Critical Matters

In this episode, Dr. Sergio Zanotti discusses the administration of vasopressor agents through peripheral intravenous lines (or what we refer to as “peripheral vasopressors”). He is joined by Dr. Elizabeth Munroe, a practicing pulmonary/critical care physician and an Assistant Professor of Pulmonary and Critical Care at Intermountain Health in Salt Lake City, Utah. Her research interests include evidence-based resuscitation practices in early sepsis and septic shock, vasopressor administration practices, peripheral vasopressor use, and clinical trials, particularly novel, pragmatic clinical trial designs. Additional resources: Peripheral Vasopressor Use in Early Sepsis-Induced Hypotension. ES Munroe, et al. JAMA Network 2025: https://pubmed.ncbi.nlm.nih.gov/40864467/ Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. Shapiro NI, et al. CLOVERS Trial. New Engl J of Med 2025: https://pubmed.ncbi.nlm.nih.gov/36688507/ Overview of Peripheral Vasopressor Use in an Academic Health System. D Shyu, et al. Ann Am Thorac Soc 2025: https://pubmed.ncbi.nlm.nih.gov/40126143/ Safety of peripheral intravenous administration of vasoactive medication. J Cardenas-Garcia, et al. J Hosp Med 2015: https://pubmed.ncbi.nlm.nih.gov/26014852/ Books mentioned in this episode: Ending Medical Reversal- Improving Outcomes, Saving Lives. By Vinayak K. Parsad, et al: https://bit.ly/4nhCNam

Fluid overload is a common problem in critically ill patients. In this episode, Dr. Sergio Zanotti discuss recognizing and managing fluid overload in the ICU with guest Dr. Michael J. Connor, Jr., a practicing intensivist and nephrologist. Dr. Connor is a Professor and Senior Physician of Critical Care Medicine & Nephrology at the Divisions of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Renal Medicine at Emory University School of Medicine. Additionally, he serves as the director of critical care nephrology at the Emory Critical Care Center at Grady Memorial Hospital. Additional resources European Society of Intensive Care Medicine Clinical Practice Guideline on fluid therapy in adult critically ill patients: Part 3- fluid removal at de-escalation phase. Intensive Care Med 2025: https://pubmed.ncbi.nlm.nih.gov/40828463/ Optimizing Fluid Therapy in the Critically Ill. International Fluid Academy website – 2025: https://www.fluidacademy.org/2025/01/17/optimising-fluid-therapy-in-the-critically-ill-introduction-to-7d/ Fluid overload in the ICU: evaluation and management. R. Claure-Del Granado and R. L. Mehta. BMC Nephrology 2016: https://pubmed.ncbi.nlm.nih.gov/27484681/ Books and music mentioned in this episode: Think Again: The Power of Knowing What You Don’t Know. By Adam Grant: https://bit.ly/4gZvz9c RUSHMERE. By Mumford & Sons: https://bit.ly/473FzKc

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

In this episode, Dr. Sergio Zanotti discusses ECPR–Extracorporeal Cardiopulmonary Resuscitation. ECPR is still be considered a niche therapy, but its relevance and availability are increasing. He is joined by Dr. Adam Green, a practicing intensivist at Cooper University Health Care and an Associate Professor of Medicine at Cooper Medical School of Rowan University (CMSRU). Dr. Green is the director of research for the division of Critical Care and has authored over 50 peer-reviewed publications. He has been part of the ECMO team at Cooper since its inception. Additional resources: Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest. The Lancet Respiratory Medicine 2025: https://www.sciencedirect.com/science/article/pii/S2213260025001225 Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest. JAMA 2022: https://jamanetwork.com/journals/jama/fullarticle/2789313 Association between increasing institutional experience with ECPR and outcomes in patients with out-of-hospital cardiac arrest: A nationwide multicenter observational study in Japan (the JAAM–OHCA registry) RESUSCITATION 2025: https://www.resuscitationjournal.com/article/S0300-9572(24)00862-1/fulltext Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Eng J of Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2204511 Books mentioned in this episode: The Perfect Predator: A Scientist’s Race to Save Her Husband from a Deadly Superbug. By S. Strathdee and T Patterson: https://amzn.to/3Hxjmez

