tag:blogger.com,1999:blog-21383521280050410722024-03-12T23:45:12.253-07:00icuroom.net December 2007 ArchiveUnknownnoreply@blogger.comBlogger31125tag:blogger.com,1999:blog-2138352128005041072.post-86867433409695531802007-12-31T18:07:00.000-08:002007-12-30T18:09:35.730-08:00<strong><span style="color:#000066;">Monday December 31, 2007<br /></span></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><strong><br /></strong><br /><strong><span style="color:#990000;">Case;</span></strong> <strong><em><span style="color:#003300;">79 year old male admitted with Non ST segment elevation acute MI (myocardial infarction). Patient is treated conservatively without any invasive intervention. Clinically patient stabalized, has no symptoms and echocardiogram remains stable. Pt. seems ready to go to telemetry floor on 4th day of admission but on review of labs, Troponin-I remain elevated around 18 ng per milliliter.<br /></span></em><br /><span style="color:#990000;"><br />Answer:</span> <span style="color:#000000;">Troponin, once secreted, remains elevated for 7-10 days.</span><br /><br /><span style="color:#000000;">Troponin I is not expressed in human skeletal muscle and is highly specific for myocardial tissue, and should not be detectable in the blood of healthy persons but remains elevated for 7 to 10 days after an episode of myocardial infarction.</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References: click to get abstract / article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://content.nejm.org/cgi/content/abstract/335/18/1342" target="_blank"><span style="font-size:78%;color:#003333;">Cardiac-Specific Troponin I Levels to Predict the Risk of Mortality in Patients with Acute Coronary Syndromes</span></a><span style="font-size:78%;color:#003333;"> - Volume 335:1342-1349, October 31, 1996, The New England Journal of Medicine</span>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-2138352128005041072.post-36617378957602980182007-12-30T09:53:00.000-08:002007-12-30T09:54:37.261-08:00<strong><span style="color:#000066;">Sunday December 30, 2007<br /></span></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><strong><br /></strong><br /><strong><span style="color:#660000;">Case;</span> <em><span style="color:#003333;">67 year old male admitted with acute GI bleed seconday to coumadin (warfarin) overdose with INR more than 7. You ordered, pRBC, FFP (fresh frozen plasma) and IV vitamin K. But you are afraid that patient may not survive before all the infusions are available. What could be your choice in such desperation?<br /></span></em><br /><br /><span style="color:#660000;">A;</span> <span style="color:#003333;">recombinant FVIIa (Novo seven)<br /></span><br /><span style="color:#000000;">In many anecdotal reports (see references), novoseven has showed very quick reversal of PT / INR.</span></strong><br /><br /><br /><span style="font-size:78%;color:#003300;">References:</span><br /><span style="font-size:78%;"><br /><span style="color:#003300;">1. Recombinant factor VIIa corrects prothrombin time in cirrhotic patients: A preliminary study: Gastroenterology 113:1930-1937, 1997</span><br /><br /><span style="color:#003300;">2. Recombinant factor VIIa (rFVIIa) successfully and rapidly corrects the excessively high international normalized ratios (INR) and prothrombin times induced by warfarin. Blood 96 (11 Part 1): 638a, 2000</span><br /><br /><span style="color:#003300;">3. Reversal of Warfarin-Induced Excessive Anticoagulation with Recombinant Human Factor VIIa Concentrate. Ann Inter Med. 137:884-888, 2002</span><br /><br /><span style="color:#003300;">4. Hemorrhagic complication of thrombocytopenia and oral anticoagulant: Is there a role for recombinant activated factor VII ?. Intensive Care Med 28 (Suppl 2):S228, 2002</span></span><br /></span>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-2138352128005041072.post-43129355476111705932007-12-29T21:46:00.000-08:002007-12-28T21:51:57.925-08:00<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSmv9YChdSvNobDa2qFL5ui56V1SjAjbRaOOyk2l1u_0y8SHVjFvXQPwrUK_GZ1g4zaj-CHejMnvspiLoPwGRVTWBlxj6eQUb-nkVm2QaqALkuY14BL0idWMLah8m8LI47W1gfoZ7iwjo/s1600-h/cf2.jpg"><img id="BLOGGER_PHOTO_ID_5149267528610605346" style="FLOAT: left; MARGIN: 0px 10px 10px 0px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSmv9YChdSvNobDa2qFL5ui56V1SjAjbRaOOyk2l1u_0y8SHVjFvXQPwrUK_GZ1g4zaj-CHejMnvspiLoPwGRVTWBlxj6eQUb-nkVm2QaqALkuY14BL0idWMLah8m8LI47W1gfoZ7iwjo/s400/cf2.jpg" border="0" /></a><br /><div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeCYLONlXCqMV5eDx2Noxh82FR_DgWn-dTT1rIM3fInrvY7DzI3BqWv8JkjqOWVphZO8iK9CpuC4ipvqEjvfo2FkclIxo0hd7nTOjMPR8P7RSWnwj_o4PdT9SEjYN6DcAYV8KWOF9iVww/s1600-h/pressure-easy.jpg"><img id="BLOGGER_PHOTO_ID_5149267451301194002" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeCYLONlXCqMV5eDx2Noxh82FR_DgWn-dTT1rIM3fInrvY7DzI3BqWv8JkjqOWVphZO8iK9CpuC4ipvqEjvfo2FkclIxo0hd7nTOjMPR8P7RSWnwj_o4PdT9SEjYN6DcAYV8KWOF9iVww/s400/pressure-easy.jpg" border="0" /></a> </div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div></div><div><strong><span style="color:#000066;">Saturday December 29, 2007<br /></span><span style="color:#cc0000;">Cuff pressure on tracheal tubes<br /></span><br /><br />Q; <em><span style="color:#003333;">What should be the optimal pressure applied to tracheal tube cuffs?</span></em><br /><br /><br /><span style="color:#000000;">A; 20 - 30 cm H2O.<br /><br />Cuff pressure should not exceed the capillary occlusion pressure of the tracheal wall. The concern is that with increasing cuff pressure beyond given threshold, it may compromise mucosal blood supply and may result in subglottic stenosis. Tracheal mucosal ischemia occurs when endotracheal tube cuff pressure exceeds above 34 cm H2O (some suggests it is safe till 40 cm H2O).<br /></span></strong></div><div><strong><span style="color:#000000;">See pictures of couple of cuff pressure check or controller devices for (endo)tracheal tubes. Click on pictures to reach company's web site. </span></strong></div><div><strong><span style="color:#000000;"><br /> </div></span></strong><div><em><span style="color:#000000;">Note: we have no relationship with any commercial product and info. given here is solely for educational purpose.<br /></span></em><br /><strong><span style="color:#003333;">Related previous pearl:</span> </strong><a href="http://icuroom-pearls-0806.blogspot.com/2006_08_29_archive.html" target="_blank"><strong><span style="color:#990000;">Endotracheal Tube Cuff Pressure and VAP</span></strong></a><br /><div></div></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-21211161368655857752007-12-28T13:59:00.000-08:002007-12-28T14:00:57.299-08:00<span style="color:#000066;"><strong>Friday December 28, 2007<br /></strong></span><strong><span style="color:#990000;">Abdominal exam in pneumothorax<br /></span><br /><br /><span style="color:#660000;">Q;</span></strong> <strong><em><span style="color:#003333;">Why abdominal exam is important in pneumothorax?