Critical Matters

In this, Dr. Sergio Zanotti discusses the management of invasive candidiasis in critically ill patients. Invasive candidiasis is frequent in critically ill patients and is associated with high mortality and morbidity. He is joined by Dr. Max Adelman, a practicing critical care and infectious disease physician at Houston Methodist Hospital. Dr. Adelman is an Assistant Professor of Medicine at Weill Cornell Medical College. Dr. Adelman's clinical interests include bacteremia, hospital-acquired infections, immunocompromised hosts, multidrug-resistant organisms, and septic shock. Additional Resources: Invasive candidiasis in critically ill patients: Fundamental concepts and future directions. Perez MA, Hoffman WJ, Perez JC, and Adelman MH. CHEST 2026. [https://pmc.ncbi.nlm.nih.gov/articles/PMC12833977/] Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure: The EMPIRICUS Randomized Clinical Trial. JAMA 2016. [https://pubmed.ncbi.nlm.nih.gov/27706483/] Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM. THE LANCET- Infectious Diseases 2025. [https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(24)00749-7/fulltext] Books and Music mentioned in this episode: Four Thousand Weeks: Time Management for Mortals. By Oliver Bukerman. [https://www.amazon.com/Four-Thousand-Weeks-Management-Mortals-ebook/dp/B08FGV64B1/ref=sr_1_1?crid=2FJQE691JB5H3&dib=eyJ2IjoiMSJ9.2e1RiAVyclMJkGOzA0_LWuOFXqzlWVq4HXhGGCLYJkq42yY3fyrFid2V2RWVYAdCocEfe-dC53eZrwRdWHCE_1MaqwrB709y5e0yLKMHz9LnfGRf5QJ-wLCRiAzdH7kVR46dRiaR2gVhC_jzwds3n5_xX_d_AW_S13TIIyLrLOqSOuv-oYr6mbT2Njsj_js3DTTqQ_mCWc9_B21M1aSFewYT6KKUt--nOvMZpRgxMDc.-la6JVEfHMmdSUeP7zTTiPceOEFurUE-heTTBp1GNYA&dib_tag=se&keywords=4000+weeks&qid=1773886412&sprefix=4000%2Caps%2C179&sr=8-1] Lonesome Drifter. By Charlie Crockett. [https://www.amazon.com/Lonesome-Drifter-Charley-Crockett/dp/B0DVCD1G2P/ref=sr_1_1?crid=22893TOCDJZWD&dib=eyJ2IjoiMSJ9.b1CwNZUYAALfDS7k8KR2RS_mSBY4uX4w0LTD3OwPjOybHyYk_aueyvzPHpeMpDY1TYwXRkAT2TKX5zpJwi1NlHBtOarry61Tx4o1MJGHmU7djgWrUecopo7wDozEYp0_041tWC02nXRMiq4_UX6XHVuPK2JBTZxbST_Zg0QZfW2uTwBP_odXrBnaKzXUo4u4s1j9GpccN1M6jdil6DbZDSB5lrKZf8Vr54xikYKm21s.l7mqkLPc0vNa6ouQ4UfDw2x4Mzs9pxEA8fag6xyy6vc&dib_tag=se&keywords=charlie+crockett+cd&qid=1773886517&sprefix=Charlie+Crockett%2Caps%2C168&sr=8-1]

In this episode, Dr. Sergio Zanotti discusses emergency management and resuscitation of patients with left-sided Impella support. We will base our discussion on a recently published United Kingdom multisociety consensus statement. Our guests for this episode are two of the authors of this consensus statement. Dr. Zanotti is joined by Dr. Waqas Akhtar, a consultant at Guy's & St Thomas' NHS Foundation Trust in the United Kingdom. Dr. Akhtar completed full postgraduate certification in Cardiology, Intensive Care & General Internal Medicine with a particular interest in cardiogenic shock, heart transplantation, and mechanical circulatory support. He is also joined by Dr. Vasileios Panoulas, a consultant cardiologist at Royal Brompton & Harefield NHS Trust and honorary senior clinical lecturer at Imperial College London. He has clinical expertise that encompasses both general and interventional cardiology. Additional resources: UK multisociety consensus statement on the emergency management and resuscitation of patients with left-sided Impella support: https://heart.bmj.com/content/early/2025/12/17/heartjnl-2025-326896 Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. DanGer Shock Investigators: https://www.nejm.org/doi/full/10.1056/NEJMoa2312572 Effect of Microaxial Flow Pump on Hemodynamics in STEMI-Related Cardiogenic Shock. DanGer Shock Investigators: https://www.jacc.org/doi/abs/10.1016/j.jacc.2025.04.062 Long-Term Outcomes of the DanGer Shock Trial. DanGer Shock Investigators: https://pubmed.ncbi.nlm.nih.gov/40888722/ Music mentioned in this episode: Unlearning. By Teddy Swims. [https://www.amazon.com/Unlearning-Teddy-Swims/dp/B096TRTRVR/ref=sr_1_2?crid=YVQGYQ768N5Y&dib=eyJ2IjoiMSJ9._NA1GMm_CKB7H0oBRpQFuEVn9mh4rVGfgEBPM5ZOBI2UH7TLuCnvk1UXEz1l8yZtZ2P3473FeVoPO_cIfFgMfx7W1B3VuCDgOtCbU27n_KRskWWOmK1kM5IsZsFWqNfFmxAaQovt8BKAsXOkkCGPBrzpJ0dBZhwNUgEbcRnW8532UhBknHkUPp_RvPmA_4Jm23WTIBymO6yQmUY2S6RWAR8LzzApr_aiShzHfdOi8V8.rrzjPsSZaTkfmFxUXXuQBHxugpdG98k_NC8HoJc54yk&dib_tag=se&keywords=Teddy+unlearning&qid=1773763757&sprefix=teddy+unlearning%2Caps%2C184&sr=8-2] Minute a Moment. By Myles Smith. [https://www.amazon.com/Minute-Moment-Myles-Smith/dp/B0F6VXGB26/ref=sr_1_2?crid=1HF04N0B8TJYJ&dib=eyJ2IjoiMSJ9.skxNq4rN2r7zMLTfEFlr3a7RJE4YLPX5J1-7b4ZK1Xr__dTZh_nKywu3I7zFQ5UccEO-B2dK06lGDSgPy2fJ9ERFtpeug3RTYLB35OlJPMSvsajkVDlWNXhXQBZ7Sa3hOOkE3MikLMRgHNL0z14oUA.qLD2-2Hej1KERoL3pp-J2ZFQPJ5LtP_yRAQBzvTbPXY&dib_tag=se&keywords=myles+smith+a+minute+a+moment&qid=1773764196&sprefix=myles+smith+a+minute+a+moment%2Caps%2C127&sr=8-2] Sable, Fable. By Bon Iver. [https://www.amazon.com/Sable-Fable-Bon-Iver/dp/B0DWT6MPVB/ref=pd_sbs_d_sccl_1_1/139-4346088-5189726?pd_rd_w=EA3jv&content-id=amzn1.sym.aa738fbd-ad05-4d11-aae2-04b598db6305&pf_rd_p=aa738fbd-ad05-4d11-aae2-04b598db6305&pf_rd_r=HSX3NG0QT7RX42C7Z7CJ&pd_rd_wg=WwdLe&pd_rd_r=067b1e38-a2b9-40fe-996c-fb4181015b9e&pd_rd_i=B0DWT6MPVB&psc=1]

