tag:blogger.com,1999:blog-23680843551190724092024-02-19T00:30:19.428-08:00icuroom.net October 2007 archiveUnknownnoreply@blogger.comBlogger31125tag:blogger.com,1999:blog-2368084355119072409.post-39878128573825235352007-10-31T08:21:00.000-07:002007-10-31T08:22:53.625-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Wednesday October 31, 2007</span><br /><span style="color:#990000;">Epinephrine for septick shock: Why not ?</span><br /><br /><br /></strong><strong><em><span style="color:#003300;">"............................<br /><br />In my practice, I use epinehrine as a first line agent vasopressor. It is 10 times cheaper than Norepinehrine (in my country) and also provides cardiac support for which I don't have to worry about dobutamine or close followup of cardiac index. No single study has ever shown that which vasopressor is superior. Epinephrine for septick shock: Why not ?"</span></em><br /><br /><br /></strong></span><span style="color:#000000;">Djillali Annane, </span><br /><span style="color:#000000;"><br />Yesterday while speaking at Canada Critical Care Forum annual meeting at Toronto, Canada. </span><a href="http://www.criticalcarecanada.com/"><span style="color:#003333;">www.criticalcarecanada.com</span></a>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-2368084355119072409.post-83836338126821329882007-10-30T19:43:00.000-07:002007-10-30T19:45:04.361-07:00<strong><span style="color:#000066;">Tuesday October 30, 2007</span><br /><br /><br /><br /><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">what is "cryo reduced plasma"?</span></em><br /><br /><span style="color:#660000;">A;</span> <span style="color:#000000;">One unit of cryoprecipitate is derived from one unit of fresh frozen plasma (FFP). Left over FFP, after removal of cryoprecipitate is called supernatant plasma or CRYO-REDUCED PLASMA.<br /></span><br /><br /><span style="color:#003333;">Clinical Significance:</span><span style="color:#000000;"> Cryo-reduced plasma is used as a treatment in plasmapheresis for TTP, not responding to regular plasma exchange with FFP. Some physicians even use it as first line for plasmapheresis/Therapeutic Plasma Exchange (TPE) for a patient with Thrombotic Thrombocytopenic Purpura (TTP).</span></strong><span style="color:#000000;"> </span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-8264984653594565732007-10-29T13:48:00.000-07:002007-10-29T13:49:43.112-07:00<strong><span style="color:#000066;">Monday October 29, 2007<br /></span><span style="color:#990000;">Hydrocortisone and Dexamethasone</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">What are the 3 major differences between Hydrocortisone and Dexamethasone ?</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">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.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">2. Mineralocorticoid : Glucocorticoid activity is 1:1 in hydrocotisone but dexamethasone has negligible mineralocorticoid activity as well it does not effect cortisol level.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">3. Half life of Hydrocortisone is 8-12 hrs and of dexametasone is 36-54 hrs.</span></strong><br /><br /><br /><span style="color:#000000;"><em><strong>See nice review </strong></em></span><a href="http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijen/vol1n2/adrenal.xml" target="_blank"><span style="color:#660000;"><em><strong>Relative Adrenal Insufficiency: Case Examples & Review</strong></em></span></a><span style="color:#000000;"><em><strong> from Bradley J. Phillips, M.D. , Boston Medical Center, Boston Univ. Schl of Med.</strong></em> <em>(ref: The Internet Journal of Endocrinology. 2005. Volume 1 Number 2)</em></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-41451096604109391402007-10-28T14:36:00.000-07:002007-10-28T14:39:52.549-07:00<strong><span style="color:#000066;">Sunday October 28, 2007<br /></span><span style="color:#990000;">A-line Tip</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;"> </span></strong><br /><strong><span style="color:#000000;">Suturing of arterial line particularly at femoral site may be tricky as catheter may get twist, turn and kink as they are relatively smaller catheter, both in length and diameter. Not only you may loose hardly obtained arterial placement but may cause significant bleeding.