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 ?


Answer: 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.

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

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

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
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 (emdicine.com)

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


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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)

Tuesday April 3, 2007
Endotrol

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?