tag:blogger.com,1999:blog-72009091984073425022024-03-23T22:42:24.481-07:00icuroom.net April 2007 ArchiveUnknownnoreply@blogger.comBlogger29125tag:blogger.com,1999:blog-7200909198407342502.post-56719512413887277332007-04-30T09:46:00.000-07:002007-04-30T09:53:18.038-07:00<p><span style="color:#000000;"><span style="color:#000066;"><strong>Monday April 30, 2007<br /></strong></span><strong><span style="color:#990000;">Glucocorticoids in early ARDS - a must read study !<br /></span><br /></strong><strong><span style="color:#660000;"><span style="font-size:85%;color:#000000;">- Maduri is back !!</span><br /></span><br />A very important study published in April 2007 issue of chest</strong> <span style="font-size:78%;">3</span><strong>, from guru of glucocorticoids in ARDS, Dr. Maduri. Earlier he proposed role of glucocorticoids in late ARDS </strong>1<strong> (which was recently negated by ARDSnet LaSRS trial</strong> 2<strong>).<br /><br />This study is about - Methylprednisolone Infusion in Early Severe ARDS and showed very promising results.</strong></span></p><span style="color:#000000;"><strong><ul><li>The 2:1 randomization trial ( (63 treated and 28 control) was conducted with </li><li>a loading dose of 1 mg/kg, followed by </li><li>an infusion of 1 mg/kg/d from day 1 to day 14, </li><li>0.5 mg/kg/d from day 15 to day 21, </li><li>0.25 mg/kg/d from day 22 to day 25, and </li><li>0.125 mg/kg/d from day 26 to day 28.<br /></li></ul></strong></span><p><span style="color:#000000;">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.</span></p><p><span style="color:#000000;"><strong><br /><br /><span style="color:#660000;">Results:</span> The response of the two groups (63 treated and 28 control) clearly diverged by day 7, with twice the proportion of treated patients achieving </strong></span></p><span style="color:#000000;"><strong><ul><li>a 1-point reduction in Lung Injury Score - LIS (69.8% vs 35.7%; p = 0.002)<br />breathing without assistance (53.9% vs 25.0%; p = 0.01). </li><li>significant reduction in C-reactive protein levels, </li><li>by day 7 had lower multiple organ dysfunction syndrome scores </li><li>a reduction in the duration of mechanical ventilation (p = 0.002), </li><li>ICU stay (p = 0.007) </li><li>ICU mortality (20.6% vs 42.9%; p = 0.03) and </li><li>a lower rate of infections (p = 0.0002).<br /></li></ul><p><br /><br /><span style="color:#660000;">Editors' comment:</span> 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</strong> <span style="font-size:78%;">4</span><strong>.<br /><br /><br /></strong><br /></span><span style="font-size:78%;color:#003333;">Reference: click to get abstract<br /><br />1. </span><a href="http://jama.ama-assn.org/cgi/content/abstract/280/2/159" target="_blank"><span style="font-size:78%;color:#003333;">Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial</span></a><span style="font-size:78%;"><span style="color:#003333;">. JAMA 1998;280,159-165<br /><br />2. </span><a href="http://content.nejm.org/cgi/content/short/354/16/1671"><span style="color:#003333;">Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress Syndrome</span></a><span style="color:#003333;"> </span></span><span style="font-size:78%;color:#003333;">- , New Engl J Med, April 20, Volume 354, Issue 16, p.1671-1684, (2006)<br /><br />3. </span><a href="http://www.chestjournal.org/cgi/content/abstract/131/4/954" target="_blank"><span style="font-size:78%;color:#003333;">Methylprednisolone Infusion in Early Severe ARDS*Results of a Randomized Controlled Trial </span></a><span style="font-size:78%;color:#003333;">- Chest. 2007; 131:954-963<br /><br />4. Glucocorticoids for ARDS: Just Do It! - Djillali Annane Chest Apr 2007: 945–946.</span></p>Unknownnoreply@blogger.com49tag:blogger.com,1999:blog-7200909198407342502.post-7806340243766281522007-04-29T08:03:00.000-07:002007-04-29T08:05:06.448-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Sunday April 29, 2007</span></strong><br /><strong><span style="color:#660000;">Obvious !!</span></strong><br /><br /><strong>This comment was first posted on CCM-L</strong> (Critical Care Medicine - List, an awesome email forum of intensivists, website is </span><a href="http://www.ccm-l.org/" target="_blank"><span style="color:#000000;">www.ccm-l.org</span></a><span style="color:#000000;">).<strong><br /><br />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...<br /></strong><br /></span><span style="color:#003333;"><em><strong><br />"Well, the Rivers paper </strong><span style="font-size:85%;color:#660000;">1</span><strong> stated what should have been standard operating procedure in all Emergency Departments. He just said let's all do it now".