Apixaban Beat Warfarin Regardless of Warfarin-Treatment Quality

"Apixaban treatment produced better outcomes in atrial fibrillation patients compared with warfarin in the ARISTOTLE trial, regardless of the quality of warfarin treatment the comparator patients received, raising the possibility that all atrial fibrillation patients might benefit by switching from warfarin to apixaban.

"The benefits of apixaban over warfarin in preventing stroke, reducing bleeding, and improving survival appear consistent regardless of a center’s quality of INR [international normalized ratio] control. Therefore, in patients with atrial fibrillation, apixaban is a safer and more effective treatment than warfarin across a wide range of warfarin management," Dr. Lars Wallentin said at the annual congress of the European Society of Cardiology. Assessment of apixaban’s efficacy and safety relative to warfarin across the range of warfarin care that was delivered was one of the trial’s prespecified analyses."


Read full report here (from Family Practice News)

Carbamzepine-induced toxic epidermal necrolysis
"Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a widespread life-threatening mucocutaneous disease where there is extensive detachment of the skin and mucous membrane. Many factors involved in the etiology of TEN including adverse drug reactions. Here we are reporting a case of toxic epidermal necrolysis in an adult male patient after receiving carbamazepine in a 38 year old male. On the18th day of carbamazepine, patient developed blisters which first appeared on the trunk, chest and arms. The erythematous rash was covering almost all over the body with epidermal detachment of 70% body surface area. There was loss of eye lashes, congestion of conjunctiva with mucopurulent discharge and exposure keratitis. The clinical impression was TEN induced by carbamazepine. Carbamazepine was stopped immediately. He was treated with high dose intravenous betamethasone and systemic and topical antibiotics. After one month, the progression of the skin lesions halted and he was discharged".


Read full text here

Carbamzepine-induced toxic epidermal necrolysis, Indian Journal of Critical Care Medicine, Year : 2011 | Volume : 15 | Issue : 2 | Page : 123--125

Q: In Salicylate toxicity what is the target of Urine PH?

Answer: 8

Renal elimination of salicylate can be achieved by alkaline diuresis to increase urine pH, ideally to more than/= 8. Alkaline diuresis is indicated for patients with any symptoms of poisoning and should not be delayed until salicylate levels are determined. This intervention is safe and exponentially increases salicylate excretion. Because hypokalemia may interfere with alkaline diuresis, patients are given a solution consisting of 1 L of 5% D/W, with 3 (50-mEq) ampules of NaHCO3, and 40 mEq of KCl. Serum K should be monitored closely.

Fidaxomicin - new antibiotic for C.diff.

Fidaxomicin (Dificid) is a non-systemic bactericidal with demonstrated selective eradication of Clostridium difficile. Interestingly, it causes minimal disruption of normal healthy intestinal flora. Obviously, It is administered orally.

Mechanism of action: It works by inhibiting the bacterial enzyme RNA polymerase, resulting in the death of Clostridium difficile.

Studies have shown that it is as effective as oral vancomycin (92.1% vs. 89.8%) but with less recurrence of C. Diff. Colitis (13.3% vs 24.0%).

Dose is 200 mg twice a day for 10 days

Call overload

(Interesting article from Kimberly Manning, FACP, published this month in ACP Hospitalist).

"So I came in with my bag on a Friday, went through my heinous work day, then admitted all night. And that night? Oh, it was a rough one. No sleep whatsoever. Saturday morning I sat at the nurses' station with my head down on my folded elbow, which was likely in a pool of disgusting sleep-slobber.

..............

And I stayed to admit seven more people that night. I did get twenty minutes of sleep—which everyone knows is twenty times worse than getting no sleep when you're that tired.
On Sunday morning, I was in a stupor and I had altered mental status for real. I fell asleep standing up twice and wrote notes in charts that looked eerily like hieroglyphics. Not good. Not good at all.
.........."
Read full article here

First Antidote for Scorpion sting!

"The U.S. Food and Drug Administration (FDA) has approved the first treatment for the excruciatingly painful sting of the Centruroides or "bark" scorpion - the most commonly encountered scorpion in the nation..........

Before Anascorp, there was no effective way to ease the pain of scorpion stings, according to the FDA.

