josh farkas 💊
@pulmcrit.bsky.social
Pulm/crit attending at U. Vermont 🐄 Zentensivist 🧘♂️ trying to post more about medicine in order to distract myself from doomscrolling 🤦♂️ author of free online critical care textbook emcrit.org/ibcc/toc/ 📖 no conflicts of interest 💰
Trimethoprim-sulfamethoxazole carries a very low (but real) risk of causing ARDS.
Duration of therapy is a risk factor (>7 days).
Could likely be minimized by avoiding unnecessarily long courses.
TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC
Duration of therapy is a risk factor (>7 days).
Could likely be minimized by avoiding unnecessarily long courses.
TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC
November 24, 2025 at 8:48 PM
Trimethoprim-sulfamethoxazole carries a very low (but real) risk of causing ARDS.
Duration of therapy is a risk factor (>7 days).
Could likely be minimized by avoiding unnecessarily long courses.
TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC
Duration of therapy is a risk factor (>7 days).
Could likely be minimized by avoiding unnecessarily long courses.
TMP-SMX is usually well tolerated, but can wreak havok (SJS, ARDS, drug-induced meningitis). #EMIMCC
New study design:
Multiply a small & uncertain number with a big number and you get a big number
The final big number looks, well, really big
This grabs headlines & gets cited
It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything
Mathematically rigorous clickbait
Multiply a small & uncertain number with a big number and you get a big number
The final big number looks, well, really big
This grabs headlines & gets cited
It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything
Mathematically rigorous clickbait
November 23, 2025 at 2:27 PM
New study design:
Multiply a small & uncertain number with a big number and you get a big number
The final big number looks, well, really big
This grabs headlines & gets cited
It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything
Mathematically rigorous clickbait
Multiply a small & uncertain number with a big number and you get a big number
The final big number looks, well, really big
This grabs headlines & gets cited
It doesn’t clarify underlying uncertainty, so it doesn’t actually illuminate anything
Mathematically rigorous clickbait
I’d propose a formal framework for reaching a “probable HRS-AKI” diagnosis.
A probable HRS-AKI dx could be reached without delay (based on H&P, chart review, and POCUS evaluation of heart & kidney)
This would allow immediate treatment in parallel with ongoing investigation.
#EMIMCC
A probable HRS-AKI dx could be reached without delay (based on H&P, chart review, and POCUS evaluation of heart & kidney)
This would allow immediate treatment in parallel with ongoing investigation.
#EMIMCC
November 23, 2025 at 2:02 PM
I’d propose a formal framework for reaching a “probable HRS-AKI” diagnosis.
A probable HRS-AKI dx could be reached without delay (based on H&P, chart review, and POCUS evaluation of heart & kidney)
This would allow immediate treatment in parallel with ongoing investigation.
#EMIMCC
A probable HRS-AKI dx could be reached without delay (based on H&P, chart review, and POCUS evaluation of heart & kidney)
This would allow immediate treatment in parallel with ongoing investigation.
#EMIMCC
In terms of osm, you dont need to worry about what the cations are doing because the anions will balance them out
I think if you did the math the actual amount of H+ liberated would be minimal.
I think if you did the math the actual amount of H+ liberated would be minimal.
November 23, 2025 at 2:24 AM
In terms of osm, you dont need to worry about what the cations are doing because the anions will balance them out
I think if you did the math the actual amount of H+ liberated would be minimal.
I think if you did the math the actual amount of H+ liberated would be minimal.
a fancy nephrology guideline trying to describe how to titrate a norepi gtt is sending me 🤣
adjust q4hr??
the whole point of a NE gtt in HRS-AKI is immediate BP control
tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great
(and peripheral IV is fine)
adjust q4hr??
the whole point of a NE gtt in HRS-AKI is immediate BP control
tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great
(and peripheral IV is fine)
November 22, 2025 at 8:57 PM
a fancy nephrology guideline trying to describe how to titrate a norepi gtt is sending me 🤣
adjust q4hr??
the whole point of a NE gtt in HRS-AKI is immediate BP control
tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great
(and peripheral IV is fine)
adjust q4hr??