</strong></em></span><br /><span style="color:#000000;"></span><br /><span style="font-size:85%;color:#000000;"><strong>David Crippen, MD, FCCM</strong></span><br /><span style="font-size:85%;color:#000000;"><strong>Associate Professor</strong></span><br /><span style="font-size:85%;color:#000000;"><strong>Department of Critical Care Medicine</strong></span><br /><span style="font-size:85%;color:#000000;"><strong>Medical Director: Neurovascular Intensive Care Unit</strong></span><br /><span style="font-size:85%;"><span style="color:#000000;"><strong>University of Pittsburgh Medical Center<br />Pittsburgh, PA 15261</strong></span><br /></span><br /><br /><span style="font-size:78%;color:#003300;">Reference: click to get abstract<br /><br />1. </span><a href="http://content.nejm.org/cgi/content/abstract/345/19/1368" target="_blank"><span style="font-size:78%;color:#003300;">Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock</span></a><span style="font-size:78%;color:#003300;"> - Volume 345:1368-1377, Number 19, November 8 2001, NEJM</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-82282525181388529312007-04-28T10:35:00.000-07:002007-04-28T10:50:44.459-07:00<strong><span style="color:#000066;">Saturday April 28, 2007<br /></span><span style="color:#990000;">Treating malaria (and other parasites) with Xigris - Drotrecogin alfa (activated) ?</span><br /><br /><br /><span style="color:#000000;">While working on our pearl </span></strong><a href="http://april-2007-icuroom.blogspot.com/2007_04_24_archive.html" target="_blank"><span style="color:#660000;"><strong>Treating HIT with Xigris?</strong></span></a><span style="color:#000000;"><strong> ,</strong> <span style="font-size:85%;">(April 24, 2007),</span><strong> 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.</strong></span><br /><br /><span style="color:#000000;"><strong><span style="color:#660000;">1.</span> <em><span style="color:#003300;">".... 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</span></em></strong> <span style="font-size:78%;color:#660000;">1.<br /></span><br /><strong><span style="color:#660000;">2.</span> </strong></span><span style="color:#003333;"><em><strong>"....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.</strong> Adjunctive therapies, including activated protein C, cannot replace source eradication<strong>"</strong></em></span><span style="color:#000000;"> <span style="font-size:78%;">2</span>.</span><a href="http://www.malariasite.com/" target="_blank"></a><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://pt.wkhealth.com/pt/re/anesb/abstract.00000524-200609000-00014.htm;jsessionid=GyNp3WpzTL21MtLzrb1zMrv9NJkwqZYpG1G3Jy6fWT29hQTn9KYy!-1905490407!-949856144!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Drotrecogin alfa (activated) in severe falciparum malaria</span></a><span style="font-size:78%;color:#003333;">. - Anaesthesia. 2006 Sep;61(9):899-902<br /><br />2. </span><a href="http://www.malariajournal.com/content/6/1/42" target="_blank"><span style="font-size:78%;color:#003333;">Severe sepsis due to severe falciparum malaria and leptospirosis co-infection treated with activated protein C</span></a><span style="font-size:78%;color:#003333;"> - Malaria Journal 2007, 6:42</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-87651561231597047092007-04-27T07:45:00.000-07:002007-04-27T07:46:49.541-07:00<strong><span style="color:#000066;">Friday April 27, 2007</span></strong><br /><br /><strong><span style="color:#000000;"><span style="color:#990000;">Scenario;</span> <em><span style="color:#003333;">While reviewing the CXR after intubation, you found an entire tooth lying in right main bronchus. What should be your response after ?<br /></span></em><br /><br /><span style="color:#990000;">Answer:</span> </span><span style="color:#000000;">Teeth should be removed immediately with bronchoscopy for 2 reasons:<br /><br /><span style="color:#660000;">1.</span> To avoid any complication like pneumonia, perforation, atelactasis etc.<br /><br /><span style="color:#660000;">2</span>. 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.</span></strong><br /><br /><img id="BLOGGER_PHOTO_ID_5058119134083950210" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDr0tZiT3M-hGvCI-528fjLXw2w9ldln7N9l3ehrlRyBlpUroyvcXTHZW4LwjWRdhwZD0gHXwtxdKR3g8JTdHrFgJq3c3OFtMy6JefdmDc79cBzxOknbnHUvsdnumR1PrpgnmuO3n02MQ3/s400/teeth.jpg" border="0" />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-71656511330900032932007-04-26T16:13:00.000-07:002007-04-26T16:15:08.120-07:00<strong><span style="color:#000066;">Thursday April 26, 2007<br /></span></strong><br /><strong><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">What's the last resort of treating clostridium difficile when all other therapies fail and patient continue to have relapsing severe clostridium difficile infection ?</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A; </span><span style="color:#000066;">Stool Donation !!</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">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.</span></strong><br /><br /><span style="font-size:78%;color:#003333;">References:</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">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.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">The effect of faecal enema on five microflora-associated characteristics in patients with antibiotic-associated diarrhoea. Scand J Gastroenterol 1999;34:580-6.</span>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-7200909198407342502.post-13602377047966263802007-04-25T17:51:00.000-07:002007-04-25T17:52:52.697-07:00<strong><span style="color:#000066;">Wednesday April 25, 2007</span><br /><br /><span style="color:#660000;"></span></strong><br /><strong><span style="color:#660000;"></span></strong><br /><strong><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">Which antibiotic may give false positive urine drug screen for opiates ?