"Severe stings can cause loss of muscle control and difficulty breathing, requiring heavy sedation and intensive care in a hospital," said Keith Boesen, managing director of the Arizona Poison and Drug Information Center in an FDA press release".

Read full report here

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 will be erroneously high and misleading.

Paper published by co-editor of this website - Dr. Faisal Masud

Establishing a Culture of Blood Management Through Education: A Quality Initiative Study of Postoperative Blood Use in CABG Patients

Blood management strategies are crucial in light of transfusion-related health risks to patients and the relative scarcity and cost of blood products. The authors describe a collaborative quality initiative to reduce blood use in their coronary artery bypass graft (CABG) population and other cardiovascular intensive care unit (CVICU) patients. A multidisciplinary team was engaged at all levels of patient care. The 2-part initiative involved a direct educational component emphasizing transfusion risk awareness and patient-centered blood management strategies accompanied by a data-based component that included monthly dissemination of blood product use to the relevant service lines. The authors observed a reduction in postoperative blood product use among CABG patients (14.3% decrease in the first year; 30.6% from 2006 to 2008) and an 18.2% reduction in blood product volume used in the entire CVICU, with no additional harm to patients and a trend toward better outcomes. This team-driven paradigm change has made blood management everyone’s initiative.

Establishing a Culture of Blood Management Through Education: A Quality Initiative Study of Postoperative Blood Use in CABG Patients at Methodist DeBakey Heart & Vascular Center,  Faisal Masud, MD,Karin Larson-Pollock, MD, MBA, Christopher Leveque, MD,5 and Daynene Vykoukal, PhD,

American Journal of Medical Quality, 26(5) 349–356

Q; What is Catamenial pneumothorax?

 

 

A; Catamenial pneumothorax is a rare condition characterized by a pneumothorax coinciding with the onset of menses. It is almost always right-sided, and generally occurs in women in their thirties and forties.

 

Exact etiology is unknown but endometriosis is suspected with possible diaphragmatic fenestrations. Damage to endometriosis with air passes into the pleural space through these holes. It may accompany with hemothorax if blood from endometriosis enters pleural cavity.

 

Acute treatment is drainage of pneumo (air), Chest tube, Pleurodesis in recurrent cases and surgical closure of diaphragmatic fenestrations if required.

 

Referral should be made to Gyn. service for hormonal and related management of endometriosis.

NIPPV for Preoxygenation in Morbidly Obese Patients

BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) with pressure support-ventilation and positive end-expiratory pressure are effective in providing oxygenation during intubation in hypoxemic patients. We hypothesized administration of oxygen (O₂) using NPPV would more rapidly increase the end-tidal O₂ concentration (ETo₂) than preoxygenation using spontaneous ventilation (SV) in morbidly obese patients.

METHODS: Twenty-eight morbidly obese patients were enrolled in this prospective randomized study. Administration of O₂ for 5 min was performed either with SV group or with NPPV (pressure support = 8 cm H₂O, positive end-expiratory pressure = 6 cm H₂O) (NPPV group). ETo₂ was measured using the anesthesia breathing circuit, and is expressed as a fraction of atmospheric concentration. The primary end-point was the number of patients with an ETo₂ >95% at the end of O₂ administration. Secondary end-points included the time to reach the maximal ETo₂ and the ETo₂ at the conclusion of O₂ administration.

RESULTS: A larger proportion of patients achieved a 95% ETo₂ at 5 min with NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal ETo₂ was significantly less in the NPPV than in the SV group (185 ± 46 vs 222 ± 42 s, P = 0.02). The mean ETo₂ at the conclusion of O₂ administration was larger in the NPPV group than the SV group (96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001). A modest, although significant, increase in gastric distension was observed in the NPPV group. No adverse effects were observed in either group.

CONCLUSION: Administration of O₂ via a facemask with NPPV in the operating room is safe, feasible, and efficient in morbidly obese patients. In this population NPPV provides a more rapid O₂ administration, achieving a higher ETo₂.

IMPLICATIONS: Noninvasive positive pressure ventilation provides a more rapid preoxygenation, achieving a higher end-tidal oxygen concentration, than spontaneous ventilation in morbidly obese patients.

The Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study  - A & A November 2008 vol. 107 no. 5 1707-1713

Q: 54 year old male is in ICU after Traumatic Brain Injury. Follow up CT scan shows cerebral edema. Resident ordered Mannitol. After 4 doses of Mannitol patient oxygen requirement on ventilator increased and CXR shows pulmonary edema. Resident ask you: If we are using mannitol to relieve cerebral edema than why does it cause the pulmonary edema?


Answer:
In patients with underlying cardiac or/and renal insufficiency, circulatory volume overload may occur due to expansion of extracellular fluid after serial mannitol administration causing pulmonary edema. It is true that mannitol is an osmotic diuretic but overwhelming hydrostatic pressure due to poor urinary output and underlying compromised cardiac function offsets the increased oncotic pressure and may lead to extravasation of fluid.

Q: Your nerdy ER doc called you to admit a 54 year old male with Mackler's triad. (Hint) Patient has previous history of alcohol abuse and perforated duodenal ulcer. What is Mackler's triad?


Answer: Mackler's triad includes

• lower chest pain,
• vomiting, and
• subcutaneous emphysema

It is a classic presentation of esophageal rupture (Boerhaave's syndrome) but present only in few patients (14%).

 

To note, the triad has been reported without esophageal perforation too.

 

Tachypnea and abdominal rigidity are usually present along with tachycardia, diaphoresis, fever, and hypotension. Unusual clues include hoarseness caused by involvement of the recurrent laryngeal nerve, tracheal shift, cervical vein distention, and proptosis.

 

Condition can quickly progress to multi-organ failure.

Q: 52 year old diabetic male with now resolving sepsis (off pressors) found to develop severe right upper quadrant (RUQ) tenderness around 7 PM. STAT ultrasound showed distended acalculous gallbladder with thickened walls (4 mm). Diagnosis of Acalculous Cholecystitis made. Time is now 10 PM. Your next step should be:

A) Make patient NPO. Follow-up with LFT (Conservative approach)

B) Make patient NPO. Start Antibiotics and call surgery in the morning

C) Make patient NPO. Start Antibiotics and call STAT Surgical consult

D) Call interventional Radiology to perform percutaneous cholecystostomy

E) Call GI service to perform endoscopic gallbladder stent placement



Answer: C

When the diagnosis of acalculous cholecystitis is established, immediate intervention is indicated because of the high risk of rapid deterioration and gallbladder perforation. The definitive treatment of acalculous cholecystitis is cholecystectomy (open or laparoscopic).

In patients who are not surgical candidates, percutaneous cholecystostomy may be performed in the interventional radiology as an alternative. Catheters are usually removed after approximately 3 weeks in critically ill patients with acalculous cholecystitis who have undergone percutaneous cholecystostomy. This allows for the development of a mature track from the skin to the gallbladder.

In patients who get declared non-surgical cases, endoscopic gallbladder stent placement has been reported as an effective palliative treatment. This involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP).

Free e-book - "Modern Pacemakers - Present and Future"

Release February 2011

 

"The book focuses upon clinical as well as engineering aspects of modern cardiac pacemakers. Modern pacemaker functions, implant techniques, various complications related to implant and complications during follow-up are covered. The issue of interaction between magnetic resonance imaging and pacemakers are well discussed. Chapters are also included discussing the role of pacemakers in congenital and acquired conduction disease. Apart from pacing for bradycardia, the role of pacemakers in cardiac resynchronization therapy has been an important aspect of management of advanced heart failure. The book provides an excellent overview of implantation techniques as well as benefits and limitations of cardiac resynchronization therapy. Pacemaker follow-up with remote monitoring is getting more and more acceptance in clinical practice; therefore, chapters related to various aspects of remote monitoring are also incorporated in the book. The current aspect of cardiac pacemaker physiology and role of cardiac ion channels, as well as the present and future of biopacemakers are included to glimpse into the future management of conductions system diseases. We have also included chapters regarding gut pacemakers as well as pacemaker mechanisms of neural networks. Therefore, the book covers the entire spectrum of modern pacemaker therapy including implant techniques, device related complications, interactions, limitations, and benefits (including the role of pacing role in heart failure), as well as future prospects of cardiac pacing".

 

Co-Editor of this website Sr. Salim Surani has authored Diaphragmatic Pacemaker in this book. (pdf)

 

The whole book can be downloaded free by clicking here (pdf)

Q: inhaled nitric oxide is given/measured as parts per million (ppm). What does it mean?

