October 2008 Archive

2008-10-31T17:33:00.000-07:00

Friday October 31, 2008

Q; While on "Rapid response team", you have been called to drug rehab. unit to evaluate a 34 year old female who found hypotensive and dizzy. Nurses confirmed that under strict watch, no narcotic has been taken by patient. As you hook the monitor, it shows frequent runs of Torsades De Pointes. Review of medicine list shows patient under treatment with methadone and 3 days ago started on Levofloxacin for suspected UTI?

Answer: Methadone induced QT prolongation, converted into Torsades due to Levaquin interaction.

Methadone is a long-acting narcotic pain medication commonly used in the treatment of narcotics addiction. Methadone causes prolongation of the QT interval and explains the development of Torsades De Pointes. Methadone causes dose-related increases in the QTC interval. Drugs taken by methadone patients may precipitate dangerous drug interactions when used with methadone, including prolongation of the QT interval.

Related Article: A Twist on Torsade: A Prolonged QT Interval on Methadone (J Gen Intern Med. 2006 November; 21(11): C9–C12)

2008-10-30T15:54:00.001-07:00

Thursday October 30, 2008

Q; After successful completion of Transjugular Intrahepatic Porto-systemic Shunt (TIPS) for variceal bleeding - hepatic encephalopathy __________ ?

A) tends to get better

B) tends to get worse

C) It has nothing to do with TIPS

Answer is B

Hepatic encephalopathy tends to get worse after successful completion of TIPS as due to shunting, blood flow to the liver is reduced, which might result in increase toxic substances reaching the brain without being metabolized first by the liver. It can be treated medically such as diet, lactulose or by narrowing of the shunt by insertion of a reducing stent.

References: click to get abstract/article

1. Treatment for hepatic encephalopathy: tips from TIPS? - Journal of Hepatology 42 (2005) 626–628

2. Hepatic encephalopathy after TIPS-- retrospective study - Vnitr Lek. 2002 May;48(5):390-5

3. TIPS for Prevention of Recurrent Bleeding in Patients with Cirrhosis: Meta-analysis of Randomized Clinical Trials - Radiology. 1999;212:411-421

2008-10-29T19:21:00.001-07:00

Wednesday October 29, 2008

Q: What is the maximum length of guide-wire to be advanced to avoid guide-wire lost and embolism during subclavian or internal jugular venous catheterization?

A: About 18 cm (may be little less in right IJ)

Beside not to loose control of guide-wire, it is appropriate to know the markings on guidewire in CVC kit. Patient height is less reliable in predicting a safe wire length. 18 cm should be considered the upper limit of guidewire introduced during central catheter placement in adults 1.

Related Previous Pearl: Peres Nomogram to calculate appropriate length of central line depth

Reference: click to get abstract

How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement - Critical Care Medicine. 28(1):138-142, January 2000

2008-10-28T16:45:00.001-07:00

Tuesday October 28, 2008
Auto-PEEP

Q; What level of extrinsic PEEP should be applied to counter act (intrinsic) auto-PEEP?

A; 75 - 85% of auto-PEEP.

Keeping extrinsic PEEP lower than auto-PEEP not only effectively counter acts auto-PEEP but also any ciruclatory depression or lung hyperinflation is unlikely to occur at extrinsic PEEP slightly lower than intrinsic PEEP value.

Read precise review on auto-peep: Auto-positive end-expiratory pressure: Mechanisms and treatment , M.M. MUGHAL, D.A. CULVER, O.A. MINAI, and A.C. ARROLIGA - CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 9 SEPTEMBER 2005

2008-10-27T07:26:00.000-07:00

Monday October 27, 2008

Q: Right main stem intubation is common but what percentage of intubations may end up in left main stem?

A: About 5%

2008-10-26T18:24:00.001-07:00

Sunday October 26, 2008

Q: Which commonly use cardiovascular drip in ICU may prolong QT interval (and may cause torsades de pointes)?

