Title: Pitfalls in Lactate Interpretation

Category: Critical Care

Posted: 12/16/2025 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Pitfalls in Lactate Interpretation

Lactate is one of the most common biomarkers used in critical care.
While an elevated lactate level is often attributed to impaired tissue oxygenation, an important pitfall in lactate interpretation in the critically ill is the failure to consider non-hypoxic causes of increased levels. These include:
- Enhanced glycolysis (B2-agonist administration, increased metabolic activity)
- Reduced clearance (hepatic failure, renal dysfunction, muscular dysfunction)
- Impaired tissue metabolism (mitochondrial dysfunction due to drug intoxication)
Additional pitfalls in lactate use in the critically ill include:
- Use of an isolated value rather than assessing longitudinal trends
- Failure to correlate elevated lactate levels with other markers of perfusion (i.e., capillary refill time)
- Use of rigid normalization targets rather than targeting therapeutic interventions to the full clinical picture

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Title: Elevated ICP in the Post-ROSC Patient

Category: Critical Care

Posted: 10/21/2025 by Mike Winters, MBA, MD

Check for Elevated ICP in the Post-ROSC Patient

More than 600,000 people experience out-of-hospital cardiac arrest (OHCA) in North America each year.
Unfortunately, only 10% of patients with OHCA survive to hospital discharge.
A key component of the ED management of the post-cardiac arrest patient centers on minimizing secondary cerebral injury.
In addition to monitoring for seizure activity in the comatose post-arrest patient, it is also recommended to assess the post-ROSC patient for elevated intracranial pressure (ICP).
This can be accomplished with neuroimaging (CT head) to look for cerebral edema, physical exam (pupillary asymmetry) and with POCUS measurements of the optic nerve sheath diameter.
In post-ROSC patients with signs of elevated ICP, raise the head of the bed, provide adequate sedation/analgesia, consider hypertonic saline, and optimize the mean arterial blood pressure.

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Title: Predicting NIV Failure

Category: Critical Care

Posted: 8/26/2025 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Predicting NIV Failure

Noninvasive ventilation (NIV) is often used in the resuscitation of critically ill patients with acute hypoxemic or hypercapnic respiratory failure.
Given the frequency of its use in both EDs and ICUs, it is important to recognize NIV failure and when patients should undergo intubation and initiation of mechanical ventilation.
Patients should be re-evaluated within approximately 60 minutes of initiation of NIV.
The HACOR score is a risk scoring tool comprised of heart rate, acidosis, consciousness, oxygenation, and respiratory rate and can be used to detect NIV failure in the hypoxemic patient.
Consider intubation in a patient with a HACOR score > 5 at 1-2 hours after NIV initiation.

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Title: When To Initiate RRT in the Critically Ill

Category: Critical Care

Posted: 7/1/2025 by Mike Winters, MBA, MD (Updated: 3/4/2026)

When To Initiate RRT in the Critically Ill Patient

Acute kidney injury (AKI) occurs in more than half of critically ill patients admitted to the ICU.
When and how to initiate renal replacement therapy (RRT) in the critically ill patient remains debated.
While a strategy of deferred RRT is preferable in many, indications for immediate RRT in patients with AKI include the following:
- Potassium > 6.5 that is refractory to medical therapy
- pH < 7.15 that is not responsive to bicarbonate administration
- Fluid overload (worsening pulmonary edema, P/F ratio < 200 mm Hg) that is refractory to diuretics

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Title: Updated Guidelines for Sedation in the Vented Patient

Category: Critical Care

Posted: 4/29/2025 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Sedation for the Mechanically Ventilated Adult ICU Patient

Critically ill patients experience pain, anxiety, delirium, agitation, and sleep disruption.
When not adequately managed, pain, anxiety, agitation, and delirium have been associated with both short- and long-term morbidity and mortality.
The Society of Critical Care Medicine recently convened a panel to update their 2018 guidelines on the management of pain, agitation/sedation, delirium, immobility, and sleep disruption in the adult ICU patient.
Based on approximately 29 RCTs, the panel updated its 2018 recommendation on sedation in the mechanically ventilated adult patient to suggest that dexmedetomidine be used, over propofol, when light sedation or delirium reduction is the goal.
Importantly, a primary side effect of dexmedetomidine is bradycardia.
As a result, the panel recommended alternative agents be considered in patients at high risk of bradycardia or when deep sedation is the goal.

