Whats the Deal with Mag / Phos

[joeDO2]

Residents order this on pts daily in addition to the BMP for inpatients. It almost never comes back abnormal and when it does it has not been by much and I have not seen it treated. Is there really a big risk here? If it is so important why isn't it included on the BMP?

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[jdh71]

Residents order this on pts daily in addition to the BMP for inpatients. It almost never comes back abnormal and when it does it has not been by much and I have not seen it treated. Is there really a big risk here? If it is so important why isn't it included on the BMP?

If they are ordering it every day, that's kind of stupid.

Phos is important for vented patients (no phos, no muscle strength for extubation). It's also a helpful marker for if the kidney failure has been going on for awhile. If phos is low is should be replaced, if it's very low it need to be replaced IV.

Mag is an INTRAcellular cation. Measurements in the serum can be hard to interpret and it can be kind of nuanced to replace. Though, if mag is low and K is low, you'll drump in K and K won't budge. My bias is to treat low serum mag - I assume since mag is an intracelular cat, that if it's low serum, it's low body, with a few grams every 8 hours for three days. I don't check again. The nice thing about mag? It's hard to hurt anybody with it.

 

[Bostonredsox]

I check both on the initial set of labs in the ED and I check the phos regularly on the HD patients. I check mg in the setting of arrhythmia and K issues. As JDH said, low mg and you'll never get the K repleted so if I find a low K, I always add a mg prior to starting to replete. They are not part of my routine daily labs on all patients.

 

[Trogghunter]

Same with correcting hypocalcemia, correct?

 

[Bostonredsox]

Same with correcting hypocalcemia, correct?

Calcium comes standard on the BMP, but albumin does not. So unless you add an albumin, you really cannot say anything about the Ca of 7.8 on your morning routine BMP. If IM suspicious of true hypocalcemia because the clinical situation fits and then Ca is low on the BMP, I check an iCal and replace if its low.

 

[MedicineDoc]

Phosphorous becomes very important in the context of refeeding syndrome. For patients with anorexia or just patients who for whatever reason have not eaten for more than 5 days a sudden sugar load can be dangerous or fatal with most deaths coming from arrhythmias but also from such things as increased strain on the heart, sudden onset of fluid retention, coma, increased oxygen demand etc. The body during starvation switches to utilizing fatty acids to conserve muscle and protein. When the body suddenly becomes exposed to an increased blood sugar the levels of electrolytes such as phosphorous, magnesium, and potassium as well as thiamine can drop dramatically as the body uses available supplies that are already depleted (although may have normal serum levels prior to refeeding) In attempt to synthesize protein, glycogen and fat in response to insulin secretion. The result can be sudden fluid retention with increased strain on the heart, sudden drop in electrolytes, increases oxygen demand with reduced oxygenation to organs, reduced ability to make ATP, ect. Scenario may go something like this malnourished patient is started on D5 drip or given NG tube feeds without consideration of possibility of development of refeeding syndrome. If there is thought to be a risk of refeeding syndrome electrolytes should supposedly be CHECKED DAILY for a week and then at least 3 times the following week. Refeeding should proceed based on NICE guidelines http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/

 

[VentdependenT]

Alcoholics need these labs.

Refeeding with phos <0.4 other day. Pt arrested. Anoxic brain injury.

Gotta replace mag in setting of hypokalemia: renal wasting K
Gotta replace mag if Ca low.

 

[joeDO2]

Thanks guys, very helpful explanations.

 

[surge55]

Calcium comes standard on the BMP, but albumin does not. So unless you add an albumin, you really cannot say anything about the Ca of 7.8 on your morning routine BMP. If IM suspicious of true hypocalcemia because the clinical situation fits and then Ca is low on the BMP, I check an iCal and replace if its low.

or just check a renal panel or cmp.

not sure why Mg doesn't get added to either, but I see why it doesn't.

 

[surge55]

Alcoholics need these labs.

Refeeding with phos <0.4 other day. Pt arrested. Anoxic brain injury.

Gotta replace mag in setting of hypokalemia: renal wasting K
Gotta replace mag if Ca low.

this stuff right here.

mg, phos, and ionized calcium are standard in the icu, but in the right setting they should be check even on the floors and in clinic.

