Icuroom-pearls

Saturday, July 01, 2006

by placebo for up to 8 days. Death or reinfarction at 30 days was significantly reduced from 677 (11.2%) of 6056 patients in the control group to 585 (9.7%) of 6036 patients in the fondaparinux group. There was a tendency to fewer severe bleeds (79 for placebo vs 61 for fondaparinux), with significantly fewer cardiac tamponade (48 vs 28) with fondaparinux at 9 days. However, there was no benefit in those undergoing primary percutaneous coronary intervention. 4, 5.Here one caution is important that fatal bleeding with Fondaparinux can be treated only with supportive treatment. Also half life of Fondaparinux is 17-21 hours. See related previous pearl LMWH and Antidot (protamine). 6References: (click to get abstrat/article)1. Comparison of Fondaparinux and Enoxaparin in Acute Coronary Syndromes - Volume 354:1464-1476, NEJM, April 6, 20062. Oasis 5 - clinicaltrials.gov3. Therapy for Patients with Acute Coronary Syndromes - New Opportunities, Volume 354:1524-1527, NEJM April 6, 20064. Effects of Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation Myocardial Infarction - JAMA. 2006;295:1519-1530. Vol. 295 No. 13, April 5, 20065. MICHELANGELO OASIS-6 : FOndaparinux in ST Elevation Myocardial Infarction6. Treatment of postoperative bleeding after fondaparinux with rFVIIa and tranexamic acid. Neth J Med 2005 May;63(5):1846
posted by ICU room Pearls @ 3:25 PM 0 comments
Sunday, April 09, 2006

Prolonged Mechanical Ventilation
Monday April 10, 2006Prolonged Mechanical Ventilation - Consensus statement of National Association for Medical Direction of Respiratory Care (NAMDRC) In May 2004, NAMDRC (chair - Neil R. MacIntyre, MD), a physician advocacy organization for excellence in the delivery of respiratory and critical care, made 12 recommendations for patients with Prolonged Mechanical Ventilation (PMV). We are putting only few salient features here. Full article can be obtained from reference.1. PMV should be defined as the need for more than / = 21 consecutive days of mechanical ventilation for more than / = 6 h/day.2. In patients with slowly resolving respiratory insufficiency, complete liberation from mechanical ventilation (or a requirement for only nocturnal NIV) for 7 consecutive days should constitute successful weaning.3. Greatest emphasis should be placed on identifying factors that are potentially reversible, especially iatrogenic factors.4. All facilities that are available to patients should be screened by the critical care team for effectiveness and safety when effecting discharge for post-ICU weaning.5. Begin considerations for PMV-focused care when tracheostomy is first considered.6. PMV weaning strategies should thus incorporate nonphysician-implemented weaning protocols that utilize daily SBTs of progressively increasing duration after a certain level of ventilatory support reduction has occurred.Reference: Management of Patients Requiring Prolonged Mechanical Ventilation - Report of a NAMDRC Consensus Conference - Chest. 2005;128:3937-3954.
posted by ICU room Pearls @ 9:30 PM 0 comments
Saturday, April 08, 2006

IV vasotec
Sunday April 9, 2006Why sometime IV vasotec (enalapril) does not work?If you are using IV Vasotec to treat hypertension, remember peak effect after the first dose may not occur for up to four hours. But the peak effect of the second and subsequent doses may exceed those of the first. Although in practical world, dose upto 5 mg IV has been prescribed but no dosage regimen has been clearly demonstrated to be more effective in treating hypertension than IV Vasotec 1.25 mg every six hours. Patients with conditions of heart failure, hyponatremia, diuretic therapy, renal dialysis, and volume depletion may drop their blood pressure precipitously and recommended starting dose should be no greater than 0.625 mg.IV Vasotec should be administrated slowly over 5 minutes.Reference: Vasotec IV - fda.gov
posted by ICU room Pearls @ 10:05 PM 0 comments
Friday, April 07, 2006

EGDT and need for PAC
Saturday April 8, 2006Early Goal-Directed Therapy and Pulmonary Artery Catheter needVarious institutions are running protocols and study in reference to Early Goal-Directed Therapy and we are learning new aspects related to this approach. Recent study from Cooper University Hospital, Camden, NJ (done by Trzeciak, Dellinger, Parillo and Colleauges), found 2 lessons:1. Emergency medicine and Critical Care collaboration can be run effectively and all end points of EGDT were successfully achieved for 20 of 22 EGDT cases. End points were CVP, MAP and ScvO2.It proved that EGDT can reliably be achieved in "real-world clinical practice". The following median times were observed:
central line insertion, 1.5 hours;
CVP goal, 6.0 hours;
MAP goal, 4.0 hours;
ScvO2 measured, 2.0 hours; and
ScvO2 goal, 5.0 hours
2. Another interesting outcome of study was Pulmonary Artery Catheter utilization in the ICU was significantly lower with EGDT (9.1%) vs pre-EGDT (43.8%) [p = 0.01].Related Previous Pearl: Shock alert - Shock bedReference:A 1-Year Experience With Implementing Early Goal-Directed Therapy for Septic Shock in the Emergency Department - Translating Research to Clinical Practice - Chest. 2006;129:225-232
posted by ICU room Pearls @ 10:18 PM 0 comments
Thursday, April 06, 2006

Permissive Hypercapnia
Friday April 7, 2006The Bohr Effect and Permissive HypercapniaOne of the physiologic basis of permissive hypercapnia is to increase unload of oxygen to tissues under decrease PH, call Bohr Effect. The Bohr Effect is an adaptation to release oxygen to the starved tissues in conditions where respiratory carbon dioxide lowers blood pH. When blood pH decreases, the ability of hemoglobin to bind to oxygen decreases, classically said "shifting of oxygen dissociation curve to the right", although the SaO2 may be relatively low. This leads many experts to ask the question - is permissive hypoxemia really bad? 2In depth, there are many other implications of permissive hypercapnia including suppressive effects on inflammatory mechanisms that may contribute to lung protection with therapeutic hypercapnia. Read informative article implications for permissive and therapeutic hypercapnia (D.A. Kregenow and E.R. Swenson, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA - Reference: Eur Respir J 2002; 20:6-11)Reference: 1. Respiratory Function of Hemoglobin - Volume 338:239-248, January 22, 19982. Permissive Hypoxemia: Is It Time To Change Our Approach? Abdelsalam Chest.2006; 129: 210-211
posted by ICU room Pearls @ 10:02 PM 0 comments

ScvO2 and SvO2
Thursday April 6, 2006central venous O2 saturation (ScvO2) or mixed venous O2 saturation (SvO2) ?Is ScvO2 interchangeable with SvO2 ? The answer is no but the debate is - can they be use independently in the mangement of sepsis ? SvO2 value is usually 5% lower than ScvO2 due to mixing of atrial and coronary sinus blood (and other factors 3). Some experts warn that substituting ScvO2 for Svo2 may produce large errors 1. Dr. Rivers of EGDT- Early Goal Directed Therapy (in which ScvO2 has been used as a mainstay of algorithm) discussed this debate in recent issue of "chest" (march, 2006) 2. And at this point the practice pattern is consist of as he wrote:"irrespective of whether the ScvO2 value equals the SvO2 value, the presence of a low ScvO2 level in patients with early sepsis portends increased morbidity and mortality"Present practice target is value of 65% for SvO2 level and 70% for Scvo2 in the resuscitation of patients with severe sepsis. ScvO2 is quick and easy to obtain in comparison to SvO2.Reference: 1. Lack of Equivalence Between Central and Mixed Venous Oxygen Saturation Chest. 2004;126:1891-18962. Mixed vs Central Venous Oxygen Saturation May Be Not Numerically Equal, But Both Are Still Clinically Useful Chest, March 1, 2006; 129(3): 507 - 5083. Central or Mixed Venous Oxygen Saturation? Kopterides et al. Chest.2005; 128: 1073-1075
posted by ICU room Pearls @ 7:44 AM 0 comments
Wednesday, April 05, 2006

How much extra phenytoin
Wednesday April 5, 2006How much extra phenytoinThe formula to decide, how much extra phenytoin should be prescribed to get level therapeutic isExtra phenytoin needed = [0.7 x IBW x (15 - current level) ] / 0.92Where IBW = Ideal body weight (note - this is 'ideal' body weight)e.g: If patient with ideal body weight of 62 kg has dilantin level of 7.4, the extra required dose would be [0.7 x 62 x (15 - 7.4)] / .92 = 330 mg or to be practical about 300 mg.Remember this formula is for patient with normal albumin and conserve renal function. Please see pearl from yesterday for phenytoin adjustment with low albumin and low CrCl hereReference:Phenytoin dosing guidelines by D.McAuley, GlobalRPh Inc.
posted by ICU room Pearls @ 12:50 PM 0 comments
Tuesday, April 04, 2006

Phenytoin level
Tuesday April 4, 2006Phenytoin (Dilantin) levelThe ideal phenytoin level is to have unbound (free) phenytoin level but if free phenytoin level is not available or turn around time is long, it should be adjusted with albumin level with following formula, called Sheiner-Tozer equation. Its not 100% accurate but give good estimate.Corrected Dilantin = measured level / [ (0.2 x albumin) + 0.1]e.g: if measured Dilantin level is 8.2 but albumin is 2.2, the corrected Dilantin level would be 8.2 / { (.2 x 2.2) + .1} = 15.2In renal patients, If patient CrCl is less than 20, use following formula.Corrected Dilantin = measured level / [ (0.1 x albumin) + 0.1]e.g: if measured Dilantin level is 8.2 but albumin is 2.2, the corrected Dilantin level would be 8.2 / { (.1 x 2.2) + .1} = 25.6See the difference ?. Just don't carried away with low level.Also be cautious, phenytoin's dose increase is not linearly related to serum levels. Small increase in dose may produce disproportionate and actually toxic serum level.
posted by ICU room Pearls @ 10:18 AM 0 comments
Monday, April 03, 2006

Nesidioblastosis
Monday April 3, 2006Nesidioblastosis - post gastric bypass complicationCase: 40 years old non-diabetic female, reliable historian, admitted to ICU with life threatening and persistent hypoglycemia. Patient is not on any medication and past medical and surgical history is significant only with gastric bypass surgery 2 years ago. Surgical service decide to take patient to OR.As gastric bypass procedures are growing in number, Nesidioblastosis (hyperinsulinemic hypoglycemia) is now a documented complication of gastric bypass surgery particularly Roux-en-Y gastric bypass surgery. Patients may present with repeated episodes of profound hypoglycemia which are actually postprandial neuroglycopenia associated with endogenous hyperinsulinemic hypoglycemia. Diagnosis is confirmed by selective arterial calcium-stimulation testing and treatment is partial pancreatectomy. Peri and post-operatively diffuse beta-cell hypertrophy and hyperplasia has been demonstrated (and resected). The exact mechanism is not clear though various explanations has been suggested.Read very nice review here from Edward E. Mason MD, Ph.D.(University of Iowa health care).References: (click to get abstract)1. Gastric Bypass and Nesidioblastosis — Too Much of a Good Thing for Islets? - NEJM , Volume 353:300-302 - July 21, 20052. Nesidioblastosis - emedicine.com
posted by ICU room Pearls @ 12:52 AM 0 comments
Saturday, April 01, 2006

Restless Legs syndrome
Sunday April 2, 2006Restless Legs syndromeEvery now and then, intensivists receive calls regarding issues which are usually not expected from critical care unit. One such instance is Restless legs syndrome. Various pharmacological agents have been described and used with success including benzodiazepines, carbamazepine and clonidine.In ICU situation, one useful drug in this regard is Ropinirole which is a Dopamine agonist. One of the effect of Ropinirole is heavy sleepiness, which can be use as benefit in ICU. Dose can be initiated from .25 mg PO QHS upto 4 mg PO QHS.References: (click to get abstract)1. Restless Legs Syndrome: Detection and Management in Primary Care - NATIONAL HEART, LUNG, AND BLOOD INSTITUTE WORKING GROUP ON RESTLESS LEGS SYNDROME - Vol. 62/No. 1 (July 1, 2000) - American Family Physician.2. Ropinirole is effective in the treatment of restless legs syndrome. TREAT RLS 2: a 12-week, double-blind, randomized, parallel-group, placebo-controlled study - Mov Disord. 2004 Dec;19(12):1414-23.
posted by ICU room Pearls @ 11:11 PM 0 comments

Pericardial Effusion on CXR reading
April 1, 2006Bedside trick ! - To suspect Pericardial Effusion on CXR readingPericardial effusion may be difficult to rule out on CXR.Most patients in ICU have a heart rate of more than 100 bpm. X-ray exposure is usually long enough to allow the heart border to move significantly. If the heart borders are sharply demarcated, consider a pericardial effusion. In other words, in normal CXR you may see little haziness at borders due to movement of heart borders inside pericardium which get lost with pericardial effusion.Another sign is presence of a thick pericardial fat stripe seen on the lateral view. Please see CXR in this regard here from teaching files of University of Ottawa.
posted by ICU room Pearls @ 11:41 AM 0 comments
Thursday, March 30, 2006

.
March 31, 2006Garlic Odor in ICUQ: Patient with which poisoning presents with garlic odor?A: Organophosphate poisoning.Thursday March 30, 2006Dilantin in TorsadeQ: Which anti-seizure drug can be use in the treatment of Torsade de pointes if conventional therapy fails?A: Phenytoin (Dilantin).References:1. Torsades de pointes therapy with phenytoin - Ann Emerg Med.1991 Feb;20(2):198-200.2. Few case reports from literature: remarkablemedicine.com
posted by ICU room Pearls @ 8:47 AM 1 comments
Wednesday, March 29, 2006

Digoxin Toxicity
Wednesday March 29, 2006Digoxin ToxicityQ: Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?A: Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it may be misleading.See full review on DIGIFAB along with dose calculator here (source: fda.gov)
posted by ICU room Pearls @ 8:37 AM 0 comments
Tuesday, March 28, 2006

Cuff leak test
Tuesday March 28, 2006Cuff leak test - to anticipate post-extubation stridorThere are atleast 3 common ways to do cuff leak test to anticipate postextubation stridor but none has been really tested in a big scientific randomized trial. And literature is full of conflicting studies.1. Bedside crude method: Deflate the cuff, +/- occlude the ETT and put your hand at mouth to feel exhaled air. (isn't it brutal?)2. Record the difference between the inspiratory tidal volume and the expiratory tidal volume while the cuff around the endotracheal tube was deflated. (Average of any three values on six consecutive breaths). Cuff leak less than 110 mL is more associated with postextubation stridor.3. Record the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation. Divide this number by the exhaled tidal volume before cuff deflation. Your answer is 'percent cuff leak'. Patients with a cuff leak of less than 10% are at risk for stridor or reintubation.Some other methods like laryngeal ultrasound has also been described in literature. Also, experts recommend to test the ability to expel secretions with an effective cough. Be aware, a low value for cuff leak may actually be due to encrusted secretions around the tube rather than to a narrowed upper airway. Reintubation equipment (including tracheostomy equipment) should be readily available during extubation and immediate postextubation period.Related previous pearl: Spontaneous Breathing Trial (SBT)References: Click to get abstract/article1. Association between reduced cuff leak volume and postextubation stridor - Chest, Vol 110, 1035-10402. Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation - J Am Coll Surg. 2000 Jun;190(6):682-7.3. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study - Eur . Respir J 2006; 27:384-3894. Predicting Extubation Failure - Is It in (on) the Cards? - Chest. 2001;120:1061-10635. Evaluation of the Cuff-Leak Test in a Cardiac Surgery Population - Chest. 1999;116:1029-10316. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support - Chest. 2001;120:375S-396S
posted by ICU room Pearls @ 1:24 AM 0 comments
Monday, March 27, 2006

Unload
Monday March 27, 2006The ‘UNLOAD’ StudyNew findings from the UNLOAD study, announced at the 2006 American College of Cardiology (ACC) 55th Scientific Session Conference in Atlanta, detail immediate and long-term benefits for heart failure patients receiving ultrafiltration therapy to treat fluid overload. This is the first randomized clinical study to compare the safety and efficacy of a non- drug-based option with standard intravenous diuretic drug therapy to treat heart failure patients. UNLOAD stands for UltrafiltratioN versus IV Diuretics for Patients HospitaLized fOr Acute Decompensated Congestive Heart Failure. This prospective, randomized multi-center trial compared the immediate and long-term effects of early ultrafiltration alone, versus intravenous diuretics alone, on weight loss, symptoms and hospitalizations of patients with decompensated heart failure and fluid overload. The ultrafiltration therapy used in the trial was administered via the Aquadex FlexFlow(TM). The Aquadex FlexFlow is a mechanical system that can remove up to one liter of excess fluid from the body in two hours, or more than a gallon in eight hours. The system received marketing clearance from the U.S. Food and Drug Administration in 2002. A Standard catheter is inserted into peripheral or central vein, which connects the patient to the Aquadex FlexFlow.Two hundred patients were enrolled at 28 medical sites. In this prospective trial, patients were randomized and placed in either the ultrafiltration group or the intravenous diuretics group, and assessed at entry and at intervals out to 90 days. There was no difference in renal function between the groups. Highlights of the UNLOAD study include statistically significant findings such as:At 48 hours into treatment, the ultrafiltration group demonstrated a:38% greater weight loss over standard care; and28% greater net fluid loss over standard care.At 90 days following hospital discharge, the ultrafiltration group demonstrated a:43% reduction in patients requiring rehospitalizations for CHF over standard care;50% reduction in the total number of rehospitalizations for CHF over standard care.52% reduction in ER or clinic visits over standard care and63% total reduction in days rehospitalized for heart failure over standard care.The benefits in weight loss and in reduction of rehospitalization were seen in all subgroups analyzed.The cost of the device is about $10,000, and each filter runs about $800.
posted by ICU room Pearls @ 9:06 AM 0 comments
Sunday, March 26, 2006

Is the Gut working
Sunday March 26, 2006Where is my food dude !!Is the Gut working? : Bowel sounds are not a reliable indicator of gastrointestinal function in critical illness. Bowl sound requires the presence of movement, intestinal contents and intraluminal air. Normally air is swallowed and in ventilated patients, particularly if receiving high doses of sedation or neuromuscular blocking agents do not swallow air. Because of this bowl sounds may be absent in patients whose gastrointestinal tract is working normally.Read this quote from study of 1479 patients - Daily enteral feeding practice on the ICU, which also looked into the factors interfering with successful administration of enteral feed: "We also found that nurses tended to overestimate gastric retention as a risk factor and, more importantly, violated the protocol by discarding a gastric retention volume of less than 200 ml over 6 hours. This behavior might be the result of a misplaced ambition to achieve safer care. Although the measurement of gastric retention is an important tool for guaranteeing safe enteral feeding, no difference is reported between gastric tube and duodenal tube use among ICU patients in terms of aspiration and nosocomial pneumonia." It was recommended to give back gastric retention of less than 250 ml (per 6 hours).Related previous pearl: Is post pyloric feeding absolute ?Reference: (Click to get article)Daily enteral feeding practice on the ICU: attainment of goals and interfering factors - Critical Care 2005, 9:R218-R225
posted by ICU room Pearls @ 8:43 AM 0 comments
Saturday, March 25, 2006

Valentino's Syndrome
Saturday March 25, 2006Valentino's SyndromeQ: What is Valentino's Syndrome ?A: A duodenal ulcer with retroperitoneal perforation presenting with pain in the right lower quadrant is called Valentino's syndrome. Usually surgery can be avoided and treatment is hydration and antibiotics.Read case presentation with radiological findings here.(Reference: NEJM, Volume 354:e9, Number 10, March 9, 2006)
posted by ICU room Pearls @ 4:40 PM 0 comments
Friday, March 24, 2006

Forearm Blood Pressure
Friday March 24, 2006Is Forearm Blood Pressure Reliable ?It is one of the common practice to use forearm as non-invasive blood pressure monitoring in case upper arm blood pressure measurements having problems. Folks from Delaware did blood pressure measurement in the forearm and then in the upper arm of 221 supine patients with their arms resting at their sides. Similar exercise was repeated with patients' head of the bed elevated at 45 degree. Analysis showed that: Noninvasive measurements of blood pressure in the forearm and upper arm cannot be interchanged irrespective of position. Important aspect of forearm BP monitoring:1. Forearm BP measurement is not recommended but if absolutely required, as if proper-size upper arm cuff is not available, make sure correct cuff size for forearm is used.2. Use and follow forearm Blood Pressure serially and DO NOT interchange Blood Pressure measurement with upper arm readings.3. Be cautious that systolic, diastolic and mean forearm blood pressure measurements are higher than upper arm blood pressure measurements with following values* Systolic BP is about 8 mm Hg higher in supine and 14 mm Hg higher at 45 degree,* Diastolic BP is about 4 mm Hg higher in supine and 9.5 mm Hg higher at 45 degree,* Mean BP is about 5 mm Hg higher in supine and 11 mm Hg higher at 45 degree.Reference:Clinical Comparison of Automatic, Noninvasive Measurements of Blood Pressure in the Forearm and Upper Arm With the Patient Supine or With the Head of the Bed Raised 45?: A Follow-Up Study - American Journal of Critical Care. 2006;15: 196-205
posted by ICU room Pearls @ 8:35 AM 0 comments
Thursday, March 23, 2006

BNP and PWP
Thursday March 23, 2006Can BNPs replace Pulmonary Wedge Pressure?With BNP as a marker of fluid overload on heart, there was a lot of enthuthiasm about using it as a non-invasive mirror for PCWP. Group of physicians from Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland studied prospectively 40 patients in the ICU requiring invasive hemodynamic monitoring. Hemodynamics were recorded simultaneously with blood sampling for both BNP and NT-proBNP. They found that due to rapidly fluctuating levels of estimated glomerular filtration rate in ICU patients - BNPs have very poor correlation with PCWP.Related previous pearls: BNP or Pro-BNP ? and Re. Nesiritide (Netrecor)References:1. Relationship Between B-Type Natriuretic Peptides and Pulmonary Capillary Wedge Pressure in the Intensive Care Unit - J Am Coll Cardiol, 2005; 45:1667-1671
posted by ICU room Pearls @ 8:58 AM 0 comments
Wednesday, March 22, 2006

SBT
Wednesday March 22, 2006Spontaneous Breathing Trial (SBT) - how long - 30 minutes or 120 minutes?Spontaneous Breathing Trial (SBT) remained one of the key clinical parameter for extubation from mechanical ventilation but there is always a debate about how long is good enough to predict successful extubation. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support published in chest 2001 recommends: "The tolerance of SBTs lasting 30 to 120 min should prompt consideration for permanent ventilator discontinuation."3Earlier one study published 7 years ago in Am. J. Respir. Crit. Care Med, showed that successful extubation can be achieved equally effectively with trials targeted to last 30 and 120 minutes 1. This has been confirmed again in another study from Washington Hospital Center, Washington, DC. 164 consecutive medical ICU patients on mechanical ventilation have been evaluated. 90-minute CPAP trial has been given and RSBI was measured at 1, 30, 60, and 90 minutes of SBT. 141 patients were successfully extubated and the mean RSBI’s for successfully extubated patients were 65, 63, 64, and 65 at 1, 30, 60, and 90 minutes, respectively. It was concluded that there is little to be gained by extending the SBT beyond the first 30 minutes 2.In this regard, read article with weaning protocols, strategies and numbers from FERNANDO FRUTOS-VIVAR, MD and ANDRÉS ESTEBAN, MD, PHD (Intensive Care Unit, Hospital Universitario de Getafe Madrid, Spain): When to wean from a ventilator: An evidence-based strategy, published in CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70, NUMBER 5 MAY 2003 page 389References: 1. Effect of Spontaneous Breathing Trial Duration on Outcome of Attempts to Discontinue Mechanical Ventilation - Am. J. Respir. Crit. Care Med., Volume 159, Number 2, February 1999, 512-5182. Analysis of Rapid Shallow Breathing Index as a Predictor for Successful Extubation from Mechanical Ventilation - Chest 2004 126: 756S-757S.3. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support- A Collective Task Force Facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine- Chest. 2001;120:375S-396S
posted by ICU room Pearls @ 7:37 AM 0 comments
Tuesday, March 21, 2006

Rapid Response Team
Tuesday March 21, 2006Rapid Response Team / Medical Emergency TeamOverall impression and anecdotal experiences are in favor of Rapid Response Team. Also IHI recommends it as part of "100,000 Lives Campaign". But unfortunately on scientific grounds we are still lacking absolute evidence for Rapid Response Team. Here we will give synopsis of 2 conflicting studies. Unfortunately again, its like comparing oranges to apples as second study comprised only of surgical patients.1. MERIT STUDY: 23 hospitals in Australia were randomized to continue functioning as usual (n=11) or to introduce a RRT/MET system (n=12). The RRT was called only to 30% of patients who fulfilled the calling criteria. Was it just an over active issue or a manifestation of poor pre-training ?. The outcomes (cardiac arrests, unplanned ICU admissions and unexpected deaths) were analyzed. And the final conclusion was: although the call to RRT/MET system (3·1 vs 8·7 per 1000 admissions) was greatly increased, but does not substantially affect the incidence of cardiac arrest (1·64 vs 1·31 per 1000 admissions; p=0·736), unplanned ICU admissions (4·68 vs 4·19 per 1000 admissions; p=0·599), or unexpected death (1·18 vs 1·06 per 1000 admissions; p=0·752).2. Bellomo and colleague's trial - effect of MET on postoperative morbidity and mortality rates: In the control period, there were 336 adverse outcomes in 190 patients, which decreased to 136 in 105 patients during the intervention period (relative risk reduction, 57.8%; p < .0001). These changes were due to significant decreases in the number of cases of respiratory failure, stroke, severe sepsis and acute renal failure (requiring renal replacement therapy). Emergency intensive care unit admissions were also reduced as well as postoperative deaths. Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days. IHI's Rapid Response Team - getting started kitSCCM's RRT/ MET forumReferences: first popup overwrites second popup1. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial, MERIT study - The Lancet 2005; 365:2091-2097 - abstract available with free registration2. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates - Critical Care Medicine: Volume 32(4) April 2004 pp 916-921
posted by ICU room Pearls @ 11:33 AM 0 comments
Sunday, March 19, 2006

Atenolol and Renal Failure
Monday March 20, 2006Atenolol & Renal FailureOne must use caution while prescribing atenolol to patients with renal insufficiency. The elimination half-life of atenolol is extensively prolonged in patient with renal failure. The normal half life of atenolol is 6 to 7 hours; however, in renal failure patients the half-life may be extended to more than 100 hours 2.The recommended dosage are following:CrCl 35 mL/min or greater - normal dosingCrCl 15 - 35 mL/min - MAX. dose 50 mg orally QDCrCl less than 15 mL/min - MAX. dose 25 mg orally QDHemodialysis: 25-50 mg orally after each dialysis session.Treatment of atenolol overdose in a patient with renal failure is recommended with serial hemodialysis and charcoal hemoperfusion 3.On the contrary, metoprolol is extensively metabolized via the hepatic system.References:1.Atenolol-DOSAGE AND ADMINISTRATION - rxlist.com2.Atenolol kinetics in renal failure - Clin Pharmacol Ther. 1980 Sep;28(3):302-93. Treatment of atenolol overdose in a patient with renal failure using serial hemodialysis and hemoperfusion and associated echocardiographic findings Vet Hum Toxicol. 2000 Aug;42(4):224-5.
posted by ICU room Pearls @ 11:51 PM 0 comments

Signout Mortality !
Sunday March 19, 2006Sign-out Mortality !Regular evening work (sign-out) round is an integral part of all tertiary/teaching ICUs in USA but unfortunately as we transit to private practice or community hospital enviroment, we tend to loose this wonderful tradition. Ever thought about poor sign-out to your colleague as a patient safety issue?. A group pf physicians from Chicago have published their study in Quality and Safety in Health Care.26 interns caring for 82 patients were interviewed after receiving sign-out from another intern. 25 discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. Ever think of sign-out as a procedure?Read interesting article related to this topic Glucose Roller Coaster with sample signout sheet at the AHRQ WebM&M website, from Bradley A. Sharpe, MD, University of California, San Francisco .Reference:Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis - Quality and Safety in Health Care 2005;14:401-407
posted by ICU room Pearls @ 10:50 AM 0 comments
Saturday, March 18, 2006

Retinoic acid Syndrome
Saturday March 18, 2006Diagnostic crireia of Retinoic acid SyndromeRetinoic acid syndrome is the major side effect of tretinoin therapy ATRA (all-trans retinoic acid) in patients with acute promyelocytic leukaemia (APL). It occurs in about quarter of patients with treatment. It has been suggested that 3 out of the following 7 signs and symptoms should be present to label patients as having Retinoic acid syndrome while getting ATRA and in the absence of other causes like sepsis 1, 2.1. Fever2. Weight Gain3. Respiratory distress4. Pulmonary infiltrates5. Pleural or pericadial effusion6. Hypotension7. Renal failureRead: Retinoic Acid Syndrome: A Case Report and Review from The Internet Journal of Oncology. 2005. Volume 2 Number 2.Bonus Pearl: Acute colonic pseudo-obstruction (Ogilvie's syndrome) is one of the another complication may happen during induction treatment with chemotherapy and all-trans-retinoic acid for acute promyelocytic leukemia 3.Reference: (click to get article )1. Incidence, Clinical Features, and Outcome of All Trans-Retinoic Acid Syndrome in 413 Cases of Newly Diagnosed Acute Promyelocytic Leukemia - Blood, Vol. 92 No. 8 (October 15), 1998: pp. 2712-27182. The "retinoic acid syndrome" in acute promyelocytic leukemia - Ann Intern Med. 1992 Aug 15;117(4):292-6.3. Acute colonic pseudo-obstruction (Ogilvie's syndrome) during induction treatment with chemotherapy and all-trans-retinoic acid for acute promyelocytic leukemia - Am J Hematol.1995 May;49(1):97-8.
posted by ICU room Pearls @ 9:38 AM 0 comments
Friday, March 17, 2006

anemia score
Friday March 17, 2006ICU anemia scoreA group of physicians from The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA have developed this ICU anemia score, which can be calculated at 6 hours after admission to intensive care unit.6 points if......Lactate more than 1.5 mg/dl5 points if......Inotropic support11 points if....Surgical patient5 points if......Non-emergent surgery3 points to.....Each g/dl of hemoglobin less than 14 g/dlRisk of anemia starts rising beyond 12 points and goes up. Also, points can be plotted on the probability of anemia graph (figure 3 in reference).Clinical Significance: Once risk of anemia is determined, earlier and more appropriate use of blood transfusion-sparing strategies can be applied such as erythropoietin.Note: Its hard to fully grasp the idea in nut-shell and icuroom.net editors strongly recommend to read article fully as available free by clicking on reference.Reference:Predicting late anemia in critical illness - Eric B Milbrandt,Gilles Clermont, Javier Martinez, Alex Kersten, Malik T Rahim and Derek C Angus - The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA -Critical Care 2006, 10:R39
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Thursday, March 16, 2006

IV insulin dose
Thursday March 16, 2006IV insulin doseAs ICUs are moving more and more towards protocol based orders, insulin drip protocol remains one of the most sought protocol. There is no proven formula available for the dose of insulin drip but one 'rule of thumb' available is as follows:(Current Blood Glucose - 60) x multiplier = number of units of insulin/hourMultiplier could range anywhere from .01 to .09 depending on level of glucose control required. Practically, start multiplier from .01/.02 and continue to escalate till desired control achieved. Control can be made tighter as needed with blood glucose level at given point. Like patient with blood sugar of 359 may start with as low as (359-60) x .01 = 3 units/hour but depending on further blood glucose level may require upto (359-60) x .09 = 27 units/hour of insulin.The best precise article we found with all insulin related protocols is Hospital management of diabetes: Beyond the sliding scale written by Dr. Etie Moghissi, Co-chair, American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. ( Reference: CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 10 OCTOBER 2004. Page 801).
posted by ICU room Pearls @ 12:04 PM 0 comments
Wednesday, March 15, 2006

Regarding Procalcitonin
Wednesday March 15, 2006Regarding Procalcitoninprocalcitonin (PCT) has been claimed to be one of the most specific marker for sepsis/infection. It increases with high specificity in response to clinically relevant bacterial infections and sepsis. PCT has a fast kinetic and can be measured as soon as 3-4 hours after infection. Normal PCT value is less than 0.5 ng/ml and its level in sepsis is generally greater than 1-2 ng/ml and often between 10 and 1000 ng/ml. As the septic infection resolves, PCT reliably returns to low values with a half-life of 24 hours and here the actual value lies to follow the trend to see response to treatment. Another cost-effective advantage is to limit the days of antibiotics depending on resolving trend of PCT value.In a recent study it was found that PCT values should be determine differently between medical and surgical patients . In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL and in medical patients, the best diagnostic cutoff value was 1.00 ng/mL. It was concluded by authors that: Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. (see reference # 2). Its real value still needs to be tested in a major trial as we have other inexpensive and generic tests available like WBC count, Lactic acid level, CRP etc.Official web site procalcitonin.comPrevious Related Pearl: C-Reactive Protein (CRP) - marker of mortality in ICU ?References: (click to get abstract - second popup overwrites first popup)1. Diagnostic and prognostic value of procalcitonin in patients with septic shock. Critical Care Medicine. 32(5):1166-1169, May 2004.2. Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock. Critical Care Medicine. 34(1):102-107, January 2006.
posted by ICU room Pearls @ 9:33 PM 0 comments
Tuesday, March 14, 2006

Hypoglycemia risk factors in ICU
Tuesday March 14, 2006Hypoglycemia risk factors in ICUWe hear a lot about effects of hyperglycemia in ICU but on the other end of spectrum, hypoglycemia could be actually more or atleast equally disastrous. Dr. Vriesendorp and coll. from Amsterdam, The Netherlands looked into record of 2,272 patients and found that 156 patients (6.9%) experienced at least one episode of hypoglycemia (glucose value less than 45 mg/dL). They found following risk factors for hypoglycemia in ICU.
CVVHD with bicarbonate-based substitution fluid,
Decrease of nutrition without adjustment for insulin infusion,
History of diabetes mellitus,
Insulin use,
Sepsis,
Inotropic support and
Simultaneous octreotide and insulin use.
Interestingly, Gastric residual during enteral nutrition without adjusting insulin infusion, liver failure, continuous venovenous hemofiltration with lactate-based substitution fluid, diminished glomerular filtration rate, dose diminishment of glucocorticoids or catecholamines, and use of β-blocking agents were not associated with hypoglycemia.Related Previous Pearl: Quinolones and errant glycemic reaction.Reference: (click to get abstract)Predisposing factors for hypoglycemia in the intensive care unit - Critical Care Medicine. 34(1):96-101, January 2006.
posted by ICU room Pearls @ 1:07 PM 0 comments
Monday, March 13, 2006

Monday March 13, 2006Introducing Resident ICU CourseUnder the banner of Society of Critical Care Medicine 23 lectures (power point) related to Critical Care Medicine have been uploaded at sitehttp://ricu.sccm.orgIt includes essential topics like Airway Management, Mechanical Ventilation, Arterial Blood Gas Interpretation, Endocrine Issues in Critical Illness, Neurologic and Neurosurgical Emergencies, Acute Kidney Dysfunction, Nutritional Support in the ICU etc.Site is free but requires registration. It involves pre and end of rotation online tests with case-scenario based questions. This web-based curriculum has been developed by the Graduate and Resident Education Committee, a committee of the Society of Critical Care Medicine. These presentations have been authored by experts in the corresponding fields and can be downloaded/saved to computer.Highly recommended for medical residents.*Site has 2 arms - Adult and Pediatric
posted by ICU room Pearls @ 7:57 AM 0 comments
Sunday, March 12, 2006

vkpower
Sunday March 12, 2006Power of Vitamin K Q; In patients with Warfarin (Coumadin) , any dose more than ______ mg of Vitamin K will make reanticoagulation difficult.Ans; 1 mg.Previous Related Pearl: 7 Pearls of Vitamin K (phytonadione) Reference: Care of Patients Receiving Long-Term Anticoagulant Therapy - S Schulman, - Volume 349:675-683, Aug 14 '03
posted by ICU room Pearls @ 8:22 AM 0 comments
Saturday, March 11, 2006

hellp
Saturday March 11, 2006Triad of HELLP SyndromeHELLP syndrome is a unique variant of preeclampsia and may manifest even before clinical signs of preeclampsia. Triad or criteria and term "HELLP" syndrome was first designated by Louis Weinstein, M.D. in 1982 in American Journal of Obstet. Gynecol. 1, and is as follows:1. Hemolysis: Abnormal blood smear - Elevated Bilirubin >1.2 mg/dl2. Elevated liver enzymes - with SGOT >72 UI / L (but has been mentioned as low as 40) and LDH >600 UI/L3. Low Platelets: Less than 100. Please note that platelet's cutoff of 100 is debatable and another classification for this syndrome called Mississippi Classification used level less than 150. Read reference # 2 which may need subscription.See impressive slide presentation here on HELLP Syndrome from JOHN ESSIEN M.D. and coll. from HOSPITAL GINECOBSTÉTRICO PROVINCIAL, CAMAGÜEY., CUBA - (its a power point presentation)Previous related pearl: IV Magnesium (Mg) infusionReferences:1.Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Weinstein L. Am J Obstet Gynecol.1982 Jan 15;142(2):159-672. Prevention of Eclampsia - letters to editor, NEJM, May 23, 2003, Volume 348:2154-2155
posted by ICU room Pearls @ 1:18 AM 0 comments
Friday, March 10, 2006

fs
Friday March 10, 2006Frog SignQ: What is Frog sign?A: In Paroxysmal Supra-Ventricular Tachycardia (PSVT) a rapid and regular bulging seen in the neck. These are actually prominent jugular venous A waves due to atrial contraction against the closed tricuspid valve, and termed as "frog sign".References:1. Brief report: the hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant tachycardia - N Engl J Med. 1992 Sep 10;327(11):772-4.2. Evaluation of Patients with Palpitations - NEJM, May, 1998, Volume 338:1369-1373
posted by ICU room Pearls @ 10:03 AM 0 comments
Thursday, March 09, 2006

ebrfsap
Thursday March 9, 2006Evidence-based recommendations for Severe Acute Pancreatitis (SAP)An international consensus conference was held in April 2004 to develop guidelines for the management of the critically ill patient with SAP and published in December 2004 issue of Critical Care Medicine. 23 evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature. We are pening here few most important recommendations but full article can be pulled from reference below.* Critically ill patients with pancreatitis be cared for by an intensivist-led multidisciplinary team with ready access to physicians skilled in endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), surgery, and interventional radiology.* Followup CT to identify local complications be delayed for 48-72 hrs when possible, as necrosis might not be visualized earlier.* Recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis.* Enteral nutrition should be initiated after initial resuscitation. The jejunal route should be used if possible and parenteral nutrition only be used when attempts at enteral nutrition have failed after a 5- to 7-day trial and when used, parenteral nutrition should be enriched with glutamine.* Sonographic- or CT-guided FNA with Gram stain and culture of pancreatic or peripancreatic tissue to discriminate between sterile and infected necrosis in patients with radiological evidence of pancreatic necrosis and clinical features consistent with infection and recommendation against debridement and/or drainage in patients with sterile necrosis.* Pancreatic debridement or drainage in patients with infected pancreatic necrosis and/or abscess confirmed by radiological evidence of gas or results of FNA. The gold standard for achieving this goal is open operative debridement. If possible, operative necrosectomy and/or drainage be delayed at least 2-3 wks to allow for demarcation of the necrotic pancreas.* In acute pancreatitis due to suspected or confirmed gallstones, urgent ERCP should be performed within 72 hrs of onset of symptoms.* Use of early volume resuscitation and lung-protective ventilation strategies for patients with acute lung injury.* In SAP with severe sepsis careful consideration be used before the administration of rh-APC based on the theoretical but unproven concern of retroperitoneal hemorrhage.Reference:Management of the critically ill patient with severe acute pancreatitis - Critical Care Medicine: Volume 32(12) December 2004 pp 2524-2536 . Sponsored by the American Thoracic (ATS), the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Française (SRLF).
posted by ICU room Pearls @ 7:16 AM 0 comments
Wednesday, March 08, 2006

Chest tube
Wednesday March 8, 2006Chest tube (tube thoracostomy) with seldinger technique - underutilize technique?Cannulation of pleural space was first described by Hippocrates (460 B.C) and in modern medicine about 140 years ago by Hillier 1. Chest tube insertion gained huge respect during 2 world wars as a life saving procedure. Over last few decades technique remain mostly unchanged with insertion either with help of trocar or with direct insertion with scalpel/clamp and finger opening of pleural space. In recent years insertion of chest tube with seldinger technique (over guide wire) has been described but still remain less popular, although, it has significant advantages over traditional method as it is less painful, easy to insert, can be master easily and ? less prone to infection. The only disadvantage is inability to 'feel' pleural space. On literature search we were unable to find any head to head study comparing seldinger technique with operative technique. There is only one attempt earlier to check literature (see reference # 2) and found that seldinger technique is no way inferior (or superior either) to traditional chest tube insertion.Chest tubes are available for seldinger technique insertion upto 36 f size. See details here from Cook (maker of Thal-Quick chest tubes).Isn't it time to graduate to seldinger technique for chest tubes as we did for central venous catheters from cut-downs? All comments are welcome. References: (click to get article) 1. Chest tube - int.med.utah.edu2. Seldinger technique chest drains and complication rate - Emerg Med J 2003; 20:169-170
posted by ICU room Pearls @ 6:21 AM 0 comments
Tuesday, March 07, 2006

ffp
Tuesday March 7, 2006Some facts about FFP Several plasma alternatives can be used for coagulation factor replacement. The most commonly used plasma component is Fresh Frozen Plasma (FFP). One unit of FFP or thawed plasma is the plasma taken from a unit of whole blood. It is frozen within eight hours of collection. FFP contains all coagulation factors in normal concentrations. Plasma may be stored for as long as I year at -18° C or colder. Thawed plasma may be transfused up to 5 days after thawing and contains slightly decreased levels of Factor V and decreased Factor VIII levels. Plasma is free of red blood cells, leukocytes and platelets. One unit is approximately 200-250mL and must be ABO compatible. Rh factor need not be considered. Since there are no viable leukocytes, plasma does not carry a risk of CMV transmission or Graft Vs. Host Disease (GVHD).The dose of FFP depends on the clinical situation and the underlying disease process. Only 15% - 35% of normal levels of factors are required to maintain normal hemostasis. When FFP is given for coagulation factor replacement, the dose is 10-20 ml/Kg (4-6 units in an adult). This dose would be expected to increase the level of coagulation factors by 20% immediately after infusion. In a 70 kg Patient: 1 Unit Plasma increases most factors ~2.5%. 4 Units Plasma increase most factors ~10%.FFP may be rapidly transfused over 20-30 minutes. The rate is mainly limited by the patient’s ability to tolerate the volume. Allergic reactions occur in approximately 1% of patients receiving FFP. The reactions are usually mild consisting of an urticarial rash (hives) and pruritus. FFP has not been associated with transmission of CMV or HTLV-I, II since these viruses are exclusively white cell associated and plasma is virtually acellular.Related previous Pearl : How much FFP?Also for your file:1. Guidelines for the use of Fresh Frozen Plasma, cryoprecipitate and cryosupernatant from British Committee for Standards in Haematology, Blood Transfusion Task Force, British Society of Haematology - British Journal of Haematology 2004; 126, 11-282. Australian National Guidelines on FFP and Cryoprecipitate
posted by ICU room Pearls @ 9:20 AM 0 comments
Monday, March 06, 2006

BEDSIDE CREATININE CLEARENCE
Monday March 6, 2006BEDSIDE CREATININE CLEARENCEThe most sensitive measure of changing renal function is not the serum creatinine, but the creatinine clearance. Serum creatinine underestimates the degree of renal insufficiency in many situations like :- Anyone with a renal insufficiency but a GFR more than 50 ml/min, because serum creatinine does not start to rise until GFR falls below 50 ml/min- Cachexia – because creatinine production is so low, serum creatinine may rise only when GFR falls below 25 ml/min- After surgery in patients who have received a lot of fluids. A 10 – 15% increase in total body water results in dilution of serum creatinine by an equivalent amount.The most useful means of estimating GFR at bedside is a two-hour creatinine clearance. There is nothing about clearance that mandates a 24-hour urine collection, particularly when there is a Foley’s catheter in place, which largely eliminates error due to urine retention. As long as the collection is carefully timed and the urine flow is more than 30 ml/hr, a collection as short as 2-hour will give reasonable data.Creatinine clearance may be calculated simply by UV/Pwhere U is the urine creatinine in mg/dl,V is the urine flow rate in ml/min andP is the serum creatinine in mg/dl.The term ‘UV’ i.e is urine creatinine times urine flow rate, represents the creatinine excretion rate. It is THIS that changes rapidly with changing GFR.Related:1. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation Classification and Stratification - National Kidney Foundation / Kidney Disease Outcomes Quality Initiative.2. ESTIMATION OF CREATININE CLEARANCE IN PATIENTS WITH UNSTABLE RENAL FUNCTION (Dr. Roger Jelliffe - School of Medicine at the University of Southern California).
posted by ICU room Pearls @ 9:24 AM 0 comments
Sunday, March 05, 2006

sb
Sunday March 5, 2006Sunday Basic !Some lessons (not all) learnt in medical school are worth remembering every moment at bedside. For intensivist, following simple fact carries huge bedside implications."Left ventricle is perfused most actively in early diastole, not when aortic pressure is at its maximum but when myocardial pressures are least". Who knows the dilemma of intensivist better than himself while trying to find that fine line between volume, pressors, hear rate and blood pressure.Related: Cardiac angioplasty and stent placement video (Dr. Tyrus Frerking - Mount Carmel health - Ohio) - needs window media player.
posted by ICU room Pearls @ 12:18 PM 0 comments
Saturday, March 04, 2006

prayer sign
Saturday March 4, 2006Prayer SignPrayer Sign - If patient shows inability to place palms flat together, it suggests difficult intubation. It is a reflection of generalised joint and cartilage immobility and tight waxy skin, particularly in diabetic patients. About 33% of diabetic patients are prone to difficult intubations. One study from Istanbul, Turkey compared 80 diabetic patients (D) with 80 non-diabetic patients (ND) undergoing elective surgery under general anaesthesia. The incidence of difficult laryngoscopy was 18.75% in Group D and 2.5% in Group ND. The incidence of the prayer sign was 31.25% in Group D and 13.75% in Group ND.Another version of prayer sign is "palm print" method in which grading of the ink impression made by the palm of the hand has been proposed as a means of screening diabetic patients in whom tracheal intubation may prove difficult. In one study, it was found to be superior to 3 other indices - Mallampati classification, thyromental distance and head extension. References: (second popup overwrites first popup)1. Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality detected using the ‘prayer sign’ - British Journal of Anaesthesia, 2003, Vol. 91, No. 1 159-1602. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics - Acta Anaesthesiol Scand. 1998 Feb;42(2):199-203.
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Friday, March 03, 2006

Peripartum Cardiomyopathy
Friday March 3, 20064 criteria of Peripartum Cardiomyopathy (PPCM)Contributed by: Saadia Faiz M.D., senior Pulmonary and Critical Care fellow, University of Texas at Houston Program.Peripartum cardiomyopathy is a deadly disease with mortality described upto 56%. Relationship of heart failure with pregnancy was first described in medical literature about 135 years ago by Virchow & Porack . In 1937 it was recognised as distinct entity with dilated cardiomyopathy by Gouley. 35 years ago Demakis and Rahimtoola defined PPCM on the basis of 4 criteria. It was modified by National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop in April 1997.1. Heart failure within the last month of pregnancy or 5 months postpartum.2. Absence of preexisting heart disease.3. No determinable etiology and4. Strict echocardiographic criteria of left ventricular dysfunction: Ejection fraction less than 45%, or M-mode fractional shortening less than 30%, or both, and end-diastolic dimension more than 2.7 cm/m2 body surface area.Related: Click here to read review article on recognition and management of maternal cardiac disease in pregnancy from British Journal of Anaesthesia (Reference: 2004 93(3):428-439)References: (second popup overwrites first popup)1. Peripartum cardiomyopathy. Demakis JG, Rahimtoola SH. Circulation. 1971 Nov;44(5):964-82. Peripartum Cardiomyopathy - National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop Recommendations and Review -JAMA. 2000;283:1183-1188. Full text available with free registration.3. Peripartum Cardiomyopathy - Cardiology in Review. 14(1):35-42, January/February 2006.
posted by ICU room Pearls @ 9:45 PM 0 comments
Thursday, March 02, 2006

howmuchffp
Thursday March 2, 2006How much FFP?Dr. Sam Schulman from Karolinska Hospital, Stockholm, Sweden wrote an excellent review on "Care of Patients Receiving Long-Term Anticoagulant Therapy" in August 14, 2003 issue of NEJM 1. Part of article suggest formula for amount of FFP (Fresh Frozen Plasma) to correct INR upto desired level in a bleeding patient from over-anticoagulation.Amount of FFP needed(ml) =(target level as percentage - present level as percentage) x Wt.(kg)The "percentage" is prothrombin complex, expressed as a percentage of normal plasma, corresponds to the mean level of the vitamin K–dependent coagulation factors. It can be compute easily with following table:INR 1 = 100 (%)INR 1.4 - 1.6 = 40INR 1.7 - 1.8 = 30INR 1.9 - 2.1 = 25INR 2.2 - 2.5 = 20INR 2.6 - 3.2 = 15INR 4.0 - 4.9 = 10INR > 5 = 5 (%)Example:In a 70 kg patient bleeding with INR of 7.5 and if our target is to bring INR down to 1.4, using above table:Total FFP needed = (40 - 5) x 70 = 2450 ml(One unit FFP usually contains 200-250 ml of FFP).Reference:Care of Patients Receiving Long-Term Anticoagulant Therapy - Sam Schulman, M.D. - Volume 349:675-683, August 14, 2003
posted by ICU room Pearls @ 11:54 AM 0 comments
Wednesday, March 01, 2006

cfif
Wednesday March 1, 2006Calories from intravenous fluid (IVF)Q: How much calories patient receive from 1 litre of D5-W drip?A: 170 calories / L
posted by ICU room Pearls @ 2:08 AM 0 comments
Tuesday, February 28, 2006

hsiceaih
Tuesday February 28, 2006Hypertonic Solution (3% NS) in cerebral edema and intracranial hypertensionQ: What is the level of Sodium (Na), you will target if hypertonic solution (3% NS) has been choose as management plan in cerebral edema and intracranial hypertension.A: 145-155 Meq/L.Although mannitol with close monitoring of serum osmolality remains mainstay of treatment, no major clinical trial has yet established the use of Hypertonic Solution (3% NS) as standard of treatment in cerebral edema and intracranial hypertension but literature has growingly show its comparable and sustained effect on lowering ICP (Intra-cranial pressure).Related: Read concise review article here on Spontaneous intracerebral hemorrhage from Dr. Matthew E. Fewel and coll., Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan (Neurosurg. Focus / Volume 15 / October, 2003)References: Click to get abstract/article (second popup overrides first popup).1. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Critical Care Medicine. 28(9):3301-3313, September 2000.2. Treatment of elevated intracranial pressure in experimental intracerebral hemorrhage: Comparison between mannitol and hypertonic saline. Qureshi AI, Wilson DA, Traystman RJ: Neurosurgery 1999; 44: 1055-1064 -via pubmed3. Hypertonic saline for cerebral edema and elevated intracranial pressure - Cleve Clin J Med. 2004 Jan;71 Suppl 1:S9-13.4. Introducing Hypertonic Saline for Cerebral Edema: An Academic Center Experience - Neurocritical Care Winter 2004, Volume 1, Issue 4, pps. 435-4405. Treatment of intracerebral haemorrhage - Lancet Neurology 2005; 4:662-672
posted by ICU room Pearls @ 9:17 AM 0 comments
Monday, February 27, 2006

iido
Monday February 27, 2006Introducing icudelirium.orgDelirium is one of the most hidden and deadly enemy in ICU. It increases mortality, it cost money and its hard to recognise. In this regard an organised effort is underway in the form of website charged by Dr. E.Wesley Ely of Vanderbilt University Medical Center.www.icudelirium.orgIt contains numerous tools and information for Critical Care staff, particularly this slide show (Dr. Ely) is worth browsing.Just to have a flavor, see this simple mnemonics from the site.D Drugs, Drugs, DrugsE Eyes, ears 1L Low 02 (MI, ARDS, PE, CHF, COPD)2I InfectionR Retention (of urine or stool), RestraintsI IctalU Underhydration/UndernutritionM Metabolic(S) Subdural, Sleep deprivation1 Poor vision and hearing are considered more risk factors than true causes, but should be "fixed" or improved if possible. Cerumen is common cause of hearing impairment.2 "Low 02 states" does NOT necessarily mean hypoxia, rather it is a reminder that patients with a hypoxic insult (e.g. Ml, stroke, PE) may present with mental status changes with or without other typical symptoms/signs of these diagnoses.
posted by ICU room Pearls @ 6:03 AM 0 comments
Sunday, February 26, 2006

haimi
Sunday February 26, 2006Hypomagnesemia and IV Magnesium (Mg) infusionHypomagnesemia has been reported in upto 60% of ICU patients and sometimes can be clinically very significant like in recovery phase of DKA (diabetic ketoacidosis). Symptoms of severe hypomagnesemia (less than 1 mEq/L) include respiratory failure, hyperactive deep-tendon reflexes, muscular fibrillations, mental status changes, tetany, seizures, positive Chvostek and Trousseau signs. EKG manifestations are prolong PR interval, widened QRS complex, ST depression, altered T waves and last but not the least is loss of voltage. About 33% of serum magnesium is protein-bound but unfortunately wide-spread test for free or active (ionized) magnesium is not available. It is a common practice to write IV Mg orders in grams or mls.1 gram of IV Mg contains 8.12 meq of Mg and 1 meq of Mg provides 12 mg of elemental Mg.One ml MgSO4 50% Solution = 4 meq MagnesiumOne ml MgSO4 10% Solution = 8 meq Magnesium Rapid IV administration can induce life threatening cardiac dysrhythmias, hypotension, flushing, sweating, sensation of warmth and hypocalcemia. In non-emergent cases, general rule of thumb is to infuse 1 gram per 1 hour. In risky situations, like impending arrhythmia, 2 grams of IV Magnesium sulfate may be given over 20 minutes. In extremely emergent cases 2 grams (16 mEq) of IV MgSO4 may be administered over 5 minutes and actually may be given as IV push if there is no permission of time.In Preeclampsia, load IV 4-6 grams of MgSO4 in 100 ml of D5W over 20-30 minutes and maintenance is 2-3 grams/hour with close monitoring of target level (goal of 4-7 mEq/L) and clinical manifestations like decrease deep tendon reflexes. It is not a bad idea to keep IV calcium at bedside during massive IV magnesium infusion as in preeclampsia. IV calcium is an antidote for magnesium overdose.In kidney dysfunction, IV magnesium dose should be reduced by about 50%.
posted by ICU room Pearls @ 12:32 AM 0 comments
Saturday, February 25, 2006

dblranss
Saturday February 25, 2006Difference between Lactate Ringer's and Normal Saline solutionsLactated Ringer's Solution was invented about 125 years ago by a British physiologist Sydney Ringer and never lost a day in its popularity. Let see its difference from normal saline.Normal Saline is the solution of 0.9% NaCl. It has a slightly higher degree of osmolality compared to blood. One litre of Normal Saline contains154 mEq/L of Na+ and154 mEq/L of Cl−One liter of Lactated Ringer's Solution contains:130 mEq/L of Na+ but total cations of 137 mEq/L , so still is isotonic.109 mEq/L of Cl−28 mEq/L of lactate4 mEq/L of potassium3 mEq/L of calcium.Lactate converts to bicarbonate in liver.Pearl: Patients with lactic acidosis usually have inadequate liver metabolism of lactate so conversion to HCO3- from the infused lactate of LR is impaired and may give false readings of serial lactate measurements but may be a better choice in regular situations where hyperchloremia restricts use of normal saline.
posted by ICU room Pearls @ 8:03 AM 0 comments
Friday, February 24, 2006

Intraabdominal compartment syndrome
Friday February 24, 2006Grading of Intra-abdominal Hypertension (intra-abdominal compartment syndrome)Burch and co. defined a grading system of IAH :Grade I (10-15 cmH2O),grade II (15-25 cmH2O),grade III (25-35 cmH2O) andgrade IV (>35 cmH2O).With massive fluid resuscitation as part of critical care management, intensivists need to be constantly cautious of this complication. End-organ damage has been described with bladder pressure as low as 10 cm H2O. Intra-abdominal Hypertension is defined as sustained or repeated pressure more than/= 12 and Intra-abdominal compartment syndrome as sustained or repeated pressure more than/= 20.Although bladder pressure is not the accurate method of diagnosing IAH but so far has been used as standard due to its bedside ease. Dr. Cheatham has proposed APP (Abdominal Perfusion Pressure) as better indicator with formulaAPP = MAP- IAP (like CPP = MAP - ICP).where MAP is mean arterial pressure and IAP is intra-abdominal pressure.Intra-abdominal Hypertension is defined as sustained or repeated APP less than or = 60See good review here with details of how to measure bladder pressure to diagnose Intra-abdominal Hypertension from euroanesthesia.org (Dr. MALBRAIN - Hôpital Sainte Elisabeth, Bruxelles, Belgium).Another review article here from emedicine.com (Dr. Paula Richard).Referencss: Click to get abstract /article1. The abdominal compartment syndrome. - Burch JM, Moore EE, Moore FA, Franciose R Surg Clin North Am. 1996 Aug;76(4):833-42.2. Abdominal Perfusion Pressure: A Superior Parameter in the Assessment of Intra-abdominal Hypertension Journal of Trauma-Injury Infection & Critical Care. 49(4):621-627, October 2000.
posted by ICU room Pearls @ 8:24 AM 0 comments
Thursday, February 23, 2006

caabp
Thursday February 23, 2006Community-Acquired Acinetobacter baumannii Pneumonia !As we are seeing more and more nosocomial infections moving out in community, recently chest has reported the largest series of CAP-AB (community-acquired pneumonia - Acinetobacter baumannii ) - and comparing its severity to HAP-AB (hospital-acquired pneumonia -Acinetobacter baumannii). 19 cases of CAP-AB has been compared to 74 cases of HAP-AB. Risk factors for CAP-AB were ever-smokers and COPD patients. It was characterized by more positive blood cultures (31.6% vs 0%), a higher frequency of ARDS (84.2% vs 17.6%), and DIC (57.9% vs 8.1%). The median survival time was only 8 days in the CAP-AB group vs 103 days in the HAP-AB group (p = 0.003). CAP-AB described to have a fulminant course, with an acute onset of dyspnea, cough, and fever that rapidly progresses to respiratory failure and shock. As discussed further in article, it may be important to consider empirical coverage for CAP-AB with presence of risk factors.Earlier series of 13 patients were studied and read this interesting conclusion: "A baumannii should be considered as a possible etiologic agent in community-acquired lobar pneumonia when (1) patients with a fulminant course present during the warmer and more humid months of the year, and (2) patients are younger alcoholics".Referencss: Click to get abstract/article (second popup overrides first popup)1. Fulminant Community-Acquired Acinetobacter baumannii Pneumonia as a Distinct Clinical Syndrome - Chest. 2006;129:102-1092. Severe Community-Acquired Pneumonia due to Acinetobacter baumannii Chest. 2001;120:1072-1077
posted by ICU room Pearls @ 9:35 AM 0 comments
Wednesday, February 22, 2006

cnucofks
Wednesday February 22, 2006Colonic Necrosis - unusual complication of Kayexalate-SorbitolWe are using sodium polystyrene sulfonate (SPS or Kayexalate) since last 45 years with great confidence. It is a common practice to add sorbitol to dissolve Kayexalate mainly to avoid fecal impaction or possible bowel obstruction. (Kayexalate binds intraluminal calcium and may cause constipation, fecal impaction or bowel obstruction). One of the relatively unknown complication of Kayexalate-sorbitol combination is colonic necrosis, although has been reported in literature earlier. The exact reason for colonic necrosis is not clear but the diagnosis can be made by the pathologic examination of post-operative specimen or material from endoscopic biopsy and may require specialized expertise and special stains. Sorbitol part is taught to be responsible for complication.Intensivist need to be wary of possible complication of acute abdomen after administration of kayexalate-sorbitol in 1% of cases, particularly in first 24-36 hours.See interesting review (full text and references) here from medscape.com with free registration. Originally, published at Southern Medical Journal , 93(5): page numbers 511-513, 2000.
posted by ICU room Pearls @ 8:29 AM 0 comments
Tuesday, February 21, 2006

sasb
Tuesday February 21, 2006Shock alert - Shock bedIn nontraumatic shock, timing is everything as proved again by this organized hospital approach from Dr. Sebat and coll.As a first step of program - 2.5 years of planning and 1 month of intensive education done for early recognition and treatment of shock. Prehospital personnel, nurses, and physicians were empowered to mobilize a Shock Alert depending on screening criteria. Shock bed was made available in ICU all the time. (please see article below for full inclusion, exclusion criteria and protocol details). In second phase, 86 and 103 patients were randomized to the control and protocol groups. The protocol group had significant reductions in the median times to interventions, as follows:intensivist arrival time - decreased from 120 minutes to 50 minutesICU admission - decreased from 167 minutes to 90 minutes2 L fluid infused - decreased from 232 minutes to 105 minutesPulmonary artery catheter placement - decreased from 230 minutes to 130 minutesResult: The hospital mortality rate was 40.7% in the control group and 28.2% in the protocol group (p = 0.035).Reference: Click to get abstract/articleA Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients - Chest. 2005;127:1729-1743
posted by ICU room Pearls @ 8:28 AM 0 comments
Monday, February 20, 2006

crusade
Monday February 20, 2006CRUSADE: Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines.
CRUSADE is a national quality improvement initiative that is designed to increase the practice of evidence-based medicine for patients diagnosed with non-ST segment elevation acute coronary syndromes (unstable angina or NSTE myocardial infarction). It has now over 400 participating sites in the US.Being an intensivist, beside guidelines and other resources available at site following tools (click to get) may be very helpful.
1. QI Clearinghouse is an extensive collection of tools likeStanding Orders for the Management of Non-ST-segment Elevation (NSTE) ACS GPIIb-IIIa Dosing Charts2. The Performance Indicators Record - Acute Care 3. The Reference Guidelines Flipchart,
posted by ICU room Pearls @ 9:31 PM 0 comments
Sunday, February 19, 2006

robtl
Sunday February 19, 2006Ratio of Bumex (Bumetanide) to Lasix (Furesmide)What is the conversion equivalence of Bumex to Lasix?1 mg of Bumex is equal to 40 mg of Lasix.
posted by ICU room Pearls @ 1:45 PM 0 comments
Saturday, February 18, 2006

dd
Saturday February 18, 2006Delphi definition - new clinical definition of acute respiratory distress syndrome (ARDS)Beside 2 definitions of ARDS used commonly - the American-European consensus conference definition and the lung injury score, a relatively new definiation - Delphi definition- developed and published last year in Journal of Critical Care and appears to have better specificity.According to Delphi definition, ARDS is diagnosed if 1- 4 of below present with 5a and/or 5b:1. PaO2/FiO2 ratio is less than or = 200 on PEEP more than or= 10.2. Bilateral airspace disease on CXR. 3. Onset is within 72 hours.4. No clinical evidence/subjective finding of CHF.5a. Objective finding of non-cardiogenic edema (PWP less than or=18 or LVEF more than or=40%)5b. Presence of risk factor for ARDS.In one of the recent study where autopsy results were matched with clinical diagnoses to determine and compare the diagnostic accuracy of all three clinical definitions of ARDS, the specificity of the most commonly use, the American-European definition, was low. References: Click to get article/abstract 1. Development of a clinical definition for acute respiratory distress syndrome using the Delphi technique. Volume 20, Issue 2, Pages 147-154 (June 2005) - caution of slow internet download2. Acute respiratory distress syndrome: Underrecognition by clinicians and diagnostic accuracy of three clinical definitions. Critical Care Medicine: Volume 33(10) October 2005 pp 2228-2234
posted by ICU room Pearls @ 9:45 PM 0 comments
Friday, February 17, 2006

me
Friday February 17, 200638,000 medication errors in 4 years - only in ICUs !!The United States Pharmacopeia (USP)* announced the largest national data set of Intensive Care Unit (ICU) medication errors. These causes are identified in the 6th annual MEDMARX® Data Report. MEDMARX, operated by USP, is an anonymous, internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors. Since its inception in 1998, MEDMARX has received more than one million reports of medication errors from more than 850 healthcare facilities across the U.S. From 2000-2004, the number of reported errors that occurred in ICUs was 38,371. Reasons include orders that were incomplete or incorrect, illegible handwriting, using abbreviations that were misinterpreted, improper use of IV pumps and a lack of familiarity with some drug information. The big 3 culprits are:1. 24.4% errors originated during the prescribing.2. 24% during transcribing of the order.3. 11% are due to incorrect programming of IV pumps.It is reported that mix-ups in the IV tubing during pump set-up or mix-ups in programming the infusion rates for each drug have resulted in serious harm.* USP is a self-sustaining nonprofit, independent, science-based public health organization. USP is the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States.Reference: Click to get abstract/article1. USP news center
posted by ICU room Pearls @ 9:12 AM 0 comments
Thursday, February 16, 2006

pms
Thursday February 16, 2006PAC-MAN study !Benefits of pulmonary artery catheter (PAC) are debatable in Critical Care. Last year ESCAPE trial 2 failed to show any benefit. Untill we get results of FACTT trial (ARDSnet), lets have a look on PAC-MAN study. (Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care) published in Lancet, last year (august 2005 issue). 1 This is one of the largest study of 1013 patients in this regard. Patients were compared to management with (n = 506) or without (n = 507) a PAC with primary end-point of hospital mortality. No difference in hospital mortality between subjects managed with or without a PAC was noted - 68% vs 66%. Complications associated with insertion of a PAC were noted in 46 of 486 patients but none were considered fatal. In subsets analysis, of patients randomized to receive either a PAC or no monitor of cardiac output, mortality was 71% [75 of 105] vs. 66% [71 of 107] and of patients randomized in ICUs allowing the possibility of an alternative monitor of cardiac output, mortality was 68% [271 of 401] vs. 66% [262 of 400].In conclusion, there was no clear evidence of benefit or harm in managing critically ill patients with a PAC.Related previous pearl: ESCAPE Trial - setback to swan lovers? References: Click to get abstract/article (secondpopup override first popup)1. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial - Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K, The Lancet - Vol. 366, Issue 9484, 06 August 2005, Pages 472-477 - (abstract-review printed at cleveland clinic journal of medicine, november 2005 page 1048)2. Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness - JAMA. 2005;294:1625-1633.3. Impact of the Pulmonary Artery Catheter in Critically Ill Patients -JAMA. 2005;294:1664-1670.
posted by ICU room Pearls @ 9:22 AM 0 comments
Wednesday, February 15, 2006

lre
Wednesday February 15, 2006Linezolid-resistant enterococcus (LRE!)This study was presented at Infectious Disease Society of America meeting 2005 from Dr. Devasia. Fifteen patients in a 500-bed teaching hospital were diagnosed with Linezolid(Zyvox)-resistant enterococcus during 13 months of study. In a comparison of these patients with 60 control patients with Linezolid-sensitive enterococcus, the resistant cases had a significantly higher mortality rate - 40% vs 7%. Interestingly, 8 LRE patients were vancomycin sensitive enterococcus but what make it thought-provoking, 8 cases out of 15 had no prior exposure to Linezolid. As expected, length of stay was way higher (35 days vs 11 days) but scary part is - median age of patients was only 54 years (vs 65 years for control).Are younger patients more prone to LRE even without prior exposure? Are we up for another battle against microbes?. Atleast one thing is sure, its time for very judicious use of Linezolid.To note, similar related report was published about 4 years ago in NEJM.References: Click to get abstract/article (secondpopup override first popup)1. Abstracts Infectious Disease Society of America Meeting 2005 - Scroll down to page 238 (abstract # 1079) - may take little time to download due to big pdf file.2. Nosocomial Spread of Linezolid-Resistant, Vancomycin-Resistant Enterococcus faecium - NEJM, March 14, 2002 Volume 346:867-869
posted by ICU room Pearls @ 8:40 AM 0 comments
Tuesday, February 14, 2006

