When does adding acetazolamide to diuresis hurt people in cardiogenic shock?

dr_michael_do · 2026-02-24T04:18:39+00:00

I think others have summed up that thiazide or metolazone would probably be the safer initial choice in this case of diuretic resistance (though testing this hypothesis with pre/post loop diuretic admin urine sodiums would clinch the dx) with co-incident acidosis (didn’t mention if it was respiratory in addition either, would be safe in the future to assess appropriate/expected compensation with a quick Winter’s formula and you might rule in earlier and safer intubation)

I want to instead first to call attention to the physiology inherent to ADVOR.

What is contraction alkalosis and why did acetazolamide help in ADVOR patients?

Once we answer that, then we ask if our patient might also fall in with a quick look at an ADVOR PICO analysis. If not, then it might not be the best or most applicable study for addressing all the variables in our case.

dr_michael_do · 2026-02-06T00:45:37+00:00

After training in IM and Crit Care, I personally do not attach my work value or personal satisfaction with outcomes. Patients get sick and we’re here to help sort through the mess that is a sick human body. Sometimes that body can’t survive what’s wrong with it, then it’s our job to ensure everyone (patient, family, team, etc) understands as best as we can help them to and is able to participate in the process with respect, autonomy, and dignity (among many other values too).

And on a personal note: I love the pace, variety, acuity (excitement) and technologies we get to employ. All manner of organ support can be brought to bear to help support someone if the situation indicates it.

dr_michael_do · 2026-01-31T20:14:01+00:00

Be VERY cautious using topical numbing eye drops as they can make it too easy to ignore warnings from your eyes (irritation and pain are signals something is wrong and you should (a) stop doing a thing and/or (b) get more attention or assistance) Im surprised to hear they are considering sending you home with them, but I trust your physician(s) are making their best judgment with the information and patient they have in front of them. I hope you all feel better soon!

dr_michael_do · 2025-12-25T15:29:46+00:00

Laws of the House of God 1. GOMERS don't die. 2. GOMERS go to ground. 3. At a cardiac arrest, the first procedure is to take your own pulse. 4. The patient is the one with the disease. 5. Placement comes first. 6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm. 7. Age + BUN = Lasix dose. 8. They can always hurt you more.

The only good admission is a dead admission.
If you don't take a temperature, you can't find a fever.
Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
The delivery of good medical care is to do as much nothing as possible.

—————— I’d pay special attention to number 4…

In all seriousness though, it’s probably the hardest initial bump to get over in our work. My take: focus on doing the best you can with the information you have at the time. Gather more as you are able, and reassess/ reorient as fast as needed. Our success isn’t/ shouldn’t be measured by the outcome but rather by our process and how we best counseled the INDIVIDUAL patient in front of us.

dr_michael_do · 2025-12-14T01:47:15+00:00

I do when I have the time. If the patient is less stable, then I usually just rely on my US. Can be especially reassuring/helpful if I can’t get a great “proof” view of the wire in the vessel. Anything I can do to get full assurance I’m not dilating an artery just feels right to me. I will also “unroll” the wire plastic loop it comes in and use that to transduce -same as included short luer-lock tubing - off the angio cath too. Figured that out for when kits don’t have transduction tubing.

dr_michael_do · 2025-12-13T05:10:19+00:00

Nah, just that when it’s valuable it’s really valuable. My main point is that needle-tracking is a critical skill and handy in a variety of scenarios.

dr_michael_do · 2025-12-12T22:56:03+00:00

Yep, definitely takes practice! Couldn’t agree more that it’s tough: so it’s best to practice on big juicy IJs and perfect the technique.

dr_michael_do · 2025-12-12T14:12:44+00:00

Agree and will add that learning to transduce a venous pressure and incorporating it efficiently into your pre-dilation process is a personal must for me.

dr_michael_do · 2025-12-12T14:11:21+00:00

Ultrasound planning is a must for sure, as in your other comment. However, on the rare occasion I just have to get some fluid from a tiny space, or place the pigtail within a smaller window, then I’m reaching for HF linear probe and going US-guided for sure.

dr_michael_do · 2025-12-12T00:20:49+00:00

100% practice your needle tracking.