</span></em><br /><br /><span style="color:#660000;">A;</span> <span style="color:#000066;">Gatifloxacin (Tequin) and other fluoroquinolones.<br /></span><br /><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.<br /><br />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.<br /></span><br /><br /><em><span style="color:#003300;">Editors' note:</span></em> <em><span style="color:#000066;">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 <span style="color:#990000;">Levaquin</span> as one of the top 3 !</span></em></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-50994529406029727302007-04-24T08:35:00.000-07:002007-04-24T08:47:02.912-07:00<strong><span style="color:#000066;">Tuesday April 24, 2007</span><br /></strong><strong><span style="color:#990000;">Treating HIT with Xigris ?<br /></span><br /><span style="color:#000000;">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) !</span><br /><br /><em><span style="color:#003300;">"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". </span></em><br /><br /><br /><br /></strong><span style="font-size:85%;color:#003300;">Reference:<br /><br />Pharmacotherapy 2006;26(3):428-434</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-48333943064516671212007-04-23T07:18:00.000-07:002007-04-23T07:21:46.813-07:00<strong><span style="color:#000066;">Monday April 23, 2007</span> </strong><br /><strong><span style="color:#990000;">Proposed iceberg model for HIT and HITT</span></strong><br /><br /><br /><img id="BLOGGER_PHOTO_ID_5056627778242584850" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigiC_R3SiqkVIlb-QqJemCoa6UdKoJoxBIDr9E-acyNg50A7geNEn1ZKOQWtdKA8v73S7PU97pfCjAjaogNQPxEFd0rUGdVYahgadqL9KoOqRcrJOiwddheVhFIKib_7PZKlTBlduYSy3J/s400/iceberg.gif" border="0" /><br /><strong><span style="color:#000000;">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). <em>As there may be many patients who may have HIT but not HITT. </em>There may be patients, who just have seroconversions and others who may have full blown thromboses at other end.</span></strong><br /><strong><span style="color:#000000;"><br /></span></strong><br /><strong><span style="color:#003300;">Review article on HIT:</span> </strong><a href="http://circ.ahajournals.org/cgi/content/full/111/20/2671" target="_blank"><span style="color:#660000;"><strong>When Heparins Promote Thrombosis - Review of Heparin-Induced Thrombocytopenia </strong></span></a><em>(Circulation. 2005;111:2671-2683.)<br /></em><br /></span><br /><strong><span style="color:#003300;">Related previous pearl:</span><span style="color:#660000;"> </span></strong><a href="http://icuroom-pearls.blogspot.com/2006/06/4-ts-of-hit.html" target="_blank"><strong><span style="color:#660000;">4 Ts of HIT</span></strong></a><strong><br /><br /></strong><strong></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-19625390004028888562007-04-22T19:50:00.000-07:002007-04-21T19:51:26.899-07:00<strong><span style="color:#000066;">Sunday April 22, 2007</span></strong><br /><strong><span style="color:#990000;">What Critical Care Medicine is all about?</span></strong><br /><br /><span style="color:#000000;"><strong>"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".</strong></span><br /><br /><br /><br /><em><span style="font-size:85%;color:#003333;"><strong>(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.<br /><br />- Editor, Iqbal Ratnani M.D)</strong></span></em>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-7200909198407342502.post-62308036899104220442007-04-21T10:19:00.000-07:002007-04-21T10:20:55.006-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Saturday April 21, 2007</span><br /></span><span style="color:#990000;">Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>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.</strong></span><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong>But what if bleeding is non-stop and life-threatening ?</strong></span><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong>Answer is off label use of activated Factor VII (</strong></span><a href="http://www.novoseven.com/" target="_blank"><strong><span style="color:#003300;">Novoseven</span></strong></a><span style="color:#000000;"><span style="color:#000000;"><strong>). In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes</strong></span> <span style="font-size:85%;">1.</span></span><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.annals.org/cgi/content/full/140/6/493" target="_blank"><span style="font-size:78%;color:#003333;">Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII </span></a><span style="font-size:78%;color:#003333;">- annals, 16 March 2004 Volume 140 Issue 6 Pages 493-494</span>Unknownnoreply@blogger.com10tag:blogger.com,1999:blog-7200909198407342502.post-23051740918474189902007-04-20T08:14:00.000-07:002007-04-20T08:16:40.361-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Friday April 20, 2007</span><br /><span style="color:#990000;">Quick way of differentiating non-gap metabolic acidosis<br /></span><br /><br />Once you determine from serum chemistry that you have a non-gap metabolic acidosis, </span></strong><br /><strong><span style="color:#000000;"><ul><li>Check the urine anion gap (UNa + UK – UCl) </li><li>If urine anion gap is positive, it is a renal cause (e.g. RTA; in reality only validated for types I, IV) </li><li>If urine anion gap is negative, the cause is extra-renal.