Selected Podcast
Challenges of uncertainty in diagnosing sepsis in ICU patients with systemic inflammation and organ dysfunction, coupled with the risks of under or over treatment.
Dr. Annette Esper discusses the challenges associated with undertreating or overtreating patients with suspected sepsis. Dr. Esper also discusses how host response testing could help with diagnostic uncertainty and impact early initiation of appropriate therapy.
Featuring:
Annette Esper, MD, Msc
Annette Esper, MD, Msc is an Associate Professor of Medicine Grady Section Chief Division of Pulmonary, Allergy, Critical Care and Sleep Emory University. Transcription:
Septicyte Tag: Subtest site rapid has recently received FDA clearance for in vitro diagnostic use to ed clinicians in differentiating Subsys from non-infectious systemic inflammation in suspected substance patients in the ICU. More details at www dot dot com.
Dr Pam Peeke (Host): Hello and welcome to the Society of Critical Care Medicine's iCritical Care podcast. I'm your host, Dr. Pam Peeke. Today, we'll be talking about the challenges of uncertainty in diagnosing sepsis in ICU patients with systemic inflammation and organ dysfunction, coupled with the risks of under or overtreatment. I'm joined by Dr. Annette Esper, Associate Professor of Medicine, Grady Section Chief Division of Pulmonary, Allergy, Critical Care and Sleep at Emory University.
Before we start, do you have any disclosures, Dr. Esper?
Dr Annette Esper: Yes. Thank you, Pam. I serve as a site PI for a device study that was sponsored by Immunexpress to test their new sepsis diagnostic.
Dr Pam Peeke (Host): Excellent. And do you have any other disclosures?
Dr Annette Esper: No.
Dr Pam Peeke (Host): Excellent. So for the audience, our learning objectives include to provide you with an overview of the challenges associated with differentiating between sepsis and infection-negative systemic inflammation in suspected sepsis patients that have varying levels of clinical suspicions and sepsis probability. As well, the overview includes an understanding of the need to promptly initiate appropriate intervention, whether that might be antibiotics for bacterial sepsis or, alternatively, order other tests, scans, et cetera, to determine the etiology of noninfectious systemic inflammation.
Finally, the audience that is listening, our peers, needs to understand the availability of a new FDA-cleared host response test to differentiate sepsis and infection-negative systemic inflammation, which might assist clinicians in their decision-making and potentially improve patient outcomes. And then lastly, the ramifications for antibiotic stewardship when considering challenges of diagnostic uncertainty.
Now, this podcast is needed because currently critical care clinicians are faced with the dilemma of under or overtreating patients suspected of sepsis. And you have to be able to initiate the sepsis bundle within one to three hours. And in that time, there are no blood culture results back to be able to refer to. And it's clinically challenging in some cases to determine if the systemic inflammation is infection-positive or infection-negative. Currently available lab tests have low sensitivity and low specificity.
And this entire podcast will also be addressing knowledge gaps, which include understanding the challenges associated with under or overtreating suspected sepsis patients. Also, how host response testing could assist with diagnostic uncertainty and impact early initiation of appropriate therapy and outcome.
So Dr. Esper, that's a lot and you have a lot to cover here. What we want to be able to address first is what is the problem when a critical care medicine specialist is faced with the dilemma a patient is assessed in a very short period of time, and you have to be able to say sepsis, that is infection that needs to be treated immediately, or what? How do you go through that decision-making algorithm in your mind?
Dr Annette Esper: Thank you, Pam. Well, I think part of the problem is that patients present in a variety of ways. And sepsis, unlike certain other emergencies such as stroke or myocardial infarction, it doesn't have like one specific diagnostic test. So we basically use our clinical judgment to assess whether this patient has an infection and whether they meet the definition for sepsis. And I think that's where it becomes very tricky because we want to be able to act very quickly in managing these patients if it is sepsis, but we want to weigh the risks and benefits of treating patients with agents such as antibiotics and considering the potential harm that treatment could have.
So I think that's the biggest challenge, is really deciding if a patient truly has an infection because of the variety of ways that they can present to us.
Dr Pam Peeke (Host): So traditionally, what has happened? Before we have new diagnostics and ways to be able to facilitate this process, what have critical care specialists done?
Dr Annette Esper: So traditionally, we've basically used clinical judgment. So, taking a patient's history, using physical exam to help us determine if there's an obvious source of infection. We've used lab values and imaging results to help guide our diagnosis. But at times, those results may not definitively tell us if someone has sepsis or not.
