Critical Matters

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Challenging dogma in the ICU (Part II) Mar 13, 2025

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In a previous episode, Dr. Sergio Zanotti explored the importance of challenging dogma, particularly when the supporting evidence is weak or absent. Today, he continues that discussion by examining critical care practices that persist despite a lack of strong scientific validation. He's joined by Dr. Mervyn Singer, an internationally recognized leader in critical care medicine. Dr. Singer is a professor of intensive care medicine at University College London and a distinguished clinician, researcher, and educator. Through his research, publications, and dynamic presentations, he has inspired Dr. Zanotti — and countless intensivists worldwide — to think critically, challenge conventions, and push the boundaries of our field. Additional resources: Challenging management dogma where evidence is non-existent, weak, or outdated: part II. DA Hofmaennner and M. Singer. Intensive Care Med2024: https://pubmed.ncbi.nlm.nih.go Challenging management dogma where evidence is non-existent, weak, or outdated. DA Hofmaennner and M. Singer. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/35303116/ Biomarker-Guided Antibiotic Duration for Hospitalized Patients with Suspected Sepsis. The ADAPT-Sepsis Randomized Clinical Trial. JAMA 2025: https://pubmed.ncbi.nlm.nih.gov/39652885/ Hyperglycemic Crises in Adults with Diabetes: A Consensus Report. Diabetes Care 2024: https://pubmed.ncbi.nlm.nih.gov/38907161/ Books and music mentioned in this episode. Influenza: The Hundred-Year Hunt to Cure the 1918 Spanish Flu Pandemic. By. Jeremy Brown: https://amzn.to/3Ftb0mO Beethoven: 9 Symphonies / Karajan 1963: https://amzn.to/3R1M9ZO

Adult congenital disease in the ICU Feb 27, 2025

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Due to advancements in medical and surgical care, the survival of patients with congenital conditions into adulthood has dramatically increased. However, as these individuals transition to adulthood, their unique physiology, chronic complications, and evolving care needs create significant challenges for their management when they are admitted to adult intensive care units (ICUs). This episode will discuss adult congenital disease in the ICU. Dr. Zanotti is joined by Dr. Cameron Dezfulian, a pediatric and adult critical care physician. He is the director of the Adult Congenital Heart Disease Program Development for the Section of Critical Care at Texas Children's Hospital and a faculty member at Cardiothoracic Critical Care at Baylor St. Luke's Medical Center. He is also a Senior Faculty member at Baylor College of Medicine in Houston, Texas. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 Special Considerations in Critical of the Congenital Heart Disease Patient. E Neethling, et al. Can J Cardiol. 2023: https://pubmed.ncbi.nlm.nih.gov/36682483/ Management of the Critically Ill Adult with Congenital Heart Disease. WB Kratzert, et al. J Cardiothorac Vasc Anesth 2018: https://pubmed.ncbi.nlm.nih.gov/29500124/ Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units. J Edwards, et al. J Crit Care 2015: https://pubmed.ncbi.nlm.nih.gov/25466316/ Down Syndrome. MJ Bull. N Eng J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMra1706537 Books and Music mentioned in this episode: The Bible: https://bit.ly/3EK4LL6

Lessons from the wrong side of the heart Feb 12, 2025

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February 7-14 marks the observance of Congenital Heart Disease Awareness Week. In this podcast episode, Dr. Sergio Zanotti provides a unique perspective on adult congenital heart disease, drawing from his journey as a lifelong patient. He offers reflections shaped by his own experiences with complex adult congenital heart disease, including insights gained from a recent medical procedure that granted him a firsthand view of patient care in the ICU. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 The Bell Curve. By Atul Gawande. The New Yorker 2004: https://www.newyorker.com/magazine/2004/12/06/the-bell-curve Website for the Adult Congenital Heart Association: https://www.achaheart.org/ Books and music mentioned in this episode: Montaigne. By Stefan Zweig: https://bit.ly/4gEOVP2 The Heart. A Novel. By Maylis De Kerangal: https://bit.ly/41ehqin The Essays: A Selection (Penguin Classics). By. Michel de Montaigne: https://bit.ly/3EvFwvW