</li></ul><div align="left"><br />Mnemonic to remember non gap metabolic acidosis is</div><div align="center"><br /><em>HARD UP</em></div><div align="left"> </div><div align="center"><br />Hyperalimentation</div><div align="center">Acetazolamide<br />RTA (Renal)</div><div align="center">Diarrhea</div><div align="center">Ureterosigmoidostomy</div><div align="center">Pancreatic fistula</div><div align="left"><br /><br /><br /><span style="color:#003300;">Related previous pearl:</span> </span></strong><a href="http://icuroom-pearls.blogspot.com/2006/07/saturday-july-15-2006-case-32-year-old.html" target="_blank"><strong><span style="color:#660000;">Metabolic acidosis from HIV meds</span></strong></a> </div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-11732108976948883222007-04-19T11:27:00.000-07:002007-04-19T11:30:08.505-07:00<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXWlYtkMbRBfgMGkleqEF6mXcgMsrZrwuHS9F0s8qPM_xJsYfyHD0WqHvCr1XF4324BMf2CMXl2ivFcWkdiFxLeBSGE0K916uGBtL9JFHS7UTbsAoNbFLAAhpWIh8E4Bgy30Sa_OPdP5CB/s1600-h/face1.jpg"><img id="BLOGGER_PHOTO_ID_5055207784745115906" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXWlYtkMbRBfgMGkleqEF6mXcgMsrZrwuHS9F0s8qPM_xJsYfyHD0WqHvCr1XF4324BMf2CMXl2ivFcWkdiFxLeBSGE0K916uGBtL9JFHS7UTbsAoNbFLAAhpWIh8E4Bgy30Sa_OPdP5CB/s320/face1.jpg" border="0" /></a><span style="color:#660000;"><strong> </strong></span><br /><span style="color:#660000;"><strong></strong></span><br /><span style="color:#660000;"><strong>Q:</strong></span> <em><strong><span style="color:#003333;">Which medicine may have cause this "bluish" discoloration of skin, known as "The blue man syndrome"?<br /></span></strong></em><br /><span style="font-size:85%;"><strong>Hint:</strong> <em><span style="color:#003300;">Its a heart medicine and may cause brownish hyperpigmentation of skin as well.</span></em></span><br /><br /><br /><br /><span style="color:#000000;"><strong><span style="color:#660000;">A:</span> Amiodarone</strong></span><br /><br /><strong><span style="color:#000000;">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.<br /></span></strong><br /><br /><span style="color:#003333;"><strong>Related previous pearls:</strong></span><br /><br /><a href="http://icuroom-pearls.blogspot.com/2005/11/amiodarone.html" target="_blank"><strong><span style="color:#660000;">Why we call it Am-iod-arone! </span></strong></a><br /><strong><span style="color:#660000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/01/friday-january-27-2006-amiodarone.html" target="_blank"><strong><span style="color:#660000;">Amiodarone Neurotoxicity!</span></strong></a><br /><strong><span style="color:#660000;"><br /></span></strong><a href="http://icuroom-pearls-november-2006.blogspot.com/2006/11/wednesday-november-1-2006-amiodarone.html" target="_blank"><strong><span style="color:#660000;">Amiodarone - Digoxin interaction !</span></strong></a><br /><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">References: click to get abstract<br /><br />1. </span><a href="http://circ.ahajournals.org/cgi/content/full/113/5/e63" target="_blank"><span style="font-size:78%;color:#003333;">The Blue Man - Amiodarone-Induced Skin Discoloration</span></a><span style="font-size:78%;color:#003333;">, Circulation. 2006;113:e63<br /><br />2. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8818442&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Dose-dependent appearance and disappearance of amiodarone-induced skin pigmentation</span></a><span style="font-size:78%;color:#003333;">. Clin Cardiol 1996; 19: 592-4.<br /><br />3. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6712888&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">The pathogenesis of amiodarone-induced pigmentation and photosensitivity</span></a><span style="font-size:78%;"><span style="color:#003333;">. Br J Dermatol 1984; 110: 451- 6.</span><br /></span><br /><div></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-38767622428860079792007-04-18T09:22:00.000-07:002007-04-18T09:23:34.256-07:00<strong><span style="color:#000066;">Wednesday April 18, 2007<br /></span></strong><strong><span style="color:#990000;">(arginine vasopressin) AVP-Receptor Antagonists</span><br /><br /><span style="color:#000000;">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.<br /><br />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.<br /><br />Conivaptan (</span></strong><a href="http://www.vaprisol.com/home.asp" target="_blank"><strong><span style="color:#003333;">Vaprisol</span></strong></a><strong><span style="color:#000000;">) 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</span>.</strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-60545967223978995182007-04-17T08:15:00.000-07:002007-04-17T08:16:29.284-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Tuesday April 17, 2007</span></span></strong><br /><strong><span style="color:#000000;"><span style="color:#990000;">Liver Complications of TPN<br /></span><br /><span style="color:#000000;">Although Parentral Nutrition is a lifesaving therapy in patients with gastrointestinal failure, its use may be associated with metabolic, infectious, and technical complications.