tag:blogger.com,1999:blog-77773822169271870902024-02-20T00:57:37.515-08:00icuroom.net February 2010 ArchiveUnknownnoreply@blogger.comBlogger27125tag:blogger.com,1999:blog-7777382216927187090.post-82261877430535823552010-02-27T00:16:00.000-08:002010-02-27T00:16:00.392-08:00<p><strong><span style="color:#000000;"><span style="color:#000066;">Saturday February 27, 2010<br /></span><br /></span></strong><strong><span style="color:#000000;"><span style="color:#660000;">Case:</span> <em><span style="color:#003333;">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.</span></em><br /><br /> </span></strong></p><p><strong><span style="color:#000000;"><br /><span style="color:#660000;">Answer</span>: </span><span style="color:#000000;">Dialysis disequilibrium syndrome.</span></strong></p><p><strong><span style="color:#000000;"><span style="color:#000000;">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</span>.</span></strong></p><p> </p><p><span style="font-size:78%;color:#003333;">Read interesting article from University of Calgary, Alberta, Canada : </span><a href="http://www.biomedcentral.com/content/1471-2369/5/9" target="_blank"><span style="font-size:78%;color:#003333;">Dialysis Disequilibrium Syndrome: Brain death following hemodialysis for metabolic acidosis and acute renal failure</span></a><span style="font-size:78%;color:#003333;"> - A case report followed with discussion and different management modalities (Ref.: BMC Nephrol. 2004; 5: 9.)</span> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-55916630383228395262010-02-26T09:00:00.000-08:002010-02-26T09:00:05.272-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Friday February 26, 2010</span><br /><span style="color:#660000;">CHADS2 Score<br /></span><br /></span><span style="color:#000000;">Several risk factor assessment algorithms have been developed to aid the clinician in decision-making regarding anticoagulation in atrial fibrillation. The CHADS2 index (Cardiac failure, Diabetes, Stroke [or S2 = TIA]) is the most widely used of these algorithms. The CHADS2 index uses a point system to determine yearly thromboembolic risk. Two points are assigned for a history of stroke or TIA, and one point is given for age over 75 or a history of hypertension, diabetes, or heart failure. High scores were associated with an increased rate of stroke.<br /><br /><br />CHF Hx = +1<br /><br />HTN Hx = +1<br /><br />Age 75 or above = +1<br /><br />Diabetes Mellitus Hx = +1<br /><br />Stroke previously or TIA Hx = +2<br /><br /><br />Warfarin is recommended for score 2 and above</span></strong><span style="color:#000000;"><br /></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-79361332757278256392010-02-25T00:08:00.000-08:002010-02-25T20:25:52.324-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday February 25, 2010<br /></span><br /><br /><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">What is the maximum joules you can use to cardiovert refractory atrial fibrillation?</span></em><br /><br /><br /><span style="color:#660000;">Answer</span>: <span style="color:#000000;">720 Joules<br /><br />Energy requirements for atrial fibrillation are 100-200 J initially and 360 J for subsequent shocks. But for refractory atrial fibrillation a study has shown good response to higher energy shocks of 720 J.</span><br /></span></strong><br /><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">Saliba W, Juratli N, Chung MK, Niebauer MJ, Erdogan O, Trohman R. Higher energy synchronized external direct current cardioversion for refractory atrial fibrillation. J Am Coll Cardiol. Dec 1999;34(7):2031-4</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-21818371698092853352010-02-24T00:28:00.000-08:002010-02-24T00:28:00.087-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday February 24, 2010</span><br /><br /><br /><span style="color:#990000;">Q:</span> <em><span style="color:#003333;">What is takotsubo cardiomyopathy?<br /></span></em><br /><br /><span style="color:#660000;">Answer</span>: Takotsubo cardiomyopathy, also known as broken-heart-syndrome, or simply stress cardiomyopathy, is a type of non-ischemic cardiomyopathy.<br /><br />The hallmark of the disease is bulging out of the apex of the heart with preserved function of the base that earned the syndrome its name "tako tsubo", or octopus trap in Japan, where it was first described.The cause appears to involve high circulating levels of catecholamines. If individual survives their initial presentation, patient usually improves within 2 months. For unknown reason - Takotsubo cardiomyopathy is more commonly seen in post-menopausal women.