Lasa
Tuesday February 14, 2006What are LASA drugsMany studies have shown so far that errors in administration of drugs remain high and actually twice in ICUs. In this regard, its important to know the term LASA medications. LASA are "look-alike sound-alike" medications and are responsible for 12.5 percent of the medication errors reported to the FDA. Other factors making it worse include illegible handwriting, look alike packaging, unclear verbal directions, similar pronunciation etc etc. We all went through the experiences of confusion between dopamine and dobutamine, phenylephrine and norepinehrine, heparin and hespan, primacor and primaxin, diflucan and diprivan and so on. Institutions are taking initiatives like computer based drug entry, verbal read backs, automated alerts, advise to prescribers to write both the brand and generic name on problematic drugs or to include the intended purpose of the medication. Make sure your institution is working on this issue as JCAHO has now made LASA drugs part of its National Patient Safety Goals and institutions are expected to prepare organisational list of LASA drugs.Click here to read position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services.Related previous Pearls:1. ICU satellite pharmacy2. Preventing intra-venous (IV) drip errors3. "Five Rights"Reference:Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units Critical Care Medicine. 25(8):1289-1297, August 1997.
posted by ICU room Pearls @ 8:43 AM 0 comments
Monday, February 13, 2006

rdf
Monday February 13, 2006Renal dose Fenoldopam ?We are done with renal dose dopamine but than we heard about renal dose norepinephrine1 and now renal dose fenoldopam? Look at this study of 300 septic patients with baseline serum creatinine concentrations less than 150 umol/L (2 mg/dL)*.150 patients with a continuous infusion of fenoldopam at 0.09 μg·kg-1·min-1 (nonhemodynamic dose) has been compared with 150 placebo patients. The primary outcome measure was the incidence of acute renal failure, defined as a serum creatinine concentration increase to >150 μmol/L (>2 mg/dL), during study drug infusion. The incidence of acute renal failure was significantly lower in the fenoldopam group compared with the control group (29 vs. 51 patients; p = .006). Also, the length of ICU stay in surviving patients was significantly lower in the fenoldopam group compared with the control group (10.64 vs. 13.4; p < .001). Its not clear why fenoldopam which is also a dopaminergic agonist like low-dose dopamine, has protective effect on kidney but dopamine does not. We need a large multiple-center trial to have more answers. * 1 mg/dL = 88.4 mol/L of serum Cr.References:Click to get article/abstract (second popup overwrites first popup)1. Renal Dose Norepinephrine! - Chest. 2004;126:335-3372. Prophylactic fenoldopam for renal protection in sepsis: A randomized, double-blind, placebo-controlled pilot trial - Critical Care Medicine: Volume 33(11) November 2005 pp 2451-2456
posted by ICU room Pearls @ 8:49 AM 0 comments
Sunday, February 12, 2006

coaii
Sunday February 12, 2006Cycling of Antibiotics in ICUConcept of antibiotics cycling to reduce antibiotics resistance remains debatable in medical literature. 2 recent papers earlier showed it may not work.1,2 But a new study of 346 patients from spain (comparing mixing in one ICU vs cycling in another ICU) published this month in Critical Care Medicine points that this may actually have some potential.Patients, who according to the physician's judgment required an anti-Pseudomonas drug, were assigned to receive 1) cefepime/ceftazidime 2) ciprofloxacin 3) a carbapenem or 4) piperacillin-tazobactam in this order. Cycling was accomplished by prescribing one of these antibiotics during 1 month each. 2 cycles were given of 4 months each. Mixing was accomplished by using the same order of antibiotic administration on consecutive patients. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention. During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07). Read precise review on different point of views in this regard here posted in pulmonaryreviews.com, september 2002 issue. Till we get more data to accept antibiotic cycling as a standard practice, lets concentrate on two basic themes - avoid unnecessary antibiotic use and prevent cross-transmission of pathogens.References: Click to get article/abstract (second popup overwrites first popup)1. Ecological theory suggests that antimicrobial cycling will not reduce antimicrobial resistance in hospitals - Proceedings of the National Academy of Sciences of the United States of America - PNAS September 7, 2004 vol. 101 no. 36 13285-132902. Antibiotic Rotation and Development of Gram-Negative Antibiotic Resistance - American Journal of Respiratory and Critical Care Medicine Vol 171. pp. 480-487, (2005)3. Comparison of antimicrobial cycling and mixing strategies in two medical intensive care units. -Critical Care Medicine. 34(2):329-336, February 2006.4. Antibiotic cycling in intensive care units: The value of organized chaos? - Bonten, Marc J. M. MD; Weinstein, Robert A. MD- Critical Care Medicine: Volume 34(2) February 2006 pp 549-551
posted by ICU room Pearls @ 8:21 AM 0 comments
Saturday, February 11, 2006

moettwn
Saturday February 11, 2006Movement of endotracheal tube (ETT) with neckExtension of neck (Chin up) will cause ETT to migrate (up or down) ? Ans.: ____________Flexion of neck (Chin down) will cause ETT to migrate (up or down) ? Ans.: ____________
Answers:Extension of neck (Chin up) will cause ETT to migrate up.Flexion of neck (Chin down) will cause ETT to migrate down.Remember: Chin up - ETT up. Chin down - ETT down.
posted by ICU room Pearls @ 7:28 AM 0 comments
Friday, February 10, 2006

nod
Friday February 10, 2006Norepinephrine or Dopamine ?Standard guidelines regarding vasopressor and inotropic support in septic shock states: "Either norepinephrine or dopamine (through a central catheter as soon as possible) is the first-choice vasopressor agent to correct hypotension in septic shock." But overall trend is going towards using norepinephrine as the first-choice vasopressor to correct hypotension in septic shock after fluid resuscitation. In a recent study from Rush University Medical Center, Chicago, IL the safety of Dopamine (DA) versus Norepinephrine (NE) as vasopressor therapy in septic shock has been compared. Sixty-six patients, 35 DA and 31 NE, has been compared. Though there was no significant difference in mortality cardiac dysrhythmias occurred in 31.4% of the DA group compared to only 3.2% for NE (p=0.003). But important aspect of study was, all cardiac dysrhythmias required an intervention.Related Pearls:1. Renal Dose Norepinephrine !2. Dopamine-S and Dopamine-R patients ? References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).1. Vasopressor and inotropic support in septic shock: An evidence-based review Critical Care Medicine: Volume 32(11) Supplement November 2004 pp S455-S4652. THE SAFETY OF DOPAMINE VERSUS NOREPINEPHRINE AS VASOPRESSOR THERAPY IN SEPTIC SHOCK - chest, 2005
posted by ICU room Pearls @ 10:01 PM 0 comments
Thursday, February 09, 2006

JCAHO "DNU" abbreviations
Thursday February 9, 2006Basic housekeeking - JCAHO mandated "Do Not Use" abbreviations As intensivists are assuming more and more leadership and role model figure in hospitals, here are the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) mandated "Do Not Use" abbreviations - meeting NPSG (National Patient Safety Goals) Requirement 2B. Please note 3 important points:1. The minimum expected level of compliance for handwritten documentation and free-text entry is 90 % and for pre-printed forms is 100 %.2. Clarification of an order prior to implementation and after-the-fact correction of the order by the clinician does not eliminate that occurrence from being counted. (If pharmacy or nurse calls you to clarify the order its an 'occurance').3. One occurrence equals one per clinician per record and three occurrences equal a Requirement for Improvement. Here is the JCAHO mandated "Do Not Use" abbreviationsDo not write U or IU - Write "unit" or "international unit".Do not write Q.D., Q.O.D. - Write "once daily and every other day". Never write a zero by itself after a decimal point (5 mg instead of 5.0 mg), and always use a zero before a decimal point ( 0.5 mg instead of .5 mg). Do not write MS or MSO4 - Write "morphine sulfate".Do not write MgSO4 - Write "magnesium sulfate".
posted by ICU room Pearls @ 6:11 PM 0 comments
Wednesday, February 08, 2006

EGDE
Wednesday February 8, 2006EARLY GOAL-DIRECTED ECHOCARDIOGRAPHY !Dr. Anthony Manasia and Coll. from Mount Sinai School of Medicine, New York, NY, have introduced this term in one of their paper presented at American College of Chest Physicians (ACCP) meeting last year at Montreal, Canada. Based on their study of 18 patients, they claim that the first echo (done within 5-6 hours of admission) changed the treatment plan in 38.8% (7/18) of the circulatory shock patients when compared to the initial management instituted by the primary ICU team. The treatment plan was changed in 11.7% (2/17) of patients following the second echo exam (done 24 hours later). The echocardiographic exam was performed by an echo-trained intensivist not involved in the patient’s care. But similar kind of retrospective observational study of 100 patients in medical ICU, 2 years back from Mayo Clinic, Rochester, MN failed to show any impressive result but to note time-period of echo was within 48 hours.Does ultra early echo in shock patients really make difference in 38.8% of patients ?. May be its time for a bigger study.References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).1. CLINICAL IMPACT OF EARLY GOAL-DIRECTED ECHOCARDIOGRAPHY IN SHOCK PATIENTS PERFORMED BY NON-CARDIOLOGIST INTENSIVISTS - chest, 20052. Echo in the Medical Intensive Care Unit: Does It Really Impact Patient Management? A Retrospective Observational Study - chest, 2003
posted by ICU room Pearls @ 8:34 AM 0 comments
Tuesday, February 07, 2006

BALTI
Tuesday February 7, 2006Adrenergic Agonists in Acute Lung Injury - BALTI trialß2-Agonists remain the most important inhaled bronchodilators and provide rapid symptom relief for many patients. Short-acting, inhaled, selective ß2-agonists remain the mainstay bronchodilators for asthma, COPD, and airway obstruction of all etiologies. The use of B-adrenergic agonists as a potential therapy for acute lung injury has generated considerable interest. B-agonists have well-recognized antiinflammatory properties and treatment with a B-agonist have shown to enhances the rate of alveolar fluid clearance by increasing intracellular cAMP.Perkins and colleagues report the results of a clinical trial of 40 patients with acute lung injury in which the effects of B-agonists were examined.1 Salbutamol (albuterol) was administered intravenously at a dose of 15 μg/kg/hour in a double-blind, randomized manner. Extravascular lung water on Day 7, the primary outcome variable, was lower in the salbutamol-treated patients compared with the placebo control subjects (9.2 vs. 13.2 ml/kg, p = 0.04). Post hoc analysis indicated that extravascular lung water was significantly lower in the treated group at earlier time points as well. Plateau airway pressure was also 6 cm H2O lower at Day 7 in the salbutamol-treated group (p = 0.049), and there was a trend toward lower acute lung injury scores in the salbutamol-treated patients.The results indicate that a multicenter clinical trial may be warranted to test the possible therapeutic benefit of B-agonist therapy for acute lung injury.References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).1. Perkins GD, McAuley DF, Thickett DR, , Gao F The b-agonist lung injury trial (BALTI): a randomized placebo-controlled clinical trial. Am J Respir Crit Care Med 2006;173:281–2872. Matthay MA, Folkesson HG, Clerici C. Lung epithelial fluid transport and the resolution of pulmonary edema. Physiol Rev 2002;82:569–600.3. McAuley DF, Frank JA, Fang X, Matthay MA. Clinically relevant concentrations of beta2-adrenergic agonists stimulate maximal cyclic adenosine monophosphate-dependent airspace fluid clearance and decrease pulmonary edema in experimental acid-induced lung injury. Crit Care Med 2004;32:1470–1476.
posted by ICU room Pearls @ 8:26 AM 0 comments
Monday, February 06, 2006

tightglycemiccontrolwhereweare
Monday February 6, 2006Tight glycemic control - where we are ?This week New England Journal of Medicine has published the second part of Dr. Van den Berghe's Intensive Insulin Therapy. This study was done on 1200 patients in medical ICU. As you may remember, her first study of 1548 patients was done in surgical unit and had shown decrease in morbidity as well as mortality. Her present study from medical ICU, though showed significant reduction in morbidity but failed to show any decrease in mortality. But most surprising part of the study, was the analysis of the subset of patients who stayed in the ICU for less than three days. Mortality was actually greater among those patients with intensive insulin therapy. We don't know yet as this data is reproducible or there are other explanations for this result such as early limitations or withdrawals of care. Also to remember, VISEP study from germany which was designed to randomize 600 subjects with medical or surgical severe sepsis to conventional or intensive insulin therapy, was stopped after recruitment of 488 subjects because of no difference in mortality and frequent hypoglycemia in the intensive insulin therapy arm.What should we do till reults of other major studies like GLUControl (3000 patients) or NICE - SUGAR (5000 patients) are pending. Here are couple of good advises.1) As Dr. Atul Malhotra wrote in editorial of same issue of NEJM - "In my opinion, a reasonable approach would be to provide adequate exogenous insulin to achieve target glucose values of less than 150 mg per deciliter (8.3 mmol per liter), at least during the first three days in the ICU. If critical illness persists beyond three days despite the provision of other proven therapies and resuscitation, a goal of normoglycemia (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) could then be considered, to maximize the potential benefits". OR2). Dr. Angus and Abraham suggested last year: "..it may be valuable to remember that, although the evidence for tight glycemic control does not yet support a grade A recommendation, it does appear to be stronger than that for continuing our existing practice of tolerating hyperglycemia. Thus, we should probably explore ways to introduce some form of tight glucose control during this interim period that seems feasible and safe given local considerations. Once better evidence is available, we can modify our plans accordingly."References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).1. Intensive Insulin Therapy in the Medical ICU - NEJM, Feb. 2, 2006, Volume 354:449-4612. Intensive Insulin Therapy in Critically Ill Patients - N Engl J Med 2001; 345:1359-1367, Nov 8, 20013.Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia - results from a randomized multicenter study (VISEP), Infection 2005;33: 19-20.4. Glucontrol Study: Comparing the Effects of Two Glucose Control Regimens by Insulin in Intensive Care Unit Patients -clinicaltrials.gov5. Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE - SUGAR STUDY) - clinicaltrials.gov6. Intensive Insulin in Intensive Care - Volume 354:516-518, NEJM, feb. 2, 20067. Intensive Insulin Therapy in Critical Illness, Angus and Abraham Am. J. Respir. Crit. Care Med..2005; 172: 1358-1359
posted by ICU room Pearls @ 8:37 AM 0 comments
Sunday, February 05, 2006

metoprololpoivconversion251isamyth
Sunday February 5, 2006Metoprolol PO:IV conversion - 2.5:1 is a myth ?IV metoprolol is not FDA-approved for treatment of hypertension but it is in common use and general rule of conversion from PO to IV form is 2.5:1. This comes from a study on 5 healthy volunteers about 30 years ago.Be aware, this is not the standard by any means. Literature shows coversion effect ranging from 2:1 to 5:1. It may be more safe to disregard any formula and to use initial dosage from 1.25-5 mg and subsequent dosage and frequency depending on the clinical response.For more detailed discussion and further references, click here to read article from medscape.com (available with free registration) - Am J Health-Syst Pharm 60(2):189-191, 2003
posted by ICU room Pearls @ 10:27 AM 0 comments
Friday, February 03, 2006

arewedoctorsmostresistanttochange
Saturday February 4, 2006Are we doctors most resistant to change? This month's issue of Critical Care Medicine has published an article on physicians lack of embracing of low tidal volume despite clear and proven benefits from Arma trial of ARDSnet. Interestingly, this study (n=88 patients) was done at an ARDSnet participating university hospital. Patients who were ventilated with a tidal volume ≤7.5 mL/kg PBW 2 days after meeting criteria for ALI was only 39% and at day 7 only 56% of patients. During this study, physicians ordered the lung-protective ventilation protocol on only 16% of patients by day 2. In another earlier study to identify the barriers to the implementation of lung-protective ventilation - nursing and respiratory therapy staff at ten ARDSnet centers point finger to physicians' unwillingness to follow a ventilator protocol or recognize the patient as having ALI/ARDS.Its almost 6 years since ARDSnet study was published and we are still having problem accepting the clear benefit ! Its time to read again famous JAMA article from 1999: " Why don't physicians follow clinical practice guidelines?.." and few major problems were deficits in physician knowledge, attitude difficulties, inertia of previous practice and behavioral issues !!!.Note: Article from CCM-02'06 also tried to postulate various reasons of this lack of embracing of low tidal volume on available data, which can be found in full content of article and it includes possible fears of side effects from this approach or may be due to the anticipation of rapid recovery by patients with less severe disease.References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)1. Underuse of lung protective ventilation: Analysis of potential factors to explain physician behavior - Critical Care Medicine. 34(2):300-306, February 2006.2. Prospective, Randomized, Multi-Center Trial of 12ml/kg Tidal Volume Positive Pressure Ventilation for Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) - ardsnet.org3. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - NEJM May 2000, Volume 342:1301-13084. Rubenfeld G, Caldwell E, Hudson L: Publication of study results does not increase use of lung protective ventilation in patients with acute lung injury. Am J Respir Crit Care Med 2001; 163:A2955. Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement - JAMA. 1999;282:1458-1465. - full article available with free registration
posted by ICU room Pearls @ 11:07 PM 0 comments

systemiccapillaryleaksyndrome
Friday February 3, 2006Systemic capillary leak syndrome Capillary leak syndrome was described first time about 45 years ago. Being an intensivist, it is an important entity to know as episode is often preceded by shock syndromes, low-flow states, infection, ischemia-reperfusion injuries, toxemias, or poisoning and fallout is usually Multiple system organ failure (MSOF). Cause and pathophysiology is still not clear but most cases have been found associated with monoclonal gammopathy, generally an IgG class. Capillary leak syndrome as name says is due to capillary hyperpermeability with massive extravasation of plasma macromolecules and acute phase usually lasts for 1-4 days. Clinical features are abdominal pain, generalized edema, hypotension with possible cardiopulmonary collapse. Acute renal failure is due to hypovolemia and rhabdomyolysis. 6 Now here is the tricky part. Acute phase is followed by recruitment of the initially extravasated fluid causing intravascular overload marked by polyuria and/or pulmonary edema. Edema is usually proportional to earlier fluid resuscitation !. Treatment with Terbullatine and Theophylline has been suggested. 3References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)1. An unusual evolution of the systemic capillary leak syndrome -Nephrol Dial Transplant (2002) 17: 492-4942. Capillary leak syndrome - orpha.net3. Treatment of the Systemic Capillary Leak Syndrome with Terbutaline and Theophylline: A Case Series - annals 1 June 1999 Volume 130 Issue 11 Pages 905-909 -full pdf article available with free registration.4. Systemic Capillary Leak Syndrome - Internal Medicine 41: 953?956, 2002, The Japanese Society of Internal Medicine5. Lethal capillary leak syndrome after a single administration of interferon beta-1b - Neurology 1999;53:2206.Idiopathic capillary leak syndrome complicated by massive rhabdomyolysis - Chest, Vol 104, 123-1267. Lethal systemic capillary leak syndrome associated with severe ventilator-induced lung injury: An experimental study.- Critical Care Medicine. 31(3):885-892, March 2003.
posted by ICU room Pearls @ 9:15 PM 0 comments
Wednesday, February 01, 2006

cpm
Thursday February 2, 2006What's new on Central pontine myelinolysis (CPM)Central pontine myelinolysis, a demyelinating disorder of central pons charaterized by pseudobulbar palsy and spastic quadriplegia, is co-diagnosed by specific MRI findings under know clinical settings or risk factors. Specific MRI findings are increased signal in the central pons on fluid-attenuated inversion recovery images (FLAIR) and hypointense lesions on T1-weighted images. 5 decades ago it was described in chronic alcoholism but over the time it was found in association with malnourished status, renal failure, diabetes mellitus, and post-orthotopic liver transplantation and came to known as hallmark of rapid correction of hyponatremia - but in recent years it has been reported with hypophosphetemia and in DKA (Diabetes Ketoacidosis) despite normal sodium level or no rapid correction of sodium. Treatment is supportive and prognosis thought to be universally fatal. In recent years there are reports of good recovery and long-term survival with proper supportive management.See nice review article Central Pontine Myelinolysis from emedicine.comReferences: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)1. Central Pontine Myelinolysis Following Hemodialysis - grand round at Depatment of Medicine, Maulana Azad Medical College, New Delhi2. MR imaging of seven presumed cases of central pontine and. extrapontine myelinolysis. -Acta Neurobiol. Exp. 2001, 61: 141-144.3. Management and Treatment of Psychotic Manifestations in Older Patients with Alcoholism: Part II - Clinical Geriatrics: 2004;12[5]:33-404. Central pontine myelinolysis temporally related to hypophosphataemia - Journal of Neurology Neurosurgery and Psychiatry 2003;74:8205. Central pontine myelinolysis in a patient with diabetic ketoacidosis - The Journal of Critical Illness - Vol. 20, No. 4 - December 20056. Parkinsonism and recovery in central and extrapontine myelinolysis - Neurology India, Vol. 53, No. 2, April-June, 2005, pp. 219-220
posted by ICU room Pearls @ 10:33 PM 0 comments

NMB
Wednesday February 1, 2006Sedation in Neuro-muscular blockade patients
This month issue of American Journal of Critical Care (see reference # 1) has published interviews of 11 patients to determine and describe the remembered experiences, who were given neuromuscular blocking agents (8=vecuronium 3=cisatracurium) and sedatives and/or analgesics (4=propofol 4=midazolam 3=lorazepam) while they were in ICU. Interview was designed with 4 themes.
1) The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams.2) The second theme was loss of control; the 2 subthemes were fighting or being tied down and being scared.3) The third theme was almost dying, and4) The fourth theme was feeling cared for.
It was found that, though patients can have positive recollections of nursing care, they can clearly recall experiences that were frightening and unpleasant, recurrent dreams or nightmares, avoidance of medical care and flashbacks or painful memories possibly leading to PTSD (posttraumatic stress disorder).
Are we doing a good job ?
Related:Neuromuscular Blockade / Paralytics guidelines (SCCM 2002)Sedation/Analgesia guidelines 2002 (SCCM)Also see our previous pearl on Train of Four (TOF) and BIS monitoringReferences / suggested readings: Click to get article/abstract1. Patients’ Recollections of Therapeutic Paralysis in the Intensive Care Unit - American Journal of Critical Care. 2006;15: 86-942. Sedation and Neuromuscular Blockade in the ICU -Chest. 2005;128:477-479
posted by ICU room Pearls @ 1:30 AM 0 comments
Monday, January 30, 2006

IPV
Tuesday January 31, 2006IPV - adjuvant therapy in COPD exacerbations ?Interesting study of 33 patients, published from france last year on acute exacerbation of COPD. Inclusion and exclusion criteria were established (see reference # 1). Patients were randomly assigned to receive either standard treatment (control group) or standard treatment plus Intrapulmonary percussive ventilation (IPV group). The IPV group underwent two daily sessions of 30 minutes performed by a chest physiotherapist through a full face mask. Thirty minutes of IPV led to a significant decrease in respiratory rate, an increase in PaO2 and a decrease in PaCO2. Exacerbation worsened in 6 out of 17 patients in the control group versus 0 out of 16 in the IPV group. Therapy was tagged successful when both worsening of the exacerbation and a decrease in pH to under 7.35, which would have required non-invasive ventilation, were avoided. Also, the hospital stay was significantly shorter in the IPV group.IPV is essentially a very effective technique to assist patients to clear retained endobronchial secretions and the resolution of diffuse patchy atelectasis. Please see full manual of IPV therapy from Dr. Bird's website here.References / suggested readings: Click to get article/abstract1. Intrapulmonary percussive ventilation in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled trial - Crit Care. 2005; 9(4): R382–R3892. Effect of Intrapulmonary Percussive Ventilation on Mucus Clearance. in Duchenne Muscular Dystrophy Patients: A Preliminary Report - Respir Care 2003;48(10):940–9473. A Comparison of Intrapulmonary Percussive Ventilation and Conventional Chest Physiotherapy for the Treatment of Atelectasis in the Pediatric Patient - Respir Care 2002:47(10):1162-11674. Airway Clearance in the ICU - rtmagazine.com - The Journal of Respiratory Care Practitioners, March 2005
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Sunday, January 29, 2006

Aprotinin
Monday January 30, 2006Should we abandon Aprotinin ?The majority of patients undergoing cardiovascular surgery routinely receive antifibrinolytic therapy - aminocaproic acid, tranexamic acid or aprotinin during and after procedure to control bleeding. Very important and large study of 4374 patients published this week in New England Journal of Medicine from Ischemia Research and Education Foundation, comparing these three agents in cardiac surgery. Study found that the use of aprotinin was associated with a dose-dependent doubling to tripling in the risk of renal failure requiring dialysis among patients undergoing primary or complex coronary-artery surgery. Probable reason of this difference is aprotinin's high affinity for the kidneys. Also, for the majority of patients undergoing primary surgery, evidence of multiorgan damage involving the heart (myocardial infarction or heart failure) and the brain (encephalopathy) in addition to the kidneys found, suggesting a generalized pattern of ischemic injury. It has been suggested in article that the replacement of aprotinin with aminocaproic acid would prevent renal failure requiring dialysis in 11,050 patients per year globally, yielding an savings of more than $1 billion per year. Also to note, Aprotinin is way more expensive than other 2 agents.Bonus Pearl: Action of captopril may get block with concurrent use of Aprotinin.References / suggested readings: Click to get article/abstract1. The Risk Associated with Aprotinin in Cardiac Surgery - NEJM Jan. 26, 2006 Volume 354:353-3652. Is Aminocaproic Acid as Effective as Aprotinin in Reducing Bleeding With Cardiac Surgery? - Circulation. 1999;99:81-893. Hemostatic effects of aprotinin, tranexamic acid and aminocaproic acid in primary cardiac surgery - Ann Thorac Surg 1999;68:2252-22564. Tranexamic acid compared with high-dose aprotinin in primary elective heart operations: Effects on perioperative bleeding and allogeneic transfusions - J Thorac Cardiovasc Surg 2000;120:520-5275. A Study of a Weight-Adjusted Aprotinin Dosing Schedule During Cardiac Surgery - Anesth Analg 2002;94:283-289
posted by ICU room Pearls @ 11:16 PM 0 comments
Saturday, January 28, 2006

whatislazarussyndrome
Sunday January 29, 2006What is Lazarus Syndrome Lazarus Syndrome is a generic term use in hospitals when patient shows sign of life after clinically declared dead, like a patient that develops vital signs after cessation of resusitative efforts or organ-donation team arrives to find a live person. The syndome is named after bible story in which Jesus brought back to life a dead person named Lazarus from his tomb. Term became very popular after publication of book "The Lazarus syndrome: Burial alive and other horrors of the undead" (Rodney Davies - 1978). In recent years, 'Lazarus Syndrome' has also been use for HIV/AIDS patients who feel having new chance of living with new HIV medications.
posted by ICU room Pearls @ 10:34 PM 0 comments

Xenical and Coumadin
Saturday January 28, 2006Xenical and Coumadin Last week FDA advisory panel voted to recommend that the regulatory agency approve the nonprescription form of weight reducing agent, Xenical (orlistat), which Glaxo would market as Alli. It may be of importance to know its possible effect with warfarin (coumadin), cyclosporin and amiodarone. Orlistat is a reversible inhibitor of lipases. It forms a covalent bond with gastric and pancreatic lipases. The inactivated enzymes are thus unavailable to hydrolyze dietary fat in the form of triglycerides into absorbable free fatty acids and monoglycerides. As a side effect deficiency of fat-soluble vitamins like Vitamin A, D, E and K may occur. Recommendation is to take a multi-vitamin two hours before Xenical. Patients on coumadin (warfarin) may have potential of bleed due to increase INR (as absorption of Vitamin K is decrease). We cannot find any mention in literature describing any such real case but frequent INR check is recommended for safety. Also to remember, Xenical can decrease the amount of cyclosporine and 25-30% reduction in systemic exposure to Amiodarone. Also, there may be some concern of electrolyte imbalance with associated diarrhea. But again, we didn't find any evidence-base literature against Xenical in our search but as xenical expects to do well as over-the-counter medicine, intensivists should be ready for any potential adverse arrival in hospital.References: Click to see abstract/article Mechanism of Action - Orlistat - Rxlist.com Important Patient Information Patient Information about XENICAL - rocheusa.comXENICAL - roche-australia.com
posted by ICU room Pearls @ 4:57 AM 0 comments
Friday, January 27, 2006

Friday January 27, 2006Amiodarone Neurotoxicity !!Amiodarone neurotoxicity has been reported in up to 40% and may easily get miss or misdiagnose when an elderly patient presents with multiple symptoms. Major manifestation are peripheral neuropathy causing proximal motor weakness, ataxia and fine resting tremor. It may also present as neuromyopathy. A case has been described with autonomic dysfunction presented as incapacitating orthostatic hypotension. Cases has been reported with Amiodarone-Induced Delirium . Most neurotoxicities are dose related and resolved with discontinuation of Amiodarone. Being an intensivist it may be important to keep this very common dose related toxicity in mind while evaluating patient with neurologic symptoms.Related: our pearl on Amiodarone pulmonary toxicity.References: Click to see abstract/article1. Amiodarone-Induced Neuromyopathy: Three Cases and a Review of the Literature - Journal of Clinical Neuromuscular Disease. 3(3):97-105, March 2002.2. Severe Ataxia Caused by Amiodarone - Volume 96, Issue 10, Pages 1463-1464 (15 November 2005) - Am J of Card3. Amiodarone toxicity presenting as pulmonary mass and peripheral neuropathy: the continuing diagnostic challenge - Postgraduate Medical Journal 2006;82:73-754. Amiodarone: Guidelines for Use and Monitoring - aafp.org - Vol 68, No. 11, Dec., 20035. Atypical pulmonary and neurologic complications of amiodarone in the same patient. Report of a case and review of the literature - Vol. 147 No. 10, October 1, 1987 - Archive of Int Med.6. Amiodarone-Induced Delirium - Am J Psychiatry 156:1119, July 1999
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Thursday, January 26, 2006

Thursday January 26, 2006Pearls of Hand Hygiene - Yaap !! - So Basic !! .Following are the national standard guideline for Hand Hygiene from Healthcare Infection Control Practices Advisory Committee. Are we doing it right way?.1. Wet hands first with water, apply an amount of product as recommended by the manufacturer, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.2. Rinse hands with water and dry thoroughly with a disposable towel.3. Use towel to turn off the faucet.4. Avoid using hot water (may increase the risk of dermatitis).5. If bar soap is used, soap racks that facilitate drainage and small bars of soap should be used .6. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings.7. The cost of hand-hygiene products should not be the primary factor influencing product selection.8. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap.9. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in ICUs or ORs).10. Keep natural nails tips less than 1/4-inch long.11. Wash hands with soap and water if exposure to spores like Bacillus anthracis or C.diff. is suspected. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.12. If hands are not visibly soiled, an alcohol-based hand rub may be use for routinely decontaminating hands.13. Decontaminate hands also before inserting indwelling urinary catheters.(Wearing rings is an unresolved issue but studies have shown increase bacterial growth beneath rings but no evidence yet on increase transmission).Read full Guideline for Hand Hygiene in Health-Care Settings .
posted by ICU room Pearls @ 8:27 AM 0 comments
Tuesday, January 24, 2006

Wednesday January 25, 2006Statins – Adjuvant Therapy for SepsisStatins are powerful hypolipemic drugs with pleiotropic effects and have been shown to improve survival in the primary and secondary prevention of atherosclerosis in numerous large randomized clinical trials. Interestingly, in many of these trials, their beneficial clinical impact included noncoronary events. Several cellular and animal models demonstrate the pleiotropic activity of statins, including anti-inflammatory and anti-oxidative properties, immunomodulatory effects, improvement in endothelial function, reduction in blood thrombogenicity, and increased nitric oxide (NO) bioavailability. Some or all of these effects may account for a substantial potential impact of statins on the complex pro- and anti-inflammatory sequence of events occurring during sepsis. A few clinical studies have been published recently in support of this hypothesis.Almog et al. conducted a prospective observational cohort study to determine the impact of statin pretreatment on the occurrence of severe sepsis in infected patients. Of 361 patients with confirmed acute bacterial infection, 82 (23%) had been receiving statins for at least 4 weeks prior to their admission. The crude mortality rate was low and did not differ significantly between the two groups (3.7% vs. 8.6%, P=0.21), but severe sepsis developed in 2.4% and 19% of patients, respectively, in the statin and no-statin group (risk ratio 0.13; 95% CI, 0.03–0.52), and the ICU admission rate was 12.2% for the no-statin group compared with only 3.7% of the statin group (P=0.025).In another retrospective review of 388 patients with bacteremia, Liappis et al reported a significant reduction in both overall (6% vs. 28%, P=0.002) and attributable (3% vs. 20%, P=0.010) mortality among patients taking statins at the time of admission compared with patients not taking statins. The survival benefit persisted after adjustment for prognostic factors in a multivariate analysis (odds ratio 7.6; 95% CI, 1.01–57.5).The available evidence today suggests that the potential for statins as adjuvant therapy for sepsis should be further tested. Given their pleiotropic effects related to many pathophysiologic determinants of sepsis, statin therapy could well be the next step in the search for adjuvant therapy.References: click to get article/abstract1. Almog Y, Shefer A, Novack V, Maimon N, Barski L, Eizinger M, Friger M, Zeller L, Danon A (2004) Prior statin therapy is associated with a decreased rate of severe sepsis. Circulation 110:880–8852. Liappis AP, Kan VL, Rochester CG, Simon GL (2001) The effect of statins on mortality in patients with bacteremia. Clin Infect Dis 33:1352–1357 -http://www.journals.uchicago.edu/CID/journal/issues/v33n8/001561/001561.html
posted by ICU room Pearls @ 11:14 PM 0 comments
Monday, January 23, 2006

Tuesday January 24, 2006HIGH FREQUENCY VENTILATIONConventional mechanical ventilation is provided at a rate < hz =" 60" href="http://www.viasyshealthcare.com/smc/reference/critical_care/ccrs/ccr-derdak.pdf" target="_blank">HIGH FREQUENCY OSCILLATORY VENTILATION: Clinical Management from VIASYS. (more details/tools at site).icuroom.net has no connection with VIASYS and info here is solely for educational purpose.References: Click to get abstract/article1. Schuster, DP, Klain, M, Snyder, JV. Comparison of high frequency jet ventilation to conventional ventilation during severe acute respiratory failure in humans. Crit Care Med 1982 Oct;10(10):625-30.2. Holzapfel, L, Robert, D, Perrin, F, et al. Comparison of high-frequency jet ventilation to conventional ventilation in adults with respiratory distress syndrome. Intensive Care Med 1987; 13:100.3. Fort, PF, Farmer, C, Westerman, J, et al. High-frequency oscillatory ventilation for adult respiratory distress syndrome. Crit Care Med 1997; 25:937.4. Mehta, S, Granton, J, MacDonald, RJ, et al. High-frequency oscillatory ventilation in adults: the Toronto experience. Chest 2004; 126:518.
posted by ICU room Pearls @ 11:37 PM 0 comments
Sunday, January 22, 2006

Monnday January 23, 2006Suture at central venous catheter site - a risk?Interesting article published in Managing Infection Control, december 2002 issue by Dr. Bierman 1 suggesting that sutures at central venous catheter site may also play part in CRBSI's (catheter related bloodstream infection). One study from Hospital of the University of Pennsylvania randomized 170 patients requiring PICCs, to suture (n = 85) or Sutureless Securement Device (n = 85). 3Beside other advantages, a significant difference noted in the number of systemic infections (10 suture vs. 2 Sutureless Securement Device group; P = .0032). And, the difference in confirmed CRBSIs was (8 suture vs 1 Sutureless Securement Device; P = .04).August 2002 Guidelines for Prevention of Intravascular Catheter-Related Infections from CDC (Center for Disease Control) acknowledged that “suture-free securement devices can be advantageous over suture in CRBSIs". 2Only commercially available Sutureless Securement Device in USA is Statlock. (icuroom.net has no connection with company and name given here is only for information purpose).References: click to get abstrat/article 1. Suture: An Unlikely Culprit in Infections and Accidental Needlesticks - Managing Infection Control, dec. 20022. Guidelines for the Prevention of Intravascular Catheter-Related Infections (MMWR 2002)3. Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters - Journal of Vascular and Interventional Radiology 13:77-81 (2002)4. OSHA Fact Sheet: Securing Medical Catheters - from STATLOCK site.
posted by ICU room Pearls @ 11:46 PM 0 comments

Sunday January 22, 2006Arterial pressure-based continuous cardiac output (APCO)In our quest of finding less and less invasive techniques for our patients, it would be interesting to evaluate arterial pressure based continuous cardiac output (APCO). The whole concept is based on measuring cardiac output simply on arterial pulsatility. Advantages are:1. It does not require any calibration.2. Connects to an existing peripheral arterial catheter.3. No injection of dilutional medium required.Click here to see video on commercially available device from Edwards Lifesciences.Some small initial studies have so far shown comparable results with intermittent bolus thermodilution cardiac output (ICO) and continuous thermodilution cardiac output (CCO).1,2,3 But before accepting this modality as a standard we need a good well controlled clinical trial as we don't know the effect of age, gender, vessel's disease state, vessel's compliance with distending pressure, body positioning etc. 4References: click to get abstrat/article1. Continuous Cardiac Output Measured by Arterial Pressure Analysis in Surgical Patients - Anesthesiology 2005; 103: A8342. CARDIAC OUTPUT DETERMINATION USING ARTERIAL PULSE: A COMPARISON OF A NOVEL ALGORITHM AGAINST CONTINUOUS AND INTERMITTENT THERMODILUTION: 166. - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A433. Pressure recording analytical method (PRAM) for measurement of cardiac output during various haemodynamic states - British Journal of Anaesthesia 2005 95(2):159-1654. Continuous cardiac output by pulse contour analysis? - British Journal of Anaesthesia, 2001, Vol. 86, No. 4 467-468
posted by ICU room Pearls @ 8:51 AM 0 comments
Friday, January 20, 2006

Saturday January 21, 2006Noise level in ICU !!Unnecessary noise in ICU can mask vital alarms, verbal communications and may be an unseen added cause of mental stress for staff itself. There are 2 kinds of noise in ICU - one you can't control like "ventilator and IV pump alarms" and other you can modify like "conversations and TV".One interesting and landmark work was done by Kahn and coll. which showed that:1. "Talking" and "TV" contribute to 49% of noise in ICU.2. EPA (Enviromental Protection Agency) recommends noise level not to exceed beyond 45 dBA in hospitals but mean peak sound level in study (medical ICU) was 80 dBA !! (which showed mark decrease with behavior modification).Do you know beepers contribute 1% to ICU noise pollution with 84 dBA - why not to turn it to vibrate mode !!. Click here to see various measures which can decrease noise pollution in ICU: (nursingspectrum.com)References: click to get abstrat/article 1. Identification and modification of environmental noise in an ICU setting - Chest, Vol 114, 535-540 - full article available as pdf2. Contribution of the Intensive Care Unit Environment to Sleep Disruption in Mechanically Ventilated Patients and Healthy Subjects - American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 708-715, (2003)3. Noise in the postanaesthesia care unit - British Journal of Anaesthesia, 2002, Vol. 88, No. 3 369-373
posted by ICU room Pearls @ 10:55 PM 0 comments

Friday January 20, 2006Cryptococcosis meningitis !!5 tips to differential diagnose cryptococcosis meningitis.1. Neck stiffness is uncommon rather non-specific signs may be present ranging anything from headache to coma including personality change.2. CT scan or MRI should be performed prior to Lumbar punture (LP) and may present with specific findings of leptomeningeal enhancement and enlarged Virchow-Robin spaces. CT scan and MRI may be normal but if scan shows mass lesion (cryptococcomas), avoid LP and consult a neurosurgeon.See images here, Radiological findings in CNS cryptococcus, from Journal of the chinese medical association 2003;66: 19-263. High opening pressure on LP (greater than 200 mm H2O) is common and may have trio of low glucose, high protein and more lymphocytes but CSF may be normal !!. The cryptococcal organism is surrounded by a polysaccharide capsule, which may protect it from the host inflammatory response.4. Make sure to send CSF for india ink. 55. Eye exam is essential to r/o optic neuritis, endophthalmitis or compressive optic neuropathy from high intracranial pressure. Quick treatment can salvage patient vision and emergent opthalmology and neurosurgical consults are indicated. (see healthy discussion at ref. # 3).References: click to get abstrat/article 1. Overwhelming CNS cryptococcus in AIDS - Neurology 2001 57: 15602. Central Nervous System Cryptococcal Invasion - hivinsite.ucsf.edu3.. Cryptococcal Meningitis Resulting in Irreversible Visual Impairment in AIDS Patients - A Report of Two Cases - SINGAPORE MEDICAL JOURNAL4. Cryptococcosis - emedicine.com5. CNS Infections Laboratory - ratsteachmicro.com
posted by ICU room Pearls @ 8:47 AM 0 comments
Thursday, January 19, 2006

Thursday January 19, 2006Angel dust !!Phencycladine is probably one of the most dangerous available street drug and as with widest variety of symptoms. 7 Pearls regarding Phencyclidine (PCP) toxicity.1. PCP can also get absorb percutaneously. 2. Patient may exhibit waxing and waning symptoms of PCP due to its reabsorbtion in duodenum.3. It has 5 properties of sympathomimetic, serotoninergic, cholinergic, anticholinergic, and narcotic effects and so can present with wide variety of symptoms including hypersalivation and bronchorrhea. 4. Nystagmus is a common presentation but hyperthermia or status epilepticus may be a presenting symptom. 5. Muscle rigidity can present as dystonia, opisthotonos or torticollis, and may cause life-threatening rhabdomyalysis. 6. Postive urine screen is usually diagnostic. 7. Dialysis does not help and treatment is supportive.References: click to get abstrat/article 1. PCP - streetdrugs.org2. PCP (Phencyclidine) - The National Institute on Drug Abuse (NIDA)3. Toxicity, Phencyclidine - emedicine.com
posted by ICU room Pearls @ 8:38 AM 0 comments
Wednesday, January 18, 2006

Wednesday January 18, 2006"Locked-in" Syndrome (coma vigilante)"patient is a silent and unresponsive witness to everything that is happening" from story of Nick Chisholm 1Patient with Locked-in syndrome is a fully conscious person, but all the voluntary muscles of the body are completely paralyzed, other than those that control eye movement. Term was first introduced about 25 years ago by Plum and Posner with complete occlusion of the basilar artery. 3Any catastrophy involving ventral pons can cause this syndrome like massive stroke, traumatic head injury, ruptured aneurysm, pontine infarction after prolonged vertebrobasilar ischaemia, haemorrhage, tumor, central pontine myelinolysis, pontine abscess or postinfective polyneuropathy. As all of the nerve tracts responsible for voluntary movement pass through the ventral pons but fortunately or unfortunately, consciousness are above the level of the ventral pons. 2Only supportive rehabilitation is the answer.Being an intensivist, it is extremely important to educate staff and to protect patient from any physical or psychological harm (like procedure without adequate analgesia), with upmost understanding that it is an "imprisoned mind buried alive in a dead body’’ (as said for character with paralysis like locked-in syndrome in Thérèse Raquin by Emile Zola - 1868).References: Click to get articles/abstract 1. The patient's journey: Living with locked-in syndrome - BMJ 2005;331:94-97 (9 July)2. Locked-in Syndrome - enotes.com3. Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: FA Davis, 1982; 3774. Locked-in syndrome: a catastrophic complication after surgery - British Journal of Anaesthesia, 2004, Vol. 92, No. 2 286-2885. Thérèse Raquin
posted by ICU room Pearls @ 8:46 AM 0 comments
Tuesday, January 17, 2006

Tuesday January 17, 2006Recovery of Critical illness polyneuropathy (CIP) and prevention with tight insulin therapyCritical illness polyneuropathy (CIP) remains a major problem in ICU particularly in post-disease phase. Very little literature is available regarding recovery from CIP. A rather small but worth looking study done in france with 2-year clinical follow-up of 19 patients who suffered from CIP. Three parameters were significantly correlated with poor recovery: 1. longer length of stay in the critical care unit, 2. longer duration of sepsis and 3. greater body weight loss.On prevention side, its worth recalling Dr. Van den Berghe famous 2001 NEJM article re. Intensive Insulin Therapy in Critically Ill Patients which showed intensive insulin therapy also reduced critical-illness polyneuropathy by 44 percent, and 49% in another followup study by same author. Here is a good review article on CIP with free registration at medscape.com: Clinical Outcomes of Critical Illness Polyneuropathy - Pharmacotherapy 22(3):373-379, 2002References: Click to get articles/abstract 1. Critical Illness PolyneuropathyA 2-Year Follow-Up Study in 19 Severe Cases - European Neurology 2000;43:61-692. Intensive Insulin Therapy in Critically Ill Patients NEJM Nov. 2001, Volume 345:1359-13673. Paresis Acquired in the Intensive Care Unit JAMA. 2002;288:2859-2867 (full article available with free registration).4. Insulin therapy protects the central and peripheral nervous system of intensive care patients - NEUROLOGY 2005;64:1348-1353
posted by ICU room Pearls @ 8:21 AM 0 comments
Monday, January 16, 2006

lovenox and protamin
Monday January 16, 2006LMWH and Antidot (protamine)If protamine is given within 4 hours of the enoxaparin (Low Molecular Weight Heparins - LMWH), then a neutralizing dose is: 1 mg of protamine per 1 mg of enoxaparin. The IV protamine should be administered slowly atleast over 10 minutes as rapid infusion may cause anaphylactoid type reaction. May repeat half of earlier dose of protamine after 6 hours with postulation that half life of enoxaparin is longer than protamine.It appears that that the LMWH anti-Xa reversal is not related to protamine-LMWH binding or LMWH size, but rather to the density of sulfate residues in the particular LMWH. Another available variety of LMWH, dalteparin (Fragmin) has higher degree of sulfonation and appear to be more responsive to protamine reversal.2 clinical pearls1. Protamine does not help in reversing bleeding from Fondaparinux (Arixtra). Only supportive treatment should be given with mean half-life of fondaparinux of 17-21 hours in mind.2. Fresh frozen plasma is ineffective in reversal of LMWH to achieve hemostasis and should not be use in these situations.References: Click to get article/abstract1. Accidental overdosage following administration of Lovenox - rxlist.com2. Incomplete Reversal of Enoxaparin Toxicity by Protamine: Implications of Renal Insufficiency, Obesity, and Low Molecular Weight Heparin Sulfate Content - Obesity Surgery, Volume 14, Number 5, 1 May 2004, pp. 695-698(4)
posted by ICU room Pearls @ 8:03 AM 0 comments
Sunday, January 15, 2006

Sunday January 15, 2006“MEL GIBSON” in ICU / ICU Daily Goals WorksheetDr. 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. 1 Here is another mnemonic "MEL GIBSON" everyday in ICU.M Medication list reviewed. E Extremities covered. (DVT prophylaxis). Also “E” for exercise (change of position, Out of bed). L Labs and Radiological studies reviewed.G Glucose control. I Infection control measures taken, including elevation of bed to 30 degrees, lines reviewed etc. B Breathing. Did we allow our patient to have sponteneous breathing everyday. This include sedation break everyday to patient. S Swan /Hemodynamics/volume status reviewed. O Oxygen supply status, including review of Oxygen Extraction ratio, if applicable.N Nutrition/GI prophylaxis.Related: Please click here to read about ICU Daily Goals Worksheet from IHI.References: Click to get articles/abstract 1. Give your patient a fast hug (at least) once a day - Critical Care Medicine. 33(6):1225-1229, June 2005
posted by ICU room Pearls @ 12:23 AM 0 comments
Saturday, January 14, 2006

vk
Saturday January 14, 20067 Pearls of Vitamin K (phytonadione) 1. Oral Vitamin K has similar efficacy as intravenous Vitamin K. 1 2. SQ (subcutaneous) Vitamin K absorption is unreliable.2 3. IM (intramuscular) Vitamin K may promote intramuscular hemorrhage. 4. IV (intravenous) Vitamin K is effective in 6 - 8 hours. 5. IV Vitamin K should be given very slow (preferably .5 mg/min). 6. IV Vitamin K may cause facial flushing, diaphoresis, chest pain, hypotension, dyspnea, anaphylaxis and cerebral thrombosis but pretreatment with antihistamines or corticosteroids is not routinely recommended. 77. Although IV Vitamin K has been decribed safe in few studies 3,7, it should be use only in life threatening bleeds from warfarin overdose or due to deficiency of vitamin K as fatality from anaphylactoid reaction could be high 4,5.References: Click here to see abstract/article:1. Comparison of Oral vs Intravenous Phytonadione (Vitamin K) in Patients With Excessive Anticoagulation - Arch Intern Med. 2003;163:2469-2473. - full article available with free registration.2. Oral Vitamin K Lowers the International Normalized Ratio More Rapidly Than Subcutaneous Vitamin K in the Treatment of Warfarin-Associated Coagulopathy - Annals - 20 August 2002, Volume 137 Issue 4, Pages 251-254 -pdf file3. The safety of intravenously administered vitamin K - via pubmed, Vet Hum Toxicol. 2002 Jun;44(3):174-6.4. Anaphylactoid reactions to vitamin K - via pumed, J Thromb Thrombolysis. 2001 Apr;11(2):175-83.5. Anaphylaxis after low dose intravenous vitamin K - via pubmed, J Emerg Med. 2003 Feb;24(2):169-726. Comparing Different Routes and Doses of Phytonadione for Reversing Excessive Anticoagulation - Arch Intern Med. 1998;158:2136-2140.7. The incidence of anaphylaxis following intravenous phytonadione (vitamin K1): a 5-year retrospective review - Annals of Allergy, Asthma and Immunology, Volume 89, Number 4, October 2002, pp. 400-406(7)
posted by ICU room Pearls @ 3:35 AM 0 comments
Friday, January 13, 2006

Friday January 13, 2006RIFLE Criteria for Acute Renal DysfunctionAcute Dialysis Quality Initiative (ADQI) Group has proposed the escalating RIFLE system using either glomerular filtration rate-GFR or urine output-UO to classify Acute Renal Failure (ARF):R = Risk of renal failure - if increase in Scr is x 1.5 or decrease in GFR is > 25% or decrease in UO is < .5 ml/kg/hr x 6 hours.I = Injury to the kidney - if increase in Scr is x 2 or decrease in GFR is > 50% or decrease in UO is < .5 ml/kg/hr x 12 hours.F = Failure of kidney function - if increase in Scr is x 3 or decrease in GFR is > 75% or Scr > 4 mg/dl or decrease in UO is < .3 ml/kg/hr x 24 hours or Anuria x 12 hours.L = Loss of kidney function - Persistent ARF > 4 weeks, andE = End-stage renal failure - Persistent ARF > 3 months.Click here to see the proposed Cone Diagram of RIFLE system for ARF.References: Click here to see abstract/article:1. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group - Critical Care 2004, 8:R204-R2122. The Outcome of Acute Renal Failure in the Intensive Care Unit According to RIFLE: Model Application, Sensitivity, and Predictability - AJKD - Volume 46, Issue 6, Pages 1038-1048 (December 2005)3. Practice patterns in the management of acute renal failure in the critically ill patient: an international survey - Advance Access published online on December 2, 2005, Nephrology Dialysis Transplantation
posted by ICU room Pearls @ 9:37 AM 0 comments
Wednesday, January 11, 2006

Thursday January 12, 2006LINEZOLID & SEROTONIN SYNDROME 3 Linezolid (Zyvox) being a reversible, nonselective monoamine oxidase inhibitors (MAOIs) can cause a serious serotonin syndrome if use concomittently with antidepressents citalopram (Celexa) 2, sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil) . Case has been reported with use of linezolid 18 days after the discontinuation of fluoxetine. Norfluoxetine (fluoxetine’s active metabolite) is thought to be the culprit. 1Being an intensivist it is a very important drug interaction need to be aware of as most patients admitted to ICU from long term care may be on antidepressents and may require Zyvox for MRSA treatment. Related: See brief review on Serotonin syndrome here from McGill University, Montreal. CMAJ • May 27, 2003; 168 (11) followed with letter Serotonin syndrome: not a benign toxidrome CMAJ • September 16, 2003; 169 (6). It was discussed in detail in our related pearl on Dec. 31, 2005References: Click to get abstract or article 1. Serotonin Syndrome Associated With Linezolid Treatment After Discontinuation of Fluoxetine - Psychosomatics 46:274-275, June 20052. Serotonin Syndrome after Concomitant Treatment with Linezolid and Citalopram - Clinical Infectious Diseases, volume 36 (2003), page 1197 - pdf file 3. Serotonin Syndrome and Linezolid - Clinical Infectious Diseases, volume 34 (2002), pages 1651–1652 - pdf file 4. The Serotonin Syndrome - NEJM, March 2005 Volume 352:1112-1120
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Tuesday, January 10, 2006

dsadrp
Wednesday January 11, 2006 Dopamine-S and Dopamine-R patients ? Interesting article published in October 2005 issue of Critical Care Medicine which concluded that "Dopamine sensitivity is associated with decreased mortality rate". In 110 patients after failure of vascular loading, Dopamine infusion started with 5 μg/kg/min and infusion rate was increased by 5 μg/kg/min every 10 mins up to a maximum dose of 20 μg/kg/min to target mean arterial pressure ≥ 70 mm Hg. (So total time needed to reach the highest dose of 20 μg/kg/min was 30 mins). Dopamine resistance was defined by a mean arterial pressure <70.>In the Dopa-S group, the 28-day mortality rate was 16% (seven of 44 patients) compared with 78% (52 of 66 patients) in the Dopa-R group (p = .0006). The capacity of dopamine resistance to predict death was associated with a sensitivity of 84% and a specificity of 74%.Do we need to qualify our patients as Dopamin-S or Dopamin-R to execute different management strategy?References: click to get article/abstract 1. Cardiovascular response to dopamine and early prediction of outcome in septic shock: A prospective multiple-center study. - Critical Care Medicine. 33(10):2172-2177, October 2005
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Tuesday January 10, 2006Doxy or Mino ! - trick in the pocket for MRSA Second generation tetracyclines has been used for MRSA (methicillin-resistant Staphylococcus aureus) for long time but with very few real data available. One study from 1984 showed cure rate of 76%. Recently Ruhe and coll. look into the issue. Though its a small study of only 24 patients but showed cure rate of 83% with "serious" MRSA icluding skin/skin structure, septic arthritis, Bacteremia/sepsis, osteomyelitis, UTI. 13 patients were treated with Doxycycline and 11 were treated with Minocycline (5 patients in minocycline group were treated in combination with rifampin +/- bactrim). Patients were treated with 100 mg PO bid dose with median total treatment time of 19 days. Also, interestingly, no patient in minocycline group complaint of vertigo. If intravenous access is an issue in a patient with serious MRSA, except for ZYVOX (linezolid) all mainstream drugs are available only in parenteral form. If Zyvox is contraindicated or not available - you have trick available in your pocket. Plus added advantage of cost-effectiveness.References: Click to get abstract or article1. Clumeck and coll. - Treatment of severe staph. infections with rifampin-minocyclin association - J of antimicrob chemother 1984;13 suppl. :C17-C222. Use of Long-Acting Tetracyclines for Methicillin-Resistant Staphylococcus aureus Infections: Case Series and Review of the Literature - Clin Infect Dis 40:1429-1434 electronically published 6 April 2005. - Caution: we found this link not working all the time but atleast refence is checked and available in hard print.
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Monday, January 09, 2006

Monday January 9, 2006Sedatives and sexual dreams - a legal liability? In 1847, after a year of ether anesthesia introduction, a dentist was convicted to 6 years of jail for sexually assaulting two girls under the influence of anaesthesia. There are well documented cases where physicians and dentists have lost their licenses for similar allegation. Anaesthetics particularly propofol (widely use in ICU) has been reported to be associated with vivid dreams and sexual fantasies though a fairly good study failed to show any association. Recently, Dr. Robert Strickland's report in this regard at the American Society of Anesthesiologists meeting has been widely reported in media and is worth reading. Click on reference # 3. References: Click to get abstract or article 1. Anesthetics cause sex hallucinations- macleans.ca 2. Dreams, images and emotions associated with propofol anaesthesia -Anaesthesia, Volume 52, Number 8, July 1997, pp. 750-755(6) 3. Anesthesia can give rise to sex illusion - ARIZONA DAILY STAR - 06.21.2005
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Sunday, January 08, 2006

Sunday January 8, 2006Peres Nomogram or rule of thumb About 15 years ago, Peres developed a nomogram for probable catheter-insertion depth based on patient height in centimeters and still considered to be applicable/reliable. For right internal jugular vein central venous catheters, "height (cm)/10" would provide the appropriate depth of insertion. For a 160-cm tall person, a catheter would be inserted to 16 cm deep but for a 200-cm tall person, the depth would be 20 cm. For left internal jugular, central venous catheter placements, "height (cm)/10 + 4" would provide the appropriate depth of insertion. For a 160-cm tall person, a catheter would be inserted to 20 cm. For a 200-cm tall person, the depth would be 24 cm. (originally described for left external jugular insertion). Caution: In left IJ placement, the catheter tip must not lie at a perpendicular angle against the superior vena cava, because of a risk of vascular erosion.Reference: Peres PW: Positioning central venous catheters: A prospective survey. Anaesth Intensive Care 1990; 18:536-539
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Saturday, January 07, 2006

Saturday January 7, 2006Changing Endotracheal tube and CombitubeFew tips to remember while changing endotracheal tube over catheter. 1. Have resuscitation cart available. 2. Make Laryngeal mask (LMA) and combitube available. 3. Make respiratory and nursing staff informed and available.4. "Don't rush". Make patient adequately sedated. Paralyse if absolutely necessary. 5. Pre-oxygenate to 100% for atleast 3-5 prior to tube change. 6. Make smaller size tube available at bedside from present one in case edematous airway encountered. 7. Confirm tube placement in regular standard way. See Full guide to Tracheal Intubation from Update in Anaesthesia and article and video on combitube from Michael Frass, MD (inventor of combitube) in our procedure section. (video is courtesy of medradio.org)
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Friday, January 06, 2006

Friday January 6, 2006Regarding CPRCPR is probably one of the most ancient procedure (800 BC) recorded in modern history. 2005 CPR guidelines from American Heart Association suggests:1. 100 compressions per minute.2. Compression depth of 1 to 2 inches.3. Allow the chest to recoil completely after each compression (target equal compression and relaxation times)4. Minimize interruptions in chest compressions. No-flow Fraction* (no-flow fraction of .17)5. Compression-ventilation ratio of 30:2 (two rescue breaths every 30 chest compressions). Do not deliver more volume or use more force than is needed to produce visible chest rise. Once intubated: ventilate at a rate of 8 to 10 breaths per minute without attempting to synchronize breaths between compressions.*NFF= No-flow Fraction was defined as the no-flow time (time periods of cardiac arrest without compressions) divided by total cardiac arrest time.Unfortunately study shows we have not mastered our most ancient procedure yet.3References:Click to get articles/abstract1. History of CPR - Fascinating insight into early attempts to resuscitate people - ukdivers.net2. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Circulation. 2005;112:IV-19 – IV-343. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest - available free with registration - JAMA - Vol. 293 No. 3, January 19, 2005
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Wednesday, January 04, 2006

Thursday January 5, 2006Hemodialysis in Salicylate overdose with normal levelHemodialysis is recommended in salicylate overdose patients with a level at or above 100 mg/dL (cut it to half if history suggest chronic ingestion). But if there is any sign of neurological manifestation, dialysis is indicated despite normal level.Salicylate cause "neuroglycopenia" (lower CNS glucose level) despite normal serum glucose. As patient gets more and more acidotic, salicylate enters CNS and by direct effect cause neuroglycopenia. 7 indications of Hemodialysis in Salicylate poisoning1. Mental status change2. Pulmonary edema3. Cerebral edema4. Associated or with renal failure5. Level at or above 100 mg/dL(half if chronic ingestion)6. If fluid overload prevents alkalinization.7. Patient continue to deteriorate clinically.References: Click to get abstract/article1. Toxicity, Salicylate - please register free at emedicine.com2.An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose -Emerg Med J 2002; 19:206-2093. Salicylic acid - intox.org
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Tuesday, January 03, 2006

Wednesday January 4, 2006Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose? Role of steroid in sepsis continue to puzzle physicians - "to do or not do" or "when to do" or "how to do" !!Study of 177 patients published this month from Annane and coll. suggests that " 7-day treatment with low doses of corticosteroids was associated with better outcomes in septic shock-associated early ARDS nonresponders, but not in responders and not in septic shock patients without ARDS (responders or nonresponders)." But study of 41 patients published in Nov. 2005 issue of Critical Care Medicine suggests that "Treatment with low-dose hydrocortisone accelerates shock reversal in early hyperdynamic septic shock...immune effects appeared to be independent of adrenal reserve".To keep record straight evidence-based guideline from SCCM at this point is: Intravenous corticosteroids (hydrocortisone 200-300 mg/day, for 7 days in three or four divided doses or by continuous infusion) are recommended in patients with septic shock who despite adequate fluid replacement require vasopressor therapy to maintain adequate blood pressure. And to identify "responders" (>9 μg/dL increase in cortisol 30-60 mins post-ACTH administration) and to discontinue therapy in these patients is optional. Clinicians should not wait for ACTH stimulation results to administer corticosteroids.In this regard another interesting study of 46 patients from Belgium concluded that: low-dose (1 μg) corticotropin stimulation test may identify a subgroup of patients in septic shock that may go missed by the high-dose test (standard 250-μg test) and these patients may also benefit from glucocorticoid replacement therapy.Hopefully, Corticus study (Corticosteroid Therapy of Septic Shock) will have some definite answer?. Let see.References: Click on article to get abstract/article1. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Critical Care Medicine. 34(1):22-30, January 2006.2. Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock. Critical Care Medicine. 33(11):2457-2464, November 2005.3. Use of corticosteroid therapy in patients with sepsis and septic shock: An evidence-based review. Critical Care Medicine. 32(11) Supplement:S527-S523, November 2004.4. Relative adrenal insufficiency in patients with septic shock: Comparison of low-dose and conventional corticotropin tests. Critical Care Medicine. 33(11):2479-2486, November 2005.5. Corticosteroid Therapy of Septic Shock – Corticus - clinicaltrials.gov
posted by ICU room Pearls @ 11:24 PM 0 comments

Tuesday January 3, 2006Procedure Tip - Does that waveform look ‘wedged’? Many a times, while placing a PA catheter we encounter waveforms that look ‘different’ and we are not sure if it’s the wedged waveform. Of course, you are going to get a CXR but it can only confirm the position and you still may not be sure if the PA catheter is wedged when the balloon is inflated! Here’s a tip.Take 2 blood samples from the pulmonary artery port: One while the balloon is deflated (mixed venous sample) and the other while the balloon is inflated (wedged sample). If the wedged PaO2 exceeds the mixed venous PaO2, then the catheter is definitely in the wedged position when the balloon is inflated. Also compare the wedged PaO2 with arterial PaO2. If the values are almost identical, the catheter may be too far in. Do you still need the CXR!Related:PACEP: Pulmonary artery catheter education project.P. A. Catheterization insertion video (from Edwards Lifesciences).Invasive HDM Troubleshooting video (from Edwards Lifesciences).Vigilance Monitor Inservice video (from Edwards Lifesciences).Videos above need windows media player
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Sunday, January 01, 2006

Neurogenic Cardiac Injury
Monday January 2, 2006Brain-Heart Connection - Neurogenic Cardiac InjuryCardiac injury may occur following many types of brain injury, including trauma, ischemic stroke, and intracerebral hemorrhage. Less common etiologies include tumors, electroconvulsive therapy, and central nervous system infections such as meningitis. Although more difficult to prove, tremendous emotional stress typically following natural disasters 2 or during war may lead to augmented sympathetic tone, abnormal electrocardiogram (ECG) changes, and cardiac injury.Subarachnoid hemorrhage (SAH)-induced cardiac injury provides a robust example of neurocardiogenic injury. Burch et al. first described neurogenic cardiac injury by demonstrating "cerebral T-wave" electrocardiographic abnormalities in humans with SAH. Elevated troponin levels 4 have also been described and provide evidence that myocardial necrosis may occur. The degree of neurologic injury is a strong predictor of myocardial necrosis after SAH. Cardiac injury, specifically left ventricular (LV) systolic dysfunction, has been described after SAH with an approximate incidence of 10% to 28%. 5 Despite recent advances in diagnostic techniques of cardiac disease, the pathophysiology remains unclear. A catecholamine-mediated mechanism of injury has been demonstrated in experimental and clinical studies.Read interesting article on Predictors of Neurocardiogenic Injury After Subarachnoid Hemorrhage in stroke (Stroke. 2004;35:548), followed by editorial comment from Dr. Shunichi Homma Myocardial Damage in Patients With Subarachnoid Hemorrhage (Stroke. 2004;35:552.)References: click to get article/abstract 1. Oppenheimer SM: The cardiac consequences of stroke. Neurol Clin North Am 1992, 10:167-176. via pubmed2. Yamabe H, et al.: Deep negative t waves and abnormal cardiac sympathetic image (123 I-MIBG) after the great Hanshin Earthquake of 1995. Am J Med Sci 1996, 311:221-224. via pubmed3. Fabinyi G: Myocardial creatine kinase isoenzyme in serum after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1977, 40:818-820.4. Horowitz MB: aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 1998, 140:87-93. The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed Aneurysmal Subarachnoid Hemorrhage5 Zaroff J, et al.: Frequency and regional distribution of LV systolic dysfunction after subarachnoid hemorrhage: an echocardiographic assessment. J Am Soc Echocardiogr 1998, 11:507.
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Sunday January 1, 2006Happy new Year - ICU Jokes What do you call 2 surgeons reading an EKG in ICU?A double blind study!!How do you treat a depressed intensivist?Give IV fluid bolus.Nurse: Doctor, what should I do 'wedge' is going up ?Intensivist: Sell !What do you call a baby get born in the high tech ICU?cordless!Intensivist: "Well, Mrs. Jones, I'm afraid you're not quite as sick as we'd hoped."
posted by ICU room Pearls @ 6:22 AM 0 comments
Saturday, December 31, 2005

ss
Saturday December 31, 2005SEROTONIN SYNDROMESerotonin syndrome is a potentially lethal condition caused by overstimulation of central and peripheral serotonin receptors. SSRI, MAOI and other antidepressants are the biggest culprits. (Everybody seems to be on some type of antidepressant these days!). Mild cases of serotonin syndrome may present with nausea, vomiting, flushing, and diaphoresis. Severe cases may present with hyperreflexia, myoclonus, muscular rigidity, hyperthermia, and autonomic instability. Diagnosis is clinical and no lab tests are available. Treatment include discontinuation of all serotonergic medications. The initial treatment of serotonin syndrome is with benzodiazepines and cyproheptadine. Cyproheptadine (Periactin) appears to be the most effective antiserotonergic agent in humans. The initial dose is 4 - 8 mg PO. This dose can be repeated in 2 hrs if no response is noted to the initial dose. Periactin therapy should be discontinued if no response is noted after 16 mg has been administered. Patients who respond to cyproheptadine are usually given 4 mg every 6 h for 48 h to prevent recurrences. Dantrolene (0.5-2.5 mg/kg IV every 6 h, maximum 10 mg/kg per 24 h or 50 to 100 mg bid PO) is a nonspecific muscle relaxant that is used occasionally in serotonin syndrome, presenting with hyperthermia.See brief review on Serotonin syndrome here from McGill University, Montreal. CMAJ • May 27, 2003; 168 (11) followed with letter Serotonin syndrome: not a benign toxidrome CMAJ • September 16, 2003; 169 (6)References: Click to get abstract or article1. Serotonin syndrome. A clinical update - Mills KC - Crit Care Clin. 1997 Oct;13(4):763-83. via pubmed2. Treatment of the serotonin syndrome with cyproheptadine - J Emerg Med., 1998 Jul-Aug;16(4):615-9. via pubmed3. The Serotonin Syndrome - NEJM, March 2005 Volume 352:1112-1120
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Friday, December 30, 2005

