Monday, April 30, 2007

Monday April 30, 2007
Glucocorticoids in early ARDS - a must read study !

- Maduri is back !!

A very important study published in April 2007 issue of chest
3, from guru of glucocorticoids in ARDS, Dr. Maduri. Earlier he proposed role of glucocorticoids in late ARDS 1 (which was recently negated by ARDSnet LaSRS trial 2).

This study is about - Methylprednisolone Infusion in Early Severe ARDS and showed very promising results.

  • The 2:1 randomization trial ( (63 treated and 28 control) was conducted with
  • a loading dose of 1 mg/kg, followed by
  • an infusion of 1 mg/kg/d from day 1 to day 14,
  • 0.5 mg/kg/d from day 15 to day 21,
  • 0.25 mg/kg/d from day 22 to day 25, and
  • 0.125 mg/kg/d from day 26 to day 28.

If the patient was extubated between days 1 and 14, the patient was advanced to day 15 of drug therapy and tapered according to schedule. Please refer to full article for further components of study including ventilator guidelines, no use of neuromuscular blockers and periodic bronchoscopy.

Results: The response of the two groups (63 treated and 28 control) clearly diverged by day 7, with twice the proportion of treated patients achieving

  • a 1-point reduction in Lung Injury Score - LIS (69.8% vs 35.7%; p = 0.002)
    breathing without assistance (53.9% vs 25.0%; p = 0.01).
  • significant reduction in C-reactive protein levels,
  • by day 7 had lower multiple organ dysfunction syndrome scores
  • a reduction in the duration of mechanical ventilation (p = 0.002),
  • ICU stay (p = 0.007)
  • ICU mortality (20.6% vs 42.9%; p = 0.03) and
  • a lower rate of infections (p = 0.0002).

Editors' comment: We stronly encourage all intensivists to read this study along with editorial written in the same issue by Dr. Djillali Annane endorsing the above protocol

Reference: click to get abstract

Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA 1998;280,159-165

Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress Syndrome
- , New Engl J Med, April 20, Volume 354, Issue 16, p.1671-1684, (2006)

Methylprednisolone Infusion in Early Severe ARDS*Results of a Randomized Controlled Trial - Chest. 2007; 131:954-963

4. Glucocorticoids for ARDS: Just Do It! - Djillali Annane Chest Apr 2007: 945–946.

Sunday, April 29, 2007

Sunday April 29, 2007
Obvious !!

This comment was first posted on CCM-L (Critical Care Medicine - List, an awesome email forum of intensivists, website is

We are reproducing the comment with permission, because of its beauty and description of essence of Critical Care Medicine so simply....While talking about sepsis...

"Well, the Rivers paper
1 stated what should have been standard operating procedure in all Emergency Departments. He just said let's all do it now".

David Crippen, MD, FCCM
Associate Professor
Department of Critical Care Medicine
Medical Director: Neurovascular Intensive Care Unit
University of Pittsburgh Medical Center
Pittsburgh, PA 15261

Reference: click to get abstract

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock - Volume 345:1368-1377, Number 19, November 8 2001, NEJM

Saturday, April 28, 2007

Saturday April 28, 2007
Treating malaria (and other parasites) with Xigris - Drotrecogin alfa (activated) ?

While working on our pearl
Treating HIT with Xigris? , (April 24, 2007), our team came across 2 interesting case reports, which should be of great interest to our friends from countries where multi-organ failure from malaria and other parasites is still an everyday occurrence. For full length discussion, click on reference # 2 below.

1. ".... We describe the care of a 61-year-old man who developed multi-organ failure secondary to severe falciparum malaria infection with parasitaemia levels of 40%. Included in his care were an exchange blood transfusion and an infusion of Drotrecogin alfa (activated). Within hours of starting the infusion of Drotrecogin alfa (activated), the patient's clinical condition stopped deteriorating. Steady improvement followed with weaning from ventilatory assistance on day 14 post admission. The patient made a full recovery and was discharged home following rehabilitation....Drotrecogin alfa (activated) may be a useful treatment in patients with multi-organ failure resulting from severe malaria 1.

