Tim Norfolk
@icmtim.bsky.social
UK single CCT ICM consultant. Strive to be humbled less often!
#Haemodynamics #POCUS #FOAM
#Haemodynamics #POCUS #FOAM
I personally think it’s great George will get to manage a £500m budget in his gap year. His UCAS application will dazzle
June 26, 2025 at 7:16 AM
I personally think it’s great George will get to manage a £500m budget in his gap year. His UCAS application will dazzle
This was version 1 and then 2. I don’t know if anyone has any insight from the authors as to why it was changed mind?
June 5, 2025 at 9:33 AM
This was version 1 and then 2. I don’t know if anyone has any insight from the authors as to why it was changed mind?
They do discuss this in the paper tbf. The non-septic group had to have no clinical evidence of sepsis documented in the EHR, & they suggest pts with culture -ve sepsis wouldn’t have been included in either group.
I worry Pct may be worsening, not improving antimicrobial stewardship 🤷♂️
I worry Pct may be worsening, not improving antimicrobial stewardship 🤷♂️
May 8, 2025 at 6:11 PM
They do discuss this in the paper tbf. The non-septic group had to have no clinical evidence of sepsis documented in the EHR, & they suggest pts with culture -ve sepsis wouldn’t have been included in either group.
I worry Pct may be worsening, not improving antimicrobial stewardship 🤷♂️
I worry Pct may be worsening, not improving antimicrobial stewardship 🤷♂️
A drop >25% predicted FR with a sensitivity of 93% and specificity of 92%❗️
It’s single centre, small pt no.s, specific inclusion/exclusion criteria & no invasive CO monitoring as the gold standard
BUT… this is an exciting test to keep an eye on & could be a welcome addition to the toolkit
2/2
It’s single centre, small pt no.s, specific inclusion/exclusion criteria & no invasive CO monitoring as the gold standard
BUT… this is an exciting test to keep an eye on & could be a welcome addition to the toolkit
2/2
May 7, 2025 at 12:29 PM
A drop >25% predicted FR with a sensitivity of 93% and specificity of 92%❗️
It’s single centre, small pt no.s, specific inclusion/exclusion criteria & no invasive CO monitoring as the gold standard
BUT… this is an exciting test to keep an eye on & could be a welcome addition to the toolkit
2/2
It’s single centre, small pt no.s, specific inclusion/exclusion criteria & no invasive CO monitoring as the gold standard
BUT… this is an exciting test to keep an eye on & could be a welcome addition to the toolkit
2/2
Sometimes checking an ScvO2 feels pointless, but other times it’s 23%
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
April 19, 2025 at 7:26 AM
Sometimes checking an ScvO2 feels pointless, but other times it’s 23%
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
P.S.
a CO2 gap of 2.3 (17mmHg) must take some beating?
NB/
There has actually been a much larger cohort published (n = 4265) in 2023
And they found the exact same thing!
“Even very fast correction rates were not associated with adverse neurological events”
jamanetwork.com/journals/jam...
There has actually been a much larger cohort published (n = 4265) in 2023
And they found the exact same thing!
“Even very fast correction rates were not associated with adverse neurological events”
jamanetwork.com/journals/jam...
April 17, 2025 at 1:06 PM
NB/
There has actually been a much larger cohort published (n = 4265) in 2023
And they found the exact same thing!
“Even very fast correction rates were not associated with adverse neurological events”
jamanetwork.com/journals/jam...
There has actually been a much larger cohort published (n = 4265) in 2023
And they found the exact same thing!
“Even very fast correction rates were not associated with adverse neurological events”
jamanetwork.com/journals/jam...
In the largest published cohort (n = 449) rapid correction occurred in ≈ 30%
In the 78 pts who corrected >12 mmol/L per day, 0 cases of cerebral oedema were identified
In fact, there was a trend towards lower mortality in the group who corrected more rapidly
2/
pubmed.ncbi.nlm.nih.gov/30948456/
In the 78 pts who corrected >12 mmol/L per day, 0 cases of cerebral oedema were identified
In fact, there was a trend towards lower mortality in the group who corrected more rapidly
2/
pubmed.ncbi.nlm.nih.gov/30948456/
April 17, 2025 at 11:12 AM
In the largest published cohort (n = 449) rapid correction occurred in ≈ 30%
In the 78 pts who corrected >12 mmol/L per day, 0 cases of cerebral oedema were identified
In fact, there was a trend towards lower mortality in the group who corrected more rapidly
2/
pubmed.ncbi.nlm.nih.gov/30948456/
In the 78 pts who corrected >12 mmol/L per day, 0 cases of cerebral oedema were identified
In fact, there was a trend towards lower mortality in the group who corrected more rapidly
2/
pubmed.ncbi.nlm.nih.gov/30948456/
The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
April 9, 2025 at 5:40 PM
The finger sweep test is in every article there is on necrotising fasciitis yet in my experience, I’ve never known a surgeon perform it. Indeed they look askance if I’ve suggested it 🫤
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
Is this a 🇬🇧 thing? Curious to hear other people’s experience…
#EMIMCC
academic.oup.com/bjs/article/...