Friday December 30, 2005Estimating Burn areaThere are 3 ways to estimate %TBSA burn (% Total Body Surface Area Burn).1. "rule of nine" remains universally accepted tool to calculate %TBSA burn. Click here to see the diagram.12. Lund-Browder chart is more accurate method of calculating %TBSA Burn. Click here to see the chart 23. Recently computer based softwares have been introduced with color coded calculation and instant resuscitation guide. See sample Surface Area Graphic Evaluation software method here. 3See most comprehensive Burn management guide at " www.burnsurgery.org "References: Click to get abstract or article1. Initial management of a major burn: II—assessment and resuscitation - BMJ 2004 ; 329:101-1032. Total Burn Care - totalburncare.com3. Surface Area Graphic Evaluation
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Thursday, December 29, 2005

Thursday December 29, 2005ReoPro and Integrilin (Glycoprotein 2b/3a Receptor Inhibitors)Although our cardiology colleauges mostly take care of intravenous antiplatelet therapy in acute situations but atleast to be aware of basic differences between 2 widely used iv antiplatelet agents. ReoPro (abciximab): is a large molecule agent and binds irreversibly to Gp2b/3a receptors of platelets and so clinical effect lasts for 7 to 10 days and for same reason needs platelet transfusion in case of bleeding. ReoPro is usually given in STEMI ( ST elevated - Myocardial infarction). It may cause severe thrombocytopenia within hours of infusion.Integrilin (eptifibatide): is a small molecule and binds reversibly to Gp2b/3a receptors of platelets and so clinical effect lasts for only 4 to 6 hours. Platelet transfusion is not required and should be avoided in case of bleeding as it may inhibits new platelet formation. Integrilin is usually given in NSTE-ACS (Non ST elevation - acute coronary syndrome). It is 50% cleared by kidney. Also dosing is weight dependent. Dosing chart is available in package insert. 4Avoid unnecessary IV or IM sticks while patient on Gp2b/3a infusion.References: Click to get abstract or article1. ABCIXIMAB - Stanford University Interventional Cardiology2. EPTIFIBATIDE - Stanford University Interventional Cardiology3. A Clinical Trial of Abciximab in Elective Percutaneous Coronary Intervention after Pretreatment with Clopidogrel - NEJM, Jan. 2004 Volume 350:232-2384. Integrilin - package insert5. Abciximab as Adjunctive Therapy to Reperfusion in Acute ST-Segment Elevation Myocardial Infarction - JAMA Vol. 293 No. 14, April 13, 2005
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Tuesday, December 27, 2005

Wednesday December 28, 2005Is confirmatory chest-x-ray always necessary?It is a standard of practice to have followup chest-x-ray following endotracheal intubation and central venous catheter insertion. But do we always absolutely need it ?. See these 2 interesting studies both comprised of 100 patients.For endotracheal tube: Prospective study of 101 patients done at Cooper Hospital, Camden, NJ showed that the incidence of acutely significant malpositions of endotracheal tube, when performed by experienced critical care personnel, were rare (one out of 101 intubations), and may be followed by routine, rather than 'stat' chest radiographs.1 For central venous catheter (IJ): Prospective study of 100 patients done at Lenox Hill Hospital, New York showed that 98 catheters were in accurate position after uncomplicated insertion of a Triple-Lumen Catheter in the Right internal jugular vein with anterior approach and concluded that it is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC and IV treatment can be initiated early. 2 (We found atleast one study in literature arguing against this work. Study of 107 patients from NIH showed 14% incidence of malpositions, and conclusion was: Chest radiographs are necessary to ensure correct internal jugular catheter position).3References: Click to get abstract or article1. Utility of postintubation chest radiographs in the intensive care unit - Critical Care 2000, 4:50-532. Is Chest Radiography Necessary After Uncomplicated Insertion of a Triple-Lumen Catheter in the Right Internal Jugular Vein, Using the Anterior Approach?* - Chest. 2005;127:220-2233. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? - Critical Care Medicine: Volume 27(9) September 1999 pp 1819-18234. Value of postprocedural chest radiographs in the adult intensive care unit - Crit Care Med 1992; 20:1513-1518
posted by ICU room Pearls @ 10:45 PM 0 comments

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Tuesday December 27, 2005Vasoconstrictor extravasationAntidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine) is PHENTOLAMINE. Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor. Keep yourself ready for fluid bolus post treatment. Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent which inhibits vasoconstriction and allow improved blood circulation through the affected area.References: Click to get abstract or article1. Drug Monographs - Phentolamine - lhsc.on.ca2. pediatric pharmacotherapy / intravenous extravasations-3. Treating Extravasation Injuries - extravasation.org4. The use of phentolamine in the prevention of dopamine-induced tissue extravasation - J Crit Care 1998 Mar;13(1):13-20
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Monday, December 26, 2005

ivi
Monday December 26, 2005Intravenous(IV) IronThere are 3 forms of IV Iron available in USA. 1. Iron dextran, 2. Iron sucrose and 3. Sodium ferric gluconate. Iron dextran definitely requires "test dose" in the presence of physician with epinephrine at bedside. About 1 out of 200 patients develops life-threatening anaphylaxis. In remaining 2 forms also, test dose is advisible. Watch time after 'test dose' is about one hour. IM or SQ administration of Iron is not standard of practice.Also dose should be calculated irrespective of form of iron use. Iron deficiency anemia: Various formulae have been described (see references) but most widely use is "Total" amount of iron in mg = { 0.3 x abw (lbs) x 100 (14.8 - present Hgb)] / 14.8abw = actual body weight 14.8 is constant as ideal HbCalculate dose at online calculator (see Ref. 2). In blood loss: "Total" iron dose (in mg) = Blood loss (ml) x present Hematocrit.The total Fe can be given as a single dose in .5 L NS over 6 hours or in divided doses over few days.References: Click to get abstract or article1. Administration of intravenous iron dextran - http://sickle.bwh.harvard.edu/2. Iron Dextran Calculator - globalrph.com 3. parental iron supplement - thedrugmonitor.com
posted by ICU room Pearls @ 7:38 AM 0 comments
Saturday, December 24, 2005

Sunday December 25, 2005Christmas Quiz QuestionQ: What's the difference between fellow and attending ?A: Fellow knows "what to do" and attending knows "what not to do"
posted by ICU room Pearls @ 11:05 PM 0 comments
Friday, December 23, 2005

Saturday December 24, 2005Is SLEDD better than CVVHD in ICU patients ?With advent of Continuous Veno-Venous Hemodialysis (CVVHD) we found some relief for our hemodynamically unstable patients with acute renal failure but CVVHD has its own cons with need of more trained staffing, cost, time, anticoagulation issues, nutrition issues etc. To find a path between two modalities (conventional HD and CVVHD), new literature is suggesting that slow extended daily hemodialysis (SLEDD) may be more or atleast equally effective. Click on Reference 1 to see small study of 20 patients comparing SLEDD and CVVHD. Nephrol Dial Transplant (2004) also found SLEDD as an effective alternative. As concluded in Intensive Care Nephrology 2000 that "..advantages (of CRRT) can, however, also be obtained with SLEDD. In addition, SLEDD is less expensive than CRRT and does not continuously immobilize the patient, leaving time open for other activities..".3 Or probably the skills and the experience of the physicians and nurses who perform dialysis are more important than the applied dialysis modalities. 4References: Click to get articles/abstract1. Comparison of slow extended daily hemodialysis (SLEDD) to continuous renal replacement therapy in acute renal failure patients in the intensive care unit (ICU) - Abstract no: 18, Kidney International Society Abstracts.2. Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy - Nephrol Dial Transplant (2004) 19: 877-8843. What Is the Renal Replacement Method of First Choice for Intensive Care Patients? - J Am Soc Nephrol 12:S40-S43, 20014. Dialysing the patient with acute renal failure in the ICU: the emperor's clothes? - Nephrol Dial Transplant (1999) 14: 2570-25735. Daily Hemodialysis and the Outcome of Acute Renal Failure - NEJM, Jan. 2002, Volume 346:305-310
posted by ICU room Pearls @ 10:48 PM 0 comments
Thursday, December 22, 2005

Friday December 23, 2005Scleroderma Renal Crisis (SRC)Scleroderma Renal Crisis is one of the few rheumatological emergency where early diagnosis and treatment can make big difference in outcome. Wrong diagnosis may lead to wrong management pathway and eventually to very high mortality. SRC is heralded with hypertensive crisis associated with acute renal failure but the pearl is to avoid IV Labetolol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. calcium channel blockers may help. Renal dialysis is a last resort. Another important differential diagnosis is from SLE (renal). 5 It has been suggested that use of steroids is associated with onset of scleroderma renal crisis.See this precise review article on SRC here from Department of Rheumatology and Internal Diseases, Medical University in Białystok, Poland. (2005)References: Click to get articles/abstract1. What Is Scleroderma Renal Crisis and How Is it Managed? via medscape.com with free registration2. Systemic Sclerosis With Renal Crisis and Pulmonary Hypertension - stanford.edu3. Long-Term Outcomes of Scleroderma Renal Crisis - 17 October 2000 Volume 133 Issue 8 Pages 600-603 - annals4. Scleroderma Renal Crisis: The Sword of Damocles. - JCR: J. of Clinical Rheum. 10(5):234-235, October 2004.5. Rheumatologic Renal Disease: SLE vs. Scleroderma - ucsf.edu
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Wednesday, December 21, 2005

Thursday December 22, 2005Whats new on Horizon - blood substitutesBeing an intensivist it is imperative to keep up with all new "stuff" on horizon. In this regard blood substitutes will soon actually be knocking on the door. Hemopure, a Bovine derived blood substitute, has been approved for use in adult patients in South Africa. Polyheme, a human derived blood substitute is already in Phase III trial in united states for hemorrhagic shock following traumatic injuries. These are solutions of chemically modified human or bovine hemoglobin which restores lost blood volume and can be given as rapid, massive infusion. One unit is equal to one unit of pRBC and can be given wide open.Advantages: Does not require typing or cross-matching before infusion and so far found not to cause transfusion reactions. Shelf life of over 12 months (ciruclation time is 1-2 days) and does not require refrigeration. Bovine based Hemopure has been said acceptable for use in Jehovah's Witnesses (?).Disadvantages: No evidence based data available yet. Concerns raised re. Mad cow disease in bovine based Hemopure !.Read interesting critical commentary on above products here from Randy Dotinga at wired.comReferences: Click to get abstract/article1. Safety and Efficacy of PolyHeme(R) in Hemorrhagic Shock Following Traumatic Injuries Beginning in the Pre-Hospital Setting - clinicaltrials.gov2. Watchtower Approves HemoPure for Jehovah's Witnesses - ajwrb.org3. Effect of Hemopure® on Prothrombin Time and Activated Partial Thromboplastin Time on Seven Coagulation Analyzers, - Clinical Chemistry. 1997;43:17924. PolyHeme - American College of Surgeons at facs.org
posted by ICU room Pearls @ 11:06 PM 0 comments
Tuesday, December 20, 2005

Wednesday December 21, 2005Vancomycin dosing in CRRTVancomycin dosing is different in CRRT (Continuous Renal Replacement Therapy) from IHD (Intermittent HemoDialysis) as vancomycin is effectively removed during CRRT. Vancomycin is 14K daltons and CRRT filter removes upto 20K daltons size molecules. Frequent monitoring of Vancomycin level is required. Different intervals has been described from 24 to 48 hours. Most agree on 10 mg/kg every 24 hours. If patient is on CVVHDF instead of CVVHD than it might go upto 15 mg/kg per day. Ultimate goal is to keep vancomycin trough atleast between 10 - 15 mcg/ml and should not fall below 8 mcg/ml.Related: See nice power point presentation on CRRT from Gregory M. Susla Pharm.D (Bayer) here .References: Click to get abstract/article1. Vancomycin dosing and monitoring - Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center (CUMC), columbia.edu2. Antimicrobial dosing in continuous renal replacement therapy - with free registration at http://infectiousdiseasenews.com3. CVVH Initial Drug Dosing Guidelines - from www.thedrugmonitor.com
posted by ICU room Pearls @ 10:48 PM 0 comments
Monday, December 19, 2005

Tuesday December 20, 2005 BNP or Pro-BNP ?Although BNP and NT-proBNP are breakdown products of same parent peptide but in laboratory BNP and NT-proBNP are 2 different tests with 2 different ranges of normal, designed for same reason. Psychologically we are so prone to use BNP that we may have NT-proBNP value in our hand but read it as BNP. There is no conversion formula. NT-proBNP is 2.5 times heavier peptide than BNP (76 amino acids vs 32 amino acids) with 3- 6 times longer half life (120 minutes vs 20 minutes). NT-proBNP get solely excreted via kidney but BNP gets only partially excreted via Kidney. In short NT-proBNP of 400 may means nothing but may be significant if its BNP. Please check: Is it BNP or NT-proBNP ?. It may require different clinical approach though for same clinical problem. Both tests have very good negative predictive value for LV-dysfunction.Do you know which assay your laboratory use?References: Click to get abstract/article1. EDUCATIONAL COMMENTARY - BNP - American Proficiency Institute – 2002 3rd Test Event2. Using BNP to diagnose, manage, and treat heart failure - CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 4, APRIL 20033. NT-ProBNP - referencelab.clevelandclinic.org May 20044. Application of NT-proBNP as a Diagnostic Marker of Cardiac Disease - available free at medscape with CME with free registration at medscape.com5. NT-proBNP test results comparable to those of BNP blood test in patients with kidney disease - rxpgnews.com
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Sunday, December 18, 2005

rdn
Monday December 19, 2005Renal Dose Norepinephrine !This interesting term was coined by Dr. Marik in August 2004 chest journal with final comment: "...In the volume-replete patient, norepinephrine is the vasopressor of choice. Norepinephrine in clinically relevant doses is a friend of the kidney and not a foe" *, while commenting on the study in the same issue from Albanèse and coll. that found that in septic patients norepinephrine infusion reestablished urine flow, with a decrease in serum creatinine levels and an increase in creatinine clearance rate after 24 hours. Although Guidelines published in Critical Care Medicine - November 2004 on "Vasopressor and inotropic support in septic shock: An evidence-based review" still recommends that: "Either norepinephrine or dopamine is the first-choice vasopressor agent to correct hypotension in septic shock." but overall trend is going in favour of norepinephrine.*From Noradrenaline and the kidney: friends or foes? - Critical Care 2001, 5:294-298References: Click to get abstract/article1. Renal Dose Norepinephrine! - Chest. 2004;126:335-3372. Renal Effects of Norepinephrine in Septic and Nonseptic Patients - Chest. 2004;126:534-5393. Noradrenaline and the kidney: friends or foes? - Crit Care 2001, 5:294-2984. Vasopressor and inotropic support in septic shock: An evidence-based review. - Critical Care Medicine. 32(11) Supplement:S455-S465, November 2004
posted by ICU room Pearls @ 10:18 PM 0 comments
Saturday, December 17, 2005

Sunday December 18, 2005Enoxaparin (Lovenox) dose in obesityThere is no standard guidelines so far available for Lovenox dose in obesity (particularly beyond 150 kg). Best way is to manage it through anti-factor Xa levels (The target therapeutic range is 0.6-1.0 IU/ml - draw 4 hours after 3rd dose). But many hospitals don't have anti-factor Xa levels available or turn around time is too long. One crude way is to dose per "adjusted body weight". ABW = IBW + 0.4 [TBW – IBW]ABW = Adjusted body weightIBW = Ideal body weightTBW = Total body weight* Obesity is defined as a BMI >30kg/m2Reference: Click to get abstract/article1. Drug Use Criteria for Low Molecular Weight Heparins and Fondaparinux - Source visn21.med.va.gov
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Friday, December 16, 2005

Saturday December 17, 2005What is SHARF score ?SHARF stands for "Stuivenberg Hospital Acute Renal Failure" (from Stuivenberg General Hospital, Antwerp, Belgium). This is a prognostic scoring system for hospital mortality of individual patients with acute renal failure - ARF. It is considered to be very predictable.Score is calculated at the time of diagnosis of ARF (SHARF T0) and the other at 48 hours later (SHARF T48). It is a complicated formula with age, albumin, prothrombin time, ventilator support, heart failure. In modified formula sepsis, hypotension and bilirubin has also been added. To compound it you have to compute age in decades, albumin and Prothrombin time according to category table and other parameters as present or absent. Probably due to its complication it never get popular. Our objective is to make intensivists be aware of its presence in literature.Click to see formulae and category table.References: Click to get abstract/article1. Prognostic value of a new scoring system for hospital mortality in acute renal failure - via pubmed - Clin Nephrol. 2000 Jan;53(1):10-7.2. Re-evaluation and modification of the Stuivenberg Hospital Acute Renal Failure (SHARF) scoring system for the prognosis of acute renal failure: an independent multicentre, prospective study - Nephrology Dialysis Transplantation 2004 19(9):2282-22883. Interim results of the SHARF4 study: outcome of acute renal failure with different treatment modalities - Critical Care 2004, 8(Suppl 1):P153
posted by ICU room Pearls @ 9:49 PM 0 comments
Thursday, December 15, 2005

Friday December 16, 2005Quick bedside test for MethemoglobinemiaA quick bedside test to strongly suspect (MetHb) Methemoglobinemia is to bubble 100% oxygen in tube with patient's dark blood. No change in Color strongly predicts Methemoglobinemia. If blood turns red on exposure to oxygen, cause is probably cardiopulmonary disease. (Same test can be done with 2 drops of patient's blood on white filter paper and exposing it to atmospheric oxygen. Change in color rule out Methemoglobinemia). Although Co-oximetry is an accurate method for measuring Methemoglobinemia, not all machines can (only newer versions can) differentiate it from another rare disorder sulfhemoglobinemia.References:1. A case of sulfhemoglobinemia and emergency measurement of sulfhemoglobin with an OSM3 CO-oximeter - Clinical Chemistry 43: 162-166, 1997;2. Pitfalls in Discriminating Sulfhemoglobin from Methemoglobin - Clinical Chemistry 43: 1098-1099, 1997;3. Methemoglobinemia - please register free at emedicine.com
posted by ICU room Pearls @ 10:20 PM 0 comments
Wednesday, December 14, 2005

fr
Thursday December 15, 2005"Five Rights"It is important that we continue to vibrate "Five Rights" message down the line to house staff and other staff involved in Critical Care to minimize medication errors.1. Right Patient.2. Right Drug.3. Right Time.4. Right Dose.5. Right Route.(Also mentioned somewhere addendum with 6. Right Documentation 7. Right Indication 8. Right to Refuse).But read this interesting constructive critique from Matthew Grissing RPh, a medication safety analyst with the Institute for Safe Medication Practices to understand what else need to be done beside "Five Rights". - Reference: P & T Vol. 27 No. 10, October 2000.
posted by ICU room Pearls @ 10:39 PM 0 comments
Tuesday, December 13, 2005

Wednesday December 14, 20057 pearls re. Milrinone 1. Milrinone need to be protected from light and if drip is discoloured or precipitation is visible (light effect) - it may be an ineffective bag.2. Dose need to be adjusted according to renal funtion. (unfortunately often get ignored in ICUs)3. Milrinone induced hypotension is more responsive to low dose vasopressin (.01 - .04 units/min).4. Initial bolus should be given atleast over 10 minutes.5. Milrinone is drug of choice over Dobutamine in cardiogenic pulmonary edema.6. Limited known is the direct beneficial role of milrinone in severe cardiac depression from calcium channel blocker overdose. (Caution about hypotension!)7. Pre-emptive perioperative infusion of milrinone in off-pump coronary artery bypass surgery showed to improve cardiac performance when compared to normal saline.References: Click to get abstract/article1. Comparative efficacy of short-term intravenous infusions of milrinone and dobutamine in acute congestive heart failure following acute myocardial infarction. Milrinone-Dobutamine Study Group - via pubmed Clin Cardiol. 1996 Jan;19(1):21-302. Vasopressin as an alternative to norepinephrine in the treatment of milrinone-induced hypotension - Critical Care Medicine: Volume 28(1) January 2000 pp 249-2523. Efficacy of pre-emptive milrinone in off-pump coronary artery bypass surgery: comparison between patients with a low and normal pre-graft cardiac index - Eur J Cardiothorac Surg 2004;26:687-693
posted by ICU room Pearls @ 10:01 PM 0 comments

Tuesday December 13, 2005Oral care in ICU Oral care is an integral part of ICU care. One recent study showed decrease in ventilator associated pneumonia (VAP) rate from 5.6 VAPs/1000 ventilator days to 2.0 VAPs/1000 ventilator days. Due to significance, one clinical trial is comparing a program of meticulous oral care using oral assessments taught by a dentist and dental hygienist with the standard nursing care typically given in ICUs. A recent study from Dutch investigators showed that 2% chlorhexidine every six hours by swabbing it onto the buccal cavity decreases VAP significantly and is way more effective than traditional .12% chlorhexidine .See one sample ORAL CARE FOR INTUBATED PATIENTS protocol - from London Health Sciences Centre, Canada.References: 1. You can make a difference in 5 minutes - Evidence-Based Nursing 2004; 7:102-1032. Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients - clinicaltrials.gov3. Oral Care Interventions in Critical Care: Frequency and Documentation - American Journal of Critical Care. 2003;12: 113-1184. Chlorhexidine 2% Preparation Reduces the Incidence of Ventilator-Associated Pneumonia - 44th Interscience Conference on Antimicrobial Agents and Chemotherapy: Abstract 3717. Presented Oct. 31, 2004 - via medscape.com with free registration)
posted by ICU room Pearls @ 8:40 AM 0 comments
Sunday, December 11, 2005

Monday December 12, 2005Continuous intravascular blood gas monitoring As ICUs are getting more and more tech-savy, intensivists have also been added with extra responsibility to know the evidence based status of different machines / technologies. In this term, one fast emerging technique is continuous intravascular blood gas monitoring. Our literature search (major work so far done in pediatric critical care) showed favourable approach to this technology despite reports of inaccurate measurement of PO2. As technique is very young, no data is available on cost effectiveness. But in adult patients overall its a good peri-operative and immediate post-operative tool particularly in cardiothoracic patients (transplant, one lung ventilation etc). Also, its a better replacement in extremely unstable patients requiring multiple ABGs such as refractory septic shock, ARDS, severe COPD and trauma patients. Related: Click here to read good review article with links to all major studies re. continuous intravascular blood gas monitoring. British Journal of Anaesthesia, 2003, Vol. 91, No. 3 397-407
posted by ICU room Pearls @ 10:15 PM 0 comments
Saturday, December 10, 2005

Sunday December 11, 2005Ice test - Poor man's test for Myasthenia GravisMost of the Myasthenia patients along with other symptoms of weakness usually exhibits ptosis. While at bedside place an ice cube over eye lids for 2 minutes. Cooling improves neuromuscular transmission. Resolution of ptosis with cooling is a positive test for Myasthenia Gravis and reported upto 80% reliable to diagnose ocular myasthenia.Related: Click here to read good review article on Myasthenia Gravis from Dr. Milind J. Kothari. The Journal of the American Osteopathic Association. Vol 104 • No 9 • Sept. 2004 • 377-384
posted by ICU room Pearls @ 10:08 PM 0 comments
Friday, December 09, 2005

Saturday December 10, 2005Vasopressin .07 units/min ?There has been a lot of enthusiasm about using vasopressin as vasopressor earlier than later in septic shock patients due to initial encouraging literature with dose of .01-.04 units/min. But anecdotally it has been tried upto .07 units/min to enhance the effect. We looked into the literature in this regard and found atleast one study where dose beyond .04 units/min was reported to be associated with higher adverse effects. Study from Vancouver, Canada looked into 50 patients with mean APACHE II score of 27. Baseline data at 0 hour was compared to 4, 24 and 48 hours of vasopressin infusion. Though most parameters improved there were six cardiac arrests; all but one occurred at a vasopressin dose of 0.05 units/min or more. The final conclusion was "Doses higher than 0.04 units/min were not associated with increased effectiveness and may have been associated with higher adverse effects."References: The effects of vasopressin on hemodynamics and renal function in severe septic shock: a case series - Intensive Care Med 2001 Aug;27(8):1416-21
posted by ICU room Pearls @ 10:27 PM 0 comments
Thursday, December 08, 2005

Friday December 9, 20057 Pearls re. Myxedema ComaMyxedema Coma is a medical emergency but being an intensivist 7 pearls are worth remembering:Myxedema Coma is a clinical diagnosis and treatment should not be delayed for laboratory confirmation.Even if enteral route is available - IV Thyroid hormone (T4 or T3) replacement is needed as GI absorption is unreliable.T4 is preferable if underlying cadiac co-morbidity is suspected.Simultaneously steroids should also be started after random cortisol level is drawn.Adding prophylactic antibiotics is not a bad idea.Hypotension is not due to volume depletion so avoid aggressive fluid resuscitation.Thermometers that can record below 90°F (32.2 C) is preferable.Read intereating case study with discussion and treatment options on Myxedema Crisis here from Israeli Journal of Emergency Medicine – in pdf - (Vol. 5, No. 4 Oct 2005)
posted by ICU room Pearls @ 9:43 PM 0 comments
Wednesday, December 07, 2005

pivde
Thursday December 8, 2005Preventing intra-venous (IV) drip errorsMany studies have shown so far that errors in administration of intravenous drugs remain high and actually even higher in ICUs. Standard protocols need to be instituted for sure at bedside to prevent errors in IV administrations but anecdotal reports shows that 2 quick interventions can decrease the rate of error significantly.1. Vasoactive drugs be infused through a dedicated site and using other separate IV site for other infusions.2. Triple sticker labeling of IV drips (at/near IV bag, pump and infusion sites).References: Click here to get article1. Ethnographic study of incidence and severity of intravenous drug errors - BMJ 2003;326:684 (29 March)2. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units - Crit Care Med 1997 Aug;25(8):1289-97.
posted by ICU room Pearls @ 11:47 PM 0 comments
Tuesday, December 06, 2005

Wednesday December 7, 2005Re. Nesiritide (Netrecor) Netrecor (nesiritide) not only walked into our hospitals for "exacerbation of CHF" but even in out-patient clinics for "tune-up of CHF" with a big bang but over time we realized its not a miracle drug. JAMA article of April 2005 actually showed that it may be associated with an increased 30-day mortality . Later reviews and reports against Netrecor and its association with renal dysfunction intensified the debate. It appears that up to date: Netrecor is indicated only for severe acute decompensated congestive heart failure (CHF) with dyspnea at rest or minimal activity and is NOT indicated for intermittent or scheduled repetitive use, to improve renal function or for diuresis. Using Netrecor merely with BNP level is not advisable.References: Click here to get article1. Short-term Risk of Death After Treatment With Nesiritide for Decompensated Heart Failure - A Pooled Analysis of Randomized Controlled Trials - JAMA. 2005;293:1900-1905. (full article available with free registration)2. Nesiritide — Not Verified - NEJM, Volume 353:113-116, July 20053. Scios press releases 4. Scientific papers related to NetrecorRe. Selective Digestive-tract Decont. - posted yesterdayResponse 1: If you look at the bulk of the literature on this topic from Europe, they exclude ICU's with MRSA concerns. This amounts to most US facilities.Response 2: SDD may not be feasible in ICUs with high prevalence of VRE and MRSA. Click this Medscape article (register free to read).
posted by ICU room Pearls @ 8:46 AM 0 comments
Monday, December 05, 2005

Tuesday December 6, 2005Selective digestive tract decontamination (SDD)SDD is widely practiced in europe but its use in USA remains low due to fear of increase in antibitics resistance. The technique applies use of oral and enteral nonabsorbable antibiotics (polymyxin B, tobramycin and amphotericin B - new reports suggest benefit of Probiotics) and IV antibiotics (cefotaxime) in the hope to prevent and eradicate oropharyngeal and gastrointestinal carriage of potentially pathogenic microorganisms (PPMs), leaving the indigenous flora, which may protect against overgrowth of resistant bacteria. Most studies favour use of SDD in prevention of ventilator-associated pneumonia (VAP) and overall decrease in ICU mortality. Are we ready to embark on this journey?References: Click here to get article1. Selective digestive decontamination decreases mortality and morbidity in the intensive care - Canadian Journal of Anesthesia 51:737-739 (2004)2. Selective decontamination of the digestive tract reduced intensive care unit and hospital mortality in adults - Evidence-Based Nursing 2004; 7:473. Selective decontamination of the digestive tract reduces mortality in critically ill patients - Critical Care 2003, 7:107-1104. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia - Am. J. Respir. Crit. Care Med., February 15, 2005; 171(4): 388 - 416
posted by ICU room Pearls @ 10:54 PM 0 comments
Sunday, December 04, 2005

Monday December 5, 2005C-Reactive Protein (CRP) - marker of mortality in ICU ?Interesting work done from Belgium looking into correlation of C-Reactive Protein with mortality in ICU. Patients with high CRP levels at ICU admission had more severe organ dysfunction, longer ICU stays, and higher mortality rates (36% if ICU admission serum CRP levels > 10 mg/dL). On 48 hours followup - decrease in CRP level was associated with a mortality rate of 15.4%, while an increased CRP level was associated with a mortality rate of 60.9%.Clinical significance: Admission CRP level can identify the patient who may require more aggressive interventions to prevent complications and similarly serial measurements.C-Reactive Protein Levels Correlate With Mortality and Organ Failure in Critically Ill Patients - Chest. 2003;123:2043-2049
posted by ICU room Pearls @ 8:36 AM 0 comments

Sunday December 4, 2005Epidemic of new fluoroquinolone induce strain of C. Diff.Centers for Disease Control and Prevention has release a report on epidemic of new fluoroquinolone induce strain of C. Diff. The New England Journal of Medicine has put out 2 reports on epidemic of a new strain of Clostridium difficile on Dec. 8 2005 issue (see in references). It is called BI/NAP1 isloates and showing a lot more resistance to fluoroquinolones (Gatifloxacin and Moxifloxacin). It appears more toxic as canadian report shows 30-day attributable mortality rate of 6.9 percent. Regular laboratory may not be equipped to do the test so you may have to specifically ask for it. Be more vigilant as early treatment is the key and with no response to oral metronidazole, early switch to oral vancomycin may be needed. Alochol can’t kill C.diff spores so washing with soap and water is required.Report 1: Georgia, Illinois, Maine, New Jersey, Oregon, and Pennsylvania. Report 2: 12 hospitals in Quebec, CanadaReferences:1. An Epidemic, Toxin Gene–Variant Strain of Clostridium difficile 2. A Predominantly Clonal Multi-Institutional Outbreak of Clostridium difficile–Associated Diarrhea with High Morbidity and Mortality3. The New Clostridium difficile — What Does It Mean?
posted by ICU room Pearls @ 7:38 AM 0 comments
Saturday, December 03, 2005

Saturday December 3, 2005Low tidal volume (TV) anyway?From ARMA trial of ARDSNET we learned about benefits of low TV in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) but reports and studies have shown benefit of low TV (or harm of high TV) in non-ALI/ARDS too. See this retrospective cohort study of 332 patients who did not have acute lung injury but required mechanical ventilation - 80 patients developed ALI within the first 5 days of mechanical ventilation. One of the main risk factors in developing ALI was the use of large tidal volume in dose-dependent manner (odds ratio 1.3 for each ml above 6 ml/kg predicted body weight). 2 lessons learned:1) We still tend to ignore the “ideal” body weight depending on height and gender and are using “actual” body weight for initial TV setup.2) We still don’t know the “optimum” TV on non-ALI patients. References: click to get abstract/article1. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation Critical Care Medicine. 32(9):1817-1824, September 2004
posted by ICU room Pearls @ 8:03 AM 0 comments
Thursday, December 01, 2005

bis
Friday December 2, 2005BIS (Bispectral Index) monitoring BIS monitoring is an underutilize tool in ICUs particularly in patients on paralytics. Experts are still debating its full value. General guide regarding BIS monitoring level, if use:100 - 80: Awake or sedation is light60 - 80: Respond to command but may not recall the event.40 - 60: Probably sedation is optimum.Less than 40: Deep sedation0: No EEG like in barbiturate coma or deep hypothermia.Key is to monitor BIS sedation scale with hemodynamics together as BIS doesn’t provide any measurement of analgesia which may be needed simultaneously with sedation.References: click to get abstract/article1. BIS Monitoring to Prevent Awareness during General Anesthesia - Anesthesiology: Volume 94(3) March 2001 pp 520-5222. BIS monitoring in ICU: advantages of the new XP generation - Critical Care 2002, 6(Suppl 1):P683. Potential Benefits of Bispectral Index Monitoring in Critical Care: A Case Study - Crit Care Nurse 2003 Aug;23(4):45-524. Use of BIS Monitoring Was Not Associated with a Reduced Incidence of Awareness - Anesth Analg.2005; 100: 1221
posted by ICU room Pearls @ 11:45 PM 0 comments

Thursday December 1, 2005Pulmonary Artery Occlusion Pressure and PEEPThere are 3 ways to correct/manage pulmonary artery occlusion pressure or pulmonary capillary wedge pressure (PCWP) in patients with PEEP (positive end-expiratory pressure) over 10.1. Follow the trend of PCWP co-relating with other clinical data and interventions.2. Corrected PCWP = Measured PCWP - .5 x (PEEP/1.36)e.g. If measured PCWP is 20 and applied PEEP is 16:Corrected PCWP = 20 - .5 (16/1.36) = 14.123. Corrected PCWP = measured PCWP - esophageal pressure.Temporary discontinuation of PEEP to measure PCWP is not safe and should be avoided.References: click to get abstract/article1. Influence of positive end-expiratory pressure on left ventricular performance - NEJM, Feb. 1981, Volume 304:387-3922. Monitoring Pulmonary Artery Pressure - Crit Care Nurse 2004 Jun;24(3):67-703. Measuring Intra-Esophageal Pressure to Assess Transmural Pulmonary Arterial Occlusion Pressure in Patients with Acute Lung Injury: A Case Series and Review - Respir Care 2000;45(9):1072-10844. Swan-Ganz Catheterization - online emedicine.com
posted by ICU room Pearls @ 9:33 PM 0 comments
Wednesday, November 30, 2005

Wednesday November 30, 2005Haloperidol (Haldol) intra-venous (IV)Use of IV Haloperidol is a common practice in ICUs but it is approved by FDA - Food and Drug Administration - for only intra-muscular (IM) use. Yes ! "IV Haldol" is still off-label.References: click to get abstract/article1. HALDOL- DOSAGE AND ADMINISTRATION - rxlist.com
posted by ICU room Pearls @ 9:22 PM 0 comments
Monday, November 28, 2005

Tuesday November 29, 2005Euthyroid Sick SyndromeWord of wisdom is not to check thyroid function test in ICUs as it takes only few hours for patient to ‘abnormalize’ thyroid function test under stress but if clinically indicated send full "Thyroid Function Test” including TSH, Total T3, Total T4, Free T4 and rT3 (reverse T3). There is no absolute trend but general rule of thumb is as patient get sicker and sicker “all fall but reverse rise” i.e rT3 (reverse T3) will be elevated.References: click to get abstract/article1. Sick euthyroid syndrome - Jennifer Best M.D - Harborview Medical Center, seattle, Washington - University of Washington, Div. of General Internal Medicine.2. Euthyroid Sick Syndrome - Serhat Aytug, MD - (please register free at emedicine.com)
posted by ICU room Pearls @ 10:30 PM 0 comments

Monday November 28, 2005Four Phases of Acetaminophen Toxicity And Rumack-Matthew Nomogram (revised).Acetaminophen (Tylenol, Paracetamol) toxicity is divided into four phases time-wise.Phase 1 (up to 24 hours): Mild symptoms Phase 2 (24- 48 hours): Right upper quadrant pain and rising Liver enzymes with deteriorating symptoms.Phase 3 (48-96 hours): Liver failurePhase 4 (4 days to 3 weeks): Resolution or death. Clinical Significance: Patient’s Acetaminophen level should be plotted on Rumack-Matthew nomogram (revised) during first 24 hours of ingestion and if it falls in "possible" or "probable" liver failure risk area of nomogram, hepatology team should be alerted (or transfer to tertiary care center with liver services) as clinical deterioration may unfold very quickly.Rumack-Matthew nomogram (revised) is available in the reference article below.References: click to get abstract/article1. Acetaminophen Intoxication and Length of Treatment: How Long Is Long Enough? - Pharmacotherapy 23(8):1052-1059, 2003 (available via medscape.com with free registration).
posted by ICU room Pearls @ 6:02 PM 0 comments
Sunday, November 27, 2005

TOF
Sunday November 27, 2005Can we go without Train of Four (TOF) ?On literature search we found atleast 2 decent (though small) studies questioning the need of Train of Four (TOF) which is considered so far to be the standard of care while patient on continuous- infusion neuromuscular blocking agents (NMB). 1. Div. of Pulm. & CCM, Med. Univ. of South Carolina, Charleston - compared 20 patients with TOF and 16 patients with best clinical assessment group and found no difference. (NMB used was Atracurium).2. Div. of Pulm. & CCM, Univ. of Mississippi Med. Center, Jackson - compared 16 patients with TOF and 14 patients with best clinical assessment group and found no difference. (NMB used was cisatracurium).But strong arguments made in favour of TOF by Dr. Sessler is also worth reading. (Click Ref. 3)See nice article covering most aspect on TOF here from Dimensions of Critical Care Nursing.References: click to get abstract/article1. Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis - Am. J. Respir. Crit. Care Med., Volume 156, Number 5, November 1997, 1556-15612. A Prospective Randomized Comparison of Train-of-Four Monitoring and Clinical Assessment During Continuous ICU Cisatracurium Paralysis - Chest. 2004;126:1267-12733. Train-of-Four To Monitor Neuromuscular Blockade? - Curtis N. Sessler, MD, FCCP - Chest. 2004;126:1018-1022.4. An Algorithm for Train-of-Four Monitoring in Patients Receiving Continuous Neuromuscular Blocking Agents - Dimensions of Critical Care Nursing, March/April 2003 Volume 22 Number 2 Pages 50 - 57
posted by ICU room Pearls @ 10:27 PM 0 comments
Saturday, November 26, 2005

Saturday November 26, 2005Is post pyloric feeding absolute ?It is not uncommon to find a patient in ICU to go without nutrition for long time only because enteral feeding tube (e.g. dobhoff) is not cleared by x-ray for post pyloric placement. Drs. Marik and Zaloga did meta-analysis of 9 prospective randomized controlled trials of 522 patients from medical, neurosurgical and trauma ICUs and found no difference in incidences of pneumonia, ICU length of stay and mortality between 2 groups (gastric and post-pyloric). Major recommendation made was: Patients who are not at high risk for aspiration should have a nasogastric/orogastric tube placed as early as possible for the initiation of enteral feeding. Small intestinal feeding tube should be considered if patient remain intolerant of gastric tube feeding despite addition of promotility agents or patients who demonstrate significant reflux or documented aspiration.References: click to get abstract/articleGastric versus post-pyloric feeding: a systematic review - Critical Care 2003, 7:R46-R51
posted by ICU room Pearls @ 11:04 PM 0 comments
Friday, November 25, 2005

Friday November 25, 2005Acute acalculous cholecystitis in ICUDiagnosis of acute acalculous cholecystitis (AAC) remains one of the most life saving skill in ICU as mortality from gallbladder rupture within 48 hours is high. Data of 39 patients published from Finland provide pretty good idea of patients prone to develop AAC. 11. Infection was the most common admission diagnosis, followed by cardiovascular surgery.2. The mean APACHE II score on admission was 25.3. The mean length of ICU stay before cholecystectomy was 8 days.4. 85% of the patients received norepinephrine infusion.5. 90% of the patients suffered respiratory failure before cholecystectomy.Champagne Sign in acute acalculous cholecystitis: (On ultrasound) emphysematous cholecystitis with gas bubbles arising in the fundus of the gallbladder.See nice review article on acalculous cholecystitis from emedicine.com (please register - free).References: click to get abstract/article1. Acute acalculous cholecystitis in critically ill patients - Acta Anaesthesiologica Scandinavica, 2004 Sep;48(8):986-91 - from pubmed -. Acta Anaesthesiologica Scandinavica is an official publication of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine.
posted by ICU room Pearls @ 7:43 AM 0 comments
Thursday, November 24, 2005

Thursday November 24, 2005Saline vs Albumin - SOAP trialAs we know that in SAFE trial (Saline vs Albumin Fluid Evaluation) there was some positive trend for albumin in severe sepsis subset patients but overall 28-days outcome was “no difference”. But this month results of SOAP (Sepsis Occurrence in Acutely ill Patients) study - with caution of various limitations to study - showed negative trend for albumin with conclusion: “Albumin administration was associated with decreased survival in this population of acutely ill patients”. Negative trend may be due to cardiac depression from decreased ionic calcium, impaired renal function and anti-thrombotic properties of albumin. Probably the real answer is bedside clinical judgement for each patient.References: click to get abstract/article1. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit - NEJM, May 2004 Volume 350:2247-22562. Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study - Critical Care 2005, 9:R745-R754
posted by ICU room Pearls @ 7:38 AM 0 comments
Wednesday, November 23, 2005

Wednesday November 23, 2005SRMD and PUDWe commonly use terms Stress ulcer (Stress Related Mucosal Disease = SRMD) and Peptic ulcer (PUD) interchangeably in ICU while talking "GI prophylaxis". But both are 2 different conditions. (Probably what we are worried in our "unit" patients is mostly SRMD). SRMD is multiple superficial erosions occurring in proximal gastric bulb involving superficial capillaries secondary to mucosal hypoperfusion and perforations are rare. PUD is few deep erosions occurring usually in duodenum involving one vessel secondary to other reasons (drugs, H.Pylori, hypersecretory states etc.) and perforation is common.From Dr. David C. Metz, nationally renowned in Acid-Peptic Diseases, lecture in Aspire 2005 (Acid Suppression Pharmacotherapy in the ICU: Re-evaluating the Evidence), an initiative to provide a critical assessment of the most current data on therapeutic approaches in acid suppression and the prevention of peptic ulcer rebleeding and stress-related mucosal disease. Launch Aspire 2005 here. Highly recommended for Critical Care nurses and house-staff.
posted by ICU room Pearls @ 2:53 AM 0 comments
Tuesday, November 22, 2005

Tuesday November 22, 2005Early CRRT in septic shockA recent observational study of 60 patients from france is published in ccforum (november, 2005) regarding early initiation of continuous veno-venous haemodiafiltration (CVVHDF), in patients meeting at the same time criteria for sepsis, refractory circulatory failure, acute renal injury, and acute lung injury. CVVHDF was started after 6–12 hours of full haemodynamic support. There are 3 interesting conclusions:1. In patients showing improvement in metabolic acidosis after 12 hours of CVVHDF, with progressive improvement in organ failures; the final mortality rate was 30%.2. Those patients who did not show any improvement in metabolic acidosis, mortality rate was 100%.3. The crude mortality rate for the whole group (53%), was significantly lower than the predicted mortality using Simplified Acute Physiology Score II (79%). References: click to get abstract/article1. Early veno-venous haemodiafiltration for sepsis-related multiple organ failure - Critical Care 2005, 9:R755-R7632. New Simplified Acute Physiology Score - from sfar.org site
posted by ICU room Pearls @ 11:31 PM 0 comments
Monday, November 21, 2005

Monday November 21, 2005Sympathetic StormingSympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units. It occurs due to uncontrolled sympathetic surge with a diminish or unmatch parasympathetic response. Acording to Baguley criteria 5 out of the 7 clinical features should be present - tachycardia, tachypnea, hyperthermia, hypertension, dystonia, posturing, and diaphoresis. Various agents have been used for treatment (see review article below) but haloperidol may worsen the symptoms.Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004. See great review article here on Sympathetic Storming from Denise M. Lemke, published in J Neurosci Nurs 36(1):4-9, 2004. © 2004. . Also available in our "B" search section at www.icuroom.net.References: click to get abstract/article1. Dysautonomia after traumatic brain injury: a forgotten syndrome? - J Neurol Neurosurg Psychiatry 1999;67:39-43 ( July )2. Paroxysmal autonomic instability with dystonia (PAID) - Arch Neurol. October 2004;61:1625.3. Paroxysmal Autonomic Instability with Dystonia After Brain Injury - Arch. Neurol. March 2004;61:321-3284. Riding Out the Storm: Sympathetic Storming After Traumatic Brain Injury - Denise M. Lemke, MSN CS-RN ANP CNRN - J Neurosci Nurs 36(1):4-9, 2004.
posted by ICU room Pearls @ 9:48 PM 0 comments
Sunday, November 20, 2005

Sunday November 20, 2005Time lag between Linezolid and ThrombocytopeniaThrombocytopenia could be multifactorial in ICU. One of the relative new cause is Linezolid (Zyvox). But thrombocytopenia with Zyvox usually doesn't occur upto 2 weeks with the initiation of treatment and could help in ruling out atleast one reason. Relatively overall its mild, reversible and due to myelosuppression. there is no evidence for anti-platelet or interference with platelet function.References: click to get abstract/article1. Hematologic Effects of Linezolid: Summary of Clinical Experience - Antimicrobial Agents and Chemotherapy, August 2002, p. 2723-2726, Vol. 46, No. 82. Linezolid and reversible myelosuppression. - JAMA 285:12913. Safety, efficacy and pharmacokinetics of linezolid for treatment of resistant Gram-positive infections in cancer patients with neutropenia - Annals of Oncology 14:795-801, 2003
posted by ICU room Pearls @ 9:52 PM 0 comments
Saturday, November 19, 2005

Saturday November 19, 2005Drotrecogin Alfa (Activated) tie to APACHE ScoreDrotrecogin Alfa (Activated) - Xigris - is without doubt an effective tool in treating sepsis but there are debates about "to do or not to do".Irrespective of reservations regarding APACHE II score itself, it is important to know the results of study from ADDRESS Study Group (Administration of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis), which concluded that it should not be use in patients with APACHE II score less than 25. There was extra risk of bleeding without any benefit. Actually subset of same study found to have higher mortality (both 28-days and inpatient) in those patients who underwent recent surgery (within 30 days) and had only single organ failure - irrespective of APACHE score. There were significantly more bleeding events in the Xigris group.See APACHE Scorings in our tools section at www.icuroom.net.References: click to get abstract/article1. Drotrecogin Alfa (Activated) for Adults with Severe Sepsis and a Low Risk of Death - NEJM - Volume 353:1332-1341 - september 29, 2005.2. Warning from Xigris
posted by ICU room Pearls @ 11:07 PM 0 comments
Friday, November 18, 2005

Friday November 18, 2005RU-486 and septic shockAs sepsis is a major bread n butter of intensivists, it may be of importance to know that abortion pill RU-486 (Mifeprex/Mifepristone) has been associated with severe septic shock. 8 deaths (4 in USA) have been reported so far. 1 Mechanism of action is not entirely clear but it is secondary to pelvic infections from common vaginal bacteria Clostridium sordellii. Dr. Miech from Brown University proposed that Mifepristone, blocks both progesterone and glucocorticoid receptors and failure of physiologically controlled cortisol and cytokine response eventually results in release of toxins from C. sordellii and lead to life threatening septic shock. 2References: click to get abstract/article1. Mifeprex (mifepristone) - FDA warning2. Pathophysiology of Mifepristone-Induced Septic Shock Due to Clostridium sordellii - The Annals of Pharmacotherapy: Vol. 39, No. 9, pp. 1483-1488
posted by ICU room Pearls @ 12:11 AM 0 comments
Thursday, November 17, 2005

Thursday November 17, 2005Unplanned extubations - decrease mortality !Interesting study published in chest (august 2005) of 100 patients (compared to controlled group) who experienced unplanned extubation but did not require reintubation. They were found to have decrease mortality and remarkably good outcomes despite longer hospital and ICU stay.Lesson learned: we are keeping our patients intubated longer than needed !!References: click to get abstract/article1. The Drive to Survive - Unplanned Extubation in the ICU - From the Critical Care Unit (Dr. Krinsley), Stamford Hospital, Stamford, CT; and Department of Surgery (Dr. Barone), Columbia University College of Physicians and Surgeons, New York, NY.
posted by ICU room Pearls @ 6:53 AM 0 comments
Wednesday, November 16, 2005

amiodarone
Wednesday November 16, 2005Am-iod-arone !!The word "iod" in Amiodarone tells as that it is an iodine based compound. No wonder it mess up thyroid metabolism. Also, another interesting clinical significance of amiodarone toxicity is high-attenuation parenchymal-pleural lesions along with similiar increased attenuation in liver or spleen. This property of high attenuation due to iodine in lung, liver and spleen is pretty diagnostic of Am-iod-arone toxicity. The risk is higher if daily dose is greater than 400 mg. Amiodarone has increase half life in lung and eventually resolve with stoppage of drug while steroid is the thrapy in between. Acute Amiodarone toxicity has been described too. See CXR and non-contrast CT slice (but appearing as contrast due to iodine accumulation) in Amiodarone Toxicity - from Radiographics in reference 2 below.References: click to get abstract/article1. Amiodarone pulmonary toxicity: CT findings in symptomatic patients - Radiology, Vol 177, 121-1252. Pulmonary Drug Toxicity: Radiologic and Pathologic Manifestations - Radiographics. 2000;20:1245-12593. Amiodarone at pneumotox.com
posted by ICU room Pearls @ 8:59 AM 0 comments
Tuesday, November 15, 2005

Tuesday November 15, 2005MAP measurement in ICU with sphygmomanometerAlthough we don't need to do sphygmomanometric blood pressure measurement in ICUs on all patients anymore but still it is reasonable to have atleast one instrument available in "unit". (A-lines are not always inserted and sometime oscillometer readings don’t get register on monitor). Most experts agreed that MAP (Mean Arterial Pressure) is more of clinical significance - it may be of interest to know that beside traditional formula available to calculate MAP i.e. MAP = { SBP + (2DP) } / 3 OR DBP + .333 (SBP-DBP), there is another formula described which has been reported as more accurate.MAP = DBP + .412 (SBP-DBP)Here is the Nomogram to quickly find MAP with above formula without calculation. - reference - Heart 2000;84:64References: click to get abstract/article1. Formula and nomogram for the sphygmomanometric calculation of the mean arterial pressure - Heart 2000;84:64 (July)2. Arterial Stiffness as Underlying Mechanism of Disagreement Between an Oscillometric Blood Pressure Monitor and a Sphygmomanometer - Hypertension. 2000;36:4843. Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research - Circulation. 2005;111:697-716
posted by ICU room Pearls @ 2:07 PM 0 comments
Monday, November 14, 2005

Monday November 14, 2005 Cameron lesionsCameron lesions are linear gastric erosions positioned at the diaphragmatic impression, in patients with large hiatus hernia. It is a distinct entity from other erosions and was described first time about 20 years ago by AJ Cameron. Clinical significance: In upto one third of cases cameron lesions can present as acute upper GI bleed which may become life-threatening. Despite treatment, 33% develop recurrence of the lesion with possible acute event requiring immediate surgery. Lesion can also cause iron deficiency anemia and chronic GI bleed.See endoscopic picture here - from Indian Journal of Gastroenterology.References: click to get abstract/article1. Linear gastric erosion. A lesion associated with large diaphragmatic hernia and chronic blood loss anemia. - Gastroenterology. 1986 Aug;91(2):338-42.2. Hiatal hernia with cameron ulcers and erosions. - Gastrointest Endosc Clin N Am. 1996 Oct;6(4):671-9.3. Cameron lesion and its laparoscopic management - Indian J Gastroenterol 2005;24:163-163
posted by ICU room Pearls @ 10:29 AM 0 comments
Sunday, November 13, 2005

Sunday November 13, 2005Potassium and phophate ratio in combo infusionIt is handy to remember that 1 mmol of intravenous phophate delivers 1.46 meq of potassium in "K-phos rider". To make it in round figure 7.5 mmol of phosphate is equal to about 10 meq of potassium and should be infuse over atleast one hour.See nice read and guideline on "K-phos" rider at ismp.org
posted by ICU room Pearls @ 5:52 PM 0 comments
Saturday, November 12, 2005

Saturday November 12, 2005Urinary Catheter related UTIs in ICUThere is a lot of emphasis on questioning everyday about nescessity of central venous lines but it may be of interest to know that urinary catheter related UTIs (urinary tract infections) makes 40% of hospital-acquired infections and 3% out of them ends up as bacteremia (and each episode of catheter-related nosocomial bacteremia costs a minimum of around US $3000). In ICUs, one recent study showed incidence density of 6 UCRI/1000 urinary catheter-days. (UCRI=urinary catheter related infection). In another study, implementation of nurse-driven surveillance of Criteria-Based Foley Catheter Guidelines (CFCG) protocol in ICU decreased UCRI from 6.4 to 1.9 per 1000 urinary catheter-days.And no condom catheter are no better !References: Click on link to get abstract/article:1.Urinary catheter-related infection in critically ill patients Critical Care 2005, 9(Suppl 1):P122. Enhancing the Safety of Critically Ill Patients by Reducing Urinary and Central Venous Catheter-related Infections - American Journal of Respiratory and Critical Care Medicine Vol 165. pp. 1475-1479, (2002)3. The Effects of Criteria-Based Foley Catheter Guidelines in an ICU - Innovations in Clinical Excellence Evidence-Based Practice Contest Winners I - Sigma Theta Tau International 38th Biennial Convention November 12-13, 2005, Indianapolis, IN
posted by ICU room Pearls @ 3:41 AM 0 comments
Friday, November 11, 2005

Friday November 11, 2005Regarding Lactate levelIt is worth to continue to emphasize to house staff that:1. if feasible 'arterial' lactate is preferable to venous lactate as it get influenced with time and pressure of tourniquet. 2. Lactate level is under-utilized blood workup in sepsis patients. Its not a perfect analogy but as CPK and MB is to chest pain, WBC (Leucocytosis) and lactate level is to sepsis. (We are still in search of troponin of sepsis!).3. Time matters exactly same in septic attack as in heart attack and brain attack. Lactate level (even venous) can help tremendously in identifying this attack early when hemodynamic is still relatively stable.See Rivers early goal directed therapy's algorithm. - (NEJM) where lactate level of 4 has been used as cutoff point to start algorithm.References: Click on link to get abstract/article:1.Changes in venous blood lactate, venous blood gases, and somatosensory evoked potentials after tourniquet application - Anesthesiology. 1988 Nov;69(5):677-822. Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock - November 2001, NEJM
posted by ICU room Pearls @ 8:19 AM 0 comments
Thursday, November 10, 2005

isp
Thursday November 10, 2005ICU satellite pharmacyAlthough there is no study done but anecdotal reports shows that decentralization of pharmacy with ICU having its own satellite pharmacy (ideally having its own critical care pharmacist) decrease medication errors and probably is more cost-effective for hospital due to focused expertise and increase communication with nurses/physicians. Similar has been recommended as "desirable services" in Position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy's Task Force on Critical Care Pharmacy Services.References: Click on link to get abstract/article:1. Declaring victory in the war against drug errors - Sept. 2005, Today’s Hospitalist.2. Position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services. - Critical Care Medicine. 28(11):3746-3750, November 2000
posted by ICU room Pearls @ 11:21 AM 0 comments
Wednesday, November 09, 2005

Wednesday November 9, 2005Donut MagnetsIf encountered with a situation where patient's AICD (Automatic Implantable Cardioverter Defibrillator) continue to fire inappropriately causing hemodynamic issues or mostly when during or after the 'code', AICD needs to be deactivated - ask for "Donut Magnets" ONLY as other regular magnets may not work. Put donut magnet directly over AICD. Once AICD deactivated you may hear a long beep(s) but important thing is to keep magnet there and tape it firmly till seen by cardiology. Its important, if patient fails cardio-pulmonary resuscitation, to deactivate AICD, confirm underlying asystole/rhythm before calling off the code.See sample of ems driven AICD deactivation protocol - from scdhec.gov
posted by ICU room Pearls @ 10:01 AM 0 comments
Tuesday, November 08, 2005

Tuesday November 8, 2005Troponin-I or Troponin-T ?As picture is getting more clear about Troponins, it appears that Troponin-I does not get affected with renal insufficiency/failure. While 'sustained' elevated Troponin-T reflects poor cardiac baseline and predicts poor overall cardiac mortality. If Troponin-I is not available in your hospital, a spike (bell curve) or continuously rising Troponin-T may be an indicator of acute coronary event but low level sustained value may just reflect baseline cardiac decompensation.Refrences: click on link to get article/abstract1. Clinical Association between Renal Insufficiency and Positive Troponin I in Patients with Acute Coronary Syndrome - Cardiology 2004;102:215-2192. Cardiac troponin-I before and after renal dialysis - Clinical Nephrology, Vol. 54 - No. 3/2003. Troponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients. - Am J Kidney Dis. 2002 Jul;40(1):68-75.
posted by ICU room Pearls @ 12:01 AM 0 comments
Monday, November 07, 2005

etstsl
Monday November 7, 2005ESCAPE Trial - setback to swan lovers?Debate on pulmonary artery catheter is non-ending in critical care culture. Recently JAMA has published 2 studies which may make swan-believers unhappy.1. ESCAPE Trial (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness): which showed that use of the PAC did not significantly affect the primary end point of days alive and out of the hospital during the first 6 months. Also, In-hospital adverse events were more common among patients in the PAC group.2. Impact of the Pulmonary Artery Catheter in Critically Ill Patients - Meta-analysis of 13 Randomized Clinical Trials which showed that in critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit.Now we have to wait for results of FACTT study from ARDSnet evaluating the use of a Pulmonary Artery Catheter versus Central Venous Catheter (CVP) in patients with Acute Lung Injury and ARDS.Refrences: click on link to get article/abstract1. The ESCAPE Trial JAMA. 2005;294:1625-16332. Impact of the Pulmonary Artery Catheter in Critically Ill Patients -JAMA. 2005;294:1664-1670.3. FACTT trial - ARDSNet
posted by ICU room Pearls @ 9:16 PM 0 comments
Sunday, November 06, 2005

Sunday November 6, 2005Is low HDL marker for sepsis mortality?Although it is a small prospective, observational cohort study of only 63 patients (National Taiwan University Hospital) but interesting to note the conclusion that:A low HDL cholesterol level (cutoff value at 20 mg/dL) on day 1 of severe sepsis was significantly associated with an increase 30 day mortality, increase ICU stay and hospital acquired infection. (All other septic parameters adjusted).Another interesting finding at continuation of work back to bench while blood samples were obtained and serum was immediately stored at -80°C until analysis : ...HDL can attenuate LPS (Lipopolysaccharide)-induced TNF-á production only if added concomitantly with, but not after, LPS exposure.Refrences: click on link to get article/abstract1. Low serum level of high-density lipoprotein cholesterol is a poor prognostic factor for severe sepsis - Critical Care Medicine: Volume 33(8) August 2005 pp 1688-1693
posted by ICU room Pearls @ 5:29 AM 0 comments
Saturday, November 05, 2005

Saturday November 5, 2005Pneumocystis Jiroveci (PCP) - previously P. carinii Patients with Pneumocystis jiroveci (PCP) usually detriorate in first 2 -3 days of treatment with worsening of A-a gradient (Alveolar-arterial gradient of oxygen) and this should not be presumed as treatment failure. If patient continue to show same trend by 5-7 days than treatment failure should be considered. Initial worsening is due to inflammation as organisms get killed and this is one of the reason to administer steroid at the initiation of PCP treatment.Nomenclature has been changed as DNA analysis by PCR (polymerase chain reaction) showed that sequences from P. jiroveci (human-derived) differ by 5% from P. carinii (rat-derived). But acronym PCP has been retained for Pneumocystis pneumonia. Jiroveci (pronounced "yee row vet zee") has been named in honor of the Czech parasitologist Otto Jirovec, who is credited with describing the microbe in humans in 1999.Refrences: click on link to get article/abstract1. A New Name (Pneumocystis jiroveci) for Pneumocystis from Humans - cdc.gov2. Pneumocystis pneumonia in humans is caused by P jiroveci not P carinii - Thorax 2004;59:83-84 (letter to editor)
posted by ICU room Pearls @ 5:20 AM 0 comments
Friday, November 04, 2005

Friday November 4, 2005Prone positioning target - O2 or PCO2 ?Literature on prone postioning in ARDS is not encouraging4 but as Dr. Alain F. Broccard showed optimism by saying: "Are We Looking at a Half-Empty or Half-Full Glass?" (ref. 2).Dr. Gattinoni's 2001 NEJM article (ref. 3) failed to show any benefit on survival despite improved oxygenation but 2 years later his article in Critical Care Medicine Journal (Ref. 1) found that ARDS patients who respond to prone positioning with reduction of their Paco2 show an increased survival at 28 days. Improved efficiency of alveolar ventilation (decreased physiologic deadspace ratio) has been concluded as an important marker of patients who will survive acute respiratory failure.So the Question is: In prone positioning should we target improve oxygenation or decreasing Paco2 ????Refrences: click on link to get article/abstract1. Decrease in Paco2 with prone position is predictive of improved outcome in acute respiratory distress syndrome - Crit Care Med 31(12):2727-2733, 20032. Prone Position in ARDS Are We Looking at a Half-Empty or Half-Full Glass? - (Chest. 2003;123:1334-1336.)3. .Effect of Prone Positioning on the Survival of Patients with Acute Respiratory Failure - NEJM, Aug. 2001- Volume 345:568-5734. Effects of Systematic Prone Positioning in Hypoxemic Acute Respiratory Failure - JAMA - Vol. 292 No. 19, November 17, 2004
posted by ICU room Pearls @ 9:10 PM 0 comments
Thursday, November 03, 2005

Thursday November 3, 2005Regarding Valproic acid (VPA; Depakote) overdoseFew important points good to know in Valproate toxicity:1. Hyperammonemia could occur without liver function test abnormalities.2. Cerebral edema may become apparent even upto 4th day post ingestion and is not dose related so close monitoring is required despite level shows normalization.3. Mechanism of action is unknow but in some patients Naloxone shows improvement in mental status so it should be considered.4. There is no antidote available but administration of L-carnitine (50 mg/kg/day) in patients with hyperammonemia and neurological symptoms may help.5. Hemodyalysis (Charcoal hemoperfusion is preferred if available) works only if level is above 100 ug/ml as protein binding sites become saturated and free drug is available for hemodyalizing.6. Free valproate level should be send in patients with unexplained altered cognition, but normal serum (protein bound) levels.Refrences: click on link to get article/abstract1. Toxicity, Valproate - emedicine.com2. Valproic acid toxicity: overview and management. - J Toxicol Clin Toxicol. 2002;40(6):789-8013 Neurotoxicity Associated With Free Valproic Acid - Am J Psychiatry 162:810, April 20054. Delayed valproic acid toxicity: A retrospective case series - Ann Emerg Med. 2002 Jun;39(6):616-21
posted by ICU room Pearls @ 8:30 AM 0 comments
Wednesday, November 02, 2005

Wednesday November 2, 2005Regarding Needle ThoracostomyNeedle thoracostomy continue to be one of the life saving procedures in ICUs for tension pneumothorax. But recent literature and anecdotal reports suggest that needle thoracostomy should be perform only in situations where severe hemodynamic compromise is imminent or diagnosis of pneumothorax is very clear. It is not a benign procedure as thought and should not be taken lightly. Blind needle thoracostomy carries good risk of lung laceration and air embolism through such a laceration is a real concern. If possible, its better to wait for radiological confirmation and perform chest tube placement in more controlled enviroment.Another point raised in recent literature is regarding length of the needle. Standard 5 cm long needle has been found to fail 25% of the procedures. (14-16 G IV cannula is preferred). If thick chest wall presumed, 6 cm long needle has been recommended.Refrences: click on link to get article/abstract1. Needle Thoracostomy - Archive of debate at trauma.org2. image of procedure site - Deptt. of Anesth. & inten. care, Chinese Univ. of Hong Kong3 Needle Thoracostomy: Implications of Computed Tomography Chest Wall Thickness - Acad Emerg Med Volume 11, Number 2 211-2134. Needle Thoracostomy in Trauma Patients: What Catheter Length Is Adequate? - Acad Emerg Med Volume 10, Number 5 495.
posted by ICU room Pearls @ 9:56 AM 0 comments
Tuesday, November 01, 2005

Tuesday November 1, 2005Immune reconstitution inflammatory syndromeImmune reconstitution inflammatory syndrome (IRIS) is relatively a newly discovered phenomenon encountered by those intensivists who take care of HIV patients. Some individuals who initiate "HAART" (Highly Active Antiretroviral Therapy) regimen develop new or paradoxical worsening of opprtunistic infections or malignancies despite improvements in surrogate markers of HIV infection. Reportedly it develops in patients with profound immunosuppression (usually below CD4 count of 100). Classic example is a study which showed that 30% of HIV patients coinfected with Cryptococcus neoformans who initiated HAARTdeveloped IRIS with higher cerebrospinal fluid opening pressures, glucose levels, and white blood cell counts.Refrences: click on link to get article/abstract1. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. - Clin Infect Dis. 2005 Apr 1;40(7):1049-52.2. Recent IRIS related articles/literature - hivandhepatitis.com3.Immune Reconstitution Inflammatory Syndrome Associated With Kaposi's Sarcoma - Journal of Clinical Oncology, Vol 23, No 22 (August 1), 2005: pp. 5224-52284. Immune Reconstitution Inflammatory Syndrome Associated With HIV and Leprosy - Arch Dermatol. 2004;140:997-1000.
posted by ICU room Pearls @ 12:14 AM 0 comments
Monday, October 31, 2005

Monday October 31, 2005IHI's 5 essentials to prevent central line infectionsWho will disagree with following 5 essentials to prevent central line infections from IHI (Institute for Healthcare Improvement).1. Washing Hands: Before and after palpating the insertion site. (Good to avoid palpation once field is ready).2. Maximal barrier precautions: yes !! - complete application of sterile drape from head to toe and those “four magic words” - cap, mask, gown and gloves.3. Use of Chlohexidine as an anti-septic: Proven to be superior than Povidone-iodine(Betadine).4. Sub-clavian as prefferd site: (may be controversial if operator is not experienced).5. Daily evaluation of necessity of line: So true !See IHI’s Central line bundle check list and complete guide in our protocol/tool section. Please register free at ihi.org for immense other resources.
posted by ICU room Pearls @ 9:51 AM 0 comments
Sunday, October 30, 2005

Sunday October 30, 2005Back to Basics - essential trace elementsImportance of seven essential trace elements is relatively way higher in ICUs due to hypermetabolic state of patients. Being an intensivist it is important to have some know how of them. Except for iron and iodine all others need to be provided with enteral and parentral formulae to satisfy atleast their RDA.1. Iron: in ICU merely checking Fe level may not give real answer of its deficiency. Always check Ferritin level (below 18 indicates deficiency).2. Selenium: important anti-oxidant and unfortunately many times not included in available enteral/parentral formulae.3. Chromium: necessary for normal glucose utilization.4. Copper: essential for formation of hemoglobin.5. Iodine: needed for proper thyroid metabolism.6. Manganese: part of Ca+/phos+ metabolism.7. Zinc: needed for proper wound healing.Refrences: Click to get abstract/article.1. Trace minerals in ICU patients: a forgotten cause of delayed recovery? - Critical Care 2004, 8(Suppl 1):P2642. Trace element supplementation modulates pulmonary infection rates after major burns: American Journal of Clinical Nutrition, Vol 68, 365-3713. Levels of oligo-elements and trace elements in patients at the time of admission in intensive care units - Nutr Hosp. 1990 Sep-Oct;5(5):338-44.4.Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients - Journal of Parenteral and Enteral Nutrition, Vol 27, Issue 5, 355-3735. EARLY ENTERAL SUPPLEMENTATION WITH PHARMACONUTRIENTS IN CRITICALLY ILL PATIENTS - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A4
posted by ICU room Pearls @ 10:16 PM 0 comments
Saturday, October 29, 2005

Saturday October 29, 2005Venous Air Embolism - VAE - immediate maneuversIf Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 steps are essential:1. Clamp the line (do not withdraw) - to prevent further air.2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.3. Place patient in Trendelenburg position - to help air trap in the apex of the ventricle.4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.Refrences: Click to get abstract/article.1. Venous Air Embolism - emedicine.com2. Gas Embolism - NEJM, feb. 2000, Volume 342:476-4823. Venous air embolism: a review. J Clin Anesth 1997;9:251-2574. Venous Air embolism - Rashad Net University
posted by ICU room Pearls @ 5:20 AM 0 comments
Friday, October 28, 2005

Friday October 28, 20053 new antibiotics Recently atleast 3 new antibiotics have been introduced in market. No doubt, these are big guns but it is important to know their drawbacks.1. INVANZ (Ertapenem): Unlike other carbapenems this antibiotic has limited role in nosocomial infections due to negligible activity against Pseudomonas aeruginosa and Acinetobacter baumanni !!2. CUBICIN (Daptomycin): Cubicin is indicated only for complicated skin and skin structure infections caused by Gram-positive organisms including MRSA (no gram-negative coverage). It has been used as off label for VRE and endocarditis but not approved by FDA. Dose dependent myopathy is a concern, and CPK monitoring is required. 3. TYGACIL (Tigecycline): has been approved for complicated skin (including MRSA) and intra-abdominal (MRSA not included) infections. It has very broad spectrum coverage. It is a distinct class similar to tetracycline. Though nick-named as "Superbug Antibiotic", experts warn against use as a first line or mono-therapy. Side effect profile is long including increase liver enzymes, azotemia, acidosis, hypophosphatemia, hyperglycemia, hypokalemia etc.Readings: Click to get abstract/article.1. Carbapenems - Dept of Anaesth. & Int. Care, The Chinese Univ. of HK2. Cubicin: cleveland clinic - pharmacotherapy update3. FDA warning letter for cubicin - pharmcast.com4. Tygacil: multum.com
posted by ICU room Pearls @ 11:26 AM 0 comments
Thursday, October 27, 2005

Thursday October 27, 2005Propofol Infusion Syndrome (PRIS)Propofol Infusion Syndrome is a serious threat when propofol is continued for more than 48 hours particularly if dose goes beyond 5mg/kg/hr. Propofol Infusion Syndrome is hallmark by unexplained metabolic acidosis, rhabdomyolysis, cardiac events, arrthymias, hepatomegaly, lipemia, renal failure and hyperkalemia. Unexplained lactic acidosis is suggested as an early marker of "PRIS". Acquired carnitine deficiency has been postulated as a cause, atleast in one article. Reference: Click to get abstract/article.1. Cremer and coll.: Long-term propofol infusion and cardiac failure in adult head-injured patients. The Lancet 2001;357:117-118 (Article available at www.thelancet.com with free registration)2. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. - Intensive Care Med. 2003 Sep;29(9):1417-25.3. Acquired Carnitine Deficiency: A Clinical Model for Propofol Infusion Syndrome? - Anesthesiology: Volume 103(4) October 2005 p 909
posted by ICU room Pearls @ 12:56 PM 0 comments
Wednesday, October 26, 2005

Wednesday October 26, 2005CPR on patient with IABP If patient requires CPR who is on Intra-Aortic Baloon Pump (IABP) - do not switch off IABP. Switch from "ECG trigger" to "Pressure trigger". IABP during CPR improves cerebral and cardiac blood flow. With CPR, on "pressure trigger", an arterial pressure tracing should be generated on console/screen and if the console is not recognising the arterial pressure tracing, chest compressions may not be adequate. (If any uncomfortness regarding IABP during code - just dial on 'standby' mode during code).1. See sample IABP care protocol in our protocol/tool section - London Health Sciences Centre, Canada at www.icuroom.net.2. See Concepts of Counterpulsation Therapy System - Datascope's complete guide to IABP in our "I" section at www.icuroom.net. Reading:P. J Overwalder: Intra Aortic Balloon Pump (IABP) Counterpulsation. The Internet Journal of Thoracic and Cardiovascular Surgery. 1999. Volume 2 Number 2.
posted by ICU room Pearls @ 8:35 AM 0 comments
Tuesday, October 25, 2005

Tuesday October 25, 2005STOP Sepsis bundle - another step forwardAfter instituting Dr. Rivers' Early Goal Directed Therapy (EGDT) in septic patients - it is imperative to implement Dr. Nguyen's "yes/NO" STOP sepsis bundle as a second step - including 1. Hemodynamic monitoring (CVP/ScvO2 ) within 2 hours2. Broad spectrum antibiotics administered
Saturday June 17, 2006
4 EKG changes in Hyperkalemia


The first EKG sign of hyperkalemia is peaked T waves and usually appears once K level go around 6 meq/L.