"....The patient was a 25-year old male admitted in the Respiratory Intensive Care Unit with fever, haemolysis, acute renal failure, hepatitis, acute lung injury (ALI) and altered sensorium. A syndromic evaluation was done and investigations revealed falciparum parasitaemia. He was treated with parenteral artesunate, ceftriaxone and doxycycline, and adjunctive therapies as for severe sepsis. Infusion of activated protein C was started 20 hours after onset of organ dysfunction, and intensive haemodialysis was instituted. Over the next four days the patient became afebrile with progressive resolution of ALI, renal failure and hepatitis. His Leptospira serology (requested as part of the evaluation) was reported positive on day 5. Dual infections are common and under-recognized in the tropics. Failure to treat potential co-infections may lead to poor outcomes. Acute lung injury in falciparum malaria has high mortality rates and therapy as for severe sepsis may improve survival. Adjunctive therapies, including activated protein C, cannot replace source eradication" 2.

Reference: click to get abstract

Drotrecogin alfa (activated) in severe falciparum malaria. - Anaesthesia. 2006 Sep;61(9):899-902

Severe sepsis due to severe falciparum malaria and leptospirosis co-infection treated with activated protein C - Malaria Journal 2007, 6:42

Friday, April 27, 2007

Friday April 27, 2007

Scenario; While reviewing the CXR after intubation, you found an entire tooth lying in right main bronchus. What should be your response after ?

Teeth should be removed immediately with bronchoscopy for 2 reasons:

1. To avoid any complication like pneumonia, perforation, atelactasis etc.

2. An intact tooth can be reimplanted and saved, if performed within an hour. Tooth should be saved in normal saline and oral surgeon should be called immediately.

Thursday, April 26, 2007

Thursday April 26, 2007

Q; What's the last resort of treating clostridium difficile when all other therapies fail and patient continue to have relapsing severe clostridium difficile infection ?

A; Stool Donation !!

Infusion of healthy stool (from donor) in patient's bowel via colonoscope, enema or a naso-jejunal tube. Sounds weird but idea is to restore human bowel flora. Actually, published reports shows that stool donation kills and eradicates C. diff. spores with a very high cure rate.


Treatment of Recurrent Clostridium difficile-Associated Diarrhea by Administration of Donated Stool Directly Through a Colonoscope - Am J Gastroenterol. 2000 Nov;95(11):3283-5.

The effect of faecal enema on five microflora-associated characteristics in patients with antibiotic-associated diarrhoea. Scand J Gastroenterol 1999;34:580-6.

Wednesday, April 25, 2007

Wednesday April 25, 2007

Q; Which antibiotic may give false positive urine drug screen for opiates ?

A; Gatifloxacin (Tequin) and other fluoroquinolones.

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.

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 !

Tuesday, April 24, 2007

Tuesday April 24, 2007
Treating HIT with Xigris ?

Continuing our theme from yesterday on Heparin-Induced Thrombocytopenia (HIT), we found an interesting case report where treatment has been done with Xigris - drotrecogin alfa (activated) !

"A patient was administered drotrecogin alfa (activated) in addition to the standard of care for presumed severe sepsis and circulatory shock. Heparin-induced thrombocytopenia (HIT) and hepatic and splenic thromboses complicated her clinical course. Because drotrecogin alfa (activated) treatment is associated with improvement in thrombotic manifestations and thrombocytopenia, it was continued as the sole antithrombotic agent after the HIT became apparent. This approach was chosen despite the patient's severe hepatic and renal dysfunction, which made the use of direct thrombin inhibitors unfavorable. She survived with a reasonable outcome and salvage of her limbs. Although this case suggests a potential role of drotrecogin alfa (activated) in the management of HIT, systematic evaluation of its efficacy in this situation is warranted".


Pharmacotherapy 2006;26(3):428-434

Monday, April 23, 2007

Monday April 23, 2007
Proposed iceberg model for HIT and HITT

Heparin-Induced Thrombocytopenia (HIT) still remains one of the most underdiagnosed condition in ICUs. Recently an iceberg model has been proposed for Heparin-Induced Thrombocytopenia (HIT) and Heparin-Induced Thrombocytopenia and Thrombosis (HITT). As there may be many patients who may have HIT but not HITT. There may be patients, who just have seroconversions and others who may have full blown thromboses at other end.

