𝐑𝐚𝐥𝐩𝐡 𝐌𝐨𝐡𝐭𝐲 𝐌𝐃 𝐌𝐏𝐇

I'm a big proponent of stopping non-essential medications for patients admitted to ICU. If you continue a dozen home meds and add two dozen ICU meds, you create a 36-drug medication list that's impossible to safely maintain (in terms of drug-drug interactions, GFR shifts, additive toxicities). This is actually a great opportunity for deprescribing: [#1] At admission, pare back the med list & focus on treating the acute problem. [#2] At discharge, think carefully about whether all those meds were needed in the first place, make sure the home med list is short & sensible.

I just updated the IBCC chapter on pulmonary vasodilators, here are new pearls I learned 🤯 🫁 The dosing of inhaled pulmonary vasodilators is a little different for ARDS versus for treatment of RV failure. In ARDS, you're shooting for selective vasodilation of the best-ventilated alveoli to maximize V-Q matching, so you want a mid-range dose (too high and you start vasodilating the worse-ventilated alveoli). In RV failure you're trying to vasodilate every alveoli as much as possible to bring down the pulmonary vascular resistance, so go high. 🫁 Nebulized milrinone causes selective pulmonary vasodilation for ~20-30 minutes, then gets systemically absorbed. One dose of nebulized milrinone in the OR is great, but scheduling milrinone nebs q4hr doesn't make pharmacological sense (it doesn't achieve consistent pulmonary vasodilation and there are risks of systemic accumulation in renal failure). IMHO milrinone nebs don't have much role in ICU. If you want to give milrinone just give it IV. 🫁 There's a gradually escalating amount of evidence supporting combined simultaneous use of inhaled epoprostenol and inhaled NO to treat RV failure. See the article by Andre Denault below. This may be a good option for RV failure before escalating to an Impella RP Flex. It's pretty easy to trial a patient on inhaled pulmonary vasodilators - if they work great, if they don't work you haven't lost much. #1/2, link in next post.

Fresh IBCC chapter: APRV guide 😁 My first APRV guide came out in 2017. I updated it during COVID in 2020. I just completely overhauled it again. Two APRV guides were published recently (one by @TheEMNerd in 2022 and one by Nieman et al. 2026). Both guides focus on how to get patients initiated on APRV. My APRV guide is consistent with them. There is a general consensus about how to get APRV started. Currently, the most challenging & controversial aspect is how to wean *off* APRV. Much less is written about this. I've described two possible approaches based on the best data that we have (Zhou et al. RCT) and basic vent weaning principles. But this remains murky. Some approaches to weaning off APRV involve a gradual removal of ventilator support, without spontaneous breathing trials. This strategy isn't consistent with modern techniques of ventilator liberation (i.e., providing comfortable non-fatiguing support with intermittent spontaneous breathing trials). APRV is a great rescue modality currently. However, for APRV to demonstrate benefit in clinical trials, proper attention is needed to rapid APRV weaning. Inadequately aggressive weaning strategies will destroy the ability of APRV to improve ventilator-free days & ICU length-of-stay. I'd love to hear about folks' experience in terms of APRV weaning. The role of APRV in ARDS remains controversial. It was hotly debated during COVID in a partisan fashion without any real conclusion. Hopefully further RCTs will clarify its precise use. This is tough because outcomes depend on how APRV is set (not simply the binary presence/absence of APRV). Aside from ARDS, APRV is pretty fabulous for mucus plugging and atelectasis. Physiologically, its ability to produce biased airflow that promotes secretion clearance is simply unparalleled (slow inspiration & fast expiration clears secretions out of the airway). So regardless of where we land with APRV for ARDS, I do think that there will always be some use for APRV in critically ill patients. So this guide will hopefully be evergreen. (#1/2, link next)