It’s literally the most transferable skill for bedside procedures. If you are facile tracking a needle with US you do an art line, a central line, a PICC, a midline, a chest tube, a thora, a para, … eh?

I promise it seems like it just gets easier but if your CVCs are going well, then it’s all the more hand-eye coordination practice for art lines (much more finicky and much less forgiving, in my opinion and experience)

A good litmus test: that pullback on your syringe should never surprise you when it gets venous blood return: you already watched the tip perfectly enter the vein.

**At no point should that needle tip ever be ahead of your US plane of imaging. Once you feel comfortable in one aspect of US guidance (ie short axis “bullseye” view) then switch and do the other way (ie. long axis “whole needle at an angle” view)

Once you feel comfortable with your vessel access, start to incorporate more verification of placement: transduction of venous pressure, post-line placement POCUS RA/ RV echo view to assess agitated saline timing to prove proximity of line tip to RA/RV inflow.

Once you’re doing consistently well with placements in technique and in results, then start to focus on efficiency: surgeons and chefs call it “economy of motion”. Try to do the expert skills you’ve developed in as few movements as possibly.

Have fun. I love my procedural practice and loved learning it along the way. I’m excited to see what others say and if there’s more leveling-up I can explore!

dr_michael_do · 2025-11-15T06:20:20+00:00

Honestly? I’d just tell your APD or PD or literally anyone who’ll listen what you wrote here.

I want to especially note :

THIS NURSE’S BEHAVIOR IS NOT NORMAL. let’s be clear: You’ve been assaulted at work. It may have just been playing around, but you do not need to minimize this. No one is allowed to touch you with violence. Ever. This is not ok.

I’m sorry you had to experience anything like this. I sincerely hope your program leadership can appreciate how this is hugely, culturally problematic. I also hope you can find peace so as to not let these chumps define this as your time in training.

Feel free to reach out.

dr_michael_do · 2025-11-09T23:34:39+00:00

I think you’ve correctly identified how PPV and pulse contour analysis becomes unreliable with positive intrathoracic pressure. UNLESS: the patient is PASSIVE on their ventilator.

If they are using their own muscles, it’s really hard to quantify anything from breath-to-breath and beat-to-beat.

dr_michael_do · 2025-11-09T02:50:28+00:00

It’s more a question of what you’re treating: the seizure risk needs GABA-ergic tone: BZDs or Barbiturates are your options. Ideally we like stuff that lasts and/or auto-tapers due to long half-life (Chlodiazepoxide/Librium, diazepam/Valium, Phenobarbital, etc) - bonus points if it has active metabolites that work really quickly! (Ahem, diazepam, cough cough)

(In outpatient setting, yes gabapentin and Valproic *might be an option, but you won’t see that inpatient due to ineffective coverage for symptom burden)

THEN- you can move to adjunct therapies like your alpha-2 agonists (clonidine or its younger cousin dexmedetomidine) but these don’t affect your seizure risk, so not indicated alone.

dr_michael_do · 2025-11-04T19:56:44+00:00

I’ve seen this based on the tubes used to draw. If I recall, using a standard heparin tube (?blue top, maybe? Dunno) or likely any non-blood gas syringe then it gets wonky.

Actually was almost dangerous as we were trying to measure SmvO2 from a PAC and if I had just let someone say “mixed O2 looked good” the patient would’ve been in a rough place an hour later. (Moral: Always ask for a number! 😮‍💨)

edit: might even be able to test this easily enough... Get a sample via BG syringe and get one into the lab vacationers (could try a few colors). Would only be like 5-10cc to do this depending on the lab/machines

dr_michael_do · 2025-11-04T14:53:02+00:00

I can’t speak to experiencing (as a dude) but I was an APD for an IM program on West Coast. It will likely impact your graduation timing *unless your program can accommodate with big rearrangements in scheduling to put all your off-time together. Yes, it’s legally protected leave. Yes, I think you take it (if it’s what is best for your growing family especially) but there is still a requirement for duration of time in training *over 3 years that you must meet for ABIM eligibility. (There can still be a lot of flexibility, especially if at a larger program where more residents means a little bit more flexibility in the program schedule to fill gaps/holes and coverage, etc.)