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-20394525181612569152010-02-23T08:31:00.000-08:002010-02-23T08:31:00.633-08:00<strong><span style="color:#000066;">Tuesday February 23, 2010</span></strong><br /><strong><span style="color:#000066;"></span></strong><br /><div align="center"><strong><span style="color:#660000;">Picture Quiz</span></strong><br /><a href="http://www.aic.cuhk.edu.hk/web8/Hi%20res/0284%20Dextrocardia.jpg"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmRb4EE6BLaynjcwnHj5_1ZDvQF74Fxb07ky5bv_Dl6Xg1FtNP8y5utm6SaLcCJVaXo5DnXwaYcGPm-y00_DMPgHLM-9AOpfj6kWdBroA0UwAFwuYRZ1eJxiywQA54LQwy0kr5N-GeiO8/s1600-h/Dextrocardia.jpg"><br /></div><img id="BLOGGER_PHOTO_ID_5441291902800459730" style="DISPLAY: block; MARGIN: 0px auto 10px; WIDTH: 301px; CURSOR: hand; HEIGHT: 400px; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmRb4EE6BLaynjcwnHj5_1ZDvQF74Fxb07ky5bv_Dl6Xg1FtNP8y5utm6SaLcCJVaXo5DnXwaYcGPm-y00_DMPgHLM-9AOpfj6kWdBroA0UwAFwuYRZ1eJxiywQA54LQwy0kr5N-GeiO8/s400/Dextrocardia.jpg" border="0" /></a> <br /><strong><span style="color:#000000;"><br /><span style="color:#660000;">Answer:</span> Dextrocardia<br />(with situs inversus, single atrium, VSD and pulmonary hypertension)</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-68910093940043668122010-02-22T09:36:00.000-08:002010-02-22T09:36:00.232-08:00<div align="center"><strong><span style="color:#000066;">Monday February 22, 2010<br /><br /><span style="color:#990000;">Interesting picture: Bilateral Renal Vein Thrombosis<br />(see filling defects)</span></span></strong></div><div align="center"><strong><span style="color:#000066;"><br /></div></span></strong><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3biXDwc27_3HtIOlh0qO86O3KnZRx3GHI5KtF17VqP_RnwZXZWdhxFNZTtPmCtjmLpwTtCg4Rj2eXjjA3qlgbiOPyRIaLzfCRv3CGntgSrt29uSK7aJ92I7tO-1tOMc3tus7I99V-XMQ/s1600-h/brvt.jpg"><img style="TEXT-ALIGN: center; MARGIN: 0px auto 10px; WIDTH: 350px; DISPLAY: block; HEIGHT: 262px; CURSOR: hand" id="BLOGGER_PHOTO_ID_5440937686961496322" border="0" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg3biXDwc27_3HtIOlh0qO86O3KnZRx3GHI5KtF17VqP_RnwZXZWdhxFNZTtPmCtjmLpwTtCg4Rj2eXjjA3qlgbiOPyRIaLzfCRv3CGntgSrt29uSK7aJ92I7tO-1tOMc3tus7I99V-XMQ/s400/brvt.jpg" /></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-81717674408227074672010-02-21T06:35:00.000-08:002010-02-21T06:35:01.002-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday February 21, 2010</span><br /><br /><br /><span style="color:#660000;">Q:</span> <span style="color:#003333;"><em>What is pseudo-pulmonary embolus syndrome?<br /><br /></em></span><br /><span style="color:#660000;">Answer:</span> The clinical scenario of collapse, shortly after an intravenous heparin bolus, most likely to be one of HIT type II is called ‘pseudo pulmonary embolus’. This is not due to a major pulmonary embolus, but is thought to be due to an endothelial injury, with sudden augmented release of IL-6, von Willebrand factor, and other adhesion molecules, resulting in an acute adult-type respiratory distress syndrome as a result of sudden vascular leak with hypoxia and hypotension.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-20696145926157149612010-02-20T00:01:00.000-08:002010-02-20T18:38:37.689-08:00<strong><span style="color:#000066;">Saturday February 20, 2010<br /></span></strong><br /><strong><span style="color:#660000;">Editors' note</span></strong>: <strong><em><span style="color:#003333;">This is not a pearl but may help people looking for generic templates<br /><br /></span></em></strong><br /><span style="color:#000000;"></span><br /><div align="center"><span style="color:#000000;"><span style="color:#990000;">Sample Central Venous Catheter Placement Procedure Note</span><br /><br /></span><span style="color:#000000;">Date ________ Time ______<br /><br /><strong>□ New central venous catheter □ Guide wire exchange</strong> </span></div><div align="center"><span style="color:#000000;"></span></div><div align="center"><span style="color:#000000;"></span></div><div align="left"><span style="color:#000000;"><strong></strong></span></div><div align="left"><span style="color:#000000;"><strong></strong></span></div><div align="left"><span style="color:#000000;"><strong>Indications</strong>: □ Hemodynamic monitor/instability<br /></div></span><div align="left"><span style="color:#000000;"></span></div><div align="left"><span style="color:#000000;"><strong>Diagnosis</strong>: ____________________<br /><br />□ Medications require central venous access<br />□ Inability to get peripheral access ___________________<br />□ Acute short term hemodialysis/apheresis<br />□ Infusion of > 3 incompatible continuous infusions or 2 continuous infusions plus blood product<br /><br /><br /><br /><strong>Consent:</strong><br /><br />□ Informed consent was obtained from _____________<br />□ This procedure was done emergently<br /><br /><br /><span style="color:#000000;"><strong>Insertion Site</strong></span>: □ Right □ Left<br /><br />□ Subclavian<br />□ Jugular<br />□ Femoral (indication required) _________<br />□ Other sites where placement attempted _________<br /><br /></span></div><div align="left"><span style="color:#000000;"><strong>Type of catheter:<br /></strong><br />□ Non-tunneled □1 □2 □3 □4 lumens<br />□ Introducer<br />□ Pulmonary artery </span></div><div align="left"><span style="color:#000000;">□ Antiseptic impregnated<br />□ Dialysis catheter </span></div><div align="left"><span style="color:#000000;">□ Other__________<br /><br /><br /><strong>Skin Prep: </strong></span></div><div align="left"><span style="color:#000000;">□ Chlorhexidine (preferred) </span></div><div align="left"><span style="color:#000000;">□ Povidone iodine<br /><br /><br /><strong>Ultrasound guided</strong>: □ Yes □ No </span></div><div align="left"><span style="color:#000000;"></div></span><div align="center"><span style="color:#000000;"></span></div><div align="left"><span style="color:#000000;"><strong>Conditions:<br /></strong><br />□ Sterile barriers: Sterile gloves, sterile gown, cap, mask, large sterile drape<br />□ Anesthetized site with lidocaine<br />□ Patient in Trendelenberg position<br />□ Modified Seldinger technique<br />□ New sterile gloves used to insert catheter during guidewire exchange<br />□ Sterile field maintained throughout procedure<br />□ Emergent line placement (consider replacement in 24 hours)<br /><br /><br /><strong>Following Procedure:<br /></strong><br />□ Blood was aspirated from all lumens, ports were flushed, and a sterile dressing was placed<br />□ Chest x-ray was ordered for SC and IJ attempt(s)<br />□ Patient tolerated without immediate complications<br />□ Patient experienced complications:<br />□ Bleeding □ EBL _________<br />□ Hematoma<br />□ Pneumothorax<br />□ Arterial puncture<br />□ Air embolism<br />□ Neurologic changes<br />□ Other __________________________<br /><br /><br /><strong>Additional comments</strong>: ____________________________________________ </span></div><div align="left"><span style="color:#000000;"><br /><br /></span></div><div align="center"><span style="color:#000000;"><strong>Time spent performing the procedure</strong> _____________<br /><br /><br /><strong>Performed by (check one)<br /></strong><br />□ Attending □ Resident/Fellow<br /></span></div><div align="center"><span style="color:#000000;">Signature ____________________<br />Print name_________<br /><br /><br />Attending physician present during critical portion(s) of procedure<br /><br />Attending Signature _________________<br />Attending name_________________________<br /><br /></span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-28949365514581354362010-02-19T04:24:00.000-08:002010-02-19T04:24:00.331-08:00<div align="center"><strong><span style="color:#000000;">Friday February 19, 2010 </span></strong></div><strong><span style="color:#000000;"><div align="center"><br /><br />Fiberoptic intubation</span></strong></div><p align="center"><br /><br /><object width="425" height="344"><param name="movie" value="http://www.youtube.com/v/Ja2vpZDG8mY&hl=en_US&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/Ja2vpZDG8mY&hl=en_US&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="425" height="344"></embed></object></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-26893284447015296002010-02-18T07:26:00.000-08:002010-02-18T07:26:00.307-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday February 18, 2010</span><br /><br /></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">What is 'Buffalo chest’?<br /></span></em><br /><br /><span style="color:#660000;">Answer</span>: An interpleural communication results in a single pleural space within a chest (or communicating pneumothoraces on both sides of chest) is called "Buffalo chest'.<br /><br /><span style="color:#003333;"><em>Background:</em></span> Each lung is enveloped in a pleural sac. The pleural sac consists of two serous membranes: the parietal pleura, which lines the thoracic wall, mediastinum and diaphragm; and the visceral pleura, which invests the lung. A potential space called the pleural cavity exists between the parietal and visceral pleura. A pneumothorax occurs when air fills this cavity. The two pleural sacs are separate structures therefore, a pneumothorax is unilateral, unless a communication exists between each pleural cavity.<br /></span></strong><br /><strong><span style="color:#000000;">A communication between each hemithorax can be congenital, iatrogenic or traumatic. It has been reported after procedures involving median sternotomy, laparoscopic surgery and heart and lung transplants. In surgical cases, the communication results from the disruption of the anterior pleural reflections.<br /><br />An interpleural communication results in a single pleural space. This is termed ‘Buffalo chest’ because North American buffalo, or bison, lack an anatomical separation between the two hemithoraces. This facilitated death by bilateral tension pneumothoraces from a hunter's single arrow to the chest.