</span></em><br /><br /><span style="color:#660000;">A;</span> <span style="color:#000000;">Abdominal distension could be appreciated in pneumothorax as increased pressure in the thoracic cavity produces caudal deviation of the diaphragm. Also, secondary pneumoperitoneum may produced as air dissects across the diaphragm through the pores of Kohn.</span><br /><br /><br /><span style="color:#003333;">Related previous pearl:</span> </strong><a href="http://january07-icuroom.blogspot.com/2007_01_17_archive.html" target="_blank"><strong><span style="color:#660000;">Skinfold or pneumothorax ?</span></strong></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-53629099635177867092007-12-27T11:37:00.000-08:002007-12-27T11:39:54.691-08:00<strong><span style="color:#000066;">Thursday December 27, 2007</span><br /></strong><strong><span style="color:#990000;">“MEL GIBSON” in ICU / ICU Daily Goals Worksheet</span></strong><br /><strong></strong><br /><span style="color:#000000;"><strong>Dr. Vincent, Jean-Louis proposed "Fast Hug" mnemonic (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control) to make sure we cover key aspects of day to day care of ICU.</strong> 1<strong> Here is another mnemonic "MEL GIBSON" everyday in ICU.</strong></span><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">M Medication list reviewed. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">E Extremities covered (DVT prophylaxis). Also “E” for exercise (change of position, Out of bed, Physical Therapy). </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">L Labs and Radiological studies reviewed.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">G Glucose control. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">I Infection control measures taken, including elevation of bed to 30 degrees, lines reviewed etc. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">B Breathing. Did we allow our patient to have sponteneous breathing everyday. This include sedation break everyday to patient. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">S Swan /Hemodynamics/volume (Saline) status reviewed. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">O Oxygen supply status, including review of Oxygen Extraction ratio, if applicable.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">N Nutrition/GI prophylaxis.</span></strong><br /><br /><strong>Related: Please click </strong><a href="http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/ICUDailyGoalsWorksheet.htm" target="_blank"><strong>here</strong></a><strong> to read about ICU Daily Goals Worksheet from IHI.</strong><br /><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">References: Click to get articles/abstract </span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200506000-00005.htm;jsessionid=DuCoYu27EMD6seSGhjnt8EaRu8EfTAAcibNoNHVUcZsN7ZAuJcfY!1155136469!-949856144!9001!-1" target="_blank"><span style="font-size:78%;color:#003333;">Give your patient a fast hug (at least) once a day</span></a><span style="font-size:78%;color:#003333;"> - Critical Care Medicine. 33(6):1225-1229, June 2005</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-78204537119550422522007-12-26T18:06:00.000-08:002007-12-26T18:07:27.387-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday December 26, 2007</span><br /></span></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><strong><span style="color:#000000;"><br /><span style="color:#660000;"><br />Case:</span> <em><span style="color:#003333;">You have been called by nurse as radial artery "A-line" continue to have 'problems'. You decide to change it over wire. Despite changing it over wire, it does not produce satisfatory waveform on monitor. What should be your next thought?</span></em><br /><br /><span style="color:#660000;"><br />Answer:</span> <span style="color:#000066;">Probable radial artery occlusion<br /></span><br /></span><span style="color:#000000;">Radial artery occlusion can be encountered in upto 30% of patients and incidence is higher than expected. It is of legal importance to document Allen's test prior to radial artery insertion and assessment of flow with ultrasound is desirable. 20-gauge cannulae is safest. Radial artery occlusion is relatively more common in females. Other factors include insertion technique (causing hematoma), low cardiac output, anticoagulation (prone to cause hematoma), duration of cannulation, vasopressors and previous surgical history etc. Heparinized solution has no advantage over regular saline flushes.<br /><br />In case of suspected ischemia, catheter should be removed and the hand should be monitored closely. Its not advisable to apply warm wrap as it may make ischemia worse. Arterial duplex Doppler sonography should be ordered to rule out arterial spasm, delineate areas of occlusion, thrombus formatiom and flow through the artery. If arterial duplex suspects spasm, a sympathetic block can be performed at bedside to induce vasodilatation. In such cases, vascular consult is recommended. If required angiography should be performed to evaluate the the need of operative intervention for clot removal, repair of lacerated radial artery, or to perform a graft procedure. Intravenous heparin can be used if no contraindication and local thrombolytic therapy can also be applied.<br /><br />Beside above treatment modalities, nursing interventions include close monitoring, splinting of arm and demarcation of ischemic area.</span></strong><br /><br /><br /><span style="color:#003333;"><br /><span style="font-size:78%;">References / recommended readings; click to get abstract / article</span></span><br /><span style="font-size:78%;"><br /><span style="color:#003333;">1. </span></span><a href="http://ajcc.aacnjournals.org/cgi/content/abstract/13/4/315"><span style="font-size:78%;color:#003333;">Cannulation Injury of the Radial Artery:</span></a><a href="http://ajcc.aacnjournals.org/cgi/content/abstract/13/4/315"><span style="font-size:78%;color:#003333;"> Diagnosis and Treatment Algorithm </span></a><span style="font-size:78%;color:#003333;">Am. J. Crit. Care., July 1, 2004; 13(4): 315 - 319.<br />2. </span><a href="http://bja.oxfordjournals.org/cgi/content/abstract/52/1/41" target="_blank"><span style="font-size:78%;color:#003333;">RADIAL ARTERY CANNULATION</span></a><span style="font-size:78%;color:#003333;"> - British Journal of Anaesthesia, 1980, Vol. 52, No. 1 41-47<br />3. Cannulation Injuries of the Radial Artery Am. J. Crit. Care., July 1, 2004; 13(4): 314 - 315.