Clearer reviewer 2 got the short in early! 🤣
March 29, 2025 at 8:03 AM
Clearer reviewer 2 got the short in early! 🤣
A great opportunity to recite this 💎:
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
March 19, 2025 at 8:30 PM
A great opportunity to recite this 💎:
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
1L of 0.9% Saline contains as much salt as 23 packets of Walkers Cheese & Onion crisps
That initial 3L resus = 69 bags worth‼️
It’s no wonder people get a bit puffy as their poor kidneys battle to pee out all that 🧂😵💫🧂
Exactly & they were excluded from CAPE-COD, which was the RCT that really changed practice. We don’t know the right answer, & I’d guess there are sub-phenotypes who they benefit/harm, but we still need to make a decision with the evidence we have & that’s the side of the fence I’m on (for now)!
February 26, 2025 at 8:26 AM
Exactly & they were excluded from CAPE-COD, which was the RCT that really changed practice. We don’t know the right answer, & I’d guess there are sub-phenotypes who they benefit/harm, but we still need to make a decision with the evidence we have & that’s the side of the fence I’m on (for now)!
Some very challenging interactions with a new surgical colleague this morning
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
February 20, 2025 at 5:36 PM
Some very challenging interactions with a new surgical colleague this morning
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
#ILookLikeASurgeon
👩⚕️ 🥰 🦄
In MINT the restrictive group achieved a median Hb of 8.8 vs 10.1 in the liberal group (where >10 was the target). So haven’t we effectively studied 10 vs just below 9 & 10 looked better?
February 18, 2025 at 3:31 PM
In MINT the restrictive group achieved a median Hb of 8.8 vs 10.1 in the liberal group (where >10 was the target). So haven’t we effectively studied 10 vs just below 9 & 10 looked better?
Very common in 🇬🇧
This is an exert from the BNF (our prescribing bible)
This is an exert from the BNF (our prescribing bible)
February 12, 2025 at 9:30 AM
Very common in 🇬🇧
This is an exert from the BNF (our prescribing bible)
This is an exert from the BNF (our prescribing bible)
Status myoclonus thus can accurately predict a poor outcome with a false +ve rate ≈ 0
BUT, whilst simple myoclonus is still an unfavourable sign, it does not rule out neurological recovery, with a range of false-positive predictive value ranging from 0-22%
link.springer.com/article/10.1...
4/
BUT, whilst simple myoclonus is still an unfavourable sign, it does not rule out neurological recovery, with a range of false-positive predictive value ranging from 0-22%
link.springer.com/article/10.1...
4/
February 9, 2025 at 9:39 AM
Status myoclonus thus can accurately predict a poor outcome with a false +ve rate ≈ 0
BUT, whilst simple myoclonus is still an unfavourable sign, it does not rule out neurological recovery, with a range of false-positive predictive value ranging from 0-22%
link.springer.com/article/10.1...
4/
BUT, whilst simple myoclonus is still an unfavourable sign, it does not rule out neurological recovery, with a range of false-positive predictive value ranging from 0-22%
link.springer.com/article/10.1...
4/
Post-anoxic status myoclonus is diagnosed in the case of continuous and generalised myoclonus persisting for >30mins & when occurring within 48 hrs has excellent specificity for predicting a poor neurological outcome.
As such it forms part of the ERC multi-modal neuro-prognostication guidelines
3/
As such it forms part of the ERC multi-modal neuro-prognostication guidelines
3/
February 9, 2025 at 9:39 AM
Post-anoxic status myoclonus is diagnosed in the case of continuous and generalised myoclonus persisting for >30mins & when occurring within 48 hrs has excellent specificity for predicting a poor neurological outcome.
As such it forms part of the ERC multi-modal neuro-prognostication guidelines
3/
As such it forms part of the ERC multi-modal neuro-prognostication guidelines
3/
Useful BNF reminder in 🇬🇧 context too.
500mg oral sodium bicarb ≈ 6mmol HCO3
1L of 1.26% sodium bicarb = 150mmol HCO3
Orders of magnitudes difference
500mg oral sodium bicarb ≈ 6mmol HCO3
1L of 1.26% sodium bicarb = 150mmol HCO3
Orders of magnitudes difference
February 5, 2025 at 9:33 AM
Useful BNF reminder in 🇬🇧 context too.
