tag:blogger.com,1999:blog-36117336742407180292024-02-20T17:19:36.026-08:00icuroom.net November 2007 ArchiveUnknownnoreply@blogger.comBlogger30125tag:blogger.com,1999:blog-3611733674240718029.post-40810513359206834212007-11-30T09:14:00.000-08:002007-12-02T10:09:49.404-08:00<span style="color:#000000;"><span style="color:#000066;">Friday November 30, 2007<br /></span><br /><br /><span style="color:#660000;"><strong>Q:</strong></span> </span><span style="color:#003333;"><strong><em>What is the maximum length of guide-wire to be advanced to avoid guide-wire lost and embolism during subclavian or internal jugular venous catheterization?</em></strong></span><br /><span style="color:#000000;"></span><br /><span style="color:#000000;"><span style="color:#660000;">A:</span> </span><span style="color:#000000;">About 18 cm (may be little less in right IJ)Beside not to loose control of guide-wire, it is appropriate to know the markings on guidewire of CVC kit used in your unit / hospital. Patient height is less reliable in predicting a safe wire length. 18 cm should be considered the upper limit of guidewire introduced during central catheter placement in adults</span> <span style="font-size:78%;">1.</span><br /><br /><span style="color:#003333;">Related Previous Pearl:</span> <a href="http://icuroom-pearls.blogspot.com/2006/01/sunday-january-8-2006-peres-nomogram.html" target="_blank"><span style="color:#660000;">Peres Nomogram to calculate appropriate length of central line depth</span></a><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference: click to get abstract</span><br /><span style="font-size:78%;color:#003333;"></span><br /><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200001000-00023.htm;jsessionid=FyfC1Vb6Czh30V048snkGy4wjQDwRbBJCvCN1kKngZqBpp6hHS13!990059801!-949856144!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement</span></a><span style="font-size:78%;color:#003333;"> - Critical Care Medicine. 28(1):138-142, January 2000.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-75082844641417110482007-11-29T19:34:00.000-08:002007-12-02T10:10:33.947-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday November 29, 2007<br /></span></span><span style="color:#660000;">Calcium in Dig toxicity</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><span style="color:#000000;"><span style="color:#330000;">Case:</span> </span><span style="color:#003333;"><em>74 year old male has been found to have arrhythmia with runs of wide complex ventricular tachycardia. Patient so far remained hemodynamically stable. You request crash cart near bed, applied pads to chest and send STAT labs and start reviewing patient's chart. You noticed 4 days ago digoxin level was 1.9 and since then his serum creatinine is steadily rising from 1.6 to 2.8. You suspected "Dig. toxicity" and called lab to run STAT dig. level. Indeed Dig. level is back with 3.4 and accompanying labs showed K+ level of 6.9. You ordered "Digi-bind" (Digoxin Immune Fab). Pharmacy informed you, "it will take time before Digi-bind gets to ICU". Interim you started treating hyperkalemia with IV insulin, D-50, IV bicarb., IV calcium and albuterol neb. treatments. Where did you go wrong ?</em></span></strong><br /><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><span style="color:#000000;"><span style="color:#330000;">Answer:</span> </span><span style="color:#000000;">Calcium has shown to make digoxin toxicity worse. It may be more wise to avoid calcium in management of hyperkalemia from digoxin toxicity. Some literature has shown the similar membrane stabalizing effect from magnesium and may be used instead of calcium.</span></strong><br /><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><span style="color:#000000;">Caution should be taken not to go very aggressive in treating hyperkalemia, or atleast potassium should be followed very closely if DigiFab is planned. With administration of DigiFab (Digibind), potassium shifts back into the cell and life threatening hypokalemia may develop rapidly. Digoxin causes a shift of potassium from inside to outside of the cell and may cause severe hyperkalemia but overall there is a whole body deficit of potassium. With administration of Digi-bind, actual hypokalemia may manifest which could be equally life threatening.</span></strong><br /><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><span style="color:#003300;">Read related interesting review: </span></strong><a href="http://emj.bmj.com/cgi/content/abstract/19/1/74" target="_blank"><strong><span style="color:#330000;">Recognising signs of danger: ECG changes resulting from an abnormal serum potassium concentration</span></strong></a><span style="color:#000000;"><strong><span style="color:#330000;">:</span></strong> A Webster, W Brady and F Morris (reference: Emerg Med J 2002; 19:74-77)</span><br /><br /><br /><br /><br /><br /><br /><br /><span style="color:#003333;">References: click to get abstract/article</span><br /><br /><br /><span style="color:#003333;">1. </span><a href="http://emj.bmj.com/cgi/content/extract/19/2/183" target="_blank"><span style="color:#003333;">Calcium for hyperkalaemia in digoxin toxicity</span></a><span style="color:#003333;"> - Emerg Med J 2002; 19:183<br />2. </span><a href="http://ndt.oxfordjournals.org/cgi/content/full/19/5/1333-a" target="_blank"><span style="color:#003333;">Using calcium salts for hyperkalaemia</span></a><span style="color:#003333;"> - Nephrol Dial Transplant (2004) 19: 1333-1334<br />3. Slow-release potassium overdose: Is there a role for magnesium? Emergency Medicine 1999;11:263–71</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-48721312633846414182007-11-28T10:41:00.000-08:002007-11-28T10:42:40.188-08:00<strong><span style="color:#000066;">Wednesday November 28, 2007<br /></span><br /></strong><br /><strong></strong><br /><strong><span style="color:#990000;"> Q;</span> <em><span style="color:#003333;">Which poisoning presents with garlic odor?</span></em></strong><br /><strong><br /><span style="color:#660000;">A:</span> <span style="color:#000000;">Organophosphate poisoning</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-38462859177985244112007-11-27T08:23:00.000-08:002007-11-27T08:26:07.880-08:00<strong><span style="color:#000066;">Tuesday November 27, 2007</span></strong><br /><strong><span style="color:#990000;">Revisiting Pulmonary Artery Diastolic-Pulmonary Wedge Pressure Gradient</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">We don't see floatation of pulmonary artery catheter (PAC) as much as we used to see. Lets revisit one important but forgotten value obtained via PAC.</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;"></span></strong><br /><div align="center"><strong><span style="color:#003333;">PADP - PAOP</span></strong></div><div align="center"><strong><span style="color:#003333;">(Pulmonary Artery Diastolic-Pulmonary Wedge Pressure Gradient).</span></strong></div><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>Most of the literature in regards to this value is 15-30 years old but proven to be very easy to calculate but very vital to follow</strong> 1, 3.</span><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>Once this gradient starts to exceeds by 6 mm Hg or more, the patient has shown to have a much poorer prognosis particularly in septic patients. Probable explanation is pulmonary venous vasoconstriction induced by endotoxemia in sepsis or postcapillary lekocyte aggregation in development of ARDS</strong> <span style="font-size:78%;">2, 4.</span></span><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">One study suggests that although an initial PAD-PWP gradient in patients with sepsis is associated with a high mortality, a much more sensitive indicator is to follow the trend. There was a 91% mortality in patients with persisting or increasing gradients</span></strong> 2.