A: Vasopressin

2008-10-25T20:49:00.001-07:00

Saturday October 25, 2008
Warning regarding scam “Certification Boards”

ABIM has received reports from several of our diplomates regarding letters and solicitations they have received from groups offering “certification” in Geriatric Medicine, Cardiology and Hospital Medicine, among other things. ABIM is concerned about the welfare of patients who may choose doctors representing themselves as “board certified” based on their possession of a certificate from unaccredited “boards” that award certificates but require no accredited training, testing or medical background review. Have you been contacted by any of the following groups? These phony “medical boards” have been reported to ABIM as fraudulent, and if you hear from them, or receive any certification information that seems suspicious, ABIM would like to know about it.

If you have been approached by an organization calling itself a board that is not a member of ABMS or the American Osteopathic Association or has not established its status by state licensure board recognition, please e-mail security@abim.org for information on these possible “scams” and what can be done to assure the professional integrity of medical specialty certification.

2008-10-24T19:07:00.000-07:00

Friday October 24, 2008
Unusual ventricular septal defect

2008-10-23T09:34:00.000-07:00

Thursday October 23, 2008

Q: What is your Diagnosis?

Answer: Right pulmonary vein aneurysm (PVA)

Congenital PVA may progressively increase in size over the years and may rupture. Pulmonary venous aneurysm may occur as a component of congenital pulmonary arteriovenous malformation (PAVMN) or traumatic pulmonary arteriovenous pseuodoaneurysm (PAP). symptoms iclude hypoxia, congestive heart failure, hemoptysis and cerebral abscess. Pulmonary venous aneurysm may also be acquired and is known to be associated with rheumatic mitral insufficiency.

All these lesions may present as a mediastinal mass. Computed tomography, echocardiography and angiography usually help to differentiate from other vascular lesions.

2008-10-22T18:05:00.001-07:00

Wednesday October 22, 2008

Q: What is half life of Xigris - Recombinant Protein C (Activated) ?

A; Xigris has a short half-life, indicating rapid inactivation of Xigris after stopping infusion and more than 70% get eliminate within 30 minutes.

General recommendations are

Discontinue Xigris 2 hours prior to performing an invasive procedure and may restart immediately after uncomplicated, less invasive procedures
Initiation of Xigris can be considered 12 hours after major invasive procedures or surgery
Prophylactic heparin/LMWH may be continued while patient is on xigris
Note:

Xigris may variably prolong the APTT. Therefore, the APTT cannot be reliably used to assess the status of the coagulopathy during Xigris infusion.

Xigris has minimal effect on the PT

2008-10-21T09:51:00.000-07:00

Tuesday October 21, 2008

Q: What percentage of patients may develop complications secondary to brachial artery cannulation?

Answer: upto 42%

It was established almost 40 years ago by Mortensen 1 that brachial artery cannulation is not an ideal location. The lack of collateral circulation about the elbow may predispose to forearm and hand ischemic complications.

Case report & review: Compartment Syndrome of the Forearm and Hand After Brachial Artery Cannulation (pdf) - Anesth Analg 1995; 81: 1092-4

Reference:

1. Mortensen JD. Clinical sequelae from arterial needle puncture, cannulation, and incision. Circulation 1967;35:1118-23.

2008-10-20T11:12:00.000-07:00

Monday October 20, 2008
Dexmedetomidine (precedex) Infusion as Adjunctive Therapy for Acute Alcohol Withdrawal

Emerging literature is very promising for Dexmedetomidine (precedex) Infusion as an adjunctive therapy to benzodiazepines in acute alcohol withdrawal.

Review of literature shows that dexmedetomidine was shown to be beneficial in alcohol withdrawal delirium first in rats about 10 years ago ! 4 but later many case series in humans have shown a rapid response to alcohol withdrawal delirium after the standard treatment. 1, 2, 3, 5 Dexmedetomidine is a selective alpha-2 adrenergic agonist that possesses a high ratio of specificity for the alpha-2 versus the alpha-1 receptor.

The biggest advantage of Dexmedetomidine over benzodiazepines in acute alcohol withdrawal therapy, is that it doesn't suppress respiratory drive and carries simultaneuos properties of analgesia, sedation and anxiolysis.