Optimizing renal replacement therapy in the ICU Jan 29, 2025

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Acute kidney injury is a frequent complication of critical illness, and a subgroup of these patients will require renal replacement therapy. In this episode. Dr. Sergio Zanotti discusses optimizing renal replacement therapy in the ICU. He is joined by Dr. Michael J. Connor, Jr., a practicing intensivist and nephrologist. He is a professor and senior physician of critical care medicine and nephrology at the Divisions of Pulmonary, Allergy, Critical Care, & Sleep Medicine and Renal Medicine at Emory University School of Medicine. In addition, he is the director of critical care nephrology at the Emory Critical Care Center at Grady Memorial Hospital. Additional resources: Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Wald R, et al. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/36066597/ Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. AKIKI Study Group. N Engl J Med 2016: https://pubmed.ncbi.nlm.nih.gov/27181456/ Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients with Acute Kidney Injury. ELAIN Trial. JAMA 2016: https://pubmed.ncbi.nlm.nih.gov/27209269/ Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis. IDEAL-ICU Investigators. N Eng J Med 2018: https://pubmed.ncbi.nlm.nih.gov/30304656/ Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. STARRT-AKI Investigators. N Engl J Med 2020: https://pubmed.ncbi.nlm.nih.gov/32668114/ Comparison of two delayed strategies for renal therapy initiation for severe acute kidney injury. AKIKI 2 Trial. Lancet 2021: https://pubmed.ncbi.nlm.nih.gov/33812488/ Books and Music mentioned in this episode: The Invisible Life of Addie LaRue. By V.E. Schwab: The Invisible-Life-Addie-LaRue Moon Music. By Coldplay: Moon-Music-Coldplay

Rational Fluid Therapy Jan 09, 2025

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In this episode, Dr. Sergio Zanotti discusses rational fluid therapy. He is joined by Dr. Adrian Wong, a practicing intensive care medicine and anesthesia physician. Dr. Wong is a consultant and clinical lead at King’s College Hospital, London. He also serves as a committee member for the Intensive Care Society FUSIC, examiner for the European Diploma of Intensive Care Medicine, on the executive committee of the International Fluid Academy. Additional resources: Intravenous fluid therapy in the perioperative and critical care setting” Executive summary of the International Fluid Academy (IFA). Malbrain ML, et al. Ann. Intensive Care 2020: https://pubmed.ncbi.nlm.nih.gov/32449147/ Multidisciplinary expert panel report on fluid stewardship: perspectives and practice. Malbrain ML, et al. Annals of Intensive Care 2023: https://pubmed.ncbi.nlm.nih.gov/37747558/ The emerging concept of fluid tolerance: A position paper. Kattan E, et al. Journal of Critical Care 2022: https://pubmed.ncbi.nlm.nih.gov/35660844/ Everything you need to know about derescuscitation. Malbrain ML, et al. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/35932335/ Start with Why. TED Talk presented by Simon Sinek: https://simonsinek.com/videos/ted-talks/ Books mentioned in this episode: Thinking Fast and Slow. By Daniel Kahneman: https://amzn.to/4hicUoj Start with Why: How Great Leaders Inspire Everybody to Take Action. By Simon Sinek: https://bit.ly/42hzt8n

2024 Year in Review Dec 26, 2024

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This episode of Critical Matters will close 2024 with a year in review. Dr. Sergio Zanotti is going solo and will discuss a couple of relevant clinical guidelines and review five clinical trials. To close, he'll share some of his favorite books for 2024. Additional Resources: Critical Care Management of Patients Post Cardiac Arrest (AHA/NCS): Hirsch KG, Abella BS, Amorim E, et al. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care. 2024;40(1):1-37: https://bit.ly/4087o1w 2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support: Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2024: https://bit.ly/4fD4o1R PREOXI Trial. Gibbs KW, Semler MW, Driver BE, et al. Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. 2024;390(23):2165-2177. doi:10.1056/NEJMoa2313680: https://bit.ly/4fD4pCX AMIKINHAL Trial. Ehrmann S, Barbier F, Demiselle J, et al. Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia. N Engl J Med. 2023;389(22):2052-2062. doi:10.1056/NEJMoa2310307: https://bit.ly/4iQQvzU REVISE Trial. Cook D, Deane A, Lauzier F, et al. Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation. N Engl J Med. 2024;391(1):9-20. doi:10.1056/NEJMoa2404245: https://bit.ly/3Pc4nqH TIGHT K Trial. O'Brien B, Campbell NG, Allen E, et al. Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery: The TIGHT K Randomized Clinical Trial. JAMA. 2024;332(12):979-988. doi:10.1001/jama.2024.17888: https://jamanetwork.com/journals/jama/fullarticle/2823246 BALANCE Trial. Daneman N, Rishu A, et al. Antibiotic Treatment for 7 versus 14 Days in Patients with Bloodstream Infections. N Engl J Med. Published online November 20, 2024. doi:10.1056/NEJMoa2404991: https://www.nejm.org/doi/abs/10.1056/NEJMoa2404991 CMD Study. Bodien YG, Allanson J, Cardone P, et al. Cognitive Motor Dissociation in Disorders of Consciousness. N Engl J Med. 2024;391(7):598-608. doi:10.1056/NEJMoa2400645: https://www.nejm.org/doi/full/10.1056/NEJMoa2400645 Books Mentioned in this Episode: Slow Productivity: The Lost Art of Accomplishment Without Burnout. By Cal New Port: https://amzn.to/4gTbkJ2 Meditations for Mortals: Four Weeks to Embrace Your Limitations and Make Time for What Counts. By Oliver Burkeman: https://bit.ly/4gURU6N Knife: Meditations After an Attempted Murder. By Salman Rushdie: https://bit.ly/3ZPsAIt

