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.

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)

Sunday November 22, 2009
Acute organophosphate toxicity !

Normally, acetylcholinesterase catalyzes the degradation of the neurotransmitter acetylcholine in the synapse (yellow panel below). Organophosphate pesticides phosphorylate acetylcholine, thereby reducing the ability of the enzyme to break down the neurotransmitter (red panel below). This produces an accumulation of acetylcholine in the central and peripheral nervous systems, resulting in an acute cholinergic syndrome via continuous neurotransmission - called M-U-D-D-L-E-S:

• miosis,
• urination,
• diarrhea,
• diaphoresis,
• lacrimation,
• excitation of the central nervous system, and
• salivation

Saturday November 21, 2009
Lets have some music in CCU !

Background: Most percutaneous coronary interventions are performed through the femoral artery. In order to stop bleeding and achieve homeostasis, a C-clamp is used after percutaneous coronary interventions. However, the experience is painful for patients and they inevitably suffer discomfort. Pain may lead to stress responses and may affect the physical and mental health of patients. One potential beneficial practice is having the patient listen to relaxing music, which might have the effect of reducing situational discomfort and pain.

Methods: A randomized controlled study was conducted during the period September 2004 to March 2005. Forty-three people (20 experimental and 23 control) were recruited from the intensive care units of two acute care hospitals in Hong Kong. Physiological and psychological variables were collected at baseline and at 15, 30 and 45 minutes.


Results:

• In the music group, there were statistically significant reductions (P = 0·001) in heart rate, respiratory rate, and oxygen saturation than the control participants at 45 minutes.
  
• In the music group, statistically significant reductions (P = 0·001) in systolic blood pressure, heart rate, respiratory rate and oxygen saturation were found at the four time points, but not in the control group.
  
• No statistically significant differences were found at baseline comparison of the two groups, but statistically significant differences in pain scores were found at 45 minutes for participants in the music group compared with the control group (P = 0·003).
  
• Participants in the control group showed statistically significant increases in pain at 45 minutes compared with baseline (P less than 0·001).
  

Conclusions: The benefits of preventing physiological reactions to pain were demonstrated. Music is a simple, safe and effective method of reducing potentially harmful physiological and psychological responses arising from pain.



Effects of music on patients undergoing a C-clamp procedure after percutaneous coronary interventions: Journal of Advanced Nursing: Volume 53 Issue 6, Pages 669 - 679 - Published Online: 8 Mar 2006

Friday November 20, 2009
CASCADE: Aspirin alone as effective as aspirin plus clopidogrel in preventing vein graft disease post-CABG


Aspirin alone is as effective as aspirin and clopidogrel in preventing vein graft disease after CABG, results of the CASCADE trial demonstrated, suggesting that the use of dual antiplatelet therapy is not supported in this population.

CASCADE researchers randomly assigned 113 patients undergoing primary multivessel CABG with at least two saphenous vein grafts to either 162 mg aspirin daily and 75 mg clopidogrel daily (n=56) or 162 mg aspirin daily and placebo (n=57). Primary outcome was vein graft intimal hyperplasia, with intimal area measured by IVUS. The study was powered for 20% clinically-relevant reduction with clopidogrel.

At one year, patency did not differ between the groups; overall patency was 95.2% in the treatment group and 95.5% in the placebo group (P=1.00).

Freedom from individual major adverse cardiac events – stroke, death and MI – and a composite of all three was similar in both groups (P=.76), as was major and minor bleeding (P=.02).


Source:

Kulik A. Presented at: American Heart Association Scientific Sessions 2009; Nov. 14-18, 2009; Orlando, Fla - http://www.theheart.org/article/1024575.do

Thursday November 19, 2009

Q: Serum alkalinization with intravenous sodium bicarbonate has been the mainstay of therapy in (CA) cyclic antidepressants (amitriptyline, desipramine, imipramine, nortriptyline, doxepin, clomipramine, and protriptyline) overdose. What is the cutoff limit of QRS complex for use of intravenous sodium bicarbonate therapy?

Answer: A QRS of 100 milliseconds or greater is generally use as the cut off for intravenous sodium bicarbonate. Beside alkalinization, sodium loading may be the most important factor in the reversal of the symptoms of cyclic antidepressant toxicity. IV normal saline are indicated for CA-induced hypotension.

Wednesday November 18, 2009


Q: Which patient is more hypoxemic?

Patient A: PaO2 85 mm Hg, SaO2 95%, Hb 7 gm%
Patient B: PaO2 55 mm Hg, SaO2 85%, Hb 15 gm%


Answer:

Calculate arterial oxygen content (CaO2) (SaO2 x Hb x 1.34) assuming PaO2 is constant

Patient A
CaO2 = .95 x 7 x 1.34 = 8.9 ml O2/dl

Patient B
CaO2 = .85 x 15 x 1.34 = 17.1 ml O2/dl

Patient A, with the higher PaO2, is more hypoxemic.


Full formula: Ca02 = (Hgb)(1.34)(Sa02) + (0.0031)(Pa02)

Tuesday November 17, 2009

Q: What is the biggest danger while evaluating CXR with subcutaneous emphysema?