Second sign is prolongation of PR interval which can be seen with K level going around or above 7 meq/L.

Absent P wave with widen QRS complex is the third manifestation and is a very dangerous sign. It means that atrial activity is lost and stage is set for ventricular tachycardia/fibrillation. It is usually seen at level around 8-9 meq/L.

Ventricular tachycardia/fibrillation is the price you pay of ignoring above changes on monitor.

Above are just rough rules of thumb. Read a very good review, Recognising signs of danger: ECG changes resulting from an abnormal serum potassium concentration (source: Emerg Med J 2002; 19:74-77)

posted by ICU room Pearls @ 3:51 PM 0 comments

Friday, June 16, 2006
Friday June 16, 2006
Carvediol (Coreg)


Q: How Carvediol (Coreg) is different from other B-blockers?

A; Coreg is a triple blocker. It blocks beta-1, beta-2 and alpha-1 receptors. Alpha-1 blockade provides vasodilation and so protection in congestive heart failure (CHF). U.S. Carvedilol Heart Failure Study with 1094 patients showed 65% lower risk of death than placebo patients 1. Dose should be started at 3.125 mg BID and titrated (as tolerated) upto 25 mg BID. Obese patients may require higher dose.

Extended release Metoprolol (Toprol XL) is another B-blocker approved from FDA for use in CHF. MERIT-HF study showed 34% reduction in mortality than placebo in patients taking Toprol XL 2.

FDA approves only Toprol-XL and Coreg for CHF.



References: Click to get article/abstract

1. The Effect of Carvedilol on Morbidity and Mortality in Patients with Chronic Heart Failure - N Engl J Med. 1996;334:1349-1355.

2. MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomised intervention trial in congestive heart failure. Lancet. 1999;353:2001-2007
posted by ICU room Pearls @ 3:05 PM 0 comments

Thursday, June 15, 2006
IV Dig
Thursday June 15, 2006
IV Digoxin


Q: You wrote an order: Digoxin 0.25 mg IV x 1.
What is missing in this order?


A; Rate: Digoxin IV should be given over at least 5 minutes. Rapid infusion of Digoxin (digitalis) may cause coronary arteriolar constriction, which may induce cardiac ischemia or make it worse. Also, it is not advisable to administer digoxin simultaneously in the same intravenous line as with other drip/drug, if possible. Another important reminder - Digoxin level should be measured just before the next scheduled dose (trough) or at least 6 to 8 hours after the last dose, to allow adequate time for equilibration of digoxin between serum and tissue.


Related previous pearl: Why sometime IV vasotec (enalapril) does not work?
posted by ICU room Pearls @ 8:19 AM 0 comments

Wednesday, June 14, 2006
Wednesday June 14, 2006
Swan is still very in !!


Lately we had some constant negative studies for pulmonary artery catheter like ESCAPE trial, PAC-MAN study and recently published ARDSnet's FACTT trial 2.

This month Critical Care Medicine published retrospective database analysis of 53,312 trauma patients 1. After all adjustments following groups showed benefit:

Patients aged 61-90 yrs,
with arrival base deficit worse than -11 and
Injury Severity Score of 25-75.
It was found that it was associated with a protective effect in patients with severe shock, regardless of age, and in older patients with moderate shock.


Also note negative outcome: Highest risk of death associated with PAC use was in younger patients who arrived at the ED without a significant base deficit. Moreover, no survival benefit was detected with PAC use in patients arriving at the ED without evidence of shock.


Conclusion: PAC insertion is associated with

improved outcome in critically injured patients with severe shock at admission, regardless of age, and
in elderly patients with moderate shock.
Related previous pearls: PAC-MAN study ! and ESCAPE Trial



Reference: Click to get article

1. Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients - Critical Care Medicine. 34(6):1597-1601, June 2006.
2. Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute Lung Injury - Volume 354:2213-2224, NEJM, May 25, 2006

posted by ICU room Pearls @ 8:58 AM 0 comments

Tuesday, June 13, 2006
CVP via PICC
Tuesday June 13, 2006

Can we measure CVP (central venous pressure) with PICCs (peripherally inserted central catheters) ?


YES: PICC lines can be used to measure CVP, if situation arise. CVP recorded via PICC lines are about 1 mm Hg higher than CVP from centrally inserted venous catheters. PICC lines need to be hooked to continuous infusion with heparinized saline at 3 mL/hr to overcome the resistance of longer length and narrower lumen of PICC line. Trend should be followed for better perception as first PICC measured CVP is reported higher, probably due to microthrombi which get flushed later on.

Dr. Black and coll. from Pennsylvania State University College of Medicine, Hershey, PA studied 77 data pairs from 12 patients with measurements recorded at end-expiration. 19-gauge dual-lumen PICCs were used and were zeroed/levelled at right atrium. To overcome the longer length, narrower lumen an so higher inherent resistance, continuous infusion device is used with heparinized saline at 3 mL/hr (like in arterial lines) 1.


Reference: Click to get article

1. Central venous pressure measurements: Peripherally inserted catheters versus centrally inserted catheters - Critical Care Medicine. 28(12):3833-3836, December 2000.
posted by ICU room Pearls @ 8:08 PM 0 comments

Monday, June 12, 2006
Monday June 12, 2006

While you are carrying 'code beeper' as an intensivist, you heard 'code blue in cafeteria'. On arrival you found 36 year old female who was in cafeteria after visiting allergy clinic, where according to daughter she received her 'expensive asthma shot'. While you were resuscitating patient from what appears to be anaphylactic shock, you keep wandering about that 'expensive asthma shot'.


Xolair: Omalizumab (xolair) is the subcutaneous injection treatment for allergic asthma that works by blocking immunoglobulin E (IgE). Anaphylaxis is rare but the tricky part is it may cause anaphylaxis even after months of successful and uneventful treatment. There is an indication in atleast one case report that polysorbate present in omalizumab may be responsible for it 1.

Per month cost of treatment is about 500 - 2000 US $.


Reference: Click to get article

1. Late-Onset Anaphylaxis to Omalizumab Reported - from acep.org site

posted by ICU room Pearls @ 4:13 PM 0 comments

Sunday, June 11, 2006
IV to PO conversion
Sunday June 11, 2006
IV to PO conversion - check med list everyday !!


58 year old male admitted with atrial fibrillation with RVR (rapid ventricular rate) and required intravenous (IV) Diltiazem (cardizem). Now patient is stable at 7 mg/hr dose. What would be the equivalent PO dose?


Diltiazem CD 240 mg po qd 1.

Usual IV to PO Cardizem is as follows:

3 mg/h = Diltiazem CD 120 mg po qd
5 mg/h = Diltiazem CD 180 mg po qd
7 mg/h = Diltiazem CD 240 mg po qd
11 mg/h = Diltiazem CD 300 mg po qd
15 mg/h = Diltiazem CD 360 mg po qd


Using this question as an excuse, the objective is to highlight the point that many times PO medications are as effective as IV (See reference # 1). Good intensivist always remain in the quest to simplify the medication list. It always help to have a savy critical care pharmacist in the team !.


Related: Sample INTRAVENOUS TO ORAL/ENTERAL (IV TO PO) MEDICATION SWITCH PROGRAM from American Society of Health-System Pharmacists' site


Reference: click to get abstract/article
1. Intravenous to Oral Conversion Table: source nih.gov
posted by ICU room Pearls @ 2:10 PM 0 comments

Saturday, June 10, 2006
Feeding in ventilated patients
Saturday June 10, 2006
Yes ! Feed Critically Ill Mechanically Ventilated Medical Patients early despite risk of VAP


There is some hesitancy in literature about early feeding for critically ill mechanically ventilated medical patients due to increase risk of ventilator-associated pneumonia (VAP) 1.

Dr. Artinian and coll. from Division of Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, MI recently looked into about 4000 patients requiring mechanical ventilation for more than 2 days 2. Those patients who received enteral feeding within 48 hours of mechanical ventilation were labeled as the "early feeding group" otherwise as "late feeding group." Results showed that

The overall ICU mortality was 18.1% vs 21.4%
The overall hospital mortality was 28.7% vs 33.5%
In substudy, three separate models were done using APACHE II, simplified acute physiology score II, and mortality prediction model at time 0. In all models, early enteral feeding was associated with

an approximately 20% decrease in ICU mortality
a 25% decrease in hospital mortality
The lower mortality rates in the early feeding group were most evident in the sickest group

The truth was found that in all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP).


Study concluded that early feeding significantly reduces ICU and hospital mortality mainly in the sickest patients and should be instituted in medical patients receiving mechanical ventilation especially in patients at high risk of death, despite being associated with an increased risk of VAP developing.


Related previous pearls:
Where is my food dude !! and Is post pyloric feeding absolute ?


Reference: click to get abstract/article
1. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial - Journal of Parenteral and Enteral Nutrition, Vol 26, Issue 3, 174-181
2. Effects of Early Enteral Feeding on the Outcome of Critically Ill Mechanically Ventilated Medical Patients - Chest. 2006;129:960-967

posted by ICU room Pearls @ 4:58 AM 0 comments

Friday, June 09, 2006
Friday June 9, 2006


Case: 76 year old female, admitted 3 days ago to your ICU with possible aspiration pneumonia. Review of report from nursing home also mention of increase diarrhea. You decide to add metronidazole (flagyl) and start the workup. Patient responded well to treatments and appears to be back to her baseline. You decide to keep patient overnight before transferring to floor in AM. Patient complaint of epigastric abdominal pain during night and on-call physician added pancreatic enzymes for AM and lipase is noted to be 1254 (was normal on admission). You could not find any apparent reason of acute pancreatitis. As C.diff came back negative you stopped the Flagyl and pancreatitis resolved.


Metronidazole Induced Pancreatitis: Acute pancreatitis is a potentially serious adverse effect of metronidazole. Any patient while on metronidazole develops nausea, vomitting and epigastric pain should be evaluated for acute pancreatitis. Acute pancreatitis may develop upto 5 weeks after metronidzole exposure and drug intake in previous weeks should be evaluated carefully particularly in long term care facility residents. Diagnosis can be confirmed with rechallenge with metronidazole but obviously it should be avoided. The mechanism of metronidazole-induced pancreatitis is not known but unlike many other antibiotics metronidazole penetrates well into pancreatic tissue and explains atleast part of the problem.


Reference: click to get abstract/article
1. Metronidazole Induced Pancreatitis. A Case Report and Review of Literature - JOP. J Pancreas(Online) 2004; 5(6):516-519
2. Metronidazole-associated pancreatitis - The Annals of Pharmacotherapy: Vol. 34, No. 10, pp. 1152-1155
3. Acute pancreatitis caused by metronidazole - Ned Tijdschr Geneeskd. 1996 Jan 6;140(1):37-8.
posted by ICU room Pearls @ 7:38 PM 0 comments

Wednesday, June 07, 2006
Thursday June 8, 2006
What if plasma exchange is not available as treatment of TTP


Q: You just diagnosed a patient with thrombotic thrombocytopenic purpura (TTP) but you were informed by the nursing supervisor that plasma exchange with fresh frozen plasma is not available in hospital due to technical reason and it will take time before patient can be transferred to a facility where the said services are available. What would be your alternate plan to bridge that time?


A; High-dose plasma infusion with rate of 25-30 mL/kg per day. When immediate plasma exchange with fresh frozen plasma is not available, simple plasma infusion can be performed until transfer to a higher care facility is available. There is always a substanial risk of fluid overload with such high plasma infusion and you have to weigh risks and benefits of the clinical decision or to watch patient closely while plasma is infusing.


Reference: click to get abstract/article

High-dose plasma infusion versus plasma exchange as early treatment of thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome - Medicine. 82(1):27-38, January 2003.
posted by ICU room Pearls @ 10:09 PM 0 comments

acetazolamide for metabolic alkalosis
Wednesday June 7, 2006
Dose of acetazolamide (diamox) for metabolic alkalosis


Many times we use acetazolamide for metabolic alkalosis in mechanically ventilated patients when nothing else is making it better. What dose should we use?. Mazur and coll. from Henry Ford Health System, Detroit, MI looked into 40 mechanically ventilated patients with a metabolic alkalosis (arterial pH more/= 7.48 and serum bicarbonate concentration more/= 26 mEq/L) which were resistant to other therapies such as fluid infusion or potassium therapy.

Study found that a single IV 500-mg dose of acetazolamide is as effective as multiple doses of IV 250 mg of acetazolamide.


Reference: click to get abstract/article

Single versus multiple doses of acetazolamide for metabolic alkalosis in critically ill medical patients: A randomized, double-blind trial. Critical Care Medicine. 27(7):1257-1261, July 1999.
posted by ICU room Pearls @ 9:26 AM 0 comments

Tuesday, June 06, 2006
Wells Score of DVT
Tuesday June 6, 2006
Wells Score of DVT

Pulmonary embolism from deep venous thrombosis remains a leading killer. Many times intensivists are faced with the question of proceeding or not with further radiological workup. Although Wells score is not the absolute score to rule out DVT and subsequently the risk of PE (some literature argue against its validity), it still remains a strong quick tool while differential diagnosis with other conditions. It has been said that if the score of low-probability is combined with negative d-dimer, the negative predictive value is 99.5% 1. In other words, you can safely hold on further radiological workup.

3 points if objective signs like localized tenderness, asymmetric calf swelling.
1.5 points if Heart Rate more than 100 beats/min
1.5 points if bedridden for more than 3 days or major surgery within 4 weeks
1.5 points if previous 'documented' diagnosis of DVT or PE
1 point if hemoptysis
1 point if active cancer
3 points if high clinical suspicion of PE (on overall clinical and lab. findings).

0 - 2 low probability,
2-6 moderate probability,
3-6 high probability

Remember,

low-probability + negative d-dimer = -ve predictive value of not having DVT is 99.5%

Related previous pearl: What if even thrombolysis fails in massive PE ?


Reference: click to get abstract/article
Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and D-dimer Philip S. Wells and coll.,Ann Intern Med 2001;135:98-107
posted by ICU room Pearls @ 12:56 PM 0 comments

Monday, June 05, 2006
Four generations of Quinolones
Monday June 5, 2006
Four generations of Quinolones


The classification of the fluoroquinolones on the basis of generations (imitating from cephalosporins) is not officially standardized, but it is now commonly use to classify them by their spectrum of action.


1st generation - Gram negative coverage but not pseudomonas (example: Nalidixic acid)

2nd generation - Gram negative coverage with pseudomonas and some gram postive coverage including s.aureus but not strep pneumoniae. (example: Ciprofloxacin, Ofloxacin, Norfloxacin)

3rd generation - Gram negative coverage with pseudomonas. More gram postive coverage including penicillin sensitive and resistant s. pneumoniae. (example: Levofloxacin, Sparfloxacin, Gatifloxacin (tequin), Moxifloxacin (avalox)). Avalox has been said to be the most effective in this generation.

4th generation - Same as 3rd generation but with anaerobic coverage (example: Trovafloxacin (Trovan) ).



Read comprehensive review on Quinolones (Source: Am Fam Physician 2002;65:455-64, authors: CATHERINE M. OLIPHANT, PHARM.D., University of Wyoming School of Pharmacy and GARY M. GREEN, M.D., Kaiser Permanente, California)
posted by ICU room Pearls @ 6:53 AM 0 comments

Sunday, June 04, 2006
Quinolones in UTI
Sunday June 4, 2006
Quinolones in UTI


Q; Name atleast one quinolone which should not be used for UTI in ICU ?

A: Moxifloxacin (avelox) - as it doesn't reach sufficient level in the urine. On the flip side, the advantage is that you don't need to adjust dose in renal insufficiency unlike other quinolones if use for other reasons. Similarly, Sparfloxacin (Zagam) and trovafloxacin (Trovan - almost off the market due to severe hepatic side effects) should not be used as these 3rd and 4th generation quinolones are more metabolized through liver.

Urinary tract infection (UTI) is a common and many time an isolated or accidental finding in ICU. Rememeber ! Bactrim (TMP/SMX) is still a first line, cost-effective and preferred antibiotic for uncomplicated UTIs. You should jump to quinolone only if your hospital's antibiogram shows local resistance higher than 20% or if patient is allergic to sulfas. Even in this instance nitrofurantoin is a very valid choice. If you decide to use quinolone - ciprofloxacin, ofloxacin, or norfloxacin is a better choice. Levofloxacin is also commonly prescribed but technically it is not really needed for UTI and just contribute to increase resistance in ICU by overuse.


Previous related pearls:

1. Quinolones and errant glycemic reaction

2. Epidemic of new fluoroquinolone induce strain of C. Diff.
posted by ICU room Pearls @ 1:52 AM 0 comments

Saturday, June 03, 2006
Saturday June 3, 2006


Q; Which one electrolyte you will be worried most in patients on TPN (Total Parenteral Nutrition) ?

A; Phosphate. About 33% of patients on TPN develop hypophosphatemia despite supplemented in solution. Patients who require insulin during TPN, or have a history of alcoholism, chronic weight loss, cancer and on diuretic therapy are at increased risk of hypophosphatemia, which also may manifest as "Refeeding syndrome". Serum phophate level below 1.5 mg/dl ( .5 mmol/L), can manifest symptoms of refeeding syndrome.

Read interesting editorial, Refeeding syndrome, Is underdiagnosed and undertreated, but treatable , from BMJ. ( BMJ 2004;328:908-909 )



References: click to get abstract/article

1. Refeeding syndrome: life-threatening, underdiagnosed, but treatable, QJM, April 1, 2005; 98(4): 318 - 319.
posted by ICU room Pearls @ 4:40 PM 0 comments

Friday, June 02, 2006
4 Ts of HIT
Friday June 2, 2006
4 Ts of HIT

Continuing our theme of Heparin-Induced Thrombocytopenia (HIT) from yesterday, lets talk today about "4 Ts" of HIT.

Thrombocytopenia - more than 50% fall

Timing of platelet count fall - Days 5 to 10, or less than/= 1 day if heparin exposure within past 30 days

Thrombosis or other sequelae - Proven thrombosis, skin necrosis, or, after heparin bolus, acute systemic reaction

Other cause for thrombocytopenia - None


American Society of Hematology has developed a full HIT score which can be seen by clicking here. 1



References: click to get abstract/article

1. When Heparins Promote Thrombosis - Review of Heparin-Induced Thrombocytopenia - Circulation. 2005;111:2671-2683
posted by ICU room Pearls @ 9:59 PM 0 comments

Thursday, June 01, 2006
Thursday June 1, 2006
Argatroban Therapy in Hepatic Dysfunction


Argatroban is a second line anti-coagulation as well as remained one of the drug of choice in patients affected with Heparin-induced thrombocytopenia (HIT). Argatroban improve outcomes in patients with HIT, by reducing new thrombosis 1 . Also reported its safety with no increase risk of bleeding 2 .

Argatroban is primarily metabolized in the liver and its dosing need to be adjusted in hepatic dysfunction. Dr. Levine and coll. from Texas has reported in this month of chest after retrospectively analysing data of 82 argatroban patients and 34 historical control therapy patients with hepatic impairments (all HIT patients) 5. Their results concluded following points:

1. In hepatic impairment 0.5 µg/kg/min is a reasonable, conservative initial dosage of argatroban.

2. serum bilirubin level appears to be a better indicator than ALT or AST of argatroban dosing requirements and argatroban should be initiated at a dose of 0.5 µg/kg/min if a patient’s serum total bilirubin level is 1.5 mg/dL.

3. Conservatic dose should be the starting point if combined hepatic/renal dysfunction is present.

4. As steady-state anticoagulation will be delayed in many patients with hepatic dysfunction, check the aPTT atleast 4 to 5 h after drug initiation or dose change.

5. Argatroban should be stopped for a more extended period in hepatic dysfuntion if an invasive procedure is planned.


Related: Sample Argatroban Protocol For HIT (from The George Washington University Hospital )


References: click to get abstract/article

1. Argatroban Anticoagulation in Patients With Heparin-Induced Thrombocytopenia - Arch Intern Med. 2003;163:1849-1856
2. Argatroban Anticoagulant Therapy in Patients With Heparin-Induced Thrombocytopenia - Circulation. 2001;103:1838
3. The Pharmacokinetics and Pharmacodynamics of Argatroban: Effects of Age, Gender, and Hepatic or Renal Dysfunction - Pharmacotherapy 2000;20,318-329
4. Argatroban Dosing in Patients with Heparin-Induced Thrombocytopenia The Annals of Pharmacotherapy: Vol. 37, No. 7, pp. 970-975.
5. Argatroban Therapy in Heparin-Induced Thrombocytopenia With Hepatic Dysfunction Chest. 2006;129:1167-1175
posted by ICU room Pearls @ 8:10 AM 0 comments

Wednesday, May 31, 2006
Wednesday May 31, 2006
Bedside tip ! - Tracheal Tube Tolerance

Some intubated patients wake up and cough on the tracheal tube, but may not be ready for extubation and you may be reluctant to re-sedate them. Consider a trial of intravenous Lidocaine. Administer 1 mg/Kg slowly over about two minutes. There is a good chance that the patient will experience immediate and dramatic relief from irritation caused by the tracheal tube (some may even sleep for a while). If the patient has a good response to the bolus, you may even start an intravenous infusion of Lidocaine at 2mg/ min. This can buy you the 1 – 3 hours the patient may need to be able to extubated the patient safely.
posted by ICU room Pearls @ 5:20 PM 0 comments

Tuesday, May 30, 2006
Capnography in CPR
Tuesday May 30, 2006
Use of Capnography in Assessment of CPR Adequacy


Myocardial blood flow is determined by the difference between aortic diastolic and right atrial pressures. Because both aorta and atrium experience the same intrathoracic pressure change during cardiopulmonary resuscitation (CPR), myocardial blood flow is very poor during cardiac resuscitation. Even high compression forces that may generate acceptable systemic and pulmonary artery pressures yield only small coronary perfusion pressures.

The arterial blood gas values during CPR manifest complex abnormalities. The reduction in cardiac output, and thus tissue perfusion, promotes anaerobic metabolism and lactic acidosis. However, arterial blood samples reflect either a normal or low PCO2 during CPR, while venous blood gases manifest both a respiratory and metabolic acidosis.

When perfusion is absent in the presence of ventilation, the primary influence on arterial acid-base status is alveolar ventilation. Venous acidosis develops as tissue beds drain CO2 and lactate is produced by anaerobic metabolism. The PCO2 in pulmonary veins increases due to reduced pulmonary blood flow and a resulting decrease in CO2 excretion.

With effective CPR or return of spontaneous circulation, pulmonary blood flow is improved and arterial pH decreases as more of the venous acid load (CO2 and lactate) reaches the arterial side. Aerobic and anaerobic metabolism produce carbon dioxide that is transported in venous blood to the lung and eliminated from the lung by minute ventilation. End-tidal CO2 is a measure of the partial pressure of carbon dioxide at the airway opening at the end of expiration.

During cardiac arrest, the abrupt decrease in cardiac output results in reduction of carbon dioxide transport from the tissues to lung and, hence, decreased carbon dioxide. More recently, capnography has been used to determine the adequacy of cardiopulmonary resuscitation.


There are 2 good sources to understand capnography:

1. capnography.com , educational site on subject from Bhavani-Shankar Kodali MD, Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, USA

2. See concise INTERPRETATION OF CAPNOGRAPHIC WAVEFORM
(from biotel.ws website)
posted by ICU room Pearls @ 8:51 AM 0 comments

Monday, May 29, 2006
Blumberg's sign
Monday May 29, 2006
Blumberg's sign

Q: You received call from an old fashioned experienced ER physician to consult a patient with hypotension and positive Blumberg's sign ?

Do you know what is Blumberg's sign ?


A; Sudden release of steadily applied pressure on a suspected area of the abdomen cause sudden stab of pain - an indication of peritonitis. Yes its another name of rebound tenderness. Ideal technique requires to watch patient's face to assess severity of pain while doing above maneuver (there is an innocent tendency to watch abdomen).

Historically this maneuver was described to assess peritoneal inflammation as an early sign of appendicitis by pressing hands over McBurney's point *. Sign was first described by a german surgeon and gynaecologist, Jacob Moritz Blumberg (1873 -1955).

* McBurney's point is located one third of the distance along a line from the front of the right pelvic bone and the belly button (click to see image).
posted by ICU room Pearls @ 1:35 PM 0 comments

Sunday, May 28, 2006
MEDiC Bill
Sunday May 28, 2006
MEDiC bill

Senators Hillary Rodham Clinton and Barack Obama have coauthored the proposed MEDiC bill. (National Medical Error Disclosure and Compensation Bill).

Main ideas of the bill:

1. This legislation would create an Office of Patient Safety and Health Care Quality within the Department of Health and Human Services. The director of this office will be responsible for establishing a National Patient Safety Database, conducting data analyses to inform policy and practice recommendations, establishing and administering the National Medical Error Disclosure and Compensation (MEDiC) program, and supporting studies related to MEDiC and the medical liability system.

2. The MEDiC program would provide federal grant support and technical assistance for doctors, hospitals, and health systems that disclose medical errors and problems with patient safety and offer fair compensation for injuries or harm. Participants would submit a safety plan and designate a patient-safety officer, to whom these disclosures and notices of related legal action would be reported.

3. If a patient was injured or harmed as a result of medical error or a failure to adhere to the standard of care, the participant would disclose the matter to the patient and offer to enter into negotiations for fair compensation. The terms of negotiation for compensation ensure confidentiality, protection for any disclosure made by a health care provider to the patient in the confines of the MEDiC program, and a patient's right to seek legal counsel; they also allow for the use of a neutral third-party mediator to facilitate the negotiation.

4. Any apology offered by a health care provider during negotiations shall be kept confidential and could not be used in any subsequent legal proceedings as an admission of guilt if those negotiations ended without mutually acceptable compensation.


Is it a fantasy land OR another bureaucratic hurdle ?. OR a real geniune workable idea as argued by senators by citing experiences and studies from University of Michigan Health System and Veterans Affairs (VA) Hospital in Lexington, Kentucky ?. Read by yourself the full article (available free by clicking link below) published by senators in The New England Journal of Medicine, Volume 354:2205-2208, Number 21. May 25, 2006

Making Patient Safety the Centerpiece of Medical Liability Reform
posted by ICU room Pearls @ 2:22 PM 0 comments

Saturday, May 27, 2006
RT or Iced Saline
Saturday May 27, 2006
Room temperature or Iced Saline ?


Critical Care literature is not clear, actually controversial, regarding the suitable temperature of the solution use as injectable to measure cardiac output via thermodilution. Let see what is the major pro & con of iced saline.

Advantage: Iced injectate gives a higher signal/noise ratio and more reliability in the measured cardiac output. Signal-to-noise ratio is an engineering term for the power ratio between a signal (meaningful information) and the background noise.

Disadvantage: Iced injectate may affect heart rate and cardiodynamics 5.

But practically does it matter ?. Also, iced solution may not be as cold as we think after it passes through the operator's hand and long port.

Overall literature favours room temperature or atleast does not show any major advantage of using iced saline 1-4.



Related: Thermodilution Cardiac Output Measurement Protocol
(sample from Univ. of Carolina Hospitals)



References:

1. Cardiac output measured by thermal dilution of room temperature injectate. - Evonuk E, Imig CJ, Greenfield W, et al: J Appl Physiol 1961; 16:271-275

2. Cardiac output by thermodilution technique. Effect of injectate's volume and temperature on accuracy and reproducibility in the critically Ill patient - Chest, Vol 84, 418-422, 1983

3. Effect of injectate volume and temperature on thermodilution cardiac output determination - Anesthesiology.1986 Jun;64(6):798-801.

4. Iced versus room temperature injectate for assessment of cardiac output, intrathoracic blood volume, and extravascular lung water by single transpulmonary thermodilution - J Crit Care. 2004 Jun;19(2):103-7.

5. The slowing of sinus rhythm during thermodilution cardiac output determination and the effect of altering injectate temperature. Anesthesiology 1985; 63:540-541
posted by ICU room Pearls @ 5:44 PM 0 comments

Friday, May 26, 2006
CO Pitfalls
Friday May 26, 2006
Cardiac Output Pitfalls


Determination of cardiac output by thermodilution has several technical pitfalls. Any deviation in technique can produce inaccurate and inconsistent results.

Basis of thermodilutional cardiac output: The method relies on an injection of a known volume of fluid (5-10 mL) into the right atrium. This fluid, either normal saline or D5W is at room (or iced at known *) temperature and therefore cooler than blood. The cooler injectate mixes with blood, thus lowering its temperature. The cooled blood is ejected into the pulmonary artery and flows past a thermistor located in the distal end of the PA catheter. The thermistor generates a change in temperature to time curve. The area under this curve is calculated by integration and is inversely proportional to the flow past the thermistor. In other words, the longer it takes for this change in temperature to “wash out,” the slower the flow past the thermistor. The converse is also true. The greater the flow, the faster the temperature “wash out,” and therefore the smaller the area under the curve. Anything that can disrupt the “washout” of this temperature change can affect the accuracy of this measurement.

* iced saline has been said to provides a better "signal-to-noise" ratio but controversy continues in literature regarding iced vs room temperature solution.


Clinical pitfalls:

1. Severe tricuspid regurgitation causes the injectate to recycle back and forth across the valve falsely lowering cardiac output.

2. An injectate volume that is too large will also falsely lower cardiac output.

3. Intracardiac shunts can falsely elevate cardiac output. In a right-to-left shunt, part of the injectate escapes through the shunt and decreases the amount of time required for washout of the temperature change. An injectate volume that is too small will cause an abbreviated washout and therefore falsely elevate the cardiac output.


Also see Pulmonary Artery Catheter Primer from American Thoracic Society (About 100 MCQ questions covering almost all aspects of PAC).


Related previous pearl: Arterial pressure-based continuous cardiac output
posted by ICU room Pearls @ 5:19 PM 0 comments

Thursday, May 25, 2006
open abdomen
Thursday May 25, 2006


Q; What is the antibiotic of choice for prophylaxis in "abdomen left open"?

A; The open abdomen (or abdomen left open after damage control) does not require antibiotic prophylaxis (unless there is an evidence of infection).


Keep as reference, nice bedside management review article:

Role of ICU in the management of the acute abdomen.

Kapadia F. Indian J Surg 2004;66:203-208


Reference:

Management of the patient with an open abdomen: techniques in temporary and definitive closure. Curr Probl Surg. 2004;41:815-876.
posted by ICU room Pearls @ 8:37 PM 0 comments

Wednesday, May 24, 2006
Hydrocortisone and Dexamethasone
Wednesday May 24, 2006
Hydrocortisone and Dexamethasone


What are the 3 major differences between Hydrocortisone and Dexamethasone ?


1. Potency of Hydrocortisone and Dexamethasone is 20:1 (precisely 20 : 0.75) - means .75 mg of dexamethasone is equal to 20 mg of hydrocortisone.

2. Mineralocorticoid : Glucocorticoid activity is 1:1 in hydrocotisone but dexamethasone has negligible mineralocorticoid activity as well it does not effect cortisol level.

3. Half life of Hydrocortisone is 8-12 hrs and of dexametasone is 36-54 hrs.


See nice review Relative Adrenal Insufficiency: Case Examples & Review from Bradley J. Phillips, M.D. , Boston Medical Center, Boston Univ. Schl of Med. (ref: The Internet Journal of Endocrinology. 2005. Volume 1 Number 2)
posted by ICU room Pearls @ 7:43 AM 0 comments

Monday, May 22, 2006
Acute Liver Failure
Tuesday May 23, 2006
Acute Liver Failure

Q; The chances of survival with medical management in acute liver failure is 26%. How much difference liver transplant can make ?

A; It goes upto 90% !!


Please see / keep in file video lecture

Acute Liver Failure: The Critical Team Approach

Dr. Lorenzo Rossaro, Chief of Gastroenterology and Hepatology and Head of the Liver Transplant Program at University of California Davis Medical Center.

(Total time: 42 minutes). Please click on above link.

You will need Real Player to see the lecture

posted by ICU room Pearls @ 10:21 PM 0 comments

PACT
Monday May 22, 2006
PACT - Critical Care distant learning course

The European Society of Intensive Care Medicine (ESICM) has designed a multidisciplinary distance-learning programme PACT, Patient-centred Acute Care Training.

Eventually, the whole programme will have 45 modules divided into 4 major areas -

CLINICAL PROBLEMS,
SKILLS AND TECHNIQUES,
ORGAN SPECIFIC PROBLEM and
PROFESSIONALISM.
The content of each module is based on real life in the ICU. Each module describes a clinical scenario in which the user is asked to interpret the nature of problems and make management decisions. At the end of each module there are self-assessment multiple-choice questions (MCQs). 12 modules are already available

ACUTE RENAL FAILURE
ALTERED CONSCIOUSNESS
ARRHYTHMIA
BASIC CLINICAL EXAMINATION
CLINICAL IMAGING
COPD and ASTHMA
HOMEOSTASTIS
MAJOR INTOXICATION
NUTRITION
PYREXIA
QUALITY ASSURANCE AND COST EFFECTIVENESS
TRAUMATIC BRAIN INJURY
Click here to get more info.

For USA intensivists, it carries CME via SCCM. See the PACT Newsletter


icuroom.net or its editors have no relationship with PACT and introduction provided here is solely for educational purpose.

posted by ICU room Pearls @ 6:49 AM 0 comments

Saturday, May 20, 2006
Intrahospital transport and VAP
Sunday May 21, 2006
Intrahospital transport - a risk factor for VAP ?

Interesting study published about 6 months ago in Critical Care Medicine1 from france where 118 ventilated patients who were transported out of the ICU were matched with 118 ventilated patients who did not undergo intrahospital transport. Adjusting all variables, the ventilator-associated pneumonia (VAP) was 26% in transported patients compared with 10% in the matched untransported patients.

Please read full article to see all inclusion criteria, methods and measurements.

The following interventions were recommended by the group to minimize VAP before transportation:

1. a written protocol focusing on the prevention of aspiration during transport of intubated patients.

2. check material and devices necessary for transport for normal working status,

3. aspirate the endotracheal tube,

4. verify endotracheal tube adequate position,

5. check the endotracheal cuff pressure,

6. fit the ventilatory circuit with a filter,

7. stop enteral nutrition,

8. aspirate gastric contents before and sometimes during transport,

9. if possible, transport the patient in semirecumbent position,

10. if necessary, sedation to obtain a Ramsay score less than 4,

11. verify the availability of the area to which the patient has to be transported.


References: click to get abstract/article

1. Intrahospital transport of critically ill ventilated patients: A risk factor for ventilator-associated pneumonia-A matched cohort study Critical Care Medicine. 33(11):2471-2478, November 2005.
posted by ICU room Pearls @ 11:18 PM 0 comments

Hypoproteinemia and cosyntropin test
Saturday May 20, 2006
Hypoproteinemia and cosyntropin test

43 year old malnourished patient admitted with septic shock. You started early goal directed therapy protocol. Patient blood pressure remained low despite showing signs of clinical improvement. You suspected adrenal insufficiency and ordered cosyntropin test. Patient failed to respond. You started low dose hydrocortisone. Next day you received call from lab that they also performed 'free cortisol' response to cosyntropin and found it appropriate to label patient as responder ?


Severe hypoproteinemia (as in this malnourished patient) may give false results and responders may get wrongly labelled as non-responders. In blood, about 90 percent of cortisol is bound to protiens (20 percent of cortisol is loosely bound to albumin and 70 percent is tightly bound to cortisol-binding globulin). Only 10 percent cortisol is in the free state. This is a major pittfall and deception to fall in while prescribing steroids in septic and hypoproteinemic patient under presumption of 'nonresponder'.

An important study reported about 2 years ago from Cleveland 1, looked into 66 critically ill patients with 36/66 had hypoproteinemia (albumin 2.5 g/dl or less) and 30/66 had near-normal serum albumin concentrations (above 2.5 g/dl). Baseline and cosyntropin stimulated serum total cortisol level as well as baseline and cosyntropin stimulated serum free cortisol level were measured. Study found that, nearly 40 percent of critically ill patients with hypoproteinemia had subnormal serum total cortisol levels, even though their adrenal function was normal as measured by free cortisol level.


Related previous pearl: Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose?



References: click to get abstract/article

1. Measurements of Serum Free Cortisol in Critically Ill Patients - Volume 350:1629-1638, April 15, 2004, NEJM
2. Septic Shock and Sepsis: A Comparison of Total and Free Plasma Cortisol Levels - The Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 1 105-114
3. Adrenal Insufficiency - Roberto Salvatori, MD JAMA. 2005;294:2481-2488
posted by ICU room Pearls @ 7:08 AM 0 comments

Thursday, May 18, 2006
HIDA, DISIDA and BRIDA scan
Friday May 19, 2006
HIDA, DISIDA and BRIDA scan

Hepatic 2,6-dimethyliminodiacetic acid (HIDA) and Diisopropyl iminodiacetic acid (DISIDA) are nuclear studies to assess the function of the gallbladder and obstruction of the Common Bile Duct (CBD) in cholecystitis, cholangitis, billiary leak and atresia. These tests are ordered when ultrasound is equivocal. When you will order HIDA Scan or DISIDA scan ?

Nuclear Medicine literature is vast in this regard but to be short and simple, HIDA scan is used when serum bilirubin is less than 5-7 mg/dl and DISIDA scan is used when serum bilirubin is more than 7 mg/dl. DISIDA scan is now largely used instead of HIDA scan. The basis of this difference is relatively higher hepatic extraction. HIDA scan can be falsely positive when the gallbladder is not filling despite absence of cholecystitis like in severe liver disease (hyperbilirubinemia), patients on TPN or patient NPO for more than 24 hours, alcohol and opiate abuse. In case, serum bilirubin is extremely high (> 30 mg/dl), you can call for Mebrofenin (BRIDA) scan. Mebrofenin has even higher hepatic extraction than DISIDA scan.

Related Previous pearl: Acute acalculous cholecystitis in ICU
posted by ICU room Pearls @ 10:54 PM 0 comments

RSBI Rate
Thursday May 18, 2006
RSBI Rate - Not only RSBI !

The Rapid Shallow Breathing Index (RSBI) remained an integral part of ventilator weaning parameter. Dr. Segal and coll. from Morristown Memorial Hospital, NJ went one step forward and looked into "RSBI Rate" (rate of change in the RSBI) with the question that as respiratory failure is a dynamic phenomenon - should serial followup of RSBI would be a more accurate predictor of weaning outcome, instead of one RSBI at a given time ?. In a prospective cohort study, patients with following criteria has been included:

requiring mechanical ventilation for more than 48hrs,
ET tube size no smaller than 7.5 in the ICU,
cleared by an intensivist (independent of study investigators) as an appropriate candidate to undergo weaning,
on hospital respiratory therapist driven weaning protocol.

Spontaneous Breathing Trial (SBT) for up to two hours given and parameters were measured periodically at SBT. The RSBI Rate was calculated by the formula:

RSBI rate: (RSBI2 - RSBI1)/ RSBI1 × 100

Out of 30 patients, 21 were successfully extubated, 3 were re-intubated within 24 hours and six were intolerants to the SBT. The RSBI on the failure plus Intolerance group was 40.2 (SD 14.7) but RSBI rate on every patient that failed or had intolerance to SBT had a RSBI Rate greater that 20%. It was concluded that the RSBI Rate less that 20% has a sensitivity of 90.4% and specificity of 100% in predicting weaning success.


Reference:

USE OF THE RATE OF CHANGE OF THE RSBI DURING SPONTANEOUS BREATHING TRIAL AS AN ACCURATE PREDICTOR OF WEANING OUTCOME - Critical Care Medicine: Volume 33(12) Abstract Supplement December 2005 p A20
posted by ICU room Pearls @ 12:35 PM 0 comments

Wednesday, May 17, 2006
Calcium in Dig toxicity
Wednesday May 17, 2006
Treating Digoxin toxicity


Case: 74 year old male has been found to have arrhythmia with runs of wide complex ventricular tachycardia. Patient so far remained hemodynamically stable. You request crash cart near bed, applied pads to chest and send STAT labs and start reviewing patient's chart. You noticed 4 days ago digoxin level was 1.9 and since then his serum creatinine is steadily rising from 1.6 to 2.8. You suspected "Dig. toxicity" and called lab to run STAT dig. level. Indeed Dig. level is back with 3.4 and accompanying labs showed K+ level of 6.9. You ordered "Digi-bind" (Digoxin Immune Fab). Pharmacy informed you, "it will take time before Digi-bind gets to ICU". Interim you started treating hyperkalemia with IV insulin, D-50, IV bicarb., IV calcium and albuterol neb. treatments.

Where did you go wrong ?


Answer: Calcium has shown to make digoxin toxicity worse. It may be more wise to avoid calcium in management of hyperkalemia from digoxin toxicity. Some literature has shown the similar membrane stabalizing effect from magnesium and may be used instead of calcium.

Caution should be taken not to go very aggressive in treating hyperkalemia, or atleast potassium should be followed very closely if DigiFab is planned. With administration of DigiFab (Digibind), potassium shifts back into the cell and life threatening hypokalemia may develop rapidly. Digoxin causes a shift of potassium from inside to outside of the cell and may cause severe hyperkalemia but overall there is a whole body deficit of potassium. With administration of Digi-bind, actual hypokalemia may manifest which could be equally life threatening.

Read related interesting review: Recognising signs of danger: ECG changes resulting from an abnormal serum potassium concentration: A Webster, W Brady and F Morris (reference: Emerg Med J 2002; 19:74-77)



References: click to get abstract/article

1. Calcium for hyperkalaemia in digoxin toxicity - Emerg Med J 2002; 19:183
2. Using calcium salts for hyperkalaemia - Nephrol Dial Transplant (2004) 19: 1333-1334
3. Slow-release potassium overdose: Is there a role for magnesium? Emergency Medicine 1999;11:263–71
posted by ICU room Pearls @ 8:17 AM 0 comments

Tuesday, May 16, 2006
K level via A-line
Tuesday May 16, 2006
Potassium level via A-line


Potassium level via arterial line may not be as reliable as through peripheral venous punture. See this interesting case report (click reference) published in British Journal of Anaesthesia, where radial arterial line consistently showed K level of 7.4 - 9.3 mEq/L without any clinical signs. Simultaneous venous sample level was 4.4 mEq/L. When cannula was slightly withdrawn, arterial potassium level came back as 4.1 mEq/L (c/w venous sample).

It was postulated that the tip of the cannula could have impinged against the vessel wall so that during withdrawal of the sample a high shear rate could have caused haemolysis of red blood cells leading to an increased potassium concentration in the blood samples.



References: click to get abstract/article

1. Apparent hyperkalaemia from blood sampled from an arterial cannula - British Journal of Anaesthesia 2004 93(3):456-458
posted by ICU room Pearls @ 7:42 AM 0 comments

Monday, May 15, 2006
Pseudothrombocytopenia
Monday May 15, 2006


Case: 52 year old male is back from cardiac angioplasty with abciximab (ReoPro) infusion. Pre-cath labs were normal. CBC was send per protocol after 4 hours of abciximab infusion and lab call with critical platelet level of 62. Abciximab was stopped and hematology consulted. Hematology advised to restart abciximab !!


Pseudothrombocytopenia:

Pseudothrombocytopenia is a common phenomenon with patients on abciximab (ReoPro). It is a benign condition and is not a real thrombocytopenia as platelets actually clump in collecting tubes containg EDTA. It is an important diagnosis to make as it may leave patient without an appropriate treatment. Diagnosis can be made by reviewing peripheral blood film or drawing blood in citrated or heparinized tube. It is not clear why abciximab cause more EDTA-induced platelet clumping.


* EDTA (Ethylenediaminetetraacetic acid) is a commonly used anticoagulant in sampling tubes for blood counts.



References: click to get abstract/article

1. Occurrence and clinical significance of pseudothrombocytopenia during abciximab therapy J Am Coll Cardiol. 2000 Jul;36(1):75-83.
2. Abciximab-Associated Pseudothrombocytopenia - Circulation. 2000;101:938
3. EDTA dependent pseudothrombocytopenia caused by antibodies against the cytoadhesive receptor of platelet gpIIB-IIIA - Journal of Clinical Pathology 1994;47:625-630
4. Pseudothrombocytopenia Volume 329:1467 Nov. 11, 1993
posted by ICU room Pearls @ 7:20 AM 0 comments

Sunday, May 14, 2006
In Hyperkalemia
Sunday May 14, 2006
In Hyperkalemia !!

Q; Nurse call you with K+ level of 7.8 (lab confirmed - no hemolysis). You ordered 10 units of IV insulin with 2 ampules of D-50, 1 ampule of calcium gluconate and 2 ampules of sodium bicarbonate in series. RT was requested to give 2 nebulizer treatments of albuterol. The final order set is followed ultimately by PO Kayexalate/sorbitol.

What is wrong in above orders for the management of hyperkalemia?

A; In the management of hyperkalemia, sodium bicarbonate should be given before calcium. Administrating bicarbonate after calcium will bind calcium and will render it ineffective. This is another reason, we don't prepare "bicarb drip" in LR (Lactated Ringer’s) as it contains calcium which will bind bicarbonate and will make the whole management ineffective.


Related previous pearls:

Difference between Lactate Ringer's and Normal Saline solutions

Colonic Necrosis - unusual complication of Kayexalate-Sorbitol
posted by ICU room Pearls @ 4:13 PM 0 comments

Friday, May 12, 2006
Hyperbaric oxygen in CO poisoning
Saturday May 13, 2006
Hyperbaric oxygen in CO poisoning

Q; What is the role of hyberbaric oxygen in the management of lethal Carbon-monoxide (CO) poisoning ?

A; It decreases the half life of CO from 5 hours to half hour and so the possible complications. It prevents lipid peroxidation in the brain and preserve ATP levels in tissue exposed to carbon monoxide. It has shown to decrease the cognitive sequelae by 46 % when compared with 'normobaric' group at 6 weeks 2.

Limitations: Hyperbaric oxygen in CO poisoning has its own limitations. It may induce "hyperoxic" seizures (rare) 3. Other adverse effects of hyperbaric oxygen includes reversible myopia, rupture of the middle ear, barotrauma to lungs 4. Hyperbaric oxygen should be reserved for lethal cases of CO poisoning.

Alternate: If hyperbaric oxygen is not available, apply 100% oxygen, high PEEP and if needed high-frequency ventilation. 100% O2 reduces half life of CO effectively to about one and half hour.

Reference: (click to get abstract)
1. Diagnosis and treatment of carbon monoxide poisoning - Respir Care Clin N Am. 1999 Jun;5(2):183-202.
2. Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning - Volume 347:1057-1067, oct. 3, 2002
3. Central nervous system oxygen toxicity during hyperbaric treatment of patients with carbon monoxide poisoning - Hampson NB, Simonson SG, Kramer CC, Piantadosi CA - UNDERSEA & HYPERBARIC MEDICINE 23 (4): 215-219 DEC 1996
4. Hyperbaric-Oxygen Therapy - Volume 334:1642-1648, june 20, 1996
posted by ICU room Pearls @ 10:07 PM 0 comments

vasopressin/norepinephrine ratio
Friday May 12, 2006
vasopressin/norepinephrine ratio in septic shock


Role of vasopressin in septic shock seems promising but we don't have enough data yet to support its regular use. Interesting study in Taiwan was done by Lin and co. and published 6 months ago in Am J Emerg Med. 182 patients (consecutive patients visiting the emergency department), who met the inclusive criteria were divided into 3 groups (per standard guidelines):

septic shock,
severe sepsis, and
sepsis.
30 healthy subjects were included as control.


The plasma vasopressin level at baseline was drawn early in course in emergency department. The plasma vasopressin level was significantly lower for those who finally developed septic shock (3.6 +/- 2.5 pg/mL) than severe sepsis (21.8 +/- 4.1 pg/mL) and sepsis group (10.6 +/- 6.5 pg/mL) - kind of bell curve.


Simultaneouly norepinephrine level was measured in the same groups. Norepinephrine level was highest for septic shock group, (3650 +/- 980 pg/mL) in comparion to severe sepsis (3600 +/- 1000 pg/mL) and sepsis group (1720 +/- 320 pg/mL).


The vasopressin/norepinephrine ratio (very early in the course) was significantly lower for the patients with final diagnosis of septic shock (P less than .001).


This study lead us to logical question: Should we use vasopressin early in septic shock instead later ? but probably it is still early to jump on vasopressin, atleast till we get results from evidence based studies such as pending VASST (Vasopressin Vs. Norepinephrine in Septic Shock) study.


*VASST is an ongoing multi-centre triple-blind randomized controlled trial being conducted in Canada and Australia to determine the effectiveness of Vasopressin compared to Norepinephrine (28-day and 90-day survival).

Previous related pearl: Vasopressin .07 units/min ?



Reference: (click to get abstract)
Low plasma vasopressin/norepinephrine ratio predicts septic shock. Am J Emerg Med. 2005 Oct;23(6):718-24.

posted by ICU room Pearls @ 7:32 AM 0 comments

Thursday, May 11, 2006
Auto-PEEP
Thursday May 11, 2006
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
posted by ICU room Pearls @ 6:20 PM 0 comments

Wednesday, May 10, 2006
TTKG
Wednesday May 10, 2006
The TransTubular Potassium Gradient - TTKG

TTKG is an index reflecting conservation of potassium by Kidney.

TTKG = (Urine-K / Plasma-K) / (Urine-Osm / Plasma-Osm)

Normal value is 8-9 in normokalemic patient and should be 10-11 in hyperkalemic patient.

Clinical significance:
1. In hyperkalemia if TTKG remains less than 7, most probable cause is hypoaldosteronism. Diagnosis can be confirmed by challenging patient with 0.05 mg of fludrocortisone, which should increase the TTKG. (Mineralcorticoid increases TTKG).

2. In hypokalemia - kidney try to conserve potassium and TTKG should fall to less than 2 (like in GI source). If TTKG remains higher, it suggests renal loss of potassium (like in diuretics).

Limitations:
1. Always check urine sodium simultaneouly. TTKG is unreliable if urine sodium is less than 25 mmol/l.
2. TTKG is unreliable if urine osmolality is less than the serum osmolality.

References: click to get abstracts/articles
1.Potassium excretion indices in the diagnostic approach to hypokalaemia - Q J Med 2000; 93: 318-319
2. Transtubular potassium concentration gradient (TTKG) and urine ammonium in differential diagnosis of hypokalemia - J Nephrol. 2000 Mar =Apr;13(2):120-5
3. Diseases of Potassium metabolism: Atlas of disease of the kidney by Robert W. Schrier, Professor and Chairman, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado

posted by ICU room Pearls @ 11:48 AM 0 comments

Monday, May 08, 2006
Contrast induced Nephropathy
Tuesday May 09, 2006
Contrast induced Nephropathy

Q: What is the cut off point to suspect Contrast induced Nephropathy ?

A; Unfortunately there is no consensus defination yet to define Contrast Induced Nephropathy but its better to be safer than sorry. The most conservative general rule is to suspect some component of contrast induced nephropathy whenever there is a 25% increase in serum creatinine concentration from the baseline, or an increase of at least 0.3 mg/dL within 48-72 hours, when no other cause could be find.

We found 2 good review articles for further reading :

1. Contrast-Induced Nephropathy, Tadhg G. Gleeson; Sudi Bulugahapitiya, dublin, Ireland. (ref.: Am J Roentgenol 183(6):1673-1689, 2004). This article is available with free registration at medscape.com

2. Radiocontrast-Induced Nephropathy, Resident Grand Rounds by Jeff S. Rose, MD at Wake Forest University School of Medicine, Winston-Salem, NC

Previous related Pearl: Preventing contrast-Induced Nephropathy
posted by ICU room Pearls @ 10:21 PM 0 comments

Heparin Induced HyperKalemia
Monday May 08, 2006
Heparin Induced HyperKalemia

Hyperkalemia from Heparin is a well know phenomenon and has been detected particularly on geriatric, renal insufficient and diabetic patients. Hyperkalemia can be anywhere from .3 to 1.7 mEq/Litre. It usually occurs around on day 3 with SQ heparin (as for DVT prophylaxis) but can occur early with IV heparin 1,2,3,4. Hyperkalemia has been reported with low- molecular weight heparins too but risk is low 5, 6, 7.

Mechanism of action: Heparin induce hypoaldosteronism and can subsequently lead to hyperkalemia 6.

Treatment: Best thing is to discontinue the culprit but if heparin is absolutely required, fludrocortisone (.1 mg/day) has been reported to be effective in heparin-induced hyperkalemia 8.



References: Click to get abstracts/articles

1. Case report - Heparin-induced hyperkalemia after cardiac surgery - Ann Thorac Surg 2002;74:1698-1700
2. Heparin-induced hyperkalemia -The Annals of Pharmacotherapy: Vol. 24, No. 3, pp. 244-246.
3. Heparin Induced HyperKalemia - Endocrine Abstracts (2002) 4 P26
4. Heparin-Induced Hyperkalemia Confirmed by Drug Rechallenge. American Journal of Physical Medicine & Rehabilitation. 79(1):93-96, January/February 2000.
5. Early onset of hyperkalemia in patients treated with low molecular weight heparin: a prospective study - Pharmacoepidemiol Drug Saf.2004 May;13(5):299-302.
6. Effect of Low-Molecular-Weight Heparin on Potassium Homeostasis - Pathophysiology of Haemostasis and Thrombosis 2002;32:107-110
7. Low Molecular Weight Heparins Can Lead To Hyperkalaemia The Internet Journal of Geriatrics and Gerontology . 2005. Volume 2 Number 2.
8. Fludrocortisone for the treatment of heparin-induced hyperkalemia - The Annals of Pharmacotherapy: Vol. 34, No. 5, pp. 606-610

posted by ICU room Pearls @ 8:27 AM 0 comments

Saturday, May 06, 2006
Our failures !!!
Sunday May 07, 2006
Our failures !!!

Some big gurus from Critical Care Medicine (all names below in reference) have penned a cumulative article on progress of Intensive Care and Emergency Medicine over the past 25 Years in recent issue of chest 1. The whole article is worth reading but the most interesting part is where authors have pointed out "Our Failures" with following mentions:

Excessive antibiotic use
Iatrogenic IV fluid overload
Excessive administration of inotropic agents
Ventilation with unnecessarily large tidal volumes
Excessive, continuous IV sedation
Unnecessary use of antiarrhythmic agents
Excessive caloric intake
Liberal blood transfusions
Traumatic effects of endotracheal intubation and airway management
Excessive ventilation in low flow states
Frequent interruption of chest compressions during CPR


Reference: Click to get abstract

1. Intensive Care and Emergency Medicine - Progress Over the Past 25 Years: Jean-Louis Vincent, MD, PhD; Mitchell P. Fink, MD, FCCP; John J. Marini, MD; Michael R. Pinsky, MD, FCCP; William J. Sibbald, MD, FCCP; Mervyn Singer, MD; Peter M. Suter, MD; Deborah Cook, MD; Paul E. Pepe, MD and Timothy Evans, MD Chest. 2006;129:1061-1067
posted by ICU room Pearls @ 9:46 PM 0 comments

ABCDEF of CXR
Saturday May 06, 2006
ABCDEF of CXR

There are many mnemoics we use in medicine. One mnemonic easy to teach house staff so they don't miss things on chest x-ray is

A (Abnormal) Air and Aqua - (like pneumothorax, pulmonary edema, pleural effusions or even free air below right diaphragm).

B Bone

C Cardia (like pericardial effusion, vena cavae, aortic knob and other cardiac contours)

D Densities (infiltrates, masses and lesions - also include hilar area)

E Elevation of diaphragm (should also take care of atelactasis)

F Foreign bodies (lines, tubes, devices etc).

posted by ICU room Pearls @ 9:11 AM 0 comments

Friday, May 05, 2006
Dialysis disequilibrium syndrome
Friday May 05, 2006

Case: 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.

Answer: Dialysis disequilibrium syndrome.

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. Read interesting article from University of Calgary, Alberta, Canada :

Dialysis Disequilibrium Syndrome: Brain death following hemodialysis for metabolic acidosis and acute renal failure - A case report followed with discussion and different management modalities (Ref.: BMC Nephrol. 2004; 5: 9.)


posted by ICU room Pearls @ 8:09 AM 0 comments

Thursday, May 04, 2006
Swan in Amniotic fluid embolism
Thursday May 04, 2006
Pulmonary Artery Catheter in Amniotic fluid embolism !!

20 years ago it was suggested by Mason that probable diagnosis of Amniotic fluid embolism can be made by analyzing pulmonary artery blood with the logic that amniotic fluid does not ordinarily enter the maternal circulation, and the identification of large numbers of fetal squamous in the postpartum pulmonary microvasculature is of clinical significance. (He applied similar argument for other similar diseases such as fat embolism). Diagnosis becomes more probable if other fetal debris such as mucin or hair is present.

Technique described: Obtain blood from the distal lumen of a pulmonary artery catheter (in wedged position). After discarding the first 10 ml of blood, draw an additional 10 ml, heparinize and analyze utilizing Papanicolaou's method.

Above technique is only suggestive of amniotic fluid embolism and not a gold standard.

References: Click to get abstract/article
1. Pulmonary microvascular cytology. A new diagnostic application of the pulmonary artery catheter - Chest, V. 88, 908-14
2. Amniotic fluid embolism - Masson RG - Clin Chest Med.1992 Dec;13(4):657-65.

posted by ICU room Pearls @ 8:31 AM 0 comments

Wednesday, May 03, 2006
Massive PE
Wednesday May 03, 2006
What if even thrombolysis fails in massive PE ?

For intensivists massive pulmonary Embolism (PE) is a dreaded situation, especially when even thrombolysis fails. Meneveau and coll. from france have studied such group of 40 patients who did not respond to thrombolysis. Results were published recently in chest.

14/40 patients who were treated by rescue surgical embolectomy were compared with 26/40 patients who were treated by repeat thrombolysis.


There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths).
Also, there were significantly more recurrent PEs in the repeat thrombolysis (35% vs 0%).
While no significant difference was observed in number of major bleed, all bleeding events in the repeat-thrombolysis group were fatal.
Study concluded that rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis.

See comprehensive review, Pulmonary Embolism just updated 2 days ago at emedicine.com by Craig Feied M.D.

References: Click to get abstract/article
1. Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism - Chest. 2006;129:1043-1050

posted by ICU room Pearls @ 2:13 PM 0 comments

Tuesday, May 02, 2006
Phosphate level in Tylenol toxicity
Tuesday May 02, 2006
Is serum phosphate level better than King’s College Hospital criteria ?

One study of 125 patients published in 'Hepatology' in 2002 looked into relation of serum phosphate level and survival in Acetaminophen-induced hepatotoxicity 1. Study found that Phosphate concentrations were significantly higher in nonsurvivors than in survivors at 48 to 72 hours after overdose as well as at 72 to 96 hours after overdose.

A threshold phosphate concentration of 3.71 mg/dL (1.2 mmol/L) at 48 to 96 hours after overdose had sensitivity of 89%, specificity of 100%, accuracy of 98%, positive predictive value of 100%, and negative predictive value of 98%. The serum phosphate level had higher sensitivity, accuracy, and positive and negative predictive values than the King’s College Hospital criteria, and it identified patients significantly earlier.

References: Click to get abstract/article
1. Serum Phosphate Is an Early Predictor of Outcome in severe Acetaminophen-Induced Hepatotoxicity Hepatology - 2002;36:659-665 -Full article available with free registration

posted by ICU room Pearls @ 12:36 PM 0 comments

Monday, May 01, 2006
IVF Bolus
Monday May 01, 2006
How to write order for IVF bolus !!

What we have learnt from guru and professor Jean-Louis Vincent is that the most important thing in Critical care Medicine is to master the 'basic and simple things'. Few months back he taught us the art of everyday rounding in ICUs with simple mnemonic of "Fast Hug" 1. In this month issue of Critical Care Medicine he precisely explains the art of fluid challenge. First he busted 5 myths about fluid bolus. Enjoy !!

* Fluid should be withheld because the CVP is high (myth).

* Fluid should be withheld because there is lung edema on the CXR (myth).

* Fluid should be withheld because the patient has already received a large volume in a short time interval (myth).

* Tachycardia is due to fluid deficit and should prompt fluid(myth).

* I gave fluids to increase the central venous pressure to 12 mm Hg to exclude an underlying hypovolemia (myth).

(Read full article to read details on each).


And now 4 parameters need to be written for IVF bolus order:


Type of Fluid.
Rate of Fluid Administration.
Goal to be Achieved.
Safety Limits.

Like NS 500 cc over 30 minutes with clinical goal of MAP of 70 mm Hg. Hold if CVP is 15 with assessment every 10 minutes !!

References:

Click to get abstract
1. Give your patient a fast hug (at least) once a day - Critical Care Medicine. 33(6):1225-1229, June 2005. - Vincent, Jean-Louis MD, PhD, FCCM
2. Fluid challenge revisited. Critical Care Medicine. 34(5):1333-1337, May 2006. Vincent, Jean-Louis MD, PhD, FCCM; Weil, Max Harry MD, PhD, ScD (Hon), FCCM

posted by ICU room Pearls @ 9:32 PM 0 comments

Sunday, April 30, 2006
Post fellowship shock syndrome
Sunday April 30, 2006
Post fellowship shock syndrome

Q; What is Post fellowship shock syndrome ?

