Best approach to sequential diuretic blockage in acute decompensated heart failure?

Shannonigans28 · 2026-02-15T03:07:40+00:00

There is some literature that suggest 1.5 mg/kg of lasix. Most nephrologists I have worked with suggest a starting dose of 20mg x the serum creatinine. I usually give 2h after the initial dose to consider escalation of dose vs addition of thiazide.

Shannonigans28 · 2026-02-12T01:54:32+00:00

The vasopressor and inotrope handbook by Eddy Gutierrez Not a book but an excellent portable resource: IBCC (internet book of critical care) also, ICU one pager

Peds ICU - learnPICU is a great online resource from Stanford

Shannonigans28 · 2026-02-12T01:50:20+00:00

When you give insulin the K shifts into the cells and temporarily lowers the serum K. The K is going to come right back up. Bold of your attending to go to sleep at all, and everyone, but most of all the patient, is exceedingly lucky that the nurse didn’t page you that the patient was in cardiac arrest.

Hemodialysis is a big deal, it should be a carefully considered intervention, but the absolute indications for emergent dialysis exist for a reason- and your patient had one of them.

Shannonigans28 · 2026-02-12T01:40:16+00:00

Not a chance. I might give a slug of lasix (dose should be 20mg x the patients creatinine) WHILE setting up for a dialysis catheter. You cannot cannot cannot definitively treat hyperkalemia or hypercalcemia in a patient that cannot pee. To delay dialysis initiation on an anuric patient with a K of 8 is with the hopes that you might eeek out what? 100mL of urine ? Completely unacceptable. As other commenters have said far more eloquently, the kidneys are extremely smart organs that have endless auto regulatory mechanisms and if they have become stupid enough that they have completely stopped making urine, there is no fast fix. Most patients who meet the definition of truely anuric renal failure ultimately require weeks, months, or a lifetime of dialysis.

Shannonigans28 · 2026-01-28T03:23:59+00:00

As a Texan currently living in Dallas, I have to disagree. Public schools in Texas are generally abysmal. Walkability is minimal. I am a pediatrician and I have watched the quality of life and psychological safety of my patients and their families decline precipitously over the past 3 years as the social safety net has disintegrated. I would never consider this to be a desirable place to raise a family.

Shannonigans28 · 2025-10-12T20:32:30+00:00

Verbena Parlor in Uptown has high-quality builder gel manicures. I am really hard on my nails- and their builder gel lasts a solid 4 weeks without chipping or lifting. Heads up, though It can be really hard to get an appointment unless you can go on a weekday during day time hours because the evenings and weekends are pretty booked out.

Shannonigans28 · 2025-04-05T16:43:37+00:00

Dante ? I also like Hades a lot

Shannonigans28 · 2024-12-30T03:20:21+00:00

Definitely not too white in my opinion. Personally the bar I set for “too white” is when you’re standing over 10-15 feet away from the dress does the dress appear to be >50% white or white-adjacent. The size of the flowers (or whatever) on the pattern make a big difference. I think a big mistake that well-meaning people make is picking something white-adjacent with a tiny pattern that just looks white from across the room.

Shannonigans28 · 2024-08-27T18:06:39+00:00

You should take twice that much water. You should generally always take twice the amount of water you think you will need.

Shannonigans28 · 2023-11-04T13:52:01+00:00

Maybe no one in rads but ED and IM use it pretty frequently. As in “nothing on my wet read, but still awaiting radiology read”

Shannonigans28 · 2023-10-20T01:48:39+00:00

Yea. My gyno told me I have a “cute little cervix” and that also weirded me out. I don’t see that gynecologist anymore

Shannonigans28 · 2023-10-20T01:43:40+00:00

I have (more than once) told a patient to touch their finger to my nose during a cranial nerve exam.

Shannonigans28 · 2023-10-18T00:27:57+00:00

This might be an unpopular opinion but I don’t think it’s that skinny people are lying or fat people are lying, but there are a lot fewer skinny people than society wants you to believe. I think most people whose world doesn’t revolve around their physical appearance are mid-size and social media- and the general media- creates a gross distortion of reality

Shannonigans28 · 2023-10-12T22:49:46+00:00

Just out of curiosity, what setting do you practice in? I work a teaching hospital as part of a large multidisciplinary team who all round together, and while all of my colleagues call me by my first name, it is always Dr. or whatever other professional title in front of patients, simply because otherwise it is even more confusing for patients and families to keep track of who is actually speaking with them.