the whole point of a NE gtt in HRS-AKI is immediate BP control
tell the ICU RN the target MAP and they will achieve it immediately... that's why NE gtts are great
(and peripheral IV is fine)
Roon is launching a social media site for USA doctors only
Looks lame
The strength of MedTwitter has always been diversity (geographic & training - docs, RNs, PAs, pharmacists etc)
Further fractionating our community isn't the way forward
I think Bluesky is ideal; we just need more people here
Looks lame
The strength of MedTwitter has always been diversity (geographic & training - docs, RNs, PAs, pharmacists etc)
Further fractionating our community isn't the way forward
I think Bluesky is ideal; we just need more people here
November 19, 2025 at 4:46 PM
Roon is launching a social media site for USA doctors only
Looks lame
The strength of MedTwitter has always been diversity (geographic & training - docs, RNs, PAs, pharmacists etc)
Further fractionating our community isn't the way forward
I think Bluesky is ideal; we just need more people here
Looks lame
The strength of MedTwitter has always been diversity (geographic & training - docs, RNs, PAs, pharmacists etc)
Further fractionating our community isn't the way forward
I think Bluesky is ideal; we just need more people here
Finished updating the IBCC chapter on septic shock
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
November 19, 2025 at 2:01 PM
Finished updating the IBCC chapter on septic shock
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
This algorithm is where I ended up 👇
Therapies should be based on several factors (not solely whether CRT is <3; CRT isn't precise so this dichotomy is problematic)
Beware of vasopressin; it may depress digital perfusion & block the goal #EMIMCC
Single-center RCT finds benefit from sepsis resus that targets perfusion index (Pi)
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
November 18, 2025 at 3:15 PM
Single-center RCT finds benefit from sepsis resus that targets perfusion index (Pi)
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
Intervention group: fix macrohemodynamics, then target Pi >1.4
I think they're right
Pi is similar to cap refill, but continuously displayed number on monitor 😍
pubmed.ncbi.nlm.nih.gov/41033063/ #EMIMCC
there's been LOTS of back-and-forth about vaso in sepsis
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
November 13, 2025 at 6:52 PM
there's been LOTS of back-and-forth about vaso in sepsis
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
(e.g., these two 2025 review articles reach totally different conclusions! Lajoye is correct IMHO)
TLDR: there is no simple answer; personalize tx 🌌
my current take on vaso in sepsis is here: emcrit.org/ibcc/shock/#... #EMIMCC
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
November 13, 2025 at 2:00 PM
Fresh IBCC: POCIT (Point-of-care infrared thermography)
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
This is basically where POCUS was 1995-2005
Technology & evidence-basis are improving
Early adopters may be interested
IMHO anything bringing us to the bedside more & forcing us to engage w/ the exam is good
emcrit.org/ibcc/pocit/ #EMIMCC
I'm revising the IBCC septic shock chapter based on ANDROMEDA-SHOCK II
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
November 10, 2025 at 1:16 PM
I'm revising the IBCC septic shock chapter based on ANDROMEDA-SHOCK II
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
would love any feedback & critique on this
ANDROMEDA algorithm is nice, but it's too complicated for everyday use. We need something simpler.
& maybe it's time to push for IR thermography 😍
emcrit.org/ibcc/sepsis/... #EMIMCC
our therapy dog posing as a lion wins halloween, thanks for playing everyone
October 31, 2025 at 4:31 PM
our therapy dog posing as a lion wins halloween, thanks for playing everyone
this same post was posted on twitter and got no engagement there either.
October 30, 2025 at 11:32 PM
this same post was posted on twitter and got no engagement there either.
updated the IBCC section on alcoholic hepatitis.
AGA 2024 guidelines seem sensible & useful (picture below)
Key points:
🍺Steroid recommended for MELD>20
🍺Aggressive multiorgan support PRN (may have hepatorenal syndrome, sepsis, etc)
🍺Consider acetylcysteine
emcrit.org/ibcc/aclf/#a... #EMIMCC
AGA 2024 guidelines seem sensible & useful (picture below)
Key points:
🍺Steroid recommended for MELD>20
🍺Aggressive multiorgan support PRN (may have hepatorenal syndrome, sepsis, etc)
🍺Consider acetylcysteine
emcrit.org/ibcc/aclf/#a... #EMIMCC
October 30, 2025 at 7:56 PM
updated the IBCC section on alcoholic hepatitis.