<br /><br />There should be a complete resolution of the ipsilateral and contralateral pneumothoraces via the single chest drain</span></strong>.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-13849836022891646622010-02-17T07:01:00.000-08:002010-02-17T07:01:00.440-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday February 17, 2010<br /></span><br /></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">Q</span>; <em><span style="color:#003333;">What is Upshaw-Schülman syndrome (USS)?</span></em><br /><br /><span style="color:#660000;"> Answer</span>: </span><span style="color:#000000;">A hereditary form of TTP (thrombotic thrombocytopenic purpura) is called the Upshaw-Schülman syndrome. Patients with this condition develop TTP in clinical situations with increased von Willebrand factor levels, e.g. infection. About 5-10% of all TTP cases are due to Upshaw-Schülman syndrome.<br /><br />Patients with Upshaw-Schulman syndrome (USS) have repeated episodes of thrombocytopenia and microangiopathic hemolytic anemia that respond to infusions of fresh frozen plasma. Inheritance of USS has been thought to be autosomal recessive, because 2 siblings in the same family are often affected but their parents are asymptomatic.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-30700560599440122622010-02-16T00:01:00.000-08:002010-02-16T00:01:00.951-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Tuesday February 16, 2010</span><br /><br /><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">The average life span of a platelet in the blood is 10 days but what is the average life span of transfused Platelets?</span></em><br /><br /><br /><span style="color:#660000;">Answer</span>: The average life span of a platelet in the blood is 10 days but transfused platelets have a short life-span, 3-4 days.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-1194616764962506762010-02-15T06:49:00.000-08:002010-02-15T06:49:00.323-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Monday February 15, 2010</span><br /><span style="color:#990000;">Rule of thumb for adjusting Amiodarone with Coumadin</span> </span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><br /><strong><span style="color:#000000;">Amiodarone 400 mg/day: Reduce Warfarin dose 40%<br />Amiodarone 300 mg/day: Reduce Warfarin dose 35%<br />Amiodarone 200 mg/day: Reduce Warfarin dose 30%<br />Amiodarone 100 mg/day: Reduce Warfarin dose 25%</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-31785677248129271642010-02-14T11:26:00.001-08:002010-02-14T11:26:00.482-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday February 14, 2010</span> </span></strong><br /><strong><span style="color:#000000;"><span style="color:#990000;">Female preponderance in ibutilide-induced torsade de pointes<br /></span><br /><span style="color:#660000;">Objective</span>: Ibutilide, a class III antiarrhythmic agent used for pharmacological cardioversion of atrial arrhythmias, has a potential to cause QT-interval prolongation and torsade de pointes. Purpose of this study was to determine whether women are more prone to develop ibutilide-induced torsade de pointes.<br /><br /><span style="color:#660000;">Methods:</span> All clinical trials, cases, case series, and related articles in English-language in addition to 51 patients from our institution on the subject were examined.<br /><br /><span style="color:#660000;">Results:</span> In a database derived from 23 reports in literature and from our institution, 1720 patients received ibutilide for cardioversion of atrial arrhythmias. Only in 87% (n=1492) patients, data were reported whether or not ibutilide caused torsade de pointes.<br /><br />The overall incidence of torsade de pointes was 3.9% (n=58) patients.<br /><br />Data on sex distribution of ibutilide-induced torsade de pointes was available in 73% (n=1096) patients. Torsade de pointes developed in 17 (5.6%) of 304 women and 24 (3%) of 792 men (P=0.05). It occurred during or within 45 min after completion of the infusion of ibutilide.<br /><br />Treatment instituted was with intravenous magnesium sulfate alone in 14% (n=8) patients, magnesium sulfate plus lidocaine in 5% (n=3) patients, magnesium sulfate with electrical cardioversion in 17% (n=10) patients, electrical cardioversion alone in 19% (n=11) patients, and precordial thump in 3% (n=2) patients.<br /><br />In 41% (n=24) of patients who developed torsade de pointes, it resolved without treatment.<br /><br />There were no reported deaths secondary to torsade de pointes associated with ibutilide infusion.<br /><br /><span style="color:#660000;">Conclusion</span>: Incidence of ibutilide-induced torsade de pointes is higher in women than in men. Greater caution must be observed while using ibutilide in women.