Related article: The Role of Dexmedetomidine (Precedex) in the Sedation of Critically Ill Patients (ref: P&T, Vol. 30 No. 3 • March 2005 , 158-161)

References: click to get abstract / article

1. Dexmedetomidine as an adjuvant in the treatment of alcohol withdrawal delirium: a case report - General Hospital Psychiatry , Volume 28 , Issue 4 , Pages 362 - 363
2. Dexmedetomidine in the Treatment of Withdrawal Syndromes in Cardiothoracic Surgery Patients - Journal of Intensive Care Medicine, Vol. 20, No. 2, 118-123 (2005)
3. Dexmedetomidine for peri-operative sedation and analgesia in alcohol addiction - Correspondence - Anaesthesia. 61(3):299-300, March 2006.
4. . Dexmedetomidine, diazepam, and propranolol in the treatment of ethanol withdrawal symptoms in the rat - Alcohol Clin Exp Res.1997 Aug;21(5):804-8
5. Dexmedetomidine Infusion as Adjunctive Therapy to Benzodiazepines for Acute Alcohol Withdrawal - Published Online, 9 September 2008, Tha annals of Pharmacotherapy.

2008-10-19T08:05:00.000-07:00

Sunday October 19, 2008

Q: What difference does it make in giving 1 ampule of calcium gluconate and 1 ampule of calcium chloride to patient?

Answer: Calcium chloride contains 3 times more elemental calcium in camparison to same dose of calcium gluconate. 1 gram of Calcium gluconate contains 4.65 mEq of elemental Calcium but 1 gram of Calcium chloride contains 13.6 mEq of elemental Calcium.

2008-10-18T20:07:00.000-07:00

Saturday October 18, 2008

Scenario: 37 year old otherwise healthy male brought to ER with acute upper airway obstruction after developing severe angioedema secondary to seafood. In view of compromised airway, emergent intubation was performed. Despite securing airway, patient oxygen saturation remained low and required significant support of PEEP and FiO2 on mechanical ventilator. Patient's JVP is noticed to be elevated with bilateral crackles on lung auscultation. CXR showed pulmonary edema. Your probable diagnosis....

Answer: Postobstructive pulmonary edema (POPE)

POPE is the sudden onset of pulmonary edema following upper airway obstruction. There are two recognized types of POPE.

Type 1 POPE: follows a sudden, severe episode of upper airway obstruction such as postextubation laryngospasm, epiglottitis, croup, and choking.

Type II POPE: develops after surgical relief of chronic upper airway obstruction like tonsillectomy and removal of upper airway tumors.

References:

Guffin TN, Har-el G, Sanders A, Lucente FE, Nash M. Acute postobstructive pulmonary edema. Otolaryngol Head Neck Surg 1995;112:235-7.

Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. Can J Anaesth 1990;37:210-8.

Oswalt CE, Gates GA, Holmstrom FM. Pulmonary edema as a complication of acute airway obstruction. Rev Surg 1977;34:364-7.

Galvis AG. Pulmonary edema complicating relief of upper airway obstruction. Am J Emerg Med 1987; 5:294-7.

Scarbrough FE, Wittenberg JM, Smith BR, Adcock DK. Pulmonary edema following postoperative laryngospasm: case reports and review of the literature. Anesth Prog 1997;44:110-6.

Dicpinigaitis PV, Mehta DC. Postobstructive pulmonary edema induced by endotracheal tube occlusion. Intensive Care Med 1995;21:1048-50.

2008-10-17T10:42:00.000-07:00

Friday October 17, 2008

Scenario: You have a 88 year old male admitted with COPD exacerbation. Patient's code status is Do Not Resuscitate (DNR) but chemical intervention is granted. Patient went into Atrial fibrillation & Rapid Ventricular Rate (RVR), with heart rate 150-170. Blood pressure is marginal and you want to avoid calcium channel blockers or beta-blockers. Electrolytes drawn 4 hours ago were reported normal. You decide to manage patient with ibutilide. Which other drug you may consider to use prior to or concomittently with Ibutalide.

Answer: Intravenous Magnesium

Ibutilide (Corvert) is indicated for the chemical conversion of atrial fibrillation. It prolongs action potential duration in myocytes and increases both atrial and ventricular refractoriness. Dose is .01 mg/kg (Up to 1mg total) IV over 10 minutes. About 2% of patients may convert into polymorphic ventricular tachycardia (torsade de pointes) and therefore Ibutilide should not be used in patients receiving concomitant drugs which prolong the QT interval. If time and clinical situation permits, some clinicians preload patients with intravenous magnesium (2-4 grams) prior to infusing ibutilide as a preventative measure for torsade de pointes (TdP).