Review article on HIT: When Heparins Promote Thrombosis - Review of Heparin-Induced Thrombocytopenia (Circulation. 2005;111:2671-2683.)

Related previous pearl: 4 Ts of HIT

Sunday, April 22, 2007

Sunday April 22, 2007
What Critical Care Medicine is all about?

"For any human there are 2 critical needs to be alive - Oxygen and Water - and thats what Critical Care Medicine is all about ! To achieve good harmony of oxygen supply and consumption or in precise words oxygen extraction ratio as well as dynamics of fluid. We put due emphasis on hemodynamics but many times forget the other essential, the oxygen. Improving oxygen delivery by improving cardiac index, Hb and oxygen saturation as well as the quest to improve the value of mixed venous oxygen may be the another core target for patients in ICU. In sicker patients pulmonary artery catheter may still be the source of guiding value for improving oxygen extraction ratio".

(Recalled this from one of the conferences I had during my Critical Care fellowship. Lately I found trend among housestaff to finish ICU rotations without understanding the basics of oxygen content, supply and consumption. Point is to teach and encourage housestaff to understand the basic concept of hemodynamics and its relationship with oxygen delivery (DO2) and oxygen consumption (VO2) and importance of mixed venous and mixed central venous (SVO2 & ScVO2) oxygen saturations. To teach them - how to calculate arterial and venous oxygen content etc.

- Editor, Iqbal Ratnani M.D)

Saturday, April 21, 2007

Saturday April 21, 2007
Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage remained a condition with high mortality. Usual treatment is high dose IV methylprednisolone (1g/day) for three to five days and in more severe cases to add IV cyclophosphamide (cyclophosphamide has a delayed effect, but may provide synergistic action with steroid). Plasmapheresis has been described to be effective particularly in diffuse alveolar hemorrhage associated with Goodpasture syndrome.

But what if bleeding is non-stop and life-threatening ?

Answer is off label use of activated Factor VII (Novoseven). In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes 1.

Reference: click to get abstract

Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII - annals, 16 March 2004 Volume 140 Issue 6 Pages 493-494

Friday, April 20, 2007

Friday April 20, 2007
Quick way of differentiating non-gap metabolic acidosis

Once you determine from serum chemistry that you have a non-gap metabolic acidosis,

  • Check the urine anion gap (UNa + UK – UCl)
  • If urine anion gap is positive, it is a renal cause (e.g. RTA; in reality only validated for types I, IV)
  • If urine anion gap is negative, the cause is extra-renal.

Mnemonic to remember non gap metabolic acidosis is


RTA (Renal)
Pancreatic fistula

Related previous pearl:
Metabolic acidosis from HIV meds

Thursday, April 19, 2007

Q: Which medicine may have cause this "bluish" discoloration of skin, known as "The blue man syndrome"?

Hint: Its a heart medicine and may cause brownish hyperpigmentation of skin as well.

A: Amiodarone

About 5% (some literature described upto 26%) of patients develop skin pigmentation from photosensitivity while on amiodarone treatment depending on dose and length of treatment. It is suggested that that UV exposure induces vasodilatation and increased diffusion of amiodarone and its metabolite desethylamiodarone in perivascular tissue, resulting in chronic accumulation of the drug. On histology, lipofuscin laden macrophages are seen.

Related previous pearls:

Why we call it Am-iod-arone!

Amiodarone Neurotoxicity!

Amiodarone - Digoxin interaction !

References: click to get abstract

The Blue Man - Amiodarone-Induced Skin Discoloration, Circulation. 2006;113:e63

Dose-dependent appearance and disappearance of amiodarone-induced skin pigmentation. Clin Cardiol 1996; 19: 592-4.

The pathogenesis of amiodarone-induced pigmentation and photosensitivity. Br J Dermatol 1984; 110: 451- 6.

