Critical Care Scenarios – Educational critical care scenarios presented in a podcast format.

Lightning rounds 65: Global health with Kwame Boateng

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We learn about how to contribute to underserved communities abroad, with Kwame Akuamoh-Boateng, DNP, ACNP-BC, FCCM.

Learn more at the Intensive Care Academy!

References

SCCM Global Outreach KEG
Want to talk to Kwame about a travel opportunity? Email him at mr.kwameboateng at geemail

Episode 101: Acalculous cholecystitis with Dennis Kim

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Dennis Kim, trauma surgeon and surgical intensivist of the Trauma ICU Rounds podcast, weighs in on the diagnosis and management of acalculous cholecystitis.

Learn more at the Intensive Care Academy!

Takeaway pearls

Acalculous cholecystitis accounts for about 10% of all cholecystitis and occurs almost exclusively in the critically ill. Risk factors include being NPO, TPN use, surgical patients, and critical illness. Enteral feeding is probably rather protective, and maybe even somewhat therapeutic.
Although data is limited, anecdotally, this disease has become much less common in the modern era, perhaps because we try to feed ICU patients earlier.
Suspect this diagnosis in a patient with inflammatory features such as fever (often low-grade) not explained by their other illness. Assess for elevations in alk phos or bilirubin, RUQ abdominal tenderness, and imaging abnormalities to unpack it further. Unfortunately, cholestasis alone can often occur in critical illness, making it difficult to differentiate from true cholecystitis.
CT scan will often be the initial study in complex patients, though RUQ ultrasound can be used if suspicions are more targeted. In general, a high-quality ultrasound is a better study, but CT is more broad, and better than a technically poor ultrasound.
(No, in this setting, it is not important for patients to be NPO before their ultrasound.)
Always CT with IV contrast! A non-contrast CT is often very little use; AKI is not a good reason to avoid contrast.
HIDA scan is a pain to obtain, but is nearly 100% accurate, if other tests are not definitive.
Gallbladder dilation is fairly non-specific in NPO or ill patients. Thickening or edema still common but more suspicious, stranding more so, and frank perforation, abscess, lack of enhancement (gangrene), or gas are highly specific. (Pericholecystic fluid is obviously only meaningful if generalized ascites is absent.)
In general, the treatment of choice is percutaneous cholecystostomy. Surgery is usually only desirable if there are more advanced complications, such as perforation or gangrene. In the least severe cases, antibiotics alone can be tried, although most of our patients are already on antibiotics when diagnosed (ie. have already “failed” this approach). It is reasonable to consider availability of resources too; small centers may not have IR available to place a perc chole, for instance.
Should General Surgery even be involved if IR is simply going to place a tube? Maybe not, unless you’re not sure what to do. But in many centers IR will not be willing to follow these patients after the tube is placed, so Surgery may be needed for the ongoing management, especially once they leave the ICU.
Should Gastroenterology be involved? Probably not routinely, but these folks are always coming up with new endoscopic maneuvers. There may be patients for whom ERCP could be a sensible therapeutic approach to stent the cystic duct (preferably without sphincterotomy), for instance in a patient too coagulopathic for perc chole, though ERCP in a critically ill patient is not always risk-free either.
Perc chole will usually treat the disease. But tubes can displace (during placement or later) or get obstructed if not regularly flushed, so keep an eye on them.
Coagulopathic patients can bleed with perc chole placement, as these usually penetrate the liver parenchyma.
Unlike calculous cholecystitis treated with perc chole (which usually warrants early transition to surgical cholecystectomy, generally during the same admission), most of these will stabilize with percutaneous drainage alone, and the tube can simply be removed once they’re eating and no longer critically ill. They’re usually left for a minimum of 4-6 weeks to let the tract mature, and before removal, a tube cholecystogram should be done (contrast injected into the tube) to ensure the cystic duct is now patent. There is usually some drainage/leakage after removal, which can irritate the skin, but usually stops on its own.
Cholecystectomy after perc chole is unfortunately more technically challenging due to distortion of the anatomy.

Episode 100: Autoimmune encephalitis testing with Tammy Smith

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Tammy Smith, assistant professor of neurology at the University of Utah within the division of Neuroimmunology and Autoimmune Neurology, and a clinical consultant at ARUP Laboratories, gives us the inside scoop on testing for autoimmune encephalitis syndromes.