<br />4. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=9699&dopt=AbstractPlus" target="_blank"><span style="font-size:78%;color:#003333;">Severe ischemia of the hand following radial artery catheterization.</span></a><span style="font-size:78%;color:#003333;"> Surgery. 1976;80:449–457<br />5. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=8866080&dopt=AbstractPlus" target="_blank"><span style="font-size:78%;color:#003333;">Ischaemia of the hand after radial artery monitoring</span></a><span style="font-size:78%;color:#003333;">. Cardiovasc Surg. 1996;4:456–458<br />6. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=3794060&dopt=AbstractPlus" target="_blank"><span style="font-size:78%;color:#003333;">Complications during and following radial artery cannulation: a prospective study</span></a><span style="font-size:78%;color:#003333;">. Intensive Care Med. 1986;12:424–428<br />7. Radial artery cannulation in 1000 patients: precautions and complications. J Hand Surg [Am]. 1977;2:482–485.<br />8. On the safety of radial artery cannulation. Anesthesiology. 1983;59:42–47.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-34070288783548306872007-12-25T18:02:00.000-08:002007-12-26T18:06:11.264-08:00<strong><span style="color:#000066;">Tuesday December 25, 2007</span></strong><br /><strong><span style="color:#990000;">Merry Christmas<br /></span></strong><br /><br /><br /><img id="BLOGGER_PHOTO_ID_5148467827174926562" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOkqlQO4YDowrrHqs3We0TNaxZ2r6SvRZXyb_rW9elk4ibJ8UnwcenFO9KfumohABbOimsYGRJdMvSl_l4AjCy-joazdH-Srty4niyCEW2-mKO_HO0Pzu0kevZSpz6-htpiHAVuP0Ubvo/s400/santa.jpg" border="0" />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-50337667472547695422007-12-24T23:04:00.000-08:002007-12-24T23:10:03.639-08:00<strong><span style="color:#000066;">Monday December 24, 2007</span></strong><br /><br /><span style="color:#660000;"><strong>Case:</strong></span> <em><strong><span style="color:#003333;">57 year old female, newly hemodialysis patient, transferred from floor to ICU after she developed seizure at the end of her dialysis session. No significant risk factor could be find otherwise. Nurse reports patient appear irritable and restless before episode and complain of headache, nausea and blurred vision. While resident was called to evaluate as patient also noticed to have muscular twitching and confusion, symptoms progressed and seizure was witnessed.</span></strong></em><br /><span style="color:#003333;"></span><br /><strong><span style="color:#000000;"><span style="color:#660000;">Answer:</span> Dialysis disequilibrium syndrome.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Dialysis disequilibrium syndrome is common during hemodialysis particularly patient’s first few dialysis sessions. It is characterized by neurologic symptoms of varying severity and actually may lead to herniation and death. The rapid reduction in BUN lowers the plasma osmolality, creating a transient osmotic gradient that promotes water movement into the cells, causing cerebral edema and consequently acute neurologic dysfunction. With better understanding of the process and newer dialysis techniques, severe form of syndrome is now not commonly seen. This not only explains that why our nephrology colleagues start with gentle but frequent sessions but also explains one of the several benefits of mannitol during dialysis.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"> Read interesting article from University of Calgary, Alberta, Canada : </span></strong><a href="http://www.biomedcentral.com/content/1471-2369/5/9" target="_blank"><strong><span style="color:#660000;">Dialysis Disequilibrium Syndrome: Brain death following hemodialysis for metabolic acidosis and acute renal failure</span></strong></a><strong><span style="color:#000000;"><span style="color:#660000;"> -</span> A case report followed with discussion and different management modalities</span></strong> (Ref.: BMC Nephrol. 2004; 5: 9.)Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-70642350021451408832007-12-23T06:02:00.000-08:002007-12-23T06:05:36.282-08:00<strong><span style="color:#000066;">Sunday December 23, 2007<br /></span><span style="color:#cc0000;">Paracentesis (Procedure video)</span></strong><span style="color:#cc0000;"><br /></span><br /><br /><object height="355" width="425"><param name="movie" value="http://www.youtube.com/v/V8jSUECts3Y&rel=1"><param name="wmode" value="transparent"><embed src="http://www.youtube.com/v/V8jSUECts3Y&rel=1" type="application/x-shockwave-flash" wmode="transparent" width="425" height="355"></embed></object>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-7279457802030782412007-12-22T09:21:00.000-08:002007-12-22T09:22:11.247-08:00<strong><span style="color:#000066;">Saturday December 22, 2007<br /></span></strong><strong><span style="color:#990000;">Re. Fentanyl Cough</span><br /><br /><span style="color:#000000;">Fentanyl is probably the most commonly used opioid in ICUs. Fentanyl is associated with coughing in upto 30% of patients. Usually its benign but may become explosive causing discomfort and increased intracranial and intra-ocular pressures. The various mechanisms proposed to explain fentanyl induced cough are inhibition of central sympathetic outflow leading to vagal predominance, histamine release or deformation of the tracheobronchial wall stimulating the irritant receptors. </span></strong><br /><br /><strong><span style="color:#000000;">Treatment is aerosol inhalation of Salbutamol, beclomethasone or sodium chromoglycate if needed.</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References: click to get abstract / article</span><br /><span style="font-size:78%;color:#003333;"><br />1. </span><a href="http://www.anesthesia-analgesia.org/cgi/content/short/92/6/1442" target="_blank"><span style="font-size:78%;color:#003333;">Explosive coughing after bolus fentanyl injection</span></a><span style="font-size:78%;color:#003333;">. Anesth Analg 2001; 92: 1442–3.<br /></span><a name="R5"></a><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=2316832&dopt=AbstractPlus" target="_blank"><span style="font-size:78%;color:#003333;">Tussive effect of a fentanyl bolus administered through a central venous catheter</span></a><span style="font-size:78%;color:#003333;">. Anaesthesia 1990; 45: 18–21.<br />3. </span><a href="http://www.cja-jca.org/cgi/content/abstract/38/3/330" target="_blank"><span style="font-size:78%;color:#003333;">Tussive effect of a fentanyl bolus</span></a><span style="font-size:78%;color:#003333;">. Can J Anaesth 1991; 38: 330–4<br />4. </span><a href="http://www.anesthesia-analgesia.org/cgi/content/abstract/57/1/31" target="_blank"><span style="font-size:78%;color:#003333;">Central vagal control of fentanyl-induced bradycardia during halothane anesthesia</span></a><span style="font-size:78%;color:#003333;">. Anesth Analg 1978; 57: 31–6<br />5. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=686415&dopt=AbstractPlus" target="_blank"><span style="font-size:78%;color:#003333;">Tracheal constriction by morphine and by fentanyl in man</span></a><span style="font-size:78%;color:#003333;">. Anesthesiology 1978; 49: 117–9.<br />6. </span><a href="http://www.cja-jca.org/cgi/content/abstract/50/3/297" target="_blank"><span style="font-size:78%;color:#003333;">Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced by iv fentanyl </span></a><span style="font-size:78%;color:#003333;">Canadian Journal of Anesthesia 50:297-300 (2003)</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-23599880678400249722007-12-21T12:08:00.001-08:002007-12-21T12:08:58.749-08:00<strong><span style="color:#000066;">Friday December 21, 2007<br /></span></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><br /><br /><strong><span style="color:#003333;"><em><br />What is the difference between Renagel and Renvela ?</em></span></strong><br /><br /><strong><span style="color:#000000;">Sevelamer is indicated for the control of serum phosphorus (P) in patients with Chronic Kidney Disease on hemodialysis. Sevelamer controls phosphorus and "Ca x P product" without the concerns of metal accumulation.<br /><br />Renagel and Renvela are two forms of Sevelamar.<br /><br />Renagel is Sevelamar Hydrochloride while Renvela is the Sevelamar carbonate. Both tablets are produced by the same company and available in 800 mg forms.<br /><br />Renvela, being in carbonate form has advantage as acid buffer and reduce the risk of acidosis. Renvela is a a next generation phosphate binder which will eventually replace Renagel (sevelamer hydrochloride).</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-73216609125276984132007-12-20T07:19:00.000-08:002007-12-20T07:21:21.393-08:00<strong><span style="color:#000066;">Thursday December 20, 2007</span><br /><span style="color:#990000;">Bedside tip - ECMO and lipid infusion</span><br /><br /><span style="color:#000000;">If you have a patient receiving extracorporeal membrane oxygenation (ECMO), TPN * should be instituted WITHOUT IV lipids. IV lipid emulsion increases the incidence of layering out, agglutination, or clot formation during ECMO. This may result in disruption of normal ECMO blood flow.</span><br /></strong><span style="font-size:85%;"><br />* TPN = Total Parenteral Nutrition<br /></span><br /><strong><br /><span style="color:#003333;">Related previous pearls:</span> </strong><a href="http://february-2007-icuroom.blogspot.com/2007_02_12_archive.html" target="_blank"><strong><span style="color:#660000;">ECMO</span></strong></a><strong>, </strong><a href="http://february-2007-icuroom.blogspot.com/2007_02_13_archive.html" target="_blank"><strong><span style="color:#660000;">ABGs while patient on ECMO</span></strong></a><br /><strong><br /><span style="color:#003333;">Important trial to watch:</span></strong> Multicenter <strong>CESAR trial</strong> - (Conventional ventilation or ECMO for Severe Adult Respiratory Failure - 180 patients) - The first international presentation of the results will be presented at the Society of Critical Care Medicine's 37th Critical Care Congess in Hawaii, February 2008.<br /><br /><br /><br /><span style="font-size:78%;color:#003333;">References :<br /><br />1. Comparison of methods for intravenous infusion of fat emulsion during extracorporeal membrane oxygenation . Pharmacotherapy 2005;25(11):1536-1540</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-79808077414174664272007-12-19T08:40:00.000-08:002007-12-19T08:42:49.289-08:00<strong><span style="color:#000066;">Wednesday December 19, 2007<br /></span></strong><strong><span style="color:#990000;">4 Carbapenems<br /></span><br /><br /><span style="color:#000000;">Doripenem is the new agent added to the list of Carbapenems, making the list to grow to 4. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><ol><li><span style="color:#000000;">Primaxin (imipenem/cilastatin), </span></li><li><span style="color:#000000;">Meropenem (Merrem), </span></li><li><span style="color:#000000;">Invanz (ertapenem) and </span></li><li><span style="color:#000000;">Doripenem (Doribax)</span></li></ol><p><span style="color:#000000;">Major points to remember about each carbapenem is<br /><br /><span style="color:#660000;">Primaxin</span> is marked by associated neurotoxicity. It may decrease seizure threshold, particularly in renal patients.<br /><br /><span style="color:#660000;">Invanz</span> is a very effective broad-spectrum choice against community acquired severe infections but does not cover pseudomonas and acinetobacter. It is now increasingly used as prophylaxis of surgical site infection following elective colorectal surgery, given as single 1-g dose given within 1 hour before surgical incision.<br /><br /><span style="color:#660000;">Meropenem</span> is safest in terms of neuro-toxicity and also covers MDR pseudumonas and acinetobacter.<br /><br />Newly introduced <span style="color:#660000;">Doripenem </span>is similar in clinical use as meropenem but is highly more effective with lower 50% inhibitory concentrations (MIC50) and 90% inhibitory concentrations (MIC90) for multidrug-resistant strains of mucoid Pseudomonas aeruginosa, nonmucoid P. aeruginosa and Burkholderia cepacia complex. This gives it advantage to be use in cases previously refractory to carbapenem therapy.<br /></span></strong><span style="color:#000000;"><br /></span><span style="font-size:78%;color:#003333;"><br /><br />References : click to get abstract/article<br /><br />1. </span><a href="http://aac.asm.org/cgi/content/abstract/49/6/2510" target="_blank"><span style="font-size:78%;color:#003333;">In Vitro Activity of Doripenem (S-4661) against Multidrug-Resistant Gram-Negative Bacilli Isolated from Patients with Cystic Fibrosis</span></a><span style="font-size:78%;color:#003333;"> - Antimicrobial Agents and Chemotherapy, June 2005, p. 2510-2511, Vol. 49, No. 6<br /><br />2. </span><a href="http://jac.oxfordjournals.org/cgi/content/abstract/54/1/144"><span style="font-size:78%;color:#003333;">Doripenem</span></a><a href="http://jac.oxfordjournals.org/cgi/content/abstract/54/1/144"><span style="font-size:78%;color:#003333;"> (S-4661), a novel carbapenem: comparative activity against contemporary pathogens including bactericidal action and preliminary in vitro methods evaluations</span></a><span style="font-size:78%;color:#003333;"> - Journal of Antimicrobial Chemotherapy 2004 54(1):144-154;</span><br /></p></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-30463959035641796362007-12-18T00:06:00.000-08:002007-12-18T00:07:46.868-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Tuesday December 18, 2007</span><br /></strong></span><span style="color:#000000;"><strong><span style="color:#990000;">Thing you may like to know about viagra !