<br /><br /><br /><span style="color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">References: click to get abstract/artice</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=648208&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Pulmonary hypertension in sepsis: Measurement by the pulmonary arterial Diastolic-pulmonary wedge pressure gradient and the influence of passive and active factors.</span></a><span style="font-size:78%;color:#003333;"> Chest 1978; 73:583-91</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7116887&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Significance of the pulmonary artery diastolic-pulmonary wedge pressure gradient in sepsis</span></a><span style="font-size:78%;color:#003333;">. Crit Care Med 1982; 10:658-61</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">3. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3395235&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Pulmonary artery diastolic and wedge pressure relationships in critically and injured patients</span></a><span style="font-size:78%;color:#003333;">. Arch Surg 1988; 123:933-6</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">4. </span><a href="http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200503000-00016.htm;jsessionid=Gx1Z0pN6vrLq5x2MfLSqkkdzn8M8B2y0jpmmJHptGzxFgnrL10Rh!-1693609116!-949856145!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Increased Pulmonary Venous Resistance Contributes to Increased Pulmonary Artery Diastolic-Pulmonary Wedge Pressure Gradient in Acute Respiratory Distress Syndrome</span></a><span style="font-size:78%;"><span style="color:#003333;"> - Anesthesiology: Volume 102(3) March 2005 pp 574-580</span> </span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-45452051168910460082007-11-26T08:42:00.000-08:002007-11-26T08:45:51.560-08:00<strong><span style="color:#000066;">Monday November 26, 2007</span></strong><br /><strong><span style="color:#990000;">Heparin Induced HyperKalemia</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Hyperkalemia from Heparin is a well know phenomenon and has been detected particularly on geriatric, renal insufficient and diabetic patients. Hyperkalemia can be anywhere from .3 to 1.7 mEq/Litre. It usually occurs around on day 3 with SQ heparin (as for DVT prophylaxis) but can occur early with IV heparin <span style="font-size:78%;">1,2,3,4.</span> Hyperkalemia has been reported with low- molecular weight heparins too but risk is low<span style="font-size:78%;"> 5, 6, 7</span>.Mechanism of action: Heparin induce hypoaldosteronism and can subsequently lead to hyperkalemia <span style="font-size:78%;">6.</span></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Treatment: Best thing is to discontinue the culprit but if heparin is absolutely required, fludrocortisone (.1 mg/day) has been reported to be effective in heparin-induced hyperkalemia</span></strong> <span style="font-size:78%;">8.</span><br /><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get abstracts/articles</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://ats.ctsnetjournals.org/cgi/content/full/74/5/1698" target="_blank"><span style="font-size:78%;color:#003333;">Case report - Heparin-induced hyperkalemia after cardiac surgery</span></a><span style="font-size:78%;color:#003333;"> - Ann Thorac Surg 2002;74:1698-1700</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.theannals.com/cgi/content/abstract/24/3/244" target="_blank"><span style="font-size:78%;color:#003333;">Heparin-induced hyperkalemia</span></a><span style="font-size:78%;color:#003333;"> -The Annals of Pharmacotherapy: Vol. 24, No. 3, pp. 244-246.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">3. </span><a href="http://www.endocrine-abstracts.org/ea/0004/ea0004p26.htm" target="_blank"><span style="font-size:78%;color:#003333;">Heparin Induced HyperKalemia</span></a><span style="font-size:78%;color:#003333;"> - Endocrine Abstracts (2002) 4 P26</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">4. </span><a href="http://www.amjphysmedrehab.com/pt/re/ajpmr/abstract.00002060-200001000-00019.htm;jsessionid=EeI2wAT53phP4F3U0EMxZzYELAgaICWOuTNGLK1o3hzIEPFmWCha!-839643570!-949856144!9001!-1" target="_blank"><span style="font-size:78%;color:#003333;">Heparin-Induced Hyperkalemia Confirmed by Drug Rechallenge</span></a><span style="font-size:78%;color:#003333;">. American Journal of Physical Medicine & Rehabilitation. 79(1):93-96, January/February 2000.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">5. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&list_uids=15133781&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Early onset of hyperkalemia in patients treated with low molecular weight heparin: a prospective study </span></a><span style="font-size:78%;color:#003333;">- Pharmacoepidemiol Drug Saf.2004 May;13(5):299-302.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">6. Effect of Low-Molecular-Weight Heparin on Potassium Homeostasis - Pathophysiology of Haemostasis and Thrombosis 2002;32:107-110</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">7. </span><a href="http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgg/vol2n2/heparin.xml" target="_blank"><span style="font-size:78%;color:#003333;">Low Molecular Weight Heparins Can Lead To Hyperkalaemia</span></a><span style="font-size:78%;color:#003333;"> The Internet Journal of Geriatrics and Gerontology . 2005. Volume 2 Number 2.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">8. </span><a href="http://www.theannals.com/cgi/content/abstract/34/5/606" target="_blank"><span style="font-size:78%;color:#003333;">Fludrocortisone for the treatment of heparin-induced hyperkalemia</span></a><span style="font-size:78%;color:#003333;"> - The Annals of Pharmacotherapy: Vol. 34, No. 5, pp. 606-610</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-79753012325606081892007-11-25T06:42:00.000-08:002007-11-26T08:46:45.399-08:00<div align="left"><strong><span style="color:#000066;">Sunday November 25, 2007<br /></span><span style="color:#990000;">What's the right length of endotracheal tube (ETT) for oral intubation?</span><br /><br /></strong><span style="color:#000000;"><strong>As a gold standard the only way to make sure that tip of ETT is atleast 2 cm away from carina (or at appropriate place) is via chest X-ray. But there are many bedside quick tricks/formulae described in literature. One such formula 1 which also found to have good clinical correlation, is<br /><br /><span style="color:#003333;"><em>ETT length (incisors to midpoint of trachea, cm) = patient's height (cm)/10+5</em></span><br /><br />Like, if patient's height is 170 cm, ETT should be taped at<br /><br />170/10 + 5 = 22 cm<br /><br /><br />Another trick is to have ETT's cuff palpable at sternal notch, a technique described about 40 years ago !</strong> 2 .<strong><br /><br /><br />Related previous pearl:</strong></span><a href="http://icuroom-pearls.blogspot.com/2006/02/moettwn.html"><span style="color:#000000;"> </span></a><br /><a href="http://icuroom-pearls.blogspot.com/2006/02/moettwn.html"><strong><span style="color:#660000;">Movement of endotracheal tube (ETT) with neck</span></strong></a><strong><span style="color:#660000;"><br /></span></strong><br /><br /><span style="font-size:78%;"><br />Reference:<br /><br />1. Anaesthesia Intensive Care 1992; 20:156;<br />2. Anesthesiology 1964; 25:169</span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-78636136674262657382007-11-24T06:52:00.000-08:002007-11-24T06:53:14.156-08:00<strong><span style="color:#000066;">Saturday November 24, 2007</span><br /><br /><br /><span style="color:#000000;">Q;</span><em><span style="color:#003333;"> Nurse call you with K+ level of 7.8 (lab confirmed - no hemolysis). You ordered 10 units of IV insulin with 2 ampules of D-50, 1 ampule of calcium gluconate and 2 ampules of sodium bicarbonate in series. RT was requested to give 2 nebulizer treatments of albuterol. The final order set is followed ultimately by PO Kayexalate/sorbitol.What is wrong in above orders for the management of hyperkalemia?