So based on our suspicion, we make a decision to either initiate treatment or to hold off and do further diagnostic studies to try to pinpoint a specific focus of infection. And it really comes down to how sick the patient is when we first see them. And that helps drive our decision on how soon to act.
Dr Pam Peeke (Host): Within one to three hours, what laboratories could you be able to avail yourself of?
Dr Annette Esper: Well, currently we use laboratory values such as determining the lactate level. Oftentimes, clinicians use procalcitonin level, other lab values such as white blood cell count and other values that give us an idea of someone's renal function and liver function. So there's general lab values that we can obtain within the first few hours of presentation to help us figure out if there's any evidence of organ dysfunction that could be a result of sepsis.
Dr Pam Peeke (Host): So, what is the morbidity and mortality associated with under or overtreatment of a patient with sepsis?
Dr Annette Esper: Well, as far as undertreatment, morbidity and mortality really depends on the severity of illness. So as you know, Pam, patients with sepsis, especially more severe sepsis, have a high mortality and that ranges and can be up to 50% mortality, depending on the severity of illness and depending on other patient risk factors such as age or immunosuppression. And then we also know that patients that have sepsis can actually have significant morbidity after having sepsis and, depending on their, again, severity length of stay in the ICU. So there's significant ramifications for undertreating and under recognizing sepsis.
And then we have to weigh that with the potential of harm from overtreating. So we know that antibiotics while they are helpful for someone with infection can also cause harm, such as kidney dysfunction or liver dysfunction, depending on the antibiotic. It can cause some hematological issues, again, depending on the antibiotics. So that's one way that we can harm people. Other ways are we think about resuscitation when it comes to patients that present with sepsis, especially septic shock. And we know that resuscitation with fluids is helpful, but can be harmful if we give patients too much fluid. So I think we have to think about that when we are really deciding whether to treat someone. And that's where the challenge is, when you're not really sure if someone has sepsis or not.
Dr Pam Peeke (Host): That's excellent. And how does organ dysfunction figure into your equation? How difficult is it to be able to understand the status of organ dysfunction when you have so little time?
Dr Annette Esper: Well, we use initial lab values to determine if someone has organ dysfunction or if someone, for example, comes in with significant hypoxemia and has lung dysfunction. But I think the issue, one thing is to recognize if somebody has organ dysfunction, but it's another thing to determine was that organ dysfunction due to an infection, and I think that's the challenge. And also recognizing, is this organ dysfunction new? So someone that comes in with a kidney injury, for example, oftentimes we may not have enough data to understand whether this is a new insult or an old insult. So determining, whether someone has organ dysfunction is very important in sepsis because that signifies more severe disease, which is associated with higher mortality and you want to be able to intervene very quickly.
Dr Pam Peeke (Host): All right. So what are the new tools that exists now to be able to facilitate this challenge of uncertainty in diagnosing sepsis in ICU patients?
Dr Annette Esper: So we all use our pretest probability when we're determining if someone has a disease process or not. And I think clinician judgment is still very important in diagnosing sepsis. So along with that, as I mentioned earlier, we use lab values and there's certain lab values that people use commonly, such as procalcitonin. But there's been a lot of controversy with using that and it's not necessarily diagnostic of sepsis.
So there is a new gene expression assay, which is referred to as SeptiCyte RAPID. And that's recently had FDA clearance and it's basically a host response test for sepsis. And what it does is it uses reverse transcription PCR, and it measures basically the expression levels of response genes that are isolated from a patient's blood. And so the output that it gives a clinician is basically four bands that help you determine whether there's a high probability of sepsis. And what studies have found with this new host response test is that, when used in conjunction with clinical assessments and vital signs and labs, it can very much help us differentiate between sepsis and non-infective SIRS.
And so I think that new technology like this would be very helpful to clinicians in better determining if someone truly has sepsis so that we can intervene more rapidly, especially in light of the new Surviving Sepsis guidelines as far as administering antibiotics within the first hour for patients with probable sepsis or sepsis and shock.
Dr Pam Peeke (Host): So walk us through how this would work. You walk into the unit, you have a new patient and there's, once again, the challenge of diagnosing sepsis here. Walk us through how you would actually utilize this tool, and basically the time period as well, since that is quite critical.