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Title: Preventing VAP in the Critically Ill, Intubated Patient

Category: Critical Care

Keywords: Critically Ill, Intubated, Mechanical Ventilation, Ventilator-Associated Pneumonia (PubMed Search)

Posted: 2/25/2025 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Non-Pharmacologic Measures to Prevent VAP

Ventilator-associated pneumonia (VAP) is one of the most common complications of mechanical ventilation and is associated with significant increases in morbidity and mortality.
With the persistence of the boarding crisis, many critically ill intubated patients remain in EDs for extended periods of time, thereby increasing their length of stay, morbidity, and mortality.
For the critically ill intubated patient, consider implementing the following non-pharmacologic interventions that have been shown to decrease the incidence of VAP:
- Strict hand hygiene compliance
- Elevating the head of the bed to 45 degrees, unless contraindicated
- Utilize endotracheal tubes with subglottic secretion drainage
The following interventions have not been consistently shown to reduce VAP:
- Continuous endotracheal cuff monitoring
- Closed endotracheal suctioning systems
- Silver-coated endotracheal tubes

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Title: High-Intensity NIPPV for Acute COPD Exacerbations

Category: Critical Care

Posted: 12/17/2024 by Mike Winters, MBA, MD

High-Intensity NIPPV for Acute COPD Exacerbations?

Noninvasive positive pressure ventilation (NIPPV) is frequently used in the management of critically ill patients with an acute COPD exacerbation, and is associated with decreased intubation rates and decreased in-hospital mortality.
“Low” intensity NIPPV, where the inspiratory positive airway pressure (IPAP) is < 18 cm H2O, is generally used in clinical practice.
“High” intensity NIPPV, where the IPAP ranges from 20-30 cm H2O has recently been shown to improve gas exchange, ventilatory function, and reduced elevated PaCO2 when compared to low-intensity NIPPV.
The recently published HAPPEN trial was a randomized trial performed in 30 centers across China and investigated whether high-intensity NIPPV reduced the need for intubation compared with low-intensity NIPPV in patients with an acute COPD exacerbation and hypercapnia.
In this trial of 300 patients, investigators found that high-intensity NIPPV significantly reduced the number of patients who met criteria for intubation compared with low-intensity NIPPV.
Importantly, patients were included and randomized in the trial if they remained hypercapnic after initially receiving 6 hours of low-intensity NIPPV.

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Title: The IVC and Fluid Resuscitation in the Critically Ill

Category: Critical Care

Posted: 10/22/2024 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Intravascular Volume and the IVC

Point-of-care ultrasound (POCUS) assessments of the inferior vena cava (IVC) are frequently used in the fluid resuscitation strategy for critically ill patients.
Numerous factors determine the appearance of the IVC, including intraabdominal pressure, mean systemic filling pressure, central venous pressure, intrathoracic pressure, and right heart function.
Given these multitude of factors, it is not surprising that literature has demonstrated that the IVC is not a reliable marker of fluid responsiveness.
Rather, focus on the use of the IVC has shifted towards assessing fluid tolerance, venous congestion, and its use as a marker on when to stop fluid administration.
POCUS assessment of the IVC is commonly performed in the long axis a few centimeters distal to the diaphragm.
Rola, et al. highlight that this location may be misleading and recommend that a more appropriate assessment be a short axis scan through the entire intrahepatic segment of the IVC, while taking into account the intrapleural and intraabdominal pressures.