AGA 2024 guidelines seem sensible & useful (picture below)
Key points:
🍺Steroid recommended for MELD>20
🍺Aggressive multiorgan support PRN (may have hepatorenal syndrome, sepsis, etc)
🍺Consider acetylcysteine
emcrit.org/ibcc/aclf/#a... #EMIMCC
AGA 2024 guidelines seem sensible & useful (picture below)
Key points:
🍺Steroid recommended for MELD>20
🍺Aggressive multiorgan support PRN (may have hepatorenal syndrome, sepsis, etc)
🍺Consider acetylcysteine
emcrit.org/ibcc/aclf/#a... #EMIMCC
The way this NEJM study on prostate CA was framed & is being publicised is misleading
13% relative reduction in prostate CA-related mortality is PITIFUL (for comparison, colonoscopy causes ~60% relative reduction)
There's obviously no dent in all-cause mortality (maybe higher with screening) #1/2
13% relative reduction in prostate CA-related mortality is PITIFUL (for comparison, colonoscopy causes ~60% relative reduction)
There's obviously no dent in all-cause mortality (maybe higher with screening) #1/2
October 30, 2025 at 2:49 PM
The way this NEJM study on prostate CA was framed & is being publicised is misleading
13% relative reduction in prostate CA-related mortality is PITIFUL (for comparison, colonoscopy causes ~60% relative reduction)
There's obviously no dent in all-cause mortality (maybe higher with screening) #1/2
13% relative reduction in prostate CA-related mortality is PITIFUL (for comparison, colonoscopy causes ~60% relative reduction)
There's obviously no dent in all-cause mortality (maybe higher with screening) #1/2
Great & important trial that demonstrates safety & efficacy of capillary refill time to guide resus
But it's a stretch to claim this shows *superiority*
If you need a risk-stratified win ratio to demonstrate superiority at a p=0.04 level, the intervention probably isn't terribly effective #EMIMCC
But it's a stretch to claim this shows *superiority*
If you need a risk-stratified win ratio to demonstrate superiority at a p=0.04 level, the intervention probably isn't terribly effective #EMIMCC
October 29, 2025 at 4:29 PM
Great & important trial that demonstrates safety & efficacy of capillary refill time to guide resus
But it's a stretch to claim this shows *superiority*
If you need a risk-stratified win ratio to demonstrate superiority at a p=0.04 level, the intervention probably isn't terribly effective #EMIMCC
But it's a stretch to claim this shows *superiority*
If you need a risk-stratified win ratio to demonstrate superiority at a p=0.04 level, the intervention probably isn't terribly effective #EMIMCC
MASSIVE RCT from Kenya showing that steroids reduce mortality in CAP
Mortality benefit easier to demonstrate w/ less resources available to salvage pts
Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered)
www.nejm.org/doi/pdf/10.1... #EMIMCC
Mortality benefit easier to demonstrate w/ less resources available to salvage pts
Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered)
www.nejm.org/doi/pdf/10.1... #EMIMCC
October 29, 2025 at 3:37 PM
MASSIVE RCT from Kenya showing that steroids reduce mortality in CAP
Mortality benefit easier to demonstrate w/ less resources available to salvage pts
Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered)
www.nejm.org/doi/pdf/10.1... #EMIMCC
Mortality benefit easier to demonstrate w/ less resources available to salvage pts
Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered)
www.nejm.org/doi/pdf/10.1... #EMIMCC
New 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
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
October 29, 2025 at 3:19 PM
New 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
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
The BICAR-ICU-2 trial just dropped!
RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI
Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia
VERY similar conclusions to BICAR-ICU-1
🧵 #1/
jamanetwork.com/journals/jam... #EMIMCC
RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI
Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia
VERY similar conclusions to BICAR-ICU-1
🧵 #1/
jamanetwork.com/journals/jam... #EMIMCC
October 29, 2025 at 2:59 PM
The BICAR-ICU-2 trial just dropped!
RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI
Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia
VERY similar conclusions to BICAR-ICU-1
🧵 #1/
jamanetwork.com/journals/jam... #EMIMCC
RCT involving IV bicarb in metabolic acidosis among patients with mod-severe AKI
Bicarb didn't affect mortality but it reduced the need for dialysis & risk of bacteremia
VERY similar conclusions to BICAR-ICU-1
🧵 #1/
jamanetwork.com/journals/jam... #EMIMCC
I continue to be shocked by how PCN allergies are misunderstood
This is from UpToDate on neutropenic fever
It's wrong
With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem
The R-chain structure that determines allergy is different
emcrit.org/ibcc/penicil... #EMIMCC #IDsky
This is from UpToDate on neutropenic fever
It's wrong
With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem
The R-chain structure that determines allergy is different
emcrit.org/ibcc/penicil... #EMIMCC #IDsky
October 28, 2025 at 8:55 PM
I continue to be shocked by how PCN allergies are misunderstood
This is from UpToDate on neutropenic fever
It's wrong
With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem
The R-chain structure that determines allergy is different
emcrit.org/ibcc/penicil... #EMIMCC #IDsky
This is from UpToDate on neutropenic fever
It's wrong
With PCN allergy, you can absolutely use cefepime, piptazo, or meropenem
The R-chain structure that determines allergy is different
emcrit.org/ibcc/penicil... #EMIMCC #IDsky
The entire IDSA guideline on diabetic foot infection doesn't include the word "cefepime." Not once.
It does recommend piperacillin-tazobactam in certain cases.
I'm not saying you *can't* use cefepime (you absolutely can and should in some cases), but such therapy isn't guideline-directed. 🤷♂️
It does recommend piperacillin-tazobactam in certain cases.