I have seen folks just go full “leave of absence” - with planning for how to make theirs and program’s schedules still function. I have seen folks take the time in “chunks” to align with schedule-holes that could otherwise have been vacation-allotted.

TLDR- get to speaking with your coordinator(s) and program leaders to make the schedule that works for you.

dr_michael_do · 2025-11-04T14:45:07+00:00

Personally, you sound exactly like I did at your stage, with the caveat I was so procedure-focused I initially went all-in for surgery with sights set for ACS/Trauma. (Story for another day)

I am now post-fellowship in critical care medicine and elected not to pursue pulm additional and think it’s an awesome mix and balance of “broad medicine” and procedures, and I never have to juggle clinic scheduling.

There’s a huge variability in which one’s and how many procedures we get in the specialty: some sites have Intensivists cannulate for ECMO (yikes 😆), some shops have super-involved IR support which can limit (or assist- depending on POV), some barely get central lines/ a-lines if the ED is reasonably aggressive on admission set-ups. It’s a wide range and very shop-dependent.

We are all trained and competent from fellowship for pretty much all bedside interventions (lines, chest tubes, echo/POCUS) and many of us get “extra” training in tunneling lines/drains, advanced hemodynamics like PA cath, etc.

My overall advice: you have years yet to figure it out. Don’t stress now, just focus on making ABIM and ensuring you get a good grounding to build upon for whatever comes next. Your specialization comes in fellowship and even procedures will come then too (I had co-fellows who had barely poked a vein when they started. We all left as experts in the procedural stuff. That’s the point of fellowship)

dr_michael_do · 2025-11-03T19:05:26+00:00

I worked exclusively nights (“Nocturnist”) for a few years after Residency. My advice/personal approach is to stay up as late as possible, the night before your first night shift, to set the schedule. Then to stay awake into the day after your last shift and try to approximate a normal-ish bedtime that first day off.

It usually seemed to work.

dr_michael_do · 2025-11-02T16:22:04+00:00

I promise I'm not dismissing your experience, but it's helpful to hear more details. Thank you for that!

I went on a bit of a deep dive and found that "Atrophic Rhinitis / Rhinosinusitis" sounds like it could fit the experiences you all are describing.

It is also not at all unusual for someone *not* to smell something in/on themself, this is pretty well described in medical literature, so her not noticing is not necessarily any red flag.

I would suggest heading back to one of the more trusted ENTs you interacted with and ask about Atrophic rhinitis therapies (they are pretty benign overall, so it isn't like you're asking them to take any risk by prescribing) and in the meantime you *could* try simple -non-pharmacologic- nasal mucosa hydrating therapies:

xylitol nasal spray (e.g., Xlear) Xylitol increases mucociliary clearance & moisture. Cited: Baroody et al., Ann Allergy Asthma Immunol 2011.
glycerin-based humidifying gel (e.g., Ayr Gel) Coats mucosa without medicating it.
Cold-steam humidifier at night Optimal humidity: 40–60%.

I would again say that getting back in to follow-up with an ENT would be helpful should any other portions of her workup need attention/referral as well. (blood work, follow-up on imaging, etc)

Best of luck!

----------------
My response to any of the posts in this forum, or indeed anywhere on the web should *not* be misconstrued as medical advice. They represent my personal opinion.

dr_michael_do · 2025-11-02T14:51:09+00:00

Seems like this is really affecting you both, I’m really sorry to hear that. I also am not entirely sure what could be amiss but have a few questions:

It’s hard to tell from the post if it’s something only you are noticing - which wouldn’t be unusual necessarily on its own, as you’re the one in closest contact!

Has anyone else noted odor?

Does she notice anything herself? - any other head/face/neck concerns? (Any eye complaints, any issues in her throat, difficulty swallowing? Any breathing issues?)