<br /><br />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.<br /><br /><em>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.</em> 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</span>.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-15427440267172193852007-04-16T11:55:00.000-07:002007-04-16T11:57:42.028-07:00<strong><span style="color:#000066;">Monday April 16, 2007</span></strong><br /><span style="color:#990000;"><strong>Auto-PEEP</strong></span><br /><br /><strong><span style="color:#660000;">Q;</span> <span style="color:#003333;"><em>What level of extrinsic PEEP should be applied to counter act (intrinsic) auto-PEEP?</em></span></strong><br /><em><span style="color:#003333;"></span></em><br /><strong><span style="color:#660000;">A;</span> <span style="color:#000000;">75 - 85% of auto-PEEP.</span></strong><br /><br /><span style="color:#000000;"><strong>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.</strong></span><br /><br /><span style="color:#000000;"><strong><span style="color:#003333;">Read precise review on auto-peep:</span> </strong></span><a href="http://www.ccjm.org/PDFFILES/Mughal9_05.pdf" target="_blank"><span style="color:#000000;"><strong><span style="color:#660000;">Auto-positive end-expiratory pressure: Mechanisms and treatment</span> </strong></span></a><span style="color:#000000;"><strong>,</strong> <span style="font-size:85%;">M.M. MUGHAL, D.A. CULVER, O.A. MINAI, and A.C. ARROLIGA - CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 9 SEPTEMBER 2005</span></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-28976921225465485792007-04-15T22:58:00.000-07:002007-04-14T23:01:49.425-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday April 15, 2007</span></span></strong><br /><strong><span style="color:#000000;"><span style="color:#990000;">Elevation of the head of the bed- 30 or 45 degrees ?</span> </span></strong><br /><strong><span style="color:#000000;"><br />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 <span style="font-size:78%;">3</span>.<br /><br />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.<br /><br />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°. <span style="font-size:78%;">2</span><br /><br />So the answer is 45 degrees or to be diplomatically right - atleast more than 30 degrees.<br /><br />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.<br /><br />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?</span></strong><br /></span><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get article/abstract</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200602000-00017.htm;jsessionid=GlRZGdWMmyqJpR9nyymJ1KnfGjhcXq2HtJmPRlvP5TyLSpJQ09DB!-1243080020!-949856145!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia</span></a><span style="font-size:78%;color:#003333;">: A randomized study - Critical Care Medicine. 34(2):396-402, February 2006.<br />2. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=10584721&amp;dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial</span></a><span style="font-size:78%;color:#003333;"> - Lancet.1999 Nov 27;354(9193):1851-8.<br />3. </span><a href="http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/Elevationoftheheadofthebed.htm" target="_blank"><span style="font-size:78%;color:#003333;">Elevation of the Head of the Bed</span></a><span style="font-size:78%;color:#003333;"> - Institute for Healthcare Improvement</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-56795939057506760042007-04-14T10:43:00.000-07:002007-04-14T10:48:54.189-07:00<strong><span style="color:#000066;">Saturday April 14, 2007</span><br /><span style="color:#990000;">HYPERTONIC</span><span style="color:#990000;"> SALINE THERAPY</span><br /><br /><span style="color:#000000;">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: </span></strong><br /><ul><li><strong><span style="color:#000000;">hyponatremic states, </span></strong></li><strong><li><span style="color:#000000;">volume resuscitation in shock,</span></li><li><span style="color:#000000;">brain injury and</span></li><li><span style="color:#000000;">Miscellaneous</span></li></ul><br /><span style="color:#660000;">Hyponatremic states</span><br /><br /><span style="color:#000000;">1. Syndrome of inappropriate antidiuretic hormone (occasionally indicated)</span><br /><span style="color:#000000;">2. Cerebral salt-wasting syndrome (indicated if hyponatremia<br />is significant)<br /><br />3. Other causes (rarely indicated) </span><br /><ul><li><span style="color:#000000;">Psychogenic polydipsia</span></li><li><span style="color:#000000;">Diuretic overuse/abuse</span></li><li><span style="color:#000000;">Addison disease</span></li><li><span style="color:#000000;">Excessive losses of gastrointestinal secretions</span></li><li><span style="color:#000000;">Late-stage cirrhosis, congestive heart failure, or renal disease</span></li></ul><span style="color:#000000;"><p><br /><span style="color:#660000;">Volume resuscitation in shock (may be beneficial)</span></p><ul><li>Hemorrhagic shock</li><li>Septic shock</li><li>Major burns<br /> </li></ul><p><span style="color:#660000;">Brain injury (may be beneficial)</span> Traumatic or nontraumatic<br /><br /><br /><span style="color:#660000;">Miscellaneous uses</span><br /><br /><span style="color:#000066;">Oral (largely historical)</span></p><ul><li>Heat-related disorders</li><li>Orthostatic hypotension</li><li>Cystic fibrosis</li></ul><p><br /><span style="color:#000066;">Parenteral uses</span></p><span style="color:#000066;"></span><ul><li>Sclerotherapy (injected directly into affected vein)</li><li>After coronary artery bypass surgery (intravenous)</li><li>Leishmaniasis (intradermal)</li><li>Midtrimester abortion (intra-amniotic)<br /> </li></ul><p></span><span style="color:#003333;">Related previous pearl:<br /></span><a href="http://icuroom-pearls.blogspot.com/2006/02/hsiceaih.html" target="_blank"><span style="color:#660000;">Hypertonic Solution (3% NS) in cerebral edema and intracranial hypertension</span></a></strong></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-28048041896073623392007-04-13T15:27:00.000-07:002007-04-13T15:29:39.809-07:00<span style="color:#000066;"><strong>Friday April 13, 2007<br /></strong></span><strong><span style="color:#660000;"><span style="color:#990000;">CVP (central venous pressure) via femoral central line</span><br /></span><br /><span style="color:#000000;">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</span></strong><span style="color:#000000;"> <span style="font-size:78%;">1</span>.<strong> Another small study later showed reliable accuracy from common iliac venous line</strong> </span><span style="font-size:78%;color:#000000;">2.<br /></span><strong><span style="color:#000000;"><br />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.<br /><br />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).<br /><br />Study concluded that CVP can be accurately measured in a femoral vein, using standard CVC, in patients with normal Intra-abdominal pressure 3.<br /><br /><br />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.<br /></span><br /><br /><span style="color:#003333;">Related previous pearls:</span> </strong><a href="http://icuroom-pearls.blogspot.com/2006/06/cvp-via-picc.html" target="_blank"><strong><span style="color:#660000;">CVP via PICC</span></strong></a><strong><span style="color:#660000;"> , </span></strong><a href="http://icuroom-pearls-november-2006.blogspot.com/2006/11/monday-november-6-2006-awareness-of.html" target="_blank"><strong><span style="color:#660000;">CVP via biggest port on venous catheter !</span></strong></a><strong><span style="color:#660000;"> , </span></strong><a href="http://icuroom-pearls-december-2006.blogspot.com/2006/12/saturday-december-09-2006-picc-or-cvc.html" target="_blank"><strong><span style="color:#660000;">PICC or CVC ?</span></strong></a><strong><span style="color:#660000;"> , </span></strong><a href="http://icuroomnet-pearls-october-2006.blogspot.com/2006_10_12_archive.html" target="_blank"><strong><span style="color:#660000;">Power PICC</span></strong></a><br /><br /><br /><br /><span style="font-family:arial;font-size:78%;color:#003333;">References: click to get abstract / article<br /><br />1. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8609751&dopt=Abstract" target="_blank"><span style="font-family:arial;font-size:78%;color:#003333;">Comparison of intrathoracic and intra-abdominal measurements of central venous pressure</span></a><span style="font-family:arial;font-size:78%;color:#003333;"> - Lancet. 1996 Apr 27;347(9009):1155-7.<br />2. </span><a href="http://www.cja-jca.org/cgi/reprint/45/8/798.pdf" target="_blank"><span style="font-family:arial;font-size:78%;color:#003333;">Central venous pressure from common iliac vein reflects right atrial pressure</span></a><span style="font-family:arial;font-size:78%;color:#003333;"> - CAN J ANAESTH 1998 / 45: 8 / pp 798-801<br />3. </span><a href="http://ccforum.com/content/11/S2/P277" target="_blank"><span style="font-family:arial;font-size:78%;color:#003333;">Central venous pressure in a femoral access: a true evaluation ? </span></a><span style="font-family:arial;font-size:78%;color:#003333;">Critical Care 2007, 11(Suppl 2):P277</span>Unknownnoreply@blogger.com12tag:blogger.com,1999:blog-7200909198407342502.post-986824153432576122007-04-12T09:06:00.000-07:002007-04-12T09:08:11.310-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Thursday April 12, 2007</span><br /><span style="color:#990000;"> Drug Induced Systemic Lupus Erythematosus (DISLE)<br /></span><br /></strong></span><span style="color:#003333;"><em>Today's pearl contributed by<br />Jennifer Burns, D.Pharm</em></span><br /><em><span style="color:#003333;">Vassar Brothers Medical Center</span></em><br /><span style="color:#000000;"><em><span style="color:#003333;">Poughkeepsie, NY<br /></span></em><strong><br /><br />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</strong> <span style="font-size:78%;">1</span><strong> , acute acalculous cholecystitis and cardiac tamponade</strong> <span style="font-size:78%;">2.</span><strong><br /><br />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.<br /><br />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</strong> (Stratton, 1985).<strong> Symptoms of DISLE are the same as in SLE but are less severe</strong> (Weinstein, 1980). </span><br /><span style="color:#000000;"><br /><strong>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.