A; Post fellowship shock syndrome is a kind of culture shock for young graduates when they transit from big tertiary care academic centers to regular community based medical practice. Transit from high tech, literature oriented, academic based and superior nursing quality to business oriented, "thats how we do things here" practice, no house staff support, no billing experience and wide spectrum of nursing quality - caught unprepared young graduates with mental and culture shock and may leave them frustrated with present situation. Its important to prepare graduating residents and fellows for future practice of medicine.

Read related article The Realities of the First Year of Practice ( NEJM CareerCenter )

(Post fellowship shock syndrome is a term invented by editors of this web-site)
posted by ICU room Pearls @ 8:32 AM 0 comments

Saturday, April 29, 2006
Nasogastric tube syndrome
Saturday April 29, 2006
Nasogastric tube syndrome


Q; 65 year old female admitted to ICU 9 days ago with small bowel obstruction. Pt. is now stable and actually is about to get transferred out of unit. Patient suddenly start complaining of choking sensation with two hands on neck. Monitor shows oxygen desaturation. Patient intubated emergently. No laryngeal or vocal edema seen on laryngoscope but vocal cord paralysis noted.

A; Nasogastric tube syndrome : Nasogastric tube syndrome was described about 25 years ago by Sofferman and coll. It is a life-threatening complication of an indwelling (more than a week) nasogastric tube. The syndrome may present as complete vocal cord abductor paralysis. The syndrome is thought to result from perforation of the NG tube-induced esophageal ulcer and infection of the posterior cricoid region (postcricoid chondritis) with subsequent dysfunction of vocal cord abduction. Unilateral paralysis of cord is also described. Treatment is protection of airway, removal of NG tube and antibiotics. Some advocates antireflux therapy too. Another variant is described with no esophageal ulcer but possibly because of ischemia of the laryngeal abductor muscle secondary to physical compression of the postcricoid blood vessels by NG tube .

References: Please click to get abstract
1. The nasogastric tube syndrome: two case reports and review of the literature. Head Neck. 2001 Jan;23(1):59-63.
2. A variant form of nasogastric tube syndrome. Intern Med. 2005 Dec;44(12):1286-90.
3. Case Report - Nasogastric Tube Syndrome: The Unilateral Variant - Medical Principles and Practice Vol. 12, No. 1, 2003
4. Sofferman, R.A. and Hubbell, R.N., "Laryngeal Complications of Nasogastric Tubes," ANNALS OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, 90:465-468, 1981.
posted by ICU room Pearls @ 7:48 AM 0 comments

Friday, April 28, 2006
Iodide in Thyroid Storm
Friday April 28, 2006
Iodide in Thyroid Storm

Q; How long should you wait to administer iodide after giving antithyroid medication in the management of thyroid storm ?

A; Atleast one hour.


Oral or rectal iodide compounds block release of thyroid hormones after starting antithyroid drug therapy. But if given early in management (before antithyroid medication become effective) it can get utilize in the synthesis of new thyroid hormone. Read nicely written review on Thyroid Storm (and Myxedema coma) by Nikolaos Stathatos, MD, and Leonard Wartofsky, MD from Washington Hospital Center in Washington, D.C. - ref.: emedmag.com, 02/15/2003 issue.
posted by ICU room Pearls @ 9:13 PM 0 comments

Wednesday, April 26, 2006
IV steroid in postextubation stridor
Thursday April 27, 2006
IV steroid to reduces postextubation stridor

Interesting study came out in May' 2006 issue of Critical Care Medicine regarding intravenous injection of methylprednisolone to reduce the incidence of postextubation stridor in intensive care unit patients. 128 patients who were intubated for more than 24 hrs with a cuff leak volume less than 24% of tidal volume but met weaning criteria were studied. 128 patients were divided into 3 groups.

placebo group (n = 43) with four injections of normal saline every 6 hrs,

4 INJ group (n = 42) with four injections of methylprednisolone (40 mg every 6 hours)

1 INJ group (n = 42) with one injection of the methylprednisolone (40 mg) followed by three injections of normal saline.

Extubation done one hour after last injection. Postextubation stridor was confirmed by examination using bronchoscopy or laryngoscopy.

Results shows that:
The incidences of postextubation stridor were lower both in the 1 injection (11.1%) and the 4 injections groups (7.1%) than in the control group (30.2%,). The side effects of steroids over 24 hrs were minimal with no obvious complications such as GI bleed, hyperglycemia, or increased risk of infection.

Please read full study for inclusion exclusion criteria, all outcomes, comparision with non-intervention group of 193 patients and discussion of study by authors.

Related previous pearl: Cuff leak tests

References: click to get abstract
1. Intravenous injection of methylprednisolone reduces the incidence of postextubation stridor in intensive care unit patients - Critical Care Medicine. 34(5):1345-1350, May 2006

posted by ICU room Pearls @ 10:16 PM 0 comments

Tuesday, April 25, 2006
LaSRS
Wednesday April 26, 2006

LATE STERIOD RESCUE STUDY (LaSRS): The Efficacy of Corticosteroids as Rescue Therapy for the Late Phase of Acute Respiratory Distress Syndrome.

Finally the results of ARDSnet's LaSRS trial are published. Out of 180 patients with ARDS of atleast 7 days, 91 were randomly assigned to the placebo group and 89 to the methylprednisolone group. Some outcomes are very unexpected :

1. There was no significant difference in the 60-day hospital mortality rate, with 26 deaths in each group.

2. At 180 days, 29 patients had died in the placebo group and 28 had died in the methylprednisolone group.

3. The methylprednisolone group had significantly more ventilator-free days than the placebo group during the first 28 days as well as at 180 days.

4. As compared with the placebo group, the methylprednisolone group also had significantly fewer days in the ICU during the first 28 days but not at day 180 !!.

5. Ventilatory assistance was resumed: 6 in the placebo group and 20 in the methylprednisolone group. Also 8 of the 20 methylprednisolone-treated patients who resumed receiving assisted ventilation died, as compared with 3 of 6 patients in the placebo group.

6. The mean serum glucose level was not significantly different between groups at baseline but was significantly higher in the methylprednisolone group than the placebo group on days 1, 2, and 4.

7. Forty-three serious infections were diagnosed in 30 patients in the placebo group, as compared with 25 serious infections in 20 patients in the methylprednisolone group.

8. There were 17 episodes of septic shock among 15 patients in the placebo group and 6 episodes among 5 patients in the methylprednisolone group.

9. Prospectively, serious neuromyopathy were reported in nine patients, all of whom were in the methylprednisolone group but interestingly retrospective chart review found no significant difference in the incidence of neuromyopathy: 21 in the placebo group and 27 in the methylprednisolone group. Also, Exposure to neuromuscular-blocking agents was not significantly more common among patients who were identified as having neuromyopathy.

10. Patients who were enrolled at least 14 days after the onset of ARDS and who were randomly assigned to receive methylprednisolone had a significantly higher case fatality rate than similar patients who were assigned to receive placebo.

Study conclusion: These results do not support the routine use of methylprednisolone for persistent ARDS despite the improvement in cardiopulmonary physiology. In addition, starting steroid therapy more than two weeks after the onset of ARDS may increase the risk of death.

Editor note: Please read whole article to be aware of limitations of study.

References:
1. Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress Syndrome - Volume 354:1671-1684, Number 16, April 20,2006
2. Protocol of study: ARDSnet.org
3. Late Steroid Rescue Study (LaSRS): The Efficacy of Corticosteroids as Rescue Therapy for the Late Phase of Acute Respiratory Distress Syndrome - clinicaltrials.gov


posted by ICU room Pearls @ 10:13 PM 0 comments

Esophageal Pressure Measurements and compliance
Tuesday April 25, 2006
Esophageal Pressure Measurements and compliance

At bedside compliance is measured as

Cs = Vt / Ppl - (PEEP + autoPEEP)

Where Cs = compliance of static thorax, Vt = tidal volume, Ppl = plateau pressure and PEEP is postive-end-expiratory pressure

or in more precise terms

C stat = Vt / (Pao end'inhalation - Pao end'exhalation)

Where Pao = pressure at the airway opening. Pao end'inhalation is same as Ppl. and Pao end'exhalation is same as TotalPEEP.

This compliance measures the whole thorax including chest wall and lungs. Normal Cs is ideally 100 ml/cm H2O or practically 50 to 80 ml/cm H2O is acceptable.

Placement of esophageal catheter can give lung compliance (CL) and chest wall compliance (Ccw) separately. Formulae are

CL = Vt / (Pao - Pes) end'inhalation - (Pao - Pes) end'exhalation
and
Ccw = Vt / (Pes - Patm) end'inhalation - (Pes - Patm) end'exhalation
or practically done simply as Ccw = Vt / Pes end'inhalation

Where Pes = Esophageal pressure and P atm = Atmospheric pressure

Normal CL and Ccw is 200 ml/cm H2O.


Read article Esophageal and Gastric Pressure Measurements , including all the basics of how to insert and measure the esophageal catheter pressures by Dr. Joshua O Benditt (ref: Resp. Care, Jan. 2005, vol 50, no. 1)

posted by ICU room Pearls @ 4:12 AM 0 comments

Sunday, April 23, 2006
CURB-65 Score
Monday April 24, 2006
CURB-65 Score

Lim and colleagues have designed a score called CURB-65 to rate mortality in community acquired pneumonia (CAP) - based on information available at initial hospital assessment. Give one point each for following values

C = Confusion
U = Urea (BUN) if more than 20 mg/dl (7 mmol/l)
R = Respiratory rate if more than / = 30/min,
B = BP if syst. less than 90 mm Hg or diast. less than/= 60 mm Hg,
65 = If age more than / = 65 years

With score 0 expected mortality is 0.7%,
With score 1 expected mortality is 3.2%,
With score 2 expected mortality is 13%,
With score 3 expected mortality is 17%,
With score 4 expected mortality is 41.5% and
With score 5 expected mortality is 57%

References:
1.Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study - W S Lim, M M van der Eerden, R Laing, W G Boersma, N Karalus, G I Town, S A Lewis and J T Macfarlane - Thorax 2003;58:377-382


posted by ICU room Pearls @ 10:52 PM 0 comments

Hemodynamic variables in septic shock
Sunday April 23, 2006
Hemodynamic variables to watch in septic shock

Dr Varpula and coll. from Helsinki, Finland tried to identify the most related hemodynamic variables in 111 septic shock patients. Data from 6 hours and 48 hours were analyzed separately. Primary endpoint was 30-day mortality. Following results were found:

1. Univariate analysis showed that lactate level on arrival and MAP-derived variables (average of all MAP values, hypotension time) during the first 6 hours correlated with the 30-day mortality.

2. The best cutoff values for hypotension and hypoperfusion times were found to be MAP of 65 mmHg and SvO2 of 70%, respectively.

In conclusion, data suggest that time spent with low BP and with inadequate CO (decrease SvO2) are the most important hemodynamic variables related to outcome. This study find threshold values in synchrony with values published in recent guidelines.

Related Sites: survivingsepsis.org

Related Previous pearls: Shock alert , ScvO2 or SvO2 ? and EGDT and PAC need


References:
1.Hemodynamic variables related to outcome in septic shock - Intensive Care Medicine, Volume 31, Number 8 , August 2005, Pages: 1066 - 1071
posted by ICU room Pearls @ 1:30 PM 0 comments

Saturday, April 22, 2006
Law of LaPlace
Saturday April 22, 2006
Law of LaPlace, PEEP and surfactant


Law of LaPlace tells us that "Pressure is always greater in smaller radius".

P = 2T/r

where P = pressure, T = tension and r = radius

So in lungs, smaller alveoli will have greater resistance for air to flow during inspiration because of higher pressure. We use PEEP to keep alveoli open during expiration (prevent derecruitment), as name says positive end-expiratory pressure. High tidal volume cause more shear force damage to smaller alveoli with each breath to overcome this pressure. Thats why, our present approach to ventilator management in ARDS is low tidal volume and optimum PEEP (See ARDSnet
Lower Tidal Volume/ Higher PEEP Reference Card).

Looking at same formula, other approach is to decrease Tension, by nature's method of applying surfactant. One study published in August 2004 looked into 'Effect of Recombinant Surfactant Protein C–Based Surfactant on the Acute Respiratory Distress Syndrome' and found no significant difference in terms of 28 days mortality or the need for mechanical ventilation but also showed that 'Patients receiving surfactant had a significant greater improvement in blood oxygenation during the first 24 hours of treatment than patients receiving standard therapy'. Actually literature suggests that "..Sufficient levels of PEEP will also help to prevent further loss of surfactant in still ‘healthy’ alveoli,"
Read Professor Lachmann's lecture -
Current status of lung protective ventilation in ARDS, discussing Law of LaPlace, surfactant and PEEP. (source: eacta.org - European Association of Cardiothoracic Anaesthesiologists)

References:
1.Effect of Recombinant Surfactant Protein C–Based Surfactant on the Acute Respiratory Distress Syndrome - Volume 351:884-892, Number 9, NEJM Aug. 26, 2004
2. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome - The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network ,Volume 351:327-336, Number 4, NEJM, july 22, 2004
posted by ICU room Pearls @ 10:18 AM 0 comments

Friday, April 21, 2006
ketek
Friday April 21, 2006

Case: 74 year old male resident of assisted living facility, admitted to ICU with exacerbation of his myasthenia gravis. He also reports newly devloped symptoms of blurred vision, difficulty focusing, and diplopia which according to him is not typical of his symptoms but you assume it as part of exacerbation of myasthenia gravis. Patient denies stopping his medicine. 3 days ago he was seen by his primary care physician for cough and was given samples of a new strong antibiotic. His neurologist has been consulted who requests you to change his antibiotic. Patient symptoms resolved within 24 hours.

Answer: Ketek (Talithromycin) is a first ketolide (cousin of macrolide), indicated for mild to moderate acute exacerbation of chronic bronchitis, acute bacterial sinusitis and in mild to moderate CAP, atypical and multi-drug resistant strains of S pneumoniae. Talithromycin unlike the macrolides has 2 strong binding sites on the bacterial ribosome and this strong dual binding helps provide coverage against resistant strains of S pneumoniae. Exacerbations of myasthenia gravis have been reported in patients with myasthenia gravis treated with Talithromycin. It cause visual disturbances like blurred vision, difficulty focusing, and diplopia by slowing the ability to accommodate and the ability to release accommodation. Other major side effects include hepatic dysfunction and potential to prolong the QTc interval.


References:
1. FDA Public Health Advisory Ketek (telithromycin) Tablets - fda.gov
2. FDA consumer info. - fda.gov
3. www.ketek.com
posted by ICU room Pearls @ 11:21 AM 0 comments

Wednesday, April 19, 2006
Ambien
Thursday April 20, 2006
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:
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
posted by ICU room Pearls @ 10:43 AM 0 comments

US guided radial artery
Wednesday April 19, 2006
Ultrasound guided insertion of radial artery catheters

Role of ultrasound guidance in central venous catheter (particularly internal jugular vessel) is well known 1 but literature on its efficacy in arterial line insertion is very scant. Levin and coll. from Hadassah University Hospital, Jerusalem, Israel has done a simple but interesting study on the use of ultrasound guidance in the insertion of radial artery catheters 2. A total of 69 patients were randomized - 34 to the ultrasound group and 35 to the palpation group. The following results were found:

* The arterial cannula was inserted on the first attempt in 21 of the 34 patients (62%) in the ultrasound group vs. 12 of the 35 patients (34%) in the palpation group.

* Overall, there were 55 total attempts (1.6 per patient) at arterial catheter insertion in the ultrasound group vs. 110 (3.1 per patient) in the palpation group.

* The mean overall time taken per patient for catheter insertion was 55.5 secs in the ultrasound group vs. 111.5 secs in the palpation group.

* In the ultrasound group, a total of 39 cannulae were used vs. 60 in the palpation group (cost effectiveness).


References:
1 Bedside Ultrasonography in the ICU Part 2 - Chest. 2005;128:1766-1781
2. Use of ultrasound guidance in the insertion of radial artery catheters - Critical Care Medicine: Volume 31(2) February 2003 pp 481-484
posted by ICU room Pearls @ 7:25 AM 0 comments

Tuesday, April 18, 2006
Wernicke's Encephalopathy
Tuesday April 18, 2006
Wernicke's Encephalopathy in ICU


Q: Can Wernicke's Encephalopathy be iatrogenic in ICU ?

A: 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

acute mental confusion
ataxia
opthalmoplegia

Read a case of Wernicke's encephalopathy. in a non-alcoholic patient with MRI findings here (Ref.: The New England Journal of Medicine, Kaineg and Hudgins 352 (19): e18, May 12, 2005)

Also full review article Wernicke's encephalopathy from Philip Salen, MD at emedicine.com

posted by ICU room Pearls @ 4:14 PM 0 comments

Sunday, April 16, 2006
Rule of 20s
Monday April 17, 2006
Progressive rule of 20s



Q: What is "progressive rule of 20s" during Pulmonary Artery Catheter insertion ?

A: During Pulmonary Artery catheter insertion from Right Internal Jugular approach:

Right atrium (or SVC) should be entered within 20 cm from skin
Right ventricle should be entered within 40 cm from skin
Pulmonary artery should be entered within 60 cm from skin

Related Previous Pearl: Procedure Tip - Does that waveform look ‘wedged’?


posted by ICU room Pearls @ 11:21 PM 0 comments

Saturday, April 15, 2006
Tacrolimus
Sunday April 16, 2006

Case: 34 year old male with recent kidney transplant admitted to your unit with mental status change and family reports witnessed seizure. While evaluating patient, nurse hand over critical lab to you with magnesium of 0.2 mg/dl, your first response is to ask potassium level but it is actually on hyperkalemic side with 5.5 meq/l. As you call his renal transplant physician and reports severe hypomagnesemia and seizure but normal BUN/Cr level, his first question is to read patient's medication list. Why ?

Tacrolimus (FK-506 or Prograf) is a macrolide, an immunosuppressive drug, use in organ transplant to reduce the risk of organ rejection. It causes hyperkalemia due to renal tubular acidosis, Type 4 (RTA-IV) but simultaneously cause hypomagnesemia, unusual to find both together. Other side effects of tacrolimus includes seizures, tremors, hypertension, confusion, calciuria, hyperglycemia, weakness, depression, cramps, and neuropathy. Apart fron side effect of severe hypomagnesemia, seizure and other neural are direct effects of tacrolimus too.

References:
1. Downregulation of Ca2+ and Mg2+ Transport Proteins in the Kidney Explains Tacrolimus (FK506)-Induced Hypercalciuria and Hypomagnesemia - J Am Soc Nephrol 15:549-557, 2004
2. FK 506-induced neurotoxicity in liver transplantation. - Wijdicks EF, Wiesner RH, Dahlke LJ, Krom RA. - Ann Neurol 1994;35:498–501.
3. Prograf Warning Letter - fda.gov
4. Tacrolimus leukoencephalopathy: A neuropathologic confirmation Lavigne et al. Neurology.2004; 63: 1132-1133
5. Progressive neurological disease induced by tacrolimus in a renal transplant recipient: Case presentation - BMC Nephrology 2006, 7:7
posted by ICU room Pearls @ 9:55 PM 0 comments

Nasal cannula after extubation
Saturday April 15, 2006
Nasal cannula vs Face mask after extubation

Technically, there is no advantage of applying face mask after extubation. Nasal cannula is actually better as it is not only cost effective, it provides greater comfort for patients. Face mask is required only when patient is extubated from high FiO2 or if there is a suspicion of oxygen flow interruption via nasal route.

Related:
HOW TO ESTABLISH A VENTILATOR WEANING PROTOCOL , Gregory P. Marelich, MD - thoracic.org


References:
1. Critical Care Medicine: The Essentials - Third Edition by John J. Marini. Arthur P. Wheeler - Page 318
2. Use of nasal cannula versus face mask after extubation in patients after cardiothoracic surgery - Critical Care Nurse, Vol 21, Issue 3, 47-53

posted by ICU room Pearls @ 9:52 AM 0 comments

Friday, April 14, 2006
Allen test
Friday April 14, 2006
A-line is here but where is Allen test !!

Its true that the usefulness of Allen test has never been tested in a big trial but it remained the recommended part before obtaining (radial) arterial blood gas or inserting (radial) arterial line as the whole concept makes common sense. But unfortunately, many times this is the most ignored part of whole procedure. Allen test was developed by legendary cardiologist from mayo clinic, Edgar Van Nuys Allen (1900 - 1961). He is well-known for his work on the administration of anti-coagulant, dicumerol to humans.

With the hand elevated and patient making fist (about 15 seconds), firm pressure applied against radial and ulnar arteries, which leads to blanching of the hand. Then, one of the arteries is released and, in the normal case the blanching disappears over the whole of the hand within 5 to 7 seconds. Test should be repeated with both arteries.

The New England Journal of Medicine has posted the free video on Placement of an Arterial Line (also demonstrating Allen test). Click here to see the link. (Volume 354:e13 - April 13, 2006)


reference:
1. Edgar Van Nuys Allen - whonamedit.com
posted by ICU room Pearls @ 9:34 AM 0 comments

Thursday, April 13, 2006
Fan Score
Thursday April 13, 2006
Fan Score (Hong-Kong criteria or 20/200 Score)

Why we don't hear about the most easiest way to assess the severity of acute pancreatitis, with only 2 parameters:

1. Azotemia - BUN more than 20 mg/dL (7.4 mmol/L)
and/or
2. Glycemia - more than 200 mg/dL ( 11 mmol/L)

Reason this criteria failed to gain ground, is conflicting reports in literature. Originally, Fan and colleague reported the sensitivity of 76% and specificity of 75% but later 2 studies failed to confirm the high sensitivity (only 33% 4 and 52% 3 respectively). Study in reference # 3 also found that best prediction to severity of acute pancreatitis was provided by the APACHE II score 24 hours post admission with sensitivity of 79% and specificity of 82% . Famous Ranson criteria in same study showed sensitivity of 79% but specificity was only 56%


Related article: New Serum Markers for the Detection of Severe Acute Pancreatitis in Humans - Am. J. Respir. Crit. Care Med., Volume 164, Number 1, July 2001, 162-170



References: (click to get abstrat/article)

1. Assessment of severity of acute pancreatitis: a comparison between old and most recent modalities used to evaluate this perennial problem - World J Gastroenterol 1999; August 5(4):283-285
2. Fan ST, Choi TK, Lai ECS, Wong J. Prediction of severity of acute pancreatitis: an alternative approach. - Gut,1989;30:1591-1595
3. Failure of the Hong Kong criteria to predict the severity of acute pancreatitis - Int J Pancreatol. 1997 Dec;22(3):201-6.
4. The Hong Kong criteria and severity prediction in acute pancreatitis - Int J Pancreatol. 1994 Jun;15(3):179-85.
posted by ICU room Pearls @ 6:52 AM 0 comments

Wednesday, April 12, 2006
Simplified Glasgow score
Wednesday April 12, 2006
Simplified Glasgow score for the assessment of severe acute pancreatitis

There have been many scores/criterias proposed for the assessment of severe acute pancreatitis including but not limited to Ranson criteria, Glasgow score, Fan score (Hong-Kong criteria), CT-scan score. Although ranson criteria remained popular, glasgow score has been said to be more precise, which is as follows:


Finding at any time during initial 48 hours - give 1 point for each parameter.

age more than 55 years
serum albumin more than 3.2 g/dL
arterial pO2 on room air more than 60 mm Hg
serum calcium more than 8 mg/dL
blood glucose more than 180 mg/dL
serum LDH more than 600 U/L
serum urea nitrogen more than 45 mg/dL
WBC count more than 15,000/mm3


Total score more than / = 3 severe pancreatitis likely.
Total score less than / = 3 severe pancreatitis is unlikely.


Related Previous Pearl:
Evidence-based recommendations for Severe Acute Pancreatitis)


References: (click to get abstrat/article)

1. Assessment of severity of acute pancreatitis: a comparison between old and most recent modalities used to evaluate this perennial problem - World J Gastroenterol 1999; August 5(4):283-285
2. Predictive evaluation of acute necrotizing pancreatitis: results of a prospective study - Presse Med. 1995 Feb 4;24(5):263-6.
3. A simplified method for computed tomographic estimation of prognosis in acute pancreatitis - Scand J Gastroenterol. 2003 Apr;38(4):433-6.
4. Management of the critically ill patient with severe acute pancreatitis - Critical Care Medicine: Volume 32(12) December 2004 pp 2524-2536 . Sponsored by the American Thoracic (ATS), the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Française (SRLF).
posted by ICU room Pearls @ 8:48 AM 0 comments

Tuesday, April 11, 2006
Fondaparinux in Acute Coronary Syndromes
Tuesday April 11, 2006
Is Fondaparinux (arixtra) superior in Acute Coronary Syndromes ?

2 major studies published this week in The New England Journal of Medicine and JAMA regarding anticaogulation with Fondaparinux (arixtra) in Acute Coronary Syndromes.

NEJM: 20,078 patients with acute coronary syndromes were randomized either to receive fondaparinux (2.5 mg daily) or enoxaparin (1 mg per kilogram of body weight twice daily) for a mean of six days. The primary outcome were death, myocardial infarction, or refractory ischemia at nine days.The number of patients with primary-outcome events was similar in the two groups (579 with fondaparinux [5.8 percent] vs. 573 with enoxaparin [5.7 percent]; But the rate of major bleeding at nine days was markedly lower with fondaparinux than with enoxaparin (217 events [2.2 percent] vs. 412 events [4.1 percent].Study concluded that Fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but it substantially reduces major bleeding and improves long term mortality and morbidity 1,2,3.

JAMA: Randomized double-blind comparison of fondaparinux 2.5 mg once daily or control for up to 8 days in 12092 patients with STEMI from 41 countries. Patients were divided into 2 strata. 1. fondaparinux initiated early and given for up to 8 days vs usual care (placebo in those in whom unfractionated heparin is not indicated). 2. unfractionated heparin for up to 48 hours followed by placebo for up to 8 days. Death or reinfarction at 30 days was significantly reduced from 677 (11.2%) of 6056 patients in the control group to 585 (9.7%) of 6036 patients in the fondaparinux group. There was a tendency to fewer severe bleeds (79 for placebo vs 61 for fondaparinux), with significantly fewer cardiac tamponade (48 vs 28) with fondaparinux at 9 days. However, there was no benefit in those undergoing primary percutaneous coronary intervention. 4, 5.

Here one caution is important that fatal bleeding with Fondaparinux can be treated only with supportive treatment. Also half life of Fondaparinux is 17-21 hours. See related previous pearl LMWH and Antidot (protamine). 6

References: (click to get abstrat/article)

1. Comparison of Fondaparinux and Enoxaparin in Acute Coronary Syndromes - Volume 354:1464-1476, NEJM, April 6, 2006
2. Oasis 5 - clinicaltrials.gov
3. Therapy for Patients with Acute Coronary Syndromes - New Opportunities, Volume 354:1524-1527, NEJM April 6, 2006
4. Effects of Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation Myocardial Infarction - JAMA. 2006;295:1519-1530. Vol. 295 No. 13, April 5, 2006
5. MICHELANGELO OASIS-6 : FOndaparinux in ST Elevation Myocardial Infarction
6. Treatment of postoperative bleeding after fondaparinux with rFVIIa and tranexamic acid. Neth J Med 2005 May;63(5):1846
posted by ICU room Pearls @ 3:25 PM 0 comments

Sunday, April 09, 2006
Prolonged Mechanical Ventilation
Monday April 10, 2006
Prolonged Mechanical Ventilation - Consensus statement of National Association for Medical Direction of Respiratory Care (NAMDRC)


In May 2004, NAMDRC (chair - Neil R. MacIntyre, MD), a physician advocacy organization for excellence in the delivery of respiratory and critical care, made 12 recommendations for patients with Prolonged Mechanical Ventilation (PMV). We are putting only few salient features here. Full article can be obtained from reference.

1. PMV should be defined as the need for more than / = 21 consecutive days of mechanical ventilation for more than / = 6 h/day.

2. In patients with slowly resolving respiratory insufficiency, complete liberation from mechanical ventilation (or a requirement for only nocturnal NIV) for 7 consecutive days should constitute successful weaning.

3. Greatest emphasis should be placed on identifying factors that are potentially reversible, especially iatrogenic factors.

4. All facilities that are available to patients should be screened by the critical care team for effectiveness and safety when effecting discharge for post-ICU weaning.

5. Begin considerations for PMV-focused care when tracheostomy is first considered.

6. PMV weaning strategies should thus incorporate nonphysician-implemented weaning protocols that utilize daily SBTs of progressively increasing duration after a certain level of ventilatory support reduction has occurred.



Reference:
Management of Patients Requiring Prolonged Mechanical Ventilation - Report of a NAMDRC Consensus Conference - Chest. 2005;128:3937-3954.
posted by ICU room Pearls @ 9:30 PM 0 comments

Saturday, April 08, 2006
IV vasotec
Sunday April 9, 2006
Why sometime IV vasotec (enalapril) does not work?


If you are using IV Vasotec to treat hypertension, remember peak effect after the first dose may not occur for up to four hours. But the peak effect of the second and subsequent doses may exceed those of the first. Although in practical world, dose upto 5 mg IV has been prescribed but no dosage regimen has been clearly demonstrated to be more effective in treating hypertension than IV Vasotec 1.25 mg every six hours. Patients with conditions of heart failure, hyponatremia, diuretic therapy, renal dialysis, and volume depletion may drop their blood pressure precipitously and recommended starting dose should be no greater than 0.625 mg.

IV Vasotec should be administrated slowly over 5 minutes.


Reference: Vasotec IV - fda.gov
posted by ICU room Pearls @ 10:05 PM 0 comments

Friday, April 07, 2006
EGDT and need for PAC
Saturday April 8, 2006
Early Goal-Directed Therapy and Pulmonary Artery Catheter need

Various institutions are running protocols and study in reference to Early Goal-Directed Therapy and we are learning new aspects related to this approach. Recent study from Cooper University Hospital, Camden, NJ (done by Trzeciak, Dellinger, Parillo and Colleauges), found 2 lessons:

1. Emergency medicine and Critical Care collaboration can be run effectively and all end points of EGDT were successfully achieved for 20 of 22 EGDT cases. End points were CVP, MAP and ScvO2.It proved that EGDT can reliably be achieved in "real-world clinical practice". The following median times were observed:

central line insertion, 1.5 hours;
CVP goal, 6.0 hours;
MAP goal, 4.0 hours;
ScvO2 measured, 2.0 hours; and
ScvO2 goal, 5.0 hours

2. Another interesting outcome of study was Pulmonary Artery Catheter utilization in the ICU was significantly lower with EGDT (9.1%) vs pre-EGDT (43.8%) [p = 0.01].


Related Previous Pearl:

Shock alert - Shock bed



Reference:
A 1-Year Experience With Implementing Early Goal-Directed Therapy for Septic Shock in the Emergency Department - Translating Research to Clinical Practice - Chest. 2006;129:225-232

posted by ICU room Pearls @ 10:18 PM 0 comments

Thursday, April 06, 2006
Permissive Hypercapnia
Friday April 7, 2006
The Bohr Effect and Permissive Hypercapnia

One of the physiologic basis of permissive hypercapnia is to increase unload of oxygen to tissues under decrease PH, call Bohr Effect. The Bohr Effect is an adaptation to release oxygen to the starved tissues in conditions where respiratory carbon dioxide lowers blood pH. When blood pH decreases, the ability of hemoglobin to bind to oxygen decreases, classically said "shifting of oxygen dissociation curve to the right", although the SaO2 may be relatively low. This leads many experts to ask the question - is permissive hypoxemia really bad? 2

In depth, there are many other implications of permissive hypercapnia including suppressive effects on inflammatory mechanisms that may contribute to lung protection with therapeutic hypercapnia. Read informative article implications for permissive and therapeutic hypercapnia (D.A. Kregenow and E.R. Swenson, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA - Reference: Eur Respir J 2002; 20:6-11)



Reference:
1. Respiratory Function of Hemoglobin - Volume 338:239-248, January 22, 1998
2. Permissive Hypoxemia: Is It Time To Change Our Approach? Abdelsalam Chest.2006; 129: 210-211
posted by ICU room Pearls @ 10:02 PM 0 comments

ScvO2 and SvO2
Thursday April 6, 2006
central venous O2 saturation (ScvO2) or mixed venous O2 saturation (SvO2) ?


Is ScvO2 interchangeable with SvO2 ? The answer is no but the debate is - can they be use independently in the mangement of sepsis ? SvO2 value is usually 5% lower than ScvO2 due to mixing of atrial and coronary sinus blood (and other factors 3). Some experts warn that substituting ScvO2 for Svo2 may produce large errors 1. Dr. Rivers of EGDT- Early Goal Directed Therapy (in which ScvO2 has been used as a mainstay of algorithm) discussed this debate in recent issue of "chest" (march, 2006) 2. And at this point the practice pattern is consist of as he wrote:

"irrespective of whether the ScvO2 value equals the SvO2 value, the presence of a low ScvO2 level in patients with early sepsis portends increased morbidity and mortality"

Present practice target is value of 65% for SvO2 level and 70% for Scvo2 in the resuscitation of patients with severe sepsis. ScvO2 is quick and easy to obtain in comparison to SvO2.



Reference:
1. Lack of Equivalence Between Central and Mixed Venous Oxygen Saturation Chest. 2004;126:1891-1896
2. Mixed vs Central Venous Oxygen Saturation May Be Not Numerically Equal, But Both Are Still Clinically Useful Chest, March 1, 2006; 129(3): 507 - 508
3. Central or Mixed Venous Oxygen Saturation? Kopterides et al. Chest.2005; 128: 1073-1075
posted by ICU room Pearls @ 7:44 AM 0 comments

Wednesday, April 05, 2006
How much extra phenytoin
Wednesday April 5, 2006
How much extra phenytoin

The formula to decide, how much extra phenytoin should be prescribed to get level therapeutic is

Extra phenytoin needed = [0.7 x IBW x (15 - current level) ] / 0.92

Where IBW = Ideal body weight (note - this is 'ideal' body weight)


e.g: If patient with ideal body weight of 62 kg has dilantin level of 7.4, the extra required dose would be [0.7 x 62 x (15 - 7.4)] / .92 = 330 mg or to be practical about 300 mg.


Remember this formula is for patient with normal albumin and conserve renal function. Please see pearl from yesterday for phenytoin adjustment with low albumin and low CrCl here


Reference:
Phenytoin dosing guidelines by D.McAuley, GlobalRPh Inc.
posted by ICU room Pearls @ 12:50 PM 0 comments

Tuesday, April 04, 2006
Phenytoin level
Tuesday April 4, 2006
Phenytoin (Dilantin) level

The ideal phenytoin level is to have unbound (free) phenytoin level but if free phenytoin level is not available or turn around time is long, it should be adjusted with albumin level with following formula, called Sheiner-Tozer equation. Its not 100% accurate but give good estimate.

Corrected Dilantin = measured level / [ (0.2 x albumin) + 0.1]


e.g: if measured Dilantin level is 8.2 but albumin is 2.2, the corrected Dilantin level would be 8.2 / { (.2 x 2.2) + .1} = 15.2


In renal patients, If patient CrCl is less than 20, use following formula.

Corrected Dilantin = measured level / [ (0.1 x albumin) + 0.1]

e.g: if measured Dilantin level is 8.2 but albumin is 2.2, the corrected Dilantin level would be 8.2 / { (.1 x 2.2) + .1} = 25.6

See the difference ?. Just don't carried away with low level.


Also be cautious, phenytoin's dose increase is not linearly related to serum levels. Small increase in dose may produce disproportionate and actually toxic serum level.
posted by ICU room Pearls @ 10:18 AM 0 comments

Monday, April 03, 2006
Nesidioblastosis
Monday April 3, 2006
Nesidioblastosis - post gastric bypass complication

Case: 40 years old non-diabetic female, reliable historian, admitted to ICU with life threatening and persistent hypoglycemia. Patient is not on any medication and past medical and surgical history is significant only with gastric bypass surgery 2 years ago. Surgical service decide to take patient to OR.


As gastric bypass procedures are growing in number, Nesidioblastosis (hyperinsulinemic hypoglycemia) is now a documented complication of gastric bypass surgery particularly Roux-en-Y gastric bypass surgery. Patients may present with repeated episodes of profound hypoglycemia which are actually postprandial neuroglycopenia associated with endogenous hyperinsulinemic hypoglycemia. Diagnosis is confirmed by selective arterial calcium-stimulation testing and treatment is partial pancreatectomy. Peri and post-operatively diffuse beta-cell hypertrophy and hyperplasia has been demonstrated (and resected). The exact mechanism is not clear though various explanations has been suggested.


Read very nice review here from Edward E. Mason MD, Ph.D.(University of Iowa health care).


References: (click to get abstract)

1. Gastric Bypass and Nesidioblastosis — Too Much of a Good Thing for Islets? - NEJM , Volume 353:300-302 - July 21, 2005

2. Nesidioblastosis - emedicine.com
posted by ICU room Pearls @ 12:52 AM 0 comments

Saturday, April 01, 2006
Restless Legs syndrome
Sunday April 2, 2006
Restless Legs syndrome

Every now and then, intensivists receive calls regarding issues which are usually not expected from critical care unit. One such instance is Restless legs syndrome. Various pharmacological agents have been described and used with success including benzodiazepines, carbamazepine and clonidine.

In ICU situation, one useful drug in this regard is Ropinirole which is a Dopamine agonist. One of the effect of Ropinirole is heavy sleepiness, which can be use as benefit in ICU. Dose can be initiated from .25 mg PO QHS upto 4 mg PO QHS.



References: (click to get abstract)

1. Restless Legs Syndrome: Detection and Management in Primary Care - NATIONAL HEART, LUNG, AND BLOOD INSTITUTE WORKING GROUP ON RESTLESS LEGS SYNDROME - Vol. 62/No. 1 (July 1, 2000) - American Family Physician.

2. Ropinirole is effective in the treatment of restless legs syndrome. TREAT RLS 2: a 12-week, double-blind, randomized, parallel-group, placebo-controlled study - Mov Disord. 2004 Dec;19(12):1414-23.
posted by ICU room Pearls @ 11:11 PM 0 comments

Pericardial Effusion on CXR reading
April 1, 2006
Bedside trick ! - To suspect Pericardial Effusion on CXR reading

Pericardial effusion may be difficult to rule out on CXR.

Most patients in ICU have a heart rate of more than 100 bpm. X-ray exposure is usually long enough to allow the heart border to move significantly. If the heart borders are sharply demarcated, consider a pericardial effusion. In other words, in normal CXR you may see little haziness at borders due to movement of heart borders inside pericardium which get lost with pericardial effusion.

Another sign is presence of a thick pericardial fat stripe seen on the lateral view. Please see CXR in this regard here from teaching files of University of Ottawa.
posted by ICU room Pearls @ 11:41 AM 0 comments

Thursday, March 30, 2006
.
March 31, 2006
Garlic Odor in ICU

Q: Patient with which poisoning presents with garlic odor?

A: Organophosphate poisoning.





Thursday March 30, 2006
Dilantin in Torsade


Q: Which anti-seizure drug can be use in the treatment of Torsade de pointes if conventional therapy fails?

A: Phenytoin (Dilantin).


References:
1. Torsades de pointes therapy with phenytoin - Ann Emerg Med.1991 Feb;20(2):198-200.
2. Few case reports from literature: remarkablemedicine.com
posted by ICU room Pearls @ 8:47 AM 1 comments

Wednesday, March 29, 2006
Digoxin Toxicity
Wednesday March 29, 2006
Digoxin Toxicity

Q: Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?

A: Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it may be misleading.


See full review on DIGIFAB along with dose calculator here (source: fda.gov)
posted by ICU room Pearls @ 8:37 AM 0 comments

Tuesday, March 28, 2006
Cuff leak test
Tuesday March 28, 2006
Cuff leak test - to anticipate post-extubation stridor

There are atleast 3 common ways to do cuff leak test to anticipate postextubation stridor but none has been really tested in a big scientific randomized trial. And literature is full of conflicting studies.

1. Bedside crude method: Deflate the cuff, +/- occlude the ETT and put your hand at mouth to feel exhaled air. (isn't it brutal?)

2. Record the difference between the inspiratory tidal volume and the expiratory tidal volume while the cuff around the endotracheal tube was deflated. (Average of any three values on six consecutive breaths). Cuff leak less than 110 mL is more associated with postextubation stridor.

3. Record the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation. Divide this number by the exhaled tidal volume before cuff deflation. Your answer is 'percent cuff leak'. Patients with a cuff leak of less than 10% are at risk for stridor or reintubation.

Some other methods like laryngeal ultrasound has also been described in literature. Also, experts recommend to test the ability to expel secretions with an effective cough. Be aware, a low value for cuff leak may actually be due to encrusted secretions around the tube rather than to a narrowed upper airway. Reintubation equipment (including tracheostomy equipment) should be readily available during extubation and immediate postextubation period.

Related previous pearl: Spontaneous Breathing Trial (SBT)


References: Click to get abstract/article
1. Association between reduced cuff leak volume and postextubation stridor - Chest, Vol 110, 1035-1040
2. Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation - J Am Coll Surg. 2000 Jun;190(6):682-7.
3. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study - Eur . Respir J 2006; 27:384-389
4. Predicting Extubation Failure - Is It in (on) the Cards? - Chest. 2001;120:1061-1063
5. Evaluation of the Cuff-Leak Test in a Cardiac Surgery Population - Chest. 1999;116:1029-1031
6. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support - Chest. 2001;120:375S-396S
posted by ICU room Pearls @ 1:24 AM 0 comments

Monday, March 27, 2006
Unload
Monday March 27, 2006
The ‘UNLOAD’ Study


New findings from the UNLOAD study, announced at the 2006 American College of Cardiology (ACC) 55th Scientific Session Conference in Atlanta, detail immediate and long-term benefits for heart failure patients receiving ultrafiltration therapy to treat fluid overload. This is the first randomized clinical study to compare the safety and efficacy of a non- drug-based option with standard intravenous diuretic drug therapy to treat heart failure patients. UNLOAD stands for UltrafiltratioN versus IV Diuretics for Patients HospitaLized fOr Acute Decompensated Congestive Heart Failure. This prospective, randomized multi-center trial compared the immediate and long-term effects of early ultrafiltration alone, versus intravenous diuretics alone, on weight loss, symptoms and hospitalizations of patients with decompensated heart failure and fluid overload. The ultrafiltration therapy used in the trial was administered via the Aquadex FlexFlow(TM). The Aquadex FlexFlow is a mechanical system that can remove up to one liter of excess fluid from the body in two hours, or more than a gallon in eight hours. The system received marketing clearance from the U.S. Food and Drug Administration in 2002. A Standard catheter is inserted into peripheral or central vein, which connects the patient to the Aquadex FlexFlow.

Two hundred patients were enrolled at 28 medical sites. In this prospective trial, patients were randomized and placed in either the ultrafiltration group or the intravenous diuretics group, and assessed at entry and at intervals out to 90 days. There was no difference in renal function between the groups. Highlights of the UNLOAD study include statistically significant findings such as:

At 48 hours into treatment, the ultrafiltration group demonstrated a:
38% greater weight loss over standard care; and
28% greater net fluid loss over standard care.

At 90 days following hospital discharge, the ultrafiltration group demonstrated a:
43% reduction in patients requiring rehospitalizations for CHF over standard care;
50% reduction in the total number of rehospitalizations for CHF over standard care.
52% reduction in ER or clinic visits over standard care and
63% total reduction in days rehospitalized for heart failure over standard care.

The benefits in weight loss and in reduction of rehospitalization were seen in all subgroups analyzed.

The cost of the device is about $10,000, and each filter runs about $800.
posted by ICU room Pearls @ 9:06 AM 0 comments

Sunday, March 26, 2006
Is the Gut working
Sunday March 26, 2006
Where is my food dude !!

Is the Gut working? : Bowel sounds are not a reliable indicator of gastrointestinal function in critical illness. Bowl sound requires the presence of movement, intestinal contents and intraluminal air. Normally air is swallowed and in ventilated patients, particularly if receiving high doses of sedation or neuromuscular blocking agents do not swallow air. Because of this bowl sounds may be absent in patients whose gastrointestinal tract is working normally.

Read this quote from study of 1479 patients - Daily enteral feeding practice on the ICU, which also looked into the factors interfering with successful administration of enteral feed: "We also found that nurses tended to overestimate gastric retention as a risk factor and, more importantly, violated the protocol by discarding a gastric retention volume of less than 200 ml over 6 hours. This behavior might be the result of a misplaced ambition to achieve safer care. Although the measurement of gastric retention is an important tool for guaranteeing safe enteral feeding, no difference is reported between gastric tube and duodenal tube use among ICU patients in terms of aspiration and nosocomial pneumonia." It was recommended to give back gastric retention of less than 250 ml (per 6 hours).

Related previous pearl: Is post pyloric feeding absolute ?


Reference: (Click to get article)
Daily enteral feeding practice on the ICU: attainment of goals and interfering factors - Critical Care 2005, 9:R218-R225

posted by ICU room Pearls @ 8:43 AM 0 comments

Saturday, March 25, 2006
Valentino's Syndrome
Saturday March 25, 2006
Valentino's Syndrome


Q: What is Valentino's Syndrome ?

A: A duodenal ulcer with retroperitoneal perforation presenting with pain in the right lower quadrant is called Valentino's syndrome. Usually surgery can be avoided and treatment is hydration and antibiotics.


Read case presentation with radiological findings here.

(Reference: NEJM, Volume 354:e9, Number 10, March 9, 2006)
posted by ICU room Pearls @ 4:40 PM 0 comments

Friday, March 24, 2006
Forearm Blood Pressure
Friday March 24, 2006
Is Forearm Blood Pressure Reliable ?

It is one of the common practice to use forearm as non-invasive blood pressure monitoring in case upper arm blood pressure measurements having problems. Folks from Delaware did blood pressure measurement in the forearm and then in the upper arm of 221 supine patients with their arms resting at their sides. Similar exercise was repeated with patients' head of the bed elevated at 45 degree. Analysis showed that: Noninvasive measurements of blood pressure in the forearm and upper arm cannot be interchanged irrespective of position. Important aspect of forearm BP monitoring:

1. Forearm BP measurement is not recommended but if absolutely required, as if proper-size upper arm cuff is not available, make sure correct cuff size for forearm is used.

2. Use and follow forearm Blood Pressure serially and DO NOT interchange Blood Pressure measurement with upper arm readings.

3. Be cautious that systolic, diastolic and mean forearm blood pressure measurements are higher than upper arm blood pressure measurements with following values

* Systolic BP is about 8 mm Hg higher in supine and 14 mm Hg higher at 45 degree,
* Diastolic BP is about 4 mm Hg higher in supine and 9.5 mm Hg higher at 45 degree,
* Mean BP is about 5 mm Hg higher in supine and 11 mm Hg higher at 45 degree.


Reference:
Clinical Comparison of Automatic, Noninvasive Measurements of Blood Pressure in the Forearm and Upper Arm With the Patient Supine or With the Head of the Bed Raised 45?: A Follow-Up Study - American Journal of Critical Care. 2006;15: 196-205
posted by ICU room Pearls @ 8:35 AM 0 comments

Thursday, March 23, 2006
BNP and PWP
Thursday March 23, 2006
Can BNPs replace Pulmonary Wedge Pressure?

With BNP as a marker of fluid overload on heart, there was a lot of enthuthiasm about using it as a non-invasive mirror for PCWP. Group of physicians from Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland studied prospectively 40 patients in the ICU requiring invasive hemodynamic monitoring. Hemodynamics were recorded simultaneously with blood sampling for both BNP and NT-proBNP. They found that due to rapidly fluctuating levels of estimated glomerular filtration rate in ICU patients - BNPs have very poor correlation with PCWP.

Related previous pearls:
BNP or Pro-BNP ? and Re. Nesiritide (Netrecor)

References:
1. Relationship Between B-Type Natriuretic Peptides and Pulmonary Capillary Wedge Pressure in the Intensive Care Unit - J Am Coll Cardiol, 2005; 45:1667-1671
posted by ICU room Pearls @ 8:58 AM 0 comments

Wednesday, March 22, 2006
SBT
Wednesday March 22, 2006
Spontaneous Breathing Trial (SBT) - how long - 30 minutes or 120 minutes?

Spontaneous Breathing Trial (SBT) remained one of the key clinical parameter for extubation from mechanical ventilation but there is always a debate about how long is good enough to predict successful extubation. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support published in chest 2001 recommends: "The tolerance of SBTs lasting 30 to 120 min should prompt consideration for permanent ventilator discontinuation."3

Earlier one study published 7 years ago in Am. J. Respir. Crit. Care Med, showed that successful extubation can be achieved equally effectively with trials targeted to last 30 and 120 minutes 1. This has been confirmed again in another study from Washington Hospital Center, Washington, DC. 164 consecutive medical ICU patients on mechanical ventilation have been evaluated. 90-minute CPAP trial has been given and RSBI was measured at 1, 30, 60, and 90 minutes of SBT. 141 patients were successfully extubated and the mean RSBI’s for successfully extubated patients were 65, 63, 64, and 65 at 1, 30, 60, and 90 minutes, respectively. It was concluded that there is little to be gained by extending the SBT beyond the first 30 minutes 2.

In this regard, read article with weaning protocols, strategies and numbers from FERNANDO FRUTOS-VIVAR, MD and ANDRÉS ESTEBAN, MD, PHD (Intensive Care Unit, Hospital Universitario de Getafe Madrid, Spain): When to wean from a ventilator: An evidence-based strategy, published in CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70, NUMBER 5 MAY 2003 page 389


References:
1. Effect of Spontaneous Breathing Trial Duration on Outcome of Attempts to Discontinue Mechanical Ventilation - Am. J. Respir. Crit. Care Med., Volume 159, Number 2, February 1999, 512-518
2. Analysis of Rapid Shallow Breathing Index as a Predictor for Successful Extubation from Mechanical Ventilation - Chest 2004 126: 756S-757S.
3. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support- A Collective Task Force Facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine- Chest. 2001;120:375S-396S
posted by ICU room Pearls @ 7:37 AM 0 comments

Tuesday, March 21, 2006
Rapid Response Team
Tuesday March 21, 2006
Rapid Response Team / Medical Emergency Team

Overall impression and anecdotal experiences are in favor of Rapid Response Team. Also IHI recommends it as part of "100,000 Lives Campaign". But unfortunately on scientific grounds we are still lacking absolute evidence for Rapid Response Team. Here we will give synopsis of 2 conflicting studies. Unfortunately again, its like comparing oranges to apples as second study comprised only of surgical patients.

1. MERIT STUDY: 23 hospitals in Australia were randomized to continue functioning as usual (n=11) or to introduce a RRT/MET system (n=12). The RRT was called only to 30% of patients who fulfilled the calling criteria.

Was it just an over active issue or a manifestation of poor pre-training ?.

The outcomes (cardiac arrests, unplanned ICU admissions and unexpected deaths) were analyzed. And the final conclusion was: although the call to RRT/MET system (3·1 vs 8·7 per 1000 admissions) was greatly increased, but does not substantially affect the incidence of cardiac arrest (1·64 vs 1·31 per 1000 admissions; p=0·736), unplanned ICU admissions (4·68 vs 4·19 per 1000 admissions; p=0·599), or unexpected death (1·18 vs 1·06 per 1000 admissions; p=0·752).

2. Bellomo and colleague's trial - effect of MET on postoperative morbidity and mortality rates: In the control period, there were 336 adverse outcomes in 190 patients, which decreased to 136 in 105 patients during the intervention period (relative risk reduction, 57.8%; p < .0001). These changes were due to significant decreases in the number of cases of respiratory failure, stroke, severe sepsis and acute renal failure (requiring renal replacement therapy). Emergency intensive care unit admissions were also reduced as well as postoperative deaths. Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days.

IHI's Rapid Response Team - getting started kit
SCCM's RRT/ MET forum

References: first popup overwrites second popup
1. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial, MERIT study - The Lancet 2005; 365:2091-2097 - abstract available with free registration
2. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates - Critical Care Medicine: Volume 32(4) April 2004 pp 916-921
posted by ICU room Pearls @ 11:33 AM 0 comments

Sunday, March 19, 2006
Atenolol and Renal Failure
Monday March 20, 2006
Atenolol & Renal Failure

One must use caution while prescribing atenolol to patients with renal insufficiency. The elimination half-life of atenolol is extensively prolonged in patient with renal failure. The normal half life of atenolol is 6 to 7 hours; however, in renal failure patients the half-life may be extended to more than 100 hours 2.The recommended dosage are following:

CrCl 35 mL/min or greater - normal dosing
CrCl 15 - 35 mL/min - MAX. dose 50 mg orally QD
CrCl less than 15 mL/min - MAX. dose 25 mg orally QD
Hemodialysis: 25-50 mg orally after each dialysis session.

Treatment of atenolol overdose in a patient with renal failure is recommended with serial hemodialysis and charcoal hemoperfusion 3.

On the contrary, metoprolol is extensively metabolized via the hepatic system.

References:
1.Atenolol-DOSAGE AND ADMINISTRATION - rxlist.com
2.Atenolol kinetics in renal failure - Clin Pharmacol Ther. 1980 Sep;28(3):302-9
3. Treatment of atenolol overdose in a patient with renal failure using serial hemodialysis and hemoperfusion and associated echocardiographic findings Vet Hum Toxicol. 2000 Aug;42(4):224-5.
posted by ICU room Pearls @ 11:51 PM 0 comments

Signout Mortality !
Sunday March 19, 2006
Sign-out Mortality !

Regular evening work (sign-out) round is an integral part of all tertiary/teaching ICUs in USA but unfortunately as we transit to private practice or community hospital enviroment, we tend to loose this wonderful tradition. Ever thought about poor sign-out to your colleague as a patient safety issue?. A group pf physicians from Chicago have published their study in Quality and Safety in Health Care.

26 interns caring for 82 patients were interviewed after receiving sign-out from another intern. 25 discrete incidents, all the result of communication failures during the preceding patient sign-out, and 21 worst events were described. Omitted content (such as medications, active problems, pending tests) or failure-prone communication processes (such as lack of face-to-face discussion) emerged as major categories of failed communication. Ever think of sign-out as a procedure?

Read interesting article related to this topic Glucose Roller Coaster with sample signout sheet at the AHRQ WebM&M website, from Bradley A. Sharpe, MD, University of California, San Francisco .

Reference:
Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis - Quality and Safety in Health Care 2005;14:401-407

posted by ICU room Pearls @ 10:50 AM 0 comments

Saturday, March 18, 2006
Retinoic acid Syndrome
Saturday March 18, 2006
Diagnostic crireia of Retinoic acid Syndrome

Retinoic acid syndrome is the major side effect of tretinoin therapy ATRA (all-trans retinoic acid) in patients with acute promyelocytic leukaemia (APL). It occurs in about quarter of patients with treatment. It has been suggested that 3 out of the following 7 signs and symptoms should be present to label patients as having Retinoic acid syndrome while getting ATRA and in the absence of other causes like sepsis 1, 2.

1. Fever
2. Weight Gain
3. Respiratory distress
4. Pulmonary infiltrates
5. Pleural or pericadial effusion
6. Hypotension
7. Renal failure

Read: Retinoic Acid Syndrome: A Case Report and Review from The Internet Journal of Oncology. 2005. Volume 2 Number 2.

Bonus Pearl: Acute colonic pseudo-obstruction (Ogilvie's syndrome) is one of the another complication may happen during induction treatment with chemotherapy and all-trans-retinoic acid for acute promyelocytic leukemia 3.

Reference: (click to get article )
1. Incidence, Clinical Features, and Outcome of All Trans-Retinoic Acid Syndrome in 413 Cases of Newly Diagnosed Acute Promyelocytic Leukemia - Blood, Vol. 92 No. 8 (October 15), 1998: pp. 2712-2718
2. The "retinoic acid syndrome" in acute promyelocytic leukemia - Ann Intern Med. 1992 Aug 15;117(4):292-6.
3. Acute colonic pseudo-obstruction (Ogilvie's syndrome) during induction treatment with chemotherapy and all-trans-retinoic acid for acute promyelocytic leukemia - Am J Hematol.1995 May;49(1):97-8.
posted by ICU room Pearls @ 9:38 AM 0 comments

Friday, March 17, 2006
anemia score
Friday March 17, 2006
ICU anemia score

A group of physicians from The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA have developed this ICU anemia score, which can be calculated at 6 hours after admission to intensive care unit.

6 points if......Lactate more than 1.5 mg/dl
5 points if......Inotropic support
11 points if....Surgical patient
5 points if......Non-emergent surgery
3 points to.....Each g/dl of hemoglobin less than 14 g/dl

Risk of anemia starts rising beyond 12 points and goes up. Also, points can be plotted on the probability of anemia graph (figure 3 in reference).

Clinical Significance: Once risk of anemia is determined, earlier and more appropriate use of blood transfusion-sparing strategies can be applied such as erythropoietin.

Note: Its hard to fully grasp the idea in nut-shell and icuroom.net editors strongly recommend to read article fully as available free by clicking on reference.

Reference:
Predicting late anemia in critical illness - Eric B Milbrandt,Gilles Clermont, Javier Martinez, Alex Kersten, Malik T Rahim and Derek C Angus - The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA -Critical Care 2006, 10:R39

posted by ICU room Pearls @ 2:07 PM 0 comments

Thursday, March 16, 2006
IV insulin dose
Thursday March 16, 2006
IV insulin dose

As ICUs are moving more and more towards protocol based orders, insulin drip protocol remains one of the most sought protocol. There is no proven formula available for the dose of insulin drip but one 'rule of thumb' available is as follows:

(Current Blood Glucose - 60) x multiplier = number of units of insulin/hour

Multiplier could range anywhere from .01 to .09 depending on level of glucose control required. Practically, start multiplier from .01/.02 and continue to escalate till desired control achieved. Control can be made tighter as needed with blood glucose level at given point. Like patient with blood sugar of 359 may start with as low as (359-60) x .01 = 3 units/hour but depending on further blood glucose level may require upto (359-60) x .09 = 27 units/hour of insulin.

The best precise article we found with all insulin related protocols is Hospital management of diabetes: Beyond the sliding scale written by Dr. Etie Moghissi, Co-chair, American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. ( Reference: CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 • NUMBER 10 OCTOBER 2004. Page 801).

posted by ICU room Pearls @ 12:04 PM 0 comments

Wednesday, March 15, 2006
Regarding Procalcitonin
Wednesday March 15, 2006
Regarding Procalcitonin

procalcitonin (PCT) has been claimed to be one of the most specific marker for sepsis/infection. It increases with high specificity in response to clinically relevant bacterial infections and sepsis. PCT has a fast kinetic and can be measured as soon as 3-4 hours after infection. Normal PCT value is less than 0.5 ng/ml and its level in sepsis is generally greater than 1-2 ng/ml and often between 10 and 1000 ng/ml. As the septic infection resolves, PCT reliably returns to low values with a half-life of 24 hours and here the actual value lies to follow the trend to see response to treatment. Another cost-effective advantage is to limit the days of antibiotics depending on resolving trend of PCT value.

In a recent study it was found that PCT values should be determine differently between medical and surgical patients . In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL and in medical patients, the best diagnostic cutoff value was 1.00 ng/mL. It was concluded by authors that: Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. (see reference # 2). Its real value still needs to be tested in a major trial as we have other inexpensive and generic tests available like WBC count, Lactic acid level, CRP etc.

Official web site procalcitonin.com

Previous Related Pearl: C-Reactive Protein (CRP) - marker of mortality in ICU ?


References: (click to get abstract - second popup overwrites first popup)
1. Diagnostic and prognostic value of procalcitonin in patients with septic shock. Critical Care Medicine. 32(5):1166-1169, May 2004.
2. Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock. Critical Care Medicine. 34(1):102-107, January 2006.

posted by ICU room Pearls @ 9:33 PM 0 comments

Tuesday, March 14, 2006
Hypoglycemia risk factors in ICU
Tuesday March 14, 2006
Hypoglycemia risk factors in ICU

We hear a lot about effects of hyperglycemia in ICU but on the other end of spectrum, hypoglycemia could be actually more or atleast equally disastrous. Dr. Vriesendorp and coll. from Amsterdam, The Netherlands looked into record of 2,272 patients and found that 156 patients (6.9%) experienced at least one episode of hypoglycemia (glucose value less than 45 mg/dL). They found following risk factors for hypoglycemia in ICU.


CVVHD with bicarbonate-based substitution fluid,
Decrease of nutrition without adjustment for insulin infusion,
History of diabetes mellitus,
Insulin use,
Sepsis,
Inotropic support and
Simultaneous octreotide and insulin use.
Interestingly, Gastric residual during enteral nutrition without adjusting insulin infusion, liver failure, continuous venovenous hemofiltration with lactate-based substitution fluid, diminished glomerular filtration rate, dose diminishment of glucocorticoids or catecholamines, and use of β-blocking agents were not associated with hypoglycemia.

Related Previous Pearl:

Quinolones and errant glycemic reaction.

Reference: (click to get abstract)
Predisposing factors for hypoglycemia in the intensive care unit - Critical Care Medicine. 34(1):96-101, January 2006.


posted by ICU room Pearls @ 1:07 PM 0 comments

Monday, March 13, 2006
Monday March 13, 2006
Introducing Resident ICU Course

Under the banner of Society of Critical Care Medicine 23 lectures (power point) related to Critical Care Medicine have been uploaded at site

http://ricu.sccm.org

It includes essential topics like Airway Management, Mechanical Ventilation, Arterial Blood Gas Interpretation, Endocrine Issues in Critical Illness, Neurologic and Neurosurgical Emergencies, Acute Kidney Dysfunction, Nutritional Support in the ICU etc.Site is free but requires registration. It involves pre and end of rotation online tests with case-scenario based questions. This web-based curriculum has been developed by the Graduate and Resident Education Committee, a committee of the Society of Critical Care Medicine. These presentations have been authored by experts in the corresponding fields and can be downloaded/saved to computer.Highly recommended for medical residents.

*Site has 2 arms - Adult and Pediatric
posted by ICU room Pearls @ 7:57 AM 0 comments

Sunday, March 12, 2006
vkpower
Sunday March 12, 2006
Power of Vitamin K

Q; In patients with Warfarin (Coumadin) , any dose more than ______ mg of Vitamin K will make reanticoagulation difficult.

Ans; 1 mg.

Previous Related Pearl: 7 Pearls of Vitamin K (phytonadione)


Reference:
Care of Patients Receiving Long-Term Anticoagulant Therapy - S Schulman, - Volume 349:675-683, Aug 14 '03
posted by ICU room Pearls @ 8:22 AM 0 comments

Saturday, March 11, 2006
hellp
Saturday March 11, 2006
Triad of HELLP Syndrome

HELLP syndrome is a unique variant of preeclampsia and may manifest even before clinical signs of preeclampsia. Triad or criteria and term "HELLP" syndrome was first designated by Louis Weinstein, M.D. in 1982 in American Journal of Obstet. Gynecol. 1, and is as follows:

1. Hemolysis: Abnormal blood smear - Elevated Bilirubin >1.2 mg/dl

2. Elevated liver enzymes - with SGOT >72 UI / L (but has been mentioned as low as 40) and LDH >600 UI/L

3. Low Platelets: Less than 100. Please note that platelet's cutoff of 100 is debatable and another classification for this syndrome called Mississippi Classification used level less than 150. Read reference # 2 which may need subscription.

See impressive slide presentation here on HELLP Syndrome from JOHN ESSIEN M.D. and coll. from HOSPITAL GINECOBSTÉTRICO PROVINCIAL, CAMAGÜEY., CUBA - (its a power point presentation)

Previous related pearl: IV Magnesium (Mg) infusion

References:
1.Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Weinstein L. Am J Obstet Gynecol.1982 Jan 15;142(2):159-67
2. Prevention of Eclampsia - letters to editor, NEJM, May 23, 2003, Volume 348:2154-2155
posted by ICU room Pearls @ 1:18 AM 0 comments

Friday, March 10, 2006
fs
Friday March 10, 2006
Frog Sign

Q: What is Frog sign?

A: In Paroxysmal Supra-Ventricular Tachycardia (PSVT) a rapid and regular bulging seen in the neck. These are actually prominent jugular venous A waves due to atrial contraction against the closed tricuspid valve, and termed as "frog sign".


References:
1. Brief report: the hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant tachycardia - N Engl J Med. 1992 Sep 10;327(11):772-4.

2. Evaluation of Patients with Palpitations - NEJM, May, 1998, Volume 338:1369-1373
posted by ICU room Pearls @ 10:03 AM 0 comments

Thursday, March 09, 2006
ebrfsap
Thursday March 9, 2006
Evidence-based recommendations for Severe Acute Pancreatitis (SAP)

An international consensus conference was held in April 2004 to develop guidelines for the management of the critically ill patient with SAP and published in December 2004 issue of Critical Care Medicine. 23 evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature. We are pening here few most important recommendations but full article can be pulled from reference below.

* Critically ill patients with pancreatitis be cared for by an intensivist-led multidisciplinary team with ready access to physicians skilled in endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), surgery, and interventional radiology.

* Followup CT to identify local complications be delayed for 48-72 hrs when possible, as necrosis might not be visualized earlier.

* Recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis.

* Enteral nutrition should be initiated after initial resuscitation. The jejunal route should be used if possible and parenteral nutrition only be used when attempts at enteral nutrition have failed after a 5- to 7-day trial and when used, parenteral nutrition should be enriched with glutamine.

* Sonographic- or CT-guided FNA with Gram stain and culture of pancreatic or peripancreatic tissue to discriminate between sterile and infected necrosis in patients with radiological evidence of pancreatic necrosis and clinical features consistent with infection and recommendation against debridement and/or drainage in patients with sterile necrosis.

* Pancreatic debridement or drainage in patients with infected pancreatic necrosis and/or abscess confirmed by radiological evidence of gas or results of FNA. The gold standard for achieving this goal is open operative debridement. If possible, operative necrosectomy and/or drainage be delayed at least 2-3 wks to allow for demarcation of the necrotic pancreas.

* In acute pancreatitis due to suspected or confirmed gallstones, urgent ERCP should be performed within 72 hrs of onset of symptoms.

* Use of early volume resuscitation and lung-protective ventilation strategies for patients with acute lung injury.

* In SAP with severe sepsis careful consideration be used before the administration of rh-APC based on the theoretical but unproven concern of retroperitoneal hemorrhage.

Reference:
Management of the critically ill patient with severe acute pancreatitis - Critical Care Medicine: Volume 32(12) December 2004 pp 2524-2536 . Sponsored by the American Thoracic (ATS), the European Respiratory Society (ERS), the European Society of Intensive Care Medicine (ESICM), the Society of Critical Care Medicine (SCCM) and the Société de Réanimation de Langue Française (SRLF).

posted by ICU room Pearls @ 7:16 AM 0 comments

Wednesday, March 08, 2006
Chest tube
Wednesday March 8, 2006
Chest tube (tube thoracostomy) with seldinger technique - underutilize technique?

Cannulation of pleural space was first described by Hippocrates (460 B.C) and in modern medicine about 140 years ago by Hillier 1. Chest tube insertion gained huge respect during 2 world wars as a life saving procedure. Over last few decades technique remain mostly unchanged with insertion either with help of trocar or with direct insertion with scalpel/clamp and finger opening of pleural space. In recent years insertion of chest tube with seldinger technique (over guide wire) has been described but still remain less popular, although, it has significant advantages over traditional method as it is less painful, easy to insert, can be master easily and ? less prone to infection. The only disadvantage is inability to 'feel' pleural space. On literature search we were unable to find any head to head study comparing seldinger technique with operative technique. There is only one attempt earlier to check literature (see reference # 2) and found that seldinger technique is no way inferior (or superior either) to traditional chest tube insertion.