Dr Annette Esper: So the way I would envision this being used is when you have someone in the ICU or in the emergency department that puts out some sort of sepsis warning, there's a variety of ways that people detect sepsis. So there's an assessment for sepsis that is made and you would initiate your sepsis order sets and any lab tests that are directed for sepsis.
And then in that first early time point of triaging, you would add this SeptiCyte RAPID test, and it has a one hour turnaround time. So that would be advantageous given that in someone that has high probability of sepsis and possible sepsis with shock, you would initiate antibiotics within an hour. So if you were able to use all of your clinical assessments and labs and get this SeptiCyte RAPID test within an hour, you would then receive a probability score, basically a band from 1 to 4 that would indicate the probability of sepsis. And so if there was a high probability of sepsis, in addition to all the other lab values and your clinical suspicion, you would initiate antibiotics within an hour.
So that's how I would envision it working. Because it is a rapid test, you can use it early on in triaging patients that are suspected of having sepsis.
Dr Pam Peeke (Host): How precise is this?
Dr Annette Esper: It has a very high sensitivity and specificity depending on the band. So a band 1 indicates that there is a low likelihood of sepsis and that has been found to have a high sensitivity and a band of 4 has been shown to have a high specificity for sepsis. And again, the test is best performed when we use it in conjunction with our clinical assessment and other labs, so that's when it performs the best. So this is not meant to replace what we do now. It's meant to be used as an aid to improve our performance with detecting sepsis currently.
Dr Pam Peeke (Host): How widely used is this now?
Dr Annette Esper: Well, it just recently got FDA cleared. So the studies looking at it just completed recently. So I'm not sure how widely available it is in the clinical setting in laboratories at different institutions.
Dr Pam Peeke (Host): And how long have you been using it?
Dr Annette Esper: Well, we just completed the study not too long ago as far as completing data collection, et cetera. So we don't have it currently. We still have it as part of our study. So we haven't incorporated it in practice yet.
Dr Pam Peeke (Host): Okay. So that's just something that I want to make certain everyone understands, that this is early on. It was just FDA cleared. What kind of a time period do you think there will be before this becomes more widely integrated?
Dr Annette Esper: I'm actually not sure. That would be a question for the company, because I'm not sure what their plan is now that it is FDA cleared.
Dr Pam Peeke (Host): Okay, excellent. So, I think if you were to now summarize this new development for your peers in critical care, are you saying then that this is a new hopeful potentially tool to be able to assist with that challenge of diagnosing sepsis in ICU patients?
Dr Annette Esper: So in light of new Surviving Sepsis guidelines and given that all hospitals have different quality measures, I think that this technology is the new hopeful in helping us accurately diagnose sepsis and be able to diagnose it sooner so that we can initiate antibiotics earlier and deescalate antibiotic use if patient truly does not have sepsis. So I'm hopeful that this along with what we use today and our clinical acumen will just make it easier for clinicians to intervene quickly.
Dr Pam Peeke (Host): Excellent. Fantastic. This has been an excellent summary of the current challenges facing critical care clinicians as they strive to be able to diagnose sepsis more precisely and yet another tool in our armamentarium to be able to do this more accurately and more precisely with better patient outcomes.
This concludes another edition of the iCritical Care podcast. I want to thank Dr. Annette Esper from Emory University for her contribution. And for the iCritical Care podcast, I'm Dr. Pam Peeke.
Septicyte Tag: Subtest site rapid has recently received FDA clearance for in vitro diagnostic use to ed clinicians in differentiating Subsys from non-infectious systemic inflammation in suspected substance patients in the ICU. More details at www dot dot com.
Dr Pam Peeke Bio:
Pamela M. Peeke, MD, MPH, FACP, FACSM is a nationally-renowned physician scientist expert and thought leader in the field of medicine. Dr. Peeke is a Pew Foundation Scholar in Nutrition and Metabolism, Assistant Professor of Medicine at the University of Maryland, holds dual master's degrees in Public Health and Policy, and is a fellow of both the American College of Physicians and the American College of Sports Medicine.
Dr. Peeke has been named one of America's top physicians by the Consumer's Research Council of America. She is a regular in-studio medical commentator for the National Networks and an acclaimed TEDx presenter and National Keynote Speaker.
Dr. Peeke is a three-time New York Times bestselling author and as a science and health advisor for Apple.