In this episode, Dr. Sergio Zanotti discusses clinical guidelines for the transfusion of platelets and fresh frozen plasma (FFP) in critically ill patients. He is joined by Dr. Angel Coz Yataco, a practicing pulmonary critical care physician. Dr Coz Yataco is on the faculty of the Cleaveland Clinic Main Campus. He is also the lead author of the recently published American College of Chest Physicians Clinical Practice Guidelines on “Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults.” Additional resources: American College of Chest Physicians Clinical Practice Guidelines on Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults. Coz Yataco a, et al. CHEST 2025: https://pubmed.ncbi.nlm.nih.gov/40074060/ Platelet Transfusion 2025 AAB and ICTMG International Clinical Practice Guidelines. JAMA 2025: https://pubmed.ncbi.nlm.nih.gov/40440268/ Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. Van Baarle LF, et al. New Eng J of Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2214322 Books mentioned in this episode: Think Again: The Power of Knowing What You Don’t Know. By Adam Grant: https://bit.ly/404783f

In this episode, Dr. Sergio Zanotti discusses the different aspects of managing pneumonia in critically ill patients. He covers the initial management of severe pneumonia, management of ventilator-associated pneumonia, and highlights the clinical approach to non-resolving pneumonia in the intensive care unit (ICU). He is joined by Dr. Andre Kalil, a physician specializing in critical care and infectious diseases. Dr. Kalil is a Professor in the Division of Infectious Diseases and Director of Transplant Infectious Diseases at the University of Nebraska Medical Center (UNMC). Additional resources: How to approach a patient hospitalized for pneumonia who is not responding to treatment? Pedro Povoa, et al. Intensive Care Med 2025: https://link.springer.com/article/10.1007/s00134-025-07903-3 Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Andre Kalil, et al. Clin Infect Dis. 2016: https://pmc.ncbi.nlm.nih.gov/articles/PMC4981759/ Management of Ventilator-Associated Pneumonia: Guidelines. M Metersky and Andre c. Kalil. Infect Dis Clin North Am. 202: https://pubmed.ncbi.nlm.nih.gov/38280768/ Hydrocortisone in Severe Community-Acquired Pneumonia. CAPE-COD Clinical Trial. N Eng J of Med 202: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145 Continuous vs. Intermittent β-Lactam Antibiotic Infusions in Critically Ill Patients with Sepsis. BLING III Clinical Trial. JAMA 2024: https://jamanetwork.com/journals/jama/fullarticle/2819971 Music mentioned in this episode: Pat Metheny Group – We Live Here: https://bit.ly/44gt8Jl Antonio Carlos Jobin – Terra Basilis: http://bit.ly/4k4Amq1 Mahler: Symphony No.9 – Chicago Symphony Orchestra: http://bit.ly/4k9sXWn

In this episode of, Dr. Sergio Zanotti explores the vital role of enteral nutrition in the ICU—a foundational element in the prevention and treatment of disease-related malnutrition among critically ill patients. He is joined by Dr. Leah Gramlich, a distinguished gastroenterologist and physician nutrition specialist from the Royal Alexandra Hospital in Alberta, Canada. Dr. Gramlich is a Professor of Medicine at the University of Alberta and the founding president of the Canadian Nutrition Society. She has also served on the Board of Directors for the American Society for Parenteral and Enteral Nutrition and chaired the Canadian Malnutrition Task Force, bringing deep expertise to this essential topic. Additional resources: Enteral Nutrition in Hospitalized Adults. Lead Gramlich, Peggi Guenter. New Engl J Med 2025: https://pubmed.ncbi.nlm.nih.gov/40239069/ Individualized nutritional support in medical inpatients at nutritional risk: a randomized clinical trial. The EFFORT Clinical Trial. Lancet 2019: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32776-4/abstract Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). Lancet Respir Med 2023: https://pubmed.ncbi.nlm.nih.gov/36958363/ The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet 2023: https://pubmed.ncbi.nlm.nih.gov/36708732/ Books mentioned in this episode: The Overstory: A Novel. By Richard Powers: https://bit.ly/43Drra1

