Thanks for Teaching Me

Hi everyone:

I’ve been working in the MICU all week, while in my “spare time,” I’ve been writing 48 letters of recommendation for fellowship. The letters are due Wednesday, so I’ll be brief.

Here’s some of what we learned this week on rounds:

• We admitted a patient for an acetaminophen overdose. After starting N-acetylcysteine, his creatinine dropped to 0.06. It turns out high dose NAC interferes with creatinine assays (and you can’t have a GFR of 1000): A Systematic Review of the Effect of N-Acetylcysteine on Serum Creatinine and Cystatin C Measurements.
• We treated a patient with dexmedetomidine for 44 hours. After stopping the drug, her heart rate rose to 150. It turns out two days of treatment is long enough to cause withdrawal. Clonidine worked beautifully: Evaluation of dexmedetomidine withdrawal in critically ill adults.
• The same patient had an AM cortisol of 2.3 with no risk factors for adrenal insufficiency, or so we thought. It turns out longstanding use of inhaled steroids can suppress adrenal function more often than we’d realized: Metabolomic profiling reveals extensive adrenal suppression due to inhaled corticosteroid therapy in asthma and Inhaled corticosteroid use for asthma is linked to adrenal suppression.
• We cared for a patient with polycystic kidney disease admitted with shock. After laying him flat to do a POCUS and straight leg raise test, his BP plummeted. It turns out large renal cysts can compress the IVC, causing hypotension. The BP rose when we raised the head of the bed: Prevalence of Inferior Vena Cava Compression in ADPKD.

It was a memorable week in the MICU with great fellows and residents and two special interns who proved that if you have to be admitted to the hospital, July is as good a time as any.*

Thanks for teaching me, Blue Team.

Now, I’m off to the MICU for one last day of rounds before returning to those letters. Enjoy your Sunday, everyone,

Mark

*H/T to Isabel Bazan.

MDS