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Title: Hepatorenal Syndrome

Category: Critical Care

Posted: 8/27/2024 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Hepatorenal Syndrome

Emergency physicians evaluate patients with cirrhosis and ascites daily.
Patients with cirrhosis are particularly susceptible to acute kidney injury (AKI), which is associated with a significant increase in hospital mortality.
Hepatorenal syndrome (HRS) is a specific type of renal dysfunction in patients with cirrhosis and ascites.
The previous classification of HRS (Type 1, Type 2) has now been replaced by HRS-AKI, HRS-AKD, and HRS-CKD.
The diagnostic criteria for HRS-AKI include:
- Increase in creatinine 0.3 mg/dL within 48 hrs or 50% from baseline value within the prior 7 days
- Lack of improvement in creatinine or urine output within 24 hrs of adequate volume resuscitation
- Absence of an alternative explanation for AKI
Management of HRS-AKI centers on accurate volume assessment, timely administration of a splanchnic vasoconstrictor (norepinephrine), administration of 20-25% albumin, and avoidance of additional nephrotoxins.

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Title: Noninvasive Ventilation for Preoxygenation in Critically Ill Patients

Category: Critical Care

Posted: 7/2/2024 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Noninvasive Ventilation for Preoxygenation

Over 1 million critically ill patients are intubated each year in the United States.
Hypoxemia can occur in up to 20% of intubations and may lead to adverse outcomes such as peri-intubation cardiovascular collapse or cardiac arrest.
Appropriate preoxygenation is critical to increase the safe apnea time and decrease the risk of hypoxemia during rapid sequence intubation (RSI).
At present, the majority of critically ill patients undergoing RSI are preoxygenated with an oxygen mask.
In a randomized, pragmatic, parallel-group trial conducted in 7 EDs and 15 ICUs in the United States, Gibbs et al compared the use of noninvasive ventilation for preoxygenation to an oxygen mask on the incidence of hypoxemia during intubation.
In over 1,300 patients, the incidence of hypoxemia during the interval between induction and 2 minutes after intubation was markedly lower in patients preoxygenated with noninvasive ventilation compared to those preoxygenation with an oxygen mask.
Importantly, the greatest benefit to noninvasive ventilation for preoxygenation was seen in patients with acute hypoxemic respiratory failure, those requiring > 70% FiO2 prior to intubation, and those with a BMI > 30.
Lastly, the trial did not enroll patients who needed emergent intubation without time for at least 3 minutes of preoxygenation.

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Title: BVM Ventilation for OHCA

Category: Critical Care

Posted: 3/26/2024 by Mike Winters, MBA, MD

Bag-Valve-Mask Ventilation During OHCA

Current OHCA resuscitation guidelines recommend a 30:2 strategy of CPR with BVM ventilations.
Idris and colleagues performed a secondary analysis of the Resuscitation Outcomes Consortium CCC clinical trial to determine the incidence of BVM ventilation during a 30:2 CPR strategy and assess the association of detectable ventilations with patient outcomes.
In 1,976 patients, the authors found that only 40% of patients had detectable ventilations (> 250 ml) in more than half of CPR pauses.
For those patients with detectable ventilations in more than 50% of pauses, there was an association with increased survival to hospital admission, increased survival to hospital discharge, and increased survival with favorable neurologic outcome.
The current study highlights the importance of proper BVM ventilation during OHCA resuscitation and the opportunity to improve performance of this vital skill.

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Title: Setting PEEP in the Intubated COPD Patient

Category: Critical Care

Posted: 2/6/2024 by Mike Winters, MBA, MD

PEEP in the Ventilated COPD Patient?

Patients with acute respiratory failure secondary to COPD often have dynamic hyperinflation and intrinsic PEEP (PEEPi).
Both dynamic hyperinflation and PEEPi adversely effect pulmonary mechanics, markedly increase the work of breathing, impair respiratory muscle function, and can result in hemodynamic compromise.
It has traditionally been felt that the application of external PEEP in the intubated COPD patient may worsen hyperinflation.
Importantly, external PEEP has been shown to improve ventilator synchrony and decrease the work of breathing.
PEEPi is measured using an end-expiratory hold maneuver in a passive, relaxed patient.
External PEEP can then be set to approximately 70% of PEEPi, followed by frequent monitoring of plateau pressures in a volume-cycled ventilation mode.