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Answer is simple. After you pass catheter over wire - suture first than remove the wire (if you are positive about right placement) or reinsert the wire once good pulsation of bright red blood confirmed. Some A-line kits (like arrow) have extra short wire (with J-shaped curve at back) to pass till you obtain secure placement. You must suture femoral A-lines as simple dressing will not secure it. Radial A-lines may be dressed tightly without sutures but it is preferable to secure it with sutures.</span></strong><br /><strong></strong><br /><strong></strong><br /><strong></strong><br /><strong><span style="color:#003333;">Related previous pearls:</span></strong><br /><strong></strong><br /><strong> </strong><a href="http://icuroom-pearls.blogspot.com/2006/05/k-level-via-line.html" target="_blank"><strong><span style="color:#660000;">Potassium level via A-line</span></strong></a><br /><strong><span style="color:#660000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/04/allen-test.html" target="_blank"><strong><span style="color:#660000;">A-line is here but where is Allen test !!</span></strong></a><br /><strong><span style="color:#660000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/04/us-guided-radial-artery.html" target="_blank"><strong><span style="color:#660000;">Ultrasound guided insertion of radial artery catheters</span></strong></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-74622402017757847582007-10-27T14:05:00.000-07:002007-10-27T14:08:54.468-07:00<strong><span style="color:#000066;">Saturday October 27, 2007</span><br /><span style="color:#990000;">Digoxin Toxicity</span><br /><br /><span style="color:#660000;">Question:</span> <em><span style="color:#003333;">Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?</span></em></strong><br /><strong></strong><br /><br /><strong><span style="color:#660000;">Answer:</span> <span style="color:#000000;">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.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-70559783366572585982007-10-26T21:39:00.000-07:002007-10-25T21:40:19.199-07:00<strong><span style="color:#000066;">Friday October 26, 2007<br /></span><br /><span style="color:#660000;">Scenario:</span> <em><span style="color:#003333;">48 year old male, hemodialysis dependent, admitted with gastro-intestinal bleed. Last dialysis was 3 days ago. Patient received 4 units of pRBC and now hemodynamically stable. Nurse calls you as she felt that rhythm looks different on monitor. Patient is asymptomatic. Walking towards patient's bed what would be your top diagnosis ?</span></em></strong><br /><strong></strong><br /><strong><span style="color:#660000;">Answer:</span> <span style="color:#000000;">HyperkalemiaTransfusion-associated hyperkalemia is a potential life threatening condition in patients with renal failure who have not been dialysed recently or with already elevated/borderline potassium level and should be followed closely.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-55358527027524019492007-10-25T10:22:00.000-07:002007-10-25T16:39:54.574-07:00<span style="color:#000066;"><strong>Thursday October 25, 2007<br /></strong></span><strong><span style="color:#990000;">Adjustment of Anion Gap (AG) for albumin<br /></span><br /><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>A big majority of patients particularly in medical-ICU are hypoalbumenic. Albumin is a major unmeasured anion and its lower level may give false normal anion gap</strong> (means normal calculated anion gap despite actual high anion gap).<br /><br /><strong>The formula to adjust anion gap with albumin is as follows</strong></span><br /><strong><div align="center"><br /><br /><span style="color:#003333;"><em>Adjusted AG = calculated AG + 2.5 (4.5 - measured albumin)<br /></em></span><br /></div></strong><span style="font-size:85%;"></span><span style="font-size:85%;">Calculated AG = Na - (Cl + HCO3)<br />4.5 = normal albumin level<br /></span><strong><br /><br /><span style="color:#660000;">Example:</span> <span style="color:#000000;">Patient has following data:<br /><br />Na = 144<br />Cl = 102<br />HCO3 = 18<br />Albumin = 2.6</span></strong><br /><strong><span style="color:#000000;"><div align="center"><br /><br />Calculated AG = 144 - (102 + 18) = 24 mEq/L<br /><br />Adjusted AG = 24 + 2.5 (4.5 - 2.6) = 24 + 2.5(1.9) = 28.75 mEq/L</div><br /></span></strong><br /><br /><br /></span><span style="font-size:78%;color:#003333;">Reference: click to get article/abstract</span><br /><br /><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199811000-00019.htm;jsessionid=HfxXnQj1S1k22RhPQG8SFx2f2Jxnz0q2Lhmmwt8yRdQtlLzy8rm9!1071114923!181195629!