Learn more at the Intensive Care Academy!

CHEST’s Procedural Skills for the Critical Care Clinician, April 23-24 2026

Takeaway pearls

When should you suspect autoimmune encephalitis in the ICU?
- Subacute symptoms (1 week to a couple months) of behavior changes, episodes of confusion, speech, wakefulness (sleeping too much or not at all).
- MRI with changes consistent with encephalitis
- Intractable seizures not easily controlled with ASMs
- History of malignancy
Antibody assays for autoimmune encephalitis are available from the Mayo Clinic, ARUP labs, as well as Quest, Athena, and Labcorp. As a rule, they go to such reference labs and are not performed in-house. Some allow individual antibody tests, while many only perform them as a panel. The turnaround time for these tests is often about two weeks. They usually use either tissue- or cell-based assays.
Most of the antibodies originally identified as causing autoimmune syndromes were paraneoplastic in origin, i.e. directly linked with malignancy. Now we are identifying an increasing number that have only a general association with malignancy (eg anti-NMDAR encephalitis), or none at all.
These panels are often some of the most expensive tests you can send; try to send them thoughtfully. ~95% of these panels (in Mayo’s published data and internal ARUP data) are completely negative, and while some of those are probably “misses” (eg the patient has an as-yet unknown antibody), many were probably unnecessary. Also problematic is incidental positives, usually irrelevant antibodies at low titers, which may then lead to needless worry and clinical confusion.
The Graus criteria provide some guidance for apparent antibody-negative encephalitis syndromes. In general, with negative tests, clinical or imaging progression despite your empiric therapy should raise the question of another missed diagnosis (eg a genetic disorder), while clinical improvement may make you think you had the right diagnosis but the test missed it.
The timeline for response to therapy varies. Pulse-dose steroids come on pretty fast (within days), and dissipates within a few days. IVIG lingers in the body around a month, and a full course of PLEX has an impact for about that long as well (about 80% antibody recovery in 1 month). PLEX is also removing other inflammatory molecules contributing to the syndrome. It’s usually best to wait about a week on one therapy before considering adding a second line (though the EXTINGUISH trial is trialing earlier introduction of immunotherapy for anti-NMDAR).
Some tests may report qualitatively (negative/positive), usually due to technical issues, but most will try to report a titer. In general higher titers are more likely to be relevant, or at least more demanding of a clinical explanation, although exact cutoffs are usually not defined. Titer does not correlate well with disease severity, however.
In general, send both a serum and CSF panel. The CSF may be more specific (antibodies in the CSF are more likely to be clinically relevant), while the serum is often more sensitive (as the antibodies are usually created here).
Prior treatment affects testing in this way:
- Steroids: probably not much
- PLEX: will transiently clear the antibodies, reducing sensitivity of your tests. (Make a note in the chart so people know a negative late test may have been falsely negative.)
- IVIG: probably does not reduce sensitivity much, but may increase the false positive rate a little, as a tested antibody could be present within the pooled IVIG), especially common antibodies like GAD-65.
ARUP has a matrix to help guide selection of the right panel. Most of the reference labs have somewhat phenotyped panels, eg one for encephalitis, one for encephalopathy, one for movement disorders. However, when the patient has overlapping symptoms, you usually do not need to send multiple panels, as they may test many of the same antibodies. Check what’s being tested. Most also offer a “everything” panel if you’re not sure what you’re doing, but it increases your risk of incidental positives.
ARUP does have a hotline offering 24/7 expert assistance if you’re not sure what you’re doing.
New antibodies are regularly added to these panels, although they’re not always completely current, so a local expert who may be aware of newer evidence of an emerging antibody not part of your panel can sometimes suggest sending something extra.
While many antibodies are still undiscovered, it is probably true that the most common and important ones have been found at this point.
In most suspected autoimmune encephalitis syndromes, especially with an antibody associated with malignancy, it is appropriate to do a broad screen for an underlying neoplasm. A contrasted pan-CT at least is reasonable. Though in fairness, the true paraneoplastic syndromes (>70-90% association with cancer) such as anti-Yo are also among the most rare encephalitis syndromes. With the highest risk antibodies, even pursuing a PET scan makes sense.
With anti-NMDAR, ultrasound of the ovaries and perhaps testicles is appropriate due to the incidence of teratomas. Any abnormality on the ovaries should be considered suspicious, even if it has a generally benign or cystic appearance; some of these are microscopic tumors. In a refractory patient, empiric oophorectomy/orchiectomy can even be considered after shared decision-making.
Other than anti-NMDAR, the most common antibodies are LGI1, GAD65, and CASPR2. In general though, it is probably unreasonable for non-subspecialists to guess a specific antibody; suspect the broad disease.
A good reason to seek subspecialty consultation or transfer would be: severe autonomic instability, lack of comfort with or access to treatment (eg rituximab, PLEX, etc), or failure to respond to initial therapies. One common issue is for community hospitals to report they’ve “sent the tests,” when in fact they’ve sent a panel that doesn’t include some important antibodies. Find out exactly which tests were done (for example, the Mayo and ARUP “paraneoplastic” panels do not include NMDAR, as it is not technically a paraneoplastic syndrome, even though it has an association with neoplasm).