Interestingly, one study also showed that prophylactic magnesium improve the antiarrhythmic efficacy of ibutilide as demonstrated by an increase in the rate of successful chemical conversion and reduction in the need for direct current cardioversion.

References: Click to get article

1. Intravenous Magnesium Sulfate Enhances the Ability of Intravenous Ibutilide to Successfully Convert Atrial Fibrillation or Flutter - Pacing and Clinical Electrophysiology, Volume 30, Number 11, November 2007 , pp. 1331-1335(5)

2. Cost Effectiveness of Ibutilide With Prophylactic Magnesium in the Treatment of Atrial Fibrillation - PharmacoEconomics, Volume (Year): 22 (2004)Issue: 13, Pages: 877-883

2008-10-16T07:50:00.000-07:00

Thursday October 16, 2008
Why ultrasound guided central line placement

Study: Real-time ultrasonographic guidance is compared to the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting. This was a prospective, randomized, clinical study. 130 patients were enrolled.

Outcome measures: Successful insertion of an internal jugular vein catheter, number of attempts, access times, and complications.

Results

Cannulation of the internal jugular vein was successful in 61 of 65 patients (93.9%) using ultrasonography and in 51 of 65 patients (78.5%) using the landmark technique, a significant difference of 15.4%
Fifty of 61 (82.0%) of the successful ultrasonographically guided catheters were inserted on the first attempt compared with 36 of 51 (70.6%) of the successful landmark catheters.
Mean access times to venipuncture and successful insertion were 138 and 281 seconds by ultrasonographic guidance and 132 and 271 seconds by the landmark technique.

There was a 10.8% complication rate, with 11 complications (16.9%) in the landmark group and 3 (4.6%) in the ultrasonographic group, a difference of 12.3%

Conclusion: Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.

Reference: click to get article

Ultrasonographic Guidance for Internal Jugular Vein Cannulation: An Educational Imperative, A Desirable Practice Alternative , Alfredo Sabbaj, Jerris R. Hedges, Annals of Emergency Medicine, November 2006 (Vol. 48, Issue 5, Pages 548-550)

2008-10-15T11:32:00.000-07:00

Wednesday October 15, 2008
Cross Sulfa allergy - just a myth?

The clinical significance of cross-reactivity of medications in a person with a "sulfa" allergy continues to perplex clinicians and complicates decisions regarding patient safety. Historically, the term "sulfa" refers to a derivative of the antimicrobial agent sulfanilamide. More recently, the term has been applied to a diverse group of drugs, all of which contain the sulfonamide chemical structure (-SO2NH2).

OBJECTIVE: To provide a critical and comprehensive review of the literature, specifically case reports and observational studies used to support the concept of cross-reactivity between sulfonylarylamines and non-sulfonylarylamines.

DATA SOURCES: A list of medications was formulated from several different review articles. A MEDLINE/PubMed search was conducted (1966-March 2004) using the individual medications and the MeSH terms of drug hypersensitivity/etiology, sulfonamides/adverse effects, and/or cross-reaction.

STUDY SELECTION AND DATA EXTRACTION: A critical review of the methodology and conclusions for each article found in the search was conducted. The manufacturer's package insert (MPI) for each drug was examined for a statement concerning possible cross-reactivity in patients with a sulfonamide allergy. If indicated, the manufacturers were contacted to obtain any clinical data supporting the statement.

DATA SYNTHESIS: A total of 33 medications were identified. Seventeen (51.5%) of the MPIs contained statements of varying degrees concerning use in patients with a "sulfonamide" allergy; 21 case series, case reports, and other articles were found.

CONCLUSIONS: After a thorough critique of the literature, it appears that the dogma of sulfonylarylamine cross-reactivity with non-sulfonylarylamines is not supported by the data. While many of the case reports on the surface support the concept of cross-reactivity, on closer examination the level of evidence in many of the cases does not conclusively support either a connection or an association between the observed cause and effect.

Reference: click to get article

Sulfonamide Cross-Reactivity: Fact or Fiction? - Published Online, 11 January 2005, The Annals of Pharmacotherapy: Vol. 39, No. 2, pp. 290-301.