Answer: This is the expression of diluting the concentrations of substances. Parts per million (ppm) means out of a million.

INO (nitric oxide) is a pulmonary vasodilator and is a gaseous blend of nitric oxide and nitrogen (0.01% and 99.99%, respectively for 100 ppm). It is supplied in aluminum cylinders as a compressed gas under high pressure (2000 pounds per square inch gauge [psig]).

Q: Concurrentt use of which medications may exacerbate risk of adrenal insufficiency from Etomidate?




Answer: Opioids or benzodiazepines


At least 2 studies showed that concurrent use of etomidate with opioids and/or benzodiazepines may to exacerbate etomidate related adrenal insufficiency. However, solid evidence is lacking.


Daniell, Harry (2008). "Opioid and benzodiazepine contributions to etomidate-associated adrenal insufficiency". Intensive Care Medicine 34: 2117–8.


Daniell, HW (2008). "Opioid contribution to decreased cortisol levels in critical care patients.". Arch Surg 143 (12): 1147-1148.

Q: Dose adjustement may be required for Precedex (Dexmedetomidine) in
A) Renal failure
B) liver failure
C) ARDS
D) Thrombocytopenia
E) Seizure disorder

Answer: Liver failure

 

Dexmedetomidine wears off clinically in approximately 6 minutes in adults, but it is extensively distributed with high protein binding. It is mostly metabolized through both the cytochrome P450 enzyme system and direct glucuronidation. It has a terminal elimination half-life of approximately 2 hours. Dose reduction may be needed in patients with hepatic dysfunction.

Q: What is Hakim's triad (also known as Adam's triad)?

Answer: It is a classic triad of Normal pressure hydrocephalus

gait disturbance,
urinary incontinence, and
dementia or mental decline

It is named after Hakim and Adams who described it first in 1965.

Reading intracranial bleed on CT scan - a bedside tip!
Intracranial bleed (ICH) on CT scan appears as an area of increased attenuation which usually remains present on scan for about 7-10 days. This may be of importance to know that the increased density of blood in relation to the surrounding parenchyma of the brain relates to the hemoglobin protein contained in extravasated blood. So, in severely anemic patients, you may have to look carefully for acute bleed as it may deceive you and may appear isodense or hypodense to the surrounding brain parenchyma.

Following is a normal appearance of ICH.

Note on LP in spinal epidural abcess

Lumbar puncture (LP) is relatively contraindicated in spinal epidural abscess. MRI is the modality of choice for diagnosis. If LP is required to rule out meningitis, extreme caution should be exercise, as lumbar puncture may introduce purulent material into the subarachnoid space.

Needle should be slowly advanced with gentle syringe aspiration if spinal epidural abscess is suspected. If purulent liquid is encountered, it should be aspirated very gently to obtain culture, and the needle should not be advanced further.

Dexmedetomidine in ICU delirium

"........Dexmedetomidine, a novel α₂-receptor agonist that does not act on GABA receptors, may prove to be an alternative sedative agent that is less likely to cause delirium. In a preliminary report of an unblinded, randomized trial conducted in postoperative cardiac surgical patients, Maldonado and colleagues described a significant reduction in the incidence of delirium associated with dexmedetomidine; 8% of patients sedated with dexmedetomidine at sternal closure developed delirium as compared with 50% of patients sedated with propofol or midazolam. Similarly, in a recently completed double-blind, randomized controlled trial it was determined that ICU patients sedated with dexmedetomidine spent fewer days in coma and more days neurologically normal (without coma or delirium) than did those sedated with lorazepam. These pilot studies suggest that larger trials are warranted to evaluate the efficacy and safety of sedation with dexmedetomidine as well as clonidine, a less selective α₂-receptor agonist, in ICU patients".

Reference:  Delirium in the intensive care unit - Crit Care. 2008; 12(Suppl 3): S3. , Published online 2008 May 14. - Timothy D Girard, Pratik P Pandharipande and E Wesley Ely

Read full article here

Selenium!

Interesting article published this month in CCM Journal regarding role of trace elements selenium, copper, and zinc in cardiac surgery.

Study was done with background that the trace elements selenium, copper, and zinc are essential for maintaining the oxidative balance. A depletion of antioxidative trace  in critically ill patients is associated with the development of multiorgan dysfunction. Cardiac surgery using cardiopulmonary bypass provokes ischemia-reperfusion-mediated oxidative stress. Authors hypothesized that an intraoperative decrease of circulating trace elements may be involved in this response.