Wednesday, April 18, 2007

Wednesday April 18, 2007
(arginine vasopressin) AVP-Receptor Antagonists

Hyponatremia may be caused by a number of conditions, including infections, heart disease, surgery, malignancy, and medication use. Clinical signs and symptoms such as hallucinations, lethargy, weakness, bradycardia, respiratory depression, seizures, coma, and death have been reported. Conventional treatment consists of fluid restriction and administration of hypertonic saline and pharmacologic agents, such as demeclocycline, lithium carbonate, and urea. These treatment options are often of limited effectiveness or difficult for patients to tolerate.

AVP (arginine vasopressin) promotes the reabsorption of water in the renal collecting ducts by activation of V2 receptors, resulting in water retention and dilution of serum solutes. The AVP-receptor antagonists, Conivaptan, Lixivaptan, and Tolvaptan, are being studied for the treatment of hyponatremia.

Conivaptan (
Vaprisol) has been shown in clinical trials to increase freewater excretion and safely normalize serum sodium concentrations in patients with hyponatremia and is well tolerated. Also in clinical trials, Lixivaptan and Tolvaptan have safely improved serum sodium concentrations in patients with hyponatremia.

Tuesday, April 17, 2007

Tuesday April 17, 2007
Liver Complications of TPN

Although Parentral Nutrition is a lifesaving therapy in patients with gastrointestinal failure, its use may be associated with metabolic, infectious, and technical complications.

The overall frequency of PN associated liver complications ranges from 7.4% to 84%. Some 15–40% of adult patients receiving long-term PN therapy may develop end-stage liver disease. The wide variation in the reported frequency is the result of heterogeneity in the population studied, the duration and composition of PN, and the liver complications reported in the studies.

Mild to moderate elevation of liver enzymes is commonly seen within two weeks after starting PN, and should not lead to extensive workup unless warranted. Liver enzymes return to normal after PN is discontinued. With long-term PN, severe liver complications may occur, such as steatosis, steatohepatitis, cholestasis, and cholelithiasis. Although PN-associated cholestasis and hepatic steatosis can coexist, steatosis is more common in adults, while cholestasis is more common in children

Monday, April 16, 2007

Monday April 16, 2007

Q; What level of extrinsic PEEP should be applied to counter act (intrinsic) auto-PEEP?

A; 75 - 85% of auto-PEEP.

Keeping extrinsic PEEP lower than auto-PEEP not only effectively counter acts auto-PEEP but also any ciruclatory depression or lung hyperinflation is unlikely to occur at extrinsic PEEP slightly lower than intrinsic PEEP value.

Read precise review on auto-peep: Auto-positive end-expiratory pressure: Mechanisms and treatment , M.M. MUGHAL, D.A. CULVER, O.A. MINAI, and A.C. ARROLIGA - CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 9 SEPTEMBER 2005

Sunday, April 15, 2007

Sunday April 15, 2007
Elevation of the head of the bed- 30 or 45 degrees ?

Answer is probably 45 degrees. Elevation of the head of the bed is a must thing in ICU, unless some contra-indication. It is an essential part of VAP (ventilator associated pneumonia) bundle. But there is some debate about the extent of elevation need to be done. Accepted level is atleast 30 degrees but many guidelines wrote for 45 degrees. IHI recommends elevation anywhere from 30 to 45 degrees 3.

Study from The Netherlands 1 compared 109 patients in the supine group to 112 in the semirecumbent group. Target for semirecumbent group was 45 degrees but the targeted backrest elevation of 45° for semirecumbent positioning was not reached, so supine position (10°) was compared with achieved semirecumbent positioning (28°). Elevation of head of bed to 28° did not prevent the development of VAP.

7 years back Drakulovic and coll. published their landmark study in lancet showing 83% decrease of bacteriologically confirmed VAP in a group of patients treated in a semirecumbent position of 45°. 2

So the answer is 45 degrees or to be diplomatically right - atleast more than 30 degrees.

But is it easy to do and keep head of bed elevated to 45 degrees in practical world ?. The study group found that despite the presence of dedicated research nurses to control and maintain patient positioning, the semirecumbent treatment position with an aimed backrest elevation of 45° is not feasible for mechanically ventilated patients.