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Title: Acute-On-Chronic Liver Failure

Category: Critical Care

Posted: 12/19/2023 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Acute-On-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is defined as an acute deterioration of liver function in a patient with cirrhosis that is associated with organ failure and has high short-term mortality.
Key extrahepatic organ failures in ACLF include the renal, CNS, respiratory, circulatory, and coagulation systems.
With respect to CNS failure in ACLF:
- Hepatic encephalopathy (HE) is the most common manifestation
- A normal ammonia level makes HE unlikely
- Benzodiazepines should be avoided
- Primary triggers for HE include infection, GIB, and aggressive diuresis
- Treatment of HE primarily consists of lactulose and rifaximin

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Title: IV Fluid Resuscitation in the Critically Ill

Category: Critical Care

Posted: 10/31/2023 by Mike Winters, MBA, MD (Updated: 3/4/2026)

IV Fluid Resuscitation

IVF administration is one of the most common interventions in the resuscitation of critically ill patients.
The primary goals of IVFs are to augment cardiac output and increase O2 delivery.
The amount and type of IVF must take into account the patient's pathophysiology and type of shock.
Sepsis remains one of the most common causes of distributive shock in the ED and ICU.
Large volumes of IVF in sepsis often do not increase cardiac output and frequently lead to organ congestion.
Rather than a fixed dose, an individualized approach to IVFs in sepsis based on the patient's history, exam, labs, monitoring, and serial reassessments is likely to lead to better outcomes.

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Title: Cardiogenic Shock

Category: Critical Care

Posted: 9/5/2023 by Mike Winters, MBA, MD

Pearls for the Patient in Cardiogenic Shock

Cardiogenic shock is generally defined as tissue hypoperfusion due to ineffective cardiac output.
Despite therapeutic advances, 30-day mortality for cardiogenic shock can reach 50%.
Though there are several different phenotypes and severity of staging, consider the following pearls in the initial resuscitation of patients with cardiogenic shock:
- Early arterial line placement for accurate blood pressure monitoring.
- Supplemental oxygen to maintain O2 > 90%.
- NIPPV to reduce the work of breathing for patients with pulmonary edema.
- Use of lung-protective ventilation for patients who require intubation and mechanical ventilation.
- Vasopressor and inotrope therapy for hemodynamic support.
  - Norepinephrine is the preferred first-line vasopressor.
  - Dobutamine or milrinone for inotrope support.
- Early revascularization for patients with cardiogenic shock due to acute MI.

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Title: Bicarbonate Therapy in the ED

Category: Critical Care

Posted: 5/16/2023 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Bicarbonate Use for Lactic Acidosis?

The administration of sodium bicarbonate to treat severe acidosis remains controversial and intensely debated.
Often, sodium bicarbonate is administered to critically ill ED patients with a lactic acidosis and pH < 7.2 while awaiting definitive therapy directed at the inciting event.
Wardi and colleagues recently conducted a narrative review of the literature on sodium bicarbonate use in select critical conditions commonly encountered in the ED.
In their review, the authors found that sodium bicarbonate had no effect on mortality in critically ill patients with a pH < 7.2. In addition, bicarbonate had no effect on hemodynamics in patients with a lactic acidosis receiving vasopressor therapy.
With the potential exception of patients with severe acidosis and AKI, the authors conclude that sodium bicarbonate is not recommended for the treatment of lactic acidosis or shock states.

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Title: Things to Consider for Persistent or Worsening Shock

Category: Critical Care

Posted: 3/21/2023 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Things to Consider for Persistent or Worsening Septic Shock

Septic shock is one of the most common critical illnesses in emergency medicine and critical care.
Norepinephrine is recommended as the initial vasopressor of choice for patients with septic shock, with vasopressin or epinephrine commonly added as a second vasopressor for patients with refractory shock.
While vasopressors are being added and titrated, it is important to consider additional diagnoses in patients with worsening or persistent septic shock. Some of these diagnoses include:
- Undetected infection that requires emergent source control
- Concomitant causes of shock: cardiogenic, PE, abdominal compartment syndrome, tamponade, adrenal insufficiency
- Severe acidosis
- MAP underestimation by a radial arterial line