Disclaimer: The iCritical Care podcast is the copyrighted material of the Society of Critical Care Medicine, and all rights are reserved. Statements of fact and opinion expressed in this podcast are those of authors and participants, and do not imply an opinion or endorsement on the part of the Society of Critical Care Medicine, its officers, volunteers, or members, or that of the podcast commercial supporter.
Septicyte Tag: Subtest site rapid has recently received FDA clearance for in vitro diagnostic use to ed clinicians in differentiating Subsys from non-infectious systemic inflammation in suspected substance patients in the ICU. More details at www dot dot com.
Dr Pam Peeke (Host): Hello and welcome to the Society of Critical Care Medicine's iCritical Care podcast. I'm your host, Dr. Pam Peeke. Today, we'll be talking about the challenges of uncertainty in diagnosing sepsis in ICU patients with systemic inflammation and organ dysfunction, coupled with the risks of under or overtreatment. I'm joined by Dr. Annette Esper, Associate Professor of Medicine, Grady Section Chief Division of Pulmonary, Allergy, Critical Care and Sleep at Emory University.
Before we start, do you have any disclosures, Dr. Esper?
Dr Annette Esper: Yes. Thank you, Pam. I serve as a site PI for a device study that was sponsored by Immunexpress to test their new sepsis diagnostic.
Dr Pam Peeke (Host): Excellent. And do you have any other disclosures?
Dr Annette Esper: No.
Dr Pam Peeke (Host): Excellent. So for the audience, our learning objectives include to provide you with an overview of the challenges associated with differentiating between sepsis and infection-negative systemic inflammation in suspected sepsis patients that have varying levels of clinical suspicions and sepsis probability. As well, the overview includes an understanding of the need to promptly initiate appropriate intervention, whether that might be antibiotics for bacterial sepsis or, alternatively, order other tests, scans, et cetera, to determine the etiology of noninfectious systemic inflammation.
Finally, the audience that is listening, our peers, needs to understand the availability of a new FDA-cleared host response test to differentiate sepsis and infection-negative systemic inflammation, which might assist clinicians in their decision-making and potentially improve patient outcomes. And then lastly, the ramifications for antibiotic stewardship when considering challenges of diagnostic uncertainty.
Now, this podcast is needed because currently critical care clinicians are faced with the dilemma of under or overtreating patients suspected of sepsis. And you have to be able to initiate the sepsis bundle within one to three hours. And in that time, there are no blood culture results back to be able to refer to. And it's clinically challenging in some cases to determine if the systemic inflammation is infection-positive or infection-negative. Currently available lab tests have low sensitivity and low specificity.
And this entire podcast will also be addressing knowledge gaps, which include understanding the challenges associated with under or overtreating suspected sepsis patients. Also, how host response testing could assist with diagnostic uncertainty and impact early initiation of appropriate therapy and outcome.
So Dr. Esper, that's a lot and you have a lot to cover here. What we want to be able to address first is what is the problem when a critical care medicine specialist is faced with the dilemma a patient is assessed in a very short period of time, and you have to be able to say sepsis, that is infection that needs to be treated immediately, or what? How do you go through that decision-making algorithm in your mind?
Dr Annette Esper: Thank you, Pam. Well, I think part of the problem is that patients present in a variety of ways. And sepsis, unlike certain other emergencies such as stroke or myocardial infarction, it doesn't have like one specific diagnostic test. So we basically use our clinical judgment to assess whether this patient has an infection and whether they meet the definition for sepsis. And I think that's where it becomes very tricky because we want to be able to act very quickly in managing these patients if it is sepsis, but we want to weigh the risks and benefits of treating patients with agents such as antibiotics and considering the potential harm that treatment could have.
So I think that's the biggest challenge, is really deciding if a patient truly has an infection because of the variety of ways that they can present to us.
Dr Pam Peeke (Host): So traditionally, what has happened? Before we have new diagnostics and ways to be able to facilitate this process, what have critical care specialists done?
Dr Annette Esper: So traditionally, we've basically used clinical judgment. So, taking a patient's history, using physical exam to help us determine if there's an obvious source of infection. We've used lab values and imaging results to help guide our diagnosis. But at times, those results may not definitively tell us if someone has sepsis or not.
So based on our suspicion, we make a decision to either initiate treatment or to hold off and do further diagnostic studies to try to pinpoint a specific focus of infection. And it really comes down to how sick the patient is when we first see them. And that helps drive our decision on how soon to act.
