Friday December 7, 2007
Resistant (uncontrolled) / Life-threatening diffuse alveolar hemorrhage
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 ?
Answer is off label use of activated Factor VII (Novoseven). In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes 1.
Reference: click to get abstract
Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII - annals, 16 March 2004 Volume 140 Issue 6 Pages 493-494
Friday, December 7, 2007
Thursday, December 6, 2007
Thursday December 6, 2007
Q; What is the re-intubation rate in your ICU ?
A; Re-intubation rates have been reported in literature anywhere from 4% - 20% but most of the experts agree that as far as its less than 15%, you are in normal / safe zone. Ideal would be less than or equal to 5%. Other way is to keep track of reintubation rate and making sure that it is not increasing in your ICU.
Related links:
HOW TO ESTABLISH A VENTILATOR WEANING PROTOCOL , Gregory P. Marelich, MD - thoracic.org
When to wean from a ventilator: An evidence-based strategy, Ref: CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70, NUMBER 5 MAY 2003 page 389
Related previous pearls:
Wednesday, December 5, 2007
Wednesday December 5, 2007
Q; How much intavenous albumin should be given to patient while removing ascitic fluid via paracentesis?
A; Per 2004 guidelines published in Hepatology 2004 Mar;39(3):841-56, for management of adult patients with ascites due to cirrhosis by Practice Guidelines Committee, American Association for the Study of Liver Diseases (AASLD),
"Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. For large-volume paracenteses, an albumin infusion of 8 to 10 g per liter of fluid removed can be considered".
(Grade II-2 evidence - Cohort or case-control analytic studies).
Read full guidelines here
Q; How much intavenous albumin should be given to patient while removing ascitic fluid via paracentesis?
A; Per 2004 guidelines published in Hepatology 2004 Mar;39(3):841-56, for management of adult patients with ascites due to cirrhosis by Practice Guidelines Committee, American Association for the Study of Liver Diseases (AASLD),
"Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. For large-volume paracenteses, an albumin infusion of 8 to 10 g per liter of fluid removed can be considered".
(Grade II-2 evidence - Cohort or case-control analytic studies).
Read full guidelines here
Tuesday, December 4, 2007
Monday, December 3, 2007
Monday December 3, 2007
What Dig. level makes you happy ?
Digoxin is known to provid reduction in hospitalizations among patients with heart failure and depressed left ventricular systolic function without improving mortality (DIG trial -The Digitalis Investigation Group trial) 1. Very interesting work published in JAMA about 3 years ago (about 3800 patients) as a followup of above trial - looking into mortality association with different Digoxin level 2 . What they found:
* SDC = serum digoxin concentration
* Patients were divided into 3 groups based on SDC at 1 month
Study suggested that the effectiveness of digoxin therapy in men with heart failure and a left ventricular ejection fraction of 45% or less may be optimized in the SDC range of 0.5 to 0.8 ng/mL.
Read interesting article: DIGOXIN DELUSIONS (from ucsf.edu)
References: Click to get abstract
1. The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure, The Digitalis Investigation Group - NEJM, Vol 336, Feb 20, 1997, number 8
2. Association of Serum Digoxin Concentration and Outcomes in Patients With Heart Failure -JAMA. 2003;289:871-878.
What Dig. level makes you happy ?
Digoxin is known to provid reduction in hospitalizations among patients with heart failure and depressed left ventricular systolic function without improving mortality (DIG trial -The Digitalis Investigation Group trial) 1. Very interesting work published in JAMA about 3 years ago (about 3800 patients) as a followup of above trial - looking into mortality association with different Digoxin level 2 . What they found:
* SDC = serum digoxin concentration
* Patients were divided into 3 groups based on SDC at 1 month
- Patients with SDCs of 0.5 to 0.8 ng/mL had a 6.3% lower mortality rate compared with patients receiving placebo.
- No reduction in mortality among patients with SDCs of 0.9 to 1.1 ng/mL,
And
- Patients with SDCs of 1.2 ng/mL and higher had an 11.8% higher absolute mortality rate than patients receiving placebo.
Study suggested that the effectiveness of digoxin therapy in men with heart failure and a left ventricular ejection fraction of 45% or less may be optimized in the SDC range of 0.5 to 0.8 ng/mL.
Read interesting article: DIGOXIN DELUSIONS (from ucsf.edu)
References: Click to get abstract
1. The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure, The Digitalis Investigation Group - NEJM, Vol 336, Feb 20, 1997, number 8
2. Association of Serum Digoxin Concentration and Outcomes in Patients With Heart Failure -JAMA. 2003;289:871-878.
Sunday, December 2, 2007
Sunday December 2, 2007
Q; Which condition may mimic pseudo-atrial flutter on EKG and monitor?
A; Parkinsonian tremor (first reported about 40 years ago 1 and later on many other reports confirmed it). Recently in, Mayo Clinic Proceedings, a case has been reported of pseudo atrial flutter with use of portable CD player by patient. 2
References:
1. MUSCLE-TREMOR ARTIFACT DUE TO PARKINSON'S SYNDROME. IT STIMULATED ATRIAL FLUTTER AND DISAPPEARED DURING SLEEP - Postgrad Med. 1965 Jun;37:718-20.
2. Atrial flutter simulated by a portable CD player - mayo clinic proceedings - march 2006,82(3), Page 383 -pdf file
Q; Which condition may mimic pseudo-atrial flutter on EKG and monitor?
A; Parkinsonian tremor (first reported about 40 years ago 1 and later on many other reports confirmed it). Recently in, Mayo Clinic Proceedings, a case has been reported of pseudo atrial flutter with use of portable CD player by patient. 2
References:
1. MUSCLE-TREMOR ARTIFACT DUE TO PARKINSON'S SYNDROME. IT STIMULATED ATRIAL FLUTTER AND DISAPPEARED DURING SLEEP - Postgrad Med. 1965 Jun;37:718-20.
2. Atrial flutter simulated by a portable CD player - mayo clinic proceedings - march 2006,82(3), Page 383 -pdf file
Saturday, December 1, 2007
Saturday December 1, 2007
Zolpidem-Induced Delirium
Relatively Zolpidem (Ambien) is a safe medicine and recently has been the 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.
Related previous pearls: SEROTONIN SYNDROME
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
Zolpidem-Induced Delirium
Relatively Zolpidem (Ambien) is a safe medicine and recently has been the 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.
Related previous pearls: SEROTONIN SYNDROME
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
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