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Anion gap and hypoalbuminemia </span></a><span style="font-size:78%;color:#003333;">- Critical Care Medicine. 26(11):1807-1810, November 1998.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-12698151275972775822007-10-24T11:17:00.000-07:002007-10-24T11:18:49.026-07:00<strong><span style="color:#000066;">Wednesday October 24, 2007<br /></span><br /><span style="color:#660000;">Scenario:</span></strong> <em><span style="color:#003333;"><strong>You have a patient with intracranial bleed. ICP monitor has been inserted by neurosurgical service. You have been asked by nurse to clarify confusion about the level of transducer for Mean Arterial pressure (MAP), so correct CPP (Cerebral Perfusion Pressure) can be calculated. What is the answer?</strong><br /></span></em><strong><br /><br /><br /><span style="color:#330000;">Answer:</span></strong> <span style="color:#000000;"><strong>To calculate CPP,<em> tansducer should be "zeroed" at the height of the head to calculate MAP. </em> There is a misconception that transducer should always be leveled / zeroed at heart level. Its not true. For Cerebral Perfusion Presuure calculation, MAP should be calculated with transducer at head (or ear) level.<br /></strong></span><br /><span style="color:#000000;"><strong>Cerebral Perfusion Pressure (CPP) is defined as the difference between the Mean Arterial Pressure (MAP) and the Intracranial Pressure (ICP).</strong></span><br /><div align="center"><br /><span style="color:#000000;"><strong>CPP = MAP - ICP</strong></span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-59709222743317407932007-10-23T09:59:00.000-07:002007-10-23T10:03:13.150-07:00<div align="left"><strong><span style="color:#000000;"><span style="color:#000066;">Tuesday October 23, 2007</span><br /><span style="color:#990000;">Critical Care Survey</span><br /><br />Please help our international colleagues by completing following Critical Care survey. It is a quick 10 questions' survey of clinical practice of Critical Care Medicine at bedside, and should not take more than one minute.<br /></span></strong></div><strong><span style="color:#000000;"><div align="center"><br /><br /><span style="font-size:130%;">Click</span></span><span style="font-size:130%;color:#660000;"> </span></strong><strong><a href="http://www.surveymonkey.com/s.aspx?sm=Vwi8HKGhj9bsZwkISORHHQ_3d_3d"><span style="font-size:130%;color:#660000;">here</span></a></strong></div><div align="center"><strong></strong></div><div align="center"><strong></strong></div><div align="center"><strong><span style="color:#660000;"></span></strong></div><div align="center"><strong><span style="color:#000000;"></span></strong></div><div align="left"><span style="color:#000000;"></span></div><div align="left"><span style="color:#000000;"></span></div><div align="left"><span style="color:#000000;"></span> </div><div align="left"><span style="color:#000000;"></span> </div><div align="left"><span style="color:#000000;">(please email </span><a href="mailto:chackojose@gmail.com"><span style="color:#003333;">chackojose@gmail.com</span></a><span style="color:#000000;"> if you cannot open survey)</span><br /><br /><br /><span style="color:#003333;"><strong><em>Survey/study conduted by<br /><br />Dr. Jose Chacko,<br />Head of Department,<br />Multidisciplinary Intensive Care Unit *,<br />Manipal Hospital,<br />Bangalore, India</em></strong></span></div><div align="left"><br /><span style="font-size:85%;color:#003333;"><em>* 23 bedded closed unit with medical, trauma and postoperative patients with an annual admission rate of about 1200</em></span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-52483359197108213732007-10-22T18:22:00.000-07:002007-10-21T18:25:26.478-07:00<strong><span style="color:#000066;">Monday October 22, 2007<br /></span><br /><br /><span style="color:#660000;">Scenario:</span> <em><span style="color:#003333;">You intubated 53 year old short female * without any complication. CXR showed ETT in right main stem. You instructed RT (Resp. Therapist) to pull ETT by 3 cm. After adjustment, patient develop significant SQ emphysema along with periorbital swelling.