Dr Pam Peeke (Host): Within one to three hours, what laboratories could you be able to avail yourself of?
Dr Annette Esper: Well, currently we use laboratory values such as determining the lactate level. Oftentimes, clinicians use procalcitonin level, other lab values such as white blood cell count and other values that give us an idea of someone's renal function and liver function. So there's general lab values that we can obtain within the first few hours of presentation to help us figure out if there's any evidence of organ dysfunction that could be a result of sepsis.
Dr Pam Peeke (Host): So, what is the morbidity and mortality associated with under or overtreatment of a patient with sepsis?
Dr Annette Esper: Well, as far as undertreatment, morbidity and mortality really depends on the severity of illness. So as you know, Pam, patients with sepsis, especially more severe sepsis, have a high mortality and that ranges and can be up to 50% mortality, depending on the severity of illness and depending on other patient risk factors such as age or immunosuppression. And then we also know that patients that have sepsis can actually have significant morbidity after having sepsis and, depending on their, again, severity length of stay in the ICU. So there's significant ramifications for undertreating and under recognizing sepsis.
And then we have to weigh that with the potential of harm from overtreating. So we know that antibiotics while they are helpful for someone with infection can also cause harm, such as kidney dysfunction or liver dysfunction, depending on the antibiotic. It can cause some hematological issues, again, depending on the antibiotics. So that's one way that we can harm people. Other ways are we think about resuscitation when it comes to patients that present with sepsis, especially septic shock. And we know that resuscitation with fluids is helpful, but can be harmful if we give patients too much fluid. So I think we have to think about that when we are really deciding whether to treat someone. And that's where the challenge is, when you're not really sure if someone has sepsis or not.
Dr Pam Peeke (Host): That's excellent. And how does organ dysfunction figure into your equation? How difficult is it to be able to understand the status of organ dysfunction when you have so little time?
Dr Annette Esper: Well, we use initial lab values to determine if someone has organ dysfunction or if someone, for example, comes in with significant hypoxemia and has lung dysfunction. But I think the issue, one thing is to recognize if somebody has organ dysfunction, but it's another thing to determine was that organ dysfunction due to an infection, and I think that's the challenge. And also recognizing, is this organ dysfunction new? So someone that comes in with a kidney injury, for example, oftentimes we may not have enough data to understand whether this is a new insult or an old insult. So determining, whether someone has organ dysfunction is very important in sepsis because that signifies more severe disease, which is associated with higher mortality and you want to be able to intervene very quickly.
Dr Pam Peeke (Host): All right. So what are the new tools that exists now to be able to facilitate this challenge of uncertainty in diagnosing sepsis in ICU patients?
Dr Annette Esper: So we all use our pretest probability when we're determining if someone has a disease process or not. And I think clinician judgment is still very important in diagnosing sepsis. So along with that, as I mentioned earlier, we use lab values and there's certain lab values that people use commonly, such as procalcitonin. But there's been a lot of controversy with using that and it's not necessarily diagnostic of sepsis.
So there is a new gene expression assay, which is referred to as SeptiCyte RAPID. And that's recently had FDA clearance and it's basically a host response test for sepsis. And what it does is it uses reverse transcription PCR, and it measures basically the expression levels of response genes that are isolated from a patient's blood. And so the output that it gives a clinician is basically four bands that help you determine whether there's a high probability of sepsis. And what studies have found with this new host response test is that, when used in conjunction with clinical assessments and vital signs and labs, it can very much help us differentiate between sepsis and non-infective SIRS.
And so I think that new technology like this would be very helpful to clinicians in better determining if someone truly has sepsis so that we can intervene more rapidly, especially in light of the new Surviving Sepsis guidelines as far as administering antibiotics within the first hour for patients with probable sepsis or sepsis and shock.
Dr Pam Peeke (Host): So walk us through how this would work. You walk into the unit, you have a new patient and there's, once again, the challenge of diagnosing sepsis here. Walk us through how you would actually utilize this tool, and basically the time period as well, since that is quite critical.
Dr Annette Esper: So the way I would envision this being used is when you have someone in the ICU or in the emergency department that puts out some sort of sepsis warning, there's a variety of ways that people detect sepsis. So there's an assessment for sepsis that is made and you would initiate your sepsis order sets and any lab tests that are directed for sepsis.