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Title: Uncommon Causes of Shock

Category: Critical Care

Posted: 1/24/2023 by Mike Winters, MBA, MD (Updated: 3/4/2026)

An Uncommon Cause of Shock

Sepsis is the most common cause of distributive shock encountered in the emergency department and intensive care unit.
Notwithstanding, it is important to consider other etiologies of shock, especially when the patient is not responding to resuscitation.
Adrenal crisis is one uncommon etiology of distributive shock whereby the diagnosis is often delayed.
Risk factors for adrenal crisis can include recent GI illness, thyrotoxicosis, recent surgery, and physical or psychological stress.
Patients often have nonspecific symptoms of generalized weakness, abdominal pain, vomiting, fever, and altered mental status.
Current guidelines recommend the administration of 100 mg of hydrocortisone in adults suspected of having adrenal crisis.

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Title: Pacer Pad Placement for TCP

Category: Critical Care

Posted: 11/29/2022 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Transcutaneous Cardiac Pacing

Transcutaneous cardiac pacing (TCP) is often attempted while preparing for transvenous cardiac pacing in critically ill patients with symptomatic bradycardia unresponsive to medical therapy.
For TCP, pacer pads can be placed in either the anterolateral (AL) or anteroposterior (AP) positions.
Current resuscitation guidelines from the American Heart Association and the European Resuscitation Council do not identify a preferred pacer pad placement for TCP.
In a recent study of patients who received TCP following cardioversion from atrial fibrillation or flutter, Moayedi and colleagues found that pacer pads placed in the AP position required less mA to capture and chest wall contractions were less severe when compared to the AL position.
In fact, capture was approximately 80% more likely with pacer pads placed in the AP position compared to the AL position.
Take Home Point: Consider placing the pacer pads in the AP position the next time you need to initiate TCP.

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Title: Timing of Source Control in Sepsis

Category: Critical Care

Posted: 10/4/2022 by Mike Winters, MBA, MD (Updated: 3/4/2026)

Optimal Timing of Source Control in Sepsis

Sepsis is the most common critical illness encountered in the emergency department.
Much of the resuscitation of patients with sepsis is focused on early and appropriate antibiotic administration, appropriate fluid resuscitation, vasopressor support, and continued hemodynamic monitoring.
Another critical pillar in sepsis resuscitation is source control. To date, there is varying literature on the optimal timing of source control in sepsis.
In a recent cohort study of approximately 5,000 patients with community-acquired sepsis, Reitz and colleagues report a 29% reduction in risk-adjusted odds of 90-day mortality for patients who had early source control (< 6 hours) compared to those with late source control (6-36 hours).
The greatest reduction in risk-adjusted 90-day mortality with early source control occurred in patients with gastrointestinal/abdominal and soft-tissue sources of infection.
Take Home Pearl: Early source control matters in sepsis resuscitation, especially in sicker patients with a GI or soft-tissue source of infection.

1-20 of 354 results by Mike Winters

Title: Pitfalls in Lactate Interpretation

Title: Elevated ICP in the Post-ROSC Patient

Title: Predicting NIV Failure

Title: When To Initiate RRT in the Critically Ill

Title: Updated Guidelines for Sedation in the Vented Patient

Title: Preventing VAP in the Critically Ill, Intubated Patient

Title: High-Intensity NIPPV for Acute COPD Exacerbations

Title: The IVC and Fluid Resuscitation in the Critically Ill

Title: Hepatorenal Syndrome

Title: Noninvasive Ventilation for Preoxygenation in Critically Ill Patients

Title: BVM Ventilation for OHCA

Title: Setting PEEP in the Intubated COPD Patient

Title: Acute-On-Chronic Liver Failure

Title: IV Fluid Resuscitation in the Critically Ill

Title: Cardiogenic Shock

Title: Bicarbonate Therapy in the ED

Title: Things to Consider for Persistent or Worsening Shock

Title: Uncommon Causes of Shock

Title: Pacer Pad Placement for TCP

Title: Timing of Source Control in Sepsis