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
Related: American Medical Association's Principles of medical ethics
Sunday, April 8, 2007
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)
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
EARLY MOBILIZATION AND AMBULATION OF VENTILATOR DEPENDENT PATIENTS IN ICU
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
cperme@tmh.tmc.edu
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
EARLY MOBILIZATION AND AMBULATION OF VENTILATOR DEPENDENT PATIENTS IN ICU
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
cperme@tmh.tmc.edu
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
1. 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
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
1. 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.
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
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?
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?
Sunday, April 1, 2007
Sunday April 1, 2007
Pseudo-hypokalemia
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.
Pseudo-hypokalemia
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.
Subscribe to:
Posts (Atom)