Another interesting question raised in discussion of Netherland's study: Is semirecumbent positioning itself a risk for VAP ? !!, as pooling of colonized oropharyngeal fluids above the inflated cuff of the endotracheal tube is common in mechanically ventilated patients and it is possible that the semirecumbent position (and all movements to keep it) stimulates leakage of oropharyngeal fluid by means of gravity. Whether ETT with continuous aspiration of subglottic secretions (CASS) will be more effective than semirecumbent positioning?

References: Click to get article/abstract

1. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study - Critical Care Medicine. 34(2):396-402, February 2006.
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial - Lancet.1999 Nov 27;354(9193):1851-8.
Elevation of the Head of the Bed - Institute for Healthcare Improvement

Saturday, April 14, 2007

Saturday April 14, 2007

Hypertonic saline is administered for a wide variety of conditions, and this multitude of indications can sometimes seem confusing. Currently, there are 3 primary indications for the use of hypertonic saline in critically ill patients:

  • hyponatremic states,
  • volume resuscitation in shock,
  • brain injury and
  • Miscellaneous

Hyponatremic states

1. Syndrome of inappropriate antidiuretic hormone (occasionally indicated)
2. Cerebral salt-wasting syndrome (indicated if hyponatremia
is significant)

3. Other causes (rarely indicated)

  • Psychogenic polydipsia
  • Diuretic overuse/abuse
  • Addison disease
  • Excessive losses of gastrointestinal secretions
  • Late-stage cirrhosis, congestive heart failure, or renal disease

Volume resuscitation in shock (may be beneficial)

  • Hemorrhagic shock
  • Septic shock
  • Major burns

Brain injury (may be beneficial) Traumatic or nontraumatic

Miscellaneous uses

Oral (largely historical)

  • Heat-related disorders
  • Orthostatic hypotension
  • Cystic fibrosis

Parenteral uses

  • Sclerotherapy (injected directly into affected vein)
  • After coronary artery bypass surgery (intravenous)
  • Leishmaniasis (intradermal)
  • Midtrimester abortion (intra-amniotic)

Related previous pearl:
Hypertonic Solution (3% NS) in cerebral edema and intracranial hypertension

Friday, April 13, 2007

Friday April 13, 2007
CVP (central venous pressure) via femoral central line

There are very few studies available correlating accuracy of CVP (central venous pressure) via femoral line. One study published in lancet a decade ago provides clue that as near the catheter tip to the right atrium, better would be the correlation
1. Another small study later showed reliable accuracy from common iliac venous line 2.

This year at 27th International Symposium on Intensive Care and Emergency Medicine held at Brussels, Belgium (27–30 March 2007), a study of 41 patients was presented, with each one of those patients had a central venous catheter (CVC) in two different locations, one placed in the internal jugular or subclavian veins, and a second in a femoral vein. Simultaneous measurements of CVP were undertaken by two different operators, with a pressure transducer zero referenced at the mid-chest. 4 patients with an intra-abdominal pressure (IAP) more than 15 mmHg were excluded.

The mean CVP measured with jugular/subclavian access was 11.3 ± 4.5 mmHg, and in the femoral access was 11.8 ± 4.4 mmHg ( P less than 0.007).

Study concluded that CVP can be accurately measured in a femoral vein, using standard CVC, in patients with normal Intra-abdominal pressure 3.

Editors' comment: Standard is CVP measurement via central line placed in thoracic region. CVP via PICC line or femoral central line should be obtained and used only when thoracic access is not feasible.

Related previous pearls:
CVP via PICC , CVP via biggest port on venous catheter ! , PICC or CVC ? , Power PICC

References: click to get abstract / article

Comparison of intrathoracic and intra-abdominal measurements of central venous pressure - Lancet. 1996 Apr 27;347(9009):1155-7.
Central venous pressure from common iliac vein reflects right atrial pressure - CAN J ANAESTH 1998 / 45: 8 / pp 798-801
Central venous pressure in a femoral access: a true evaluation ? Critical Care 2007, 11(Suppl 2):P277

Thursday, April 12, 2007

Thursday April 12, 2007
Drug Induced Systemic Lupus Erythematosus (DISLE)

Today's pearl contributed by
Jennifer Burns, D.Pharm

Vassar Brothers Medical Center
Poughkeepsie, NY

As many as 10% of diagnosed cases of SLE are drug-related. From Critical Care perspective there are reports of acute DISLE like fulminating hydralazine-induced lupus pneumonitis
1 , acute acalculous cholecystitis and cardiac tamponade 2.

