophyvap is particularly interesting since there seems to be growing evidence to support using a short course of abx for prophylaxis. Will need to do a formal journal club on that one. 000
Prasad Nadendla @ventwhisperer.bsky.social · 13/03/2026Hemodynamic-directed CPR question for everyone: If you have an A-line during arrest and compressions are generating a dBP >30-40 mmHg, do you consider holding ACLS epi pushes? Curious who is individualizing CPR here. #CritCareresuscitationjournal.comThe association between intra-arrest arterial blood pressure and return of spontaneous circulation in out-of-hospital cardiac arrestThe optimal haemodynamic parameter for goal-directed resuscitation in out-of-hospital cardiac arrest (OHCA) remains uncertain. This study aimed to characterise the association between invasive blood p... 331
Prasad Nadendla @ventwhisperer.bsky.social · 10/03/2026That a nice summary of the advantages and disadvantages. 110
Prasad Nadendla @ventwhisperer.bsky.social · 10/03/2026Thanks for the articles. Next time we do a hemodynamics conference I'm going to bring these up. 100
Prasad Nadendla @ventwhisperer.bsky.social · 10/03/2026I need to practice measuring IVDP. Do most ultrasounds have the software for the pressure estimation? 100
Prasad Nadendla @ventwhisperer.bsky.social · 10/03/2026Great read, Lars. I definitely won't put as much stock into single-beat Ees estimates after seeing that. But I still firmly believe in the 4-interface model. Individualized shock assessment with POCUS beats generic macro-hemodynamic targets any day. 110
Prasad Nadendla @ventwhisperer.bsky.social · 09/03/2026We are moving more and more into an individualized shock management era and POCUS is leading the way. I've been working on incorporating the interfaces model and estimating Ea/Ees for ventricular arterial uncoupling. #FOAMED #CritCare #POCUSskypmc.ncbi.nlm.nih.govPoint of View: A Holistic Four-Interface Conceptual Model for Personalizing Shock ResuscitationThe resuscitation of a patient in shock is a highly complex endeavor that should go beyond normalizing mean arterial pressure and protocolized fluid loading. We propose a holistic, four-interface conceptual model of shock that we believe can benefit ... 120
Prasad Nadendla @ventwhisperer.bsky.social · 25/02/2026💡 Takeaway: While there may be a signal for delayed RRT, we need a dedicated trial with unconfounded parameters to actually prove it. No ☠️ benefit. 📚 I put the exact protocols & FOAMed links for this & 50+ other trials in a living ICU Cheat Sheet. Access the Google Doc here 👇docs.google.comLandmark Studies in Critical Care MedicineLandmark Studies in Critical Care Medicine 🫁 Pulmonary & Respiratory Medicine Acute Respiratory Distress Syndrome (ARDS) ARMA (Ventilation with Lower Tidal Volumes - 2000): Showed a significant mortal... 020
Prasad Nadendla @ventwhisperer.bsky.social · 25/02/2026My Take: The protocol mandated RRT if pH ≤ 7.15. Because Bicarb directly raises pH, it's hard for me to view the reduced RRT rate as a definitive clinical win. It feels like we might just be treating the trigger number rather than saving nephrons. 110
Prasad Nadendla @ventwhisperer.bsky.social · 25/02/2026📊 The Trial: BICARICU-2 (The Lancet, 2025) Evaluated patients with severe metabolic acidemia (pH ≤ 7.20) and Stage 2-3 AKI. The Abstract: IV bicarb didn't improve 90-day survival, BUT it significantly delayed and reduced the need for Renal Replacement Therapy (RRT) from 50% to 35%. 110
Prasad Nadendla @ventwhisperer.bsky.social · 25/02/2026🚨 Septic shock, AKI, pH 7.15. Do you start a Bicarb drip? Does it save kidneys or just treat a number? I built an open-access "Landmark ICU Trials" cheat sheet/reference for rounds. Let's look at a new addition: BICARICU-2. 👇 #MedSky #CritCare #Nephrology #FOAMed #MedEd 120
Reposted by Prasad Nadendlajosh farkas 💊 @pulmcrit.bsky.social · 23/11/2025ADQI/ICA guidelines finally scrapped the 48-hour mandatory albumin infusion before formally diagnosing HRS-AKI I’ve argued against this for years (it delays tx for 3 days & you miss optimal window for intervention) HRS-AKI carries a massive ~30% in-hospital mortality, its an emergency…media.tenor.coma close up of a man 's face with a beard looking at the camera .ALT: a close up of a man 's face with a beard looking at the camera . 1191
Prasad Nadendla @ventwhisperer.bsky.social · 07/11/2025Institution dependent and nursing dependent. 000
Prasad Nadendla @ventwhisperer.bsky.social · 31/10/2025New ESICM guidelines on circulatory shock. www.esicm.org/esicm-guidel... 000
Reposted by Prasad Nadendlajosh farkas 💊 @pulmcrit.bsky.social · 29/10/2025New RCT: Avoiding A-line in shock didn't affect mortality (trend towards *reduction*) & decreased line complications They avoided A-lines despite patients requiring pretty substantial doses of vasopressors Very #zentensivist Don't need to rush to an A-line www.nejm.org/doi/full/10.... #EMIMCC 22712
Prasad Nadendla @ventwhisperer.bsky.social · 29/10/2025When looking at the secondary endpoints I think it's pretty telling. 000
Prasad Nadendla @ventwhisperer.bsky.social · 29/10/2025jamanetwork.com/journals/jam...jamanetwork.comHemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic ShockThis randomized clinical trial examines whether a personalized hemodynamic resuscitation protocol targeting capillary refill time was more effective than usual care in patients with early septic shock... 010