Lightning rounds 64: The new Surviving Sepsis guidelines with Hallie Prescott

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Hallie Prescott, pulm/crit physician and co-chair of the recent Surviving Sepsis guideline writing committee, gives some insight into the new document, including a few interesting additions and some points of controversy.

For more thoughts, especially from an EM perspective, Scott Weingart also interviewed Hallie over at EMcrit.

Learn more at the Intensive Care Academy!

Takeaway pearls

The new guidelines suggest/recommend:
- Prehospital sepsis screening, and in systems with >60 minutes to hospital evaluation and the appropriate systems in place, prehospital antibiotic administration. (This is a fairly narrow recommendation that won’t apply to many in the US, mostly rural systems with long transport times.)
- Don’t give anaerobic antibiotic coverage if not suspicious of anaerobic infection
- Target a MAP >65 in most, but in patients >65 years old, target only >60.
- Don’t use qSOFA exclusively for screening; use other more sensitive tools like NEWS.
- Consider SDD (selective decontamination of the digestive tract), the use of targeted local and systemic antibiotics in intubated patients to reduce the bacterial load in the upper GI tract and reduce the risk of VAP. This has a long presence in the literature and is more practiced in Europe than the US, but the data is fairly good.
- Suggest measuring serum lactate, and perhaps trending it, but not necessarily trying to normalize it.
- Prolonged infusions of beta-lactam antibiotics are supported (for subsequent doses; the first dose should still be a bolus) due to reasonably positive data.
- If final cultures are negative, consider deescalating/stopping antimicrobials. (Obviously, this means most patients have already received a few days of therapy by then.)
Other old standards like 30 cc/kg fluid boluses and early antibiotic administration remain. Some are upset about this, as they have been translated into US quality measures (the SEP-1 CMS standard) that invoke monetary penalties when not adhered to—a standard that has caused much headache for EM particularly. But Hallie says: this is a global standard with >25 nations involved, and is oriented around medical realities. Translating it into national quality standards, rightly/wrongly, appropriately or bluntly, is not the business of the guideline group, and is purely an American issue.

Lightning rounds 63: How to be right, with Scott Weingart

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Scott Weingart, ED intensivist and seminal educator from the EMCrit podcast, shares his thoughts on how we should be finding truth nowadays: how to read journals, choose experts, use AI, and resolve disagreement.

Learn more at the Intensive Care Academy!