DISLE affects males and females almost equally, whites more often than blacks, and is more common in older patients than idiopathic SLE (Kale, 1985). The average age of SLE at the time of diagnosis is 35.8 whereas that of DISLE is 60.7 and 53.5 associated with procainamide and hydralazine, respectively. This is probably due to the more frequent use of antihypertensive and antiarrhythmic medication in the older population.

There appears to be a racial difference in the incidence of DISLE, with the percentage of DISLE patients who are white being 86 to 95% for hydralazine and 95% for procainamide; likewise 64% of the patients with idiopathic SLE are white
(Stratton, 1985). Symptoms of DISLE are the same as in SLE but are less severe (Weinstein, 1980).

Drugs with a hydrazine or amino group linked to an aromatic ring, such as HYDRALAZINE, PROCAINAMIDE and ISONIAZID, are most often linked to DISLE (Reidenberg, 1981). Hydralazine, procainamide, and isoniazid have been demonstrated in controlled prospective studies to cause increased ANA titers or a SLE type illness.

In those patients receiving hydralazine, DISLE is rarely seen in daily doses less than 200 milligrams. Interestingly, there is good evidence that those patients who are identified as slow acetylators are at a higher risk of developing DISLE, but a correlation between idiopathic SLE and the acetylator phenotype is poorly understood
(Totoritis, 1985)(Anon, 1974). In fact, the drugs most often implicated in DISLE are all metabolized in the liver by acetylation (eg, hydralazine, procainamide, anticonvulsants, INH).


Fulminating hydralazine-induced lupus pneumonitis - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506

Acute acalculous cholecystitis and cardiac tamponade in a patient with drug-induced lupus - Rheumatology 2001; 40: 709-711

Wednesday, April 11, 2007

Wednesday April 11, 2007
Upper extremity deep vein thrombosis (UEDVT)

Upper extremity deep vein thrombosis (UEDVT) should no longer be regarded as an uncommon and benign disease. It is usually associated with risk factors, as central venous lines, malignancy, and coagulation defects. However, up to 20% of UEDVTs are apparently spontaneous. The clinical picture is characterized by swelling, pain, and functional impairment, although UEDVT may be completely asymptomatic.

Objective testing is mandatory prior to instituting anticoagulation because the prevalence of UEDVT is less than 50% in symptomatic subjects, and compression ultrasound or color Doppler represents the preferred diagnostic methods.

Up to 36% of the patients develop pulmonary embolism, which may be fatal. Unfractionated or low-molecular-weight heparin followed by oral anticoagulation should be regarded as the treatment of choice. Thrombolysis and surgery may be indicated in selected cases.

Tuesday, April 10, 2007

Tuesday April 10, 2007
Cricoid Pressure - Avoiding the pitfall

Continuing our theme from yesterday on
intubation / RSI,

There is a tendency to apply cricoid pressure on every patient during intubation but if difficult intubation is anticipated, using cricoid pressure is debatable because it should only be used with deep sedation to avoid laryngospasm. It is ineffective and even dangerous in a patient who still has reflexes.

Rapid sequence intubation should be used with cricoid pressure to reduce the risk of regurgitation and inhalation.

See a nice review
The Cricoid Pressure - Dr. Sanjib Das Adhikary, Dr. Krishnan B. S. - Indian J. Anaesth. 2006; 50 (1) : 12 - 19

Monday, April 9, 2007

Monday April 9, 2007
Revisiting RSI or Rapid Sequence Induction protocol

RSI protocol is aimed at quick, safe and organized emergent endotracheal intubation by using several medications. Very important consideration to remember is, unlike planned intubation for anesthesia, we should presume that patient’s stomach might be full and complication like aspiration can happen.