500mg oral sodium bicarb ≈ 6mmol HCO3
1L of 1.26% sodium bicarb = 150mmol HCO3
Orders of magnitudes difference
500mg oral sodium bicarb ≈ 6mmol HCO3
1L of 1.26% sodium bicarb = 150mmol HCO3
Orders of magnitudes difference
🇬🇧 Anaesthetist pals:
Trying to educate myself on the role of CPET testing prior to major intra-abdominal surgery.
Seems to be good evidence for its ability to predict mortality/morbidity/LOS, but any data to suggest routine HDU admission based on CPET scores actually improves patient outcomes?
Trying to educate myself on the role of CPET testing prior to major intra-abdominal surgery.
Seems to be good evidence for its ability to predict mortality/morbidity/LOS, but any data to suggest routine HDU admission based on CPET scores actually improves patient outcomes?
January 28, 2025 at 8:21 PM
🇬🇧 Anaesthetist pals:
Trying to educate myself on the role of CPET testing prior to major intra-abdominal surgery.
Seems to be good evidence for its ability to predict mortality/morbidity/LOS, but any data to suggest routine HDU admission based on CPET scores actually improves patient outcomes?
Trying to educate myself on the role of CPET testing prior to major intra-abdominal surgery.
Seems to be good evidence for its ability to predict mortality/morbidity/LOS, but any data to suggest routine HDU admission based on CPET scores actually improves patient outcomes?
Question for MedSky community:
Has anyone seen obstructive shock physiology resulting from dynamic hyperinflation in a ̲𝚜̲̲𝚙̲̲𝚘̲̲𝚗̲̲𝚝̲̲𝚊̲̲𝚗̲̲𝚎̲̲𝚘̲̲𝚞̲̲𝚜̲̲𝚕̲̲𝚢̲ ̲𝚋̲̲𝚛̲̲𝚎̲̲𝚊̲̲𝚝̲̲𝚑̲̲𝚒̲̲𝚗̲̲𝚐̲ patient with a severe COPD/asthma exacerbation?
#EMIMCC
Has anyone seen obstructive shock physiology resulting from dynamic hyperinflation in a ̲𝚜̲̲𝚙̲̲𝚘̲̲𝚗̲̲𝚝̲̲𝚊̲̲𝚗̲̲𝚎̲̲𝚘̲̲𝚞̲̲𝚜̲̲𝚕̲̲𝚢̲ ̲𝚋̲̲𝚛̲̲𝚎̲̲𝚊̲̲𝚝̲̲𝚑̲̲𝚒̲̲𝚗̲̲𝚐̲ patient with a severe COPD/asthma exacerbation?
#EMIMCC
January 24, 2025 at 9:36 PM
Question for MedSky community:
Has anyone seen obstructive shock physiology resulting from dynamic hyperinflation in a ̲𝚜̲̲𝚙̲̲𝚘̲̲𝚗̲̲𝚝̲̲𝚊̲̲𝚗̲̲𝚎̲̲𝚘̲̲𝚞̲̲𝚜̲̲𝚕̲̲𝚢̲ ̲𝚋̲̲𝚛̲̲𝚎̲̲𝚊̲̲𝚝̲̲𝚑̲̲𝚒̲̲𝚗̲̲𝚐̲ patient with a severe COPD/asthma exacerbation?
#EMIMCC
Has anyone seen obstructive shock physiology resulting from dynamic hyperinflation in a ̲𝚜̲̲𝚙̲̲𝚘̲̲𝚗̲̲𝚝̲̲𝚊̲̲𝚗̲̲𝚎̲̲𝚘̲̲𝚞̲̲𝚜̲̲𝚕̲̲𝚢̲ ̲𝚋̲̲𝚛̲̲𝚎̲̲𝚊̲̲𝚝̲̲𝚑̲̲𝚒̲̲𝚗̲̲𝚐̲ patient with a severe COPD/asthma exacerbation?
#EMIMCC
I don’t disagree, but sometimes perfect is the enemy of good. I take a little reassurance from the various Kaplan-Meier curves too. Most of the group separation occurs by day 4, which makes me think it’s the first few days that make the difference
December 17, 2024 at 8:27 AM
I don’t disagree, but sometimes perfect is the enemy of good. I take a little reassurance from the various Kaplan-Meier curves too. Most of the group separation occurs by day 4, which makes me think it’s the first few days that make the difference
December 6, 2024 at 10:45 AM