 

[MedicineDoc]

this stuff right here.

mg, phos, and ionized calcium are standard in the icu, but in the right setting they should be check even on the floors and in clinic.

There is nothing magical about the ICU. All it is is for closer monitoring with nursing that is used to dealing with critical care and maybe mech vent. There are Pts that are dni that are on bipap for prolonged periods. Separating them in your mind any more than that is asking for trouble especially since you are the one making the call on sending them there or taking them out of the ICU anyway.

 

[surge55]

There is nothing magical about the ICU. All it is is for closer monitoring with nursing that is used to dealing with critical care and maybe mech vent. There are Pts that are dni that are on bipap for prolonged periods. Separating them in your mind any more than that is asking for trouble especially since you are the one making the call on sending them there or taking them out of the ICU anyway.

...ok?

 

[VentdependenT]

There is nothing magical about the ICU. All it is is for closer monitoring with nursing that is used to dealing with critical care and maybe mech vent. There are Pts that are dni that are on bipap for prolonged periods. Separating them in your mind any more than that is asking for trouble especially since you are the one making the call on sending them there or taking them out of the ICU anyway.

David Blane is magical!

 

[MedicineDoc]

...ok?

You said "standard in the ICU" that's BS. They are the standard of care when they are called for based on the patient. You don't say this patient is in the ICU I'm going to monitor their phosphate and magnesium. That's stupid.

 

[Bostonredsox]

I agree with medicinedoc, which itself is appalling as he's a family medicine trained hospitalist 😛

In larger institutions, even the community shop I'm in, patients on the SDU, the tele floor and even the gmfs, are often very very sick. Severe mag, phos and K problems are often encountered there. I have had to deal with DKAs that were pretty sick on the floor because my unit was full. You need to individualize your tests and therapies based on the patient, not what unit they are in because there severity of illness can actually be far closer than you might think.

 

[VentdependenT]

You said "standard in the ICU" that's BS. They are the standard of care when they are called for based on the patient. You don't say this patient is in the ICU I'm going to monitor their phosphate and magnesium. That's stupid.

Probably has more to do with the programs culture than stupidity

 

[surge55]

I agree with medicinedoc, which itself is appalling as he's a family medicine trained hospitalist 😛

In larger institutions, even the community shop I'm in, patients on the SDU, the tele floor and even the gmfs, are often very very sick. Severe mag, phos and K problems are often encountered there. I have had to deal with DKAs that were pretty sick on the floor because my unit was full. You need to individualize your tests and therapies based on the patient, not what unit they are in because there severity of illness can actually be far closer than you might think.

we check them on everyone in the ICU; but also check on them on any patient in the right situation, ie what I actually said.

you two need to learn to read. sheesh.

 

[Bostonredsox]

we check them on everyone in the ICU; but also check on them on any patient in the right situation, ie what I actually said.

you two need to learn to read. sheesh.

And what I am saying is there are floor pts who need them checked, and icu patients who do not. A hypertensive emerg who comes to me in the unit on a nicardapine drip which I wean off in 12 hours, get there orals restarted and properly dosed and shipped out to the floor the next morning does not need mg and phos levels. Not everyone in the unit is always a true "unit patient". For instance at my shop only the ccu nurses can titrate esmolol. So if an AFib'r gets a viral URI and comes in with RVR and is put on esmolol, they come to the unit. I could care less what there phos is. Not every unit patient needs the full gambit unless your at a tertiary care center. In that case more than likely do to the shortage of beds and high level of transferring-in acuity, every unit patient is probably severely ill.

 

[surge55]

And what I am saying is there are floor pts who need them checked, and icu patients who do not. A hypertensive emerg who comes to me in the unit on a nicardapine drip which I wean off in 12 hours, get there orals restarted and properly dosed and shipped out to the floor the next morning does not need mg and phos levels. Not everyone in the unit is always a true "unit patient". For instance at my shop only the ccu nurses can titrate esmolol. So if an AFib'r gets a viral URI and comes in with RVR and is put on esmolol, they come to the unit. I could care less what there phos is. Not every unit patient needs the full gambit unless your at a tertiary care center. In that case more than likely do to the shortage of beds and high level of transferring-in acuity, every unit patient is probably severely ill.