<br /></span><br /><br /></strong><br /><span style="font-size:78%;color:#003333;">Female preponderance in ibutilide-induced torsade de pointes - International Journal of Cardiology, Volume 95, Issue 2, Pages 219-222</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-12534862652393931492010-02-13T09:54:00.000-08:002010-02-13T09:54:00.600-08:00<div align="center"><strong><span style="color:#000000;"><span style="color:#000066;">Saturday February 13, 2010<br /></span><span style="color:#990000;">Picture Quiz</span><br /></div></span></strong><div align="center"><strong><span style="color:#000000;"><span style="color:#000000;"></span></span></strong> </div><div align="center"><strong><span style="color:#000000;"><span style="color:#000000;">KUB in a patient presenting with acute abdominal pain.<br /></span></span></strong></div><div align="center"><strong><span style="color:#000000;"><span style="color:#000000;">Tips: Thumbprinting in the region of the splenic flexure and dilatation of the proximal small-bowel.</span> </span></strong><br /><br /></div><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgH6ulYPoJNkMAMYBILY1cKfSpKtqL6D7rGCw18eGtLg2lktJuoR4yYq1qTh6IT_AQIPeQCib-DBdOXkIqbY8Q3YXaanDvxUd0W2ddacsove4h0KJINqeigh6ukgeKOdQoZK24LAsg1UwI/s1600-h/ic.jpg"><img style="TEXT-ALIGN: center; MARGIN: 0px auto 10px; WIDTH: 324px; DISPLAY: block; HEIGHT: 400px; CURSOR: hand" id="BLOGGER_PHOTO_ID_5437602493321182258" border="0" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgH6ulYPoJNkMAMYBILY1cKfSpKtqL6D7rGCw18eGtLg2lktJuoR4yYq1qTh6IT_AQIPeQCib-DBdOXkIqbY8Q3YXaanDvxUd0W2ddacsove4h0KJINqeigh6ukgeKOdQoZK24LAsg1UwI/s400/ic.jpg" /></a><br /><br /><strong><span style="color:#000000;"><span style="color:#660000;">Answer:</span> Ischemic colitis.<br /><br />Ischemic colitis occurs due to any clinical condition which cause insufficient blood supply to a segment or the entire colon. This disease results in ischemic necrosis of varying severities that can range from superficial mucosal involvement to full-thickness transmural necrosis. Patients usually present with colicky abdominal pain associated with vomiting, diarrhea, or rectal bleeding</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-38236215729630115952010-02-12T10:45:00.000-08:002010-02-12T21:57:16.387-08:00<p><strong><span style="color:#000000;"><span style="color:#000066;">Friday February 12, 2010</span><br /></span><span style="color:#990000;">About Dabigatran</span></strong></p><p><strong><span style="color:#000000;">Dabigatran is an anticoagulant from the class of the direct thrombin inhibitors. It is being studied for various clinical indications and may replace warfarin as the preferred anticoagulant in many cases. Unlike warfarin it works right away and does not require INR monitoring.</span></strong></p><p><strong><span style="color:#000000;">Phase 3 clinical trials are ongoing in treatment and prevention of secondary venous thromboembolism (VTE) in post-operative orthopedic patients; long-term prophylaxis in acute coronary syndrome and stroke patients with atrial fibrillation and symptomatic VTE because of various causes. Dabigatran at doses of 150 mg and 220 mg once daily when compared with the standard 40 mg dose of enoxaparin once daily, confirmed that dabigatran performed as well as enoxaparin in preventing thrombosis, with a similar risk profile.</span></strong></p><p><strong><span style="color:#000000;">Absorption is unrelated to food but may be decreased if taken with a proton pump inhibitor. Metabolism is slowed in people taking quinidine, verapamil, or amiodarone.</span></strong></p><p><strong><span style="color:#000000;">Approval from FDA is expected in 2010.</span></strong> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-15219096401546452382010-02-11T22:46:00.000-08:002010-02-11T22:50:58.864-08:00<strong><span style="color:#000066;">Thursday February 11, 2010</span></strong>
<br /><strong><span style="color:#990000;">Is fresh blood better ?</span></strong>
<br /><strong><span style="color:#000000;"></span></strong>
<br /><strong><span style="color:#000000;">Results of one study span over 10 years including 12,264 patients (total median transfusion of 4 pRBC units), done at Mayo Clinic, Rochester, MN - found that</span></strong>
<br /><strong><span style="color:#000000;"><ul><li>adjusted in-hospital mortality was 5% if pRBC was stored for less than 7 days </li><li>adjusted in-hospital mortality was 8% if pRBC was stored for 7-14 days </li><li>adjusted in-hospital mortality was 13% if pRBC was stored for more than 14 days</li></ul>
<br />This corresponds to a reduction in the risk of in-hospital mortality of 62% for patients receiving pRBC stored for less than 7 days.</span></strong>
<br /></span></strong>
<br />
