#51 Listener Mailbag #2

This week on Critical Care Time, we’re turning the mic over to you, our brilliant listeners! In this special Q&A episode, Nick and Cyrus read your comments, tackle your toughest clinical questions, and share how your insights have sent them diving back into PubMed, Reddit, and beyond. Whether you’re commuting, charting, or on break in the ICU, this episode is packed with practical pearls, literature deep-dives, and the human stories that make critical care so rewarding. Thank you for helping us learn and grow—let’s jump right in!



🤮 Anatomically Difficult Airway


Episode: Anatomically Difficult Airway

David & Grace ask Q: After an awake intubation with perfect topicalization, is there any role for paralytics?

Key Points:

  • Paralytics and induction agents serve as a safety margin if topicalization or sedation is incomplete and significant c.

  • Risk of tube dislodgement or vigorous coughing: paralysis prevents tube loss or airway trauma.

  • Always have meds ready to convert to RSI if the awake plan falters.



💔 Cardiogenic Shock & Angiotensin II

Episode: Inotropes

Max A asks Q: Can ATII be used in cardiogenic shock when ATHOS only enrolled high-output shock?

Discussion:

  • ATHOS-3 Trial: Enrolled patients with ScvO₂ > 70% & CVP > 8 mmHg or CI > 2.3 L/min/m² PubMed

  • Systematic Review (n = 195): Efficacy & safety of ATII in combined cardiogenic/vasodilatory shock—likely safe 📖 PubMed 36753927

  • Clinical takeaway: Consider ATII as part of your vasopressor arsenal, especially in mixed shock states.



💉 Vasopressors: Phentolamine & Hydroxocobalamin

Reference Episode: Vasopressors

  1. Phentolamine Extravasation (Q by Sunjeev)

    • Local infiltration → minimal systemic hypotension risk.

  2. Hydroxocobalamin in Sepsis (Q by Laura)

    • Observational case reports suggest AKI risk, but likely confounded by indication.

    • Discolors urine/plasma—interferes with creatinine & dialysis assays.

    • Alternative: Methylene blue may have more robust safety data in septic shock.

Critical Care Time infographic on Vasopressors

🚑 Leading a Difficult or Traumatic Code

Episode: Running a Code

Hasan shares a personal anecdote and provides a great concise summary of our approach.

Top 3 Debrief Steps:

  1. 🙏 Moment of Silence — Honor the patient & allow team reflection

  2. ✔️ What Went Well? — Highlight positive actions & teamwork

  3. 🔄 What Could We Improve? — Normalize errors; plan for next time

ICU OnePager on how to Run a Code. See ICU OnePager for more.


👩‍⚕️ PAs & NPs in the ICU (“APPs” Debate)

Episode: APPs in the ICU

Several listeners brought up some points here:

  • Alan: Calls for mandatory ICU experience before NP programs; concerns about credentialing rigor.

  • Gary: Clarifies NP board certification & recertification every 5 years; defends term “APP” for clarity.

  • Tommy: Corrects that PA rotations require 2,000+ clinical hours, not 1,000.

Takeaway: The paths to competency differ—balance experience requirements with access to advanced practice roles. This is a fast changing field (since we did the episode a new pathway for critical care certification was proposed)… stay tuned for more



🌬️ Hypoxemia Masterclass Feedback

Episode: Hypoxemia Masterclass

Listeners: Jacob, Collen & anonymous listeners

  • Praise for clear physiology pearls, case-based examples, and concise teaching.

  • Hosts commit to more physiology-focused episodes next season!

ICU OnePager on Hypoxia & Hypoxemia


🆚 PREOXI Trial Clarifications

Episode: Journal Club #3: The PREOXI Trial

Listener: Sean asks about how pre-ventilation (e.g. ambu bag) was provided.

  • Had to go into the supplement to answer some of these points.

  • Yes the trial allowed BVM use, but rate differed by group, and even in the oxygen mask most patients were not pre-ventilated: 8.9% in NIV arm vs. 30.8% in oxygen mask arm.

  • Trial focus: NIV vs. mask preoxygenation, not prohibition of BVM.




🎯 Extubation Strategies & SBT Duration

Episode: Tube-Be-or-Not-Tube-Be: Extubation

Listener: Alan provides some great historical context about the challenges of providing long T-piece trials.,

  • 30-minute SBTs are generally adequate.

  • Historical context: 3-hour T-piece trials were labor intensive!

  • RSBI: A step-change in weaning, though clearly imperfect.

ICU OnePager approach to weaning

👨‍⚕️ “Beneath the Drape” Reactions

Episode: Beneath the Drape

Listeners: Civic NG, fellow Tom

  • Emotional interviews with Drs. Allin & Wischmeyer resonate—humanism in medicine is vital.


⚡ Rapid-Fire Round: Cirrhosis & LR Pearl

  • Pearl busted: Lactate ≠ lactic acid; lactate is a conjugate base and doesn’t worsen acidosis.

  • In cirrhosis, balanced crystalloids (e.g., LR) may be renal-protective over NS.


🩺 Pleural Infections: Anaerobic Coverage

  • Anaerobes ~20% of pleural infections—empiric anaerobic coverage recommended even if cultures grow aerobes.


🌍 Global Praise & Reviews

From Bulgaria to Australia, nurses, pharmacists, fellows, and attendings worldwide thank CCT for evidence-based, practical content!


📝 Future Episode Ideas

  • We love your suggestions:

    • “Landing” the sick ICU patient: transitions of care

    • Deep dive into neurocritical care

    • Hosts’ favorite books & learning resources

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#51 Sepsis 101