How important are vancomycin levels? Not very.... at least as a marker of efficacy. True, higher levels probably are associated with increased nephrotoxicity (above 15 mcg/mL) - Antimicrob Agents Chemother. 2013 ;57:734-44But the notion that troughs of 15-20 mcg/mL are the holy grail of therapeutic drug monitoring targets is simply not supported by data.What we know: vancomycin AUC/MIC in the mid 300 to 400s (let's just say > 400) or so range is likely the [...]

Obviously any patient that requires mechanical ventilation for 48 hours or has "coagulopathy" should get stress ulcer prophylaxis (SUP) right? maybe not....when the above risk factors where identified in 1994 by Deborah Cook (N Engl J Med. 1994;330(6):377-81.) and studies validating SUP as an effective means of preventing GI bleeding in critically ill patients were published (Crit Care Med.1993;21:1844-9. and Crit Care Med. 1993;21:19-30 - btw, cimetidine continuous infusion, really?) critical care was quite different [...]

I frequently encounter people touting that "The INR of FFP is like 1.6 or something". Indeed I learned something similar myself at some point. It turns out however that the mean INR of FFP is actually 1.1 (Transfusion 2005;45:1234-5.). So why does it seem like no matter how much FFP you tend to give, it is very difficult to get the INR much lower than 1.6 or so?As can be seen from the image below [...]

I frequently encounter people touting that "The INR of FFP is like 1.6 or something". Indeed I learned something similar myself at some point. It turns out however that the mean INR of FFP is actually 1.1 (Transfusion 2005;45:1234-5.). So why does it seem like no matter how much FFP you tend to give, it is very difficult to get the INR much lower than 1.6 or so?As can be seen from the image below [...]

With the recent publication of the SMART and SALT-ED trials, the chloride rich vs poor (balanced/buffered) crystalloid debate is back in the spotlight after a break post the orginal Yunos JAMA 2012 and SPLIT JAMA 2015. Something I commonly hear from internal medicine residents however is that LR and plasma-lyte should DEFINITELY be avoided in the setting of hyperkalemia, since they contain 4 and 5 meq/L of potassium respectively.It turns out however that normal saline [...]

With the recent publication of the SMART and SALT-ED trials, the chloride rich vs poor (balanced/buffered) crystalloid debate is back in the spotlight after a break post the orginal Yunos JAMA 2012 and SPLIT JAMA 2015. Something I commonly hear from internal medicine residents however is that LR and plasma-lyte should DEFINITELY be avoided in the setting of hyperkalemia, since they contain 4 and 5 meq/L of potassium respectively.It turns out however that normal saline [...]

One question I commonly encounter on rounds is "does acidosis reduce the activity of catecholamines?" While I think that at this point it is relatively clear that acidosis likely reduces LV contractility due to reduced intracellular calcium entry as well as H+ competition for calcium binding sites on myocardial troponin, I think that the notion that catecholamines "don't work as well in acidosis" is less clear. The bulk of the data that comprises this idea [...]