Friday, October 31, 2008

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)

Thursday, October 30, 2008

Thursday October 30, 2008

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

Wednesday, October 29, 2008

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?

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

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

Tuesday, October 28, 2008

Tuesday October 28, 2008

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

Monday, October 27, 2008

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%

Sunday, October 26, 2008

Sunday October 26, 2008

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

A: Vasopressin

Saturday, October 25, 2008

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 for information on these possible “scams” and what can be done to assure the professional integrity of medical specialty certification.