In this episode, Dr. Sergio Zanotti discusses a structured approach to ECMO emergencies, focusing on recognizing cardiac arrest, organizing the team response, and early ECMO troubleshooting to support key life-saving interventions. He is joined by Dr. Waqas Akhtar, a consultant at Guy's & St Thomas' NHS Foundation Trustin the United Kingdom. Dr. Akhtar completed full postgraduate certification in Cardiology, Intensive Care & General Internal Medicine, with a particular interest in cardiogenic shock, heart transplantation, and mechanical circulatory support Additional resources: British societies guideline on the management of emergencies in patients on extracorporeal membrane oxygenation. Waqas Akhtar, et al. Intensive Care Med 2025: https://pubmed.ncbi.nlm.nih.gov/41051555/ UK multisociety consensus statement on the emergency and resuscitation of patients with left-sided Impella support. Waqas Akhtar, et al. BMJ Journals 2026: https://heart.bmj.com/content/early/2025/12/17/heartjnl-2025-326896 Books mentioned in this episode: His Dark Materials Series: The Golden Compass; The Subtle Knife; The Amber Spyglass: https://bit.ly/4cmSXgB

In this episode, Dr. Zanotti discusses the role of Procalcitonin in the ICU. He is joined by Dr. Simran Gupta, an infectious disease specialist at Brigham & Women's Hospital in Boston. Dr. Gupta has additional training in Clinical Research, Transplant, and Infectious Disease. She recently published an article on reassessing the role of Procalcitonin in critically ill patients with sepsis. Additional resources: Reassessing Procalcitonin-Guided Antibiotic Therapy in Critically Ill Patients with Sepsis: Lessons from the ADAPT-Sepsis Trial. S. Gupta, et al. Clinical Infectious Disease 2025: https://pubmed.ncbi.nlm.nih.gov/40579227/ 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/ Procalcitonin-guided antibiotic therapy may shorten the length of treatment and may improve survival- a systematic review and meta-analysis. M Papp, et al. Crit Care 2023: https://pubmed.ncbi.nlm.nih.gov/37833778/ Books and entertainment mentioned in this episode: Shantaram: A Novel. By Gregory David Roberts: https://bit.ly/4ovVHKX SHANTARAM – Apple TV series: https://tv.apple.com/us/show/shantaram/umc.cmc.atxsrive40xli3zh3uxjimut

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

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 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 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. 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. 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 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

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

In this episode, Dr. Sergio Zanotti discusses rational fluid therapy. He is joined by Dr. Adrian Wong, a practicing intensive care medicine and anesthesia physician. Dr. Wong is a consultant and clinical lead at King's College Hospital, London. He also serves as a committee member for the Intensive Care Society FUSIC, examiner for the European Diploma of Intensive Care Medicine, on the executive committee of the International Fluid Academy. Additional resources: Intravenous fluid therapy in the perioperative and critical care setting" Executive summary of the International Fluid Academy (IFA). Malbrain ML, et al. Ann. Intensive Care 2020: https://pubmed.ncbi.nlm.nih.gov/32449147/ Multidisciplinary expert panel report on fluid stewardship: perspectives and practice. Malbrain ML, et al. Annals of Intensive Care 2023: https://pubmed.ncbi.nlm.nih.gov/37747558/ The emerging concept of fluid tolerance: A position paper. Kattan E, et al. Journal of Critical Care 2022: https://pubmed.ncbi.nlm.nih.gov/35660844/ Everything you need to know about derescuscitation. Malbrain ML, et al. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/35932335/ Start with Why. TED Talk presented by Simon Sinek: https://simonsinek.com/videos/ted-talks/ Books mentioned in this episode: Thinking Fast and Slow. By Daniel Kahneman: https://amzn.to/4hicUoj Start with Why: How Great Leaders Inspire Everybody to Take Action. By Simon Sinek: https://bit.ly/42hzt8n