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
Friday, October 17, 2008
Thursday, October 16, 2008
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
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)
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)
Wednesday, October 15, 2008
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.
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.
Tuesday, October 14, 2008
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.
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.
Monday, October 13, 2008
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.
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.
Sunday, October 12, 2008
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
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.
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.
Saturday, October 11, 2008
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.
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