Chest tubes are available for seldinger technique insertion upto 36 f size. See details here from Cook (maker of Thal-Quick chest tubes).

Isn't it time to graduate to seldinger technique for chest tubes as we did for central venous catheters from cut-downs? All comments are welcome.

References: (click to get article)

1. Chest tube - int.med.utah.edu
2. Seldinger technique chest drains and complication rate - Emerg Med J 2003; 20:169-170
posted by ICU room Pearls @ 6:21 AM 0 comments

Tuesday, March 07, 2006
ffp
Tuesday March 7, 2006
Some facts about FFP

Several plasma alternatives can be used for coagulation factor replacement. The most commonly used plasma component is Fresh Frozen Plasma (FFP). One unit of FFP or thawed plasma is the plasma taken from a unit of whole blood. It is frozen within eight hours of collection. FFP contains all coagulation factors in normal concentrations. Plasma may be stored for as long as I year at -18° C or colder. Thawed plasma may be transfused up to 5 days after thawing and contains slightly decreased levels of Factor V and decreased Factor VIII levels. Plasma is free of red blood cells, leukocytes and platelets. One unit is approximately 200-250mL and must be ABO compatible. Rh factor need not be considered. Since there are no viable leukocytes, plasma does not carry a risk of CMV transmission or Graft Vs. Host Disease (GVHD).

The dose of FFP depends on the clinical situation and the underlying disease process. Only 15% - 35% of normal levels of factors are required to maintain normal hemostasis. When FFP is given for coagulation factor replacement, the dose is 10-20 ml/Kg (4-6 units in an adult). This dose would be expected to increase the level of coagulation factors by 20% immediately after infusion. In a 70 kg Patient: 1 Unit Plasma increases most factors ~2.5%. 4 Units Plasma increase most factors ~10%.

FFP may be rapidly transfused over 20-30 minutes. The rate is mainly limited by the patient’s ability to tolerate the volume. Allergic reactions occur in approximately 1% of patients receiving FFP. The reactions are usually mild consisting of an urticarial rash (hives) and pruritus. FFP has not been associated with transmission of CMV or HTLV-I, II since these viruses are exclusively white cell associated and plasma is virtually acellular.

Related previous Pearl : How much FFP?

Also for your file:
1. Guidelines for the use of Fresh Frozen Plasma, cryoprecipitate and cryosupernatant from British Committee for Standards in Haematology, Blood Transfusion Task Force, British Society of Haematology - British Journal of Haematology 2004; 126, 11-28

2. Australian National Guidelines on FFP and Cryoprecipitate

posted by ICU room Pearls @ 9:20 AM 0 comments

Monday, March 06, 2006
BEDSIDE CREATININE CLEARENCE
Monday March 6, 2006
BEDSIDE CREATININE CLEARENCE

The most sensitive measure of changing renal function is not the serum creatinine, but the creatinine clearance. Serum creatinine underestimates the degree of renal insufficiency in many situations like :

- Anyone with a renal insufficiency but a GFR more than 50 ml/min, because serum creatinine does not start to rise until GFR falls below 50 ml/min

- Cachexia – because creatinine production is so low, serum creatinine may rise only when GFR falls below 25 ml/min

- After surgery in patients who have received a lot of fluids. A 10 – 15% increase in total body water results in dilution of serum creatinine by an equivalent amount.

The most useful means of estimating GFR at bedside is a two-hour creatinine clearance. There is nothing about clearance that mandates a 24-hour urine collection, particularly when there is a Foley’s catheter in place, which largely eliminates error due to urine retention. As long as the collection is carefully timed and the urine flow is more than 30 ml/hr, a collection as short as 2-hour will give reasonable data.

Creatinine clearance may be calculated simply by UV/P

where U is the urine creatinine in mg/dl,
V is the urine flow rate in ml/min and
P is the serum creatinine in mg/dl.

The term ‘UV’ i.e is urine creatinine times urine flow rate, represents the creatinine excretion rate. It is THIS that changes rapidly with changing GFR.


Related:

1. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation Classification and Stratification - National Kidney Foundation / Kidney Disease Outcomes Quality Initiative.

2. ESTIMATION OF CREATININE CLEARANCE IN PATIENTS WITH UNSTABLE RENAL FUNCTION (Dr. Roger Jelliffe - School of Medicine at the University of Southern California).
posted by ICU room Pearls @ 9:24 AM 0 comments

Sunday, March 05, 2006
sb
Sunday March 5, 2006
Sunday Basic !

Some lessons (not all) learnt in medical school are worth remembering every moment at bedside. For intensivist, following simple fact carries huge bedside implications.

"Left ventricle is perfused most actively in early diastole, not when aortic pressure is at its maximum but when myocardial pressures are least".

Who knows the dilemma of intensivist better than himself while trying to find that fine line between volume, pressors, hear rate and blood pressure.

Related: Cardiac angioplasty and stent placement video (Dr. Tyrus Frerking - Mount Carmel health - Ohio) - needs window media player.
posted by ICU room Pearls @ 12:18 PM 0 comments

Saturday, March 04, 2006
prayer sign

Saturday March 4, 2006
Prayer Sign

Prayer Sign - If patient shows inability to place palms flat together, it suggests difficult intubation. It is a reflection of generalised joint and cartilage immobility and tight waxy skin, particularly in diabetic patients. About 33% of diabetic patients are prone to difficult intubations. One study from Istanbul, Turkey compared 80 diabetic patients (D) with 80 non-diabetic patients (ND) undergoing elective surgery under general anaesthesia. The incidence of difficult laryngoscopy was 18.75% in Group D and 2.5% in Group ND. The incidence of the prayer sign was 31.25% in Group D and 13.75% in Group ND.

Another version of prayer sign is "palm print" method in which grading of the ink impression made by the palm of the hand has been proposed as a means of screening diabetic patients in whom tracheal intubation may prove difficult. In one study, it was found to be superior to 3 other indices - Mallampati classification, thyromental distance and head extension.


References: (second popup overwrites first popup)
1. Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality detected using the ‘prayer sign’ - British Journal of Anaesthesia, 2003, Vol. 91, No. 1 159-160
2. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics - Acta Anaesthesiol Scand. 1998 Feb;42(2):199-203.
posted by ICU room Pearls @ 2:12 PM 0 comments

Friday, March 03, 2006
Peripartum Cardiomyopathy
Friday March 3, 2006
4 criteria of Peripartum Cardiomyopathy (PPCM)

Contributed by: Saadia Faiz M.D., senior Pulmonary and Critical Care fellow, University of Texas at Houston Program.


Peripartum cardiomyopathy is a deadly disease with mortality described upto 56%. Relationship of heart failure with pregnancy was first described in medical literature about 135 years ago by Virchow & Porack . In 1937 it was recognised as distinct entity with dilated cardiomyopathy by Gouley. 35 years ago Demakis and Rahimtoola defined PPCM on the basis of 4 criteria. It was modified by National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop in April 1997.

1. Heart failure within the last month of pregnancy or 5 months postpartum.

2. Absence of preexisting heart disease.

3. No determinable etiology and

4. Strict echocardiographic criteria of left ventricular dysfunction: Ejection fraction less than 45%, or M-mode fractional shortening less than 30%, or both, and end-diastolic dimension more than 2.7 cm/m2 body surface area.

Related: Click here to read review article on recognition and management of maternal cardiac disease in pregnancy from British Journal of Anaesthesia (Reference: 2004 93(3):428-439)


References: (second popup overwrites first popup)

1. Peripartum cardiomyopathy. Demakis JG, Rahimtoola SH. Circulation. 1971 Nov;44(5):964-8
2. Peripartum Cardiomyopathy - National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) Workshop Recommendations and Review -JAMA. 2000;283:1183-1188. Full text available with free registration.
3. Peripartum Cardiomyopathy - Cardiology in Review. 14(1):35-42, January/February 2006.
posted by ICU room Pearls @ 9:45 PM 0 comments

Thursday, March 02, 2006
howmuchffp
Thursday March 2, 2006
How much FFP?

Dr. Sam Schulman from Karolinska Hospital, Stockholm, Sweden wrote an excellent review on "Care of Patients Receiving Long-Term Anticoagulant Therapy" in August 14, 2003 issue of NEJM 1. Part of article suggest formula for amount of FFP (Fresh Frozen Plasma) to correct INR upto desired level in a bleeding patient from over-anticoagulation.

Amount of FFP needed(ml) =
(target level as percentage - present level as percentage) x Wt.(kg)

The "percentage" is prothrombin complex, expressed as a percentage of normal plasma, corresponds to the mean level of the vitamin K–dependent coagulation factors. It can be compute easily with following table:

INR 1 = 100 (%)
INR 1.4 - 1.6 = 40
INR 1.7 - 1.8 = 30
INR 1.9 - 2.1 = 25
INR 2.2 - 2.5 = 20
INR 2.6 - 3.2 = 15
INR 4.0 - 4.9 = 10
INR > 5 = 5 (%)

Example:
In a 70 kg patient bleeding with INR of 7.5 and if our target is to bring INR down to 1.4, using above table:

Total FFP needed = (40 - 5) x 70 = 2450 ml

(One unit FFP usually contains 200-250 ml of FFP).


Reference:
Care of Patients Receiving Long-Term Anticoagulant Therapy - Sam Schulman, M.D. - Volume 349:675-683, August 14, 2003
posted by ICU room Pearls @ 11:54 AM 0 comments

Wednesday, March 01, 2006
cfif
Wednesday March 1, 2006
Calories from intravenous fluid (IVF)


Q: How much calories patient receive from 1 litre of D5-W drip?

A: 170 calories / L
posted by ICU room Pearls @ 2:08 AM 0 comments

Tuesday, February 28, 2006
hsiceaih
Tuesday February 28, 2006
Hypertonic Solution (3% NS) in cerebral edema and intracranial hypertension


Q: What is the level of Sodium (Na), you will target if hypertonic solution (3% NS) has been choose as management plan in cerebral edema and intracranial hypertension.

A: 145-155 Meq/L.


Although mannitol with close monitoring of serum osmolality remains mainstay of treatment, no major clinical trial has yet established the use of Hypertonic Solution (3% NS) as standard of treatment in cerebral edema and intracranial hypertension but literature has growingly show its comparable and sustained effect on lowering ICP (Intra-cranial pressure).


Related: Read concise review article here on Spontaneous intracerebral hemorrhage from Dr. Matthew E. Fewel and coll., Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan (Neurosurg. Focus / Volume 15 / October, 2003)



References: Click to get abstract/article (second popup overrides first popup).
1. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Critical Care Medicine. 28(9):3301-3313, September 2000.
2. Treatment of elevated intracranial pressure in experimental intracerebral hemorrhage: Comparison between mannitol and hypertonic saline. Qureshi AI, Wilson DA, Traystman RJ: Neurosurgery 1999; 44: 1055-1064 -via pubmed
3. Hypertonic saline for cerebral edema and elevated intracranial pressure - Cleve Clin J Med. 2004 Jan;71 Suppl 1:S9-13.
4. Introducing Hypertonic Saline for Cerebral Edema: An Academic Center Experience - Neurocritical Care Winter 2004, Volume 1, Issue 4, pps. 435-440
5. Treatment of intracerebral haemorrhage - Lancet Neurology 2005; 4:662-672
posted by ICU room Pearls @ 9:17 AM 0 comments

Monday, February 27, 2006
iido
Monday February 27, 2006
Introducing icudelirium.org

Delirium is one of the most hidden and deadly enemy in ICU. It increases mortality, it cost money and its hard to recognise. In this regard an organised effort is underway in the form of website charged by Dr. E.Wesley Ely of Vanderbilt University Medical Center.

www.icudelirium.org

It contains numerous tools and information for Critical Care staff, particularly this slide show (Dr. Ely) is worth browsing.

Just to have a flavor, see this simple mnemonics from the site.

D Drugs, Drugs, Drugs
E Eyes, ears 1
L Low 02 (MI, ARDS, PE, CHF, COPD)2
I Infection
R Retention (of urine or stool), Restraints
I Ictal
U Underhydration/Undernutrition
M Metabolic
(S) Subdural, Sleep deprivation

1 Poor vision and hearing are considered more risk factors than true causes, but should be "fixed" or improved if possible. Cerumen is common cause of hearing impairment.

2 "Low 02 states" does NOT necessarily mean hypoxia, rather it is a reminder that patients with a hypoxic insult (e.g. Ml, stroke, PE) may present with mental status changes with or without other typical symptoms/signs of these diagnoses.
posted by ICU room Pearls @ 6:03 AM 0 comments

Sunday, February 26, 2006
haimi
Sunday February 26, 2006
Hypomagnesemia and IV Magnesium (Mg) infusion

Hypomagnesemia has been reported in upto 60% of ICU patients and sometimes can be clinically very significant like in recovery phase of DKA (diabetic ketoacidosis). Symptoms of severe hypomagnesemia (less than 1 mEq/L) include respiratory failure, hyperactive deep-tendon reflexes, muscular fibrillations, mental status changes, tetany, seizures, positive Chvostek and Trousseau signs. EKG manifestations are prolong PR interval, widened QRS complex, ST depression, altered T waves and last but not the least is loss of voltage. About 33% of serum magnesium is protein-bound but unfortunately wide-spread test for free or active (ionized) magnesium is not available. It is a common practice to write IV Mg orders in grams or mls.

1 gram of IV Mg contains 8.12 meq of Mg and 1 meq of Mg provides 12 mg of elemental Mg.
One ml MgSO4 50% Solution = 4 meq Magnesium
One ml MgSO4 10% Solution = 8 meq Magnesium

Rapid IV administration can induce life threatening cardiac dysrhythmias, hypotension, flushing, sweating, sensation of warmth and hypocalcemia. In non-emergent cases, general rule of thumb is to infuse 1 gram per 1 hour. In risky situations, like impending arrhythmia, 2 grams of IV Magnesium sulfate may be given over 20 minutes. In extremely emergent cases 2 grams (16 mEq) of IV MgSO4 may be administered over 5 minutes and actually may be given as IV push if there is no permission of time.

In Preeclampsia, load IV 4-6 grams of MgSO4 in 100 ml of D5W over 20-30 minutes and maintenance is 2-3 grams/hour with close monitoring of target level (goal of 4-7 mEq/L) and clinical manifestations like decrease deep tendon reflexes. It is not a bad idea to keep IV calcium at bedside during massive IV magnesium infusion as in preeclampsia. IV calcium is an antidote for magnesium overdose.

In kidney dysfunction, IV magnesium dose should be reduced by about 50%.
posted by ICU room Pearls @ 12:32 AM 0 comments

Saturday, February 25, 2006
dblranss
Saturday February 25, 2006
Difference between Lactate Ringer's and Normal Saline solutions

Lactated Ringer's Solution was invented about 125 years ago by a British physiologist Sydney Ringer and never lost a day in its popularity. Let see its difference from normal saline.

Normal Saline is the solution of 0.9% NaCl. It has a slightly higher degree of osmolality compared to blood. One litre of Normal Saline contains

154 mEq/L of Na+ and
154 mEq/L of Cl−

One liter of Lactated Ringer's Solution contains:

130 mEq/L of Na+ but total cations of 137 mEq/L , so still is isotonic.
109 mEq/L of Cl−
28 mEq/L of lactate
4 mEq/L of potassium
3 mEq/L of calcium.

Lactate converts to bicarbonate in liver.

Pearl: Patients with lactic acidosis usually have inadequate liver metabolism of lactate so conversion to HCO3- from the infused lactate of LR is impaired and may give false readings of serial lactate measurements but may be a better choice in regular situations where hyperchloremia restricts use of normal saline.
posted by ICU room Pearls @ 8:03 AM 0 comments

Friday, February 24, 2006
Intraabdominal compartment syndrome
Friday February 24, 2006
Grading of Intra-abdominal Hypertension (intra-abdominal compartment syndrome)


Burch and co. defined a grading system of IAH :

Grade I (10-15 cmH2O),
grade II (15-25 cmH2O),
grade III (25-35 cmH2O) and
grade IV (>35 cmH2O).


With massive fluid resuscitation as part of critical care management, intensivists need to be constantly cautious of this complication. End-organ damage has been described with bladder pressure as low as 10 cm H2O. Intra-abdominal Hypertension is defined as sustained or repeated pressure more than/= 12 and Intra-abdominal compartment syndrome as sustained or repeated pressure more than/= 20.

Although bladder pressure is not the accurate method of diagnosing IAH but so far has been used as standard due to its bedside ease. Dr. Cheatham has proposed APP (Abdominal Perfusion Pressure) as better indicator with formula

APP = MAP- IAP (like CPP = MAP - ICP).
where MAP is mean arterial pressure and IAP is intra-abdominal pressure.

Intra-abdominal Hypertension is defined as sustained or repeated APP less than or = 60

See good review here with details of how to measure bladder pressure to diagnose Intra-abdominal Hypertension from euroanesthesia.org (Dr. MALBRAIN - Hôpital Sainte Elisabeth, Bruxelles, Belgium).

Another review article here from emedicine.com (Dr. Paula Richard).


Referencss: Click to get abstract /article
1. The abdominal compartment syndrome. - Burch JM, Moore EE, Moore FA, Franciose R Surg Clin North Am. 1996 Aug;76(4):833-42.
2. Abdominal Perfusion Pressure: A Superior Parameter in the Assessment of Intra-abdominal Hypertension Journal of Trauma-Injury Infection & Critical Care. 49(4):621-627, October 2000.


posted by ICU room Pearls @ 8:24 AM 0 comments

Thursday, February 23, 2006
caabp
Thursday February 23, 2006
Community-Acquired Acinetobacter baumannii Pneumonia !


As we are seeing more and more nosocomial infections moving out in community, recently chest has reported the largest series of CAP-AB (community-acquired pneumonia - Acinetobacter baumannii ) - and comparing its severity to HAP-AB (hospital-acquired pneumonia -Acinetobacter baumannii). 19 cases of CAP-AB has been compared to 74 cases of HAP-AB. Risk factors for CAP-AB were ever-smokers and COPD patients. It was characterized by more positive blood cultures (31.6% vs 0%), a higher frequency of ARDS (84.2% vs 17.6%), and DIC (57.9% vs 8.1%). The median survival time was only 8 days in the CAP-AB group vs 103 days in the HAP-AB group (p = 0.003). CAP-AB described to have a fulminant course, with an acute onset of dyspnea, cough, and fever that rapidly progresses to respiratory failure and shock. As discussed further in article, it may be important to consider empirical coverage for CAP-AB with presence of risk factors.

Earlier series of 13 patients were studied and read this interesting conclusion: "A baumannii should be considered as a possible etiologic agent in community-acquired lobar pneumonia when (1) patients with a fulminant course present during the warmer and more humid months of the year, and (2) patients are younger alcoholics".


Referencss: Click to get abstract/article (second popup overrides first popup)

1. Fulminant Community-Acquired Acinetobacter baumannii Pneumonia as a Distinct Clinical Syndrome - Chest. 2006;129:102-109
2. Severe Community-Acquired Pneumonia due to Acinetobacter baumannii Chest. 2001;120:1072-1077
posted by ICU room Pearls @ 9:35 AM 0 comments

Wednesday, February 22, 2006
cnucofks
Wednesday February 22, 2006
Colonic Necrosis - unusual complication of Kayexalate-Sorbitol


We are using sodium polystyrene sulfonate (SPS or Kayexalate) since last 45 years with great confidence. It is a common practice to add sorbitol to dissolve Kayexalate mainly to avoid fecal impaction or possible bowel obstruction. (Kayexalate binds intraluminal calcium and may cause constipation, fecal impaction or bowel obstruction). One of the relatively unknown complication of Kayexalate-sorbitol combination is colonic necrosis, although has been reported in literature earlier. The exact reason for colonic necrosis is not clear but the diagnosis can be made by the pathologic examination of post-operative specimen or material from endoscopic biopsy and may require specialized expertise and special stains. Sorbitol part is taught to be responsible for complication.

Intensivist need to be wary of possible complication of acute abdomen after administration of kayexalate-sorbitol in 1% of cases, particularly in first 24-36 hours.


See interesting review (full text and references) here from medscape.com with free registration. Originally, published at Southern Medical Journal , 93(5): page numbers 511-513, 2000.

posted by ICU room Pearls @ 8:29 AM 0 comments

Tuesday, February 21, 2006
sasb
Tuesday February 21, 2006
Shock alert - Shock bed

In nontraumatic shock, timing is everything as proved again by this organized hospital approach from Dr. Sebat and coll.

As a first step of program - 2.5 years of planning and 1 month of intensive education done for early recognition and treatment of shock. Prehospital personnel, nurses, and physicians were empowered to mobilize a Shock Alert depending on screening criteria. Shock bed was made available in ICU all the time. (please see article below for full inclusion, exclusion criteria and protocol details). In second phase, 86 and 103 patients were randomized to the control and protocol groups. The protocol group had significant reductions in the median times to interventions, as follows:

intensivist arrival time - decreased from 120 minutes to 50 minutes
ICU admission - decreased from 167 minutes to 90 minutes
2 L fluid infused - decreased from 232 minutes to 105 minutes
Pulmonary artery catheter placement - decreased from 230 minutes to 130 minutes

Result: The hospital mortality rate was 40.7% in the control group and 28.2% in the protocol group (p = 0.035).


Reference: Click to get abstract/article
A Multidisciplinary Community Hospital Program for Early and Rapid Resuscitation of Shock in Nontrauma Patients - Chest. 2005;127:1729-1743
posted by ICU room Pearls @ 8:28 AM 0 comments

Monday, February 20, 2006
crusade
Monday February 20, 2006
CRUSADE: Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines.

CRUSADE is a national quality improvement initiative that is designed to increase the practice of evidence-based medicine for patients diagnosed with non-ST segment elevation acute coronary syndromes (unstable angina or NSTE myocardial infarction). It has now over 400 participating sites in the US.
Being an intensivist, beside guidelines and other resources available at site following tools (click to get) may be very helpful.

1. QI Clearinghouse is an extensive collection of tools like
Standing Orders for the Management of Non-ST-segment Elevation (NSTE) ACS
GPIIb-IIIa Dosing Charts

2. The Performance Indicators Record - Acute Care

3. The Reference Guidelines Flipchart,

posted by ICU room Pearls @ 9:31 PM 0 comments

Sunday, February 19, 2006
robtl
Sunday February 19, 2006
Ratio of Bumex (Bumetanide) to Lasix (Furesmide)

What is the conversion equivalence of Bumex to Lasix?
1 mg of Bumex is equal to 40 mg of Lasix.
posted by ICU room Pearls @ 1:45 PM 0 comments

Saturday, February 18, 2006
dd
Saturday February 18, 2006
Delphi definition - new clinical definition of acute respiratory distress syndrome (ARDS)

Beside 2 definitions of ARDS used commonly - the American-European consensus conference definition and the lung injury score, a relatively new definiation - Delphi definition- developed and published last year in Journal of Critical Care and appears to have better specificity.

According to Delphi definition, ARDS is diagnosed if 1- 4 of below present with 5a and/or 5b:

1. PaO2/FiO2 ratio is less than or = 200 on PEEP more than or= 10.

2. Bilateral airspace disease on CXR.

3. Onset is within 72 hours.

4. No clinical evidence/subjective finding of CHF.

5a. Objective finding of non-cardiogenic edema (PWP less than or=18 or LVEF more than or=40%)

5b. Presence of risk factor for ARDS.

In one of the recent study where autopsy results were matched with clinical diagnoses to determine and compare the diagnostic accuracy of all three clinical definitions of ARDS, the specificity of the most commonly use, the American-European definition, was low.


References: Click to get article/abstract
1. Development of a clinical definition for acute respiratory distress syndrome using the Delphi technique. Volume 20, Issue 2, Pages 147-154 (June 2005) - caution of slow internet download
2. Acute respiratory distress syndrome: Underrecognition by clinicians and diagnostic accuracy of three clinical definitions. Critical Care Medicine: Volume 33(10) October 2005 pp 2228-2234

posted by ICU room Pearls @ 9:45 PM 0 comments

Friday, February 17, 2006
me
Friday February 17, 2006
38,000 medication errors in 4 years - only in ICUs !!

The United States Pharmacopeia (USP)* announced the largest national data set of Intensive Care Unit (ICU) medication errors. These causes are identified in the 6th annual MEDMARX® Data Report. MEDMARX, operated by USP, is an anonymous, internet-accessible program used by hospitals and related institutions nationwide to report, track, and analyze medication errors. Since its inception in 1998, MEDMARX has received more than one million reports of medication errors from more than 850 healthcare facilities across the U.S. From 2000-2004, the number of reported errors that occurred in ICUs was 38,371. Reasons include orders that were incomplete or incorrect, illegible handwriting, using abbreviations that were misinterpreted, improper use of IV pumps and a lack of familiarity with some drug information. The big 3 culprits are:

1. 24.4% errors originated during the prescribing.
2. 24% during transcribing of the order.
3. 11% are due to incorrect programming of IV pumps.

It is reported that mix-ups in the IV tubing during pump set-up or mix-ups in programming the infusion rates for each drug have resulted in serious harm.

* USP is a self-sustaining nonprofit, independent, science-based public health organization. USP is the official public standards-setting authority for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States.


Reference: Click to get abstract/article
1. USP news center
posted by ICU room Pearls @ 9:12 AM 0 comments

Thursday, February 16, 2006
pms
Thursday February 16, 2006
PAC-MAN study !

Benefits of pulmonary artery catheter (PAC) are debatable in Critical Care. Last year ESCAPE trial 2 failed to show any benefit. Untill we get results of FACTT trial (ARDSnet), lets have a look on PAC-MAN study. (Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care) published in Lancet, last year (august 2005 issue). 1 This is one of the largest study of 1013 patients in this regard. Patients were compared to management with (n = 506) or without (n = 507) a PAC with primary end-point of hospital mortality. No difference in hospital mortality between subjects managed with or without a PAC was noted - 68% vs 66%. Complications associated with insertion of a PAC were noted in 46 of 486 patients but none were considered fatal.

In subsets analysis, of patients randomized to receive either a PAC or no monitor of cardiac output, mortality was 71% [75 of 105] vs. 66% [71 of 107] and of patients randomized in ICUs allowing the possibility of an alternative monitor of cardiac output, mortality was 68% [271 of 401] vs. 66% [262 of 400].

In conclusion, there was no clear evidence of benefit or harm in managing critically ill patients with a PAC.

Related previous pearl: ESCAPE Trial - setback to swan lovers?




References: Click to get abstract/article (secondpopup override first popup)

1. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial - Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, Brampton W, Williams D, Young D, Rowan K, The Lancet - Vol. 366, Issue 9484, 06 August 2005, Pages 472-477 - (abstract-review printed at cleveland clinic journal of medicine, november 2005 page 1048)
2. Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness - JAMA. 2005;294:1625-1633.
3. Impact of the Pulmonary Artery Catheter in Critically Ill Patients -JAMA. 2005;294:1664-1670.
posted by ICU room Pearls @ 9:22 AM 0 comments

Wednesday, February 15, 2006
lre
Wednesday February 15, 2006
Linezolid-resistant enterococcus (LRE!)

This study was presented at Infectious Disease Society of America meeting 2005 from Dr. Devasia. Fifteen patients in a 500-bed teaching hospital were diagnosed with Linezolid(Zyvox)-resistant enterococcus during 13 months of study. In a comparison of these patients with 60 control patients with Linezolid-sensitive enterococcus, the resistant cases had a significantly higher mortality rate - 40% vs 7%. Interestingly, 8 LRE patients were vancomycin sensitive enterococcus but what make it thought-provoking, 8 cases out of 15 had no prior exposure to Linezolid. As expected, length of stay was way higher (35 days vs 11 days) but scary part is - median age of patients was only 54 years (vs 65 years for control).

Are younger patients more prone to LRE even without prior exposure? Are we up for another battle against microbes?. Atleast one thing is sure, its time for very judicious use of Linezolid.

To note, similar related report was published about 4 years ago in NEJM.


References: Click to get abstract/article (secondpopup override first popup)
1. Abstracts Infectious Disease Society of America Meeting 2005 - Scroll down to page 238 (abstract # 1079) - may take little time to download due to big pdf file.
2. Nosocomial Spread of Linezolid-Resistant, Vancomycin-Resistant Enterococcus faecium - NEJM, March 14, 2002 Volume 346:867-869
posted by ICU room Pearls @ 8:40 AM 0 comments

Tuesday, February 14, 2006
Lasa
Tuesday February 14, 2006
What are LASA drugs


Many studies have shown so far that errors in administration of drugs remain high and actually twice in ICUs. In this regard, its important to know the term LASA medications. LASA are "look-alike sound-alike" medications and are responsible for 12.5 percent of the medication errors reported to the FDA. Other factors making it worse include illegible handwriting, look alike packaging, unclear verbal directions, similar pronunciation etc etc. We all went through the experiences of confusion between dopamine and dobutamine, phenylephrine and norepinehrine, heparin and hespan, primacor and primaxin, diflucan and diprivan and so on. Institutions are taking initiatives like computer based drug entry, verbal read backs, automated alerts, advise to prescribers to write both the brand and generic name on problematic drugs or to include the intended purpose of the medication. Make sure your institution is working on this issue as JCAHO has now made LASA drugs part of its National Patient Safety Goals and institutions are expected to prepare organisational list of LASA drugs.

Click here to read position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services.


Related previous Pearls:

1. ICU satellite pharmacy
2. Preventing intra-venous (IV) drip errors
3. "Five Rights"

Reference:
Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units Critical Care Medicine. 25(8):1289-1297, August 1997.
posted by ICU room Pearls @ 8:43 AM 0 comments

Monday, February 13, 2006
rdf
Monday February 13, 2006
Renal dose Fenoldopam ?

We are done with renal dose dopamine but than we heard about renal dose norepinephrine1 and now renal dose fenoldopam? Look at this study of 300 septic patients with baseline serum creatinine concentrations less than 150 umol/L (2 mg/dL)*.

150 patients with a continuous infusion of fenoldopam at 0.09 μg·kg-1·min-1 (nonhemodynamic dose) has been compared with 150 placebo patients. The primary outcome measure was the incidence of acute renal failure, defined as a serum creatinine concentration increase to >150 μmol/L (>2 mg/dL), during study drug infusion. The incidence of acute renal failure was significantly lower in the fenoldopam group compared with the control group (29 vs. 51 patients; p = .006). Also, the length of ICU stay in surviving patients was significantly lower in the fenoldopam group compared with the control group (10.64 vs. 13.4; p < .001). Its not clear why fenoldopam which is also a dopaminergic agonist like low-dose dopamine, has protective effect on kidney but dopamine does not. We need a large multiple-center trial to have more answers.

* 1 mg/dL = 88.4 mol/L of serum Cr.

References:Click to get article/abstract (second popup overwrites first popup)
1. Renal Dose Norepinephrine! - Chest. 2004;126:335-337
2. Prophylactic fenoldopam for renal protection in sepsis: A randomized, double-blind, placebo-controlled pilot trial - Critical Care Medicine: Volume 33(11) November 2005 pp 2451-2456


posted by ICU room Pearls @ 8:49 AM 0 comments

Sunday, February 12, 2006
coaii
Sunday February 12, 2006
Cycling of Antibiotics in ICU

Concept of antibiotics cycling to reduce antibiotics resistance remains debatable in medical literature. 2 recent papers earlier showed it may not work.1,2 But a new study of 346 patients from spain (comparing mixing in one ICU vs cycling in another ICU) published this month in Critical Care Medicine points that this may actually have some potential.

Patients, who according to the physician's judgment required an anti-Pseudomonas drug, were assigned to receive 1) cefepime/ceftazidime 2) ciprofloxacin 3) a carbapenem or 4) piperacillin-tazobactam in this order. Cycling was accomplished by prescribing one of these antibiotics during 1 month each. 2 cycles were given of 4 months each. Mixing was accomplished by using the same order of antibiotic administration on consecutive patients. The main outcome variable was the proportion of patients acquiring enteric or nonfermentative Gram-negative bacilli resistant to the antibiotics under intervention.

During mixing, a significantly higher proportion of patients acquired a strain of Pseudomonas aeruginosa resistant to cefepime (9% vs. 3%, p = .01), and there was a trend toward a more frequent acquisition of resistance to ceftazidime (p = .06), imipenem (p = .06), and meropenem (p = .07).

Read precise review on different point of views in this regard here posted in pulmonaryreviews.com, september 2002 issue. Till we get more data to accept antibiotic cycling as a standard practice, lets concentrate on two basic themes - avoid unnecessary antibiotic use and prevent cross-transmission of pathogens.


References: Click to get article/abstract (second popup overwrites first popup)
1. Ecological theory suggests that antimicrobial cycling will not reduce antimicrobial resistance in hospitals - Proceedings of the National Academy of Sciences of the United States of America - PNAS September 7, 2004 vol. 101 no. 36 13285-13290
2. Antibiotic Rotation and Development of Gram-Negative Antibiotic Resistance - American Journal of Respiratory and Critical Care Medicine Vol 171. pp. 480-487, (2005)
3. Comparison of antimicrobial cycling and mixing strategies in two medical intensive care units. -Critical Care Medicine. 34(2):329-336, February 2006.
4. Antibiotic cycling in intensive care units: The value of organized chaos? - Bonten, Marc J. M. MD; Weinstein, Robert A. MD- Critical Care Medicine: Volume 34(2) February 2006 pp 549-551

posted by ICU room Pearls @ 8:21 AM 0 comments

Saturday, February 11, 2006
moettwn
Saturday February 11, 2006
Movement of endotracheal tube (ETT) with neck


Extension of neck (Chin up) will cause ETT to migrate (up or down) ?
Ans.: ____________
Flexion of neck (Chin down) will cause ETT to migrate (up or down) ? Ans.: ____________




Answers:
Extension of neck (Chin up) will cause ETT to migrate up.
Flexion of neck (Chin down) will cause ETT to migrate down.

Remember: Chin up - ETT up. Chin down - ETT down.

posted by ICU room Pearls @ 7:28 AM 0 comments

Friday, February 10, 2006
nod
Friday February 10, 2006
Norepinephrine or Dopamine ?

Standard guidelines regarding vasopressor and inotropic support in septic shock states: "Either norepinephrine or dopamine (through a central catheter as soon as possible) is the first-choice vasopressor agent to correct hypotension in septic shock." But overall trend is going towards using norepinephrine as the first-choice vasopressor to correct hypotension in septic shock after fluid resuscitation. In a recent study from Rush University Medical Center, Chicago, IL the safety of Dopamine (DA) versus Norepinephrine (NE) as vasopressor therapy in septic shock has been compared. Sixty-six patients, 35 DA and 31 NE, has been compared. Though there was no significant difference in mortality cardiac dysrhythmias occurred in 31.4% of the DA group compared to only 3.2% for NE (p=0.003). But important aspect of study was, all cardiac dysrhythmias required an intervention.

Related Pearls:
1. Renal Dose Norepinephrine !
2. Dopamine-S and Dopamine-R patients ?

References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).
1. Vasopressor and inotropic support in septic shock: An evidence-based review Critical Care Medicine: Volume 32(11) Supplement November 2004 pp S455-S465
2. THE SAFETY OF DOPAMINE VERSUS NOREPINEPHRINE AS VASOPRESSOR THERAPY IN SEPTIC SHOCK - chest, 2005

posted by ICU room Pearls @ 10:01 PM 0 comments

Thursday, February 09, 2006
JCAHO "DNU" abbreviations
Thursday February 9, 2006
Basic housekeeking - JCAHO mandated "Do Not Use" abbreviations

As intensivists are assuming more and more leadership and role model figure in hospitals, here are the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) mandated "Do Not Use" abbreviations - meeting NPSG (National Patient Safety Goals) Requirement 2B. Please note 3 important points:

1. The minimum expected level of compliance for handwritten documentation and free-text entry is 90 % and for pre-printed forms is 100 %.

2. Clarification of an order prior to implementation and after-the-fact correction of the order by the clinician does not eliminate that occurrence from being counted. (If pharmacy or nurse calls you to clarify the order its an 'occurance').

3. One occurrence equals one per clinician per record and three occurrences equal a Requirement for Improvement.

Here is the JCAHO mandated "Do Not Use" abbreviations


Do not write U or IU - Write "unit" or "international unit".
Do not write Q.D., Q.O.D. - Write "once daily and every other day".

Never write a zero by itself after a decimal point (5 mg instead of 5.0 mg), and always use a zero before a decimal point ( 0.5 mg instead of .5 mg).

Do not write MS or MSO4 - Write "morphine sulfate".
Do not write MgSO4 - Write "magnesium sulfate".


posted by ICU room Pearls @ 6:11 PM 0 comments

Wednesday, February 08, 2006
EGDE
Wednesday February 8, 2006
EARLY GOAL-DIRECTED ECHOCARDIOGRAPHY !

Dr. Anthony Manasia and Coll. from Mount Sinai School of Medicine, New York, NY, have introduced this term in one of their paper presented at American College of Chest Physicians (ACCP) meeting last year at Montreal, Canada. Based on their study of 18 patients, they claim that the first echo (done within 5-6 hours of admission) changed the treatment plan in 38.8% (7/18) of the circulatory shock patients when compared to the initial management instituted by the primary ICU team. The treatment plan was changed in 11.7% (2/17) of patients following the second echo exam (done 24 hours later). The echocardiographic exam was performed by an echo-trained intensivist not involved in the patient’s care. But similar kind of retrospective observational study of 100 patients in medical ICU, 2 years back from Mayo Clinic, Rochester, MN failed to show any impressive result but to note time-period of echo was within 48 hours.

Does ultra early echo in shock patients really make difference in 38.8% of patients ?. May be its time for a bigger study.



References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).
1. CLINICAL IMPACT OF EARLY GOAL-DIRECTED ECHOCARDIOGRAPHY IN SHOCK PATIENTS PERFORMED BY NON-CARDIOLOGIST INTENSIVISTS - chest, 2005
2. Echo in the Medical Intensive Care Unit: Does It Really Impact Patient Management? A Retrospective Observational Study - chest, 2003
posted by ICU room Pearls @ 8:34 AM 0 comments

Tuesday, February 07, 2006
BALTI
Tuesday February 7, 2006
Adrenergic Agonists in Acute Lung Injury - BALTI trial

ß2-Agonists remain the most important inhaled bronchodilators and provide rapid symptom relief for many patients. Short-acting, inhaled, selective ß2-agonists remain the mainstay bronchodilators for asthma, COPD, and airway obstruction of all etiologies. The use of B-adrenergic agonists as a potential therapy for acute lung injury has generated considerable interest. B-agonists have well-recognized antiinflammatory properties and treatment with a B-agonist have shown to enhances the rate of alveolar fluid clearance by increasing intracellular cAMP.

Perkins and colleagues report the results of a clinical trial of 40 patients with acute lung injury in which the effects of B-agonists were examined.1 Salbutamol (albuterol) was administered intravenously at a dose of 15 μg/kg/hour in a double-blind, randomized manner. Extravascular lung water on Day 7, the primary outcome variable, was lower in the salbutamol-treated patients compared with the placebo control subjects (9.2 vs. 13.2 ml/kg, p = 0.04). Post hoc analysis indicated that extravascular lung water was significantly lower in the treated group at earlier time points as well. Plateau airway pressure was also 6 cm H2O lower at Day 7 in the salbutamol-treated group (p = 0.049), and there was a trend toward lower acute lung injury scores in the salbutamol-treated patients.

The results indicate that a multicenter clinical trial may be warranted to test the possible therapeutic benefit of B-agonist therapy for acute lung injury.


References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).
1. Perkins GD, McAuley DF, Thickett DR, , Gao F The b-agonist lung injury trial (BALTI): a randomized placebo-controlled clinical trial. Am J Respir Crit Care Med 2006;173:281–287
2. Matthay MA, Folkesson HG, Clerici C. Lung epithelial fluid transport and the resolution of pulmonary edema. Physiol Rev 2002;82:569–600.
3. McAuley DF, Frank JA, Fang X, Matthay MA. Clinically relevant concentrations of beta2-adrenergic agonists stimulate maximal cyclic adenosine monophosphate-dependent airspace fluid clearance and decrease pulmonary edema in experimental acid-induced lung injury. Crit Care Med 2004;32:1470–1476.

posted by ICU room Pearls @ 8:26 AM 0 comments

Monday, February 06, 2006
tightglycemiccontrolwhereweare
Monday February 6, 2006
Tight glycemic control - where we are ?

This week New England Journal of Medicine has published the second part of Dr. Van den Berghe's Intensive Insulin Therapy. This study was done on 1200 patients in medical ICU. As you may remember, her first study of 1548 patients was done in surgical unit and had shown decrease in morbidity as well as mortality. Her present study from medical ICU, though showed significant reduction in morbidity but failed to show any decrease in mortality. But most surprising part of the study, was the analysis of the subset of patients who stayed in the ICU for less than three days. Mortality was actually greater among those patients with intensive insulin therapy. We don't know yet as this data is reproducible or there are other explanations for this result such as early limitations or withdrawals of care. Also to remember, VISEP study from germany which was designed to randomize 600 subjects with medical or surgical severe sepsis to conventional or intensive insulin therapy, was stopped after recruitment of 488 subjects because of no difference in mortality and frequent hypoglycemia in the intensive insulin therapy arm.

What should we do till reults of other major studies like GLUControl (3000 patients) or NICE - SUGAR (5000 patients) are pending. Here are couple of good advises.

1) As Dr. Atul Malhotra wrote in editorial of same issue of NEJM - "In my opinion, a reasonable approach would be to provide adequate exogenous insulin to achieve target glucose values of less than 150 mg per deciliter (8.3 mmol per liter), at least during the first three days in the ICU. If critical illness persists beyond three days despite the provision of other proven therapies and resuscitation, a goal of normoglycemia (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) could then be considered, to maximize the potential benefits". OR

2). Dr. Angus and Abraham suggested last year: "..it may be valuable to remember that, although the evidence for tight glycemic control does not yet support a grade A recommendation, it does appear to be stronger than that for continuing our existing practice of tolerating hyperglycemia. Thus, we should probably explore ways to introduce some form of tight glucose control during this interim period that seems feasible and safe given local considerations. Once better evidence is available, we can modify our plans accordingly."



References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup).
1. Intensive Insulin Therapy in the Medical ICU - NEJM, Feb. 2, 2006, Volume 354:449-461
2. Intensive Insulin Therapy in Critically Ill Patients - N Engl J Med 2001; 345:1359-1367, Nov 8, 2001
3.Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia - results from a randomized multicenter study (VISEP), Infection 2005;33: 19-20.
4. Glucontrol Study: Comparing the Effects of Two Glucose Control Regimens by Insulin in Intensive Care Unit Patients -clinicaltrials.gov
5. Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE - SUGAR STUDY) - clinicaltrials.gov
6. Intensive Insulin in Intensive Care - Volume 354:516-518, NEJM, feb. 2, 2006
7. Intensive Insulin Therapy in Critical Illness, Angus and Abraham Am. J. Respir. Crit. Care Med..2005; 172: 1358-1359
posted by ICU room Pearls @ 8:37 AM 0 comments

Sunday, February 05, 2006
metoprololpoivconversion251isamyth
Sunday February 5, 2006
Metoprolol PO:IV conversion - 2.5:1 is a myth ?

IV metoprolol is not FDA-approved for treatment of hypertension but it is in common use and general rule of conversion from PO to IV form is 2.5:1. This comes from a study on 5 healthy volunteers about 30 years ago.

Be aware, this is not the standard by any means. Literature shows coversion effect ranging from 2:1 to 5:1. It may be more safe to disregard any formula and to use initial dosage from 1.25-5 mg and subsequent dosage and frequency depending on the clinical response.


For more detailed discussion and further references, click here to read article from medscape.com (available with free registration) - Am J Health-Syst Pharm 60(2):189-191, 2003
posted by ICU room Pearls @ 10:27 AM 0 comments

Friday, February 03, 2006
arewedoctorsmostresistanttochange
Saturday February 4, 2006
Are we doctors most resistant to change?

This month's issue of Critical Care Medicine has published an article on physicians lack of embracing of low tidal volume despite clear and proven benefits from Arma trial of ARDSnet. Interestingly, this study (n=88 patients) was done at an ARDSnet participating university hospital. Patients who were ventilated with a tidal volume ≤7.5 mL/kg PBW 2 days after meeting criteria for ALI was only 39% and at day 7 only 56% of patients. During this study, physicians ordered the lung-protective ventilation protocol on only 16% of patients by day 2. In another earlier study to identify the barriers to the implementation of lung-protective ventilation - nursing and respiratory therapy staff at ten ARDSnet centers point finger to physicians' unwillingness to follow a ventilator protocol or recognize the patient as having ALI/ARDS.

Its almost 6 years since ARDSnet study was published and we are still having problem accepting the clear benefit ! Its time to read again famous JAMA article from 1999: " Why don't physicians follow clinical practice guidelines?.." and few major problems were deficits in physician knowledge, attitude difficulties, inertia of previous practice and behavioral issues !!!.

Note: Article from CCM-02'06 also tried to postulate various reasons of this lack of embracing of low tidal volume on available data, which can be found in full content of article and it includes possible fears of side effects from this approach or may be due to the anticipation of rapid recovery by patients with less severe disease.

References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)
1. Underuse of lung protective ventilation: Analysis of potential factors to explain physician behavior - Critical Care Medicine. 34(2):300-306, February 2006.
2. Prospective, Randomized, Multi-Center Trial of 12ml/kg Tidal Volume Positive Pressure Ventilation for Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) - ardsnet.org
3. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - NEJM May 2000, Volume 342:1301-1308
4. Rubenfeld G, Caldwell E, Hudson L: Publication of study results does not increase use of lung protective ventilation in patients with acute lung injury. Am J Respir Crit Care Med 2001; 163:A295
5. Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement - JAMA. 1999;282:1458-1465. - full article available with free registration
posted by ICU room Pearls @ 11:07 PM 0 comments

systemiccapillaryleaksyndrome
Friday February 3, 2006
Systemic capillary leak syndrome

Capillary leak syndrome was described first time about 45 years ago. Being an intensivist, it is an important entity to know as episode is often preceded by shock syndromes, low-flow states, infection, ischemia-reperfusion injuries, toxemias, or poisoning and fallout is usually Multiple system organ failure (MSOF). Cause and pathophysiology is still not clear but most cases have been found associated with monoclonal gammopathy, generally an IgG class. Capillary leak syndrome as name says is due to capillary hyperpermeability with massive extravasation of plasma macromolecules and acute phase usually lasts for 1-4 days. Clinical features are abdominal pain, generalized edema, hypotension with possible cardiopulmonary collapse. Acute renal failure is due to hypovolemia and rhabdomyolysis. 6 Now here is the tricky part. Acute phase is followed by recruitment of the initially extravasated fluid causing intravascular overload marked by polyuria and/or pulmonary edema. Edema is usually proportional to earlier fluid resuscitation !. Treatment with Terbullatine and Theophylline has been suggested. 3

References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)
1. An unusual evolution of the systemic capillary leak syndrome -Nephrol Dial Transplant (2002) 17: 492-494
2. Capillary leak syndrome - orpha.net
3. Treatment of the Systemic Capillary Leak Syndrome with Terbutaline and Theophylline: A Case Series - annals 1 June 1999 Volume 130 Issue 11 Pages 905-909 -full pdf article available with free registration.
4. Systemic Capillary Leak Syndrome - Internal Medicine 41: 953?956, 2002, The Japanese Society of Internal Medicine
5. Lethal capillary leak syndrome after a single administration of interferon beta-1b - Neurology 1999;53:220
6.Idiopathic capillary leak syndrome complicated by massive rhabdomyolysis - Chest, Vol 104, 123-126
7. Lethal systemic capillary leak syndrome associated with severe ventilator-induced lung injury: An experimental study.- Critical Care Medicine. 31(3):885-892, March 2003.
posted by ICU room Pearls @ 9:15 PM 0 comments

Wednesday, February 01, 2006
cpm
Thursday February 2, 2006
What's new on Central pontine myelinolysis (CPM)

Central pontine myelinolysis, a demyelinating disorder of central pons charaterized by pseudobulbar palsy and spastic quadriplegia, is co-diagnosed by specific MRI findings under know clinical settings or risk factors. Specific MRI findings are increased signal in the central pons on fluid-attenuated inversion recovery images (FLAIR) and hypointense lesions on T1-weighted images. 5 decades ago it was described in chronic alcoholism but over the time it was found in association with malnourished status, renal failure, diabetes mellitus, and post-orthotopic liver transplantation and came to known as hallmark of rapid correction of hyponatremia - but in recent years it has been reported with hypophosphetemia and in DKA (Diabetes Ketoacidosis) despite normal sodium level or no rapid correction of sodium. Treatment is supportive and prognosis thought to be universally fatal. In recent years there are reports of good recovery and long-term survival with proper supportive management.

See nice review article Central Pontine Myelinolysis from emedicine.com


References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)
1. Central Pontine Myelinolysis Following Hemodialysis - grand round at Depatment of Medicine, Maulana Azad Medical College, New Delhi
2. MR imaging of seven presumed cases of central pontine and. extrapontine myelinolysis. -Acta Neurobiol. Exp. 2001, 61: 141-144.
3. Management and Treatment of Psychotic Manifestations in Older Patients with Alcoholism: Part II - Clinical Geriatrics: 2004;12[5]:33-40
4. Central pontine myelinolysis temporally related to hypophosphataemia - Journal of Neurology Neurosurgery and Psychiatry 2003;74:820
5. Central pontine myelinolysis in a patient with diabetic ketoacidosis - The Journal of Critical Illness - Vol. 20, No. 4 - December 2005
6. Parkinsonism and recovery in central and extrapontine myelinolysis - Neurology India, Vol. 53, No. 2, April-June, 2005, pp. 219-220
posted by ICU room Pearls @ 10:33 PM 0 comments

NMB
Wednesday February 1, 2006
Sedation in Neuro-muscular blockade patients


This month issue of American Journal of Critical Care (see reference # 1) has published interviews of 11 patients to determine and describe the remembered experiences, who were given neuromuscular blocking agents (8=vecuronium 3=cisatracurium) and sedatives and/or analgesics (4=propofol 4=midazolam 3=lorazepam) while they were in ICU. Interview was designed with 4 themes.


1) The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams.
2) The second theme was loss of control; the 2 subthemes were fighting or being tied down and being scared.
3) The third theme was almost dying, and
4) The fourth theme was feeling cared for.


It was found that, though patients can have positive recollections of nursing care, they can clearly recall experiences that were frightening and unpleasant, recurrent dreams or nightmares, avoidance of medical care and flashbacks or painful memories possibly leading to PTSD (posttraumatic stress disorder).


Are we doing a good job ?


Related:
Neuromuscular Blockade / Paralytics guidelines (SCCM 2002)
Sedation/Analgesia guidelines 2002 (SCCM)
Also see our previous pearl on Train of Four (TOF) and BIS monitoring

References / suggested readings: Click to get article/abstract
1. Patients’ Recollections of Therapeutic Paralysis in the Intensive Care Unit - American Journal of Critical Care. 2006;15: 86-94
2. Sedation and Neuromuscular Blockade in the ICU -Chest. 2005;128:477-479

posted by ICU room Pearls @ 1:30 AM 0 comments

Monday, January 30, 2006
IPV
Tuesday January 31, 2006
IPV - adjuvant therapy in COPD exacerbations ?

Interesting study of 33 patients, published from france last year on acute exacerbation of COPD. Inclusion and exclusion criteria were established (see reference # 1). Patients were randomly assigned to receive either standard treatment (control group) or standard treatment plus Intrapulmonary percussive ventilation (IPV group). The IPV group underwent two daily sessions of 30 minutes performed by a chest physiotherapist through a full face mask. Thirty minutes of IPV led to a significant decrease in respiratory rate, an increase in PaO2 and a decrease in PaCO2. Exacerbation worsened in 6 out of 17 patients in the control group versus 0 out of 16 in the IPV group. Therapy was tagged successful when both worsening of the exacerbation and a decrease in pH to under 7.35, which would have required non-invasive ventilation, were avoided. Also, the hospital stay was significantly shorter in the IPV group.

IPV is essentially a very effective technique to assist patients to clear retained endobronchial secretions and the resolution of diffuse patchy atelectasis. Please see full manual of IPV therapy from Dr. Bird's website here.

References / suggested readings: Click to get article/abstract
1. Intrapulmonary percussive ventilation in acute exacerbations of COPD patients with mild respiratory acidosis: a randomized controlled trial - Crit Care. 2005; 9(4): R382–R389
2. Effect of Intrapulmonary Percussive Ventilation on Mucus Clearance. in Duchenne Muscular Dystrophy Patients: A Preliminary Report - Respir Care 2003;48(10):940–947
3. A Comparison of Intrapulmonary Percussive Ventilation and Conventional Chest Physiotherapy for the Treatment of Atelectasis in the Pediatric Patient - Respir Care 2002:47(10):1162-1167
4. Airway Clearance in the ICU - rtmagazine.com - The Journal of Respiratory Care Practitioners, March 2005


posted by ICU room Pearls @ 11:05 PM 0 comments

Sunday, January 29, 2006
Aprotinin
Monday January 30, 2006
Should we abandon Aprotinin ?

The majority of patients undergoing cardiovascular surgery routinely receive antifibrinolytic therapy - aminocaproic acid, tranexamic acid or aprotinin during and after procedure to control bleeding. Very important and large study of 4374 patients published this week in New England Journal of Medicine from Ischemia Research and Education Foundation, comparing these three agents in cardiac surgery. Study found that the use of aprotinin was associated with a dose-dependent doubling to tripling in the risk of renal failure requiring dialysis among patients undergoing primary or complex coronary-artery surgery. Probable reason of this difference is aprotinin's high affinity for the kidneys. Also, for the majority of patients undergoing primary surgery, evidence of multiorgan damage involving the heart (myocardial infarction or heart failure) and the brain (encephalopathy) in addition to the kidneys found, suggesting a generalized pattern of ischemic injury. It has been suggested in article that the replacement of aprotinin with aminocaproic acid would prevent renal failure requiring dialysis in 11,050 patients per year globally, yielding an savings of more than $1 billion per year. Also to note, Aprotinin is way more expensive than other 2 agents.

Bonus Pearl: Action of captopril may get block with concurrent use of Aprotinin.

References / suggested readings: Click to get article/abstract
1. The Risk Associated with Aprotinin in Cardiac Surgery - NEJM Jan. 26, 2006 Volume 354:353-365
2. Is Aminocaproic Acid as Effective as Aprotinin in Reducing Bleeding With Cardiac Surgery? - Circulation. 1999;99:81-89
3. Hemostatic effects of aprotinin, tranexamic acid and aminocaproic acid in primary cardiac surgery - Ann Thorac Surg 1999;68:2252-2256
4. Tranexamic acid compared with high-dose aprotinin in primary elective heart operations: Effects on perioperative bleeding and allogeneic transfusions - J Thorac Cardiovasc Surg 2000;120:520-527
5. A Study of a Weight-Adjusted Aprotinin Dosing Schedule During Cardiac Surgery - Anesth Analg 2002;94:283-289

posted by ICU room Pearls @ 11:16 PM 0 comments

Saturday, January 28, 2006
whatislazarussyndrome
Sunday January 29, 2006
What is Lazarus Syndrome

Lazarus Syndrome is a generic term use in hospitals when patient shows sign of life after clinically declared dead, like a patient that develops vital signs after cessation of resusitative efforts or organ-donation team arrives to find a live person. The syndome is named after bible story in which Jesus brought back to life a dead person named Lazarus from his tomb. Term became very popular after publication of book "The Lazarus syndrome: Burial alive and other horrors of the undead" (Rodney Davies - 1978). In recent years, 'Lazarus Syndrome' has also been use for HIV/AIDS patients who feel having new chance of living with new HIV medications.
posted by ICU room Pearls @ 10:34 PM 0 comments

Xenical and Coumadin
Saturday January 28, 2006
Xenical and Coumadin

Last week FDA advisory panel voted to recommend that the regulatory agency approve the nonprescription form of weight reducing agent, Xenical (orlistat), which Glaxo would market as Alli. It may be of importance to know its possible effect with warfarin (coumadin), cyclosporin and amiodarone. Orlistat is a reversible inhibitor of lipases. It forms a covalent bond with gastric and pancreatic lipases. The inactivated enzymes are thus unavailable to hydrolyze dietary fat in the form of triglycerides into absorbable free fatty acids and monoglycerides. As a side effect deficiency of fat-soluble vitamins like Vitamin A, D, E and K may occur. Recommendation is to take a multi-vitamin two hours before Xenical. Patients on coumadin (warfarin) may have potential of bleed due to increase INR (as absorption of Vitamin K is decrease). We cannot find any mention in literature describing any such real case but frequent INR check is recommended for safety. Also to remember, Xenical can decrease the amount of cyclosporine and 25-30% reduction in systemic exposure to Amiodarone. Also, there may be some concern of electrolyte imbalance with associated diarrhea. But again, we didn't find any evidence-base literature against Xenical in our search but as xenical expects to do well as over-the-counter medicine, intensivists should be ready for any potential adverse arrival in hospital.

References: Click to see abstract/article

Mechanism of Action - Orlistat - Rxlist.com
Important Patient Information Patient Information about XENICAL - rocheusa.com
XENICAL - roche-australia.com
posted by ICU room Pearls @ 4:57 AM 0 comments

Friday, January 27, 2006
Friday January 27, 2006
Amiodarone Neurotoxicity !!

Amiodarone neurotoxicity has been reported in up to 40% and may easily get miss or misdiagnose when an elderly patient presents with multiple symptoms. Major manifestation are peripheral neuropathy causing proximal motor weakness, ataxia and fine resting tremor. It may also present as neuromyopathy. A case has been described with autonomic dysfunction presented as incapacitating orthostatic hypotension. Cases has been reported with Amiodarone-Induced Delirium . Most neurotoxicities are dose related and resolved with discontinuation of Amiodarone. Being an intensivist it may be important to keep this very common dose related toxicity in mind while evaluating patient with neurologic symptoms.

Related: our pearl on Amiodarone pulmonary toxicity.


References: Click to see abstract/article
1. Amiodarone-Induced Neuromyopathy: Three Cases and a Review of the Literature - Journal of Clinical Neuromuscular Disease. 3(3):97-105, March 2002.
2. Severe Ataxia Caused by Amiodarone - Volume 96, Issue 10, Pages 1463-1464 (15 November 2005) - Am J of Card
3. Amiodarone toxicity presenting as pulmonary mass and peripheral neuropathy: the continuing diagnostic challenge - Postgraduate Medical Journal 2006;82:73-75
4. Amiodarone: Guidelines for Use and Monitoring - aafp.org - Vol 68, No. 11, Dec., 2003
5. Atypical pulmonary and neurologic complications of amiodarone in the same patient. Report of a case and review of the literature - Vol. 147 No. 10, October 1, 1987 - Archive of Int Med.
6. Amiodarone-Induced Delirium - Am J Psychiatry 156:1119, July 1999


posted by ICU room Pearls @ 12:01 AM 0 comments

Thursday, January 26, 2006
Thursday January 26, 2006
Pearls of Hand Hygiene - Yaap !! - So Basic !! .

Following are the national standard guideline for Hand Hygiene from Healthcare Infection Control Practices Advisory Committee. Are we doing it right way?.

1. Wet hands first with water, apply an amount of product as recommended by the manufacturer, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

2. Rinse hands with water and dry thoroughly with a disposable towel.

3. Use towel to turn off the faucet.

4. Avoid using hot water (may increase the risk of dermatitis).

5. If bar soap is used, soap racks that facilitate drainage and small bars of soap should be used .

6. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings.

7. The cost of hand-hygiene products should not be the primary factor influencing product selection.

8. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap.

9. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in ICUs or ORs).

10. Keep natural nails tips less than 1/4-inch long.

11. Wash hands with soap and water if exposure to spores like Bacillus anthracis or C.diff. is suspected. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.

12. If hands are not visibly soiled, an alcohol-based hand rub may be use for routinely decontaminating hands.

13. Decontaminate hands also before inserting indwelling urinary catheters.

(Wearing rings is an unresolved issue but studies have shown increase bacterial growth beneath rings but no evidence yet on increase transmission).

Read full Guideline for Hand Hygiene in Health-Care Settings .
posted by ICU room Pearls @ 8:27 AM 0 comments

Tuesday, January 24, 2006
Wednesday January 25, 2006
Statins – Adjuvant Therapy for Sepsis

Statins are powerful hypolipemic drugs with pleiotropic effects and have been shown to improve survival in the primary and secondary prevention of atherosclerosis in numerous large randomized clinical trials. Interestingly, in many of these trials, their beneficial clinical impact included noncoronary events. Several cellular and animal models demonstrate the pleiotropic activity of statins, including anti-inflammatory and anti-oxidative properties, immunomodulatory effects, improvement in endothelial function, reduction in blood thrombogenicity, and increased nitric oxide (NO) bioavailability. Some or all of these effects may account for a substantial potential impact of statins on the complex pro- and anti-inflammatory sequence of events occurring during sepsis. A few clinical studies have been published recently in support of this hypothesis.

Almog et al. conducted a prospective observational cohort study to determine the impact of statin pretreatment on the occurrence of severe sepsis in infected patients. Of 361 patients with confirmed acute bacterial infection, 82 (23%) had been receiving statins for at least 4 weeks prior to their admission. The crude mortality rate was low and did not differ significantly between the two groups (3.7% vs. 8.6%, P=0.21), but severe sepsis developed in 2.4% and 19% of patients, respectively, in the statin and no-statin group (risk ratio 0.13; 95% CI, 0.03–0.52), and the ICU admission rate was 12.2% for the no-statin group compared with only 3.7% of the statin group (P=0.025).

In another retrospective review of 388 patients with bacteremia, Liappis et al reported a significant reduction in both overall (6% vs. 28%, P=0.002) and attributable (3% vs. 20%, P=0.010) mortality among patients taking statins at the time of admission compared with patients not taking statins. The survival benefit persisted after adjustment for prognostic factors in a multivariate analysis (odds ratio 7.6; 95% CI, 1.01–57.5).

The available evidence today suggests that the potential for statins as adjuvant therapy for sepsis should be further tested. Given their pleiotropic effects related to many pathophysiologic determinants of sepsis, statin therapy could well be the next step in the search for adjuvant therapy.

References: click to get article/abstract
1. Almog Y, Shefer A, Novack V, Maimon N, Barski L, Eizinger M, Friger M, Zeller L, Danon A (2004) Prior statin therapy is associated with a decreased rate of severe sepsis. Circulation 110:880–885
2. Liappis AP, Kan VL, Rochester CG, Simon GL (2001) The effect of statins on mortality in patients with bacteremia. Clin Infect Dis 33:1352–1357 -http://www.journals.uchicago.edu/CID/journal/issues/v33n8/001561/001561.html

posted by ICU room Pearls @ 11:14 PM 0 comments

Monday, January 23, 2006
Tuesday January 24, 2006
HIGH FREQUENCY VENTILATION

Conventional mechanical ventilation is provided at a rate < 2 Hz (1 Hz = 60 breaths/min). With high frequency ventilation (HFV), rates are provided at 2 – 15 Hz. The frequency range is determined by the specific technique and the size of the patient. Regardless of the technique, adults are generally ventilated at the low end of the rate spectrum and neonates at the high end of the spectrum. There are three techniques that have been classified as high frequency ventilation:

High frequency positive pressure ventilation (HFPPV)
High frequency Oscillation (HFO)
High frequency jet ventilation (HFJV)


With HFPPV conventional ventilators are used to provide rates at the low end of the HFV spectrum.

HFO has both an active inspiratory and expiratory phase. Oscillators establish gas flow by the movement of a diaphragm or piston, perpendicular to a bias flow that moves across the airway. With HFO, rates across the whole frequency spectrum are possible but in general 10 to 15 Hz range are most common with neonates and 3 to 8 Hz range are used with adults. The two conceptual advantages to HFO are lower peak airway pressures and the fact that non bulk-flow mechanisms may improve V/Q matching. Inadequate humidification is a well-known complication when using high gas flows and delivered minute volumes and may result in necrotizing tracheobronchitis. HFO may also cause direct physical airway damage.

During HFJV, gas under high pressure is injected into the airway with a secondary gas source entrained to provide tidal volume. With the HFJV, both a jet ventilator and conventional ventilator may be needed to establish gas delivery in the low to middle part of the HFV rate spectrum. This form of ventilation is mostly used in the operating room where a surgeon is working in the airway (laser Rx of papilloma on vocal cords) and an ETT cannot be placed or as an emergency airway. It is also used in the treatment of a disrupted airway or massive bronchopleural fistula as the non-bulk flow of gas decreases the amount of gas escaping out of the fistula. HFJV has been approved by the FDA for ventilating patients in whom a large and persistent bronchopleural fistula has developed.


See nice Review article HIGH FREQUENCY OSCILLATORY VENTILATION: Clinical Management from VIASYS. (more details/tools at site).

icuroom.net has no connection with VIASYS and info here is solely for educational purpose.


References: Click to get abstract/article
1. Schuster, DP, Klain, M, Snyder, JV. Comparison of high frequency jet ventilation to conventional ventilation during severe acute respiratory failure in humans. Crit Care Med 1982 Oct;10(10):625-30.
2. Holzapfel, L, Robert, D, Perrin, F, et al. Comparison of high-frequency jet ventilation to conventional ventilation in adults with respiratory distress syndrome. Intensive Care Med 1987; 13:100.
3. Fort, PF, Farmer, C, Westerman, J, et al. High-frequency oscillatory ventilation for adult respiratory distress syndrome. Crit Care Med 1997; 25:937.
4. Mehta, S, Granton, J, MacDonald, RJ, et al. High-frequency oscillatory ventilation in adults: the Toronto experience. Chest 2004; 126:518.
posted by ICU room Pearls @ 11:37 PM 0 comments

Sunday, January 22, 2006
Monnday January 23, 2006
Suture at central venous catheter site - a risk?

Interesting article published in Managing Infection Control, december 2002 issue by Dr. Bierman 1 suggesting that sutures at central venous catheter site may also play part in CRBSI's (catheter related bloodstream infection). One study from Hospital of the University of Pennsylvania randomized 170 patients requiring PICCs, to suture (n = 85) or Sutureless Securement Device (n = 85). 3

Beside other advantages, a significant difference noted in the number of systemic infections (10 suture vs. 2 Sutureless Securement Device group; P = .0032). And, the difference in confirmed CRBSIs was (8 suture vs 1 Sutureless Securement Device; P = .04).


August 2002 Guidelines for Prevention of Intravascular Catheter-Related Infections from CDC (Center for Disease Control) acknowledged that “suture-free securement devices can be advantageous over suture in CRBSIs". 2


Only commercially available Sutureless Securement Device in USA is Statlock. (icuroom.net has no connection with company and name given here is only for information purpose).


References: click to get abstrat/article
1. Suture: An Unlikely Culprit in Infections and Accidental Needlesticks - Managing Infection Control, dec. 2002
2. Guidelines for the Prevention of Intravascular Catheter-Related Infections (MMWR 2002)
3. Sutureless Securement Device Reduces Complications of Peripherally Inserted Central Venous Catheters - Journal of Vascular and Interventional Radiology 13:77-81 (2002)
4. OSHA Fact Sheet: Securing Medical Catheters - from STATLOCK site.
posted by ICU room Pearls @ 11:46 PM 0 comments

Sunday January 22, 2006
Arterial pressure-based continuous cardiac output (APCO)

In our quest of finding less and less invasive techniques for our patients, it would be interesting to evaluate arterial pressure based continuous cardiac output (APCO). The whole concept is based on measuring cardiac output simply on arterial pulsatility. Advantages are:

1. It does not require any calibration.
2. Connects to an existing peripheral arterial catheter.
3. No injection of dilutional medium required.