In this episode, Dr. Zanotti discusses the science of hope. He's joined by Dr. Stephen Trzeciak, a physician-scientist, the Edward D. Viner Endowed Chief of Medicine at Cooper University Health Care, and Professor and Chair of Medicine at Cooper Medical School of Rowan University in Camden, New Jersey. Dr. Trzeciak is a practicing intensivist and a clinical researcher with more than 100 publications in the scientific literature. In addition, he is co-author of two excellent books: Wonder Drug: 7 Scientifically Proven Ways That Serving Others Is the Best Medicine for Yourself (2022) and Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference (2019). Additional resources: Recovery Expectations and Long-term Prognosis of Patients with Coronary Heart Disease Barefoot JC, et al. JAMA Internal Medicine 2011: https://pubmed.ncbi.nlm.nih.gov/21357800/ Optimism and Rehospitalization After Coronary Artery Bypass Graft Surgery. Scheler MF, et al. JAMA Int Med 1999: https://pubmed.ncbi.nlm.nih.gov/10219928/ The median is not the message. By Jay Gould: https://journalofethics.ama-assn.org/sites/joedb/files/2018-05/mnar1-1301.pdf Books mentioned in this episode: Man’s Search for Meaning. By Viktor E. Frankl: https://bit.ly/3SqsNyt Wonder Drug: 7 Scientifically Proven Ways That Serving Others Is the Best Medicine for Yourself. By Stephen Trzeciak and Anthony Mazzarelli: https://bit.ly/4kiyA5q Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. By Stephen Trzeciak and Anthony Mazzarelli: https://bit.ly/43ul5IE

In this episode, Dr. Sergio Zanotti focuses on the nuances of mechanical ventilation in patients with severe asthma. Previously, he explored the medical management of acute asthma exacerbations. Today, he takes a deeper dive into ventilatory strategies tailored to this high-risk population. He's joined by Dr. Emily Damuth, a dual-trained emergency medicine and critical care physician. Dr. Damuth is an Assistant Professor of Medicine and Emergency Medicine at Cooper Medical School of Rowan University and practices clinically in both the Emergency Department and Intensive Care Unit at Cooper University Hospital in Camden, New Jersey. She is also an Assistant Program Director for the Critical Care Medicine Fellowship and is actively involved in the ECMO program. A passionate educator, she teaches mechanical ventilation through lectures and simulation and has received multiple teaching awards for her contributions to medical education. Additional resources: Links: Management of Life-Threatening Asthma. O. Garner, et al. CHEST 2022; https://pubmed.ncbi.nlm.nih.gov/35218742/ Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure. J. Zakrajsek, et al. CHEST 2023: https://pubmed.ncbi.nlm.nih.gov/36191634/ Ventilator Graphics and Respiratory Mechanics in the Patient With Obstructive Lung Disease. R. Dhand. Respiratory Care 2005: https://pubmed.ncbi.nlm.nih.gov/15691394/ Books mentioned in this episode: Seabiscuit: An American Legend. By Laura Hillenbrand: https://bit.ly/3EY24pJ Pisto: The Life of Pete Maravich. By Mark Kriegel: https://bit.ly/3GIarq6 Good Inside: A Practical Guide to Resilient Parenting Prioritizing Connection Over Correction. By Becky Kennedy: https://bit.ly/4iSTnes

In this episode, Dr. Zanotti discussed the Society of Critical Care Medicine “Focused Update on the Clinical Guidelines for the Prevention and Management of Pain, Anxiety. Agitation/Sedation. Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU." This is also known as the PADIS Guidelines. He is joined by Joanna L. Stollings, PharmD, a Board-Certified Pharmacotherapy Specialist and a Board-Certified Critical Care Pharmacotherapy Specialist. Joanna is the Medical Intensive Care Unit (MICU) Clinical Pharmacy Specialist at the Vanderbilt University Medical Center. She also served as vice chair for the PADIS Guideline Focused Update and co-authored the guidelines. Additional resources: Society of Critical Care Medicine Focused Update on the Clinical Guidelines for the Prevention and Management of Pain, Anxiety. Agitation/Sedation. Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. PADIS 2025 Update: https://pubmed.ncbi.nlm.nih.gov/39982143/ Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. PADIS 2018 Guidelines: https://pubmed.ncbi.nlm.nih.gov/30113379/ Link to a previous episode of Critical Matters discussing the PADIS 2018 Guidelines: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=635606964 Landing page for the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center: https://www.icudelirium.org/ Books mentioned in this episode: The Prophet. By Kahlil Gibran: https://bit.ly/4lA2Jhx