Critical Matters

In this episode Dr. Sergio Zanotti discusses the recently released Clinical Practice Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults. This guideline is a report of the American College of Cardiology / American Heart Association Joint Committee on Clinical Practice Guidelines. He is joined by Dr. Mark Creager, the lead author and chair of the writing committee for these guidelines. Dr. Creager is Professor of Medicine and Professor of Surgery at the Geisel School of Medicine at Dartmouth. A past president of the American Heart Association, he is an internationally recognized leader in vascular and cardiovascular medicine with more than 400 scientific publications. Additional resources: 2026 AHA/ACC/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology / American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2026: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001415 Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2023: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001117 Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. CHEST 20: https://journal.chestnet.org/article/S0012-3692(21)01506-3/fulltext Books mentioned in this episode: Team of Rivals: The Political Genius of Abraham Lincoln. By Doris Kearns Goodwin: https://bit.ly/4skCS0c Alexander Hamilton. By Ron Chernow: https://bit.ly/4rFuxTw Vascular Medicine: A Companion to Braunwald’s Heart Disease. By Mark Creager et al.: https://bit.ly/4uHZ4Dc

Dr Waqas Akhtar, consultant in cardiology and intensive care who led the British guideline on ECMO emergencies. He discusses why ECMO emergencies matter, differences between VA and VV support, a two-team response model, rapid circuit troubleshooting, flow-based management, training needs, and service design pearls. Practical, focused, and action-oriented.

Dr. Firas Mussa, a vascular surgeon and professor at McGovern Medical School, dives deep into the complex world of acute type B aortic dissection. He emphasizes the critical role of intensivists in managing these urgent cases and unpacks the differences between dissection types. Mussa discusses risk factors like hypertension, outlines diagnostic standards, and explores treatment options, including TEVAR. He also highlights the importance of ICU protocols in improving patient outcomes and factors influencing clinical trials. Personal reflections and book recommendations add a nice touch!

Simran Gupta, an infectious disease specialist at Brigham and Women's Hospital, shares her expertise on procalcitonin (PCT) in the ICU. She delves into the biology and clinical applications of PCT, emphasizing its potential to reduce unnecessary antibiotic use. Gupta discusses the ADAPT-Sepsis trial, highlighting how it supports shorter antibiotic courses without compromising patient survival. She also addresses challenges clinicians face in discontinuing antibiotics and offers practical tips for effective PCT use in critical care, all while reflecting on personal growth and recommending the book 'Shantaram'.

Join Dr. Eduardo Kattan, a critical care physician and leading researcher on septic shock, as he discusses the pivotal role of Capillary Refill Time (CRT) in assessing peripheral perfusion. He explains how CRT can guide treatment strategies, especially in early septic shock. With insights from the ANDROMEDA-SHOCK trials, Dr. Kattan highlights the importance of personalized care and the challenges of measuring CRT in diverse populations. His reflections on future research directions and practical tips for implementation make this conversation invaluable for medical professionals.

Dr. Elizabeth Munroe, a pulmonary and critical care physician from Intermountain Health, shares her insights on peripheral vasopressor administration. She reveals how this method is shifting clinical practices, especially in sepsis management. The conversation includes historical perspectives on central lines, recent safety studies, and the CLOVERS trial’s findings. Munroe emphasizes the practicality of peripheral access for urgent needs and outlines strategies for safe administration. She advocates for open-mindedness in evolving medical practices underpinned by robust evidence.

Joining Dr. Sergio Zanotti is Dr. Michael J. Connor, Jr., a revered figure in Critical Care Medicine and Nephrology at Emory University. They dive deep into the critical issue of fluid overload in the ICU, discussing its impact on patient survival and organ recovery. Dr. Connor explains how fluid overload arises, its detrimental effects on kidneys, and strategies for effective management, including the phased approach to fluid management. He emphasizes the importance of objective measurement and the judicious use of diuretics, while reflecting on valuable lessons learned throughout his career.

Originally posted in April of 2023, we are sharing this episode of Critical Matters again as Dr. Sergio Zanotti's discussion about the long journey to healing and recovery for those who've survived critical illness in the ICU remains pertinent and important. This conversation features Dr. Margaret Herridge, Professor of Medicine, Senior Scientist in Critical Care and Respiratory Medicine at the University of Toronto. Dr. Herridge is also Director of Critical Care Research. Director of the RECOVER Program, and Clinical Director of the Grace RECOVER Program for Chronic Critical Illness, in the University Health Network, Toronto, Canada. Additional Resources: Outcomes after Critical Illness. M. Herridge and E. Azoulay: https://pubmed.ncbi.nlm.nih.gov/36884324/ Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Hopkins RO, et al: https://pubmed.ncbi.nlm.nih.gov/10390379/ One-year outcomes in survivors of the acute respiratory distress syndrome. Herridge m, et al: https://pubmed.ncbi.nlm.nih.gov/12594312/ Long-term cognitive impairment after critical illness. Pandharipande PP, et al: https://pubmed.ncbi.nlm.nih.gov/24088092/ The RECOVER Program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation. Herridge M, et al: https://pubmed.ncbi.nlm.nih.gov/26974173/ Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study. Gayat E, et al: https://pubmed.ncbi.nlm.nih.gov/29347987/ Symptoms of anxiety and depression in family members of intensive care unit patients. Pochard F, et al: https://pubmed.ncbi.nlm.nih.gov/11588447/ Books Mentioned in this Episode: Bel Canto. By Ann Patchett: bit.ly/3nWs7Vp Commonwealth. By Ann Patchett: bit.ly/43pWSCt

Dr. Adam Green, a practicing intensivist and associate professor at Cooper University, joins Dr. Sergio Zanotti to discuss the growing relevance of Extracorporeal Cardiopulmonary Resuscitation (ECPR). They delve into the evolution of ECMO practices, emphasizing patient selection and timing during cardiac arrest. Green highlights the ethical complexities in critical care decisions and the vital role of effective communication with families. The discussion also touches on emerging insights around patient outcomes and the rapid protocols that shape life-saving interventions.

Dr. Angel Coz Yataco, a practicing pulmonary critical care physician and lead author of the latest guidelines from the American College of Chest Physicians, joins the discussion on transfusion practices in the ICU. He delves into the complexities and inconsistencies in platelet and fresh frozen plasma transfusions, advocating for evidence-based, personalized approaches based on individual patient needs. The conversation also emphasizes humility in medicine and the intriguing concept of 'aggressive waiting' in patient care, underscoring the delicate balance between intervention and observation.