</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A;</span> <span style="color:#000000;"> In the management of hyperkalemia, sodium bicarbonate should be given before calcium. Administrating bicarbonate after calcium will bind calcium and will render it ineffective. This is another reason, we don't prepare "bicarb drip" in LR (Lactated Ringer’s) as it contains calcium which will bind bicarbonate and will make the whole management ineffective </span>.</strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-27951569472920597702007-11-24T06:40:00.000-08:002007-11-24T06:42:56.435-08:00<strong><span style="color:#003333;">Friday November 23, 2007<br /></span></strong><br /><strong><span style="color:#000000;">Q; </span><span style="color:#003333;"><em>Which antibiotic may give false positive urine drug screen for opiates ?</em></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">A; Gatifloxacin (Tequin) and other fluoroquinolones.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Fluoroquinolones as a class are among compounds that have a propensity to cross-react with enzyme immunoassay urine drug screens for opiates. The exact mechanism is unknown.False-positive results could have negative effects on patient care so analysis with another assay method should be done to verify the urine drug screen.</span></strong><br /><br /><span style="color:#003333;"><em>Editors' note: Tequin has been taken off USA market last year but as mentioned in JAMA's article (reference # 2), 13 quinolones were tested and 11 of the 13 quinolones caused some opiate activity by at least 1 assay system. So be careful with all quinolones. Actually, JAMA report mentioned Levaquin as one of the top 3 !</em></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-49575832661371794362007-11-22T19:34:00.000-08:002007-11-21T19:36:20.407-08:00<strong><span style="color:#000066;">Thursday November 22, 2007<br /></span><span style="color:#990000;">Nasogastric tube syndrome</span></strong><a href="http://icuroom-pearls.blogspot.com/2006/03/cuff-leak-test.html" target="_blank"></a><br /><strong></strong><br /><strong><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">65 year old female admitted to ICU 9 days ago with small bowel obstruction. Pt. is now stable and actually is about to get transferred out of unit. Patient suddenly start complaining of choking sensation with two hands on neck. Monitor shows oxygen desaturation. Patient intubated emergently. No laryngeal or vocal edema seen on laryngoscope but vocal cord paralysis noted.</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A;</span> <em><span style="color:#003333;">Nasogastric tube syndrome :</span></em> <span style="color:#000000;">Nasogastric tube syndrome was described about 25 years ago by Sofferman and coll. It is a life-threatening complication of an indwelling (more than a week) nasogastric tube. The syndrome may present as complete vocal cord abductor paralysis. The syndrome is thought to result from perforation of the NG tube-induced esophageal ulcer and infection of the posterior cricoid region (postcricoid chondritis) with subsequent dysfunction of vocal cord abduction. Unilateral paralysis of cord is also described. Treatment is protection of airway, removal of NG tube and antibiotics. Some advocates antireflux therapy too. Another variant is described with no esophageal ulcer but possibly because of ischemia of the laryngeal abductor muscle secondary to physical compression of the postcricoid blood vessels by NG tube.</span></strong><br /><br /><span style="color:#003333;"><br /><span style="font-size:78%;">References: Please click to get abstract</span></span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11190859&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">The nasogastric tube syndrome: two case reports and review of the literature</span></a><span style="font-size:78%;color:#003333;">. Head Neck. 2001 Jan;23(1):59-63.<br />2. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16415551&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">A variant form of nasogastric tube syndrome.</span></a><span style="font-size:78%;color:#003333;"> Intern Med. 2005 Dec;44(12):1286-90.<br />3. </span><a href="http://content.karger.com/ProdukteDB/produkte.asp?Doi=68162" target="_blank"><span style="font-size:78%;color:#003333;">Case Report - Nasogastric Tube Syndrome: The Unilateral Variant</span></a><span style="font-size:78%;color:#003333;"> - Medical Principles and Practice Vol. 12, No. 1, 2003<br />4. Sofferman, R.A. and Hubbell, R.N., "Laryngeal Complications of Nasogastric Tubes," ANNALS OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, 90:465-468, 1981.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-73993581434377972262007-11-21T07:23:00.000-08:002007-11-21T07:25:15.392-08:00<strong><span style="color:#000000;">Wednesday November 21, 2007</span></strong><br /><strong><span style="color:#990000;">Difference between Lactate Ringer's and Normal Saline solutions</span></strong><br /><br /><strong>Lactated Ringer's Solution was invented about 125 years ago by a British physiologist Sydney Ringer. It is a different intravenous solution from normal saline.</strong><br /><strong></strong><br /><strong><span style="color:#003333;">Normal Saline</span> is the solution of 0.9% NaCl. It has a slightly higher degree of osmolality compared to blood. One litre of Normal Saline contains</strong><br /><strong></strong><br /><strong>154 mEq/L of Na+ and</strong><br /><strong>154 mEq/L of Cl−</strong><br /><strong></strong><br /><strong>One liter of <span style="color:#003333;">Lactated Ringer's</span> Solution contains:</strong><br /><strong></strong><br /><strong>130 mEq/L of Na+ but total cations of 137 mEq/L , so still is isotonic.</strong><br /><strong>109 mEq/L of Cl−28 mEq/L of lactate</strong><br /><strong>4 mEq/L of potassium</strong><br /><strong>3 mEq/L of calcium.</strong><br /><strong></strong><br /><strong>Lactate converts to bicarbonate in liver. </strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-21369474420580712142007-11-20T07:55:00.000-08:002007-11-20T07:56:48.447-08:00<strong><span style="color:#000066;">Tuesday November 20, 2007<br /></span><br /><br /><span style="color:#660000;">Q:</span> <span style="color:#003333;">Propofol causes deficiency of which essential element ?</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">A:</span> Zinc Though propofol cause greater urinary losses of zinc and lower serum zinc concentrations, the actual clinical implication is not established .</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Related previous Pearl: </span></strong><a href="http://icuroom-pearls.blogspot.com/2005/10/sunday-october-30-2005-back-to-basics.html" target="_blank"><strong><span style="color:#660000;">Essential trace elements</span></strong></a><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference:</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1.Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients - Intensive care medicine. Supplement (Intensive care med., Suppl.) , 2000, vol. 26, n 4, pp. S 413-S421</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-33368113573312983102007-11-19T06:02:00.000-08:002007-11-19T06:04:14.596-08:00<strong><span style="color:#000066;">Monday November 19, 2007<br /></span><span style="color:#990000;">Scleroderma Renal Crisis (SRC)</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">Scleroderma Renal Crisis is one of the few rheumatological emergency where early diagnosis and treatment can make big difference in outcome. Wrong diagnosis may lead to wrong management pathway and eventually to very high mortality.