Click here to see video on commercially available device from Edwards Lifesciences.

Some small initial studies have so far shown comparable results with intermittent bolus thermodilution cardiac output (ICO) and continuous thermodilution cardiac output (CCO).1,2,3 But before accepting this modality as a standard we need a good well controlled clinical trial as we don't know the effect of age, gender, vessel's disease state, vessel's compliance with distending pressure, body positioning etc. 4

References: click to get abstrat/article

1. Continuous Cardiac Output Measured by Arterial Pressure Analysis in Surgical Patients - Anesthesiology 2005; 103: A834
2. CARDIAC OUTPUT DETERMINATION USING ARTERIAL PULSE: A COMPARISON OF A NOVEL ALGORITHM AGAINST CONTINUOUS AND INTERMITTENT THERMODILUTION: 166. - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A43
3. Pressure recording analytical method (PRAM) for measurement of cardiac output during various haemodynamic states - British Journal of Anaesthesia 2005 95(2):159-165
4. Continuous cardiac output by pulse contour analysis? - British Journal of Anaesthesia, 2001, Vol. 86, No. 4 467-468
posted by ICU room Pearls @ 8:51 AM 0 comments

Friday, January 20, 2006
Saturday January 21, 2006
Noise level in ICU !!

Unnecessary noise in ICU can mask vital alarms, verbal communications and may be an unseen added cause of mental stress for staff itself. There are 2 kinds of noise in ICU - one you can't control like "ventilator and IV pump alarms" and other you can modify like "conversations and TV".

One interesting and landmark work was done by Kahn and coll. which showed that:

1. "Talking" and "TV" contribute to 49% of noise in ICU.

2. EPA (Enviromental Protection Agency) recommends noise level not to exceed beyond 45 dBA in hospitals but mean peak sound level in study (medical ICU) was 80 dBA !! (which showed mark decrease with behavior modification).

Do you know beepers contribute 1% to ICU noise pollution with 84 dBA - why not to turn it to vibrate mode !!. Click here to see various measures which can decrease noise pollution in ICU: (nursingspectrum.com)


References: click to get abstrat/article

1. Identification and modification of environmental noise in an ICU setting - Chest, Vol 114, 535-540 - full article available as pdf
2. Contribution of the Intensive Care Unit Environment to Sleep Disruption in Mechanically Ventilated Patients and Healthy Subjects - American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 708-715, (2003)
3. Noise in the postanaesthesia care unit - British Journal of Anaesthesia, 2002, Vol. 88, No. 3 369-373
posted by ICU room Pearls @ 10:55 PM 0 comments

Friday January 20, 2006
Cryptococcosis meningitis !!

5 tips to differential diagnose cryptococcosis meningitis.


1. Neck stiffness is uncommon rather non-specific signs may be present ranging anything from headache to coma including personality change.

2. CT scan or MRI should be performed prior to Lumbar punture (LP) and may present with specific findings of leptomeningeal enhancement and enlarged Virchow-Robin spaces. CT scan and MRI may be normal but if scan shows mass lesion (cryptococcomas), avoid LP and consult a neurosurgeon.

See images here, Radiological findings in CNS cryptococcus, from Journal of the chinese medical association 2003;66: 19-26

3. High opening pressure on LP (greater than 200 mm H2O) is common and may have trio of low glucose, high protein and more lymphocytes but CSF may be normal !!. The cryptococcal organism is surrounded by a polysaccharide capsule, which may protect it from the host inflammatory response.

4. Make sure to send CSF for india ink. 5

5. Eye exam is essential to r/o optic neuritis, endophthalmitis or compressive optic neuropathy from high intracranial pressure. Quick treatment can salvage patient vision and emergent opthalmology and neurosurgical consults are indicated. (see healthy discussion at ref. # 3).


References: click to get abstrat/article

1. Overwhelming CNS cryptococcus in AIDS - Neurology 2001 57: 1560
2. Central Nervous System Cryptococcal Invasion - hivinsite.ucsf.edu
3.. Cryptococcal Meningitis Resulting in Irreversible Visual Impairment in AIDS Patients - A Report of Two Cases - SINGAPORE MEDICAL JOURNAL
4. Cryptococcosis - emedicine.com
5. CNS Infections Laboratory - ratsteachmicro.com
posted by ICU room Pearls @ 8:47 AM 0 comments

Thursday, January 19, 2006
Thursday January 19, 2006
Angel dust !!


Phencycladine is probably one of the most dangerous available street drug and as with widest variety of symptoms. 7 Pearls regarding Phencyclidine (PCP) toxicity.
1. PCP can also get absorb percutaneously.

2. Patient may exhibit waxing and waning symptoms of PCP due to its reabsorbtion in duodenum.

3. It has 5 properties of sympathomimetic, serotoninergic, cholinergic, anticholinergic, and narcotic effects and so can present with wide variety of symptoms including hypersalivation and bronchorrhea.

4. Nystagmus is a common presentation but hyperthermia or status epilepticus may be a presenting symptom.

5. Muscle rigidity can present as dystonia, opisthotonos or torticollis, and may cause life-threatening rhabdomyalysis.

6. Postive urine screen is usually diagnostic.

7. Dialysis does not help and treatment is supportive.

References: click to get abstrat/article
1. PCP - streetdrugs.org
2. PCP (Phencyclidine) - The National Institute on Drug Abuse (NIDA)
3. Toxicity, Phencyclidine - emedicine.com
posted by ICU room Pearls @ 8:38 AM 0 comments

Wednesday, January 18, 2006
Wednesday January 18, 2006
"Locked-in" Syndrome (coma vigilante)


"patient is a silent and unresponsive witness to everything that is happening" from story of Nick Chisholm 1


Patient with Locked-in syndrome is a fully conscious person, but all the voluntary muscles of the body are completely paralyzed, other than those that control eye movement. Term was first introduced about 25 years ago by Plum and Posner with complete occlusion of the basilar artery. 3

Any catastrophy involving ventral pons can cause this syndrome like massive stroke, traumatic head injury, ruptured aneurysm, pontine infarction after prolonged vertebrobasilar ischaemia, haemorrhage, tumor, central pontine myelinolysis, pontine abscess or postinfective polyneuropathy. As all of the nerve tracts responsible for voluntary movement pass through the ventral pons but fortunately or unfortunately, consciousness are above the level of the ventral pons. 2

Only supportive rehabilitation is the answer.

Being an intensivist, it is extremely important to educate staff and to protect patient from any physical or psychological harm (like procedure without adequate analgesia), with upmost understanding that it is an "imprisoned mind buried alive in a dead body’’ (as said for character with paralysis like locked-in syndrome in Thérèse Raquin by Emile Zola - 1868).

References: Click to get articles/abstract
1. The patient's journey: Living with locked-in syndrome - BMJ 2005;331:94-97 (9 July)
2. Locked-in Syndrome - enotes.com
3. Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: FA Davis, 1982; 377
4. Locked-in syndrome: a catastrophic complication after surgery - British Journal of Anaesthesia, 2004, Vol. 92, No. 2 286-288
5. Thérèse Raquin
posted by ICU room Pearls @ 8:46 AM 0 comments

Tuesday, January 17, 2006
Tuesday January 17, 2006
Recovery of Critical illness polyneuropathy (CIP) and prevention with tight insulin therapy

Critical illness polyneuropathy (CIP) remains a major problem in ICU particularly in post-disease phase. Very little literature is available regarding recovery from CIP. A rather small but worth looking study done in france with 2-year clinical follow-up of 19 patients who suffered from CIP. Three parameters were significantly correlated with poor recovery:

1. longer length of stay in the critical care unit,
2. longer duration of sepsis and
3. greater body weight loss.

On prevention side, its worth recalling Dr. Van den Berghe famous 2001 NEJM article re. Intensive Insulin Therapy in Critically Ill Patients which showed intensive insulin therapy also reduced critical-illness polyneuropathy by 44 percent, and 49% in another followup study by same author.

Here is a good review article on CIP with free registration at medscape.com: Clinical Outcomes of Critical Illness Polyneuropathy - Pharmacotherapy 22(3):373-379, 2002

References: Click to get articles/abstract
1. Critical Illness PolyneuropathyA 2-Year Follow-Up Study in 19 Severe Cases - European Neurology 2000;43:61-69
2. Intensive Insulin Therapy in Critically Ill Patients NEJM Nov. 2001, Volume 345:1359-1367
3. Paresis Acquired in the Intensive Care Unit JAMA. 2002;288:2859-2867 (full article available with free registration).
4. Insulin therapy protects the central and peripheral nervous system of intensive care patients - NEUROLOGY 2005;64:1348-1353
posted by ICU room Pearls @ 8:21 AM 0 comments

Monday, January 16, 2006
lovenox and protamin
Monday January 16, 2006
LMWH and Antidot (protamine)

If protamine is given within 4 hours of the enoxaparin (Low Molecular Weight Heparins - LMWH), then a neutralizing dose is: 1 mg of protamine per 1 mg of enoxaparin. The IV protamine should be administered slowly atleast over 10 minutes as rapid infusion may cause anaphylactoid type reaction. May repeat half of earlier dose of protamine after 6 hours with postulation that half life of enoxaparin is longer than protamine.

It appears that that the LMWH anti-Xa reversal is not related to protamine-LMWH binding or LMWH size, but rather to the density of sulfate residues in the particular LMWH. Another available variety of LMWH, dalteparin (Fragmin) has higher degree of sulfonation and appear to be more responsive to protamine reversal.

2 clinical pearls

1. Protamine does not help in reversing bleeding from Fondaparinux (Arixtra). Only supportive treatment should be given with mean half-life of fondaparinux of 17-21 hours in mind.

2. Fresh frozen plasma is ineffective in reversal of LMWH to achieve hemostasis and should not be use in these situations.


References: Click to get article/abstract
1. Accidental overdosage following administration of Lovenox - rxlist.com
2. Incomplete Reversal of Enoxaparin Toxicity by Protamine: Implications of Renal Insufficiency, Obesity, and Low Molecular Weight Heparin Sulfate Content - Obesity Surgery, Volume 14, Number 5, 1 May 2004, pp. 695-698(4)

posted by ICU room Pearls @ 8:03 AM 0 comments

Sunday, January 15, 2006
Sunday January 15, 2006
“MEL GIBSON” in ICU / ICU Daily Goals Worksheet

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. 1 Here is another mnemonic "MEL GIBSON" everyday in ICU.

M Medication list reviewed.

E Extremities covered. (DVT prophylaxis). Also “E” for exercise (change of position, Out of bed).

L Labs and Radiological studies reviewed.


G Glucose control.

I Infection control measures taken, including elevation of bed to 30 degrees, lines reviewed etc.

B Breathing. Did we allow our patient to have sponteneous breathing everyday. This include sedation break everyday to patient.

S Swan /Hemodynamics/volume status reviewed.

O Oxygen supply status, including review of Oxygen Extraction ratio, if applicable.

N Nutrition/GI prophylaxis.

Related: Please click here to read about ICU Daily Goals Worksheet from IHI.

References: Click to get articles/abstract
1. Give your patient a fast hug (at least) once a day - Critical Care Medicine. 33(6):1225-1229, June 2005
posted by ICU room Pearls @ 12:23 AM 0 comments

Saturday, January 14, 2006
vk
Saturday January 14, 2006
7 Pearls of Vitamin K (phytonadione)

1. Oral Vitamin K has similar efficacy as intravenous Vitamin K. 1

2. SQ (subcutaneous) Vitamin K absorption is unreliable.2

3. IM (intramuscular) Vitamin K may promote intramuscular hemorrhage.

4. IV (intravenous) Vitamin K is effective in 6 - 8 hours.

5. IV Vitamin K should be given very slow (preferably .5 mg/min).

6. IV Vitamin K may cause facial flushing, diaphoresis, chest pain, hypotension, dyspnea, anaphylaxis and cerebral thrombosis but pretreatment with antihistamines or corticosteroids is not routinely recommended. 7

7. Although IV Vitamin K has been decribed safe in few studies 3,7, it should be use only in life threatening bleeds from warfarin overdose or due to deficiency of vitamin K as fatality from anaphylactoid reaction could be high 4,5.

References: Click here to see abstract/article:
1. Comparison of Oral vs Intravenous Phytonadione (Vitamin K) in Patients With Excessive Anticoagulation - Arch Intern Med. 2003;163:2469-2473. - full article available with free registration.
2. Oral Vitamin K Lowers the International Normalized Ratio More Rapidly Than Subcutaneous Vitamin K in the Treatment of Warfarin-Associated Coagulopathy - Annals - 20 August 2002, Volume 137 Issue 4, Pages 251-254 -pdf file
3. The safety of intravenously administered vitamin K - via pubmed, Vet Hum Toxicol. 2002 Jun;44(3):174-6.
4. Anaphylactoid reactions to vitamin K - via pumed, J Thromb Thrombolysis. 2001 Apr;11(2):175-83.
5. Anaphylaxis after low dose intravenous vitamin K - via pubmed, J Emerg Med. 2003 Feb;24(2):169-72
6. Comparing Different Routes and Doses of Phytonadione for Reversing Excessive Anticoagulation - Arch Intern Med. 1998;158:2136-2140.
7. The incidence of anaphylaxis following intravenous phytonadione (vitamin K1): a 5-year retrospective review - Annals of Allergy, Asthma and Immunology, Volume 89, Number 4, October 2002, pp. 400-406(7)
posted by ICU room Pearls @ 3:35 AM 0 comments

Friday, January 13, 2006
Friday January 13, 2006
RIFLE Criteria for Acute Renal Dysfunction

Acute Dialysis Quality Initiative (ADQI) Group has proposed the escalating RIFLE system using either glomerular filtration rate-GFR or urine output-UO to classify Acute Renal Failure (ARF):

R = Risk of renal failure - if increase in Scr is x 1.5 or decrease in GFR is > 25% or decrease in UO is < .5 ml/kg/hr x 6 hours.

I = Injury to the kidney - if increase in Scr is x 2 or decrease in GFR is > 50% or decrease in UO is < .5 ml/kg/hr x 12 hours.

F = Failure of kidney function - if increase in Scr is x 3 or decrease in GFR is > 75% or Scr > 4 mg/dl or decrease in UO is < .3 ml/kg/hr x 24 hours or Anuria x 12 hours.

L = Loss of kidney function - Persistent ARF > 4 weeks, and

E = End-stage renal failure - Persistent ARF > 3 months.


Click here to see the proposed Cone Diagram of RIFLE system for ARF.



References: Click here to see abstract/article:
1. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group - Critical Care 2004, 8:R204-R212
2. The Outcome of Acute Renal Failure in the Intensive Care Unit According to RIFLE: Model Application, Sensitivity, and Predictability - AJKD - Volume 46, Issue 6, Pages 1038-1048 (December 2005)
3. Practice patterns in the management of acute renal failure in the critically ill patient: an international survey - Advance Access published online on December 2, 2005, Nephrology Dialysis Transplantation
posted by ICU room Pearls @ 9:37 AM 0 comments

Wednesday, January 11, 2006
Thursday January 12, 2006
LINEZOLID & SEROTONIN SYNDROME 3

Linezolid (Zyvox) being a reversible, nonselective monoamine oxidase inhibitors (MAOIs) can cause a serious serotonin syndrome if use concomittently with antidepressents citalopram (Celexa) 2, sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil) . Case has been reported with use of linezolid 18 days after the discontinuation of fluoxetine. Norfluoxetine (fluoxetine’s active metabolite) is thought to be the culprit. 1

Being an intensivist it is a very important drug interaction need to be aware of as most patients admitted to ICU from long term care may be on antidepressents and may require Zyvox for MRSA treatment. Related: See brief review on Serotonin syndrome here from McGill University, Montreal. CMAJ • May 27, 2003; 168 (11) followed with letter Serotonin syndrome: not a benign toxidrome CMAJ • September 16, 2003; 169 (6). It was discussed in detail in our related pearl on Dec. 31, 2005

References: Click to get abstract or article
1. Serotonin Syndrome Associated With Linezolid Treatment After Discontinuation of Fluoxetine - Psychosomatics 46:274-275, June 2005
2. Serotonin Syndrome after Concomitant Treatment with Linezolid and Citalopram - Clinical Infectious Diseases, volume 36 (2003), page 1197 - pdf file
3. Serotonin Syndrome and Linezolid - Clinical Infectious Diseases, volume 34 (2002), pages 1651–1652 - pdf file
4. The Serotonin Syndrome - NEJM, March 2005 Volume 352:1112-1120
posted by ICU room Pearls @ 10:10 PM 0 comments

Tuesday, January 10, 2006
dsadrp
Wednesday January 11, 2006
Dopamine-S and Dopamine-R patients ?

Interesting article published in October 2005 issue of Critical Care Medicine which concluded that "Dopamine sensitivity is associated with decreased mortality rate".

In 110 patients after failure of vascular loading, Dopamine infusion started with 5 μg/kg/min and infusion rate was increased by 5 μg/kg/min every 10 mins up to a maximum dose of 20 μg/kg/min to target mean arterial pressure ≥ 70 mm Hg. (So total time needed to reach the highest dose of 20 μg/kg/min was 30 mins). Dopamine resistance was defined by a mean arterial pressure <70.>In the Dopa-S group, the 28-day mortality rate was 16% (seven of 44 patients) compared with 78% (52 of 66 patients) in the Dopa-R group (p = .0006). The capacity of dopamine resistance to predict death was associated with a sensitivity of 84% and a specificity of 74%.

Do we need to qualify our patients as Dopamin-S or Dopamin-R to execute different management strategy?

References: click to get article/abstract
1. Cardiovascular response to dopamine and early prediction of outcome in septic shock: A prospective multiple-center study. - Critical Care Medicine. 33(10):2172-2177, October 2005

posted by ICU room Pearls @ 9:02 PM 0 comments

Tuesday January 10, 2006
Doxy or Mino ! - trick in the pocket for MRSA

Second generation tetracyclines has been used for MRSA (methicillin-resistant Staphylococcus aureus) for long time but with very few real data available. One study from 1984 showed cure rate of 76%.

Recently Ruhe and coll. look into the issue. Though its a small study of only 24 patients but showed cure rate of 83% with "serious" MRSA icluding skin/skin structure, septic arthritis, Bacteremia/sepsis, osteomyelitis, UTI. 13 patients were treated with Doxycycline and 11 were treated with Minocycline (5 patients in minocycline group were treated in combination with rifampin +/- bactrim). Patients were treated with 100 mg PO bid dose with median total treatment time of 19 days. Also, interestingly, no patient in minocycline group complaint of vertigo.

If intravenous access is an issue in a patient with serious MRSA, except for ZYVOX (linezolid) all mainstream drugs are available only in parenteral form. If Zyvox is contraindicated or not available - you have trick available in your pocket. Plus added advantage of cost-effectiveness.

References: Click to get abstract or article
1. Clumeck and coll. - Treatment of severe staph. infections with rifampin-minocyclin association - J of antimicrob chemother 1984;13 suppl. :C17-C22
2. Use of Long-Acting Tetracyclines for Methicillin-Resistant Staphylococcus aureus Infections: Case Series and Review of the Literature - Clin Infect Dis 40:1429-1434 electronically published 6 April 2005. - Caution: we found this link not working all the time but atleast refence is checked and available in hard print.
posted by ICU room Pearls @ 2:12 PM 0 comments

Monday, January 09, 2006
Monday January 9, 2006
Sedatives and sexual dreams - a legal liability?

In 1847, after a year of ether anesthesia introduction, a dentist was convicted to 6 years of jail for sexually assaulting two girls under the influence of anaesthesia. There are well documented cases where physicians and dentists have lost their licenses for similar allegation. Anaesthetics particularly propofol (widely use in ICU) has been reported to be associated with vivid dreams and sexual fantasies though a fairly good study failed to show any association.

Recently, Dr. Robert Strickland's report in this regard at the American Society of Anesthesiologists meeting has been widely reported in media and is worth reading. Click on reference # 3.


References: Click to get abstract or article
1. Anesthetics cause sex hallucinations- macleans.ca
2. Dreams, images and emotions associated with propofol anaesthesia -Anaesthesia, Volume 52, Number 8, July 1997, pp. 750-755(6)
3. Anesthesia can give rise to sex illusion - ARIZONA DAILY STAR - 06.21.2005
posted by ICU room Pearls @ 12:17 PM 0 comments

Sunday, January 08, 2006
Sunday January 8, 2006
Peres Nomogram or rule of thumb

About 15 years ago, Peres developed a nomogram for probable catheter-insertion depth based on patient height in centimeters and still considered to be applicable/reliable.

For right internal jugular vein central venous catheters, "height (cm)/10" would provide the appropriate depth of insertion. For a 160-cm tall person, a catheter would be inserted to 16 cm deep but for a 200-cm tall person, the depth would be 20 cm.

For left internal jugular, central venous catheter placements, "height (cm)/10 + 4" would provide the appropriate depth of insertion. For a 160-cm tall person, a catheter would be inserted to 20 cm. For a 200-cm tall person, the depth would be 24 cm. (originally described for left external jugular insertion). Caution: In left IJ placement, the catheter tip must not lie at a perpendicular angle against the superior vena cava, because of a risk of vascular erosion.

Reference: Peres PW: Positioning central venous catheters: A prospective survey. Anaesth Intensive Care 1990; 18:536-539
posted by ICU room Pearls @ 11:33 AM 0 comments

Saturday, January 07, 2006
Saturday January 7, 2006
Changing Endotracheal tube and Combitube

Few tips to remember while changing endotracheal tube over catheter.

1. Have resuscitation cart available.

2. Make Laryngeal mask (LMA) and combitube available.

3. Make respiratory and nursing staff informed and available.

4. "Don't rush". Make patient adequately sedated. Paralyse if absolutely necessary.

5. Pre-oxygenate to 100% for atleast 3-5 prior to tube change.

6. Make smaller size tube available at bedside from present one in case edematous airway encountered.

7. Confirm tube placement in regular standard way.


See Full guide to Tracheal Intubation from Update in Anaesthesia and article and video on combitube from Michael Frass, MD (inventor of combitube) in our procedure section. (video is courtesy of medradio.org)
posted by ICU room Pearls @ 3:41 PM 0 comments

Friday, January 06, 2006
Friday January 6, 2006
Regarding CPR

CPR is probably one of the most ancient procedure (800 BC) recorded in modern history. 2005 CPR guidelines from American Heart Association suggests:

1. 100 compressions per minute.

2. Compression depth of 1 to 2 inches.

3. Allow the chest to recoil completely after each compression (target equal compression and relaxation times)

4. Minimize interruptions in chest compressions. No-flow Fraction* (no-flow fraction of .17)

5. Compression-ventilation ratio of 30:2 (two rescue breaths every 30 chest compressions). Do not deliver more volume or use more force than is needed to produce visible chest rise. Once intubated: ventilate at a rate of 8 to 10 breaths per minute without attempting to synchronize breaths between compressions.

*NFF= No-flow Fraction was defined as the no-flow time (time periods of cardiac arrest without compressions) divided by total cardiac arrest time.

Unfortunately study shows we have not mastered our most ancient procedure yet.3

References:

Click to get articles/abstract
1. History of CPR - Fascinating insight into early attempts to resuscitate people - ukdivers.net
2. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Circulation. 2005;112:IV-19 – IV-34
3. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest - available free with registration - JAMA - Vol. 293 No. 3, January 19, 2005
posted by ICU room Pearls @ 12:23 AM 0 comments

Wednesday, January 04, 2006
Thursday January 5, 2006
Hemodialysis in Salicylate overdose with normal level

Hemodialysis is recommended in salicylate overdose patients with a level at or above 100 mg/dL (cut it to half if history suggest chronic ingestion). But if there is any sign of neurological manifestation, dialysis is indicated despite normal level.
Salicylate cause "neuroglycopenia" (lower CNS glucose level) despite normal serum glucose. As patient gets more and more acidotic, salicylate enters CNS and by direct effect cause neuroglycopenia.

7 indications of Hemodialysis in Salicylate poisoning

1. Mental status change
2. Pulmonary edema
3. Cerebral edema
4. Associated or with renal failure
5. Level at or above 100 mg/dL(half if chronic ingestion)
6. If fluid overload prevents alkalinization.
7. Patient continue to deteriorate clinically.

References: Click to get abstract/article
1. Toxicity, Salicylate - please register free at emedicine.com
2.An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose -Emerg Med J 2002; 19:206-209
3. Salicylic acid - intox.org
posted by ICU room Pearls @ 9:07 AM 0 comments

Tuesday, January 03, 2006
Wednesday January 4, 2006
Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose?

Role of steroid in sepsis continue to puzzle physicians - "to do or not do" or "when to do" or "how to do" !!

Study of 177 patients published this month from Annane and coll. suggests that " 7-day treatment with low doses of corticosteroids was associated with better outcomes in septic shock-associated early ARDS nonresponders, but not in responders and not in septic shock patients without ARDS (responders or nonresponders)." But study of 41 patients published in Nov. 2005 issue of Critical Care Medicine suggests that "Treatment with low-dose hydrocortisone accelerates shock reversal in early hyperdynamic septic shock...immune effects appeared to be independent of adrenal reserve".

To keep record straight evidence-based guideline from SCCM at this point is: Intravenous corticosteroids (hydrocortisone 200-300 mg/day, for 7 days in three or four divided doses or by continuous infusion) are recommended in patients with septic shock who despite adequate fluid replacement require vasopressor therapy to maintain adequate blood pressure. And to identify "responders" (>9 μg/dL increase in cortisol 30-60 mins post-ACTH administration) and to discontinue therapy in these patients is optional. Clinicians should not wait for ACTH stimulation results to administer corticosteroids.

In this regard another interesting study of 46 patients from Belgium concluded that: low-dose (1 μg) corticotropin stimulation test may identify a subgroup of patients in septic shock that may go missed by the high-dose test (standard 250-μg test) and these patients may also benefit from glucocorticoid replacement therapy.

Hopefully, Corticus study (Corticosteroid Therapy of Septic Shock) will have some definite answer?. Let see.

References: Click on article to get abstract/article
1. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Critical Care Medicine. 34(1):22-30, January 2006.
2. Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock. Critical Care Medicine. 33(11):2457-2464, November 2005.
3. Use of corticosteroid therapy in patients with sepsis and septic shock: An evidence-based review. Critical Care Medicine. 32(11) Supplement:S527-S523, November 2004.
4. Relative adrenal insufficiency in patients with septic shock: Comparison of low-dose and conventional corticotropin tests. Critical Care Medicine. 33(11):2479-2486, November 2005.
5. Corticosteroid Therapy of Septic Shock – Corticus - clinicaltrials.gov
posted by ICU room Pearls @ 11:24 PM 0 comments

Tuesday January 3, 2006
Procedure Tip - Does that waveform look ‘wedged’?

Many a times, while placing a PA catheter we encounter waveforms that look ‘different’ and we are not sure if it’s the wedged waveform. Of course, you are going to get a CXR but it can only confirm the position and you still may not be sure if the PA catheter is wedged when the balloon is inflated! Here’s a tip.

Take 2 blood samples from the pulmonary artery port: One while the balloon is deflated (mixed venous sample) and the other while the balloon is inflated (wedged sample). If the wedged PaO2 exceeds the mixed venous PaO2, then the catheter is definitely in the wedged position when the balloon is inflated. Also compare the wedged PaO2 with arterial PaO2. If the values are almost identical, the catheter may be too far in. Do you still need the CXR!

Related:
PACEP: Pulmonary artery catheter education project.
P. A. Catheterization insertion video (from Edwards Lifesciences).
Invasive HDM Troubleshooting video (from Edwards Lifesciences).
Vigilance Monitor Inservice video (from Edwards Lifesciences).
Videos above need windows media player
posted by ICU room Pearls @ 5:36 PM 0 comments

Sunday, January 01, 2006
Neurogenic Cardiac Injury
Monday January 2, 2006
Brain-Heart Connection - Neurogenic Cardiac Injury

Cardiac injury may occur following many types of brain injury, including trauma, ischemic stroke, and intracerebral hemorrhage. Less common etiologies include tumors, electroconvulsive therapy, and central nervous system infections such as meningitis. Although more difficult to prove, tremendous emotional stress typically following natural disasters 2 or during war may lead to augmented sympathetic tone, abnormal electrocardiogram (ECG) changes, and cardiac injury.

Subarachnoid hemorrhage (SAH)-induced cardiac injury provides a robust example of neurocardiogenic injury. Burch et al. first described neurogenic cardiac injury by demonstrating "cerebral T-wave" electrocardiographic abnormalities in humans with SAH. Elevated troponin levels 4 have also been described and provide evidence that myocardial necrosis may occur. The degree of neurologic injury is a strong predictor of myocardial necrosis after SAH. Cardiac injury, specifically left ventricular (LV) systolic dysfunction, has been described after SAH with an approximate incidence of 10% to 28%. 5 Despite recent advances in diagnostic techniques of cardiac disease, the pathophysiology remains unclear. A catecholamine-mediated mechanism of injury has been demonstrated in experimental and clinical studies.

Read interesting article on Predictors of Neurocardiogenic Injury After Subarachnoid Hemorrhage in stroke (Stroke. 2004;35:548), followed by editorial comment from Dr. Shunichi Homma Myocardial Damage in Patients With Subarachnoid Hemorrhage (Stroke. 2004;35:552.)

References: click to get article/abstract

1. Oppenheimer SM: The cardiac consequences of stroke. Neurol Clin North Am 1992, 10:167-176. via pubmed
2. Yamabe H, et al.: Deep negative t waves and abnormal cardiac sympathetic image (123 I-MIBG) after the great Hanshin Earthquake of 1995. Am J Med Sci 1996, 311:221-224. via pubmed
3. Fabinyi G: Myocardial creatine kinase isoenzyme in serum after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1977, 40:818-820.
4. Horowitz MB: aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 1998, 140:87-93. The use of cardiac troponin-I (cTnI) to determine the incidence of myocardial ischemia and injury in patients with aneurysmal and presumed Aneurysmal Subarachnoid Hemorrhage
5 Zaroff J, et al.: Frequency and regional distribution of LV systolic dysfunction after subarachnoid hemorrhage: an echocardiographic assessment. J Am Soc Echocardiogr 1998, 11:507.
posted by ICU room Pearls @ 11:12 PM 0 comments

Sunday January 1, 2006
Happy new Year - ICU Jokes


What do you call 2 surgeons reading an EKG in ICU?
A double blind study!!


How do you treat a depressed intensivist?
Give IV fluid bolus.


Nurse: Doctor, what should I do 'wedge' is going up ?
Intensivist: Sell !


What do you call a baby get born in the high tech ICU?
cordless!


Intensivist: "Well, Mrs. Jones, I'm afraid you're not quite as sick as we'd hoped."

posted by ICU room Pearls @ 6:22 AM 0 comments

Saturday, December 31, 2005
ss
Saturday December 31, 2005
SEROTONIN SYNDROME

Serotonin syndrome is a potentially lethal condition caused by overstimulation of central and peripheral serotonin receptors. SSRI, MAOI and other antidepressants are the biggest culprits. (Everybody seems to be on some type of antidepressant these days!). Mild cases of serotonin syndrome may present with nausea, vomiting, flushing, and diaphoresis. Severe cases may present with hyperreflexia, myoclonus, muscular rigidity, hyperthermia, and autonomic instability. Diagnosis is clinical and no lab tests are available.

Treatment include discontinuation of all serotonergic medications. The initial treatment of serotonin syndrome is with benzodiazepines and cyproheptadine. Cyproheptadine (Periactin) appears to be the most effective antiserotonergic agent in humans. The initial dose is 4 - 8 mg PO. This dose can be repeated in 2 hrs if no response is noted to the initial dose. Periactin therapy should be discontinued if no response is noted after 16 mg has been administered. Patients who respond to cyproheptadine are usually given 4 mg every 6 h for 48 h to prevent recurrences. Dantrolene (0.5-2.5 mg/kg IV every 6 h, maximum 10 mg/kg per 24 h or 50 to 100 mg bid PO) is a nonspecific muscle relaxant that is used occasionally in serotonin syndrome, presenting with hyperthermia.


See brief review on Serotonin syndrome here from McGill University, Montreal. CMAJ • May 27, 2003; 168 (11) followed with letter Serotonin syndrome: not a benign toxidrome CMAJ • September 16, 2003; 169 (6)

References: Click to get abstract or article
1. Serotonin syndrome. A clinical update - Mills KC - Crit Care Clin. 1997 Oct;13(4):763-83. via pubmed
2. Treatment of the serotonin syndrome with cyproheptadine - J Emerg Med., 1998 Jul-Aug;16(4):615-9. via pubmed
3. The Serotonin Syndrome - NEJM, March 2005 Volume 352:1112-1120
posted by ICU room Pearls @ 11:21 AM 0 comments

Friday, December 30, 2005
Friday December 30, 2005
Estimating Burn area

There are 3 ways to estimate %TBSA burn (% Total Body Surface Area Burn).

1. "rule of nine" remains universally accepted tool to calculate %TBSA burn. Click here to see the diagram.1

2. Lund-Browder chart is more accurate method of calculating %TBSA Burn. Click here to see the chart 2

3. Recently computer based softwares have been introduced with color coded calculation and instant resuscitation guide. See sample Surface Area Graphic Evaluation software method here. 3

See most comprehensive Burn management guide at
" www.burnsurgery.org "


References: Click to get abstract or article
1. Initial management of a major burn: II—assessment and resuscitation - BMJ 2004 ; 329:101-103
2. Total Burn Care - totalburncare.com
3. Surface Area Graphic Evaluation
posted by ICU room Pearls @ 5:02 AM 0 comments

Thursday, December 29, 2005
Thursday December 29, 2005
ReoPro and Integrilin (Glycoprotein 2b/3a Receptor Inhibitors)

Although our cardiology colleauges mostly take care of intravenous antiplatelet therapy in acute situations but atleast to be aware of basic differences between 2 widely used iv antiplatelet agents.

ReoPro (abciximab): is a large molecule agent and binds irreversibly to Gp2b/3a receptors of platelets and so clinical effect lasts for 7 to 10 days and for same reason needs platelet transfusion in case of bleeding. ReoPro is usually given in STEMI ( ST elevated - Myocardial infarction). It may cause severe thrombocytopenia within hours of infusion.

Integrilin (eptifibatide): is a small molecule and binds reversibly to Gp2b/3a receptors of platelets and so clinical effect lasts for only 4 to 6 hours. Platelet transfusion is not required and should be avoided in case of bleeding as it may inhibits new platelet formation. Integrilin is usually given in NSTE-ACS (Non ST elevation - acute coronary syndrome). It is 50% cleared by kidney. Also dosing is weight dependent. Dosing chart is available in package insert. 4

Avoid unnecessary IV or IM sticks while patient on Gp2b/3a infusion.

References: Click to get abstract or article

1. ABCIXIMAB - Stanford University Interventional Cardiology
2. EPTIFIBATIDE - Stanford University Interventional Cardiology
3. A Clinical Trial of Abciximab in Elective Percutaneous Coronary Intervention after Pretreatment with Clopidogrel - NEJM, Jan. 2004 Volume 350:232-238
4. Integrilin - package insert
5. Abciximab as Adjunctive Therapy to Reperfusion in Acute ST-Segment Elevation Myocardial Infarction - JAMA Vol. 293 No. 14, April 13, 2005
posted by ICU room Pearls @ 9:15 AM 0 comments

Tuesday, December 27, 2005
Wednesday December 28, 2005
Is confirmatory chest-x-ray always necessary?

It is a standard of practice to have followup chest-x-ray following endotracheal intubation and central venous catheter insertion. But do we always absolutely need it ?. See these 2 interesting studies both comprised of 100 patients.

For endotracheal tube: Prospective study of 101 patients done at Cooper Hospital, Camden, NJ showed that the incidence of acutely significant malpositions of endotracheal tube, when performed by experienced critical care personnel, were rare (one out of 101 intubations), and may be followed by routine, rather than 'stat' chest radiographs.1

For central venous catheter (IJ): Prospective study of 100 patients done at Lenox Hill Hospital, New York showed that 98 catheters were in accurate position after uncomplicated insertion of a Triple-Lumen Catheter in the Right internal jugular vein with anterior approach and concluded that it is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC and IV treatment can be initiated early. 2 (We found atleast one study in literature arguing against this work. Study of 107 patients from NIH showed 14% incidence of malpositions, and conclusion was: Chest radiographs are necessary to ensure correct internal jugular catheter position).3

References: Click to get abstract or article

1. Utility of postintubation chest radiographs in the intensive care unit - Critical Care 2000, 4:50-53
2. Is Chest Radiography Necessary After Uncomplicated Insertion of a Triple-Lumen Catheter in the Right Internal Jugular Vein, Using the Anterior Approach?* - Chest. 2005;127:220-223
3. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? - Critical Care Medicine: Volume 27(9) September 1999 pp 1819-1823
4. Value of postprocedural chest radiographs in the adult intensive care unit - Crit Care Med 1992; 20:1513-1518
posted by ICU room Pearls @ 10:45 PM 0 comments

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Tuesday December 27, 2005
Vasoconstrictor extravasation

Antidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine) is PHENTOLAMINE. Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor. Keep yourself ready for fluid bolus post treatment. Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent which inhibits vasoconstriction and allow improved blood circulation through the affected area.

References: Click to get abstract or article

1. Drug Monographs - Phentolamine - lhsc.on.ca
2. pediatric pharmacotherapy / intravenous extravasations-
3. Treating Extravasation Injuries - extravasation.org
4. The use of phentolamine in the prevention of dopamine-induced tissue extravasation - J Crit Care 1998 Mar;13(1):13-20
posted by ICU room Pearls @ 8:09 AM 0 comments

Monday, December 26, 2005
ivi
Monday December 26, 2005
Intravenous(IV) Iron

There are 3 forms of IV Iron available in USA. 1. Iron dextran, 2. Iron sucrose and 3. Sodium ferric gluconate. Iron dextran definitely requires "test dose" in the presence of physician with epinephrine at bedside. About 1 out of 200 patients develops life-threatening anaphylaxis. In remaining 2 forms also, test dose is advisible. Watch time after 'test dose' is about one hour. IM or SQ administration of Iron is not standard of practice.

Also dose should be calculated irrespective of form of iron use.

Iron deficiency anemia: Various formulae have been described (see references) but most widely use is

"Total" amount of iron in mg = { 0.3 x abw (lbs) x 100 (14.8 - present Hgb)] / 14.8

abw = actual body weight 14.8 is constant as ideal Hb

Calculate dose at online calculator (see Ref. 2).

In blood loss:

"Total" iron dose (in mg) = Blood loss (ml) x present Hematocrit.

The total Fe can be given as a single dose in .5 L NS over 6 hours or in divided doses over few days.

References: Click to get abstract or article
1. Administration of intravenous iron dextran - http://sickle.bwh.harvard.edu/
2. Iron Dextran Calculator - globalrph.com
3. parental iron supplement - thedrugmonitor.com


posted by ICU room Pearls @ 7:38 AM 0 comments

Saturday, December 24, 2005
Sunday December 25, 2005
Christmas Quiz Question

Q: What's the difference between fellow and attending ?
A: Fellow knows "what to do" and attending knows "what not to do"
posted by ICU room Pearls @ 11:05 PM 0 comments

Friday, December 23, 2005
Saturday December 24, 2005
Is SLEDD better than CVVHD in ICU patients ?

With advent of Continuous Veno-Venous Hemodialysis (CVVHD) we found some relief for our hemodynamically unstable patients with acute renal failure but CVVHD has its own cons with need of more trained staffing, cost, time, anticoagulation issues, nutrition issues etc. To find a path between two modalities (conventional HD and CVVHD), new literature is suggesting that slow extended daily hemodialysis (SLEDD) may be more or atleast equally effective. Click on Reference 1 to see small study of 20 patients comparing SLEDD and CVVHD. Nephrol Dial Transplant (2004) also found SLEDD as an effective alternative. As concluded in Intensive Care Nephrology 2000 that "..advantages (of CRRT) can, however, also be obtained with SLEDD. In addition, SLEDD is less expensive than CRRT and does not continuously immobilize the patient, leaving time open for other activities..".3 Or probably the skills and the experience of the physicians and nurses who perform dialysis are more important than the applied dialysis modalities. 4

References: Click to get articles/abstract
1. Comparison of slow extended daily hemodialysis (SLEDD) to continuous renal replacement therapy in acute renal failure patients in the intensive care unit (ICU) - Abstract no: 18, Kidney International Society Abstracts.
2. Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: towards an adequate therapy - Nephrol Dial Transplant (2004) 19: 877-884
3. What Is the Renal Replacement Method of First Choice for Intensive Care Patients? - J Am Soc Nephrol 12:S40-S43, 2001
4. Dialysing the patient with acute renal failure in the ICU: the emperor's clothes? - Nephrol Dial Transplant (1999) 14: 2570-25735. Daily Hemodialysis and the Outcome of Acute Renal Failure - NEJM, Jan. 2002, Volume 346:305-310
posted by ICU room Pearls @ 10:48 PM 0 comments

Thursday, December 22, 2005
Friday December 23, 2005
Scleroderma Renal Crisis (SRC)

Scleroderma Renal Crisis is one of the few rheumatological emergency where early diagnosis and treatment can make big difference in outcome. Wrong diagnosis may lead to wrong management pathway and eventually to very high mortality. SRC is heralded with hypertensive crisis associated with acute renal failure but the pearl is to avoid IV Labetolol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. calcium channel blockers may help. Renal dialysis is a last resort. Another important differential diagnosis is from SLE (renal). 5 It has been suggested that use of steroids is associated with onset of scleroderma renal crisis.

See this precise review article on SRC here from Department of Rheumatology and Internal Diseases, Medical University in Białystok, Poland. (2005)

References: Click to get articles/abstract
1. What Is Scleroderma Renal Crisis and How Is it Managed? via medscape.com with free registration
2. Systemic Sclerosis With Renal Crisis and Pulmonary Hypertension - stanford.edu
3. Long-Term Outcomes of Scleroderma Renal Crisis - 17 October 2000 Volume 133 Issue 8 Pages 600-603 - annals
4. Scleroderma Renal Crisis: The Sword of Damocles. - JCR: J. of Clinical Rheum. 10(5):234-235, October 2004.
5. Rheumatologic Renal Disease: SLE vs. Scleroderma - ucsf.edu

posted by ICU room Pearls @ 11:01 PM 0 comments

Wednesday, December 21, 2005
Thursday December 22, 2005
Whats new on Horizon - blood substitutes

Being an intensivist it is imperative to keep up with all new "stuff" on horizon. In this regard blood substitutes will soon actually be knocking on the door. Hemopure, a Bovine derived blood substitute, has been approved for use in adult patients in South Africa. Polyheme, a human derived blood substitute is already in Phase III trial in united states for hemorrhagic shock following traumatic injuries. These are solutions of chemically modified human or bovine hemoglobin which restores lost blood volume and can be given as rapid, massive infusion. One unit is equal to one unit of pRBC and can be given wide open.

Advantages: Does not require typing or cross-matching before infusion and so far found not to cause transfusion reactions. Shelf life of over 12 months (ciruclation time is 1-2 days) and does not require refrigeration. Bovine based Hemopure has been said acceptable for use in Jehovah's Witnesses (?).

Disadvantages: No evidence based data available yet. Concerns raised re. Mad cow disease in bovine based Hemopure !.

Read interesting critical commentary on above products here from Randy Dotinga at wired.com

References: Click to get abstract/article
1. Safety and Efficacy of PolyHeme(R) in Hemorrhagic Shock Following Traumatic Injuries Beginning in the Pre-Hospital Setting - clinicaltrials.gov
2. Watchtower Approves HemoPure for Jehovah's Witnesses - ajwrb.org
3. Effect of Hemopure® on Prothrombin Time and Activated Partial Thromboplastin Time on Seven Coagulation Analyzers, - Clinical Chemistry. 1997;43:1792
4. PolyHeme - American College of Surgeons at facs.org
posted by ICU room Pearls @ 11:06 PM 0 comments

Tuesday, December 20, 2005
Wednesday December 21, 2005
Vancomycin dosing in CRRT

Vancomycin dosing is different in CRRT (Continuous Renal Replacement Therapy) from IHD (Intermittent HemoDialysis) as vancomycin is effectively removed during CRRT. Vancomycin is 14K daltons and CRRT filter removes upto 20K daltons size molecules. Frequent monitoring of Vancomycin level is required. Different intervals has been described from 24 to 48 hours. Most agree on 10 mg/kg every 24 hours. If patient is on CVVHDF instead of CVVHD than it might go upto 15 mg/kg per day. Ultimate goal is to keep vancomycin trough atleast between 10 - 15 mcg/ml and should not fall below 8 mcg/ml.

Related: See nice power point presentation on CRRT from Gregory M. Susla Pharm.D (Bayer) here .

References: Click to get abstract/article
1. Vancomycin dosing and monitoring - Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center (CUMC), columbia.edu
2. Antimicrobial dosing in continuous renal replacement therapy - with free registration at http://infectiousdiseasenews.com
3. CVVH Initial Drug Dosing Guidelines - from www.thedrugmonitor.com

posted by ICU room Pearls @ 10:48 PM 0 comments

Monday, December 19, 2005
Tuesday December 20, 2005
BNP or Pro-BNP ?

Although BNP and NT-proBNP are breakdown products of same parent peptide but in laboratory BNP and NT-proBNP are 2 different tests with 2 different ranges of normal, designed for same reason. Psychologically we are so prone to use BNP that we may have NT-proBNP value in our hand but read it as BNP. There is no conversion formula. NT-proBNP is 2.5 times heavier peptide than BNP (76 amino acids vs 32 amino acids) with 3- 6 times longer half life (120 minutes vs 20 minutes). NT-proBNP get solely excreted via kidney but BNP gets only partially excreted via Kidney. In short NT-proBNP of 400 may means nothing but may be significant if its BNP. Please check: Is it BNP or NT-proBNP ?. It may require different clinical approach though for same clinical problem. Both tests have very good negative predictive value for LV-dysfunction.

Do you know which assay your laboratory use?

References: Click to get abstract/article
1. EDUCATIONAL COMMENTARY - BNP - American Proficiency Institute – 2002 3rd Test Event
2. Using BNP to diagnose, manage, and treat heart failure - CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 4, APRIL 20033. NT-ProBNP - referencelab.clevelandclinic.org May 2004
4. Application of NT-proBNP as a Diagnostic Marker of Cardiac Disease - available free at medscape with CME with free registration at medscape.com
5. NT-proBNP test results comparable to those of BNP blood test in patients with kidney disease - rxpgnews.com

posted by ICU room Pearls @ 10:49 PM 0 comments

Sunday, December 18, 2005
rdn
Monday December 19, 2005
Renal Dose Norepinephrine !

This interesting term was coined by Dr. Marik in August 2004 chest journal with final comment: "...In the volume-replete patient, norepinephrine is the vasopressor of choice. Norepinephrine in clinically relevant doses is a friend of the kidney and not a foe" *, while commenting on the study in the same issue from Albanèse and coll. that found that in septic patients norepinephrine infusion reestablished urine flow, with a decrease in serum creatinine levels and an increase in creatinine clearance rate after 24 hours. Although Guidelines published in Critical Care Medicine - November 2004 on "Vasopressor and inotropic support in septic shock: An evidence-based review" still recommends that: "Either norepinephrine or dopamine is the first-choice vasopressor agent to correct hypotension in septic shock." but overall trend is going in favour of norepinephrine.

*From Noradrenaline and the kidney: friends or foes? - Critical Care 2001, 5:294-298

References: Click to get abstract/article

1. Renal Dose Norepinephrine! - Chest. 2004;126:335-337
2. Renal Effects of Norepinephrine in Septic and Nonseptic Patients - Chest. 2004;126:534-539
3. Noradrenaline and the kidney: friends or foes? - Crit Care 2001, 5:294-298
4. Vasopressor and inotropic support in septic shock: An evidence-based review. - Critical Care Medicine. 32(11) Supplement:S455-S465, November 2004
posted by ICU room Pearls @ 10:18 PM 0 comments

Saturday, December 17, 2005
Sunday December 18, 2005
Enoxaparin (Lovenox) dose in obesity

There is no standard guidelines so far available for Lovenox dose in obesity (particularly beyond 150 kg). Best way is to manage it through anti-factor Xa levels (The target therapeutic range is 0.6-1.0 IU/ml - draw 4 hours after 3rd dose). But many hospitals don't have anti-factor Xa levels available or turn around time is too long. One crude way is to dose per "adjusted body weight".

ABW = IBW + 0.4 [TBW – IBW]

ABW = Adjusted body weight
IBW = Ideal body weight
TBW = Total body weight

* Obesity is defined as a BMI >30kg/m2

Reference: Click to get abstract/article
1. Drug Use Criteria for Low Molecular Weight Heparins and Fondaparinux - Source visn21.med.va.gov
posted by ICU room Pearls @ 11:08 PM 0 comments

Friday, December 16, 2005
Saturday December 17, 2005
What is SHARF score ?

SHARF stands for "Stuivenberg Hospital Acute Renal Failure" (from Stuivenberg General Hospital, Antwerp, Belgium). This is a prognostic scoring system for hospital mortality of individual patients with acute renal failure - ARF. It is considered to be very predictable.

Score is calculated at the time of diagnosis of ARF (SHARF T0) and the other at 48 hours later (SHARF T48). It is a complicated formula with age, albumin, prothrombin time, ventilator support, heart failure. In modified formula sepsis, hypotension and bilirubin has also been added. To compound it you have to compute age in decades, albumin and Prothrombin time according to category table and other parameters as present or absent. Probably due to its complication it never get popular. Our objective is to make intensivists be aware of its presence in literature.

Click to see formulae and category table.


References: Click to get abstract/article
1. Prognostic value of a new scoring system for hospital mortality in acute renal failure - via pubmed - Clin Nephrol. 2000 Jan;53(1):10-7.
2. Re-evaluation and modification of the Stuivenberg Hospital Acute Renal Failure (SHARF) scoring system for the prognosis of acute renal failure: an independent multicentre, prospective study - Nephrology Dialysis Transplantation 2004 19(9):2282-2288
3. Interim results of the SHARF4 study: outcome of acute renal failure with different treatment modalities - Critical Care 2004, 8(Suppl 1):P153

posted by ICU room Pearls @ 9:49 PM 0 comments

Thursday, December 15, 2005
Friday December 16, 2005
Quick bedside test for Methemoglobinemia

A quick bedside test to strongly suspect (MetHb) Methemoglobinemia is to bubble 100% oxygen in tube with patient's dark blood. No change in Color strongly predicts Methemoglobinemia. If blood turns red on exposure to oxygen, cause is probably cardiopulmonary disease. (Same test can be done with 2 drops of patient's blood on white filter paper and exposing it to atmospheric oxygen. Change in color rule out Methemoglobinemia). Although Co-oximetry is an accurate method for measuring Methemoglobinemia, not all machines can (only newer versions can) differentiate it from another rare disorder sulfhemoglobinemia.

References:
1. A case of sulfhemoglobinemia and emergency measurement of sulfhemoglobin with an OSM3 CO-oximeter - Clinical Chemistry 43: 162-166, 1997;
2. Pitfalls in Discriminating Sulfhemoglobin from Methemoglobin - Clinical Chemistry 43: 1098-1099, 1997;
3. Methemoglobinemia - please register free at emedicine.com
posted by ICU room Pearls @ 10:20 PM 0 comments

Wednesday, December 14, 2005
fr
Thursday December 15, 2005
"Five Rights"

It is important that we continue to vibrate "Five Rights" message down the line to house staff and other staff involved in Critical Care to minimize medication errors.

1. Right Patient.
2. Right Drug.
3. Right Time.
4. Right Dose.
5. Right Route.

(Also mentioned somewhere addendum with 6. Right Documentation 7. Right Indication 8. Right to Refuse).

But read this interesting constructive critique from Matthew Grissing RPh, a medication safety analyst with the Institute for Safe Medication Practices to understand what else need to be done beside "Five Rights". - Reference: P & T Vol. 27 No. 10, October 2000.
posted by ICU room Pearls @ 10:39 PM 0 comments

Tuesday, December 13, 2005
Wednesday December 14, 2005
7 pearls re. Milrinone

1. Milrinone need to be protected from light and if drip is discoloured or precipitation is visible (light effect) - it may be an ineffective bag.

2. Dose need to be adjusted according to renal funtion. (unfortunately often get ignored in ICUs)

3. Milrinone induced hypotension is more responsive to low dose vasopressin (.01 - .04 units/min).

4. Initial bolus should be given atleast over 10 minutes.

5. Milrinone is drug of choice over Dobutamine in cardiogenic pulmonary edema.

6. Limited known is the direct beneficial role of milrinone in severe cardiac depression from calcium channel blocker overdose. (Caution about hypotension!)

7. Pre-emptive perioperative infusion of milrinone in off-pump coronary artery bypass surgery showed to improve cardiac performance when compared to normal saline.


References: Click to get abstract/article

1. Comparative efficacy of short-term intravenous infusions of milrinone and dobutamine in acute congestive heart failure following acute myocardial infarction. Milrinone-Dobutamine Study Group - via pubmed Clin Cardiol. 1996 Jan;19(1):21-30

2. Vasopressin as an alternative to norepinephrine in the treatment of milrinone-induced hypotension - Critical Care Medicine: Volume 28(1) January 2000 pp 249-252

3. Efficacy of pre-emptive milrinone in off-pump coronary artery bypass surgery: comparison between patients with a low and normal pre-graft cardiac index - Eur J Cardiothorac Surg 2004;26:687-693
posted by ICU room Pearls @ 10:01 PM 0 comments

Tuesday December 13, 2005
Oral care in ICU

Oral care is an integral part of ICU care. One recent study showed decrease in ventilator associated pneumonia (VAP) rate from 5.6 VAPs/1000 ventilator days to 2.0 VAPs/1000 ventilator days. Due to significance, one clinical trial is comparing a program of meticulous oral care using oral assessments taught by a dentist and dental hygienist with the standard nursing care typically given in ICUs. A recent study from Dutch investigators showed that 2% chlorhexidine every six hours by swabbing it onto the buccal cavity decreases VAP significantly and is way more effective than traditional .12% chlorhexidine .

See one sample ORAL CARE FOR INTUBATED PATIENTS protocol - from London Health Sciences Centre, Canada.

References:

1. You can make a difference in 5 minutes - Evidence-Based Nursing 2004; 7:102-103
2. Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients - clinicaltrials.gov
3. Oral Care Interventions in Critical Care: Frequency and Documentation - American Journal of Critical Care. 2003;12: 113-118
4. Chlorhexidine 2% Preparation Reduces the Incidence of Ventilator-Associated Pneumonia - 44th Interscience Conference on Antimicrobial Agents and Chemotherapy: Abstract 3717. Presented Oct. 31, 2004 - via medscape.com with free registration)
posted by ICU room Pearls @ 8:40 AM 0 comments

Sunday, December 11, 2005
Monday December 12, 2005
Continuous intravascular blood gas monitoring

As ICUs are getting more and more tech-savy, intensivists have also been added with extra responsibility to know the evidence based status of different machines / technologies. In this term, one fast emerging technique is continuous intravascular blood gas monitoring. Our literature search (major work so far done in pediatric critical care) showed favourable approach to this technology despite reports of inaccurate measurement of PO2. As technique is very young, no data is available on cost effectiveness. But in adult patients overall its a good peri-operative and immediate post-operative tool particularly in cardiothoracic patients (transplant, one lung ventilation etc). Also, its a better replacement in extremely unstable patients requiring multiple ABGs such as refractory septic shock, ARDS, severe COPD and trauma patients.

Related: Click here to read good review article with links to all major studies re. continuous intravascular blood gas monitoring. British Journal of Anaesthesia, 2003, Vol. 91, No. 3 397-407
posted by ICU room Pearls @ 10:15 PM 0 comments

Saturday, December 10, 2005
Sunday December 11, 2005
Ice test - Poor man's test for Myasthenia Gravis

Most of the Myasthenia patients along with other symptoms of weakness usually exhibits ptosis. While at bedside place an ice cube over eye lids for 2 minutes. Cooling improves neuromuscular transmission. Resolution of ptosis with cooling is a positive test for Myasthenia Gravis and reported upto 80% reliable to diagnose ocular myasthenia.

Related: Click here to read good review article on Myasthenia Gravis from Dr. Milind J. Kothari. The Journal of the American Osteopathic Association. Vol 104 • No 9 • Sept. 2004 • 377-384
posted by ICU room Pearls @ 10:08 PM 0 comments

Friday, December 09, 2005
Saturday December 10, 2005
Vasopressin .07 units/min ?

There has been a lot of enthusiasm about using vasopressin as vasopressor earlier than later in septic shock patients due to initial encouraging literature with dose of .01-.04 units/min. But anecdotally it has been tried upto .07 units/min to enhance the effect. We looked into the literature in this regard and found atleast one study where dose beyond .04 units/min was reported to be associated with higher adverse effects. Study from Vancouver, Canada looked into 50 patients with mean APACHE II score of 27. Baseline data at 0 hour was compared to 4, 24 and 48 hours of vasopressin infusion. Though most parameters improved there were six cardiac arrests; all but one occurred at a vasopressin dose of 0.05 units/min or more. The final conclusion was "Doses higher than 0.04 units/min were not associated with increased effectiveness and may have been associated with higher adverse effects."


References:

The effects of vasopressin on hemodynamics and renal function in severe septic shock: a case series - Intensive Care Med 2001 Aug;27(8):1416-21
posted by ICU room Pearls @ 10:27 PM 0 comments

Thursday, December 08, 2005
Friday December 9, 2005
7 Pearls re. Myxedema Coma

Myxedema Coma is a medical emergency but being an intensivist 7 pearls are worth remembering:

Myxedema Coma is a clinical diagnosis and treatment should not be delayed for laboratory confirmation.

Even if enteral route is available - IV Thyroid hormone (T4 or T3) replacement is needed as GI absorption is unreliable.

T4 is preferable if underlying cadiac co-morbidity is suspected.

Simultaneously steroids should also be started after random cortisol level is drawn.

Adding prophylactic antibiotics is not a bad idea.

Hypotension is not due to volume depletion so avoid aggressive fluid resuscitation.

Thermometers that can record below 90°F (32.2 C) is preferable.

Read intereating case study with discussion and treatment options on Myxedema Crisis here from Israeli Journal of Emergency Medicine – in pdf - (Vol. 5, No. 4 Oct 2005)
posted by ICU room Pearls @ 9:43 PM 0 comments

Wednesday, December 07, 2005
pivde
Thursday December 8, 2005
Preventing intra-venous (IV) drip errors

Many studies have shown so far that errors in administration of intravenous drugs remain high and actually even higher in ICUs. Standard protocols need to be instituted for sure at bedside to prevent errors in IV administrations but anecdotal reports shows that 2 quick interventions can decrease the rate of error significantly.

1. Vasoactive drugs be infused through a dedicated site and using other separate IV site for other infusions.

2. Triple sticker labeling of IV drips (at/near IV bag, pump and infusion sites).

References: Click here to get article
1. Ethnographic study of incidence and severity of intravenous drug errors - BMJ 2003;326:684 (29 March)
2. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units - Crit Care Med 1997 Aug;25(8):1289-97.
posted by ICU room Pearls @ 11:47 PM 0 comments

Tuesday, December 06, 2005
Wednesday December 7, 2005
Re. Nesiritide (Netrecor)

Netrecor (nesiritide) not only walked into our hospitals for "exacerbation of CHF" but even in out-patient clinics for "tune-up of CHF" with a big bang but over time we realized its not a miracle drug. JAMA article of April 2005 actually showed that it may be associated with an increased 30-day mortality . Later reviews and reports against Netrecor and its association with renal dysfunction intensified the debate. It appears that up to date: Netrecor is indicated only for severe acute decompensated congestive heart failure (CHF) with dyspnea at rest or minimal activity and is NOT indicated for intermittent or scheduled repetitive use, to improve renal function or for diuresis. Using Netrecor merely with BNP level is not advisable.

References: Click here to get article
1. Short-term Risk of Death After Treatment With Nesiritide for Decompensated Heart Failure - A Pooled Analysis of Randomized Controlled Trials - JAMA. 2005;293:1900-1905. (full article available with free registration)
2. Nesiritide — Not Verified - NEJM, Volume 353:113-116, July 2005
3. Scios press releases
4. Scientific papers related to Netrecor


Re. Selective Digestive-tract Decont. - posted yesterday

Response 1: If you look at the bulk of the literature on this topic from Europe, they exclude ICU's with MRSA concerns. This amounts to most US facilities.

Response 2: SDD may not be feasible in ICUs with high prevalence of VRE and MRSA. Click this Medscape article (register free to read).
posted by ICU room Pearls @ 8:46 AM 0 comments

Monday, December 05, 2005
Tuesday December 6, 2005
Selective digestive tract decontamination (SDD)

SDD is widely practiced in europe but its use in USA remains low due to fear of increase in antibitics resistance. The technique applies use of oral and enteral nonabsorbable antibiotics (polymyxin B, tobramycin and amphotericin B - new reports suggest benefit of Probiotics) and IV antibiotics (cefotaxime) in the hope to prevent and eradicate oropharyngeal and gastrointestinal carriage of potentially pathogenic microorganisms (PPMs), leaving the indigenous flora, which may protect against overgrowth of resistant bacteria. Most studies favour use of SDD in prevention of ventilator-associated pneumonia (VAP) and overall decrease in ICU mortality. Are we ready to embark on this journey?

References: Click here to get article
1. Selective digestive decontamination decreases mortality and morbidity in the intensive care - Canadian Journal of Anesthesia 51:737-739 (2004)
2. Selective decontamination of the digestive tract reduced intensive care unit and hospital mortality in adults - Evidence-Based Nursing 2004; 7:47
3. Selective decontamination of the digestive tract reduces mortality in critically ill patients - Critical Care 2003, 7:107-110
4. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia - Am. J. Respir. Crit. Care Med., February 15, 2005; 171(4): 388 - 416
posted by ICU room Pearls @ 10:54 PM 0 comments

Sunday, December 04, 2005
Monday December 5, 2005
C-Reactive Protein (CRP) - marker of mortality in ICU ?

Interesting work done from Belgium looking into correlation of C-Reactive Protein with mortality in ICU. Patients with high CRP levels at ICU admission had more severe organ dysfunction, longer ICU stays, and higher mortality rates (36% if ICU admission serum CRP levels > 10 mg/dL). On 48 hours followup - decrease in CRP level was associated with a mortality rate of 15.4%, while an increased CRP level was associated with a mortality rate of 60.9%.

Clinical significance: Admission CRP level can identify the patient who may require more aggressive interventions to prevent complications and similarly serial measurements.

C-Reactive Protein Levels Correlate With Mortality and Organ Failure in Critically Ill Patients - Chest. 2003;123:2043-2049
posted by ICU room Pearls @ 8:36 AM 0 comments

Sunday December 4, 2005
Epidemic of new fluoroquinolone induce strain of C. Diff.

Centers for Disease Control and Prevention has release a report on epidemic of new fluoroquinolone induce strain of C. Diff. The New England Journal of Medicine has put out 2 reports on epidemic of a new strain of Clostridium difficile on Dec. 8 2005 issue (see in references). It is called BI/NAP1 isloates and showing a lot more resistance to fluoroquinolones (Gatifloxacin and Moxifloxacin). It appears more toxic as canadian report shows 30-day attributable mortality rate of 6.9 percent. Regular laboratory may not be equipped to do the test so you may have to specifically ask for it. Be more vigilant as early treatment is the key and with no response to oral metronidazole, early switch to oral vancomycin may be needed.

Alochol can’t kill C.diff spores so washing with soap and water is required.

Report 1: Georgia, Illinois, Maine, New Jersey, Oregon, and Pennsylvania.
Report 2: 12 hospitals in Quebec, Canada

References:
1. An Epidemic, Toxin Gene–Variant Strain of Clostridium difficile
2. A Predominantly Clonal Multi-Institutional Outbreak of Clostridium difficile–Associated Diarrhea with High Morbidity and Mortality
3. The New Clostridium difficile — What Does It Mean?
posted by ICU room Pearls @ 7:38 AM 0 comments

Saturday, December 03, 2005
Saturday December 3, 2005
Low tidal volume (TV) anyway?

From ARMA trial of ARDSNET we learned about benefits of low TV in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) but reports and studies have shown benefit of low TV (or harm of high TV) in non-ALI/ARDS too. See this retrospective cohort study of 332 patients who did not have acute lung injury but required mechanical ventilation - 80 patients developed ALI within the first 5 days of mechanical ventilation. One of the main risk factors in developing ALI was the use of large tidal volume in dose-dependent manner (odds ratio 1.3 for each ml above 6 ml/kg predicted body weight). 2 lessons learned:

1) We still tend to ignore the “ideal” body weight depending on height and gender and are using “actual” body weight for initial TV setup.

2) We still don’t know the “optimum” TV on non-ALI patients.

References: click to get abstract/article

1. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation Critical Care Medicine. 32(9):1817-1824, September 2004
posted by ICU room Pearls @ 8:03 AM 0 comments

Thursday, December 01, 2005
bis
Friday December 2, 2005
BIS (Bispectral Index) monitoring

BIS monitoring is an underutilize tool in ICUs particularly in patients on paralytics. Experts are still debating its full value. General guide regarding BIS monitoring level, if use:

100 - 80: Awake or sedation is light
60 - 80: Respond to command but may not recall the event.
40 - 60: Probably sedation is optimum.
Less than 40: Deep sedation
0: No EEG like in barbiturate coma or deep hypothermia.

Key is to monitor BIS sedation scale with hemodynamics together as BIS doesn’t provide any measurement of analgesia which may be needed simultaneously with sedation.

References: click to get abstract/article
1. BIS Monitoring to Prevent Awareness during General Anesthesia - Anesthesiology: Volume 94(3) March 2001 pp 520-522
2. BIS monitoring in ICU: advantages of the new XP generation - Critical Care 2002, 6(Suppl 1):P68
3. Potential Benefits of Bispectral Index Monitoring in Critical Care: A Case Study - Crit Care Nurse 2003 Aug;23(4):45-52
4. Use of BIS Monitoring Was Not Associated with a Reduced Incidence of Awareness - Anesth Analg.2005; 100: 1221

posted by ICU room Pearls @ 11:45 PM 0 comments

Thursday December 1, 2005
Pulmonary Artery Occlusion Pressure and PEEP

There are 3 ways to correct/manage pulmonary artery occlusion pressure or pulmonary capillary wedge pressure (PCWP) in patients with PEEP (positive end-expiratory pressure) over 10.

1. Follow the trend of PCWP co-relating with other clinical data and interventions.

2. Corrected PCWP = Measured PCWP - .5 x (PEEP/1.36)
e.g. If measured PCWP is 20 and applied PEEP is 16:
Corrected PCWP = 20 - .5 (16/1.36) = 14.12

3. Corrected PCWP = measured PCWP - esophageal pressure.

Temporary discontinuation of PEEP to measure PCWP is not safe and should be avoided.

