Giacomo De Luca

...🧵This is a thread about 8.4% sodium bicarbonate (aka bicarb amp) in critical care. This the first part in a series of three about sodium bicarbonate 🧂in critical care: 🧐I will get in deep to complexities, benefits, risks and clinical implications of this (overused) drug.

👉🏻 – at Cortona, Tuscany

😱 Can you believe these serum sodium and osmolarity levels are real? 😅 🧂 Which is your personal record? 🇮🇹 @IM_Crit_ @icmteaching @kidney_boy @iceman_ex @ross_prager @ThinkingCC @cliffreid @drshahrul80 @eddyjoemd @FH_Verbrugge @intensivaev @nickmmark @NephroP @lzavorszky

You can guess potassium level by looking at EKG 😅 🦈. > loss of P waves > STEMI - like pattern V1-V3 (shark fin) @smithECGBlog @IM_Crit_ @PulmCrit @iceman_ex @ThinkingCC @EM_RESUS – at Piacenza, Emilia Romagna

🚨Alarm bells always go off when I see “cellulitis with septic shock”. It’s either nec fasc with septic shock or toxic shock syndrome. #criticalcare – at Piacenza, Emilia Romagna

📜 A critical care tale📜 💬 "It's not always sepsis fault." 👉🏻 unclear clinical picture consisting of overwhelmimg AKI and thrombocytopenia should prompt you considering TMAs (aHUS, STEC-HUS, TTP). journal.chestnet.org/article… – at Piacenza, Emilia Romagna

"The first physician to see the patient often makes the decision that matters the most." #criticalcare – at Piacenza, Emilia Romagna

💥2026 IDSA UPDATE on the Treatment of AntimicrobialResistant Gram-Negative Infections.💥 My take-home messages: 👉🏻Any gram-negative organism has the potential to carry ESBL genes; however, they are most prevalent in Escherichia coli, Klebsiella pneumoniae, and Klebsiella oxytoca. Routine ESBL testing is not performed by most clinical microbiology laboratories and is not considered compulsory by the CLSI[21]. Rather, E. coli, K. pneumoniae, or K. oxytoca isolates resistant to ceftriaxone (i.e., ceftriaxone minimum inhibitory concentrations [MICs] ≥4 µg/mL) is a threshold commonly acknowledged as a surrogate for ESBL-production. 👉🏻 If piperacillin-tazobactam is initiated as empiric therapy for an uUTI caused by an organism subsequently identified as an ESBL-E and the patient demonstrates clinical improvement, neither a change in therapy nor an extension of treatment duration is necessary. The panel suggests piperacillin-tazobactam as an alternative treatment option for cUTI caused by ESBL-E in patients who are not critically ill and who do not have concomitant bacteremia. In contrast, piperacillin-tazobactam is not suggested for the treatment of ESBL-E infections at sites outside of the urinary tract, even when in vitro susceptibility to piperacillin tazobactam is demonstrated. 👉🏻 Cefepime is suggested for the treatment of infections caused by organisms at moderate risk of significant AmpC production (i.e., E. cloacae complex, K. aerogenes, C. freundii, H. alvei), if cefepime MICs are in the susceptible or susceptible dose-dependent range (i.e., ≤8 µg/mL) and provided an ESBL gene has not been identified. 👉🏻 Ceftriaxone (or cefotaxime or ceftazidime) is not suggested for the treatment of invasive infections caused by organisms at moderate risk of clinically significant AmpC production (i.e., E. cloacae complex, K. aerogenes, C. freundii, H. alvei). In cases of non-severe infection in which ceftriaxone was initiated empirically, and the patient demonstrates clinical improvement with adequate source control, continuation of ceftriaxone to complete the treatment course may be reasonable. 👉🏻 Piperacillin-tazobactam is not suggested for the treatment of invasive infections caused by Enterobacterales at moderate risk of clinically significant inducible AmpC production. In light of the limited ability of tazobactam to protect piperacillin from AmpC hydrolysis in vitro and at least a few observational studies suggesting poorer clinical outcomes with the use of piperacillin-tazobactam compared to cefepime/carbapenems, the panel suggests caution with prescribing piperacillin-tazobactam for serious infections caused by AmpC-E. 👉🏻 For patients who are critically ill and/or have hypoalbuminemia, imipenem or meropenem are preferred over ertapenem. In contrast to imipenem and meropenem, ertapenem is highly protein bound, resulting in a prolonged serum half-life[83]. In patients with hypoalbuminemia, the unbound fraction of ertapenem increases, leading to enhanced clearance and a shortened serum half-life. 🔥Meropenem 🔥 > uUTI: 1 grams IV every 8 hours, infused over 30 minutes > All other infections: 1-2 gram IV every 8 hours, infused over 3 hours (if feasible); 👉🏻 2 g preferred for obesity, central nervous system infections, and extracorporeal membrane oxygenation or CrCL ≥130 mL/min . – at Piacenza, Emilia Romagna

The dangerous truth: Some of the sickest patients look deceptively stable early. #criticalcare

👉🏻 Let's start talking about "perfusion responsiveness” or “flow-responsiveness” as CRT response to hemodynamic manipulation. Tips and pitfalls about testing CRT in daily clinical practice?🤔 @ThinkingCC @icmteaching @IM_Crit_ @khaycock2 @katiewiskar @msiuba @nickmmark @ross_prager @NephroP @iceman_ex

👉 Hemodynamic incoherence = Persistent microcirculatory failure despite restored systemic hemodynamics

Increasing systemic blood flow does not reverse tissue hypoperfusion in some patients with septic shock (often in late stages), due to loss of hemodynamic coherence aka macro-to-microcirculatory uncoupling. Assessing microcirculatory dysfunction is the future of care.

Creatinine is: ▪️ Late ▪️ Diluted by fluids ▪️ Affected by muscle mass ▪️ Misleading in ICU

👉🏻emdocs.net/emdocs-podcast-ep… – at Piacenza, Emilia Romagna

Refractory septic shock is persistent hypoperfusion in a fluid-unresponsive patient requiring high-dose vasopressors (> 0.5 gamma/kg/min basal norepi equivalent) after appropriate resuscitation and after excluding other causes of shock. – at Assago, Lombardia

Deep dive into central lines management in critically ill patients.🇮🇹 #criticalcare – at Piacenza, Emilia Romagna