I guess I shouldnt have said 'every' one of them, because yeah you are right. we've admitted the same types of patients to our unit as well - a guy who needs amiodarone drip and our telemetry unit was full; a gi bleeder whose hgb dropped from 9 to 8 and the nocturnist got squeamish and dumped the patient on us, etc. but yeah, we get a LOT of sick patients too and we check these on nearly everyone, at least at admission.

 

[Instatewaiter]

You said "standard in the ICU" that's BS. They are the standard of care when they are called for based on the patient. You don't say this patient is in the ICU I'm going to monitor their phosphate and magnesium. That's stupid.

Well it depends on how sick the patients are in your ICU. If you're putting every shmuck who needs bipap in the unit, perhaps not. But, in a truly acute unit basically everyone who comes in should have it.

 

[MedicineDoc]

Well it depends on how sick the patients are in your ICU. If you're putting every shmuck who needs bipap in the unit, perhaps not. But, in a truly acute unit basically everyone who comes in should have it.

What is it? Phosphorous? Ridiculous. SDN where every intern is not only an attending but a super doctor on the Internet. As stated before intensive care is a nursing issue for closer monitoring and is driven by nursing capabilities. As in anyone who can't be cared for safely or at least optimally on a particular floor either because of need for reduced nursing to patient ratio or nursing capability to deal with a particular disease state.

 

[surge55]

What is it? Phosphorous? Ridiculous. SDN where every intern is not only an attending but a super doctor on the Internet. As stated before intensive care is a nursing issue for closer monitoring and is driven by nursing capabilities. As in anyone who can't be cared for safely or at least optimally on a particular floor either because of need for reduced nursing to patient ratio or nursing capability to deal with a particular disease state.

if you think the only difference is better nursing then you need to go back to medical school.

 

[MedicineDoc]

if you think the only difference is better nursing then you need to go back to medical school.

I'm not going to play word games with interns who speak in vague sentences like we "do it on all icu patients" because that's what you do when you do that. Because just because its because I said so. You need to go back to kindergarten.

 

[gutonc]

A reminder that personal insults are not appropriate on SDN. Please keep it civil.

 

[surge55]

A reminder that personal insults are not appropriate on SDN. Please keep it civil.

right; he's essentially insulting all of icu medicine.

 

[MedicineDoc]

right; he's essentially insulting all of icu medicine.

Surge: "But, but he's doing that". Moderator: "Medicine doc stop doing that to surge"...
Hilarious.

 

[jdh71]

Sounds like what we have here is a FP with a chip on his shoulder

I think we should remember that when we see anything posted by this guy

Just filter it and then try not to knee jerk post anything

It would be like if someone with special needs started posting on the forum and we all knew it. Would we get mad at that person? No. We might even make them into a mascot - a politically correct mascot of course.

 

[surge55]

Sounds like what we have here is a FP with a chip on his shoulder

I think we should remember that when we see anything posted by this guy

Just filter it and then try not to knee jerk post anything

It would be like if someone with special needs started posting on the forum and we all knew it. Would we get mad at that person? No. We might even make them into a mascot - a politically correct mascot of course.

 

[MedicineDoc]

Sounds like what we have here is a FP with a chip on his shoulder

I think we should remember that when we see anything posted by this guy

Just filter it and then try not to knee jerk post anything

It would be like if someone with special needs started posting on the forum and we all knew it. Would we get mad at that person? No. We might even make them into a mascot - a politically correct mascot of course.

I think you need to get your phosphorous checked IMMEDIATELY phosphorous boy.

 

[jdh71]

I think you need to get your phosphorous checked IMMEDIATELY phosphorous boy.

lolwut?!

In what world does this even begin to become a decent come-back?!



Ok.

Ok.

Ok.

I'll give you a mulligan on this one. We'll pretend this one didn't happen. Try it again, but this time put a little thought into it! I can't get my jimmies rustled if its too lame.

You can do it!

 

[BlackNDecker]

Lol...this place never changes.

PO4 - sure, we all check it on vented patients...but is this just dogma or is there actual data supporting this practice? Somebody school me on this.

iCa - this should ONLY be checked in one clinical scenario: patient dialyzing on a citrate bath. The correlation between iCa and tCa is poor (I've studied the statistical dis-correlation in our lab - one of the busiest in the world). As such, using one to confirm the other is a ridiculous waste of money, personnel, blood gas analyzers, and blood specimens. RIP iCa

Mg - our medicine forefathers have already shown that serum magnesium does not correlate with tissue (specifically myocardial) magnesium levels. So if you're concerned that a patient with frequent PVCs or runs of NSVT has low mag then you should just replace.

