The Queen's Rotting Smile
In 16th century England, sugar transformed from a rare medieval seasoning into a status symbol for the wealthy elite, with Queen Elizabeth I leading the sweet-toothed charge. As colonial trade brought sugar flowing into Elizabethan England, it became the centerpiece of lavish banquets and cookbooks for the aristocracy, though its dental consequences remained largely unknown. The queen's legendary love of sweets went so far that she even used a sugar-based toothpaste, a dental decision that modern experts would certainly question.
By 1599, when German traveler Paul Hentzner encountered the 65-year-old queen, he noted her black teeth—a direct result of her lifelong sugar addiction. Surprisingly, this dental deterioration became a fashion statement, as black teeth signaled wealth and sugar accessibility. The trend grew so popular that less affluent people began artificially blackening their teeth with soot to mimic the elite's sugar-induced decay. This peculiar beauty standard eventually disappeared after Elizabeth I's reign, demonstrating how even dental disasters can become desirable when associated with royalty and riches.
Welcome to the 108th edition of ResusNation!
How Could You NOT Prone Your Patients?
As a critical care physician, I've become a strong advocate for prone positioning, especially with our extensive clinical experience supporting its benefits. When faced with a patient on toxic FiO2 levels with no contraindications to proning, I believe we have a clear obligation to implement this intervention given its proven mortality benefit. How could we justify withholding a therapy that saves lives?
On my inaugural podcast with Dr. Nick Ghionne (see later in newsletter for the link) we discuss the physiological advantages of prone positioning extend well beyond survival rates. We talked about the significant hemodynamic improvements, enhanced pulmonary function, better diuresis, and improved secretion clearance due to the favorable tracheal positioning when patients are on their bellies. With such a comprehensive range of benefits addressing multiple aspects of critical illness, prone positioning has become an essential component of my approach to managing severe respiratory failure.
Watch the full video here and leave a comment.
Don't forget to like and follow my IG, TikTok, YT, Facebook or Linkedin accounts.
Lifetime Access For Only $79!
Did you miss ResusX:ReUnion? If you weren't there live for ResusX:ReUnion then you missed an amazing experience with 3 days of education and over 50 faculty members. Fortunately for you, we got the whole incredible event captured on video and you can start watching it right now!
These videos were recorded in high-definition and have remastered audio. When you register you'll also have access to high-yield summaries that you can download to take with you on the go. You'll also be able to earn CME or CEU credits as you watch.
And because I'm grateful that you are a newsletter subscriber, I'm giving you this conference at the lowest price we've ever offered, at $79 for lifetime access! We only have a limited number of these dicsounts avaialble so if you want this discount do not wait...once these discounted registrations are gone....they're gone! Thanks for being part of ResusNation.
|
Talking Shift: Refractory Hypoxemia
In this debut episode of the "Talking Shift" podcast, host Dr. Nick Ghionne discusses managing refractory hypoxemia in critical care. Using a case example of a 62-year-old male with influenza-induced ARDS, Dr. Ghionne explains his methodical approach to ventilator management when patients remain hypoxemic despite aggressive interventions. He emphasizes the importance of first properly sedating patients to get accurate ventilator readings before making adjustments, and details how driving pressure (plateau pressure minus PEEP) guides ventilation strategies.
The conversation highlights several escalating interventions for persistent hypoxemia. Dr. Ghionne advocates for careful PEEP adjustments based on driving pressure measurements, considering advanced modes like Airway Pressure Release Ventilation (APRV) in certain cases, and implementing early prone positioning for its proven mortality benefit. While medications like epoprostenol can improve oxygenation numbers, he recommends using them only after evidence-based interventions with mortality benefits have been implemented.
Key Takeaways:
-
When managing refractory hypoxemia, first ensure adequate sedation to obtain accurate ventilator measurements, then use driving pressure (plateau pressure minus PEEP) to guide PEEP adjustments.
-
Prone positioning is one of only two interventions (along with low tidal volume ventilation) proven to reduce mortality in ARDS and should be implemented early when patients meet criteria.
-
Pulmonary vasodilators like epoprostenol should be considered only after optimizing ventilator settings and implementing prone positioning, as they improve oxygenation but have no mortality benefit.
Check out this video of Dr. Haney Mallemat with special guest Nick Ghionne from ResusX:ReVolved now!
Does Dexmedetomidine Actually Worsen Outcomes in Refractory Septic Shock?
A multicenter, randomized, double-blind pilot trial investigated whether dexmedetomidine could reduce vasopressor resistance in patients with refractory septic shock. The ADRESS study enrolled 32 patients across 5 French ICUs, measuring arterial pressure response to phenylephrine at 0, 6, and 12 hours after treatment initiation. Researchers hypothesized that dexmedetomidine might normalize sympathetic hyperactivation and restore vasopressor sensitivity in these critically ill patients, potentially improving outcomes.
