Critical Care Medicine
14 cases on malignant hyperthermia and LAST crisis management, neuromuscular-blockade reversal and sedation strategy, perioperative anaphylaxis and massive transfusion, ICU delirium and stress-dose steroid decisions, and refeeding, analgosedation, and bronchospasm management — choose a case below to open its full multi-voice debate.
A college wrestler crashes into a fulminant MH crisis under his first general anesthetic. Three weeks later his mother, a confirmed RYR1 carrier, is scheduled for an elective cholecystectomy — the same disease, a completely different pharmacologic question.
A regional block goes systemic mid-injection. The lipid emulsion isn't the hard part — the hard part is running a cardiac arrest algorithm that overturns half of what ACLS usually says to do.
One patient's kidneys can't clear the sugammadex-rocuronium complex. The next patient's kidneys are fine, but she's on a hormonal IUD sugammadex is labeled to interact with. Same drug choice, two unrelated reasons it might be wrong.
A minute after the antibiotic infusion starts, her airway pressures spike and her pressure collapses. The drug is right; the dose and route the emergency department would use are wrong for a patient who's already got a line in and a monitor running.
A shattered pelvis is bleeding faster than the ratio protocol can keep components arriving. The trauma bay has four units of low-titer O-positive whole blood sitting in a cooler that would simplify everything — if the arithmetic behind it actually holds up here.
The trauma team wants TXA reflexively, the way it's given in every major hemorrhage protocol. The actual question isn't whether to give it — it's whether the three-hour clock the evidence is built on already ran out somewhere on the highway.
An 81-year-old is about to have his hip fixed. Everyone agrees delirium prophylaxis matters — the disagreement is whether a scheduled sedative, a scheduled antipsychotic, or simply doing the unglamorous non-drug things well is what actually prevents it in someone his age.
Everyone in the room learned to reach for hydrocortisone the moment a chronic steroid user goes to the OR. The newer literature says that reflex may be treating a crisis that, at her steroid dose and this surgery's severity, was never actually coming.
His blood pressure won't hold even with the bleeding source controlled and blood products running. The vasopressor literature everyone reaches for by habit was built on septic shock — a different physiology, borrowed here without much to confirm it transfers.
Severe ARDS bought him days of neuromuscular blockade layered on stress-dose steroids for refractory shock. Both drugs did their job. The question now is whether the combination itself is quietly building the weakness that will keep him on the ventilator longest.
A severely malnourished trauma patient finally has a working gut. The randomized evidence for feeding her slowly is real — but it was built on patients who had already crashed their phosphate, and hers hasn't moved yet.
His home methadone dose alone exceeds what most post-surgical patients receive for actual pain. Standard weight-based ICU opioid dosing would leave him both under-treated for surgical pain and in withdrawal at the same time.
Airway pressures climb the moment the surgeon starts working near his diaphragm. Under general anesthesia, with no patient to ask about their breathing, the usual asthma-attack escalation ladder doesn't apply the same way.
Coming off bypass, the protamine that's supposed to close out the case instead nearly closes his right heart down. This isn't the titrated-dosing question that comes up before protamine is ever given — it's what to do once a catastrophic reaction is already underway.