2008-10-14T00:55:00.000-07:00

Tuesday October 14, 2008

Q: Which type of infrarenal abdominal aortic aneurysm (AAA) is more dangerous? (choose one)

A) Fusiform or B) Saccular

Answer: Saccular

Most (90%) infrarenal aneurysms are fusiform in appearance. It bulges or balloons out on all sides of the aorta.

A saccular aneurysm is balloon-shaped with a narrow neck, bulges out from the main arterial segment (bulges or balloons out only on one side) and is the most likely to rupture.

A pseudoaneurysm, or false aneurysm, is an enlargement of only the outer layer of the blood vessel wall. Sometimes, a tear can occur on the inside layer of the vessel resulting in blood filling in between the layers of the blood vessel wall, creating a pseudoaneurysm.

2008-10-13T07:34:00.000-07:00

Monday October 13, 2008
Respiratory Failure Classification

Type I: Hypoxemic Failure (PaO2 < 60 at sea level)

Type II: Hypercapnic Failure (PCO2 > 45 mm hg)

Type III: Perioperative respiratory failure (increase atelectasis due to low functional residual capacity)

Type IV: Respiratory failure due to Shock. Type IV describes patients who are intubated and ventilated in the process of resuscitation for shock.

2008-10-12T13:37:00.000-07:00

Sunday October 12, 2008
Silver-Coated Endotracheal Tubes decreases incidence of Ventilator-Associated Pneumonia?

Interesting study recently published in JAMA 1

Design, Setting, and Participants: Prospective, randomized, single-blind, controlled study from 54 centers in North America. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized.

Primary outcome measure: VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 104 colony-forming units/mL or greater in patients intubated for 24 hours or longer.

Other outcomes measures: VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse event.

Results
Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients) in the group receiving the silver-coated tube and 7.5% (56/743) in the group receiving the uncoated tube, with a relative risk reduction of 35.9%
The silver-coated endotracheal tube was associated with delayed occurrence of VAP
No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events

Conclusion: Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.

Reference: click to get abstract

Silver-Coated Endotracheal Tubes and Incidence of Ventilator-Associated Pneumonia, The NASCENT Randomized Trial , JAMA. 2008;300(7):805-813.

2008-10-11T00:08:00.000-07:00

Saturday October 11, 2008

What is your Diagnosis?

Answer: Right bronchus intermedius intubation causing Right upper lobe atelectasis along with all of left lung collapse.

About 10% of ETT are initially placed in the right main stem bronchus. If tip is in bronchus intermedius, RUL will become atelectatic along with all of left lung.

2008-10-10T20:15:00.000-07:00

Friday October 10, 2008

Q; What is Hemodialysis induced Vancomycin rebound phenomenon?

A; There is a rebound in vancomycin plasma concentrations at the end of the session. The plasma profile of vancomycin concentrations versus time indicates that concentrations decrease dramatically during the session and then increase when the session is stopped. This rebound may result from drug recirculation from plasma protein binding sites.

Clinical Significance: This rebound may be clinically significant, and it must be taken into account when determining vancomycin trough levels. It is recommended that determination of vancomycin trough levels in patients undergoing chronic haemodialysis should be performed before the haemodialysis session.

Reference: click to get abstract

Clinical review: Use of vancomycin in haemodialysis patients Crit Care. 2002; 6(4): 313–316

2008-10-09T16:01:00.000-07:00

Thursday October 9, 2008
The feasibility of using ultrasound - for assessment of tracheal intubation / ruling out esophageal intubation

2008-10-08T16:48:00.000-07:00

Wednesday October 8, 2008
Risk of death in ARDS - dead space fraction

Severity of hypoxemia, imaging and none of the single variable is predictive of risk of death in acute respiratory distress syndrome (ARDS) when measured early in the course of the disease. However the quintile of dead space fraction correlated well with later mortality in a few observational studies and in at least prospective study. The dead space fraction was independent risk factor for death.

dead-space fraction = (PaCO2 – PeCO2) ÷ PaCO2

PeCO2 is a mean expired carbon dioxide fraction and is measured with a bedside metabolic monitor. Metabolic monitoring (metabolic cart) is noninvasive and is used widely for metabolic and nutritional assessment.

Study Details

The dead-space fraction was prospectively measured in 179 intubated patients, a mean (±SD) of 10.9±7.4 hours after the ARDS had developed. Additional clinical and physiological variables were analyzed with the use of multiple logistic regression. The study outcome was mortality before hospital discharge.