The study found concerning results: patients receiving dexmedetomidine had significantly lower vasopressor sensitivity at baseline and all time points compared to placebo. More importantly, the dexmedetomidine group experienced significantly higher early mortality (50% vs 13% at day 3, p=0.022), requiring the data safety monitoring board to halt the trial early. Although the mortality difference diminished at later time points, dexmedetomidine-treated patients also required higher peak norepinephrine doses and had fewer vasopressor-free days. Interestingly, dexmedetomidine did not cause the anticipated bradycardia that often concerns clinicians.
Bottom Line: Despite theoretical benefits seen in previous studies, this trial raises serious safety concerns about dexmedetomidine in refractory septic shock. The baseline imbalance in vasopressor sensitivity between groups complicates interpretation, but the significant increase in early mortality should prompt caution. Clinicians should avoid dexmedetomidine in refractory septic shock outside clinical trials until larger studies can definitively establish its safety and efficacy in this vulnerable population.
Here's my Takeaways:
-
Finding: Patients receiving dexmedetomidine had 37% higher absolute early mortality (50% vs 13% at day 3, p=0.022) compared to placebo
-
Practice Impact: Dexmedetomidine should be avoided in patients with refractory septic shock requiring high-dose vasopressors
-
Population: Mechanically ventilated ICU patients with septic shock requiring ≥0.25 μg/kg/min norepinephrine and showing signs of persistent circulatory failure
-
Limitation: Baseline imbalance in vasopressor sensitivity between groups complicates interpretation of causal relationship between dexmedetomidine and outcomes
Want to learn more? Read the full study "Dexmedetomidine to Reduce Vasopressor Resistance in Refractory Septic Shock: α2 Agonist Dexmedetomidine for REfractory Septic Shock (ADRESS): A Double-Blind Randomized Controlled Pilot Trial" by Dargent A, Bourredjem A, Jacquier M, Bohe J, Argaud L, Levy B, Fournel I, Cransac A, Badie J, Quintin L, Quenot JP in Crit Care Med. 2025
Save the Date: ResusX25
Mark your calendars! We're thrilled to announce that ResusX 2025, the premier resuscitation conference of the year, is returning for its seventh spectacular year. Join us September 29 - October 1, 2025, as we take over Philadelphia's iconic Punchline Comedy Club for our most ambitious event yet.
The overwhelming interest we've received through emails and messages has shown just how exited the ResusNation is for this announcement. We're pulling out all the stops to bring you an unforgettable experience featuring the leading voices in resuscitation medicine - live and in person. Don't miss your chance to be part of this landmark event in the City of Brotherly Love. Stay tuned for more details about our world-class speakers, innovative sessions, and more.
We're finalizing an action-packed schedule, including specialized post-conference workshops. Full CME and CEU details will be available on our website shortly.
Given the intimate venue and unprecedented interest in ResusX 2025, we anticipate tickets will sell out rapidly. As a valued newsletter subscriber, we want to ensure you have priority access to registration. So here's how to secure your spot:
If you're committed to attending ResusX 2025, simply complete our priority access form below. You'll receive immediate notification when ticket sales open, giving you first opportunity to register. Based on the overwhelming response we've already received, we expect tickets to be claimed quickly during this priority registration period.
Complete the Priority Access Form
Watch the March Videos Now!
If you're an All-Access Member, you're in for some great content this month. We have FIVE videos hand-picked by our staff that are high-yield and our most highly watched. We're featuring
- Propersi on "Capecod Trial"
- Schauer on "Trauma Contributions from the Military"
- Fornari on "Cerebral Edema in Pediatric DKA"
- Kim on "Everything You Wanted to Know About Thoracotomies"
- Weingart on "Trauma Team Leader"
Each month we bring you fresh new content from the best of the best in resuscitation. If you're an All-Access member, go watch these videos NOW! If you're not, then sign up here.
Are you a member of ResusNation? For less than a cup of coffee, you can get even more content from CriticalCareNow. Digital teaching sessions, podcasts, free video lectures, grand rounds, and so much more can be your today. Come watch on replay all the content that CriticalCareNow does live. Check out the membership options below and decide the right one for you.
Do you want even more resus content anytime you want? For less than a cup of coffee, you can get even more content from @CriticalCareNow. Digital teaching sessions, free video lectures, grand rounds, and so much more can be your today. Come watch on replay all the content that @CriticalCareNow does live.
Check out the membership options below and decide the right one for you.
Get Access To The ResusNation Today!
Responses