<br /></span><br />There are recent reports and FDA warning for cases of sudden decreases or loss of hearing following the use of PDE5 inhibitors, Viagra, Levitra, and Cialis (erectile dysfunction) and Revatio (pulmonary arterial hypertension). Hearing loss is mostly unilateral, may be sudden and may accompanied by tinnitus, vertigo and dizziness. Also, there are concerns that hearing loss may persist for long.<br /><br />As PDE5 inhibitors are getting more commonly used in ICUs for pulmonary HTN, it may be of importance to be aware of this side effect.<br /></strong></span><br /><span style="font-size:78%;"><br /><span style="color:#003333;">Reference:<br /><br /></span></span><a href="http://www.fda.gov/CDER/Drug/InfoSheets/HCP/ED_HCP.htm" target="_blank"><span style="font-size:78%;color:#003333;">Sildenafil (marketed as Viagra and Revatio) Vardenafil (marketed as Levitra) Tadalafil (marketed as Cialis) </span></a><span style="font-size:78%;color:#003333;">- FDA</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-45364670520248878992007-12-17T10:37:00.000-08:002007-12-17T10:41:57.073-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Monday December 17, 2007</span><br /></span></strong><strong><span style="color:#990000;">Re. Purple Glove Syndrome</span></strong><br /><strong><span style="color:#000000;"><br />Here are few responses re. our pearl from 2 days back, </span></strong><a href="http://december2007icuroom.blogspot.com/2007_12_14_archive.html" target="_blank"><strong><span style="color:#000066;">Phenytoin induced Purple glove syndrome</span></strong></a><br /><strong><span style="color:#000000;"><br /></span></strong><br /></span></strong><strong><span style="color:#000000;"><span style="color:#660000;">1)</span> <em>"I've given a lot of phenytoin over the years and I've never seen this. Neither have most of the people I know. The Mayo epilepsy group are are very good, and I don't discount what they have written (upto 5.9% *) but it seems unusual that no one else seems to see it more often than once in a blue moon. I have seen bad extravasations, which is more likely the cause of the problem. And, the crystallization of phenytoin in microvessels makes no sense as an explanation of a local complication for a drug being given intravenously. </em></span></strong><br /><strong><span style="color:#000000;"><em></em></span></strong><br /><strong><span style="color:#000000;"><em>Disclaimer: Much of the phenytoin I've given has been through a central line, where this wouldn't be an issue ".</em></span></strong><br /><span style="color:#000000;"></span><br /><span style="font-size:85%;color:#000000;">* (Ref. # 1 in said pearl: </span><a href="http://www.neurology.org/cgi/content/abstract/51/4/1034" target="_blank"><span style="font-size:85%;color:#003333;">Incidence and clinical consequences of purple glove syndrome in patients receiving intravenous phenytoin</span></a><span style="color:#000000;"><span style="font-size:85%;">, Neurology, 1998:51:1034-1039),</span> </span><br /><span style="color:#000000;"><strong><br /></strong><br />Thomas P. Bleck MD FCCM<br />Ruggles Chairman of Neurology, Evanston Northwestern Healthcare;<br />Vice Chair for Academic Programs, Department of Neurology, and<br />Professor of Neurology, Neurological Surgery, and Medicine,<br />Northwestern University Feinberg School of Medicine<br />Founding Past President, The Neurocritical Care Society(</span><a href="http://www.neurocriticalcare.org/" target="_blank" rel="nofollow"><span style="color:#000000;">http://www.neurocriticalcare.org</span></a><span style="color:#000000;">)</span><br /></span><span style="color:#000000;"><br /><strong><br /><span style="color:#660000;"></span></strong><br /><strong><span style="color:#660000;">2)</span> <em>"It must be once in a blue moon, as I have witnessed this only twice during my practice. Please check out the link below</em> </strong><br /><br /></span><a href="http://www.aafp.org/afp/20070315/photo.html" target="_blank"><span style="color:#000066;">Photo Quiz - Distal Upper Extremity Edema and Discoloration</span></a><span style="color:#000000;"> </span><br /></span><span style="color:#000000;"><br />Surindra J. Singh, M.D., Intensivist, VAMC, Salem, VA 24153 </span><a href="mailto:Surindra.Singh@va.gov"><span style="color:#000000;">Surindra.Singh@va.gov</span></a><br /><span style="color:#000000;"><strong><br /></strong></span><br /></span><span style="color:#000000;"><strong><br /></strong></span><span style="color:#000000;"><strong></strong></span><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong><span style="color:#660000;">3)</span> <em>"This is well described with thiopentone and other drugs which is worsened by inadvertent intra-arterial injection.(Intravenous injection is followed by secondary arterial spasm) Things to do is heparinization. IV /intrarterial lignocaine and a symptathetic blockade by an axillary block to relieve reflex vsasopspasm. The one thing NOT to do is remove the intrarterial line if this happens due to inadvertent intrarterial injection. immediately inject any vasodilator like nitroglycerine or nitroprusside, heparin and papaverine diluted in blood through the line. If the line is removed intrarterial accesss will be lost. Many a time so called intravenous access is actually due to an intrarterial placement of a variant branch of the radial arterywhich being a smaller brach does not give a very good arterial flashback.This is well described in the 1960's by Bailey in his textbook of emergency surgery. A point well to be learnt from a historical textbook that has a lot of home truths which are true even today".</em></strong></span><br /><span style="color:#000000;"><br />"Prasanna Simha M" , </span><a href="mailto:prasannasimha@gmail.com"><span style="color:#000000;">prasannasimha@gmail.com</span></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-27558381414852627432007-12-16T04:21:00.000-08:002007-12-16T04:23:11.838-08:00<strong><span style="color:#000066;">Sunday December 16, 2007<br /></span></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><br /><br /><strong><span style="color:#660000;">Case:</span></strong> <em><strong><span style="color:#003333;">47 year old male of Indian sub-continent origin admitted to ICU with status epilepticus. Patient has recently been started on TB prophylaxis medicine at his new work place. What is your probable diagnosis and what would be the treatment?