References: click to get abstract/article
1. Influence of positive end-expiratory pressure on left ventricular performance - NEJM, Feb. 1981, Volume 304:387-392
2. Monitoring Pulmonary Artery Pressure - Crit Care Nurse 2004 Jun;24(3):67-70
3. Measuring Intra-Esophageal Pressure to Assess Transmural Pulmonary Arterial Occlusion Pressure in Patients with Acute Lung Injury: A Case Series and Review - Respir Care 2000;45(9):1072-1084
4. Swan-Ganz Catheterization - online emedicine.com
posted by ICU room Pearls @ 9:33 PM 0 comments

Wednesday, November 30, 2005
Wednesday November 30, 2005
Haloperidol (Haldol) intra-venous (IV)

Use of IV Haloperidol is a common practice in ICUs but it is approved by FDA - Food and Drug Administration - for only intra-muscular (IM) use. Yes ! "IV Haldol" is still off-label.

References: click to get abstract/article
1. HALDOL- DOSAGE AND ADMINISTRATION - rxlist.com

posted by ICU room Pearls @ 9:22 PM 0 comments

Monday, November 28, 2005
Tuesday November 29, 2005
Euthyroid Sick Syndrome

Word of wisdom is not to check thyroid function test in ICUs as it takes only few hours for patient to ‘abnormalize’ thyroid function test under stress but if clinically indicated send full "Thyroid Function Test” including TSH, Total T3, Total T4, Free T4 and rT3 (reverse T3). There is no absolute trend but general rule of thumb is as patient get sicker and sicker “all fall but reverse rise” i.e rT3 (reverse T3) will be elevated.

References: click to get abstract/article
1. Sick euthyroid syndrome - Jennifer Best M.D - Harborview Medical Center, seattle, Washington - University of Washington, Div. of General Internal Medicine.
2. Euthyroid Sick Syndrome - Serhat Aytug, MD - (please register free at emedicine.com)
posted by ICU room Pearls @ 10:30 PM 0 comments

Monday November 28, 2005
Four Phases of Acetaminophen Toxicity And Rumack-Matthew Nomogram (revised).

Acetaminophen (Tylenol, Paracetamol) toxicity is divided into four phases time-wise.

Phase 1 (up to 24 hours): Mild symptoms

Phase 2 (24- 48 hours): Right upper quadrant pain and rising Liver enzymes with deteriorating symptoms.

Phase 3 (48-96 hours): Liver failure

Phase 4 (4 days to 3 weeks): Resolution or death.

Clinical Significance: Patient’s Acetaminophen level should be plotted on Rumack-Matthew nomogram (revised) during first 24 hours of ingestion and if it falls in "possible" or "probable" liver failure risk area of nomogram, hepatology team should be alerted (or transfer to tertiary care center with liver services) as clinical deterioration may unfold very quickly.

Rumack-Matthew nomogram (revised) is available in the reference article below.

References: click to get abstract/article
1. Acetaminophen Intoxication and Length of Treatment: How Long Is Long Enough? - Pharmacotherapy 23(8):1052-1059, 2003 (available via medscape.com with free registration).
posted by ICU room Pearls @ 6:02 PM 0 comments

Sunday, November 27, 2005
TOF
Sunday November 27, 2005
Can we go without Train of Four (TOF) ?

On literature search we found atleast 2 decent (though small) studies questioning the need of Train of Four (TOF) which is considered so far to be the standard of care while patient on continuous- infusion neuromuscular blocking agents (NMB).

1. Div. of Pulm. & CCM, Med. Univ. of South Carolina, Charleston - compared 20 patients with TOF and 16 patients with best clinical assessment group and found no difference. (NMB used was Atracurium).

2. Div. of Pulm. & CCM, Univ. of Mississippi Med. Center, Jackson - compared 16 patients with TOF and 14 patients with best clinical assessment group and found no difference. (NMB used was cisatracurium).

But strong arguments made in favour of TOF by Dr. Sessler is also worth reading. (Click Ref. 3)


See nice article covering most aspect on TOF here from Dimensions of Critical Care Nursing.

References: click to get abstract/article
1. Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis - Am. J. Respir. Crit. Care Med., Volume 156, Number 5, November 1997, 1556-1561
2. A Prospective Randomized Comparison of Train-of-Four Monitoring and Clinical Assessment During Continuous ICU Cisatracurium Paralysis - Chest. 2004;126:1267-1273
3. Train-of-Four To Monitor Neuromuscular Blockade? - Curtis N. Sessler, MD, FCCP - Chest. 2004;126:1018-1022.
4. An Algorithm for Train-of-Four Monitoring in Patients Receiving Continuous Neuromuscular Blocking Agents - Dimensions of Critical Care Nursing, March/April 2003 Volume 22 Number 2 Pages 50 - 57
posted by ICU room Pearls @ 10:27 PM 0 comments

Saturday, November 26, 2005
Saturday November 26, 2005
Is post pyloric feeding absolute ?

It is not uncommon to find a patient in ICU to go without nutrition for long time only because enteral feeding tube (e.g. dobhoff) is not cleared by x-ray for post pyloric placement. Drs. Marik and Zaloga did meta-analysis of 9 prospective randomized controlled trials of 522 patients from medical, neurosurgical and trauma ICUs and found no difference in incidences of pneumonia, ICU length of stay and mortality between 2 groups (gastric and post-pyloric). Major recommendation made was: Patients who are not at high risk for aspiration should have a nasogastric/orogastric tube placed as early as possible for the initiation of enteral feeding. Small intestinal feeding tube should be considered if patient remain intolerant of gastric tube feeding despite addition of promotility agents or patients who demonstrate significant reflux or documented aspiration.

References: click to get abstract/article
Gastric versus post-pyloric feeding: a systematic review - Critical Care 2003, 7:R46-R51
posted by ICU room Pearls @ 11:04 PM 0 comments

Friday, November 25, 2005
Friday November 25, 2005
Acute acalculous cholecystitis in ICU

Diagnosis of acute acalculous cholecystitis (AAC) remains one of the most life saving skill in ICU as mortality from gallbladder rupture within 48 hours is high. Data of 39 patients published from Finland provide pretty good idea of patients prone to develop AAC. 1

1. Infection was the most common admission diagnosis, followed by cardiovascular surgery.
2. The mean APACHE II score on admission was 25.
3. The mean length of ICU stay before cholecystectomy was 8 days.
4. 85% of the patients received norepinephrine infusion.
5. 90% of the patients suffered respiratory failure before cholecystectomy.

Champagne Sign in acute acalculous cholecystitis: (On ultrasound) emphysematous cholecystitis with gas bubbles arising in the fundus of the gallbladder.

See nice review article on acalculous cholecystitis from emedicine.com (please register - free).

References: click to get abstract/article
1. Acute acalculous cholecystitis in critically ill patients - Acta Anaesthesiologica Scandinavica, 2004 Sep;48(8):986-91 - from pubmed -. Acta Anaesthesiologica Scandinavica is an official publication of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine.
posted by ICU room Pearls @ 7:43 AM 0 comments

Thursday, November 24, 2005
Thursday November 24, 2005
Saline vs Albumin - SOAP trial

As we know that in SAFE trial (Saline vs Albumin Fluid Evaluation) there was some positive trend for albumin in severe sepsis subset patients but overall 28-days outcome was “no difference”. But this month results of SOAP (Sepsis Occurrence in Acutely ill Patients) study - with caution of various limitations to study - showed negative trend for albumin with conclusion: “Albumin administration was associated with decreased survival in this population of acutely ill patients”. Negative trend may be due to cardiac depression from decreased ionic calcium, impaired renal function and anti-thrombotic properties of albumin. Probably the real answer is bedside clinical judgement for each patient.

References: click to get abstract/article
1. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit - NEJM, May 2004 Volume 350:2247-2256
2. Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study - Critical Care 2005, 9:R745-R754
posted by ICU room Pearls @ 7:38 AM 0 comments

Wednesday, November 23, 2005
Wednesday November 23, 2005
SRMD and PUD

We commonly use terms Stress ulcer (Stress Related Mucosal Disease = SRMD) and Peptic ulcer (PUD) interchangeably in ICU while talking "GI prophylaxis". But both are 2 different conditions. (Probably what we are worried in our "unit" patients is mostly SRMD).

SRMD is multiple superficial erosions occurring in proximal gastric bulb involving superficial capillaries secondary to mucosal hypoperfusion and perforations are rare.

PUD is few deep erosions occurring usually in duodenum involving one vessel secondary to other reasons (drugs, H.Pylori, hypersecretory states etc.) and perforation is common.

From Dr. David C. Metz, nationally renowned in Acid-Peptic Diseases, lecture in Aspire 2005 (Acid Suppression Pharmacotherapy in the ICU: Re-evaluating the Evidence), an initiative to provide a critical assessment of the most current data on therapeutic approaches in acid suppression and the prevention of peptic ulcer rebleeding and stress-related mucosal disease. Launch Aspire 2005 here. Highly recommended for Critical Care nurses and house-staff.
posted by ICU room Pearls @ 2:53 AM 0 comments

Tuesday, November 22, 2005
Tuesday November 22, 2005
Early CRRT in septic shock

A recent observational study of 60 patients from france is published in ccforum (november, 2005) regarding early initiation of continuous veno-venous haemodiafiltration (CVVHDF), in patients meeting at the same time criteria for sepsis, refractory circulatory failure, acute renal injury, and acute lung injury. CVVHDF was started after 6–12 hours of full haemodynamic support. There are 3 interesting conclusions:

1. In patients showing improvement in metabolic acidosis after 12 hours of CVVHDF, with progressive improvement in organ failures; the final mortality rate was 30%.

2. Those patients who did not show any improvement in metabolic acidosis, mortality rate was 100%.

3. The crude mortality rate for the whole group (53%), was significantly lower than the predicted mortality using Simplified Acute Physiology Score II (79%).

References: click to get abstract/article
1. Early veno-venous haemodiafiltration for sepsis-related multiple organ failure - Critical Care 2005, 9:R755-R763
2. New Simplified Acute Physiology Score - from sfar.org site
posted by ICU room Pearls @ 11:31 PM 0 comments

Monday, November 21, 2005
Monday November 21, 2005
Sympathetic Storming

Sympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units. It occurs due to uncontrolled sympathetic surge with a diminish or unmatch parasympathetic response. Acording to Baguley criteria 5 out of the 7 clinical features should be present - tachycardia, tachypnea, hyperthermia, hypertension, dystonia, posturing, and diaphoresis. Various agents have been used for treatment (see review article below) but haloperidol may worsen the symptoms.

Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004.


See great review article here on Sympathetic Storming from Denise M. Lemke, published in J Neurosci Nurs 36(1):4-9, 2004. © 2004. . Also available in our "B" search section at www.icuroom.net.

References: click to get abstract/article
1. Dysautonomia after traumatic brain injury: a forgotten syndrome? - J Neurol Neurosurg Psychiatry 1999;67:39-43 ( July )
2. Paroxysmal autonomic instability with dystonia (PAID) - Arch Neurol. October 2004;61:1625.
3. Paroxysmal Autonomic Instability with Dystonia After Brain Injury - Arch. Neurol. March 2004;61:321-328
4. Riding Out the Storm: Sympathetic Storming After Traumatic Brain Injury - Denise M. Lemke, MSN CS-RN ANP CNRN - J Neurosci Nurs 36(1):4-9, 2004.
posted by ICU room Pearls @ 9:48 PM 0 comments

Sunday, November 20, 2005
Sunday November 20, 2005
Time lag between Linezolid and Thrombocytopenia

Thrombocytopenia could be multifactorial in ICU. One of the relative new cause is Linezolid (Zyvox). But thrombocytopenia with Zyvox usually doesn't occur upto 2 weeks with the initiation of treatment and could help in ruling out atleast one reason. Relatively overall its mild, reversible and due to myelosuppression. there is no evidence for anti-platelet or interference with platelet function.

References: click to get abstract/article
1. Hematologic Effects of Linezolid: Summary of Clinical Experience - Antimicrobial Agents and Chemotherapy, August 2002, p. 2723-2726, Vol. 46, No. 8
2. Linezolid and reversible myelosuppression. - JAMA 285:1291
3. Safety, efficacy and pharmacokinetics of linezolid for treatment of resistant Gram-positive infections in cancer patients with neutropenia - Annals of Oncology 14:795-801, 2003
posted by ICU room Pearls @ 9:52 PM 0 comments

Saturday, November 19, 2005
Saturday November 19, 2005
Drotrecogin Alfa (Activated) tie to APACHE Score

Drotrecogin Alfa (Activated) - Xigris - is without doubt an effective tool in treating sepsis but there are debates about "to do or not to do".

Irrespective of reservations regarding APACHE II score itself, it is important to know the results of study from ADDRESS Study Group (Administration of Drotrecogin Alfa (Activated) in Early Stage Severe Sepsis), which concluded that it should not be use in patients with APACHE II score less than 25. There was extra risk of bleeding without any benefit. Actually subset of same study found to have higher mortality (both 28-days and inpatient) in those patients who underwent recent surgery (within 30 days) and had only single organ failure - irrespective of APACHE score. There were significantly more bleeding events in the Xigris group.

See APACHE Scorings in our tools section at www.icuroom.net.

References: click to get abstract/article
1. Drotrecogin Alfa (Activated) for Adults with Severe Sepsis and a Low Risk of Death - NEJM - Volume 353:1332-1341 - september 29, 2005.
2. Warning from Xigris
posted by ICU room Pearls @ 11:07 PM 0 comments

Friday, November 18, 2005
Friday November 18, 2005
RU-486 and septic shock

As sepsis is a major bread n butter of intensivists, it may be of importance to know that abortion pill RU-486 (Mifeprex/Mifepristone) has been associated with severe septic shock. 8 deaths (4 in USA) have been reported so far. 1 Mechanism of action is not entirely clear but it is secondary to pelvic infections from common vaginal bacteria Clostridium sordellii. Dr. Miech from Brown University proposed that Mifepristone, blocks both progesterone and glucocorticoid receptors and failure of physiologically controlled cortisol and cytokine response eventually results in release of toxins from C. sordellii and lead to life threatening septic shock. 2

References: click to get abstract/article
1. Mifeprex (mifepristone) - FDA warning
2. Pathophysiology of Mifepristone-Induced Septic Shock Due to Clostridium sordellii - The Annals of Pharmacotherapy: Vol. 39, No. 9, pp. 1483-1488
posted by ICU room Pearls @ 12:11 AM 0 comments

Thursday, November 17, 2005
Thursday November 17, 2005
Unplanned extubations - decrease mortality !

Interesting study published in chest (august 2005) of 100 patients (compared to controlled group) who experienced unplanned extubation but did not require reintubation. They were found to have decrease mortality and remarkably good outcomes despite longer hospital and ICU stay.

Lesson learned: we are keeping our patients intubated longer than needed !!

References: click to get abstract/article
1. The Drive to Survive - Unplanned Extubation in the ICU - From the Critical Care Unit (Dr. Krinsley), Stamford Hospital, Stamford, CT; and Department of Surgery (Dr. Barone), Columbia University College of Physicians and Surgeons, New York, NY.
posted by ICU room Pearls @ 6:53 AM 0 comments

Wednesday, November 16, 2005
amiodarone
Wednesday November 16, 2005
Am-iod-arone !!

The word "iod" in Amiodarone tells as that it is an iodine based compound. No wonder it mess up thyroid metabolism. Also, another interesting clinical significance of amiodarone toxicity is high-attenuation parenchymal-pleural lesions along with similiar increased attenuation in liver or spleen. This property of high attenuation due to iodine in lung, liver and spleen is pretty diagnostic of Am-iod-arone toxicity. The risk is higher if daily dose is greater than 400 mg. Amiodarone has increase half life in lung and eventually resolve with stoppage of drug while steroid is the thrapy in between. Acute Amiodarone toxicity has been described too.

See CXR and non-contrast CT slice (but appearing as contrast due to iodine accumulation) in Amiodarone Toxicity - from Radiographics in reference 2 below.

References: click to get abstract/article
1. Amiodarone pulmonary toxicity: CT findings in symptomatic patients - Radiology, Vol 177, 121-125
2. Pulmonary Drug Toxicity: Radiologic and Pathologic Manifestations - Radiographics. 2000;20:1245-1259
3. Amiodarone at pneumotox.com

posted by ICU room Pearls @ 8:59 AM 0 comments

Tuesday, November 15, 2005
Tuesday November 15, 2005
MAP measurement in ICU with sphygmomanometer

Although we don't need to do sphygmomanometric blood pressure measurement in ICUs on all patients anymore but still it is reasonable to have atleast one instrument available in "unit". (A-lines are not always inserted and sometime oscillometer readings don’t get register on monitor). Most experts agreed that MAP (Mean Arterial Pressure) is more of clinical significance - it may be of interest to know that beside traditional formula available to calculate MAP i.e. MAP = { SBP + (2DP) } / 3 OR DBP + .333 (SBP-DBP), there is another formula described which has been reported as more accurate.

MAP = DBP + .412 (SBP-DBP)

Here is the Nomogram to quickly find MAP with above formula without calculation. - reference - Heart 2000;84:64

References: click to get abstract/article
1. Formula and nomogram for the sphygmomanometric calculation of the mean arterial pressure - Heart 2000;84:64 (July)
2. Arterial Stiffness as Underlying Mechanism of Disagreement Between an Oscillometric Blood Pressure Monitor and a Sphygmomanometer - Hypertension. 2000;36:484
3. Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research - Circulation. 2005;111:697-716
posted by ICU room Pearls @ 2:07 PM 0 comments

Monday, November 14, 2005
Monday November 14, 2005
Cameron lesions

Cameron lesions are linear gastric erosions positioned at the diaphragmatic impression, in patients with large hiatus hernia. It is a distinct entity from other erosions and was described first time about 20 years ago by AJ Cameron. Clinical significance: In upto one third of cases cameron lesions can present as acute upper GI bleed which may become life-threatening. Despite treatment, 33% develop recurrence of the lesion with possible acute event requiring immediate surgery. Lesion can also cause iron deficiency anemia and chronic GI bleed.

See endoscopic picture here - from Indian Journal of Gastroenterology.

References: click to get abstract/article
1. Linear gastric erosion. A lesion associated with large diaphragmatic hernia and chronic blood loss anemia. - Gastroenterology. 1986 Aug;91(2):338-42.
2. Hiatal hernia with cameron ulcers and erosions. - Gastrointest Endosc Clin N Am. 1996 Oct;6(4):671-9.
3. Cameron lesion and its laparoscopic management - Indian J Gastroenterol 2005;24:163-163
posted by ICU room Pearls @ 10:29 AM 0 comments

Sunday, November 13, 2005
Sunday November 13, 2005
Potassium and phophate ratio in combo infusion

It is handy to remember that 1 mmol of intravenous phophate delivers 1.46 meq of potassium in "K-phos rider". To make it in round figure 7.5 mmol of phosphate is equal to about 10 meq of potassium and should be infuse over atleast one hour.

See nice read and guideline on "K-phos" rider at ismp.org
posted by ICU room Pearls @ 5:52 PM 0 comments

Saturday, November 12, 2005
Saturday November 12, 2005
Urinary Catheter related UTIs in ICU

There is a lot of emphasis on questioning everyday about nescessity of central venous lines but it may be of interest to know that urinary catheter related UTIs (urinary tract infections) makes 40% of hospital-acquired infections and 3% out of them ends up as bacteremia (and each episode of catheter-related nosocomial bacteremia costs a minimum of around US $3000). In ICUs, one recent study showed incidence density of 6 UCRI/1000 urinary catheter-days. (UCRI=urinary catheter related infection). In another study, implementation of nurse-driven surveillance of Criteria-Based Foley Catheter Guidelines (CFCG) protocol in ICU decreased UCRI from 6.4 to 1.9 per 1000 urinary catheter-days.

And no condom catheter are no better !

References: Click on link to get abstract/article:
1.Urinary catheter-related infection in critically ill patients Critical Care 2005, 9(Suppl 1):P12
2. Enhancing the Safety of Critically Ill Patients by Reducing Urinary and Central Venous Catheter-related Infections - American Journal of Respiratory and Critical Care Medicine Vol 165. pp. 1475-1479, (2002)
3. The Effects of Criteria-Based Foley Catheter Guidelines in an ICU - Innovations in Clinical Excellence Evidence-Based Practice Contest Winners I - Sigma Theta Tau International 38th Biennial Convention November 12-13, 2005, Indianapolis, IN
posted by ICU room Pearls @ 3:41 AM 0 comments

Friday, November 11, 2005
Friday November 11, 2005
Regarding Lactate level

It is worth to continue to emphasize to house staff that:

1. if feasible 'arterial' lactate is preferable to venous lactate as it get influenced with time and pressure of tourniquet.

2. Lactate level is under-utilized blood workup in sepsis patients. Its not a perfect analogy but as CPK and MB is to chest pain, WBC (Leucocytosis) and lactate level is to sepsis. (We are still in search of troponin of sepsis!).

3. Time matters exactly same in septic attack as in heart attack and brain attack. Lactate level (even venous) can help tremendously in identifying this attack early when hemodynamic is still relatively stable.

See Rivers early goal directed therapy's algorithm. - (NEJM) where lactate level of 4 has been used as cutoff point to start algorithm.

References: Click on link to get abstract/article:
1.Changes in venous blood lactate, venous blood gases, and somatosensory evoked potentials after tourniquet application - Anesthesiology. 1988 Nov;69(5):677-82
2. Early Goal-directed Therapy in the Treatment of Severe Sepsis and Septic Shock - November 2001, NEJM
posted by ICU room Pearls @ 8:19 AM 0 comments

Thursday, November 10, 2005
isp
Thursday November 10, 2005
ICU satellite pharmacy

Although there is no study done but anecdotal reports shows that decentralization of pharmacy with ICU having its own satellite pharmacy (ideally having its own critical care pharmacist) decrease medication errors and probably is more cost-effective for hospital due to focused expertise and increase communication with nurses/physicians. Similar has been recommended as "desirable services" in Position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy's Task Force on Critical Care Pharmacy Services.

References: Click on link to get abstract/article:
1. Declaring victory in the war against drug errors - Sept. 2005, Today’s Hospitalist.
2. Position paper on critical care pharmacy services from Society of Critical Care Medicine and American College of Clinical Pharmacy Task Force on Critical Care Pharmacy Services. - Critical Care Medicine. 28(11):3746-3750, November 2000
posted by ICU room Pearls @ 11:21 AM 0 comments

Wednesday, November 09, 2005
Wednesday November 9, 2005
Donut Magnets

If encountered with a situation where patient's AICD (Automatic Implantable Cardioverter Defibrillator) continue to fire inappropriately causing hemodynamic issues or mostly when during or after the 'code', AICD needs to be deactivated - ask for "Donut Magnets" ONLY as other regular magnets may not work. Put donut magnet directly over AICD. Once AICD deactivated you may hear a long beep(s) but important thing is to keep magnet there and tape it firmly till seen by cardiology. Its important, if patient fails cardio-pulmonary resuscitation, to deactivate AICD, confirm underlying asystole/rhythm before calling off the code.

See sample of ems driven AICD deactivation protocol - from scdhec.gov

posted by ICU room Pearls @ 10:01 AM 0 comments

Tuesday, November 08, 2005
Tuesday November 8, 2005
Troponin-I or Troponin-T ?

As picture is getting more clear about Troponins, it appears that Troponin-I does not get affected with renal insufficiency/failure. While 'sustained' elevated Troponin-T reflects poor cardiac baseline and predicts poor overall cardiac mortality. If Troponin-I is not available in your hospital, a spike (bell curve) or continuously rising Troponin-T may be an indicator of acute coronary event but low level sustained value may just reflect baseline cardiac decompensation.

Refrences: click on link to get article/abstract
1. Clinical Association between Renal Insufficiency and Positive Troponin I in Patients with Acute Coronary Syndrome - Cardiology 2004;102:215-219
2. Cardiac troponin-I before and after renal dialysis - Clinical Nephrology, Vol. 54 - No. 3/200
3. Troponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients. - Am J Kidney Dis. 2002 Jul;40(1):68-75.
posted by ICU room Pearls @ 12:01 AM 0 comments

Monday, November 07, 2005
etstsl
Monday November 7, 2005
ESCAPE Trial - setback to swan lovers?

Debate on pulmonary artery catheter is non-ending in critical care culture. Recently JAMA has published 2 studies which may make swan-believers unhappy.

1. ESCAPE Trial (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness): which showed that use of the PAC did not significantly affect the primary end point of days alive and out of the hospital during the first 6 months. Also, In-hospital adverse events were more common among patients in the PAC group.

2. Impact of the Pulmonary Artery Catheter in Critically Ill Patients - Meta-analysis of 13 Randomized Clinical Trials which showed that in critically ill patients, use of the PAC neither increased overall mortality or days in hospital nor conferred benefit.

Now we have to wait for results of FACTT study from ARDSnet evaluating the use of a Pulmonary Artery Catheter versus Central Venous Catheter (CVP) in patients with Acute Lung Injury and ARDS.

Refrences: click on link to get article/abstract
1. The ESCAPE Trial JAMA. 2005;294:1625-1633
2. Impact of the Pulmonary Artery Catheter in Critically Ill Patients -JAMA. 2005;294:1664-1670.
3. FACTT trial - ARDSNet

posted by ICU room Pearls @ 9:16 PM 0 comments

Sunday, November 06, 2005
Sunday November 6, 2005
Is low HDL marker for sepsis mortality?

Although it is a small prospective, observational cohort study of only 63 patients (National Taiwan University Hospital) but interesting to note the conclusion that:

A low HDL cholesterol level (cutoff value at 20 mg/dL) on day 1 of severe sepsis was significantly associated with an increase 30 day mortality, increase ICU stay and hospital acquired infection. (All other septic parameters adjusted).

Another interesting finding at continuation of work back to bench while blood samples were obtained and serum was immediately stored at -80°C until analysis : ...HDL can attenuate LPS (Lipopolysaccharide)-induced TNF-á production only if added concomitantly with, but not after, LPS exposure.

Refrences: click on link to get article/abstract
1. Low serum level of high-density lipoprotein cholesterol is a poor prognostic factor for severe sepsis - Critical Care Medicine: Volume 33(8) August 2005 pp 1688-1693

posted by ICU room Pearls @ 5:29 AM 0 comments

Saturday, November 05, 2005
Saturday November 5, 2005
Pneumocystis Jiroveci (PCP) - previously P. carinii

Patients with Pneumocystis jiroveci (PCP) usually detriorate in first 2 -3 days of treatment with worsening of A-a gradient (Alveolar-arterial gradient of oxygen) and this should not be presumed as treatment failure. If patient continue to show same trend by 5-7 days than treatment failure should be considered. Initial worsening is due to inflammation as organisms get killed and this is one of the reason to administer steroid at the initiation of PCP treatment.

Nomenclature has been changed as DNA analysis by PCR (polymerase chain reaction) showed that sequences from P. jiroveci (human-derived) differ by 5% from P. carinii (rat-derived). But acronym PCP has been retained for Pneumocystis pneumonia. Jiroveci (pronounced "yee row vet zee") has been named in honor of the Czech parasitologist Otto Jirovec, who is credited with describing the microbe in humans in 1999.

Refrences: click on link to get article/abstract
1. A New Name (Pneumocystis jiroveci) for Pneumocystis from Humans - cdc.gov
2. Pneumocystis pneumonia in humans is caused by P jiroveci not P carinii - Thorax 2004;59:83-84 (letter to editor)

posted by ICU room Pearls @ 5:20 AM 0 comments

Friday, November 04, 2005
Friday November 4, 2005
Prone positioning target - O2 or PCO2 ?

Literature on prone postioning in ARDS is not encouraging4 but as Dr. Alain F. Broccard showed optimism by saying: "Are We Looking at a Half-Empty or Half-Full Glass?" (ref. 2).

Dr. Gattinoni's 2001 NEJM article (ref. 3) failed to show any benefit on survival despite improved oxygenation but 2 years later his article in Critical Care Medicine Journal (Ref. 1) found that ARDS patients who respond to prone positioning with reduction of their Paco2 show an increased survival at 28 days. Improved efficiency of alveolar ventilation (decreased physiologic deadspace ratio) has been concluded as an important marker of patients who will survive acute respiratory failure.

So the Question is: In prone positioning should we target improve oxygenation or decreasing Paco2 ????

Refrences: click on link to get article/abstract
1. Decrease in Paco2 with prone position is predictive of improved outcome in acute respiratory distress syndrome - Crit Care Med 31(12):2727-2733, 2003
2. Prone Position in ARDS Are We Looking at a Half-Empty or Half-Full Glass? - (Chest. 2003;123:1334-1336.)
3. .Effect of Prone Positioning on the Survival of Patients with Acute Respiratory Failure - NEJM, Aug. 2001- Volume 345:568-573
4. Effects of Systematic Prone Positioning in Hypoxemic Acute Respiratory Failure - JAMA - Vol. 292 No. 19, November 17, 2004

posted by ICU room Pearls @ 9:10 PM 0 comments

Thursday, November 03, 2005
Thursday November 3, 2005
Regarding Valproic acid (VPA; Depakote) overdose

Few important points good to know in Valproate toxicity:

1. Hyperammonemia could occur without liver function test abnormalities.

2. Cerebral edema may become apparent even upto 4th day post ingestion and is not dose related so close monitoring is required despite level shows normalization.

3. Mechanism of action is unknow but in some patients Naloxone shows improvement in mental status so it should be considered.

4. There is no antidote available but administration of L-carnitine (50 mg/kg/day) in patients with hyperammonemia and neurological symptoms may help.

5. Hemodyalysis (Charcoal hemoperfusion is preferred if available) works only if level is above 100 ug/ml as protein binding sites become saturated and free drug is available for hemodyalizing.

6. Free valproate level should be send in patients with unexplained altered cognition, but normal serum (protein bound) levels.

Refrences: click on link to get article/abstract
1. Toxicity, Valproate - emedicine.com
2. Valproic acid toxicity: overview and management. - J Toxicol Clin Toxicol. 2002;40(6):789-801
3 Neurotoxicity Associated With Free Valproic Acid - Am J Psychiatry 162:810, April 2005
4. Delayed valproic acid toxicity: A retrospective case series - Ann Emerg Med. 2002 Jun;39(6):616-21

posted by ICU room Pearls @ 8:30 AM 0 comments

Wednesday, November 02, 2005
Wednesday November 2, 2005
Regarding Needle Thoracostomy

Needle thoracostomy continue to be one of the life saving procedures in ICUs for tension pneumothorax. But recent literature and anecdotal reports suggest that needle thoracostomy should be perform only in situations where severe hemodynamic compromise is imminent or diagnosis of pneumothorax is very clear. It is not a benign procedure as thought and should not be taken lightly. Blind needle thoracostomy carries good risk of lung laceration and air embolism through such a laceration is a real concern. If possible, its better to wait for radiological confirmation and perform chest tube placement in more controlled enviroment.

Another point raised in recent literature is regarding length of the needle. Standard 5 cm long needle has been found to fail 25% of the procedures. (14-16 G IV cannula is preferred). If thick chest wall presumed, 6 cm long needle has been recommended.

Refrences: click on link to get article/abstract
1. Needle Thoracostomy - Archive of debate at trauma.org
2. image of procedure site - Deptt. of Anesth. & inten. care, Chinese Univ. of Hong Kong
3 Needle Thoracostomy: Implications of Computed Tomography Chest Wall Thickness - Acad Emerg Med Volume 11, Number 2 211-213
4. Needle Thoracostomy in Trauma Patients: What Catheter Length Is Adequate? - Acad Emerg Med Volume 10, Number 5 495.

posted by ICU room Pearls @ 9:56 AM 0 comments

Tuesday, November 01, 2005
Tuesday November 1, 2005
Immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) is relatively a newly discovered phenomenon encountered by those intensivists who take care of HIV patients. Some individuals who initiate "HAART" (Highly Active Antiretroviral Therapy) regimen develop new or paradoxical worsening of opprtunistic infections or malignancies despite improvements in surrogate markers of HIV infection. Reportedly it develops in patients with profound immunosuppression (usually below CD4 count of 100). Classic example is a study which showed that 30% of HIV patients coinfected with Cryptococcus neoformans who initiated HAARTdeveloped IRIS with higher cerebrospinal fluid opening pressures, glucose levels, and white blood cell counts.

Refrences: click on link to get article/abstract
1. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. - Clin Infect Dis. 2005 Apr 1;40(7):1049-52.
2. Recent IRIS related articles/literature - hivandhepatitis.com
3.Immune Reconstitution Inflammatory Syndrome Associated With Kaposi's Sarcoma - Journal of Clinical Oncology, Vol 23, No 22 (August 1), 2005: pp. 5224-5228
4. Immune Reconstitution Inflammatory Syndrome Associated With HIV and Leprosy - Arch Dermatol. 2004;140:997-1000.
posted by ICU room Pearls @ 12:14 AM 0 comments

Monday, October 31, 2005
Monday October 31, 2005
IHI's 5 essentials to prevent central line infections

Who will disagree with following 5 essentials to prevent central line infections from IHI (Institute for Healthcare Improvement).

1. Washing Hands: Before and after palpating the insertion site. (Good to avoid palpation once field is ready).

2. Maximal barrier precautions: yes !! - complete application of sterile drape from head to toe and those “four magic words” - cap, mask, gown and gloves.

3. Use of Chlohexidine as an anti-septic: Proven to be superior than Povidone-iodine(Betadine).

4. Sub-clavian as prefferd site: (may be controversial if operator is not experienced).

5. Daily evaluation of necessity of line: So true !

See IHI’s Central line bundle check list and complete guide in our protocol/tool section. Please register free at ihi.org for immense other resources.
posted by ICU room Pearls @ 9:51 AM 0 comments

Sunday, October 30, 2005
Sunday October 30, 2005
Back to Basics - essential trace elements

Importance of seven essential trace elements is relatively way higher in ICUs due to hypermetabolic state of patients. Being an intensivist it is important to have some know how of them. Except for iron and iodine all others need to be provided with enteral and parentral formulae to satisfy atleast their RDA.

1. Iron: in ICU merely checking Fe level may not give real answer of its deficiency. Always check Ferritin level (below 18 indicates deficiency).

2. Selenium: important anti-oxidant and unfortunately many times not included in available enteral/parentral formulae.

3. Chromium: necessary for normal glucose utilization.

4. Copper: essential for formation of hemoglobin.

5. Iodine: needed for proper thyroid metabolism.

6. Manganese: part of Ca+/phos+ metabolism.

7. Zinc: needed for proper wound healing.

Refrences: Click to get abstract/article.
1. Trace minerals in ICU patients: a forgotten cause of delayed recovery? - Critical Care 2004, 8(Suppl 1):P264
2. Trace element supplementation modulates pulmonary infection rates after major burns: American Journal of Clinical Nutrition, Vol 68, 365-371
3. Levels of oligo-elements and trace elements in patients at the time of admission in intensive care units - Nutr Hosp. 1990 Sep-Oct;5(5):338-44.
4.Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients - Journal of Parenteral and Enteral Nutrition, Vol 27, Issue 5, 355-373
5. EARLY ENTERAL SUPPLEMENTATION WITH PHARMACONUTRIENTS IN CRITICALLY ILL PATIENTS - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A4

posted by ICU room Pearls @ 10:16 PM 0 comments

Saturday, October 29, 2005
Saturday October 29, 2005
Venous Air Embolism - VAE - immediate maneuvers

If Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 steps are essential:

1. Clamp the line (do not withdraw) - to prevent further air.

2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.

3. Place patient in Trendelenburg position - to help air trap in the apex of the ventricle.

4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).

5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).

6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).

7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.

Refrences: Click to get abstract/article.

1. Venous Air Embolism - emedicine.com
2. Gas Embolism - NEJM, feb. 2000, Volume 342:476-482
3. Venous air embolism: a review. J Clin Anesth 1997;9:251-257
4. Venous Air embolism - Rashad Net University

posted by ICU room Pearls @ 5:20 AM 0 comments

Friday, October 28, 2005
Friday October 28, 2005
3 new antibiotics

Recently atleast 3 new antibiotics have been introduced in market. No doubt, these are big guns but it is important to know their drawbacks.

1. INVANZ (Ertapenem): Unlike other carbapenems this antibiotic has limited role in nosocomial infections due to negligible activity against Pseudomonas aeruginosa and Acinetobacter baumanni !!

2. CUBICIN (Daptomycin): Cubicin is indicated only for complicated skin and skin structure infections caused by Gram-positive organisms including MRSA (no gram-negative coverage). It has been used as off label for VRE and endocarditis but not approved by FDA. Dose dependent myopathy is a concern, and CPK monitoring is required.

3. TYGACIL (Tigecycline): has been approved for complicated skin (including MRSA) and intra-abdominal (MRSA not included) infections. It has very broad spectrum coverage. It is a distinct class similar to tetracycline. Though nick-named as "Superbug Antibiotic", experts warn against use as a first line or mono-therapy. Side effect profile is long including increase liver enzymes, azotemia, acidosis, hypophosphatemia, hyperglycemia, hypokalemia etc.

Readings: Click to get abstract/article.

1. Carbapenems - Dept of Anaesth. & Int. Care, The Chinese Univ. of HK
2. Cubicin: cleveland clinic - pharmacotherapy update
3. FDA warning letter for cubicin - pharmcast.com
4. Tygacil: multum.com
posted by ICU room Pearls @ 11:26 AM 0 comments

Thursday, October 27, 2005
Thursday October 27, 2005
Propofol Infusion Syndrome (PRIS)

Propofol Infusion Syndrome is a serious threat when propofol is continued for more than 48 hours particularly if dose goes beyond 5mg/kg/hr. Propofol Infusion Syndrome is hallmark by unexplained metabolic acidosis, rhabdomyolysis, cardiac events, arrthymias, hepatomegaly, lipemia, renal failure and hyperkalemia. Unexplained lactic acidosis is suggested as an early marker of "PRIS". Acquired carnitine deficiency has been postulated as a cause, atleast in one article.


Reference: Click to get abstract/article.

1. Cremer and coll.: Long-term propofol infusion and cardiac failure in adult head-injured patients. The Lancet 2001;357:117-118 (Article available at www.thelancet.com with free registration)
2. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. - Intensive Care Med. 2003 Sep;29(9):1417-25.
3. Acquired Carnitine Deficiency: A Clinical Model for Propofol Infusion Syndrome? - Anesthesiology: Volume 103(4) October 2005 p 909
posted by ICU room Pearls @ 12:56 PM 0 comments

Wednesday, October 26, 2005
Wednesday October 26, 2005
CPR on patient with IABP

If patient requires CPR who is on Intra-Aortic Baloon Pump (IABP) - do not switch off IABP. Switch from "ECG trigger" to "Pressure trigger". IABP during CPR improves cerebral and cardiac blood flow. With CPR, on "pressure trigger", an arterial pressure tracing should be generated on console/screen and if the console is not recognising the arterial pressure tracing, chest compressions may not be adequate. (If any uncomfortness regarding IABP during code - just dial on 'standby' mode during code).

1. See sample IABP care protocol in our protocol/tool section - London Health Sciences Centre, Canada at www.icuroom.net.

2. See Concepts of Counterpulsation Therapy System - Datascope's complete guide to IABP in our "I" section at www.icuroom.net.


Reading:
P. J Overwalder: Intra Aortic Balloon Pump (IABP) Counterpulsation. The Internet Journal of Thoracic and Cardiovascular Surgery. 1999. Volume 2 Number 2.
posted by ICU room Pearls @ 8:35 AM 0 comments

Tuesday, October 25, 2005
Tuesday October 25, 2005
STOP Sepsis bundle - another step forward

After instituting Dr. Rivers' Early Goal Directed Therapy (EGDT) in septic patients - it is imperative to implement Dr. Nguyen's "yes/NO" STOP sepsis bundle as a second step - including

1. Hemodynamic monitoring (CVP/ScvO2 ) within 2 hours

2. Broad spectrum antibiotics administered within 4 hours

3. EGDT achieved at 6 hours (CVP of 8 mm Hg or higher, MAP of 65 mm Hg or higher, ScvO2 of 70% or higher)

4. Monitor for decreasing lactate, and

5. Administer steroid if the patient is on a vasopressor.

See Dr. Nguyen's - Loma Linda University's STOP sepsis bundle in our protocol/tool section at www.icuroom.net


References:
1. About the STOP Sepsis Bundle Toolkit - H. Bryant Nguyen, MD, MS
2. IMPROVING THE UNIFORMITY OF CARE WITH THE STOP SEPSIS BUNDLE - Critical Care Medicine: Volume 32(12) Supplement December 2004 p A11
posted by ICU room Pearls @ 1:41 PM 0 comments

Monday, October 24, 2005
ICP
Monday October 24, 2005
ICP (Intracranial pressure) wave forms

ICP monitoring waveform has a flow of 3 upstrokes in one wave.

P1 = (percussion wave) represents arterial pulsation
P2 = (Tidal wave) represents intracranial compliance
P3 = (Dicrotic wave) represents aortic valve closure

In normal ICP waveform P1 should have highest upstroke, P2 in between and P3 should show lowest upstroke.

On eyeballing the monitor, if P2 is higher than P1 - it indicates intracranial hypertension.


Extre reading: click to get full article:
Monitoring and interpretation of intracranial pressure - Journal of Neurology Neurosurgery and Psychiatry 2004;75:813-821
posted by ICU room Pearls @ 9:28 PM 0 comments

Sunday, October 23, 2005
Sunday October 23, 2005
Visiting Basics - age adjustment for A-a Gradient

As we are encountering more and more geriatric population with pulmonary symptoms, it is advisible to remind house staff to first adjust normal A-a Gradient value per age before jumping to calculate PAO2. Normal Gradient of 80 years old patient may not be consider acceptable for 20 years old.

Two quick formulae for age adjustment are:

1. Normal A-a Gradient = Age/4 + 4
(For 80 years old is 24 but for 20 years old is 9)

2. Normal A-a gradient = (Age+10) / 4
(For 80 years old is 22.5 but for 20 years old is 7.5)


(A-a Gradient = Alveolar-arterial Gradient)

See Nice Review on A-a Gradient - Dr. Lawrence Martin.


posted by ICU room Pearls @ 8:04 PM 0 comments

Saturday, October 22, 2005
Saturday October 22, 2005
Hypothermic Shivering

As induction of hypothermia is gaining more ground in our ICUs for acute stroke patients - associated shivering remains a major issue. One trick of the trade is to add oral Buspirone (15-60 mg in 2-3 divided doses) with traditional IV Meperidine. The combination of buspirone and meperidine has been found to act synergistically to reduce the shivering (and dose of meperidine) while causing little sedation or respiratory toxicity.

(Re-warming should be slow and controlled to avoid complications. For rewarming tips see related MGH's Hypothermia Protocol after Cardiac Arrest in our protocol section).

References: Click to get abstract
1. Buspirone and Meperidine Synergistically Reduce the Shivering Threshold - Anesth Analg 2001;93:1233-1239
2. Controlled trials of hypothermia in stroke - strokecenter.org

posted by ICU room Pearls @ 4:47 PM 0 comments

Friday, October 21, 2005
Friday October 21, 2005
Call for dialysis in Lithium overdose

Call for Hemodialysis in Lithium toxicity is "clinical" depending on symptoms particularly neurological symptoms such as myoclonus, seizure, confusion or coma. There is no laboratory cutoff value as patient with chronic exposure to lithium may show clinical signs at much lower value. Also some recent data favors CVVHD (or HD followed by CVVHD) as it showed to prevent rebound of lithium serum concentration.

See complete Toxicology manual in our "T" search at www.icuroom.net

References: click on link to get article:
1. Lithium - Utah Poison Control Center
2. To dialyse or not to dialyse… - pwr point presentation - S. Gosselin, MD
3. HD followed by continuous hemofiltration..: Am J Kidney Dis. 2001 May;37(5):1044-7
posted by ICU room Pearls @ 12:03 AM 0 comments

Thursday, October 20, 2005
Thursday October 20, 2005
Free cotisol - not 'ripe' yet !

April 15, 2004 NEJM article advocates using "free" cortisol level before initiating steroid therapy in critically ill patients but "free" cortisol is not part of the game yet ! Evidence (and guidelines) is still in favor of use of low dose steroid (+/- florinef) in septic shock. We need to wait for the result of substudy of CORTICUS trial (steroid therapy of septic shock) which will compare total and free cortisol levels in septic shock patients.


References: click on link to get article:
1. Serum Free Cortisol in Critically Ill Patients - NEJM
2. CORTICUS TRIAL - clinicaltrials.gov
3. Free cortisol levels should not be used to determine adrenal responsiveness - ccforum.com
posted by ICU room Pearls @ 9:26 PM 0 comments

Tuesday, October 18, 2005
Wednesday October 19, 2005
Hypocalcemia in massive transfusion

Ideally you should not "reflexly" replace low calcium after massive transfusion as hypocalcemia is usually transient (citrate get metabolize through liver very quickly). Replacement required only if there are clinical signs of hypocalcemia particularly prolong QT interval. It is advisible to follow "ionized calcium" if replacement desired. Another electrolyte to keep eye on is Magnesium as citrate has an equal binding affinity for ionized magnesium.

See manual Massive transfusion in our "M" search at www.icuroom.net

References: click on link to get article:
1. Transfusion for Massive Blood Loss - Trauma.org
2. Management of prolonged QT interval during a massive transfusion: calcium, magnesium or both? - Canadian Journal of Anesthesia 47:792-795 (2000)
posted by ICU room Pearls @ 11:10 PM 0 comments

Tuesday October 18, 2005
Off label use of Novoseven and cost concern

A growing literature suggests that there may be indications for the off label use of NovoSeven (rFVIIa) like critical coagulopathy; intracerebral hemorrhage; severe liver disease; to achieve hemostasis in acute variceal bleed; high-risk surgeries; blood loss from trauma; platelet disorders etc.

It is important to develop official policy / protocol due to high cost. Cost of single 4.8 mg vial (4800 ug) is about 4-5,000 US dollars. Usual dose is about 90 ug/kg (every 2 hours till hemostasis achieved) !! - Go figure out !!

Click to view FDA Warning letter re. NovoSeven

References: click on link to get article:
1. Off-Label Use of rFVIIa - P & T Community
2. INFORMATION ABOUT FACTOR VIIa - labs-sec.uhs-sa.com
3. NovoSeven for Traumatic Coagulopathy - Dr. Karim Brohi at trauma.org
4. Novoseven for Acute Intracerebral Hemorrhage - NEJM
5. Efficacy of Novoseven in cirrhotic patients with upper gastrointestinal bleeding: A randomised double-blind trial. J Hepatol. 2003;38 (Suppl 2):13

posted by ICU room Pearls @ 12:13 AM 0 comments

Sunday, October 16, 2005
Monday October 17, 2005
DIC Scoring

The Subcommittee on DIC of the International Society on Thrombosis and Haemostasis (ISTH) has developed a scoring card for disseminated intravascular coagulation (DIC) - each for "overt" and "non-overt" DIC. Following is the scoring for "overt" DIC.

1. platelet count ( >100 = 0; < 100 =" 1;" 50 =" 2)">

2. elevated fibrin degradation products (no increase = 0; moderate increase= 2; strong increase= 3)

3. PT upper limit of ref. range (<3 secs =" 0;"> 3 secs = 1; > 6 sec. = 2)

4. fibrinogen level ( > 100 mg/dl = 0; < dl =" 1)">

Score of 5: compatible with overt DIC

References: click on link to get article:
1. Towards Definition, Clinical and Laboratory Criteria, and scoring system for DIC - Thromb Haemost 2001; 86: 1327–30
2. Towards Definition, Clinical and Laboratory Criteria, and scoring system for DIC - ISTH
posted by ICU room Pearls @ 11:07 PM 0 comments

Saturday, October 15, 2005
Sunday October 16, 2005
Proton Pump Inhibitors (PPIs) and C.diff.

It is interesting to note few recent reports showing that: "Patients in hospital who received proton pump inhibitors may be at increased risk of C. difficile diarrhea".

Also See C. DIFF. PATHWAY in our Protocol section at www.icuroom.net.


References: get full text by clicking link
1. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors - CMAJ • July 6, 2004; 171 (1).
posted by ICU room Pearls @ 9:38 PM 0 comments

Friday, October 14, 2005
qaegr
Saturday October 15, 2005
Quinolones and errant glycemic reaction.

Contributed by: Drs. Badar and Tuazon: Pulmonary, Critical Care and Sleep medicine services, MH Southwest Hospital, Houston, TX

As use of quinolones is on rise in our ICUs, this is important to know a reported adverse reaction associated with Gatifloxacin (Tequin) - hypoglycemia and in some cases as 'resistant hypoglycemia'. Patients with history of diabetes and with concomitant use of hypoglycemic agents seems more prone to hypoglycemia. The exact mechanism of hypoglycemia is unknown, but increase in serum insulin level after quinolone administration is suspected. Some cases of hyperglycemia reported too. We also found atleast one case report of fatal hypoglycemia associated with levofloxacin (levaquin). 4

Interesting Site: Fluoroquinolone Toxicity Research Foundation


References:
1. Canadian Adverse Reaction Newsletter - Volume 13, Number 3, July 2003
2. Gatifloxacin as a Possible Cause of Serious Postoperative Hypoglycemia - Anesth Analg.2005; 101: 635-636.
3. Severe Hyperglycemia During Renally Adjusted Gatifloxacin Therapy - Ann. Pharmacother., July 1, 2005; 39(7): 1349 - 1352.
4. Fatal hypoglycemia associated with levofloxacin. Pharmacoepidemiol Drug Saf. 2005 Jan;14(1):31-40.
posted by ICU room Pearls @ 11:06 PM 0 comments

roundingupardsnettrials
Friday October 14, 2005
Rounding up ARDSNET TRIALS

1. ARMA study: In patients with ALI / ARDS, lower TV (6 ml/kg of ideal body weight) results in decreased mortality and increases days without ventilator.1

2. ALVEOLI Study: In patients with ALI / ARDS, clinical outcomes are same whether lower or higher PEEP levels are used (with low TV and limited PlPr). 2

3. KARMA Study: In patients with ALI / ARDS, ketoconazole did not reduce mortality or duration of mechanical ventilation or improve lung function. 3

4. LARMA Study: lisofylline had no beneficial effects in ALI / ARDS. 4

5. LATE STERIOD RESCUE STUDY (LaSRS): The Efficacy of steroids as Rescue Therapy for the Late Phase of ARDS - Publication pending.

6. FACTT Study - 2 parts : - Ongoing Trial
1) Swan(PAC) vs Central Venous Catheter for Management of ALI / ARDS.
2) "Fluid Conservative" vs "Fluid Liberal" Management of ALI / ARDS) 5


References:
1. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - N Engl J Med. 2000;342:1301-1308

2. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome - N Engl J Med 2004;351:327-336
3. Ketoconazole for Early Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome - JAMA, 2000;283:1995-2002
4. Randomized, placebo-controlled trial of lisofylline for early treatment of acute lung injury and ARDS - Crit Care Med. 2002; 30(1):1-6
5. Protocol details - FACTT Trial - ARDSnet
posted by ICU room Pearls @ 10:34 PM 0 comments

Thursday, October 13, 2005
sucralfateandhypophosphatemia
Thursday October 13, 2005
Sucralfate and Hypophosphatemia

If you decide (and very well rightly) to choose sucralfate as your choice of stress ulcer prophylaxis - just make sure you keep eye on phosphate level as it tends to cause hypophosphatemia. (But in no way it should stop you from using it). Many drugs if deliver via enteral route may see decrease bioavailability with sucralfate as Warfarin, Dilantin, Cipro., Digoxin etc. So as a precaution administer sucralfate about 2 hours before enteral admininstration of medicines.
posted by ICU room Pearls @ 12:10 PM 0 comments

Wednesday, October 12, 2005
argatrobanandinr
Wednesday October 12, 2005
Argatroban and INR

Please note that you do not follow regular INR level to monitor Coumadin while overlapping with Argtroban. You may have to perform Special Coagulation Study - Chromogenic Xa level. General recommendation is to overlap argatroban and coumadin for no less than 5 days after starting coumadin at 5 mg/day and on day 3-4, obtain a Chromogenic Xa level.

Chromogenic Xa level of 40% corresponds to an INR of 2
Chromogenic Xa level of 20% corresponds to an INR of 3
Chromogenic Xa should be therapeutic for 24 hours before discontinuing argatroban.

And if above study is not available in your lab, general rule of thumb is to have INR atleast above 4.


Recommended Readings: Click on link to go to reference.
1. Argatroban - Massachusetts General Hospital
2. The International Normalized Ratio during Concurrent Warfarin and Argatroban Anticoagulation -Clinical Chemistry. 1999;45:409-412
posted by ICU room Pearls @ 8:32 PM 0 comments

Tuesday, October 11, 2005
vaphapandhcap
Tuesday October 11, 2005
VAP, HAP and HCAP

Beside VAP (Ventilator-associated Pneumonia) - it is important to know 2 other terms HAP (Hospital-acquired Pneumonia) and HCAP (Healthcare-associated Pneumonia) as it may influence choice of antibiotics in early management as risk factors for MDR pathogens may be high.

HAP is pneumonia either 1) early onset that occurs within 4 days (Anbx sensitive) or 2) late onset that occurs after 4 days of hospitalization (risk for MDR pathogens).

HCAP is pneumonia that occurs 1) hospitalization for 2 days or more in the preceding 90 days or 2) residence in Nursing home or any extended care facility or 3) Home infusion therapy or 4) long term dialysis within 30 days or 5) Home wound care or 6) Family member with MDR pathogen or 7) Antibiotics in last 90 days or 8) immunosuppressive disease / therapy.


Reference.

Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia: Am. J. Respir. Crit. Care Med. 2005; 171: 388-416
posted by ICU room Pearls @ 9:23 AM 0 comments

Monday, October 10, 2005
intensiviststaffedhospitalsimproveoutcome

Monday October 10, 2005
Intensivist staffed hospitals improve outcome

Studies after studies have proved that intensivist driven ICUs improve outcome in hospitals.

Picture contributed by:
Jeff Scott
Director of Intensive Care
SWFRMC, Fort Myers, Florida

Recommended reading: Click on link to go to reference.
1. "Closed" ICUs and Other Models of Care for Critically Ill Patients - Agency for Healthcare Research and Quality.
2. Implement an Intensivist Model in the Intensive Care Unit (ICU) - IHI
3. Captaining the Ship During a Storm - Chest
posted by ICU room Pearls @ 8:49 AM 0 comments

Saturday, October 08, 2005
mf95icus
aSunday October 9, 2005
M-F 9-5 ICUs ?

contributed by: Wanda Lewis - Critical Care Nurse at Memorial Hermann Healthcare System, Houston - Texas

4 years ago one of the largest study in history looking into 3.8 millions lives over 10 years done in Toronto, Canada - clearly showed that: "...the relative increase in mortality associated with weekend admission appeared to be greatest for the conditions that were especially lethal". (PE was in top 3). Isn't many many ICUs in our country are in reality still functioning as M-F 9-5 ?

Recommended reading: Click on link to go to reference.
1. Mortality among Patients Admitted to Hospitals on Weekends - NEJM 08/30/2001
posted by ICU room Pearls @ 11:08 PM 0 comments

preventingcontrastinducednephropathy
Saturday October 8, 2005
Preventing contrast-Induced Nephropathy

Except for IV hydration so far no strategy has proved of clear cut benefit in preventing Radiocontrast-Induced Nephropathy including famous Mucomyst (N-Acetylcysteine). But it is interesting to know that a recent randomized controlled trial has shown that: "Hydration with sodium bicarbonate before contrast exposure is more effective than only hydration with saline in prophylaxis of contrast-induced renal failure"1.

All patients undergoing contrasted studies should be volume replete with saline 1 mL/kg/h for at least 12 hours before and after the procedure - warranting clinical judgment.

Recommended reading: Click on link to go to reference.
1. Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate - JAMA 2004;292:1428-1428. (full text available with free reg.)
2. N-Acetylcysteine and Radiocontrast-Induced Nephropathy - Jeff S. Rose, MD



posted by ICU room Pearls @ 9:06 AM 0 comments

Thursday, October 06, 2005
7pearlsonfeveranddrawingbloodcultures
Friday October 7, 2005
7 pearls on Fever and drawing blood cultures

1. Ideally all ICUs should have "Fever Protocol".

2. All fevers don't require treatment in ICUs as there are atleast 25 non-infectious reasons of fever in ICUs.

3. Generally, experts agree on non-axillary 101 F (38.3 C) level as defining point of Fever.

4. Atleast 2 blood cultures (preferably 10 minutes apart) from different peripheral venipunture sites are required.

5. Atleast 10 (preferably 20) ml of blood should be collected per bottle as sensitivity is highly related to blood volume.

6. Central catheters to collect culture should be use only if venipuntures are difficult and if use, most recently placed catheter should be utilize.

7. Use of hypothermia blankets should be discouraged and in fact even antipyretics should not be use routinely for symptomatic treatment.

Recommended reading: Click on link to go to reference.
1. Fever in ICU - Chest 2000 2.
PRACTICE PARAMETERS FOR NEW FEVER - SCCM / IDSA 1998
posted by ICU room Pearls @ 11:26 PM 0 comments

Wednesday, October 05, 2005
vapbundle
Thursday October 6, 2005
VAP bundle

Experts have included many maneuvers to decrease Vantilator-associated pneumonia including continuous subglottic secretion removal, OG tubes instead of NG tubes, use of oral hygiene with chlorhexidine gluconate and selective digestive tract decontamination but IHI recommends atleast following 4 key components in daily goal checklist.

1. Elevation of the Head of the Bed
2. Daily "Sedation Vacations"
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis

Recommended Readings: Click on links to go to reference
1. VAP bundle - IHI
2. Seven strategies to prevent VAP - Hospitalist Today 05/2005
posted by ICU room Pearls @ 11:13 PM 0 comments

candidiasischangingspectrumofspecies
Tuesday October 5, 2005
Candidiasis - changing spectrum of species

Prophylactic coverage with Diflucan (fluconazole) is still very valid for fungal infections but note that spectrum of candidal infection is progressively showing change from albicans to non-albicans (C. Krusei and C. glabrata) species. It reminds us that Amphotericin B (though we call it Amphoterrible) is still a major player. Also, availability of Caspofungin (Cancidas) is a big relief with better side effect profile.

Recommended Readings: Click on links to go to reference
1. Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use. J Hosp Infect. 2002 Jan;50(1):56-65
2. The changing face of nosocomial candidemia: epidemiology, resistance, and drug therapy. - Am J Health Syst Pharm. 1999 Mar 15;56(6):525-33
3. Comparison of Caspofungin and Amphotericin B for Invasive Candidiasis - NEJM - 12/2002
4. Caspofungin versus Liposomal Amphotericin B for Empirical Antifungal Therapy in Patients with Persistent Fever and Neutropenia - NEJM 09/2004
posted by ICU room Pearls @ 9:52 PM 0 comments

Tuesday, October 04, 2005
flushingoflines
Tuesday October 4, 2005
Flushing of lines

As we are diagnosing more and more HIT (Heaprin induced Thrombocytopenia) in our ICUs - it is important to know:

1. Saline flush is as effective as heparin flush for venous catheters.

2. Heparin flush is still preferable for A-lines but if contra-indicated or concern of HIT - 1.4% Na-citrate solution is an effective alternative.

Recommended Readings:
http://bmj.bmjjournals.com/cgi/content/full/316/7136/969 - BMJ
http://www.chestjournal.org/cgi/content/abstract/103/3/882 - Chest
posted by ICU room Pearls @ 9:58 AM 0 comments

Monday, October 03, 2005
calciumchannelblokadeoverdoseandglucagon
Monday October 3, 2005
Calcium channel blokade overdose and Glucagon

Glucagon is a very viable option in Calcium channel blokade (Cardizem, Verapamil, adalat etc) overdose treatment. But if it is consider in management plan - its advisible to administer before Calcium infusion as erratic blood calcium level may mask full effect of glucagon.

Recommended Readings:
Toxicity, Calcium Channel Blocker - Dr. B.Z. Horowitz - - posted on emedicine.com
posted by ICU room Pearls @ 12:35 PM 0 comments

Sunday, October 02, 2005
centralcathetersointmentandcare
Sunday October 2, 2005
Central catheters, ointment and care

As against common belief, application of ointment at catheter insertion site does not decrease the infection rate. Actually application of antibiotic ointments (e.g., bacitracin) to catheter-insertion sites increases the rate of catheter colonization by fungi and promotes the emergence of antibiotic-resistant bacteria. Also, after insertion of central venous catheter - simple dressing with gauze and tape is enough (change on average 24-48 hours). Occlusive dressings may increase colonizations at site. Water impermeable dressings like Tegaderm or Duoderm may infact increase chances of catheter related septicemia.

Recommended Readings:
1. Preventing Complications of Central Venous Catheterization, David C. McGee, M.D.,, NEJM, March 03, Volume 348:1123-1133.
2. Marshall DA and coll. Occlusive dressings, Arch Surg 1990;125:1136-1139.
3. Hoffman and coll. Meta-analysis on dressings, JAMA 1992; 267:2072-2076.
posted by ICU room Pearls @ 1:27 PM 0 comments

Saturday, October 01, 2005
deficienciesofscoringsystem
Saturday, 1 October 2005
Deficiencies of Scoring system?

Interestingly neither blood glucose nor lactic acid level is part of any famous ICU scoring system including SOFA, SAPS or APACHE II - which have independently shown direct proportionality with mortality in recent literature and are part of latest guidelines. (Please see complete adult and pediatrics medical, surgical and trauma Scoring guide in "Protocols/Tools" section - courtesy of Society Francaise d’Anesthesie et de Reanimation at www.icuroom.net)
posted by ICU room Pearls @ 9:10 AM 0 comments

Friday, September 30, 2005
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Friday, 30 September 2005
Betadine in procedures

Before starting procedure, make sure that Betadine stays in skin contact for atleast 2/3 minutes - as Iodine inside the complex need some time to get release from the carrier molecule (polyvinylpyrrolidone) and act. Slow release of iodine from carrier molecule is a desired effect as it prolongs the action as well as decrease irritation of skin. (Reason to bring this point is to discourage the practice of quickly wipe betadine and "get rid of" procedure). Residents have been seen to wipe off site after procedure with Saline or ETOH to make procedure look 'clean' but this decreases the antimicrobial effect of Betadine.

(chlohexadine is superior for anti-septic use than Betadine).



Thursday, 29 September 2005
Hagen-Poiseuille equation and IVF bolus lines

Technically Central line (TLC or PICC line) is not ideal for IVF bolus due to longer length and smaller radius. 2 Large bore (say 18 gauge) peripheral IVs or one large bore central IV (cordis) are real placements for aggressive resuscitation (due to bigger radius and shorter length). [As per Hagen-Poiseuille equation just 2 fold increase in radius increase flow by 16 fold but 2 fold increase in length decrease flow by 50%].



Wednesday, 28 September 2005
Propofol and Green urine

Propofol infusion is noticed to turn colour of urine green. It is a benign potential side effect of Propofol. Recognition of this side effect is important as it averts unnecessary further workup and limits medical expenditures.



Tuesday, 27 September 2005
Propylene Glycol and Ativan

Being an intensivist it is imperative to understand the dangers of propylene glycol with Lorazepam drip - particularly if it is continued beyond 48 hours and dose > 10 mg/hr. Any unexplained high anion gap metabolic acidosis with elevated osmol gap, should prompt the diagnosis of propylene gylcol toxicity. It may also cause CNS depression, arrhythmias and renal dysfuntion. Propylene glycol is a viscous, colorless liquid solvent used for many drugs with poor aqueous solubility including lorazepoam, diazepam, esmolol, nitroglycerin, pentobarbital, phenytoin, trimethoprim/sulfamethoxazole and others.



Monday, 26 September 2005
Advantage of fondaparinux

Advantage of fondaparinux (Arixtra) over Heparin and LMW-Heparin is no reported complication of Heparin-Induced Thrombocytopenia (HIT) so far. Usual dose for DVT prophylaxis including hip fracture, hip replacement, or knee replacement surgeries is 2.5 mg SQ QD and 7.5 mg SQ QD for treatment of DVT and PE.(Dose adjustement is required in weight below 50 kg or over 100 kg and also in renal insufficiency).



Sunday, 25 September 2005
Ecstasy

Ecstasy (MDMA) may cause Hyponatremia (SIADH), leading to cerebral edema and seizures. In the ED/ICU, always consider this possibility in any patient with known or suspected MDMA ingestion who presents with an altered mental status as it may progress quickly.



Saturday, 24 September 2005
Digibind and hypokalemia

With administration of DigiFab (Digibind), serum potassium concentration should be followed very closely. Because it shifts potassium back into the cell and life threatening hypokalemia may develop rapidly.(Actually, Digoxin causes a shift of potassium from inside to outside of the cell, sometime causing a life-threatening hyperkalemia. At end, patient may have severe hyperkalemia but a whole body deficit of potassium and with administration of Digifab, actual hypokalemia may manifest which could be equally life threatening).



Friday, 23 September 2005
Work Ethics

3 Basic Principles of work Ethics:
Non-Malfeasance: Do no harm.
Beneficence: Advance the good.
Autonomy: Pt. has right to choose treatment.



Thursday, 22 September 2005
Xigris and DVT prophylaxis.

DVT Prophylaxis: Concomitant use of SQ low dose heparin (upto 5000 units q8) did not appear to affect safety with Xigris and may be continued while Xigris is on. Age: is not an any contraindication to administration of Xigris. Pregnancy: is also not a contraindication but Xigris should be given to pregnant women only if clearly needed.



Wednesday, 21 September 2005
ABGs in DKA

Obtaining "Arterial" ABG has no significant clinical role in diagnosis or mangement of suspected DKA patients - except it is a painful procedure. "Venous" pH correlates well to serve as a substitute. Also, administration of Bicarbonate has virtually no role in DKA. Actually, it has been correlated with cerebral edema in children.



Tuesday, 20 September 2005
Etomidate

"Single dose" Etomidate (.3mg/kg) is still a valid choice for intubation due to its minimal effect on hemodynamic changes, faster effect (15 sec) and short duration (3-7 mins). Adrenocortical suppression after single dose is transient and has not shown any significant clinical effect. (It may lowers seizure threshold ).



Monday, 19 September 2005
Thyroid storm and steroid

Addition of steroid (Hydrocotisone 100 mg q8 or Decadron 2 mg q6) has shown better outcome in management of Thyroid storm along with Tylenol, Propranolol, PTU/Methimazole and KI. Also note: 1.Aspirin is relatively contraindicated for control of pyrexia in thyroid storm. 2. First dose of KI should be given atleast one hour after first dose of Anti-thyroid drug.



Sunday, 18 September 2005
Pseudo-hypokalemia

If Pseudo-hypokalemia is suspected, real potassium level can be measured by sending specimen quickly (preferably taking manually to lab as soon as drawn) and requesting to measure potassium level in separated plasma or serum.(Pseudo-hypokalemia is usually seen with very high WBC count, when the drawn sample is allowed to sit at room temperature for longer period of time. It happens due to uptake of plasma potassium by high leukocytes in the sample).



Saturday, 17 September 2005
Acetadote

As we may see higher use of IV Mucomyst (with FDA approval of Acedadote) for Tylenol overdose, its not a bad idea to keep IV Benadryl and Steroid at bedside as flushing, urticaria and angioedema are frequent side effects. Also caution is advised in patients with Asthma and Bronchospasm.



Friday, 16 September 2005
Epogen and Iron

epoetin alfa (Epogen/Procrit) will not work if patient's Iron level is low. (Role of epoetin alfa in ICU setting is controversial and generally judicious use is recommended).



Thursday, 15 September 2005
Demerol and Zyvox

Try to avoid using Demerol with Zyvox (even prescribed within last 2 weeks). It may induce 'symptom cluster' - fever, agitation, seizure, coma or death.