Medications fall into three categories:

1) Pretreatment agents:
  • Oxygen, use 100% with reservoir mask, avoid positive pressure ventilation.
  • Fentanyl (3mcg/kg)
  • Lidocaine may suppress the cough reflex (1.5 mg/kg)
  • Atropine may decrease the bradycardia

2) Induction agents:
  • Pentothal (4 mg/kg)
  • Etomidate (0.3 mg/kg) (may induce adrenocortical dysfunction)
  • Ketamine (1-2 mg/kg)
  • Midazolam (0.25 mg/kg)
  • Propofol

3) Paralyzing agents:
  • Succinylcholine (2mg/kg) - may induce hyperkalemia
  • Vecuronium (0.15 mg/kg),
  • Rocuronium (0.8 mg/kg)

Related previous link: Preventing sympathetic surge during head injury patient's intubation

2 great reviews

Airway Management of the Critically Ill Patient Rapid-Sequence Intubation, Chest. 2005;127:1397-1412

Rapid Sequence Induction (

Other related link Quick dose calculator of drugs used in RSBI, by just entering weight

To share with readers, here is an email from overseas.

"I have to send to you to admire this excellent site which will help a lot physician around the globe to master acute emergency which will help to reduce mortality and morbidity, thank you for such state of art work. I hope it will remain free for all the users!!....

Dr hany alfayed"

Sunday, April 8, 2007

Sunday April 8, 2007
3 Basic Principles of Medical Ethics

Non-Malfeasance: Do no harm
Beneficence: Advance the good
Autonomy: Pt. has right to choose treatment

American Medical Association's Principles of medical ethics

Saturday, April 7, 2007

Saturday April 7, 2007
Bedside procedure tip

While inserting cordis (large bore IV) for purpose of floating pulmonary artery catheter (PAC), it is always advisible to flush it well with normal saline via side port. If it is not flush properly, blood may get clotted on cordis wall and may hinder the free floatation of PAC.

In one instance of anecdotal experience with author, PAC felt stuck inside chest and resistance noted. Presumptive diagnosis of knotting made but STAT CXR showed cordis and swan looped as "C" below clavicle and no knotting noted. With flushing of sideport of cordis, swan floated well and waveforms obtained. Repeat CXR showed appropriate course. (we have CXRs available but decide not to submit to avoid any violation).

(Name of contributor and institution holded on request.)

(Anecdotals described here may not be tested in clinical trials and may solely be only personal experiencs)

Friday, April 6, 2007

Friday April 6, 2007

Today's pearl contributed by:
Christiane Perme, PT CCS
Board Certified Cardiovascular and Pulmonary Clinical Specialist
Senior Physical Therapist
Department of Physical Therapy and Occupational Therapy
The Methodist Hospital,
Texas Medical Center, Houston, Texas

ICU patients have limited mobility due to life support, monitoring equipment, multiple medical problems, and muscle weakness. Early ambulation of mechanically ventilated patients enhances functional outcomes by optimizing cardiopulmonary and neuromuscular status. This intervention can lead to a reduced length of hospital stay, higher functional capability, overall reduced costs, and an increase in the patient’s quality of life.

Bailey and colleagues (1) in his study concluded that early activity is feasible and safe in mechanically ventilated patients. The study also proposes that early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness.

Perme and colleagues (2) reported a case of an LVAD (left ventricular assist device) patient who required prolonged mechanical ventilation post-operatively. Early and aggressive physical therapy was provided including ambulation on a portable ventilator. This case suggests that improving mobility of these patients has the potential to facilitate ventilator weaning as well as to improve outcomes of transplantation.

Mechanically ventilated patients in ICU can be safety mobilized when appropriate measures are taken.

References: click to get abstract/article

1. Bailey P, Thomsen G, Spuhler V, Blair R, Jewekes J, Bezdjian L, Veale K, Rodriguez, AS, Hopkins R.
Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine 2007.Vol. 35 Number 1.139-145
2. Perme C, Southard R, Joyce D, Noon G, Loebe M.
Early mobilization of LVAD recipients who require prolonged mechanical ventilation. Texas Heart Institute Journal 2006; 33:130—3

Thursday, April 5, 2007

Thursday April 5, 2007
Ambien Induced Delirium

Relatively Zolpidem (Ambien) is a safe medicine and recently has been one of a drug of choice in critical care units to induce sleep. But it is important to be aware of reported cases of ambien related psychosis, delirium and mania. Atleast one case is reported with visual perception distortion after a single dose of zolpidem.