<br /><br />SRC is heralded with hypertensive crisis associated with acute renal failure but the pearl is to avoid IV Labetolol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. (yes! its a renal crisis but require ACE-I). calcium channel blockers may help. Renal dialysis is a last resort.<br /><br />Another important differential diagnosis is from SLE (renal). 5 It has been suggested that use of steroids is associated with onset of scleroderma renal crisis.<br /><br />See this precise review article on SRC </span></strong><a href="http://www.amb.edu.pl/roczniki/roczniki_2005_supl_1/volumes/75_Lewandowski_Domyslawska.pdf" target="_blank"><strong><span style="color:#660000;">here</span></strong></a><strong><span style="color:#000000;"> from Department of Rheumatology and Internal Diseases, Medical University in Białystok, Poland. (2005)<br /></span></strong><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get articles/abstract</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.medscape.com/viewarticle/507319" target="_blank"><span style="font-size:78%;color:#003333;">What Is Scleroderma Renal Crisis and How Is it Managed?</span></a><span style="font-size:78%;color:#003333;"> via </span><a href="http://www.medscape.com/" target="_self"><span style="font-size:78%;color:#003333;">medscape.com</span></a><span style="font-size:78%;color:#003333;"> with free registration</span><br /><span style="font-size:78%;color:#003333;"><br />2. </span><a class="l" href="http://aramis.stanford.edu/downloads/medsger.ar44.1663to1666.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Systemic Sclerosis With Renal Crisis and Pulmonary Hypertension</span></a><span style="font-size:78%;color:#003333;"> - stanford.edu</span><br /></span><span style="font-size:78%;color:#003333;"><br />3. </span><a href="http://www.annals.org/cgi/reprint/133/8/600.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Long-Term Outcomes of Scleroderma Renal Crisis</span></a><span style="font-size:78%;color:#003333;"> - 17 October 2000 Volume 133 Issue 8 Pages 600-603 - annals</span><br /></span><span style="font-size:78%;color:#003333;"><br />4. Scleroderma Renal Crisis: The Sword of Damocles. - JCR: J. of Clinical Rheum. 10(5):234-235, October 2004.<br /><br />5. </span><a class="l" onmousedown="return clk(this.href,'res','20','')" href="http://medicine.ucsf.edu/housestaff/Chiefs_cover_sheets/rheum_renal_dz.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Rheumatologic Renal Disease: SLE vs. Scleroderma</span></a><span style="font-size:78%;color:#003333;"> - ucsf.edu</span><br /></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-27285224404075508522007-11-18T09:42:00.000-08:002007-11-18T09:43:49.093-08:00<strong><span style="color:#000066;">Sunday November 18, 2007<br /></span><span style="color:#990000;">Clonidine in alcohol withdrawal</span></strong><br /><strong><br /><span style="color:#000000;">Relatively unknown but clonidine is a very viable option beside benzodiazepines in ETOH withdrawal symptoms.<br /><br />Clonidine reverses central adrenergic discharge, relieving tachycardia, hypertension, tachypnea, tremor, and possibly some craving for alcohol. Also in patch form, it provides a part of sedation.<br /><br />Oral dose of clonidine is 0.1- 0.2 mg tid. It can also be use in IV drip form but with caution (not available in USA as IV).<br /><br />Please note, though clonidine is very effective in the treatment of alcohol, opiate, nicotine withdrawal syndromes, attention-deficit/hyperactivity disorder (ADHD) and Tourette's syndrome -but does not help if symptoms progress to seizures and hallucinations-delirium tremens.<br /></span><br /><span style="color:#003333;"><br />2 major cautions for ICU physicians:<br /></span><br /><span style="color:#000000;">1. Clonidine itself can cause withdrawal symptoms if discontinued abruptly. It should be slowly decreased over several days to avoid withdrawal symptoms. Withdrawal can cause hypertension, irritability, nervousness, insomnia, and headache.<br />2. Clonidine dose should be reduced and should be use with caution in patients with chronic renal failure and coronary artery disease.</span><br /><br /><br /><br /><span style="color:#003333;">Trivia:</span> <em><span style="color:#000066;">Clonidine was first introduced in 1960s as a nasal decongestant.</span></em></strong><br /><br /><br /><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">Reference: Click to get abstract<br /><br />1. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&list_uids=3327372&cmd=Retrieve&indexed=google" target="_blank"><span style="font-size:78%;color:#003333;">Clonidine and alcohol withdrawal </span></a><span style="font-size:78%;color:#003333;">- Adv Alcohol Subst Abuse. 1987;7(1):17-28</span><br /><span style="font-size:78%;color:#003333;"><br />2. </span><a href="http://jama.ama-assn.org/cgi/content/abstract/278/2/144" target="_blank"><span style="font-size:78%;color:#003333;">Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal</span></a><span style="font-size:78%;color:#003333;"> - JAMA, Vol. 278 No. 2, July 9, 1997</span><br /></span><span style="font-size:78%;color:#003333;"><br />3. </span><a href="http://bja.oxfordjournals.org/cgi/content/abstract/68/1/106"><span style="font-size:78%;color:#003333;">CLONIDINE </span></a><a href="http://bja.oxfordjournals.org/cgi/content/abstract/68/1/106"><span style="font-size:78%;color:#003333;">IN THE TREATMENT OF ALCOHOL WITHDRAWAL IN THE INTENSIVE CARE UNIT</span></a><span style="font-size:78%;color:#003333;">- British Journal of Anaesthesia, 1992, Vol. 68, No. 1 106-108</span><br /></span><span style="font-size:78%;color:#003333;"><br />4. </span><a href="http://www.anesthesia-analgesia.org/cgi/content/abstract/98/3/738"><span style="font-size:78%;color:#003333;">Intrathecal and Oral Clonidine as Prophylaxis for Postoperative Alcohol withdrawal</span></a><a href="http://www.anesthesia-analgesia.org/cgi/content/abstract/98/3/738"><span style="font-size:78%;color:#003333;"> Syndrome: A Randomized Double-Blinded Study</span></a><span style="font-size:78%;color:#003333;"> - Anesth. Analg., March 1, 2004; 98(3): 738 - 744.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-63489442748418112302007-11-17T12:16:00.000-08:002007-11-17T12:18:06.174-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Saturday November 17, 2007</span></strong><br /></span><span style="color:#990000;"><strong>Hemodynamic monitoring video</strong></span><br /><span style="color:#000000;"><br /><strong></strong><br /><strong>Watch and keep in file this excellent presentation on Pulmonary Artery Catheter and Arterial waveforms. Total presentation is about 36 minutes. It has 3 modules<br /><br /><span style="color:#660000;">Module 1:</span> Interpretation Requirements, Central Venous Pressure, Right Ventricular Wave, Pulmonary Artery Wave, Wedge Pressures, PAOP Interpretation.