<br /><br />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</strong> <span style="color:#000000;">(Totoritis, 1985)(Anon, 1974).</span><strong> In fact, the drugs most often implicated in DISLE are all metabolized in the liver by acetylation (eg, hydralazine, procainamide, anticonvulsants, INH).</strong></span><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">Reference:<br /><br />1. </span><a href="http://www3.interscience.wiley.com/cgi-bin/abstract/112636800/ABSTRACT?CRETRY=1&SRETRY=0" target="_blank"><span style="font-size:78%;color:#003333;">Fulminating hydralazine-induced lupus pneumonitis</span></a><span style="font-size:78%;color:#003333;"> - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506<br /><br />2. </span><a href="http://rheumatology.oxfordjournals.org/cgi/content/full/40/6/709" target="_blank"><span style="font-size:78%;color:#003333;">Acute acalculous cholecystitis and cardiac tamponade in a patient with drug-induced lupus </span></a><span style="font-size:78%;color:#003333;">- Rheumatology 2001; 40: 709-711</span>Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-7200909198407342502.post-66103129132093500652007-04-11T07:45:00.001-07:002007-04-11T07:45:53.299-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday April 11, 2007</span><br /><span style="color:#990000;">Upper extremity deep vein thrombosis (UEDVT)</span><br /><br /></span><span style="color:#000000;">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.<br /><br />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.<br /><br />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.</span></strong><span style="color:#000000;"> </span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-61747902038523010292007-04-10T15:42:00.000-07:002007-04-10T15:44:03.914-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Tuesday April 10, 2007</span><br /></strong><strong><span style="color:#990000;">Cricoid Pressure - Avoiding the pitfall<br /></span><br />Continuing our theme from yesterday on </strong></span><a href="http://april-2007-icuroom.blogspot.com/2007/04/monday-april-9-2007-revisiting-rsi-or.html" target="_blank"><span style="color:#660000;"><strong>intubation / RSI</strong></span></a><span style="color:#000000;"><strong>,<br /><br />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.<br /><br />Rapid sequence intubation should be used with cricoid pressure to reduce the risk of regurgitation and inhalation.<br /><br /><br /><br />See a nice review </strong></span><a href="http://medind.nic.in/iad/t06/i1/iadt06i1p12.pdf" target="_blank"><strong><span style="color:#660000;">The Cricoid Pressure</span></strong></a><span style="color:#000000;"><strong> -</strong> <em>Dr. Sanjib Das Adhikary, Dr. Krishnan B. S. - Indian J. Anaesth. 2006; 50 (1) : 12 - 19</em></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-85816527548698986102007-04-09T13:30:00.000-07:002007-04-09T13:34:44.236-07:00<strong><span style="color:#000066;">Monday April 9, 2007<br /></span><span style="color:#990000;">Revisiting RSI or Rapid Sequence Induction protocol</span></strong><br /><strong><br /><span style="color:#000000;">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 <em>patient’s stomach might be full and complication like aspiration can happen. </em></span><br /><em><br /></em><span style="color:#000000;">Medications fall into three categories:</span><br /> <span style="color:#000000;"><br /></span><span style="color:#660000;">1)</span> <span style="color:#003333;">Pretreatment agents:</span><br /></span><span style="color:#003333;"><ul><li></span>Oxygen, use 100% with reservoir mask, avoid positive pressure ventilation. </li><li>Fentanyl (3mcg/kg) </li><li>Lidocaine may suppress the cough reflex (1.5 mg/kg) </li><li>Atropine may decrease the bradycardia </li></ul><br /><span style="color:#660000;">2)</span> <span style="color:#003333;">Induction agents:</span><br /><ul><li>Pentothal (4 mg/kg) </li><li>Etomidate (0.3 mg/kg) (may induce adrenocortical dysfunction) </li><li>Ketamine (1-2 mg/kg) </li><li>Midazolam (0.25 mg/kg) </li><li>Propofol </li></ul><br /><span style="color:#660000;">3)</span> <span style="color:#003333;">Paralyzing agents:</span><br /><ul><li>Succinylcholine (2mg/kg) - may induce hyperkalemia </li><li>Vecuronium (0.15 mg/kg), </li><li>Rocuronium (0.8 mg/kg)<br /> </li></ul><p><span style="color:#003300;">Related previous link:</span> </strong><a href="http://icuroompearls-september2006.blogspot.com/2006/09/saturday-september-23-2006-preventing.html" target="_blank"><strong><span style="color:#660000;">Preventing sympathetic surge during head injury patient's intubation</span></strong></a><br /><strong><br /></strong></p><p><strong><span style="color:#003333;">2 great reviews </span></strong></p><p><a href="http://www.chestjournal.org/cgi/content/abstract/127/4/1397" target="_blank"><strong><span style="color:#660000;">Airway Management of the Critically Ill Patient Rapid-Sequence Intubation</span></strong></a><strong>,</strong> <em>Chest. 