</span></strong></em><br /><br /><strong><span style="color:#003333;"><span style="color:#660000;"></span></span></strong><br /><strong><span style="color:#003333;"><span style="color:#660000;"></span></span></strong><br /><strong><span style="color:#003333;"><span style="color:#660000;">Answer:</span> Isoniazid (INH) induced seizures.</span></strong><br /><br /><strong><span style="color:#000000;">Isoniazid (INH) induced seizures is unique in the sense that it is usually refractory to standard anticonvulsant therapy. Even dose as low as as 1.5 g can be neurologically toxic.<br /></span></strong><br /><strong><span style="color:#000000;">INH induced seizure requires administration of a specific antidote, pyridoxine (B-6), with dose of 5 gram in IV form. Dose can be repeated 2 to 3 times if needed.</span></strong><strong><span style="color:#000000;"><br /></span></strong><strong><span style="color:#000000;"><br /><br /><br /></span></strong><br /><span style="font-size:78%;color:#003333;">Reference: click to get article</span><br /></span></strong><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://medind.nic.in/iae/t06/i3/iaet06i3p205.pdf" target="_blank"><span style="font-size:78%;color:#003333;">INH Induced Status Epilepticus: Response to Pyridoxine</span></a><span style="font-size:78%;color:#003333;"> - [Indian J Chest Dis Allied Sci 2006; 48: 205-206].</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-29078433191964101512007-12-15T11:36:00.000-08:002007-12-15T11:38:43.209-08:00<strong><span style="color:#000066;">Saturday December 15, 2007</span><br /></strong><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427"></a><strong><span style="color:#990000;"> Wernicke's Encephalopathy in ICU</span></strong><br /><strong></strong><br /><strong><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">Can Wernicke's Encephalopathy be iatrogenic in ICU ?</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A:</span> <span style="color:#000000;">Yes, it can be precipitated in any patient by glucose (like D-5, D-10 or D-50) administration who is thiamine deficient. It is not limited to alcoholics and can happen in any nutritionally deficient patient. It is always a good idea to add thiamine in D-5 drip in patients who are at risk of Wernicke's Encephalopathy. Disorder was described about 25 years ago by Carl Wernicke as a triad of </span></strong><br /><strong></strong><br /><strong><ul><li><span style="color:#000000;">acute mental confusion </span></li><li><span style="color:#000000;">ataxia </span></li><li><span style="color:#000000;">opthalmoplegia </span></li></ul><span style="color:#000000;"></span><br /></strong><strong><span style="color:#000000;">Read a case of Wernicke's encephalopathy. in a non-alcoholic patient with MRI findings </span></strong><a href="http://content.nejm.org/cgi/content/full/352/19/e18" target="_blank"><strong><span style="color:#660000;">here</span></strong></a> <em>( Ref.: The New England Journal of Medicine, Kaineg and Hudgins 352 (19): e18, May 12, 2005 )</em><br /><br /></strong><strong><span style="color:#333333;">Also see full review article </span></strong><a href="http://www.emedicine.com/EMERG/topic642.htm" target="_blank"><strong><span style="color:#660000;">Wernicke's encephalopathy</span></strong></a><strong><span style="color:#333333;"> at emedicine.com</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">Refrences: click to get abstract/article<br /><br />1. Incidence and clinical consequences of purple glove syndrome in patients receiving intravenous phenytoin, Neurology, 1998:51:1034-1039.<br />2. </span><a href="http://www.ingentaconnect.com/content/bsc/epi/2001/00000042/00000009/art00009" target="_blank"><span style="font-size:78%;color:#003333;">A prospective study of the purple glove syndrome</span></a><span style="font-size:78%;color:#003333;"> , Epilepsia, 2001:42(9):1156-1159.<br />3. Purple glove syndrome : A complication of intravenous phenytoin, J. of Neuroscience Nursing, 1992:24(8):340-345.<br />4. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=1289432&cmd=showdetailview&indexed=google" target="_blank"><span style="font-size:78%;color:#003333;">Purple glove syndrome: a complication of intravenous phenytoin</span></a><span style="color:#003333;"><span style="font-size:78%;">. - J Neurosci Nurs.1992 Dec;24(6):340-5 </span><br /></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-44009543669894952162007-12-14T21:23:00.000-08:002007-12-14T21:29:56.185-08:00<strong><span style="color:#000066;">Friday December 14, 2007<br /></span><span style="color:#990000;">Phenytoin induced Purple glove syndrome</span></strong><br /><br /><br /><strong>Purple glove syndrome also known as PGS is a progressive distal limb edema, discoloration, and pain after peripheral administration of phenytoin. If unrecognised, it may lead to severe skin necrosis, limb ischemia and to compartment syndromes. It is a fairly unknown and under diagnosed complication with IV Phenytoin and reported in upto 5% of cases. It is mostly overlooked due to reflexly made diagnosis of cellulitis at IV site.</strong><br /><strong><br /><br /><span style="color:#000066;">Mechanism of action:</span> 2 probable mechanisms has been described.<br /><br /><br />1. Phenytoin is poorly soluble at neutral PH. Solutions like sodium hydroxide, propylene glycol and ethanol are added to enhance solubility by increasing PH. Highly alkaline solution may induce vasoconstriction and thrombosis in vessels – may allow leakage into interstitial space.<br /><br /><br />2. Mixing of alkaline phenytoin solution with blood induce precip. of phenytoin crystals, leading to obstruction of micro vessels causing ischemia and also may induce leakage.<br /><br /><br /><span style="color:#000066;">Treatment :</span> is mostly supportive with elevation of limb, compression, dry, gentle heat, galvanic stimulation and in severe cases fasciotomy, skin grafting or amputation.</strong><br /><br /><br /></strong><img id="BLOGGER_PHOTO_ID_5144066443474233554" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB47XyTVCnLJdaIRwIutqLSkd6B9ejWPaFZYar3eR-W4xdTOrI69b1JWyqESZ9hc7JJLBwP-KsM0651UyX9U8jR3fkT5M5xXEHVu9jBO4yTwEfmbsa-dxMvItO2yoh5GdU4Z1Dos0MdJ0/s400/pgs2.gif" border="0" /><br /><span style="font-size:78%;color:#003333;">Refrences: click to get abstract/article<br /><br />1. Incidence and clinical consequences of purple glove syndrome in patients receiving intravenous phenytoin, Neurology, 1998:51:1034-1039.<br />2. </span><a href="http://www.ingentaconnect.com/content/bsc/epi/2001/00000042/00000009/art00009" target="_blank"><span style="font-size:78%;color:#003333;">A prospective study of the purple glove syndrome</span></a><span style="font-size:78%;color:#003333;"> , Epilepsia, 2001:42(9):1156-1159.