Return of the PAC Dec 11, 2024

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In this episode Dr. Zanotti discusses the current role of pulmonary artery catheters in critical care medicine. He is joined by Dr. Steven Hollenberg a critical care and cardiology physician. Dr. Hollenberg is a professor of medicine at Emory University School of Medicine and director of cardiac intensive care at the Emory Heart & Vascular Center. Additional resources: Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock. Kanwar MK, et al. J Card Fail. 2023 Sep;29(9):1234-1244: https://pubmed.ncbi.nlm.nih.gov/37187230/ Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. Bernard S Kadosh, et al. JACC Heart Failure 2023: https://pubmed.ncbi.nlm.nih.gov/37318422/ Complete Hemodynamic Profiling With Pulmonary Artery Catheters in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. A Reshad Garan, et al. JACC Heart Failure 2020: https://pubmed.ncbi.nlm.nih.gov/33121702/ Right Heart Catheterization in Cardiogenic Shock Is Associated With Improved Outcomes: Insights From the Nationwide Readmissions Database. Sagar Ranka, et al. J Am Heart Assoc 2021: https://pubmed.ncbi.nlm.nih.gov/34423652/ Books mentioned in this episode: I Contain Multitudes: The Microbes Within Us and a Grander View of Life. By Ed Yong: https://www.amazon.com/Contain-Multitudes-Microbes-Within-Grander/dp/0062368605/ref=sr_1_1?crid=1EVOY6OVQZ437&dib=eyJ2IjoiMSJ9.Na-UJShWq7ngsH9dxvSV2Q.Ob-k26_k01p5WzKzo4CWnsvD4Jjq9RU1krhQhmUi9u4&dib_tag=se&keywords=I+contain+platitudes&qid=1732299607&sprefix=i+contain+platitudes%2Caps%2C132&sr=8-1 Kind of Blue. Miles Davis: https://www.amazon.com/Kind-Blue-Vinyl-Miles-Davis/dp/B0041TM5OU/ref=sr_1_2?crid=E6F0PBPV33BG&dib=eyJ2IjoiMSJ9.4Kk2sCHn8DAOl9j_qadqsZPMVZPlOuKNXg9vv_NTPEYrl10vHYNIC5-wrGJeFpn9K8rSS8aspG9zhJHjAyDqiIUiC9VKvvHjzQsAGmr4wP9VWUPWumInjcS72CDmoaEYr3h2Uoiy8yt-YfYFHm7Y-6XoPecnwju8_zumwohrrhYWC0X6rR8Ui3Xhp6ILDU3sBNb50TJ6iq_fjataiHX7X6fBL1YnUo3X-uBcnQVfKtc.v-zGaYaLVvE7BGxS1c-2_Brbwsq1kAxVKEuxqsaBci8&dib_tag=se&keywords=Miles+Davis+Kind+of+Blue&qid=1732299762&sprefix=miles+davis+kind+of+blue%2Caps%2C139&sr=8-2 Brahms: Ein Deutsches Requiem. Sir Simon Rattle: https://www.amazon.com/Brahms-Ein-Deutsches-Requiem-German/dp/B000MTEDIE/ref=sr_1_5?crid=2UCHLINLHSETV&dib=eyJ2IjoiMSJ9.aDG2ZKyB5OnEgO3Z6_VOsNplIVSXmtXffLy2Jrylq4vgaRHEYDyBsz_4YG1fE_88IJxJ2ScnxhBvvDkVZjauoazwhTEMef0o_nJN25zUb_7oXFNkPMo_U4WBLhgK5njVOkm2ae67weI5roWsx-KbokunvjgAf-tXngA30o2xDQxh0-9y0kJbJRdKtVY63PcPv3yp9YdOrpgo2PO-gpspQsio7uJ-dgz5SY1vX1je3U4.aMm-IxbuxnZSIacaIBGZWc36GYliQP4r-9f9-SBq5tQ&dib_tag=se&keywords=Brahms+requiem&qid=1732299866&sprefix=brahms+requiem%2Caps%2C142&sr=8-5e

