Sunday October 7, 2007
Carvedilol (Coreg)



Q: How Carvedilol (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

Saturday October 6, 2007
On reintubation rate

Here is a little twist if you are proud of your too low reintubation rate !!

"A reintubation rate of 5% to 15% is acceptable; lower rates indicate the patients are being kept on the ventilator too long, while higher rates suggest that they are being taken off too soon". - Dr. Neil R. Macintyre - at ACCP annual meeting, october 23, 2006


Related links:

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

When to wean from a ventilator: An evidence-based strategy, Ref: CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70, NUMBER 5 MAY 2003 page 389


Related previous pearls:

Spontaneous Breathing Trial (SBT) - how long - 30 or 120 minutes?,

IV steroid to reduces postextubation stridor

Friday October 5, 2007
Our progress card on Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients


"Chest" recently reported physicians' progress card on Venous Thromboembolism Prophylaxis in 15,156 Acutely Ill Hospitalized Medical Patients from 52 hospitals in 12 countries via program called IMPROVE (international Medical Prevention Registry on Venous Thromboembolism).


Results:

• Only approximately 60% of patients who either met the ACCP criteria for requiring prophylaxis or were eligible for enrollment in randomized clinical trials that have shown the benefits of pharmacologic prophylaxis actually received prophylaxis.


• Intermittent pneumatic compression was the most common form of medical prophylaxis utilized in the United States, although it was used very rarely in other countries (22% vs 0.2%, respectively).


• Unfractionated heparin was the most frequent pharmacologic approach used in the United States (21% of patients), with low-molecular-weight heparin used most frequently in other participating countries (40%).


• There was also variable use of elastic stockings in the United States and other participating countries (3% vs 7%, respectively.

Conclusions; Data suggest that physicians’ practices for providing VTE prophylaxis to acutely ill hospitalized medical patients are suboptimal.




Reference: click to get article

1. Venous Thromboembolism Prophylaxis in Acutely Ill Hospitalized Medical Patients - Chest. 2007; 132:936-945

Thursday October 4, 2007
Hypothermia and hypocapnia !

Editors' note: Many time objective of our pearls is to introduce concepts which may be only of academic interest but intensivist need to be atleast aware of it.


Q: What's the relationship of CO2 production with level of hypothermia?

A: For every degree below 37 c, CO2 production decrease approximately by 10%, due to decrease metabolic demand. During post-operative warming, it should be kept in mind, anticipating rise in CO2 while weaning ventilator.

Wednesday October 3, 2007
Rocephin and calcium !


The safety labeling for IV ceftriaxone (Rocephin) has been updated by FDA to describe the potential risks associated with concomitant use of calcium or calcium-containing solutions in patients of any age (despite most reports are from neonates).

Per Roche, the maker of Rocephin, "the theoretical possibility exists for an interaction between ceftriaxone and IV calcium-containing solutions in patients other than neonates." Therefore, the use of ceftriaxone with calcium products is now contraindicated in all age groups.

Cases of fatal reactions with calcium-ceftriaxone precipitates in the lungs and kidneys have been reported in both term and premature neonates. Some of these cases occurred even when ceftriaxone and the calcium-containing products were administered by different routes at different times.

Because of the risk for particulate precipitation, ceftriaxone should not be mixed with calcium-containing solutions/products or reconstituted with calcium-containing diluents such as Ringer's or Hartmann's solution. Concomitant administration of ceftriaxone with calcium-containing solutions or products is likewise contraindicated, even via different infusion lines; 48 hours should elapse between the last dose of ceftriaxone and their use.


Reference: click to get article/abstract

1. IMPORTANT CLARIFICATION OF PRESCRIBING INFORMATION, fda - medwatch - Ceftriazone - August 2007

Tuesday October 2, 2007
Ethanol drip in Ethylene Glycol


Q; How you write Ethanol drip in Ethylene Glycol poisoning assuming you don't have Fomepizole or Dialysis available ?


A: Ethylene Glycol poisoning is common and can have bleak outcomes. Intensivists should be aware of all the possible interventions available. Antidotal therapy is based on preventing the alcohol dehydrogenase enzyme from metabolizing ethylene glycol into toxic byproducts. In case Fomepizole or Dialysis is not available, Ethanol will competitively inhibit alcohol dehydrogenase. But the serum ethanol level must be monitored frequently.Therapeutic ethanol is administered in a bolus followed by a continuous infusion. Initially, 7.5 to 10 mL/Kg of 10% ethanol, in D5W, is administered over 30 minutes. Then, a continuous infusion of 1 to 2 mL/Kg/hr of 10% ethanol is infused until the patient has eliminated all of the EG from his serum. It is important to keep the serum ethanol level at 100 to 150 mg/dL so as to completely inhibit the alcohol dehydrogenase enzyme.

Actual antidote or first line therapy is Fomepizole (Antizol) with fewer side effects. Fomepizole blocks alcohol dehydrogenase. Fomepizole is administered as 15 mg/Kg (up to 1 Gm) initially, then 10 mg/Kg q12h times four doses, and then 15 mg/Kg q12 hours until ethylene glycol level <10>


Bonus Pearl: Fomepizole can also be use as an antidote in Methanol overdose.

Monday October 1, 2007

Scenario: A patient was transferred to Critical Care Unit in septic shock. 4 out of 4 blood cultures were positive for Staphylococcus epidermidis and E. coli. Patient moved from Mexico to United States approximately six months ago for the treatment of HTLV-1 associated Lymphoma and has been on chemotherapy. What is the most likely cause of sepsis?

Diagnosis: Strongyloidiasis.

Strongyloides stercoralis is endemic in many areas of the world and is associated with HTLV-1. There is increased risk of disseminated strongyloides in immunocompromised individuals, and can result in pllymicrobial bacteremia.


Read very precise review article at emedicine.com: Strongyloides Stercoralis

click to get larger image

Reference: click to get abstract/article

1. A Canadian immigrant with coinfection of Strongyloides stercoralis and human T-lymphotropic virus 1 - CMAJ • August 28, 2007; 177 (5).

2. Complicated and fatal Strongyloides infection in Canadians: risk factors, diagnosis and management - CMAJ • August 31, 2004; 171 (5).