Of course alot of the "routine monitoring" we do is either because nursing bugs us to do it or we saw someone else do it and never questioned it.

Cliffs notes:
SDN never changes
PO4 - where's the evidence?
iCa - unnecessary in 99.999999999% of clinical scenarios
Mg - just do it bruh

 

[surge55]

Lol...this place never changes.

PO4 - sure, we all check it on vented patients...but is this just dogma or is there actual data supporting this practice? Somebody school me on this.

iCa - this should ONLY be checked in one clinical scenario: patient dialyzing on a citrate bath. The correlation between iCa and tCa is poor (I've studied the statistical dis-correlation in our lab - one of the busiest in the world). As such, using one to confirm the other is a ridiculous waste of money, personnel, blood gas analyzers, and blood specimens. RIP iCa

Mg - our medicine forefathers have already shown that serum magnesium does not correlate with tissue (specifically myocardial) magnesium levels. So if you're concerned that a patient with frequent PVCs or runs of NSVT has low mag then you should just replace.

Of course alot of the "routine monitoring" we do is either because nursing bugs us to do it or we saw someone else do it and never questioned it.

Cliffs notes:
SDN never changes
PO4 - where's the evidence?
iCa - unnecessary in 99.999999999% of clinical scenarios
Mg - just do it bruh

PO4: lots of evidence shows this is related to increased mortality (both low and high). it's reasonable to get at least one baseline level and replace as necessary, and if high, address why it is (secondary hypoparathyroidism, etc). too many articles to post.

ICa: http://jasn.asnjournals.org/content/19/7/1257.full

Mg: agreed

 

[jdh71]

They didn't teach you how to use pubmed at the world famous?

http://www.annclinlabsci.org/content/40/2/144.short

You're a big boy and can find your own your own from here. I mean, I know cardiology is like the Ortho of medicine but this is embarassing. And remember just because you put a stent in the gomer, don't mean ya fixed his dyspnea and can feel free to blame the lungs. 😉

Lol...this place never changes.

PO4 - sure, we all check it on vented patients...but is this just dogma or is there actual data supporting this practice? Somebody school me on this.

iCa - this should ONLY be checked in one clinical scenario: patient dialyzing on a citrate bath. The correlation between iCa and tCa is poor (I've studied the statistical dis-correlation in our lab - one of the busiest in the world). As such, using one to confirm the other is a ridiculous waste of money, personnel, blood gas analyzers, and blood specimens. RIP iCa

Mg - our medicine forefathers have already shown that serum magnesium does not correlate with tissue (specifically myocardial) magnesium levels. So if you're concerned that a patient with frequent PVCs or runs of NSVT has low mag then you should just replace.

Of course alot of the "routine monitoring" we do is either because nursing bugs us to do it or we saw someone else do it and never questioned it.

Cliffs notes:
SDN never changes
PO4 - where's the evidence?
iCa - unnecessary in 99.999999999% of clinical scenarios
Mg - just do it bruh

 

[Instatewaiter]

I'm not going to play word games with interns who speak in vague sentences like we "do it on all icu patients" because that's what you do when you do that. Because just because its because I said so. You need to go back to kindergarten.

Very mature.

Also I find it funny that a family medicine doc is telling pulm critical care and cardiology fellows how to practice critical care...

 

[MedicineDoc]

Very mature.

Also I find it funny that a family medicine doc is telling pulm critical care and cardiology fellows how to practice critical care...

Conversation getting boring so trying to draw the spark back in as the cardiologist is not biting on the word games without substance? I believe it was the critical care fellow telling the cardiology guy he was ignorant when it comes to things other than cardiology. Medical knowledge is there for anyone who cares to learn it and to continue to learn post residency. The original response was that drawing a phosphourous on every ICU patient was program culture dependent per the critical care fellow. the rest of his posts were sdn garbage entertainment after it was decided by an intern who couldn't tell why he drew phosphorous on every ICU patient so decided he would make it the " the FM doc is insulting critical care docs ". Your IM or fellow designation is not going to help you if you decide to slack off. I practice in the icu everyday and have done so for years now including residency where we managed our own unit patients at a regional medical center covering a large portion of my state. If you stick to medical fact based arguments this wont turn into a stupidity contest. If it does turn into such a contest I'm betting you will be the winner. Also, I did an IM prelim yr and my unoppossed FM program which turns out about 50 percent hospitalist and FM trained EM docs was vastly superior to the IM program where I did a prelim yr.