Takeaway pearls

Scott subscribes to around 60 journals and reads them monthly, meaning skimming the topic index, then for any titles that jump out at him he reads the abstracts, then the actual article for any that still look relevant. He doesn’t recommend doing that. Reading around 10 journals would get you most of the high-yield updates, and you could probably get away with 3–4. It’ll take you about an hour a month.
Read at least the methods and results. The discussion, abstract, and conclusion are mostly a mini-review paper. Ask: is this “generalizable,” meaning applicable to me—my patients, my practice, my questions? Could we implement this here? Ask also how your personal clinical expertise bears upon this (sometimes it’s greater than that of the authors). Finally, ask if the rigor of the paper supports the findings, though you may need to turn to methodological experts here given the complexity of modern studies. (Statistical and methodological experts are available out there, whether in your department or on the internet.)
Signals of confidence, charisma, or “reasonableness” are no longer useful (if they ever were) markers of good knowledge in experts, authorities, pundits, authors, podcasters, etc. In fact, truth-tellers are often less compelling communicators, as they tend to hedge and equivocate; that’s what the truth looks like, not clear messages, the latter of which are often fabricated.
One tool for managing this: seek disconfirmation. When pursuing opinions and expert perspectives, don’t look for those that agree with your prior beliefs, look for those that disagree; that is far more likely to be meaningful and useful data if you’re truly curious about what you’ll find. Even if your mind isn’t changed afterwards, your beliefs will become clearer and deeper. Especially in the current era of algorithms, subcultures, echo chambers, and AI tools that tend to agree with you, you need to actively seek these differing views. You should be able to make the counter-argument to your beliefs better than anyone who truly believes it—that’s when you really understand your own views.
When you find a differing view, rather than engaging knee-jerk opposition, ask why? What is different in their population, approach, environment, etc that leads to a differing view from this reasonable person? If your first reaction is “WTF are you talking about?” try to transition into “Hmm… wtf are you talking about?”
Clinical experience always needs to be thoughtfully integrated into the literature. The subtle lessons of experience are not always studied, and a large study of pooled patients may not address this specific patient’s situation. However, we also tend to overweigh the value of personal lessons, especially when it comes attached to emotional experiences.
A psychological pitfall for educators, and especially modern content creators (podcasters, bloggers, talking heads, YouTubers, etc) is the pull of speaking to create controversy rather than truth. We have lost great scientists and clinicians from the realm of real medicine towards hucksterism by this temptation.
AI today is reasonably good at acting as a medical librarian, i.e. “tell me (with references) the major studies addressing this point.” For this purpose, it is probably better than limited attempts at scouring the literature with PubMed, although all it’s doing is scouring the Internet for commentaries that have referred to the literature, and may therefore miss smaller/less known studies. It is less good at answering specific clinical questions, although it can be a useful idea generator, such as suggesting possibilities for your differential you hadn’t considered… since it remembers all facts, and is good at pattern recognition.
Fight the natural tendency of AI agents to be agreeable by prompting them towards disconfirmation, i.e. “tell me where I’m wrong.” If you solicit agreement or even use a neutral framing, they will tend to roll with whatever you suggest.
When thinking or teaching, you will be more right and righteous if you speak in probabilities or allow the possibility of uncertainty, then if you speak in platitudes. Say you could be wrong, estimate a degree of probability… if you think in certainty, you anchor yourself and can never become more correct with new data.
95% of your decisions should be made in advance, either as shared or internal guidelines, based on your current assessment of our knowledge and how you do what you do. The other 5% will require intensive thought at the time, which is a good thing as long as it’s only 5%, and maybe you can generalize your decisions so that decision will be autopilot next time.
Listen to differing perspectives and opinions from different sources to add qualitatively to your market of ideas, without trying too hard to weigh which is a “better” opinion or source, as this is mostly impossible; with that perspective, you don’t need to worry as much about the validity of the source as long as it’s worth hearing.
However, give very little weight to “voting,” or considering how often you hear a perspective. In the modern era of algorithmically served content, media echo chambers, and self-selecting subcultures, as well as the growing rise of completely AI-generated content in infinite volumes, you are likely to hear many voices that share the same opinion, regardless of whether it’s right or wrong, and quantity of perceived voices may have no correlation to the actual number of people who believe something. In fact, many seemingly different sources are really just echoing or referring back to one original source, not reflecting new opinions. “I hear it all the time/everyone thinks that” is no longer a useful tool for finding truth.

Episode 99: RV failure in the MICU

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We chat about managing a complex MICU patient with RV failure in the setting of renal failure and sepsis, with Amos Dodi, nocturnal intensivist at Einstein/Montefiore and author of a recent narrative review on the RV.

Learn more at the Intensive Care Academy!