This observational study was done on 60 patients undergoing cardiac surgery with cardiopulmonary bypass.

Selenium, copper, and zinc were measured after induction of anesthesia and 1 hr after admission to the intensive care unit. All patients were separated in a priori defined subgroups according to the development of no organ failure, single organ failure, and more than/= 2 organ failures in the postoperative period.

In all patients, blood levels of selenium, copper, and zinc were significantly reduced after end of surgery. During their intensive care unit stay, 17 patients were free from any organ failure, while 31 patients developed single-organ failure and 12 patients multiple organ failure.

Multilogistic regression analysis showed that selenium concentrations at end of surgery were independently associated with the postoperative occurrence of multiorgan failure.

Authors concluded that cardiac surgery using cardiopulmonary bypass resulted in a profound intraoperative decrease of whole blood levels of antioxidant trace elements. Low selenium concentrations at end of surgery were an independent predictor for the postoperative development of multiorgan failure.


The intraoperative decrease of selenium is associated with the postoperative development of multiorgan dysfunction in cardiac surgical patients - Stoppe, Christian; Schälte, Gereon; Rossaint, Rolf; Coburn, Mark; Graf, Beatrix; Spillner, Jan; Marx, Gernot; Rex, Steffen, Critical Care Medicine. 39(8):1879-1885, August 2011.

Q: 54 year old male with ESRD is admitted with hyperkalemia. While hemodialysis is pending patient is administered calcium, insulin, glucose, kayexalate and albuterol. Patient went into repiratory distress requiring intubation. CXR shows no pulmonary edema and repeat labs showed potassium level in normal range of 4.8 mEq/L. Physical exam shows severe wheezing?



Answer: Paradoxical bronchospasm to albuterol

Paradoxical bronchospasm is a rare complication of albuterol therapy. The true mechanism of the phenomenon is unknown.Confirmed diagnosis based on rechallenge.

Raghunathan K, Nagajothi N., Paradoxical bronchospasm: a potentially life threatening adverse effect of albuterol., South Med J.2006 Mar;99(3):288-9.

A note on Propofol and sulfa allergy

Not all propofols are contraindicated in sulfa allergy. There is one form of generic propofol which contains a sulfite. It is intentionally added to retard bacterial growth to avoid contamination. Patients with an allergy to sulfa shouldn't receive this generic form of propofol, as an anaphylactic reaction may occur.

Another form of generic propofol is available which contains benzyl alcohol for inhibition of bacterial growth instead of a sulfite, and is safer to use in patients with sulfa allergy.

On other note, propofol contains soybean oil, glycerol, and egg yolk phospholipid. Therefore, contraindications to propofol administration include allergy to soybeans or egg lecithin.

Q: 52 year old male with chronic pain and muscle spasm problem and on baclofen pump brought to ED with delirium and mental status change.


Answer: Baclofen withdrawal syndrome

Abrupt withdrawal of baclofen due to mechanical or other reason may cause serious and even life-threatening symptoms including fluctuation of consciousness, agitation, restlessness, delusions, hallucinations, delirium, tachycardia, autonomic changes, seizures, spasticity and tremors. Severe rebound spasm may cause severe rhabdomyolysis.

Treatment is to resume the drug. If intrathecal route is not available, oral replacement should be started ASAP.

Q: What is the IV to PO conversion of Tacrolimus (Prograf)?


Answer: Oral dose = 4 x IV dose

The oral dose should be divided q 12 hrs with monitoring of usual target level = 5 - 15 mg/L.

Q: Etomidate has its peak effect within how many minutes?


Answer: one minute

Etomidate causes loss of consciousness after one arm-brain circulation time and has its peak effect around one minute.

Q: What are the plateau waves in ICP monitoring?

Answer: Normal ICP wave form has 3 upstrokes - P1, P2 and P3. Presence of Plateau waves, also called Lundberg A waves are clinically significant and represent very high ICP or very advanced intracranial hypertension. Plateau waves come as steep increases in ICP lasting for 5 to 10 minutes. They are always pathological and indicative of probable early brain herniation.This waveform is seen in a patient with an ICP 50 – 100 mm Hg