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

💯💯

my favorite is when a consultant recommends “admit to ICU” in the chart without talking to us 🙄

I’ve never heard if this before… just when you thought you’d heard of every dumb idea…

it’s pretty wild that they managed to get IRBs to approve an RCT of terlipressin vs placebo (CONFIRM trial)

yeah of course it worked, probably dopamine would be better than placebo 🤷‍♂️

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.

Yes, they are super into terlipressin.

As an ICU person, I must admit I don't see the attraction to terli.

(Full disclosure: my center doesn't have terlipressin, regardless, but for any ICU patient, norepinephrine seems easier to use, equally as effective, and lower risk of pulmonary edema)

I read a lot of guidelines. I've never seen a guideline ever that specified exactly how to titrate norepinephrine in this way. This isn't normal.

The Na+ can't be blown off.

Some dissolved CO2 may be blown off but the quantative amount is small and the tonicity is determined by the sodium concentration (active osmole) so I don't think this CO2 loss will affect tonicity shifts.

yes, I've seen a fair number of these patients with low lactate who respond well to epinephrine with an elevation in their lactate and shock resolution... consistent with your paper!

agree, in the USA osteopaths are equivalent to MDs. many of my colleagues are DOs. its confusing.

super sick patients who should mount a lactic acidosis but dont often have autonomic dysfunction with inability to produce endogenous epinephrine; they may respond well to exogenous epinephrine

emcrit.org/pulmcrit/und...

Roon: Welcome to our exclusionary doctors' lounge.

Me: Meh, I'd rather hang out at the nursing station in the ICU eating chicken nuggets, gossiping, and smacktalking about antibiotics and pressors I don't like.

#EMIMCC

💯💯

there is no way a MedTwitter clone can survive with USA docs alone

it’s totally doomed

i think they seriously miscalculated the importance of fancy USA doctor credentials