2005;127:1397-1412</em></p><p><a href="http://www.emedicine.com/emerg/topic939.htm" target="_blank"><span style="color:#660000;"><strong>Rapid Sequence Induction</strong></span></a><em> (emdicine.com)<br /></em><strong><br /></strong></p><p><strong><span style="color:#003333;">Other related link</span> </strong><a href="http://www.rnpalm.com/RSI_download.htm" target="_blank"><strong><span style="color:#660000;">Quick dose calculator of drugs used in RSBI, by just entering weight</span></strong></a><br /><br /><br /><em><span style="font-size:85%;color:#003333;">To share with readers, here is an email from overseas.<br /><br />"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!!....<br /><br />Dr hany alfayed"</span></em></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-88566725215279314942007-04-08T17:24:00.000-07:002007-04-08T17:25:50.373-07:00<strong><span style="color:#000066;">Sunday April 8, 2007<br /></span><span style="color:#990000;">3 Basic Principles of Medical Ethics<br /></span><br /><span style="color:#000000;"><span style="color:#003333;">Non-Malfeasance:</span> Do no harm<br /><span style="color:#003333;">Beneficence:</span> Advance the good<br /><span style="color:#003333;">Autonomy:</span> Pt. has right to choose treatment</span><br /> </strong><br /><strong><br />Related: </strong><a href="http://www.ama-assn.org/ama/pub/category/2512.html" target="_blank"><strong><span style="color:#660000;">American Medical Association's Principles of medical ethics</span></strong></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-55531143404920014312007-04-07T12:37:00.000-07:002007-04-07T12:40:35.141-07:00<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHNbYq6UEn1u0rUnwA9Gv3vmpyaJXVlmXBONk8SgG33vuF3JbeOO3KX9MDNLV4fWlnwI9cSWKTLXjrP5gD05hMHW4OeGids_C89Ae03B9-0CPpvEs5D1POEZZ4qMN42D0C9coqW85qkB6W/s1600-h/introd.jpg"><img id="BLOGGER_PHOTO_ID_5050773417951831218" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHNbYq6UEn1u0rUnwA9Gv3vmpyaJXVlmXBONk8SgG33vuF3JbeOO3KX9MDNLV4fWlnwI9cSWKTLXjrP5gD05hMHW4OeGids_C89Ae03B9-0CPpvEs5D1POEZZ4qMN42D0C9coqW85qkB6W/s400/introd.jpg" border="0" /></a><br /><div><strong><span style="color:#000066;">Saturday April 7, 2007</span></strong><br /><span style="color:#990000;">Bedside procedure tip</span><br /><br /><strong><span style="color:#000000;">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.<br /><br />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).<br /></span></strong><br /><em><span style="color:#000000;">(Name of contributor and institution holded on request.)<br /></span></em><br /><em><span style="color:#000000;">(Anecdotals described here may not be tested in clinical trials and may solely be only personal experiencs)</span></em></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7200909198407342502.post-26386942296618065382007-04-06T17:30:00.000-07:002007-04-06T17:32:21.874-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Friday April 6, 2007</span></strong></span><br /><span style="color:#000000;"><strong><span style="color:#990000;">EARLY MOBILIZATION AND AMBULATION OF VENTILATOR DEPENDENT PATIENTS IN ICU</span><br /><br /></strong></span><span style="color:#000000;"><strong></strong><strong><span style="color:#990000;"></span></strong></span><span style="color:#000000;"><span style="color:#990000;"><em><span style="font-size:85%;color:#003300;">Today's pearl contributed by:</span></em><br /></span><strong> </strong><em><span style="font-size:85%;">Christiane Perme, PT CCS<br />Board Certified Cardiovascular and Pulmonary Clinical Specialist<br />Senior Physical Therapist<br />Department of Physical Therapy and Occupational Therapy<br />The Methodist Hospital,<br />Texas Medical Center, Houston, Texas<br /></span></em></span><a href="mailto:cperme@tmh.tmc.edu"><span style="font-size:85%;color:#000000;"><em>cperme@tmh.tmc.edu</em></span></a><br /><strong><span style="color:#000000;"><br /><br />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.<br /><br />Bailey and colleagues<span style="font-size:85%;"> (1)</span> 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.<br /><br />Perme and colleagues <span style="font-size:85%;">(2)</span> 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.<br /><br />Mechanically ventilated patients in ICU can be safety mobilized when appropriate measures are taken.</span></strong><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. Bailey P, Thomsen G, Spuhler V, Blair R, Jewekes J, Bezdjian L, Veale K, Rodriguez, AS, Hopkins R.</span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200701000-00022.htm;jsessionid=GV8QB8vQ1l69Q1rqFcQmKWYytKFRpZZNKQyC8dBdyPV1Jh0x6dKg!534415943!-949856144!8091!-1"><span style="font-size:78%;color:#003333;"> </span></a><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200701000-00022.htm;jsessionid=GV8QB8vQ1l69Q1rqFcQmKWYytKFRpZZNKQyC8dBdyPV1Jh0x6dKg!534415943!-949856144!8091!-1"><span style="font-size:78%;color:#003333;">Early activity is feasible and safe in respiratory failure patients</span></a><span style="font-size:78%;color:#003333;">. Critical Care Medicine 2007.Vol. 35 Number 1.139-145<br />2. Perme C, Southard R, Joyce D, Noon G, Loebe M. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16878612&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Early mobilization of LVAD recipients who require prolonged mechanical ventilation.</span></a><span style="font-size:78%;color:#003333;"> Texas Heart Institute Journal 2006; 33:130—3</span>Unknownnoreply@blogger.com70