<br /><span style="font-size:78%;color:#003333;">Reference: ATS 2007 poster presentations: The 2007 International Conference Abstracts of the American Thoracic Society (ATS) are published in the American Journal of Respiratory and Critical Care Medicine, Volume 175, Abstracts Issue, April 2007.</span>
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-43122118470847610862010-02-10T07:58:00.000-08:002010-02-10T07:58:00.265-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday February 10, 2010</span>
<br /></span></strong><strong><span style="color:#000000;"><span style="color:#990000;">A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial
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<br /><span style="color:#660000;">Background</span>: Standard treatment of critically ill patients undergoing mechanical ventilation is continuous sedation. Daily interruption of sedation has a beneficial effect, and in the general intesive care unit of Odense University Hospital, Denmark, standard practice is a protocol of no sedation. We aimed to establish whether duration of mechanical ventilation could be reduced with a protocol of no sedation versus daily interruption of sedation.</span></strong>
<br /><strong><span style="color:#000000;">
<br /><span style="color:#660000;">Methods</span>: Of 428 patients assessed for eligibility, we enrolled 140 critically ill adult patients who were undergoing mechanical ventilation and were expected to need ventilation for more than 24 h. Patients were randomly assigned in a 1:1 ratio (unblinded) to receive:
<br /><ul><li>no sedation (n=70 patients); or</li><li>sedation (20 mg/mL propofol for 48 h, 1 mg/mL midazolam thereafter) with daily interruption until awake (n=70, control group). </li></ul>Both groups were treated with bolus doses of morphine (2·5 or 5 mg).
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<br /><span style="color:#660000;">The primary outcome:</span> was the number of days without mechanical ventilation in a 28-day period, and we also recorded the length of stay in the intensive care unit (from admission to 28 days) and in hospital (from admission to 90 days).
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<br /><span style="color:#660000;">Findings:</span> 27 patients died or were successfully extubated within 48 h, and, as per our study design, were excluded from the study and statistical analysis.
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<br /><ul><li>Patients receiving no sedation had significantly more days without ventilation (n=55; mean 13·8 days) than did those receiving interrupted sedation (n=58; mean 9·6 days, p=0·0191). </li><li>No sedation was also associated with a shorter stay in the intensive care unit (p=0·0316), and, for the first 30 days studied, in hospital (p=0·0039), than was interrupted sedation. </li><li>No difference was recorded in the occurrences of accidental extubations, the need for CT or MRI brain scans, or ventilator-associated pneumonia. </li><li>Agitated delirium was more frequent in the intervention group than in the control group(p=0·0400).
<br /></li></ul><span style="color:#660000;">Interpretation</span>: No sedation of critically ill patients receiving mechanical ventilation is associated with an increase in days without ventilation. A multicentre study is needed to establish whether this effect can be reproduced in other facilities.
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<br /><span style="font-size:78%;color:#003333;">
<br /></span><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673609620729/abstract?rss=yes" target="_blank"><span style="font-size:78%;color:#003333;">A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial </span></a><span style="font-size:78%;color:#003333;">- The Lancet, Volume 375, Issue 9713, Pages 475 - 480, 6 February 2010</span>
<br /></span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-67703525461568369012010-02-09T00:32:00.000-08:002010-02-09T00:32:00.143-08:00<strong><span style="color:#000066;">Tuesday February 9, 2010</span>
<br /><span style="color:#990000;">On Vimpat (lacosamide)</span>
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<br /><span style="color:#000000;">Lacosamide is a medication for the adjunctive treatment of partial-onset seizures and diabetic neuropathic pain.</span></strong>
<br /><strong><span style="color:#000000;">
<br />The precise mechanism underlying the anti-epileptic effects of lacosamide is not fully clear but it is said that lacosamide selectively enhances slow inactivation of voltage-gated sodium channels, resulting in stabilization of hyperexcitable neuronal membranes. lacosamide is found to significantly reduce seizure frequency when given in addition to other antiepileptics, at doses of 400 and 600 milligrams a day. In diabetic neuropathy, lacosamide also provided significantly better pain relief when compared to placebo.