CHEST’s Procedural Skills for the Critical Care Clinician, April 23-24 2026

References

Amos’s RV failure review: Dodi, A.E., Jacobs, M. Acute Right Ventricular Failure in the Medical ICU. Lung 203, 107 (2025). https://doi.org/10.1007/s00408-025-00862-y

Takeaway pearls

Distinguishing the cause of shock in a patient with chronic PH is always challenging. Echo can be harder to interpret, but extremes can be called: frank hypovolemia, frank RV failure. Don’t forget to correlate clinically, eg feeling the extremities to estimate SVR.
Measuring CVP can be very valuable in these patients. The spot value can be hard to interpret, but trends can be revealing; if the CVP suddenly jumps, consider the RV is giving up.
Response to therapy can also be a potent diagnostic tool, such as the response to inotropy, or a fluid challenge.
Avoid hypoxemia, hypercarbia, hypotension, acidosis, all of which increase the PVR and hence RV strain. Limit fluid inputs from drips.
Favor vasopressin as a PVR-sparing pressor, perhaps with low-dose epinephrine as a titratable inopressor, though caution with vaso causing coronary ischemia in an RV already at risk of it due to dilation.
Intubating the RV failure patient should be done with great caution and respect, and really, deferred if possible. The team should proceed with awareness of the risk of hemodynamic decompensation (ideally one provider tasked to this purpose peri-intubation). Induction agents should be hemodynamically stable, preoxygenation should be optimal, and be delicate with BVM use to limit intrathoracic pressure.
A PA catheter has potential utility, although expertise has dwindled these days. It is not impossible that placing a foreign body across the TV, through the RV into the PAs could even worsen RV function somewhat. Non-invasive cardiac output monitors may have a role as well although the benefit has not be clearly shown.
Volume management and diuresis can sometimes be guided by the urine sodium.

Lightning rounds 61: Credentialing and privileging, with Christopher Newman

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We dive into the confusing rabbit hole of medical staffing, credentialing, and privileging, particularly for the critical care APP, with Chris Newman, pediatric critical care PA and Vice Chair for Clinical Performance at the University of Colorado.

Check out the REVIVE conference here!

Check out the CHEST Procedural Skills for the Critical Care Clinician course here!

Learn more at the Intensive Care Academy!

Takeaway pearls

The medical staff office regulates the medical staff, which includes physicians and APPs. The latter may actually be voiting “members” of the medical stuff, or have some kind of affiliate status; the relevance of this is their eligibility to vote and sit on its committees, which sets the policies and manages governance. Either way though, APPs are subject to the medical staff office’s regulation.
Credentialing is the process of ensuring medical staff have the right and competence to work in the hospital, mostly confirming basic job requirements like graduating training programs. Privileging is the process of determining what specific things you are allowed to do in the hospital.
Privileges are broken into core privileges, which are things any provider should know how to do (i.e. taught in school): perform H&Ps, order meds and tests, interpret them, etc. Special privileges are those that require additional training, usually procedures. Some of the latter may become core privileges over time.
Special privileges are needed for anything “infrequent and high risk,” which requires some judgment – i.e. if a procedure is not listed, does that mean you cannot do it, or that it does not even require special privileges? Which procedures are listed is determined by the judgment of the clinicians in medical staffing, and the list is not always perfect.
All of these processes are hospital based, usually not part of state law, and are also often subject to Joint Commission regulation. However your hospital handles them, it is expected to follow its own policies consistently.
Learners are managed under policies for proctoring, not privileges. A person with procedural privileges can generally supervise a learner without privileges to perform it; if that’s a student, it is considered to be “done” by the proctor, and if by a licensed provider without privileges, it is “done” by the learner under supervision. Such a learner may eventually obtain their own privileges (usually by meeting a requirement of either numbers or observed competence or both). The exact rules of how all this works is governed by a proctoring policy which can be looked up.
While many providers may feel it is accepted, or even an ethical obligation, to perform procedures they are trained but not privileged to perform in an emergency (i.e. to save a life when a privileged person is not immediately available), there is usually no explicit allowance for this in hospital policy, so buyer beware.
If you don’t like how your processes work, change them.

Lightning rounds 60: The nuances of insulin, with Melissa Nestor

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We chat with Melissa Nestor, clinical pharmacist in neurocritical care, about tho subtleties of glucose and insulin management in the ICU.

Learn more at the Intensive Care Academy!

Episode 98: Running rapid responses

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We discuss the practicalities of running a rapid response, including crowd management, coordinating with primary services, working outside the ICU, and rapidly obtaining and synthesizing diagnostic data.

Learn more at the Intensive Care Academy!

Lightning rounds 59: The nuances of nebulizers, with Keith Lamb

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We explore the practical intricacies of nebulized medications, including timing, dosing, types of devices, and more, with Keith Lamb (@kdlamb1), RRT, RRT-ACCS, FAARC, FCCM.

Learn more at the Intensive Care Academy!