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
Friday, April 13, 2007
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).
Reference:
1. Fulminating hydralazine-induced lupus pneumonitis - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506
2. Acute acalculous cholecystitis and cardiac tamponade in a patient with drug-induced lupus - Rheumatology 2001; 40: 709-711
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).
Reference:
1. Fulminating hydralazine-induced lupus pneumonitis - Arthritis Care & Research - Volume 55, Issue 3 , Pages 501 - 506
2. 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.
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
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:
Fentanyl (3mcg/kg) Lidocaine may suppress the cough reflex (1.5 mg/kg) Atropine may decrease the bradycardia
2) Induction agents:
3) Paralyzing agents:
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:
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 intubation2 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
To share with readers, here is an email from overseas.
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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
Related: American Medical Association's Principles of medical ethics
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
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.
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