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<br />The apparent lack of sedative effects makes this agent attractive for patients who are prone to develop somnolence with other anti-epileptic drugs(AEDs). On the other hand, reports of potential electrocardiogram changes with lacosamide suggest that caution is needed before using this drug in patients with pre-existing cardiac disease and in those taking drugs known to cause PR prolongation.</span></strong>
<br /></span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-69890819011443048892010-02-08T08:06:00.000-08:002010-02-08T19:33:35.743-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Monday February 8, 2010</span><br /><br /><br /><span style="color:#660000;">Q;</span> <em><span style="color:#000066;"><span style="color:#003333;">Patient with C. Diff. Colitis is having no improvement with PO Flagyl. You ordered PO Vancomycin. Pharmacy informed you that PO Vancomycin is not available. What would be your trick of trade here?</span><br /></span></em><br /><br /><span style="color:#660000;">A</span>; Actually, IV Vancomycin can be given via oral route. It works just as well, and a lot cheaper. The ordered dose may be diluted in water and given to the patient to drink. Common flavoring syrups may be added to the solution to improve taste.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-37319452039358238322010-02-07T00:50:00.000-08:002010-02-07T00:50:00.159-08:00<strong><span style="color:#000066;">Sunday February 7, 2010</span></strong><br /><strong><span style="color:#000000;"><span style="color:#990000;">Picture Diagnosis<br /></span><br /></span><span style="color:#003333;"><em></em></span></strong><br /><strong><span style="color:#003333;"><em>CT scan with a mass, round with well defined borders. Note: thick-walled cavity with low attenuation center and contrast-enhanced periphery</em></span></strong><br /><br /><img id="BLOGGER_PHOTO_ID_5435019215180426786" style="DISPLAY: block; MARGIN: 0px auto 10px; WIDTH: 360px; CURSOR: hand; HEIGHT: 245px; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiezcMSTRGm62_Jvx4Z33wiDGSjsiUHFuxj3DZxkcpaqjpJYPqssUjczyWHxSb6OqmJwXecINBnGu9rKR3XhrVwpa5vMxYzZ_GTyK_aoCb2BLsybsNmH79OZA3JQlqcqmkh8qVZGW-sBZg/s400/aab.JPG" border="0" /> <br /><br /><br /><strong><span style="color:#000000;"><span style="color:#660000;">Answer:</span> Amebic liver abscess<br /><br />Amebic liver abscess is the most frequent extraintestinal manifestation of Entamoeba histolytica infection. This infection is caused by the protozoa E histolytica, which ascends the portal venous system. Amebic liver abscess is an important cause of space-occupying lesions of the liver, mainly in developing countries</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-20123961138180273432010-02-06T00:08:00.000-08:002010-02-06T00:08:00.390-08:00<span style="color:#000000;"><strong><span style="color:#000066;">Saturday February 6, 2010</span>
<br />
<br /></strong></span>
<br /><span style="color:#000000;"><strong><em><span style="color:#003333;"><span style="color:#660000;">Q:</span> All of the following can be use as treatment of hyponatremia in Cerebral salt wasting (CSW) after Subarachnoid hemorrhage except:
<br />
<br />A) Hypertonic saline (3%)
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<br />B) Normal Saline or Salt tablets
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<br />C) Conivaptan (Vaprisol)
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<br />D) Fluid restriction
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<br />E) fludrocortisone (Florinef</span></em></strong>)
<br /><strong>
<br />
<br /><span style="color:#660000;">Answer:</span> <span style="color:#000000;">D
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<br />Overall, the treatment for hyponatremia in CSW is aimed at restoring normovolemia with normal serum sodium levels. Often if the patient is without symptoms, aggressive treatment is unnecessary. </span></strong></span>
<br /><strong>
<br /><span style="color:#000000;">In general, patients with CSW will receive an order for intravenous normal saline. Depending on the sodium and fluid balance and the patient's symptoms, hypertonic 3% saline at an initial rate of 25-50 ml/hour, 325 mg salt tablets, and/or 1-2 mg daily of oral fludrocortisone (Florinef) may also be used.