<br />3. Purple glove syndrome : A complication of intravenous phenytoin, J. of Neuroscience Nursing, 1992:24(8):340-345.<br />4. </span><a href="http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=1289432&cmd=showdetailview&indexed=google" target="_blank"><span style="font-size:78%;color:#003333;">Purple glove syndrome: a complication of intravenous phenytoin</span></a><span style="font-size:78%;color:#003333;">. - J Neurosci Nurs.1992 Dec;24(6):340-5</span>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-2138352128005041072.post-39997680577682189362007-12-13T01:00:00.000-08:002007-12-13T12:20:38.859-08:00<strong><span style="color:#000099;">Thursday December 13, 2007</span> </strong><br /><strong><span style="color:#990000;">Value of Troponins in Acute Pulmonary Embolism</span> </strong><br /><br /><strong><span style="color:#000000;">Troponin level is still struggling to find its place in non-cardiac diseases. A meta-analysis is performed in Italy to see prognostic value of troponins in acute pulmonary embolism for short-term death and adverse outcome events (composite of death and any of the following: shock, need for thrombolysis, endotracheal intubation, catecholamine infusion, cardiopulmonary resuscitation, or recurrent pulmonary embolism). </span></strong><br /><strong><br /><span style="color:#000000;">Data of 20 studies, spread from January 1998 to November 2006 (including 1985 patients) were included in the analysis.<br /><br />Results: </span><br /><span style="color:#000000;"><ul><li>122 of 618 patients with elevated troponin levels died (19.7%) compared with 51 of 1367 with normal troponin levels (3.7%). </li><li>Elevated troponin levels were significantly associated with short-term mortality, with death resulting from pulmonary embolism and with adverse outcome events </li><li>Elevated troponin levels were associated with a high mortality in the subgroup of hemodynamically stable patients.</li></ul><br />Study concluded that — Elevated troponin levels identify patients with acute pulmonary embolism at high risk of short-term death and adverse outcome events.<br /></span></strong><br /><br /><span style="font-size:78%;color:#003333;">Reference: Click to get abstract/article<br /><br /></span><a href="http://circ.ahajournals.org/cgi/content/abstract/116/4/427" target="_blank"><span style="font-size:78%;color:#003333;">Prognostic Value of Troponins in Acute Pulmonary Embolism</span></a><span style="font-size:78%;color:#003333;"> - Circulation. 2007;116:427-433.)</span><br /></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-83875991832628168252007-12-12T10:44:00.000-08:002007-12-13T10:48:14.058-08:00<strong><span style="color:#000066;">Wednesday December 12, 2007</span></strong><br /><strong><span style="color:#990000;">Clonidine Toxicity</span> </strong><br /><strong></strong><br /><strong><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">The treatment of clonidine toxicity is mostly supportive. Which antidote has shown (only anecdotal reports) to reverse altered mental status and associated hypotension with clonidine toxicity ?</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A;</span> <span style="color:#003333;">Naloxone (Narcan).</span></strong><br /><strong></strong><br /><strong>There are few case reports in literature describing naloxone to improve the altered mental status associated with clonidine toxicity. It also reverses hypotension but may induce severe hypertension while reversing clonidine effect and should be use with caution. Dose should be initiated from 0.2 IV and can be titrated upto 2 mg IV. Doses upto 5-10 mg have been reported but again caution should be exercise.</strong><br /><strong></strong><br /><strong>Another antidote described in literature for clonidine toxicity is yohimbine.</strong> <em>(Yohimbine is a central alpha2-adrenergic antagonist).</em><strong> The dose is a single 5.4 mg tablet via enteral route.</strong><br /><strong></strong><br /><strong>Dopamine is the choice of vasopressor in clonidine induced hypotension after IVF boluses. And, atrpoine to counteract bradycardia associted with it.</strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References: click to get abstract / article</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3752658&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Reversal of clonidine toxicity by naloxone </span></a><span style="font-size:78%;color:#003333;">- Ann Emerg Med. 1986 Oct;15(10):1229-31.</span><br /><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12126186&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Clonidine toxicity revisited</span></a><span style="font-size:78%;color:#003333;"> - J Toxicol Clin Toxicol. 2002;40(2):145-55.</span><br /><span style="font-size:78%;color:#003333;">3. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8906769&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Yohimbine as an antidote for clonidine overdose</span></a><span style="font-size:78%;color:#003333;"> - Am J Emerg Med.1996 Nov;14(7):678-80.</span><br /><span style="font-size:78%;color:#003333;">4. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7013572&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Clonidine overdose: report of six cases and review of the literature</span></a><span style="font-size:78%;color:#003333;"> - Ann Emerg Med. 1981 Feb;10(2):107-12.</span><br /><span style="font-size:78%;color:#003333;">5. </span><a href="http://www.emedicine.com/emerg/topic809.htm" target="_blank"><span style="font-size:78%;color:#003333;">Toxicity, Clonidine</span></a><span style="font-size:78%;color:#003333;"> - emedicine.com</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-54770332883902230612007-12-11T10:37:00.000-08:002007-12-13T10:41:41.671-08:00<strong><span style="color:#000066;">Tuesday December 11, 2007</span></strong><br /><strong><span style="color:#990000;">Why PO Demerol is not a good idea !!</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>Overall, demerol (meperidine) is falling out of favor and has been referred by many as 'demon' due to neurotoxicity of its metabolite normeperidine. Fortunately PO (by mouth) demerol is not as popular as IV but it should be avoided at all. PO demerol is way more dangerous than IV demerol. 50% of PO demerol get metabolized first pass via liver and give high level of normeperidine in blood which has long half life of 15-30 hours even with normal kidney function and may accumulate to cause tremors, myoclonus, hallucinations and seizure. Hemodialysis has been described to help in normeperidine toxicity</strong> 1.