 

[wholeheartedly]

iCa - this should ONLY be checked in one clinical scenario: patient dialyzing on a citrate bath. The correlation between iCa and tCa is poor (I've studied the statistical dis-correlation in our lab - one of the busiest in the world). As such, using one to confirm the other is a ridiculous waste of money, personnel, blood gas analyzers, and blood specimens. RIP iCa

Given the number of iCa's I run during my avg 10 hour night shift, I'm wondering if we're talking about the same place (one of the busiest labs in the world I believe). I kinda get sick of them.

 

[jdh71]

Conversation getting boring so trying to draw the spark back in as the cardiologist is not biting on the word games without substance? I believe it was the critical care fellow telling the cardiology guy he was ignorant when it comes to things other than cardiology. Medical knowledge is there for anyone who cares to learn it and to continue to learn post residency. The original response was that drawing a phosphourous on every ICU patient was program culture dependent per the critical care fellow. the rest of his posts were sdn garbage entertainment after it was decided by an intern who couldn't tell why he drew phosphorous on every ICU patient so decided he would make it the " the FM doc is insulting critical care docs ". Your IM or fellow designation is not going to help you if you decide to slack off. I practice in the icu everyday and have done so for years now including residency where we managed our own unit patients at a regional medical center covering a large portion of my state. If you stick to medical fact based arguments this wont turn into a stupidity contest. If it does turn into such a contest I'm betting you will be the winner. Also, I did an IM prelim yr and my unoppossed FM program which turns out about 50 percent hospitalist and FM trained EM docs was vastly superior to the IM program where I did a prelim yr.

You you get your feelings hurt this much in real life?

 

[MedicineDoc]

Those are matter of fact statements. No feelings hurt. In real life no one cares who is FM or IM its how you do your job.

 

[surge55]

Those are matter of fact statements. No feelings hurt. In real life no one cares who is FM or IM its how you do your job.

sure, you may be good at your job, but you're also insolent. your insulting posts did not deserve a medical response. if you must see said medical response, it has been provided, if you bothered to read instead of just attacking posters.

ps - there are fewer and fewer jobs out there for FM trained hospitalists. I've noticed a big shift in it just in the past few years, and it's still shifting.

 

[MedicineDoc]

Yeah right I've worked at just about every hospital in my state with multiple opportunies even in the largest cities and there are tons of FM hospitalists.

 

[jdh71]

Those are matter of fact statements. No feelings hurt. In real life no one cares who is FM or IM its how you do your job.

The chip on your shoulder comes off of you like a stink bro

I haven't seen you work, so all I have is your word for it, kind of like when someone tells me they have a black belt on the internets, but I am fairly skeptical you are as good taking care of critical illness as people who have had more specific training. If FP training is roughly broken down into three parts adult medicine, peds, and obstetrics, much of that out-patient with only a single month of required ICU time and if I'm generous and allow you 2 whole years of adult medicine, you have much, much fewer years of formal training than someone who does an adult specific residency and then does an adult specific critical care fellowship. I mean, maybe you're not killing people, but I doubt based on years of training a long that you can really hang over the long haul. Though, even that doesn't matter, not really, not in here.

The problem you have in here is that you show up and act like a douche, and then when the "kick the *****" session starts you try and act all wounded, and even have the temerity to attempt to pull the "moral high ground" card, when you've been down in it getting all muddy like the rest of us. Which makes you even worse because you're also a hypocrite.