<br /><br /><span style="color:#660000;">Module 2:</span> Effect of Respiratory Artifact, Abnormal Waveforms, Common Abnormal Waves, Avoiding Errors<br /><br /><span style="color:#660000;">Module 3:</span> Accurate Waveforms,Technical Requirements, Zeroing and Leveling, Arterial Line Accuracy, Using a Square Wave Test</strong></span><br /></span><br /><span style="color:#000000;"></span><br /><div align="center"><span style="color:#000000;"><strong>Click </strong></span><a href="http://www6.medical.philips.com/cmsmedia/hemo_1/hemo_1_files/default.htm" target="_blank"><strong><span style="color:#990000;">here</span></strong></a><span style="color:#000000;"><strong> to watch presentation</strong></span></div><br /><br /><span style="color:#000000;"><span style="color:#003333;">Presented by:</span> Tom Ahrens DNS RN CCRN CS Barnes-Jewish Hospital St. Louis, Mo<br /></span><br /><span style="font-size:78%;color:#000000;">To view this content you need Microsoft's newest version of Windows Media Player. Click the Windows Media Player 9 Series button to install, which you can download free </span><a href="http://www.microsoft.com/windows/windowsmedia/download/AllDownloads.aspx?displang=en&qstechnology=" target="_blank"><span style="font-size:78%;color:#000000;">here</span></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-77433195643107134712007-11-16T10:52:00.000-08:002007-11-16T10:56:39.337-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Friday November 16, 2007<br /></span></strong></span><strong><span style="color:#990000;">Intensivists do make difference</span></strong><br /><strong></strong><br /><span style="color:#000000;"><span style="color:#000000;"><strong>Here is another study endorsing the positive effect of intensivists on ICU mortality. This study was performed to examine the association of closed vs open models with patient mortality with ALI (acute lung injury).<br /><br />Closed ICUs</strong> are defined as units that required patient transfer to or mandatory patient comanagement by an intensivist.<strong> Open ICUs </strong>as those relying on other organizational models.<br /><strong><br /><br />13 ICUs were designated closed and 11 open.<br /><br /><br /><span style="color:#660000;">Results:</span> </strong></span></span><br /><br /><ul><li><span style="color:#000000;"><span style="color:#000000;"><strong>Closed ICUs had reduced hospital mortality </strong>(adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). </span></span></li><span style="color:#000000;"><span style="color:#000000;"><li><strong>Consultation by a pulmonologist in open ICUs was not associated with improved mortality </strong>(adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62).<strong> </strong></li><li><strong>The use of low tidal volume in patients with ALI was different between closed and open ICUs. In open ICUs had triple the risk of receiving injurious (>12 ml/kg PBW) tidal volumes, whereas patients in closed ICUs were almost three times more likely to receive lung-protective tidal volumes (6.5 ml/kg PBW) on Day 3 of mechanical ventilation after ALI onset. </strong></li></ul></span></span><br /><strong><span style="color:#660000;">Conclusions:</span> Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.</strong><strong> </strong><br /><strong></strong><strong><br /></strong><br /><br /></span><span style="font-size:78%;color:#003333;">Reference: click to get abstract/article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://ajrccm.atsjournals.org/cgi/content/abstract/176/7/685" target="_blank"><span style="font-size:78%;color:#003333;">Effect of Intensive Care Unit Organizational Model and Structure on Outcomes in Patients with Acute Lung Injury</span></a><span style="font-size:78%;color:#003333;"> - American Journal of Respiratory and Critical Care Medicine Vol 176. pp. 685-690, (2007)</span><br /></span></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-19845523035685331882007-11-15T08:04:00.000-08:002007-11-15T08:05:42.373-08:00<strong><span style="color:#000066;">Thursday November 15, 2007<br /></span> <span style="color:#990000;">Sympathetic Storming</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">Sympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units. It occurs due to uncontrolled sympathetic surge with a diminish or unmatch parasympathetic response. Acording to Baguley criteria 5 out of the 7 clinical features should be present - </span></strong><br /><strong><span style="color:#000000;"><ol><li>tachycardia, </li><li>tachypnea, </li><li>hyperthermia, </li><li>hypertension, </li><li>dystonia, </li><li>posturing and </li><li>diaphoresis</li></ol><p>Various agents have been used for treatment (see review article below) but haloperidol may worsen the symptoms.Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004. </p><p><em>See great review article </em></span></strong><a href="http://www.aann.org/ce/pdf/jnn02-04a.pdf" target="_blank"><strong><em><span style="color:#660000;">here</span></em></strong></a><strong><span style="color:#000000;"><em> on Sympathetic Storming from Denise M. Lemke, published in J Neurosci Nurs 36(1):4-9, 2004. © 2004</em></span></strong></p><strong><br /></strong><br /><span style="font-size:78%;color:#003333;">References: click to get abstract/article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://jnnp.bmjjournals.com/cgi/content/full/67/1/39" target="_blank"><span style="font-size:78%;color:#003333;">Dysautonomia after traumatic brain injury: a forgotten syndrome?</span></a><span style="font-size:78%;color:#003333;"> - J Neurol Neurosurg Psychiatry 1999;67:39-43 ( July )<br />2. </span><a href="http://archneur.ama-assn.org/cgi/content/extract/61/10/1625"><span style="font-size:78%;color:#003333;">Pa</span></a><a href="http://archneur.ama-assn.org/cgi/content/extract/61/10/1625"><span style="font-size:78%;color:#003333;">roxysmal autonomic instability with dystonia (PAID)</span></a><span style="font-size:78%;color:#003333;"> - Arch Neurol. October 2004;61:1625.<br />3. </span><a href="http://archneur.ama-assn.org/cgi/content/abstract/61/3/321" target="_blank"><span style="font-size:78%;color:#003333;">Paroxysmal Autonomic Instability with Dystonia After Brain Injury</span></a><span style="font-size:78%;color:#003333;"> - Arch. Neurol. March 2004;61:321-328</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-89802215559216693052007-11-14T17:59:00.000-08:002007-11-14T18:00:58.415-08:00<strong><span style="color:#000066;">Wednesday November 14, 2007<br /></span><span style="color:#990000;">Venous Air Embolism - VAE - immediate maneuvers</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">If Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 steps are essential:</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">1. Clamp the line (do not withdraw) - to prevent further air.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">3. Place patient in Trendelenburg position - to help air trap in the apex of the ventricle.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.</span></strong><br /><br /><br /><br /><span style="font-size:78%;color:#003333;">Refrences: Click to get abstract/article.</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.emedicine.com/emerg/topic787.htm" target="_blank"><span style="font-size:78%;color:#003333;">Venous Air Embolism </span></a><span style="font-size:78%;color:#003333;">- emedicine.com<br />2. </span><a href="http://content.nejm.org/cgi/content/extract/342/7/476"><span style="font-size:78%;color:#003333;">Gas Embolism</span></a><a href="http://content.nejm.org/cgi/content/extract/342/7/476"><span style="font-size:78%;color:#003333;"> </span></a><span style="font-size:78%;color:#003333;">- NEJM, feb. 2000, Volume 342:476-482<br />3. Venous air embolism: a review. J Clin Anesth 1997;9:251-257</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-89572687266244390972007-11-13T07:20:00.000-08:002007-11-13T14:34:28.098-08:00<strong><span style="color:#000000;"><span style="color:#000000;">Tuesday November 13, 2007<br /></span></span><span style="color:#990000;">Propofol and colorful urine (and hair !)