</span><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>See nice review at medscape.com -</strong> <span style="font-size:85%;">free registration required</span><strong>: </strong></span><a href="http://www.medscape.com/viewarticle/481374" target="_blank"><span style="color:#660000;"><strong>Meperidine is Alive and Well in the New Millennium: Evaluation of Meperidine Usage Patterns and Frequency of Adverse Drug Reactions</strong></span></a><span style="color:#000000;"><span style="color:#660000;"> </span><em>(Dr. Seifert and Dr. Kennedy, Ref: Pharmacotherapy 24(6):776-783, 2004)</em></span><br /><strong><span style="color:#000000;"></span></strong><br /><strong></strong><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.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10620557&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Successful treatment of normeperidine neurotoxicity by hemodialysis </span></a><span style="font-size:78%;color:#003333;">- Am J Kidney Dis. 2000 Jan;35(1):146-9.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-8125072325026746552007-12-10T10:31:00.000-08:002007-12-13T10:36:30.741-08:00<strong><span style="color:#000066;">Monday December 10, 2007</span></strong><br /><strong><span style="color:#990000;">How many attempts to intubate?</span></strong><br /><br /><br /><strong>Its hard to give up procedure if you are failing it !! For intubation, ASA (American Society of Anesthesiologists) recommends to limit laryngoscopic attempts to three. Dr. Thomas C. Mort from Hartford Hospital, CT entered 2833 Critically-ill patients, suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration into an emergency intubation quality improvement database. Data confirmed that the number of laryngoscopic attempts were directly proportional with the incidence of airway and hemodynamic adverse events (more than 2 attempts). </strong><br /><strong></strong><strong><br /></strong><strong><ul><li>incidence of hypoxemia went from 11.8% to 70%, </li><li>incidence of regurgitation of gastric contents went from 1.9% to 22%, </li><li>incidence of aspiration of gastric contents went from 0.8% to 13%, </li><li>incidence of bradycardia went from 1.6% to 21%, and </li><li>incidence of cardiac arrest went from 0.7% to 11% </li></ul><br /><br />Call for help !! and remember, to limit intubation attempts to 3, unless untill you are trained to deal with 'difficult intubations'.</strong><br /><br /><br /><br /><br /><br /><span style="font-size:78%;color:#003333;">References: click to get abstract/article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.anesthesia-analgesia.org/cgi/content/abstract/99/2/607" target="_blank"><span style="font-size:78%;color:#003333;">Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts -</span></a><span style="font-size:78%;color:#003333;"> Anesth Analg 2004;99:607-613</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-91025304366598388342007-12-09T04:37:00.001-08:002007-12-13T10:28:08.362-08:00<strong><span style="color:#000066;">Sunday, December 9, 2007</span></strong><br /><strong></strong><br /><strong></strong><br /><strong><span style="color:#660000;">Q:</span> <span style="color:#003333;"><em>what is "cryo reduced plasma"?<br /></em></span><br /><span style="color:#660000;">A;</span> Yesterday we learned that: one unit of cryoprecipitate is derived from one unit of fresh frozen plasma (FFP). Left over FFP, after removal of cryoprecipitate is called supernatant plasma or CRYO-REDUCED PLASMA.<br /><br /><br /><span style="color:#003333;">Clinical Significance</span>: Cryo-reduced plasma is used as a treatment in plasmapheresis for TTP, not responding to regular plasma exchange with FFP. Some physicians even use it as first line for plasmapheresis/Therapeutic Plasma Exchange (TPE) for a patient with Thrombotic Thrombocytopenic Purpura (TTP).</strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-50827537639029878082007-12-08T09:30:00.001-08:002007-12-13T10:26:55.084-08:00<strong><span style="color:#000066;">Saturday December 8, 2007</span></strong><br /><strong><span style="color:#990000;">Ethanol drip in Ethylene Glycol</span></strong><br /><strong></strong><br /><strong><span style="color:#660000;">Q; </span><span style="color:#003333;"><em>How you write Ethanol drip in Ethylene Glycol poisoning assuming you don't have Fomepizole or Dialysis available ?</em></span></strong><br /><strong></strong><br /><strong><span style="color:#660000;">A:</span> <span style="color:#000000;">Ethylene Glycol poisoning is common and can have bleak outcomes. Intensivists should be aware of all the possible interventions available. Antidotal therapy is based on preventing the alcohol dehydrogenase enzyme from metabolizing ethylene glycol into toxic byproducts. In case Fomepizole or Dialysis is not available, Ethanol will competitively inhibit alcohol dehydrogenase. But the serum ethanol level must be monitored frequently.Therapeutic ethanol is administered in a bolus followed by a continuous infusion. </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Initially, 7.5 to 10 mL/Kg of 10% ethanol, in D5W, is administered over 30 minutes. Then, a continuous infusion of 1 to 2 mL/Kg/hr of 10% ethanol is infused until the patient has eliminated all of the EG from his serum.</span> </strong><br /><strong></strong><br /><strong>It is important to keep the serum ethanol level at 100 to 150 mg/dL so as to completely inhibit the alcohol dehydrogenase enzyme.</strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2138352128005041072.post-28302617985167418412007-12-07T09:25:00.000-08:002007-12-13T10:24:36.628-08:00<strong><span style="color:#000066;">Friday December 7, 2007</span></strong><br /><strong><span style="color:#990000;">Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Diffuse alveolar hemorrhage remained a condition with high mortality. Usual treatment is high dose IV methylprednisolone (1g/day) for three to five days and in more severe cases to add IV cyclophosphamide (cyclophosphamide has a delayed effect, but may provide synergistic action with steroid). Plasmapheresis has been described to be effective particularly in diffuse alveolar hemorrhage associated with Goodpasture syndrome.But what if bleeding is non-stop and life-threatening ?</span></strong><br /><strong><span style="color:#000000;"></span></strong><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"><span style="color:#003333;"><strong>Novoseven</strong></span></a><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="color:#000000;">1<strong>.</strong></span><br /><strong></strong><br /><strong><span style="color:#003333;"></span></strong><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.com0