Tuesday November 6, 2007
Intensive care of patients with acute liver failure


This month "Critical Care Medicine" has published a CME article:

Intensive care of patients with acute liver failure:
Recommendations of the U.S. Acute Liver Failure Study Group

This is a very concise review on the said topic dealing with all ICU aspects of Acute Liver Failure including

• Etiology-Specific Treatments like in acetaminophen overdose
• Hepatic Encephalopathy and Hyperammonemia
• Infection Prophylaxis and Surveillance
• Sedation and Analgesia
• Correction of the Bleeding Diathesis
• Assessment of Prognosis and Liver Transplant Listing Criteria
• Nutrition
• Seizure Prophylaxis and Surveillance
• Treatment of Circulatory Dysfunction
• Management of Cerebral edema
• Management of Intracranial Hypertension: Specific Recommendations
• Mechanical Ventilation
• Renal Replacement Therapy (RRT); Management of Fluids and Electrolytes
• MANAGEMENT OF ALF DURING AND AFTER OLT
• Intraoperative and Postoperative Monitoring

Its an important article to be aware of. Article is by subscription but reference can be found below.



Related video/lecture: Acute Liver Failure: The Critical Team Approach by Dr. Lorenzo Rossaro, Head of the Liver Transplant Program at UC Davis Med Center (this video requires real player)




References: click to get abstract/article

1. Intensive care of patients with acute liver failure: Recommendations of the U.S. Acute Liver Failure Study Group Critical Care Medicine. 35(11):2498-2508, November 2007.

Monday November 5, 2007
On stress dose steroid (update from Canada Critical Care Forum meeting)

There was a lot of debate and update particularly in view of results from recent CORTICUS trial. As expected, Dr. Annane, was at center of attraction.

Dr. Annane stand with results of his JAMA 2002 study which showed positive influence of stress dose steroid in septic shock. In his view, CORTICUS trial did not re-produce the same results due to following 3 main reasons:

1. Patient population was not as selected to produce same results. Many eligible patients were excluded.
2. 72 hours has been allowed to start stress dose steroid in contrast to early start (24 hours) as in 2002 study.
3. Fludrocortisone was not added which could have made a significant difference in outcome.

Also, while answering a question - he recommends not to exceed the dose beyond 200 mg per day in divided doses or preferably in continuous drip (to avoid peak sugar levels).

Despite his stand on use of low / stress dose steroid in septic shock - with performing corticotropin test - he expressed his concern about overuse of steroids in septic shock.

Please note that updated guidelines on sepsis from SCCM / ISF recommends use of hydrocortisone if septic shock is unresponsive to pressors. Fludrocortisone as well as corticotropin test is not recommended.



References: click to get abstract/article

1. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871.

Sunday November 4, 2007
Do not treat acidosis aggressively in CO poisoning

Non-invasive Pulse-ox is not reliable in CO poisoing and 100% NRM should be applied ASAP in any suspected CO poisoning irrespective of pulse-ox on monitor. CO has high affinity for Hemoglobin (HB) - forming HbCO and it absorbs light almost identically to that of oxyhemoglobin, making pulse-ox very unreliable. 100% Oxygen delivery displaces CO from Hb and decrease its half life from 4.5 hours to 1 hour.

But the most unknown point in CO poisoning management is to not to treat acidosis very aggressively and PH of even 7.15 is acceptable for 2 reasons:

1. Acidosis is good in CO poisoning ! , as it causes rightward shift in the oxyhemoglobin dissociation curve, increasing tissue oxygen availability (Bohr effect).

2. Simultaneously, acidosis improves progressively by itself with 100% oxygen therapy and over treatment may push patient later into severe alkalosis.



Related previous pearl:

Hyperbaric oxygen in CO poisoning

The Bohr Effect and Permissive Hypercapnia

Saturday November 3, 2007
Hypothermia portal

Following site is an excellent portal of hypothermia from University of Pennsylvania.

Therapeutic Hypothermia

It has links to therapeutic hypothermia protocols from 14 major institution around the nation, a long list of references and links to various networks.

Site has ppt. presentation, Hypothermia after cardiac arrest from Benjamin Abella, MD MPhil.

See interesting concept Post-Cardiac Arrest Early Goal Directed Therapy from site.

Friday November 2, 2007
Vasoconstrictor extravasation

Antidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine) is PHENTOLAMINE. Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor.

Keep y ourself ready for fluid bolus post treatment. Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent which inhibits vasoconstriction and allow improved blood circulation through the affected area.



References: Click to get abstract or article

1. Drug Monographs - Phentolamine - lhsc.on.ca
2. Treating Extravasation Injuries - extravasation.org
3. The use of phentolamine in the prevention of dopamine-induced tissue extravasation - J Crit Care 1998 Mar;13(1):13-20

Thursday November 1, 2007
criticalcarenutrition.com

Unfortunately nutrition in ICUs does not get due importance. Following website is an important link to know.

www.criticalcarenutrition.com

Important areas to visit include 'Tools and training kit'

• Enteral Nutrition in The Critically Ill : Practice Guidelines
• Enteral Nutrition: Management of Diarrhea Guideline
• Placement of Small Bowel Feeding Tubes
• Parenteral Nutrition Guidelines
• Daily EN checklist

There are various power point presentations including

• Practical Aspects of Nutrition Support in the ICU
• More Evidence For The Safety and Efficacy of Post Pyloric Feeding in the ICU patient
• Evaluation of Three Different Strategies for Post-Pyloric Placement of Enteral Feeding Tubes