<br /></span></em><br /><br /><span style="color:#660000;">Answer:</span> <span style="color:#000066;">Tracheal tear due to repositioning of the tube without cuff deflation !</span><br /><br /><span style="color:#000000;">Tracheobronchial laceration is a potential serious complication of endotracheal intubation. It can occur following uneventful intubation. Most injuries are in the lower third of the trachea .<br /><br />Most common causes include:</span></strong><br /><strong></strong><br /><ul><li><strong><span style="color:#000000;">Overinflation of the cuff, resulting in necrosis of the mucosa after prolonged intubation</span></strong></li><li><strong><span style="color:#000000;">Repositioning of the tube without cuff deflation</span></strong></li><li><strong><span style="color:#000000;">Patient movement</span></strong></li><li><strong><span style="color:#000000;">A sudden increase in the intratracheal pressure caused by vigorous coughing in the presence of the endotracheal tube</span></strong></li><li><strong><span style="color:#000000;">Inappropriate tube size </span></strong></li><li><strong><span style="color:#000000;">COPD</span></strong></li><li><strong><span style="color:#000000;">Conditions associated with a weakness of the membranous trachea (eg, elderly patient, steroid therapy) </span></strong></li><li><strong><span style="color:#000000;">Mucosal erosion or perforation of the anterior cartilaginous tracheal wall from the tip of the tube or the stylet.<br /></span><br /></strong></li></ul><p><em><span style="color:#003333;">* Almost all cases of postintubation tracheal laceration are reported in short female patients.<br /></span></em><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">Reference: Click to get article/abstract<br /><br />1. </span><a href="http://www.chestjournal.org/cgi/content/short/128/1/434" target="_blank"><span style="font-size:78%;color:#003333;">A 63-Year-Old Woman With Subcutaneous Emphysema Following Endotracheal Intubation</span></a><span style="font-size:78%;color:#003333;"> - Chest. 2005;128:434-438</span> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-41602177030669313972007-10-21T21:46:00.000-07:002007-10-20T21:50:26.857-07:00<strong><span style="color:#000066;">Sunday October 21, 2007<br /></span><br /><br /></strong><span style="color:#000000;">Re. our video pearl from yesterday - </span><a href="http://october-2007-icuroom.blogspot.com/2007_10_20_archive.html" target="_blank"><span style="color:#000000;"><span style="color:#660000;">Ultrasound guided venous catheter placement</span> </span></a><span style="color:#000000;">, we received following feedback: <em><span style="color:#003333;">Cool video and well done. Couple of comments are of sterile technique which was not followed, clorhexidine vs povidone and no time out emphasized on video.</span></em> - "Luis Urrutia" </span><a href="mailto:urrutialuis@yahoo.com"><span style="color:#003333;">urrutialuis@yahoo.com</span></a><br /><strong><br /><br /><span style="color:#990000;">Endotracheal intubation and common pitfalls - 2 videos</span></strong><br /><br /><br /><object width="425" height="350"><param name="movie" value="http://www.youtube.com/v/eRkleyIJi9U"></param><param name="wmode" value="transparent"></param><embed src="http://www.youtube.com/v/eRkleyIJi9U" type="application/x-shockwave-flash" wmode="transparent" width="425" height="350"></embed></object><br /><br /><object width="425" height="350"><param name="movie" value="http://www.youtube.com/v/5ueZ9YO2sRM"></param><param name="wmode" value="transparent"></param><embed src="http://www.youtube.com/v/5ueZ9YO2sRM" type="application/x-shockwave-flash" wmode="transparent" width="425" height="350"></embed></object>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-24501065947827482182007-10-20T06:46:00.000-07:002007-10-20T06:48:47.684-07:00<strong><span style="color:#000066;">Saturday October 20, 2007</span><br /><span style="color:#990000;">Ultrasound guided venous catheter placement - video<br /></span><br /><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">(click</span></strong><a href="http://www.youtube.com/watch?v=Ahz1SPKTiBU" target="_blank"><strong><span style="color:#000000;"> </span><span style="color:#003333;">here</span></strong></a><strong><span style="color:#000000;">, if you can't watch video on this page)</span></strong><br /><br /><br /><object height="350" width="425"><param name="movie" value="http://www.youtube.com/v/Ahz1SPKTiBU"><param name="wmode" value="transparent"><embed src="http://www.youtube.com/v/Ahz1SPKTiBU" type="application/x-shockwave-flash" wmode="transparent" width="425" height="350"></embed></object>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-23773715888594708232007-10-19T23:17:00.000-07:002007-10-18T23:36:51.763-07:00<strong><span style="color:#000066;">Friday October 19, 2007</span><br /><span style="color:#990000;">Acute A. fib. and Digoxin</span><br /><br /><br /><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">44 year old male with CHF went into Atrial fibrillation with RVR (Rapid Ventricular Rate) of 160 to 180 beats per minute. You ordered Digoxin 0.25 mg IV but after 15 minutes, there is no response ?<br /></span></em><br /><br /><span style="color:#660000;">Answer:</span> <span style="color:#000000;">Digoxin is an effective medicine for control of Atrial fibrillation associated RVR particularly in patients with congestive heart failure and left ventricular systolic dysfunction. But this is of importance to know that Digoxin is not a treatment for very acute management of A.fib. <em>The onset of action is usually at 30 minutes with a peak effect in 2 - 3 hours.</em></span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-4045870083607585902007-10-18T15:08:00.000-07:002007-10-18T15:14:32.326-07:00<strong><span style="color:#000066;">Thursday October 18, 2007</span><br /><span style="color:#990000;">2 ways of CVP measurement</span></strong><br /><br /><strong><span style="color:#000000;">Central Venous Pressure can be measured in 2 units - cm H2O and mm Hg, depending on which system is used. CVP in ICUs is usually measured in mmHg via electronic monitor.<br /><br />The conversion formula of CVP in cm H2O to mm Hg is:</span></strong><span style="color:#000000;"><br /></span><span style="color:#000000;"><div align="center"><br /><strong><br /></strong><span style="color:#003333;"><strong>10 mm H20 = 7.5 mm Hg<br />Or to be precise<br />1 mm Hg = 1.36 cm H2O</strong></span></div><br /><br /></span><span style="color:#000000;"><em>Normal CVP is 2-8 mmHg and 5 - 10 cmH2O</em></span><br /><br /></span><br /><strong><span style="color:#000000;">Here is one nice reference article on CVP, </span></strong><a href="http://www.srlf.org/data/Upload/Consensus/pdf/338.pdf" target="_blank"><strong><span style="color:#660000;">Central Venous Pressure monitoring</span></strong></a><strong><span style="color:#000000;"> ( Sheldon Magder, McGill University Health Centre, Division of Critical Care, Montreal, Canada - Current Opinion in Critical Care 2006, 12:000–000)<br /><br />Below is the picture of manometer way of CVP measurement<br /><br />Click <a href="http://www.hku.hk/anaesthe/LearNet/measure.htm"><span style="color:#660000;">here</span></a> to go to full reference article - Measuring Central Venous Pressure from Deptt. of Anaesthesiology, Univ. of Hong Kong.</span></strong><br /><br /><br /><img id="BLOGGER_PHOTO_ID_5122802159459990690" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhewYqkChvqsLVW0GLszyjagPHdgofQZ5NPZlkWsegC1dlT8Fja0F_Y-cd5nFD09vJNoilxzgp2GLOwEJgXWRaBC0IgJpO4aNV9vy6xCL3mOpKZDAUjWKtUP-QXEsx_VRQxw3NlqryU2xyI/s400/cvp.gif" border="0" />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-7921214073262942042007-10-17T21:36:00.000-07:002007-10-16T21:41:36.004-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday October 17, 2007<br /></span><br /><br /><span style="color:#660000;"></span></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">What is the physiologic amount of cortisol secreted by adrenals per day?<br /></span></em><br /><br /></span></strong><strong><span style="color:#000000;"></span></strong><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">A;</span> </span><span style="color:#000066;">Adults secrete about 20 mg of cortisol daily.