Critical Matters

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

In this episode, Dr. Sergion Zanotti discusses TEE in cardiac arrest and shock. Critical care clinicians commonly utilize transthoracic echocardiography in the ICU as part of their point-of-care-ultrasonography (POCUS) toolkit. However, there is a growing push to train intensivists in using transesophageal echocardiography (TEE) for cardiac arrest and peri-arrest situations in the ICU. Our guest is Dr. Sara Nikravan, a cardiothoracic anesthesia critical care physician with training in advanced perioperative echocardiography. Dr. Nikravan is an Associate Professor of Cardiothoracic Anesthesiology and Critical Care Medicine at the University of Washington Medical School and practices at the UW Medical Center. She is recognized as an expert and master educator in Critical Care, Perioperative echocardiography, and Point of Care Ultrasound. She has authored numerous peer-reviewed papers and is the guidelines co-chair of the Society of Critical Care Medicine Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024, recently published in Critical Care Medicine.  Additional links: Society of Critical Care Medicine Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024, Crit Care Med 2025: https://pubmed.ncbi.nlm.nih.gov/39982182/ Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week. JACC 2020: https://pubmed.ncbi.nlm.nih.gov/32762909/ Landing page for the Resuscitative TEE Project website: https://www.resuscitativetee.com/ Books mentioned in this episode: The Prophet. By Kahlil Gibran: https://www.amazon.com/dp/998247037X?psc=1&smid=ATVPDKIKX0DER&ref_=chk_typ_imgToDp

In this episode, Dr. Sergio Zanotti explores one of medicine's fastest-evolving frontiers: artificial intelligence (AI). From predictive analytics to decision-support tools, AI is beginning to influence how we deliver critical care — but what does that actually mean for frontline clinicians? Dr. Zanotti is joined by Dr. Sharad Patel, a critical care physician with additional board certification in nephrology and Echocardiography. He is a Critical Care Intensivist at Cooper University Health Care, the assistant program Director for the Internal Medicine Residency Program, and an Assistant Professor of Medicine at Cooper Medical School of Rowan University. Dr. Patel is deeply interested in applying artificial intelligence and technology at the bedside. Additional resources: Landing page for New England Journal of Medicine – AI in Medicine section. A multitude of articles and resources on the topic: https://www.nejm.org/ai-in-medicine Attention Is All You Need. A Vaswani et al. NIPS 2017: https://proceedings.neurips.cc/paper_files/paper/2017/file/3f5ee243547dee91fbd053c1c4a845aa-Paper.pdf Artificial Intelligence Courses Online: https://www.coursera.org/courses?query=artificial%20intelligence UDEMY landing page for AI courses. https://www.udemy.com/AI Books mentioned in this episode: Meditations. By Marcus Aurelius (Author), Gregory Hayes (Translator): https://amzn.to/4iLvfLA Thinking Fast and Slow. By Daniel Kahneman: https://bit.ly/4c6pANu

In a previous episode, Dr. Sergio Zanotti explored the importance of challenging dogma, particularly when the supporting evidence is weak or absent. Today, he continues that discussion by examining critical care practices that persist despite a lack of strong scientific validation. He's joined by Dr. Mervyn Singer, an internationally recognized leader in critical care medicine. Dr. Singer is a professor of intensive care medicine at University College London and a distinguished clinician, researcher, and educator. Through his research, publications, and dynamic presentations, he has inspired Dr. Zanotti — and countless intensivists worldwide — to think critically, challenge conventions, and push the boundaries of our field. Additional resources: Challenging management dogma where evidence is non-existent, weak, or outdated: part II. DA Hofmaennner and M. Singer. Intensive Care Med2024: https://pubmed.ncbi.nlm.nih.go Challenging management dogma where evidence is non-existent, weak, or outdated. DA Hofmaennner and M. Singer. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/35303116/ Biomarker-Guided Antibiotic Duration for Hospitalized Patients with Suspected Sepsis. The ADAPT-Sepsis Randomized Clinical Trial. JAMA 2025: https://pubmed.ncbi.nlm.nih.gov/39652885/ Hyperglycemic Crises in Adults with Diabetes: A Consensus Report. Diabetes Care 2024: https://pubmed.ncbi.nlm.nih.gov/38907161/ Books and music mentioned in this episode. Influenza: The Hundred-Year Hunt to Cure the 1918 Spanish Flu Pandemic. By. Jeremy Brown: https://amzn.to/3Ftb0mO Beethoven: 9 Symphonies / Karajan 1963: https://amzn.to/3R1M9ZO

Due to advancements in medical and surgical care, the survival of patients with congenital conditions into adulthood has dramatically increased. However, as these individuals transition to adulthood, their unique physiology, chronic complications, and evolving care needs create significant challenges for their management when they are admitted to adult intensive care units (ICUs). This episode will discuss adult congenital disease in the ICU. Dr. Zanotti is joined by Dr. Cameron Dezfulian, a pediatric and adult critical care physician. He is the director of the Adult Congenital Heart Disease Program Development for the Section of Critical Care at Texas Children's Hospital and a faculty member at Cardiothoracic Critical Care at Baylor St. Luke's Medical Center. He is also a Senior Faculty member at Baylor College of Medicine in Houston, Texas. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 Special Considerations in Critical of the Congenital Heart Disease Patient. E Neethling, et al. Can J Cardiol. 2023: https://pubmed.ncbi.nlm.nih.gov/36682483/ Management of the Critically Ill Adult with Congenital Heart Disease. WB Kratzert, et al. J Cardiothorac Vasc Anesth 2018: https://pubmed.ncbi.nlm.nih.gov/29500124/ Adults with childhood-onset chronic conditions admitted to US pediatric and adult intensive care units. J Edwards, et al. J Crit Care 2015: https://pubmed.ncbi.nlm.nih.gov/25466316/ Down Syndrome. MJ Bull. N Eng J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMra1706537 Books and Music mentioned in this episode: The Bible: https://bit.ly/3EK4LL6

February 7-14 marks the observance of Congenital Heart Disease Awareness Week. In this podcast episode, Dr. Sergio Zanotti provides a unique perspective on adult congenital heart disease, drawing from his journey as a lifelong patient. He offers reflections shaped by his own experiences with complex adult congenital heart disease, including insights gained from a recent medical procedure that granted him a firsthand view of patient care in the ICU. Additional resources: ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease. Circulation 2008: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.108.190690 The Bell Curve. By Atul Gawande. The New Yorker 2004: https://www.newyorker.com/magazine/2004/12/06/the-bell-curve Website for the Adult Congenital Heart Association: https://www.achaheart.org/ Books and music mentioned in this episode: Montaigne. By Stefan Zweig: https://bit.ly/4gEOVP2 The Heart. A Novel. By Maylis De Kerangal: https://bit.ly/41ehqin The Essays: A Selection (Penguin Classics). By. Michel de Montaigne: https://bit.ly/3EvFwvW