I bet you're a lot of "fun" to work with in real life. Quite a few of the smaller rural city gigs I'm looking at . . . they are looking to bring me in to run the shop and eventually replace the ICU coverage by FPs and Hospitalists with pulmonary and critical care trained people. So your days may be numbered. Though in the model I'm thinking of, you'll still do admits at night for us. Heh. 😉

 

[MedicineDoc]

The chip on your shoulder comes off of you like a stink bro

I haven't seen you work, so all I have is your word for it, kind of like when someone tells me they have a black belt on the internets, but I am fairly skeptical you are as good taking care of critical illness as people who have had more specific training. If FP training is roughly broken down into three parts adult medicine, peds, and obstetrics, much of that out-patient with only a single month of required ICU time and if I'm generous and allow you 2 whole years of adult medicine, you have much, much fewer years of formal training than someone who does an adult specific residency and then does an adult specific critical care fellowship. I mean, maybe you're not killing people, but I doubt based on years of training a long that you can really hang over the long haul. Though, even that doesn't matter, not really, not in here.

The problem you have in here is that you show up and act like a douche, and then when the "kick the *****" session starts you try and act all wounded, and even have the temerity to attempt to pull the "moral high ground" card, when you've been down in it getting all muddy like the rest of us. Which makes you even worse because you're also a hypocrite.

I bet you're a lot of "fun" to work with in real life. Quite a few of the smaller rural city gigs I'm looking at . . . they are looking to bring me in to run the shop and eventually replace the ICU coverage by FPs and Hospitalists with pulmonary and critical care trained people. So your days may be numbered. Though in the model I'm thinking of, you'll still do admits at night for us. Heh. 😉

Besides the aside above garbage I wont reply to since we ran the hospital as residents including ICU patients every month even as interns with upper level how do you figure your IM training with your "icu" months as a resident gave you more inpatient experience? Do you think that our hospitals patients got 1/3 the care? Makes alot of sense. No ID doctors. No intensivists. A couple of old school pulmonary doctors who rounded in the morning (if your patient wasnt there by 9 am they got seen the next day) who thought the establishment of critical care board certification aside from pulmonology was a sham power move.

 

[Bostonredsox]

FM vs IM doesn't really matter. In the next 3-5 years SHM is going to get approval for the hospitalist medicine boards. The so called "Fellow of hospital medicine". Whether you are fm or IM you will have to pass these boards to be a hospitalist. Once this happens, weak FPs, and sadly, weak IMs will be weeded out of the hospitalist world. Hospital medicine is its own world. being boarded in fm and to an extent even IM, does not mean you possess the skillset to be a hospitalist.

 

[Bostonredsox]

Besides the aside above garbage I wont reply to since we ran the hospital as residents including ICU patients every month even as interns with upper level how do you figure your IM training with your "icu" months as a resident gave you more inpatient experience? Do you think that our hospitals patients got 1/3 the care? Makes alot of sense. No ID doctors. No intensivists. A couple of old school pulmonary doctors who rounded in the morning (if your patient wasnt there by 9 am they got seen the next day) who thought the establishment of critical care board certification aside from pulmonology was a sham power move.

What you describe is what my program is. Except in 36 months I did 21 months of what you described. The rest was all medicine subspecialty. No outpt FP, urology, orthopedics, Peds, OB garbage. IM @ a community hospital. Produces high quality critical care hospitalists IMO. Well at least 2-3 of us.

 

[MedicineDoc]

Even if we were doing outpatient pedis it was only after we had seen our patients in the hospital. Also as I have said before outpatient and inpatients are not separate species. Inpatient is a continuation of treatment of outpatient disease. This the push within IM to add more outpatient training. Otherwise you have a bunch of docs thinking everything needs to be treated in the hospital pushing up length of stay.

 

[jdh71]

Besides the aside above garbage I wont reply to since we ran the hospital as residents including ICU patients every month even as interns with upper level how do you figure your IM training with your "icu" months as a resident gave you more inpatient experience? Do you think that our hospitals patients got 1/3 the care? Makes alot of sense. No ID doctors. No intensivists. A couple of old school pulmonary doctors who rounded in the morning (if your patient wasnt there by 9 am they got seen the next day) who thought the establishment of critical care board certification aside from pulmonology was a sham power move.

What I think is that you don't even know what you don't know and I think that probably makes your dangerously arrogant.

Like I said, I haven't seen you work. I'm simply skeptical that you are actually as good as you think you are. That's all son. Heh.