</span></strong><span style="color:#990000;"><br /></span><br /><br /><strong><span style="color:#000000;">Propofol infusion is noticed to turn color of urine usually <span style="color:#003333;">green</span>. There are also case reports describing other colors with propofol like <span style="color:#ff6666;">pink</span>, <span style="color:#333333;">white </span>and <span style="color:#330000;">brown </span>though green urine carries the trademark. Incidence is around 1% and usually associated with propofol infusion longer than 72 hours. It takes about 2-6 hours for urine to resume its natural color after stopping propofol. It is associated with respiratory alkalosis as respiratory alkalosis increases the formation of metabolites responsible for green color.<br /><br />There is atleast one case report in literature where discoloration of hair secondary to propofol is reported <span style="font-size:78%;">1.</span><br /><br />It is a benign potential side effect of Propofol and does not require any intervention. Recognition of this side effect is important as it averts unnecessary further workup and limits medical expenditures.</span></strong><br /><br /><br /><br /><span style="font-size:78%;color:#003333;">References: </span><br /><span style="font-size:78%;color:#003333;"><br />1. Propofol and the color green . Anaesthesia 1989;44(1):82.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-37178408980849034832007-11-12T13:32:00.000-08:002007-11-12T13:34:03.167-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Monday November 12, 2007</span><br /><br /><br /><span style="color:#660000;">Scenario;</span> </strong><strong><em><span style="color:#000066;"><span style="color:#003333;">62 year old male with long history of atrial fibrillation and chronically on Digoxin admitted with dizzyness and found to have 3rd degree AV block. Patient is hemodynamically stable. Patient informed you that about a year ago, he had similar episode and was found to have high digoxin level and was treated with "antidote of digoxin". Later his digoxin dose was decreased by his cardiologist. You assume "Dig toxicity" and indeed Dig. level reported as 3.4 micrograms/ml. You ordered "Digibind". What step you should take in view of history of previously received "digibind" ?</span><br /></span></em><br /><br /><br /><span style="color:#660000;">Answer:</span> </strong></span><span style="color:#000000;"><strong>Skin allergy test for digoxin immune Fab.<br /><br />Since allergy testing can delay urgently needed therapy, it is not absolutely required before treatment of life-threatening digitalis toxicity with digoxin immune Fab (ovine), but should be considered if situation permits, particularly with previous history.<br /><br />Skin testing should be considered for high risk individuals with history of multiple allergies, patients who previously treated with digoxin immune Fab. and patients with allergy to papaya extracts.</strong> Papain is used to cleave the whole antibody into Fab and Fc fragments, and traces of papain or inactivated papain residues may be present in digoxin immune Fab (ovine).<br /><strong><br />One should consider the possibility of anaphylactic, hypersensitivity or febrile reactions to digoxin immune Fab (ovine), even with first dose. </strong></span><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong><span style="color:#000066;">How to perform:</span> Diluting 0.1 mL of reconstituted Digibind (9.5 mg/mL) in 9.9 mL sterile isotonic saline (1:100 dilution, 95 µg/mL). Injecting 0.1 mL of the 1:100 dilution (9.5 µg) intradermally and observing for an urticarial wheal surrounded by a zone of erythema. The test should be read at 20 minutes. </strong></span><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong>If skin testing causes a systemic reaction, a tourniquet should be applied above the site of testing. In case of full blown anaphylactic, hypersensitivity or febrile reactions to digoxin immune Fab (ovine) on test dose or infusion, the drug infusion should be discontinued and appropriate therapy initiated using oxygen, volume expansion, diphenhydramine, corticosteroids and airway management as indicated. Epinephrine should be use very cautiously and only if needed due to higher risk of arrthymias in the setting of digitalis toxicity.</strong></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-71211132516005387182007-11-11T20:13:00.000-08:002007-11-10T20:17:50.494-08:00<div align="left"><strong><span style="color:#000066;">Sunday November 11, 2007</span><br /><span style="color:#990000;">amurthy.com<br /></span><br /><span style="color:#000000;">On sundays, we try to provide links to other Critical Care related endeavours on internet. In this regard, following site provides good synopsis on different topics and could be a quick source for residents' handout.</span></strong></div><strong><span style="color:#000000;"><div align="center"><br /></span><br /><br /></strong><span style="color:#660000;"></span><a href="http://amurthy.com/contents.html" target="_blank"><strong><span style="color:#660000;">amurthy.com</span></strong></a><br /><strong><br /></strong></div><strong><div align="left"><br /><span style="color:#000000;">Recommended reads include</span></div><ul><li><div align="left"><span style="color:#000000;">Heparin induced thrombocytopenia</span></div></li><li><div align="left"><span style="color:#000000;">ICU Blood Glucose Protocol</span></div></li><li><div align="left"><span style="color:#000000;">Toxicology Overview</span></div></li><li><div align="left"><span style="color:#000000;">Myasthenia gravis</span></div></li><li><div align="left"><span style="color:#000000;">Intensivist burnout</span></div></li><li><div align="left"><span style="color:#000000;">ICU management of organ donor </span></div></li><li><div align="left"><span style="color:#000000;">Burn critical care</span></strong> </div></li></ul>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-20038799704255787002007-11-10T20:30:00.000-08:002007-11-09T20:32:02.696-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Saturday November 10, 2007</span><br /><span style="color:#990000;">7 Pearls of Vitamin K (phytonadione)</span><br /><br /><br />1. Oral Vitamin K has similar efficacy as intravenous Vitamin K. </strong>1<strong><br /><br />2. SQ (subcutaneous) Vitamin K absorption is unreliable.</strong>2<br /><strong><br />3. IM (intramuscular) Vitamin K may promote intramuscular hemorrhage.<br /><br />4. IV (intravenous) Vitamin K is effective in 6 - 8 hours.<br /><br />5. IV Vitamin K should be given very slow (preferably .5 mg/min).<br /><br />6. IV Vitamin K may cause facial flushing, diaphoresis, chest pain, hypotension, dyspnea, anaphylaxis and cerebral thrombosis but pretreatment with antihistamines or corticosteroids is not routinely recommended.</strong> 7<br /><strong><br />7. Although IV Vitamin K has been decribed safe in few studies</strong><span style="font-size:85%;"> 3,7</span><strong>, it should be use only in life threatening bleeds from warfarin overdose or due to deficiency of vitamin K as fatality from anaphylactoid reaction could be high</strong> 4,5<strong>.<br /></strong></span><br /><br /><span style="font-size:78%;color:#003333;">References: Click here to see abstract/article:</span><br /><span style="font-size:78%;"><br /><span style="color:#003333;">1. </span></span><a href="http://archinte.ama-assn.org/cgi/content/abstract/163/20/2469" target="_blank"><span style="font-size:78%;color:#003333;">Comparison of Oral vs Intravenous Phytonadione (Vitamin K) in Patients With Excessive Anticoagulation</span></a><span style="font-size:78%;color:#003333;"> - Arch Intern Med. 2003;163:2469-2473. - full article available with free registration.<br />2. </span><a href="http://www.annals.org/cgi/reprint/137/4/251.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Oral Vitamin K Lowers the International Normalized Ratio More Rapidly Than Subcutaneous Vitamin K in the Treatment of Warfarin-Associated Coagulopathy</span></a><span style="font-size:78%;color:#003333;"> - Annals - 20 August 2002, Volume 137 Issue 4, Pages 251-254 -pdf file<br />3. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12046975&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">The safety of intravenously administered vitamin K</span></a><span style="font-size:78%;color:#003333;"> - via pubmed, Vet Hum Toxicol. 2002 Jun;44(3):174-6.<br />4. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11406734&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Anaphylactoid reactions to vitamin K</span></a><span style="font-size:78%;color:#003333;"> - via pumed, J Thromb Thrombolysis. 2001 Apr;11(2):175-83.<br />5. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12609647&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Anaphylaxis after low dose intravenous vitamin K </span></a><span style="font-size:78%;color:#003333;">- via pubmed, J Emerg Med. 2003 Feb;24(2):169-72<br />6. </span><a href="http://archinte.ama-assn.org/cgi/content/abstract/158/19/2136" target="_blank"><span style="font-size:78%;color:#003333;">Comparing Different Routes and Doses of Phytonadione for Reversing Excessive Anticoagulation</span></a><span style="font-size:78%;color:#003333;"> - Arch Intern Med. 1998;158:2136-2140.<br />7. </span><a href="http://www.ingentaconnect.com/content/acaai/aaai/2002/00000089/00000004/art00016" target="_blank"><span style="font-size:78%;color:#003333;">The incidence of anaphylaxis following intravenous phytonadione (vitamin K1): a 5-year retrospective review</span></a><span style="font-size:78%;color:#003333;"> - Annals of Allergy, Asthma and Immunology, Volume 89, Number 4, October 2002, pp. 400-406(7)</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-46287649527503524042007-11-09T07:29:00.000-08:002007-11-09T07:32:45.639-08:00<strong><span style="color:#000066;">Friday November 9, 2007</span><br /><span style="color:#990000;">Fall of Aprotinin !</span></strong><br /><strong><br /></strong><span style="color:#000000;"><strong>This week Bayer, maker of aprotinin, has announced that it has elected to temporarily suspend worldwide marketing of Trasylol® (aprotinin injection) until final results from the Canadian BART trial is available</strong> <span style="font-size:78%;">3</span><strong>. The BART study is an independent randomized, controlled trial being conducted in high-risk cardiac surgery patients</strong> <span style="font-size:78%;">4</span><strong>. On October 19, 2007, FDA was notified of the Data Safety Monitoring Board’s (DSMB) recommendation to stop patient enrollment in the aprotinin treatment group arm of the BART study. The preliminary findings suggest that, compared to the antifibrinolytic drugs, epsilon-aminocaproic acid and tranexamic acid, aprotinin increases the risk of death</strong> <span style="font-size:78%;">5.</span></span><br /><br /><span style="color:#000000;"><em>BART = Blood conservation using antifibrinolytics: A randomized trial in a cardiac surgery population</em> </span><br /><br /><strong><span style="color:#000000;">In last couple of years, use of aprotinin has been questioned following coronary artery bypass grafting, particularly in view of availability of safer and less expensive alternatives (aminocaproic acid and tranexamic acid) . Aprotinin, also known as bovine pancreatic trypsin inhibitor is a protein that is administered by injection to reduce bleeding during complex surgery. Its main effect is the slowing down of fibrinolysis .</span></strong><br /><span style="color:#000000;"></span><br /><span style="color:#000000;"><strong>One major article published in January 2006 in The New England Journal of Medicine concluded that the use of aprotinin was associated with a dose-dependent <em>doubling to tripling in the risk of renal failure</em> requiring dialysis among patients undergoing primary or complex coronary-artery surgery. Also, it was suggested that for the majority of patients undergoing primary surgery, evidence of <em>multiorgan damage</em> involving the heart (myocardial infarction or heart failure) and the brain (encephalopathy) in addition to the kidneys shows a <em>generalized pattern of ischemic injury</em></strong> <span style="font-size:78%;">1.</span></span><br /><span style="color:#000000;"></span><br /><span style="color:#000000;"><strong>Same group of investigators, published an article in February 2007 issue of JAMA, looking into mortality data of 3876 patients from 62 medical centers assessed at 6 weeks, 6 months, and annually for 5 years after CABG surgery</strong> <span style="font-size:78%;">2</span><strong>, comparing aminocaproic acid and tranexamic acid, aprotinin, or no antibleeding agent (control). Study found that Aprotinin treatment was associated with significantly <em>increased long term mortality</em> compared with control, whereas neither aminocaproic acid nor tranexamic acid was associated with increased mortality.</strong></span><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">FDA issued a relabeling of aprotinin on December 15, 2006, confining it to use only in high-risk coronary artery bypass graft patients.</span></strong> <br /><br /><br /><br /><span style="font-size:78%;color:#003333;">References / suggested readings: Click to get article/abstract</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://content.nejm.org/cgi/content/short/354/4/353" target="_blank"><span style="font-size:78%;color:#003333;">The Risk Associated with Aprotinin in Cardiac Surgery</span></a><span style="font-size:78%;color:#003333;"> - NEJM Jan. 26, 2006 Volume 354:353-365<br />2. </span><a href="http://jama.ama-assn.org/cgi/content/abstract/297/5/471" target="_blank"><span style="font-size:78%;color:#003333;">Mortality Associated With Aprotinin During 5 Years Following Coronary Artery Bypass Graft Surgery</span></a><span style="font-size:78%;color:#003333;"> - JAMA. 2007;297:471-479, Vol. 297 No. 5, February 7, 2007<br />3. </span><a href="http://www.trasylol.com/Trasylol_11_05_07.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Bayer Temporarily Suspends Global Trasylol® Marketing</span></a><span style="font-size:78%;color:#003333;"> - trasylol.com<br />4. </span><a href="http://www.cja-jca.org/cgi/content/full/53/suppl_1/26231" target="_blank"><span style="font-size:78%;color:#003333;">MAJOR OUTCOMES FOLLOWING HIGH RISK CARDIAC SURGERY </span></a><span style="font-size:78%;color:#003333;">Canadian Journal of Anesthesia 53:26231 (2006)<br />5. </span><a href="http://www.fda.gov/CDER/DRUG/advisory/aprotinin.htm" target="_blank"><span style="font-size:78%;color:#003333;">FDA Public Health Advisory</span></a><span style="font-size:78%;color:#003333;"> - fda.gov</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-9176775550483700412007-11-08T07:16:00.000-08:002007-11-08T07:18:31.104-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday November 8, 2007<br /></span></span><span style="color:#990000;">Suture at central venous catheter site - a risk ?</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>Interesting article published in Managing Infection Control, december 2002 issue by Dr. Bierman </strong><span style="font-size:78%;">1</span><strong> suggesting that sutures at central venous catheter site may also play part in CRBSI's (catheter related bloodstream infection). </strong></span><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>One study from Hospital of the University of Pennsylvania randomized 170 patients requiring PICCs, to suture (n = 85) or Sutureless Securement Device (n = 85). </strong>3 <strong>Beside other advantages, a significant difference noted in the number of systemic infections (10 suture vs. 2 Sutureless Securement Device group; P = .0032). And, the difference in confirmed CRBSIs was (8 suture vs 1 Sutureless Securement Device; P = .04).