One way to combat the problem is to decrease the prescribing dose particularly in elderly population and in hypoalbuminemia (5 mg instead of 10 mg). Also, female population has been reported to have more plasma level with same dose. Also note that Zolpidem metabolized through liver so it may be necessary to decrease the dose in liver insufficiency.

References: click to get abstract/article

Delirium associated with zolpidem - The Annals of Pharmacotherapy: Vol. 35, No. 12, pp. 1562-1564
2. Zolpidem-Induced Delirium With Mania in an Elderly Woman - Psychosomatics 45:88-89, February 2004
3. Zolpidem-induced agitation and disorganization. - Gen Hosp Psychiatry. 1996 Nov;18(6):452-3. (pubmed)
4. Zolpidem-induced psychosis. - Ann Clin Psychiatry.1996 Jun;8(2):89-91. (pubmed)
5. Clinical pharmacokinetics of zolpidem in various physiological and pathological conditions, in Imidazopyridines in Sleep Disorders. Edited by Sauvanet JP, Langer SZ, Morselli PL. New York, Raven Press, 1988, pp 155–163
6. Zolpidem-Induced Distortion in Visual Perception - The Annals of Pharmacotherapy: Vol. 37, No. 5, pp. 683-686

Wednesday, April 4, 2007

Wednesday April 4, 2007
Daptomycin (Cubicin) and renal failure

As Daptomycin has now been approved for right-sided MSSA and MRSA endocarditis since our previous pearl *, and as we are seeing it more in ICUs, it would be of worth to re-visit that, Cubicin needs to be adjusted in renal failure. With CrCl less than 30, it should be given every 48 hours. It is recommended to be given on hemodialysis day following hemodialysis. Daptomycin doesn't get cleared in CVVHD and need to adjusted as renal failure dose.

Related previous pearls:

Daptomycin induced rhabdomyolysis

3 new antibiotics *

* Since this previous pearl, Cubicin is approved for right-sided MSSA and MRSA endocarditis.

Tuesday, April 3, 2007

Tuesday April 3, 2007

Q: What is that ring on ETT (endotracheal tube) ?

A; Endotrol (trade name) is a modification of regular ETT with a ring attached at the proximal end. While intubating, pulling the ring makes distal tip goes anterior and help ETT in directing towards vocal cord. It is said to be helpful in hardly visualize vocal cords, in difficult intubations and in blind nasal intubations.

Related previous pearls:

The GlideScope, Airtraq, Light Wand and How many attempts to intubate?

Monday, April 2, 2007

Monday April 2, 2007

Q: Which electrolyte abnormality may prevent Neostigmine from resolving Oglivie's syndrome?

A; Potassium

Acute colonic pseudo-obstruction or Ogilvie syndrome, is an acute large bowel obstruction with no evidence of mechanical colonic obstruction. It is said to be due to invasion and destruction of the splanchnic nerves, superior mesenteric ganglion, and celiac nerve plexus.

Neostigmine, an acetylcholinesterase inhibitor, increases acetylcholine concentrations at the enteric nervous system neuromuscular junctions, enabling smooth muscle to contract. Neostigmine is given as intravenous, 2 mg over 5 minutes. A repeat dosage may be given if necessary. Side effects of neostigmine include sweating, salivation, bradycardia, hypotension, and bronchospasm. Due to possible bradycardia, atropine should be available at bedside. The neostigmine is eliminated by kidney and should be use with caution in renal failure.

An anecdotal report indicates that patients with hypokalemia, may not respond to neostigmine.

References: click to get article
Acute colonic pseudo-obstruction (Ogilvie's syndrome) in critical care unit - Year : 2004, Volume : 8, Issue : 1, Page : 43-45

Sunday, April 1, 2007

Sunday April 1, 2007

Pseudo-hypokalemia is usually seen with very high WBC count, when the drawn sample is allowed to sit at room temperature for longer period of time. It happens due to uptake of plasma potassium by high leukocytes in the sample.

If Pseudo-hypokalemia is suspected, real potassium level can be measured by sending specimen quickly to the lab, and requesting to measure potassium level in separated plasma or serum.