 

[BlackNDecker]

PO4: lots of evidence shows this is related to increased mortality (both low and high). it's reasonable to get at least one baseline level and replace as necessary, and if high, address why it is (secondary hypoparathyroidism, etc). too many articles to post.

ICa: http://jasn.asnjournals.org/content/19/7/1257.full

Mg: agreed

Great article. Thanks for sharing!

They didn't teach you how to use pubmed at the world famous?

http://www.annclinlabsci.org/content/40/2/144.short

You're a big boy and can find your own your own from here. I mean, I know cardiology is like the Ortho of medicine but this is embarassing. And remember just because you put a stent in the gomer, don't mean ya fixed his dyspnea and can feel free to blame the lungs. 😉

That article the best you got? No control for confounders and significant overlap in PO4 levels between those who were successfully weaned and those who were not. I thought you would've learned to critically review an article at this point in your training😉

I was on a plane and, believe it or not, the boarding door was closing when I sent that reply. Plus, it's always interesting to see what articles others dig up.

 

[jdh71]

That article the best you got? No control for confounders and significant overlap in PO4 levels between those who were successfully weaned and those who were not. I thought you would've learned to critically review an article at this point in your training😉

I was on a plane and, believe it or not, the boarding door was closing when I sent that reply. Plus, it's always interesting to see what articles others dig up.

The best? I don't know. I just plugged in some key words to pubmed and found one on vent weaning. I suggest you do the same.

And we both know that EBM is largely bull**** for just about anything. So what is really the point?

 

[BlackNDecker]

Agree and quit trying to be condescending. Of course I know how to search pubmed. I'm limited to my smart phone at present and refuse to review abstracts as a surrogate for full access.

I find it ridiculous that things as routine and simple as electrolyte replacement are based on a thin veil of "evidence". This has probably been most widely publicized with the apparent association between long-term oral calcium supplementation (without Vit D) and CV risk. More concerning, and oddly unpublicized, is the increase in mortality among otherwise healthy multivitamin users in multiple observational studies and meta-analyses.

What still troubles me about the current practice of "routine electrolyte monitoring and replacement" is the following example:
60ish yo pt walks into the ED with cough. Over the ensuing 5 hrs of his evaluation (3 hr wait, 2 hr assessment) he becomes septic. His tCa and iCa were normal when he walked into the ED. His iCa falls as he becomes septic but the tCa obviously would not change. He is admitted to the MICU (or CCU if he has a tnT elevation...lol) and his labs are all rechecked...now we are probably 7 hrs into his septic process. The iCa now flags as below the lower reference range. So, the intern replaces it. It's rechecked the following morning...again, below the reference range and is replaced. Again, we'd all agree that in the absence of massive diarrhea or aggressive diuresis that tCa is completely unchanged.

1) where did it go? Intracellular most certainly. Where in the cell? Attached to the mitochondria. Do the mitochondria appreciate all the excess intercellular calcium? Of course not. This would theoretically contribute to multi organ dysfunction.
2) how were the reference ranges established? Off random sampling of healthy controls. What does the calcium handling of healthy controls and septic patients have in common? Lol...probably nothing.
3) what is the long term outcome of parenteral calcium replacement in critically ill patients?

 

[Instatewaiter]

Besides the aside above garbage I wont reply to since we ran the hospital as residents including ICU patients every month even as interns with upper level how do you figure your IM training with your "icu" months as a resident gave you more inpatient experience? Do you think that our hospitals patients got 1/3 the care? Makes alot of sense. No ID doctors. No intensivists. A couple of old school pulmonary doctors who rounded in the morning (if your patient wasnt there by 9 am they got seen the next day) who thought the establishment of critical care board certification aside from pulmonology was a sham power move.

I have to agree with JDH.*You assume you are equivalent but looking at the way FM is trained compared to IM it makes me wonder how you guys feel comfortable in the ICU at all...

The FM training is focused on outpatient therapy. Of the rest it's split between OB, Peds and Medicine. Furthermore, the attendings that train you are FM docs- it's like the blind leading the blind.

Also, personally I think open ICUs are an antiquated concept and lead to suboptimal care. The **** I see coming out of community shops with FM coverage and open ICUs lead me to believe everything you are saying is a lie.

That you feel comfortable lecturing people who literally are critical care docs astounds me. Perhaps you should go to the OB forum and tell them how much better you are at C-sections...