I'm not saying you *can't* use cefepime (you absolutely can and should in some cases), but such therapy isn't guideline-directed. 🤷♂️
October 27, 2025 at 3:22 PM
The entire IDSA guideline on diabetic foot infection doesn't include the word "cefepime." Not once.
It does recommend piperacillin-tazobactam in certain cases.
I'm not saying you *can't* use cefepime (you absolutely can and should in some cases), but such therapy isn't guideline-directed. 🤷♂️
It does recommend piperacillin-tazobactam in certain cases.
I'm not saying you *can't* use cefepime (you absolutely can and should in some cases), but such therapy isn't guideline-directed. 🤷♂️
New blog: Fresh dueling guidelines about post-arrest care from the AHA and ESICM
💔 BP targets
💔 Who needs an emergent cath?
💔 O2 targets
💔 pan-CT scans
💔 temp targets
💔 neuroprognostication
Which guideline do I love? 😍 You'll have to read the post to find out.
emcrit.org/pulmcrit/202... #EMIMCC
💔 BP targets
💔 Who needs an emergent cath?
💔 O2 targets
💔 pan-CT scans
💔 temp targets
💔 neuroprognostication
Which guideline do I love? 😍 You'll have to read the post to find out.
emcrit.org/pulmcrit/202... #EMIMCC
October 26, 2025 at 2:51 PM
New blog: Fresh dueling guidelines about post-arrest care from the AHA and ESICM
💔 BP targets
💔 Who needs an emergent cath?
💔 O2 targets
💔 pan-CT scans
💔 temp targets
💔 neuroprognostication
Which guideline do I love? 😍 You'll have to read the post to find out.
emcrit.org/pulmcrit/202... #EMIMCC
💔 BP targets
💔 Who needs an emergent cath?
💔 O2 targets
💔 pan-CT scans
💔 temp targets
💔 neuroprognostication
Which guideline do I love? 😍 You'll have to read the post to find out.
emcrit.org/pulmcrit/202... #EMIMCC
We’ve known for a while that drowning pancreatitis patients is bad
the WATERFALL RCT recently showed benefit from a more conservative fluid strategy
the authors used the study protocol to create a concrete fluid protocol which is very good
so we have a good, evidence-based fluid protocol 😃 #2/6
the WATERFALL RCT recently showed benefit from a more conservative fluid strategy
the authors used the study protocol to create a concrete fluid protocol which is very good
so we have a good, evidence-based fluid protocol 😃 #2/6
October 24, 2025 at 1:28 PM
We’ve known for a while that drowning pancreatitis patients is bad
the WATERFALL RCT recently showed benefit from a more conservative fluid strategy
the authors used the study protocol to create a concrete fluid protocol which is very good
so we have a good, evidence-based fluid protocol 😃 #2/6
the WATERFALL RCT recently showed benefit from a more conservative fluid strategy
the authors used the study protocol to create a concrete fluid protocol which is very good
so we have a good, evidence-based fluid protocol 😃 #2/6
this is from a 2000-word review article with a dozen authors on a purely gastroenterology topic.
I've been noticing this pattern more and more: a large & bizarre collection of authors that doesn't make organic sense.
Does anyone understand exactly what is going on here? Some sort of article mill?
I've been noticing this pattern more and more: a large & bizarre collection of authors that doesn't make organic sense.
Does anyone understand exactly what is going on here? Some sort of article mill?
October 11, 2025 at 2:07 PM
this is from a 2000-word review article with a dozen authors on a purely gastroenterology topic.
I've been noticing this pattern more and more: a large & bizarre collection of authors that doesn't make organic sense.
Does anyone understand exactly what is going on here? Some sort of article mill?
I've been noticing this pattern more and more: a large & bizarre collection of authors that doesn't make organic sense.
Does anyone understand exactly what is going on here? Some sort of article mill?
The difference between an expert vs amateur DKA resus is really efficiency
Patients are overwhelmingly likely to do well regardless
Expert resus may accelerate resolution & avoid re-opening the gap
So there are other hills to die on
If your protocols work efficiently, there’s no reason to change
Patients are overwhelmingly likely to do well regardless
Expert resus may accelerate resolution & avoid re-opening the gap
So there are other hills to die on
If your protocols work efficiently, there’s no reason to change
October 5, 2025 at 11:56 AM
The difference between an expert vs amateur DKA resus is really efficiency
Patients are overwhelmingly likely to do well regardless
Expert resus may accelerate resolution & avoid re-opening the gap
So there are other hills to die on
If your protocols work efficiently, there’s no reason to change
Patients are overwhelmingly likely to do well regardless
Expert resus may accelerate resolution & avoid re-opening the gap
So there are other hills to die on
If your protocols work efficiently, there’s no reason to change