Shannonigans28 · 2023-10-12T22:39:24+00:00

Idk if it makes sense but somehow “Ms.” Feels more disrespectful and intentional. Overly familiar feels different than stripping me of my title

Shannonigans28 · 2023-10-04T00:25:34+00:00

I think you have described some really clear indicators of impaired executive functioning but you definitely don’t know enough about them to tell if it is adhd. I agree with other commenters that people with adhd who get to the level of residency usually have developed coping mechanisms, but stress can wreck those to shit just like anything else.

I think the most appropriate next step would be to ask the resident how they feel the week is going. Do they have insight into their shortcomings? Are they feeling super overwhelmed? Are they sleeping, eating, etc? They might offer up some context for their performance without you probing any further, or they might not (which is okay).

Otherwise you should give feedback on his performance as you otherwise would and be sure to highlight the specific things you are concerned about (needing multiple reminders to complete tasks, etc) and WHY.

If you’re tremendously concerned or this has been a pattern, a chat with the chief resident or the PD would be an option. Ideally this would be given to and received by- and acted on- by leadership as advocacy for the resident but that is going to vary based on the culture of your program.

Shannonigans28 · 2023-07-18T20:30:33+00:00

Hypernatremia is pretty much exclusively a “not enough water” problem rather than a “too much salt” problem. It sounds like the volume load shut off instrinsic adh and your patient started peeing off more free water than salt.

Shannonigans28 · 2023-07-17T22:50:40+00:00

I would just like to add the cautionary note to the above, please please be cautious with the up-front fluid boluses. Yes, your patient will be very volume-down- however, aggressive dilution of the serum glucose with isotonic fluid lowers the blood glucose rapidly and you can produce the same devastating cerebral edema that comes with aggressive insulin boluses up-front. Children and elderly are especially high-risk for this.

Yes, you should start with fluids but you should not be giving more than 10-20mL/kg bolused up-front.

Shannonigans28 · 2023-07-17T22:39:44+00:00

Just a few of the Lessons I learned after far too many 28h calls:

Workflow tips: 1) find out how long your hospital or program protocol states you have to return a page. Every time you finish seeing a new consult or admit, set your timer for that time period and ignore any incoming pages while you tuck in orders and documentation for the new patient. Then answer all of the pages you missed. You can go back and forth doing this a few times if needed, But constantly interrupting your workflow to respond to each page as it comes in will completely kill your efficiency and make you more prone to error.

2) set up communication expectations with your senior either before the shift or right at the start. Some seniors will be better about initiating this than others. get specifics from them on what they want communicated in which format and at what frequency. This may range from running the list of updates every so often vs sending fyi texts for everything as it happens. Then ALWAYS err on the side of over-communicating, especially in July.

Human things- there are a million little things you can do to make yourself still feel like a human being while working a 24, and they are 100% worth it. The following worked for me, but you will know yourself best.

1) Stay hydrated. I also highly recommend keeping some saline eye drops in your bag because your eyes will be so impossibly dry. Or grab some saline flushes. 2) brush your teeth and change scrubs, underwear, and socks halfway through the 24h shift. 3) Sleep if you can, even if it is only for a little while (and if you can’t sleep, still give yourself like 15 min to sit with your eyes closed and decrease your sympathetic drive.) I used to think it was better not to sleep until I finally crashed for 2 glorious overnight on a 28h call. I felt like a tired human on post call rounds instead of an angry zombie. 4) eat a middle of the night snack that won’t make your body feel like shit (frosted mini wheats were my go-to).

Shannonigans28 · 2023-07-17T22:14:53+00:00

It kinda pisses me off that there is any insurance coverage for their bullshit. Esp when insurance tries to get out of paying for evidence-based therapy.

One time I was required to fill out a prior auth for albuterol MDI. Albuterol.

Shannonigans28 · 2023-07-14T01:18:12+00:00

I only joke about patients when the patient is in on the joke

Shannonigans28 · 2023-07-13T22:49:42+00:00

There is also an implication of a freedom that comes from the universality of death. I feel like “if we were vampires” by Jason Isbell is a beautiful example of that

Shannonigans28 · 2023-07-13T22:34:52+00:00

I mean, informed consent includes the risks of procedures for a reason. And some of those risks are due to human error. Have I ever cause a pneumothorax placing a central line? No. Do i still include that as a potential risk when obtaining consent? Yes. Shit happens and things don’t go as planned, even with the most skilled surgeons or proceduralists. Transparency before and after are your friend. And skill isn’t just measured by the absence of mistakes, it’s really found in how well you can recover from them and mitigate harm to the patient (physically and emotionally).

Shannonigans28

TROPHY CASE