Monday November 30, 2009
Bedside trick - Placing large bore IV in patients with suboptimal veins.

Firstly, a small-bore (20- to 24-gauge) hand or wrist IV started after applying a continuous-pressure tourniquet to the upper extremity. Without deflating the tourniquet, through the new IV, a crystalloid solution is given (50-60 mls), to distend all veins of the upper extremity. Now you can place a large bore catheter into the vein that wasn’t even there five minutes ago.

Sunday November 29, 2009
CBC in Adrenal Crisis


Q: Chemistry of Adrenal Crisis is marked by hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia. What finding on CBC is highly suggestive of Adrenal crisis along with said chemistry?

Answer: Anemia, lymphocytosis, and eosinophilia in CBC along with hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia in chemistry are highly suggestive of Adrenal Crisis.

Friday November 27, 2009
ST elevation MI diagnosed in the setting of a paced rhythm

Thursday November 26, 2009


Q: What is catamenial hemoptysis?

Answer: Hemoptysis that is recurrent and coincident with menses.

The cause is intrathoracic endometriosis, usually involving the pulmonary parenchyma but occasionally affecting the airways.

Previous Related Pearl: Catamenial pneumothorax

Wednesday November 25, 2009
Initiation of Inappropriate Antibiotics - Fivefold Reduction of Survival in Septic Shock

Objective: Our goal was to determine the impact of the initiation of inappropriate antimicrobial therapy on survival to hospital discharge of patients with septic shock.

Methods: The appropriateness of initial antimicrobial therapy, the clinical infection site, and relevant pathogens were retrospectively determined for 5,715 patients with septic shock in three countries.

Results: Therapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall, the survival rate was 43.7%.

• There were marked differences in the distribution of comorbidities, clinical infections, and pathogens in patients who received appropriate and inappropriate initial antimicrobial therapy.
• The survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively.
• Similar differences in survival were seen in all major epidemiologic, clinical, and organism subgroups.
• The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia.
• After adjustment for acute physiology and chronic health evaluation II score, comorbidities, hospital site, and other potential risk factors, the inappropriateness of initial antimicrobial therapy remained most highly associated with risk of death

Conclusions: Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a fivefold reduction in survival. Efforts to increase the frequency of the appropriateness of initial antimicrobial therapy must be central to efforts to reduce the mortality of patients with septic shock.



Reference: Click to get abstract

Initiation of Inappropriate Antimicrobial Therapy Results in a Fivefold Reduction of Survival in Human Septic Shock - CHEST November 2009 vol. 136 no. 5 1237-1248

Tuesday November 24, 2009
Classic vs Delayed TRALI syndrome

Characteristics of the “classic TRALI syndrome” are:

• time of onset within 2 hours (usually up to 6 hours);
• rapid development;
• no other risk factors for ALI except transfusion;
• anti-neutrophil antibodies pathophysiology and
• onset after a single unit of blood product.

Characteristics of the “delayed TRALI syndrome” are:

• time of onset 6-72 hours after transfusion;
• slow development of clinical presentation;
• patients have other risk factors for ALI (i.e. sepsis, aspiration, near-drowning, disseminated intravascular coagulation, trauma, pneumonia, drug overdose, fracture, burns and cardiopulmonary bypass);
• two- step pathophysiology and
• common after massive transfusion (40-57%)
  

Monday November 23, 2009
Bedside trick!

Scenario: You are inserting an emergent femoral central line in a severely vasculopath patient with exhausted upper vessels. Patient has previous history of IVC filter placement. What would be your worry?



Answer: Dislodgment of Inferior Vena Caval Filter.

Many cases have been reported in literature where IVC filters get dislodged by guidewires during the insertion of central venous catheters. 3 precautions/tricks can prevent this complication

• Limiting the distance that a guidewire is inserted into a vein during central line insertion.
• Inserting the straight end of the guidewire would also be effective.
• Inserting a smaller length central venous catheter (16 cm) instead of full 20 cm length central venous catheter.

Guidewire Dislodgment of Inferior Vena Cava Filters During Insertion of Central Venous Catheters - Vascular and Endovascular Surgery, Vol. 31, No. 5, 587-593 (1997)