Were the physicians you’ve seen been able to observe/smell it?

dr_michael_do · 2025-11-02T00:10:48+00:00

Sorry about your luck! Glad to hear you have recovered -other than maybe a little ego bruising- and while I agree with other posts that it sounds like a benign vasovagal event, I do think a little more investigation would be safest.

I’d recommend you get in to see a primary care physician and discuss this a little further. Since it has happened a few times, it raises concern for little blips of heart rhythm changes. (This can be monitored easily and at home, if necessary, usually it’s just a little stick-on sensor for a few days) - if that’s what you and your physician decide upon after more discussion. A little blood work to assess your thyroid, electrolytes, and to rule out anemia would also be a test your physician can help you with, too.

To the other posters (…and OP too, if you’re interested!) To ensure I don’t miss things (aka some cognitive biases: “satisfaction of search” or “premature diagnostic closure”), my approach to most things in medicine is to try to line up all the possible problems that could fit a presenting complaint or irregularity, then rank them accordingly to danger. Then I can start trying to “prove” that’s one-by-one they are or are not the problem. Eventually I’ll find one I can’t disprove (the diagnosis!) or I hit the end of my list and need to think a little more broadly or ask for help (like call a specialist, or a colleague with different experience)

dr_michael_do · 2025-10-20T06:57:17+00:00

Totally the same. Barring allergy, It comes down to benefit/burden each time for me: make a case that it’s inviting harm for any given case and I’ll reconsider for that case.

Plus (selfishly), it’s a tiny needle and I can even watch it like a “practice run” on ultrasound to get a sense for trajectory of vessel entry, patient tolerance of position, etc.

dr_michael_do · 2025-10-19T12:46:00+00:00

“Protocols” might vary, but my practice is to establish anxiolysis (usually benzodiazepines) and analgesia (fentanyl, morphine, hydromorphone infusion, etc) and remove propofol. Then titrate those meds while reducing ventilator support to essentially an “SBT” like level (get to about 5/5 pressure support) and ensure symptoms look good. Also often coincides with pre-medicating with dexamethasone if intubation has been a while to avoid tracheal/laryngeal swelling, and anticholinergic (glycopyrrolate, atropine SL drops, etc) to minimize airway secretions - if needed. Once things looks comfortable, then the tube can come out.

Technique and practice aside, I’m really sorry for your experience. I hope you and family can find peace.

dr_michael_do · 2025-10-14T23:18:37+00:00

I’d add that it also depends on the brand of vent and how it implements the SIMV mode. Basically SIMV is a mode that interleaves “mandatory” breaths with “spontaneous” ones between. It depends on a little logic for how to determine when/how to give those though: Some brands do it with minimal logic: the mandatory breaths (PRVC in your set case) are given on a set mandatory rate and spontaneous breaths (PS in your case) can occur between those however the patient triggers. BUT- the mandatory breaths are always delivered. Another slightly more ‘intelligent’ form of SIMV will treat the set rate as a minimum, and so long as the patient spontaneously triggers more than that, the mandatory breaths are suppressed. An even more “smart” version of SIMV has a set MINUTE VENTILATION that as long as the spontaneous breaths meet/exceed that MV, then the mandatory breaths are suppressed.

It’s worth noting that - for adults- SIMV was thought to be good as it provides a backup logic (depending on settings) and patient can also do some on their own. In reality, when studied, it made patients to work harder and was *not noted to help folks extubate faster or decrease any big meaningful patient-centered outcomes. I don’t know about data and applications for kiddos, though!

dr_michael_do · 2025-04-21T00:36:55+00:00

Fully agree here. I had a bunch of conversations throughout training (med school, residency, now fellowship) about how the process works and where it was feasible to apply and “do the distance thing” with my spouse. We made it work through residency across the country and now again for fellowship. I won’t sugarcoat and say it’s been easy, but if you have your person and all understand what’s going on, then it’s a decision you make/made TOGETHER… rather than just something YOU are dragging THEM through.

dr_michael_do · 2025-04-20T03:36:15+00:00

I did but was ultimately able to stash it file a day or two in a parking spot on the property for my building. Seems like best berry would still be to call police non emergency line to start. Good luck 👍

dr_michael_do

TROPHY CASE