<br /></span>
<br /><span style="color:#000000;">In SIADH, the preferred treatment in the general population is fluid restriction. However, in patients with aneurysmal Subarachnoid hemorrhage (SAH), great care must be taken because of the risk of vasospasm in these patients. It carries risk of increased incidence of infarction in patients treated for supposed SIADH with fluid restriction. Other types of treatment include the infusion of hypertonic saline in conjunction with loop diuretics or newly available arginine vasopressin antagonist (Conivaptan).</span></strong>
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<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-31717737464787222742010-02-05T00:40:00.000-08:002010-02-05T00:40:00.699-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Friday February 5, 2010</span><br /><span style="color:#990000;">Cialis/Viagra in the treatment of cerebral vasospasm</span><br /><br /><br /></span></strong><a name="ASec1"></a><strong><span style="color:#000000;"><span style="color:#660000;">Background </span>The pathogenesis of cerebral vasospasm is likely to be multifactorial. Strong evidence has indicated that decreasing levels of NO after SAH seem to be important. A PDE-V inhibitor, tadalafil, theoretically increases NO levels. Our study investigated the vasodilatory efficacy of tadalafil on the cerebral arteries with measurement of basilar artery diameters on angiography.<br /></span></strong><a name="ASec2"></a><strong><span style="color:#000000;"><br /><br /><span style="color:#660000;">Methods</span> We used 42 male Wistar-Albino rats to test our hypothesis. They were assigned randomly into the following seven groups:<br /><br />group 1: control (only saline),<br />group 2: SAH only (killed on day 2),<br />group 3: SAH + tadalafil (killed on day 2),<br />group 4: SAH only (killed on day 4),<br />group 5: SAH + tadalafil (killed on day 4),<br />group 6: saline + tadalafil (killed on day 2) and<br />group 7: saline + tadalafil (killed on day 4).<br /><br />The three different parts of basilar artery diameters were measured angiographically.<br /></span></strong><a name="ASec3"></a><strong><span style="color:#000000;"><br /><span style="color:#660000;">Results</span> </span></strong><br /><ul><li><strong><span style="color:#000000;">There were statistically significant differences between the SAH and SAH groups treated with tadalafil at days 2 and 4. </span></strong></li><li><strong><span style="color:#000000;">Comparison between control and tadalafil groups showed no significant differences. This result indicated that tadalafil has a vasodilatory effect on vasoconstricted arteries, but no effect on normal basilar arteries.<br /></span></strong><a name="ASec4"></a><span style="color:#000000;"><strong><br /><span style="color:#660000;">Conclusion</span> Our study results showed that tadalafil has a vasodilatory effect on <em>both acute and chronic periods of cerebral vasospasm</em>. We also concluded that cerebral angiography can be used safely for investigation of cerebral vasospasm in animal studies.</strong><br /><br /></span><span style="font-size:78%;color:#003333;"><br /></span><a href="http://www.springerlink.com/content/u175676h60241154/" target="_blank"><span style="font-size:78%;color:#003333;">A new approach to the treatment of cerebral vasospasm: the angiographic effects of tadalafil on experimental vasospasm</span></a><span style="font-size:78%;color:#003333;"> - Acta Neurochirurgica, - Published online: 20 October 2009</span> </li></ul>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-49370910690664513932010-02-04T00:09:00.000-08:002010-02-04T00:09:00.316-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday February 4, 2010<br /></span><br /><br /><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">It is well known that Keppra (levetiracetam) is eliminated via renal route. Approximately how much of levetiracetam is removed during a standard 4-hour hemodialysis procedure?<br /></span></em><br /><br /><span style="color:#660000;">Answer:</span> Approximately 50% of the pool of levetiracetam in the body is removed during a standard 4-hour hemodialysis procedure. Supplemental doses should be given to patients after dialysis.<br /><br />Clearance of levetiracetam is correlated with creatinine clearance. Total body clearance of levetiracetam is reduced in patients with impaired renal function by 40% in the mild group (CLcr = 50-80 mL/min), 50% in the moderate group (CLcr = 30-50 mL/min) and 60% in the severe renal impairment group (CLcr less than 30 mL/min). In anuric (end stage renal disease) patients, the total body clearance decreased 70% compared to normal subjects.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7777382216927187090.post-41355591715323486512010-02-03T00:39:00.000-08:002010-02-03T00:39:00.209-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday February 3, 2010</span><br /><span style="color:#990000;">Ethics in Medicine - The Rule of Double Effect (RDE)</span><br /><br /><br />RDE stipulates that 4 conditions must be met before an act with both good and bad consequences may be morally justified. </span></strong><br /><strong><span style="color:#000000;"><ol><li><span style="color:#660000;"><em>The nature of the act.</em></span> The act itself must not be intrinsically wrong and not be in a category that is absolutely prohibited. </li><li><em><span style="color:#660000;">The agent's intention</span></em>. The agent must intend only the good and not the bad effect, although the bad effect, such as respiratory depression following administration of opiates, may be foreseen but not intended. </li><li><em><span style="color:#660000;">The distinction between means and effects</span></em>. The bad effect, such as death, must not be the means used to bring about the good effect, such as the relief of suffering. </li><li><em><span style="color:#660000;">Proportionality between the good effect and the bad effect</span></em>. An action is undertaken for a proportionally grave reason for permitting the foreseen bad effect.<br /></li></ol></span></strong>Unknownnoreply@blogger.com0