Answer: Missing underlying pneumothorax

The air may interdigitate with the muscle bundles to produce a characteristic linear streaky pattern, especially in the pectoralis muscles over the chest. When the streaky linear densities become widespread over the anterior and posterior chest walls, subcutaneous emphysema can obscure underlying pleural white line of a pneumothorax.

Monday November 16, 2009

Q: What is the salvage treatment for severe pruritis in cirrhotic patient if all coventional and non-conventional treatment fails?

Answer: Plasmapheresis



References:

1. Plasmapheresis in the treatment of cholestasis-induced pruritus Ugeskr Laeger. 2006 Feb 20;168(8):779-81.

2. Role of plasmapheresis in the treatment of severe pruritus in pregnant patients with primary biliary cirrhosis: case reports - Can J Gastroenterol. 2008 May;22(5):505-7.

3. Plasmapheresis for the treatment of intrahepatic cholestasis of pregnancy refractory to medical treatment - American Journal of Obstetrics and Gynecology, Volume 192, Issue 6, Pages 2088-2089

Sunday November 15, 2009


Short but interesting video of
Alveolar recruitment with PEEP

Saturday November 14, 2009
How Wound V.A.C. Therapy System works

The V.A.C. Therapy System is comprised of three essential components that actively work together to help induce cellular wound healing through promotion of granulation tissue formation.

1. V.A.C. Therapy Unit Provides intermittent and continuous therapy with integrated patient safety features
2. SensaT.R.A.C.™ Technology Regulates pressure at the wound site to provide accurate delivery of prescribed therapy settings
3. V.A.C. GranuFoam™ Dressings Help induce the necessary mechanisms to promote granulation tissue formation

How V.A.C. Therapy Works on the Cellular Level

Under negative pressure, V.A.C. Therapy with V.A.C. GranuFoam Dressings applies both mechanical and biological forces to the wound to create an environment that promotes wound healing. These forces are known as macrostrain and microstrain.

Macrostrain is the visible stretch that occurs when negative pressure contracts the foam. Macrostrain

• Draws wound edges together
• Provides direct and complete wound bed contact
• Evenly distributes negative pressure
• Removes exudate and infectious materials

Microstrain is the microdeformation at the cellular level, which leads to cell stretch. Microstrain:

• Reduces edema
• Promotes perfusion
• Increases cellular proliferation and migration
• Promotes granulation tissue formation
  

Friday November 13, 2009
Central line complication

A 40-year-old man with Crohn's disease underwent an uncomplicated operation involving lysis of adhesions that were causing intestinal obstruction. After surgery, a cardiologist inserted a central venous catheter through the left subclavian vein. No problems with catheterization were noted. Three weeks later, after discharge, mild pain and edema developed in the patient's right lower leg. He was treated with antibiotics for 1 week, and his symptoms diminished. Six months after the operation, the patient presented with posterior cervical pain. A guide wire, presumably lost during the insertion of the central venous catheter, was protruding from the back of his neck (Panel A, arrow). A computed tomographic scan showed the fractured guide wire in the central venous system (Panel B, arrows). The wire protruding from the back of the neck was removed easily; however, it was difficult to remove the part of the wire involving the saphenous vein, and an open procedure with general anesthesia was required. The involved leg vein was thrombosed and occluded. At 1 year of follow-up, the patient was free of symptoms and signs.

Source:

Guo H, Lee JD, Guo M. Guidewire loss: mishap or blunder? Heart 2006;92:602-602

Thursday November 12, 2009


Q: What percentage of patients may experience neurotoxicity from Amiodarone?

Answer: About 3%

Neurologic problems from Amiodarone use include tremor, gait ataxia, peripheral neuropathy, and cognitive impairment. The primary risk factor for amiodarone neurotoxic effects was duration of treatment, not age, drug dose, sex, or indication for therapy. Where this could be assessed, the adverse effects were usually but not always reversible.

Higher estimates of neurotoxic effects in the early amiodarone era may be related to a much higher daily dose.

Reference: click to get abstract

Frequency, Characteristics, and Risk Factors for Amiodarone Neurotoxicity - Arch Neurol. 2009;66(7):865-869

Wednesday November 11, 2009
Sotalol and electrolytes

Calcium: Taking sotalol with a calcium dramatically reduces the absorption of the drug. Consequently, people who take a calcium supplement should take sotalol an hour before or two hours after the calcium.

Magnesium: Sotalol has a side effect of torsades de pointes. This side effect can be prevented by supplemental magnesium.

Potassium: Sotalol with hypokalemia have an increased risk of developing a serious heart arrhythmia. Therefore, special care should be taken when sotalol is prescribed with potassium-depleting diuretics.

Tuesday November 10, 2009
Management of Renal Failure in End Stage Liver Disease

(Total time 44:21)

Monday November 9, 2009

Q: What is the mechanism of action of B-blockers in reducing portal hypertension which ultimately help in reducing variceal bleeding?

Answer: Nonselective beta-blockers like propranolol and nadolol, reduce portal pressure through both local and systemic effects by 9% to 31%.

Local: In the splanchnic circulation, blockade of the vasodilating beta2 adrenoreceptors results in unrestricted alpha-adrenergic activity, splanchnic arteriolar vasoconstriction, and decreased portal inflow.

Systemic: Blockade of the cardiac beta1 receptors decreases the heart rate and cardiac output and secondarily decreases portal inflow.