Choice Framing in ICU Goals of Care Meetings Nov 28, 2024

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In this episode, Dr. Sergio Zanotti discusses the application of behavioral economics to clinical practice, specifically choice framing in ICU goals-of-care Meetings. He is joined by Dr. Joanna Hart, a pulmonary critical care physician and assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. She is also a core faculty member of the Palliative and Advanced Illness Research Center and is affiliated with the Center for Health Incentives and Behavioral Economics. Additional Resources: Clinician’s Use of Choice Framing in ICU Family Meetings. Joanna L Hart et al. Crit Care Med 2024: https://pubmed.ncbi.nlm.nih.gov/38912880/ Using Default Options and Other Nudges to Improve Critical Care. Scott Halpern. Crit Care Med 2019: https://pmc.ncbi.nlm.nih.gov/articles/PMC5826616/ Books mentioned in this episode: Demon Copperhead. By Barbara Kingsolver: https://bit.ly/4hYCqQv Thinking Fast and Slow. By Daniel Kahneman: https://bit.ly/4i3eknK Nudge. By Richard H. Thaler, et al.: https://bit.ly/3YUqxlG

Management of Complications Post-Cardiotomy Nov 12, 2024

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In this episode, Dr. Sergio Zanotti discusses the management of critically ill patients after cardiac surgery, focusing on the clinical management of two important complications: hemorrhage and cardiac arrest. He is joined by Dr. Christopher Noel, a critical care attending at Cooper University Healthcare. Dr. Noel is also an assistant professor of medicine at Cooper Medical School of Rowan University and associate program director for the Critical Care Medicine Fellowship and the Clerkship Director for Critical Care Medicine Clerkships for Medical Students. Additional resources: American Association for Thoracic Surgery (AATS) TSRA Primer- Critical Care: https://www.aats.org/tsra-primer-post-operative-bleeding https://www.aats.org/tsra-primer-cardiac-arrest-post-cardiotomy The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery. Ann Thorac Surg 2017: https://pubmed.ncbi.nlm.nih.gov/28122680/ Society of Cardiovascular Anesthesiologists clinical practice improvement advisory for the management of perioperative bleeding and hemostasis in cardiac surgery patients. J of Cardiothoracic and Vascular Anesthesia 2019: https://pubmed.ncbi.nlm.nih.gov/31613811/ Music mentioned in this episode: The Outsiders. By Eric Church: https://bit.ly/4fHvxkp Collective Soul. By Collective Soul: https://bit.ly/3AzLcUd

Hyperglycemic Emergencies Oct 22, 2024

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In this episode, Dr. Sergio Zanotti discuss the management of critically ill patients undergoing hyperglycemic emergencies. He is joined by Dr. George Willis, a practicing emergency medicine physician. Dr. Willis is an Associate Professor and Associate Program Director for Emergency Medicine at the University of Texas Health Science Center in San Antonio, where he also serves as Vice Chair of Faculty Affairs. A recognized clinical educator, he holds a particular interest in endocrine emergencies, vascular emergencies, procedural education, and medical education. Additional resources: Hyperglycemic Crises in Adults with Diabetes: A Consensus Report. GE Umpierez, et al. Diabetes Care 2024: https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis. WH Self, et al. JAMA 2020: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670314/ Evaluation and Management of the Critically Ill Adult with Diabetic Ketoacidosis. B Long, GC Willis, S Lentz, et al. J Emerg Med 2020: https://pubmed.ncbi.nlm.nih.gov/32763063/ The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis) Impacts on ED operational Metrics. Acad Emerg Med 2023: https://pubmed.ncbi.nlm.nih.gov/36775281/ Books mentioned in this episode: Kintsugi: Finding Strength in Imperfection. By Celine Santini: https://bit.ly/3NCdAYB

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