</strong></span><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>August 2002 Guidelines for Prevention of Intravascular Catheter-Related Infections from CDC (Center for Disease Control) acknowledged that “suture-free securement devices can be advantageous over suture in CRBSIs".</strong> 2</span><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Only commercially available Sutureless Securement Device in USA is </span></strong><a href="http://www.statlock.com/" target="_blank"><strong><span style="color:#000000;">Statlock</span></strong></a><span style="color:#000000;"><strong>. *<br /><br /></strong></span><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;">* (icuroom.net has no connection with company and name given here is only for information purpose).</span><br /><br /><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">References: click to get abstrat/article </span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.statlock.com/article_sutures2.html" target="_blank"><span style="font-size:78%;color:#003333;">Suture: An Unlikely Culprit in Infections and Accidental Needlesticks</span></a><span style="font-size:78%;color:#003333;"> - Managing Infection Control, dec. 2002<br />2. </span><a href="http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/preventionguidelines.pdf" target="_blank"><span style="font-size:78%;color:#003333;">Guidelines for the Prevention of Intravascular Catheter-Related Infections (MMWR 2002)</span></a><br /><span style="font-size:78%;color:#003333;">3. </span><a href="http://www.jvir.org/cgi/content/full/13/1/77" target="_blank"><span style="font-size:78%;color:#003333;">Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters</span></a><span style="font-size:78%;color:#003333;"> - Journal of Vascular and Interventional Radiology 13:77-81 (2002)<br />4. </span><a href="http://www.statlock.com/osha_jcaho_safety_standards.html" target="_blank"><span style="font-size:78%;color:#003333;">OSHA Fact Sheet: Securing Medical Catheters</span></a><span style="font-size:78%;color:#003333;"> - from STATLOCK site</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-55458012506820793152007-11-07T09:46:00.000-08:002007-11-09T07:35:27.216-08:00<strong><span style="color:#000066;">Wednesday November 7, 2007<br /></span><span style="color:#990000;">Argatroban anticoagulation in Critically Ill Patients</span></strong><br /><strong><br /><span style="color:#000000;">Since we are diagnosing more and more HIT (Heparin Induced Thrombocytopenia), Argatroban has entered into mainstream ICU care !</span><br /><br /><span style="color:#000000;">But care should be taken in prescribing Argatroban. See this important study published this year in The Annals of Pharmacotherapy regarding dosing of Argatroban for critically ill patients with multiple organ dysfunction (MODS) and suspected or proven heparin induced thrombocytopenia (HIT). </span><br /><br /><span style="color:#000000;"><span style="color:#003333;">METHOD:</span> Prospective observation of 24 consecutive patients with suspected HIT who were being anticoagulated with argatroban using 2 µg/kg/min in the first 5 patients and 0.2 µg/kg/min in the subsequent 19 patients.</span><br /><span style="color:#003333;"><br />RESULTS:</span><br /><br /><br /><ul><li><span style="color:#000000;">Infusion of argatroban 2 µg/kg/min over 4 hours caused bleeding complications in 3 patients as aPTT increased from 51 to 86 secs, and INR increased from 1.4 ± 0.4 to 2.5. </span></li><li><span style="color:#000000;">Infusion of argatroban 0.2 µg/kg/min over 4 hours provided sufficient anticoagulation without bleeding complications. The aPTT in this population increased from 44 ± 9 to 59 ± 13 seconds (p <></li></ul><span style="color:#000000;"></span><br /><span style="color:#000000;">Coagulation variables (aPTT, PT, INR) were significantly different between both dosing regimens after 4 hours of infusion.</span><br /><br /><br /><br /><span style="color:#003333;">CONCLUSIONS:<br /></span><span style="color:#000000;">In critically ill patients with MODS, argatroban 2 µg/kg/min, as recommended by the manufacturer, resulted in extensive anticoagulation. <em>A tenfold lower starting dose is sufficient and safe for effective anticoagulation in this specific patient population.</em></span></strong></span><br /><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">References: click to get abstract/article<br /><br />1. </span><a href="http://www.theannals.com/cgi/content/abstract/41/5/749" target="_blank"><span style="font-size:78%;color:#003333;">Argatroban Anticoagulation in Critically Ill Patients</span></a><span style="font-size:78%;color:#003333;"> - The Annals of Pharmacotherapy: Vol. 41, No. 5, pp. 749-754.</span><br /><span style="color:#000000;"></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3611733674240718029.post-64515288023336459122007-11-06T09:18:00.000-08:002007-11-06T14:52:12.950-08:00<div align="left"><span style="color:#000000;"><strong><span style="color:#000066;">Tuesday November 6, 2007</span><br /><span style="color:#990000;">Intensive care of patients with acute liver failure</span><br /><br /><br />This month "Critical Care Medicine" has published a CME article: </strong></span></div><span style="color:#000000;"><strong><div align="center"><br /><br /><span style="color:#003333;"><em>Intensive care of patients with acute liver failure:<br />Recommendations of the U.S. Acute Liver Failure Study Group</em></span> </div><div align="left"><br /><br />This is a very concise review on the said topic dealing with all ICU aspects of Acute Liver Failure including</strong></span><span style="color:#000000;"><br /></div></span><span style="color:#000000;"><ul><li><strong>Etiology-Specific Treatments like in acetaminophen overdose</strong></li><li><strong>Hepatic Encephalopathy and Hyperammonemia</strong></li><li><strong>Infection Prophylaxis and Surveillance </strong></li><li><strong>Sedation and Analgesia</strong></li><li><strong>Correction of the Bleeding Diathesis</strong></li><li><strong>Assessment of Prognosis and Liver Transplant Listing Criteria</strong></li><li><strong>Nutrition </strong></li><li><strong>Seizure Prophylaxis and Surveillance </strong></li><li><strong>Treatment of Circulatory Dysfunction</strong></li><li><strong>Management of Cerebral edema</strong></li><li><strong>Management of Intracranial Hypertension: Specific Recommendations </strong></li><li><strong>Mechanical Ventilation </strong></li><li><strong>Renal Replacement Therapy (RRT); Management of Fluids and Electrolytes </strong></li><li><strong>MANAGEMENT OF ALF DURING AND AFTER OLT </strong></li><li><strong>Intraoperative and Postoperative Monitoring </strong></li></ul><br /><br /><strong>Its an important article to be aware of. Article is by subscription but reference can be found below.<br /><br /><br /><br /><span style="color:#003333;">Related video/lecture:</span> </strong></span><a href="http://webcast.ucsd.edu:8080/ramgen/UCSD_TV/8320.rm" target="_blank"><span style="color:#660000;"><strong>Acute Liver Failure: The Critical Team Approach</strong></span></a><span style="color:#000000;"><strong> by Dr. Lorenzo Rossaro, Head of the Liver Transplant Program at UC Davis Med Center</strong> (this video requires real player)</span><br /><br /><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">References: click to get abstract/article<br /><br />1. </span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200711000-00004.htm;jsessionid=Hv8MM9LQjvZWJrTVVXr5Lrhz6SZ8bLG2yk3my8rlZXGCZJCQMVMQ!-1947435345!181195628!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Intensive care of patients with acute liver failure: </span></a><span style="font-size:78%;color:#003333;">Recommendations of the U.S. Acute Liver Failure Study Group Critical Care Medicine. 35(11):2498-2508, November 2007.</span><br /><br /></span></span>Unknownnoreply@blogger.com0