Results
The mean dead-space fraction was markedly elevated (0.58±0.09) early in the course of the ARDS and was higher among patients who died than among those who survived (0.63±0.10 vs. 0.54±0.09)
The dead-space fraction was an independent risk factor for death: for every 0.05 increase, the odds of death increased by 45 percent
The only other independent predictors of an increased risk of death were the Simplified Acute Physiology Score II, an indicator of the severity of illness and quasistatic respiratory compliance

Conclusions: Increased dead-space fraction is a feature of the early phase of the acute respiratory distress syndrome. Elevated values are associated with an increased risk of death

Pulmonary Dead-Space Fraction as a Risk Factor for Death in the Acute Respiratory Distress Syndrome - NEJM,Volume 346:1281-1286, Number 17, April 25, 2002

2008-10-07T06:12:00.000-07:00

Tuesday October 7, 2008
Predicted body weights

The mantra of "low tidal volume" in ARDS is based on predicted body weight. This is a calculation based on age, gender and height.

Predicted body weight for men:

50 + (2.3 x [height in inches - 60])
or
50 + (0.91 x [height in centimeters - 152.4])

.
Predicted body weight for women:

45 + (2.3 x [height in inches - 60])
or
45 + (0.91 x [height in centimeters-152.4])

Reference: http://www.ardsnet.org/node/77460

2008-10-06T16:41:00.000-07:00

Monday October 6, 2008
Do we have standardization of Intensive Care Units across the Globe

Wunsch and his colleague did the retrospective review of existing national administrative data. They identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible.

Setting: USA, France, UK, Canada, Belgium, Germany, Netherlands, and Spain.

Results: No standard definition existed for acute care hospital and ICU across countries.

Hospital bed varied in #: USA = 221/100,000, Germany = 593/100,000
Adults ICU bed: UK = 3.3/100,000, Germany = 24/100,000
ICU admissions: UK = 216/100,000, Germany = 2353/100,000
Ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90)
There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = -.82)

Conclusion: Services vary drastically between countries with significant differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality.

Editor Comments: Need for standardization among ICU criteria would be a way to compare morbidity and mortality.

Reference: click to get abstract

Wunsch, H, Angus D, Harrison D, Collang O et al. Variation in critical care services across North America and Western Europe. Critical Care Medicine. 36(10):2787-e8, October 2008

2008-10-05T15:36:00.000-07:00

Sunday October 5, 2008
Early percutaneous coronary intervention after fibrinolysis for acute ST elevation MI: Is there any role?

Bauer and his colleague evaluated the outcome of early percutaneous coronary intervention (PCI) after fibrinolysis in patients presenting with ST elevation MI. 2230 consecutive patients with STEMI treated with fibrinolysis were divided into two groups:
patients treated with fibrinolysis only (n = 1540) or
with additional PCI (n = 690) within a median of 150 min

Results:
In-hospital mortality (9.3% versus 5.9%) and death/myocardial re-infarction (13.9% versus 9.7%) occurred significantly less often in the PCI group but after adjustment for the confounding factors in the propensity score analysis PCI did not significantly affect hospital mortality and death/myocardial re-infarction in the overall patient collective.
Major bleeding complications were observed more often in the PCI group (7.3% versus 4.2%).
In patients with a higher risk profile (TIMI risk score more than/=5) (n = 494) PCI was associated with a significant reduction of hospital mortality and death/myocardial re-infarction

Conclusions: In the overall patients' collective early PCI after fibrinolysis is not associated with an improved clinical outcome. However, in patients with a higher risk profile an early invasive strategy is associated with a risk reduction for mortality and the combined endpoint of death/myocardial re-infarction.

Reference: click to get abstract

Brauer T, Koeth O et al. Early percutaneous coronary intervention after fibrinolysis for acute ST elevation myocardial infarction: results of two German multi-center registries (ACOS and GOAL). Acute cardiac Care 2007; 9 (2): 97-103

2008-10-04T00:14:00.000-07:00

Saturday October 4, 2008
Ultrafiltration in decompensated CHF

Loop diuretics, have been the therapeutic icon for decades, however it may be associated with increased morbidity and mortality because of deleterious effects on neurohormonal activation, electrolyte balance, and cardiac and renal function. Ultrafiltration, an alternative method of sodium and water removal, safely improves hemodynamic in heart failure patients as reconfirmed again in a recently announced study 1.