And then in that first early time point of triaging, you would add this SeptiCyte RAPID test, and it has a one hour turnaround time. So that would be advantageous given that in someone that has high probability of sepsis and possible sepsis with shock, you would initiate antibiotics within an hour. So if you were able to use all of your clinical assessments and labs and get this SeptiCyte RAPID test within an hour, you would then receive a probability score, basically a band from 1 to 4 that would indicate the probability of sepsis. And so if there was a high probability of sepsis, in addition to all the other lab values and your clinical suspicion, you would initiate antibiotics within an hour.
So that's how I would envision it working. Because it is a rapid test, you can use it early on in triaging patients that are suspected of having sepsis.
Dr Pam Peeke (Host): How precise is this?
Dr Annette Esper: It has a very high sensitivity and specificity depending on the band. So a band 1 indicates that there is a low likelihood of sepsis and that has been found to have a high sensitivity and a band of 4 has been shown to have a high specificity for sepsis. And again, the test is best performed when we use it in conjunction with our clinical assessment and other labs, so that's when it performs the best. So this is not meant to replace what we do now. It's meant to be used as an aid to improve our performance with detecting sepsis currently.
Dr Pam Peeke (Host): How widely used is this now?
Dr Annette Esper: Well, it just recently got FDA cleared. So the studies looking at it just completed recently. So I'm not sure how widely available it is in the clinical setting in laboratories at different institutions.
Dr Pam Peeke (Host): And how long have you been using it?
Dr Annette Esper: Well, we just completed the study not too long ago as far as completing data collection, et cetera. So we don't have it currently. We still have it as part of our study. So we haven't incorporated it in practice yet.
Dr Pam Peeke (Host): Okay. So that's just something that I want to make certain everyone understands, that this is early on. It was just FDA cleared. What kind of a time period do you think there will be before this becomes more widely integrated?
Dr Annette Esper: I'm actually not sure. That would be a question for the company, because I'm not sure what their plan is now that it is FDA cleared.
Dr Pam Peeke (Host): Okay, excellent. So, I think if you were to now summarize this new development for your peers in critical care, are you saying then that this is a new hopeful potentially tool to be able to assist with that challenge of diagnosing sepsis in ICU patients?
Dr Annette Esper: So in light of new Surviving Sepsis guidelines and given that all hospitals have different quality measures, I think that this technology is the new hopeful in helping us accurately diagnose sepsis and be able to diagnose it sooner so that we can initiate antibiotics earlier and deescalate antibiotic use if patient truly does not have sepsis. So I'm hopeful that this along with what we use today and our clinical acumen will just make it easier for clinicians to intervene quickly.
Dr Pam Peeke (Host): Excellent. Fantastic. This has been an excellent summary of the current challenges facing critical care clinicians as they strive to be able to diagnose sepsis more precisely and yet another tool in our armamentarium to be able to do this more accurately and more precisely with better patient outcomes.
This concludes another edition of the iCritical Care podcast. I want to thank Dr. Annette Esper from Emory University for her contribution. And for the iCritical Care podcast, I'm Dr. Pam Peeke.
Septicyte Tag: Subtest site rapid has recently received FDA clearance for in vitro diagnostic use to ed clinicians in differentiating Subsys from non-infectious systemic inflammation in suspected substance patients in the ICU. More details at www dot dot com.
Dr Pam Peeke Bio:
Pamela M. Peeke, MD, MPH, FACP, FACSM is a nationally-renowned physician scientist expert and thought leader in the field of medicine. Dr. Peeke is a Pew Foundation Scholar in Nutrition and Metabolism, Assistant Professor of Medicine at the University of Maryland, holds dual master's degrees in Public Health and Policy, and is a fellow of both the American College of Physicians and the American College of Sports Medicine.
Dr. Peeke has been named one of America's top physicians by the Consumer's Research Council of America. She is a regular in-studio medical commentator for the National Networks and an acclaimed TEDx presenter and National Keynote Speaker.
Dr. Peeke is a three-time New York Times bestselling author and as a science and health advisor for Apple.
Disclaimer: The iCritical Care podcast is the copyrighted material of the Society of Critical Care Medicine, and all rights are reserved. Statements of fact and opinion expressed in this podcast are those of authors and participants, and do not imply an opinion or endorsement on the part of the Society of Critical Care Medicine, its officers, volunteers, or members, or that of the podcast commercial supporter.