Findings: Among 200 decompensated CHF patients randomized to ultrafiltration or intravenous diuretics,
48 hours weight (P = 0.001) and net fluid loss (P = 0.001) were greater in the ultrafiltration group. Dyspnea scores were similar.
At 90 days, the ultrafiltration group had fewer heart failure rehospitalizations/patient (P = 0.022) and patients presenting for unscheduled visits (21 vs. 44%; P = 0.009).
No serum creatinine differences occurred between the groups.

Conclusion: In decompensated CHF, ultrafiltration causes greater fluid and weight loss, as well as have a fewer rehospitalization rate and unscheduled visit.

Related previous pearl: The ‘UNLOAD’ Study

Reference: click to get abstract

Costanzo, MR. Ultrafiltration in the management of heart failure. Current Opinion in Critical Care. 14(5):524-530, October 2008.

2008-10-03T14:26:00.000-07:00

Friday October 3, 2008

Case: 58 year male brought to ER with high fever along with mental status change. In ER patient had a witnessed seizure. Urine output is marginal. You received following lab values

Hb 7 gm/dl, Platelets: 14 /μL, Cr.: 2.6 mg/dl

Your next line of action along with treating rescuing airway and treating seizure is: (choose one)

A) Initiate Sepsis protocol
B) Perform Lumbar punture (to rule out meningitis)
C) Transfue platelets
D) Call for plasmapheresis
E) Initiate Dialysis

Answer: D

This patient most probably has thrombotic thrombocytopenic purpura (TTP). It has 5 basic criteria

thrombocytopenia,
Microangiopathic hemolytic anemia,
CNS dysfunction,
fever, and
renal failure

The therapeutic effects of plasmapheresis in the critically ill patient with TTP are often dramatic: Severe neurologic manifestations may disappear, and laboratory abnormalities may diminish in a few hours. Platelet transfusions should be avoided because they have been accompanied by marked deterioration in either renal or neurologic status. The treatment of seizures in TTP is the same as for seizures with other complicated hematologic disorders.

Splenectomy is a reasonable treatment option for TTP patients refractory to standard TPE or who have experienced multiple and/or complicated relapses 2.

Review at emedicine.com: Thrombotic thrombocytopenic purpura (TTP)

Reference: Click to get abstrat

1. Thrombotic thrombocytopenic purpura: Treatment with plasmapheresis - American Journal of Hematology, Vol. 24 issue 4, Pages 329 - 339, Published Online: 11 Jul 2006

2. Role of splenectomy in patients with refractory or relapsed thrombotic thrombocytopenic purpura. Aqui NA, Stein SH, Konkle B, Abrams CS, Strobl FJ. Journal of Clinical Apheresis 2003;18:51-54.

2008-10-02T17:40:00.000-07:00

Thursday October 2, 2008

Case: You inserted central line. While you were on your way to check CXR to confirm line placement, nurse request you to check KUB also to confirm enteral feeding tube placement (DHT). Interestingly, KUB shot this morning had IVC filter which is no more present there?

Answer: Guide wire during central line procedure probably travelled into inferior vena cava and dislodged IVC filter !!

Related previous pearls:

Guide wire length
Peres Nomogram

References: click to get abstract / article

1. Guidewire Dislodgment of Inferior Vena Cava Filters During Insertion of Central Venous Catheters, Vascular and Endovascular Surgery, Vol. 31, No. 5, 587-593 (1997)

2. Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 2000; 28: 138–42

3. Greenfield Inferior Vena Cava Filter Dislodged During Central Venous Catheter placement, Chest 1994;106;957-959

2008-10-01T12:37:00.000-07:00

Wednesday October 1, 2008

Q: Propofol may lower the serum concentration of which essential element?

A: Zinc

Propofol treated patients have shown greater urinary losses of zinc and iron and to lower serum zinc concentrations. But the clinical significance of trace metal losses is unclear and requires further study.

Reference: click to get abstract

1. Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients - Intensive care medicine Supplement 2000, vol. 26, n4, pp. S413-S421 (30 ref.)