</span></strong><br /><span style="color:#000000;"><br /><strong><span style="color:#000000;">We use anywhere from 200 - 300 mg of hydrocortisone as stress dose to encounter adrenal insufficiency. In USA, we prescribe it in divided doses and our european counterpart use it in a continuous drip and mostly along with fludrocortisone. But it may be of interest to know that physiologically, adrenal cortex in adults secrete only 20 mg of cortisol daily. It also secretes 2 mg of corticosterone which has similar activity. We use higher dose under presumption that due to stress body may require higher cortisol level. Usually, if its pure adrenal insufficiancy, restoration of BP and general improvement may be seen within 1 hour after the initial dose of hydrocortisone.</span></strong><br /><span style="color:#000000;"></span><br /><strong><span style="color:#000000;">Some experts advise to leave the dose at 20 mg per day of hydrocortisone once hemodynamics are improved and stress is resolved and taper it later</span></strong> <span style="font-size:78%;">1.</span></span><br /></span><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Related previous pearl:</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/05/hypoproteinemia-and-cosyntropin-test.html" target="_blank"><strong><span style="color:#660000;">Hypoproteinemia and cosyntropin test</span></strong></a><br /><strong><span style="color:#660000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/01/wednesday-january-4-2006-low-dose.html" target="_blank"><strong><span style="color:#660000;">Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose?</span></strong></a><br /><strong><span style="color:#660000;"></span></strong><br /><a href="http://icuroom-pearls.blogspot.com/2006/05/hydrocortisone-and-dexamethasone.html" target="_blank"><strong><span style="color:#660000;">Hydrocortisone and Dexamethasone</span></strong></a><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Relevant study to know:</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><a href="http://www.clinicaltrials.gov/ct/show/NCT00147004" target="_blank"><strong><span style="color:#660000;">Corticus study</span></strong></a><strong><span style="color:#000000;"> (Corticosteroid Therapy of Septic Shock).</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference: </span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. The ICU Book : Paul L. Marino : 2nd edition: Page 770</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-17017913190175149552007-10-16T07:55:00.000-07:002007-10-16T07:58:14.657-07:00<strong><span style="color:#000066;">Tuesday October 16, 2007</span></strong><br /><strong><span style="color:#000066;"></span></strong><br /><strong><span style="color:#000066;"></span></strong><br /><strong><span style="color:#000066;"><span style="color:#660000;">Q:</span> </span><span style="color:#003333;"><em>What is your diagnosis ?<br /></em></span></strong><br /><br /><p><img id="BLOGGER_PHOTO_ID_5121948478875335826" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgC4m2LSfUqZCoJkycZsMGXT1ZbPDFFovpSWdk-035LtK80XdJaoX4TNChWwuxsyRL5IHVkTZkwuXI9FLf8GtUeGvHeqKZ5WgaYX1bd0xlxP4O31WTsIzkSpra-SF1KXuXmSMrwjAdM5t7d/s400/gastrothorax1.jpg" border="0" /></p><p>Tuesday October 16, 2007<br /><br /><br /><br />Q: What is your diagnosis ?<br /><br /><br /><br /><strong><span style="color:#660000;">Answer:</span></strong> <strong><span style="color:#000000;"><span style="color:#000066;">Tension gastrothorax</span><br /><br />Tension Gastrothorax is a frequent complication of trauma with diaphragmatic injury. In the spontaneously ventilating patient the negative pressure generated in the thoracic cavity progressively sucks the stomach into the chest with each breath. Eventually, respiratory and haemodynamic compromise ensue, as with a classic tension pneumothorax.<br /><br />Its important to differential diagnosis from Tension Pneumothorax.<br /><br />Immediate treatment is either Nasogastric tubes placement to decompress the stomach - although placement may be difficult due to difficulty in passing the diaphragm, or Positive pressure ventilation to allow immediate re-expansion of the lung which forces intraperitoneal contents back into the abdomen.<br /><br />As operative repair is the eventual treatment, its better to just intubate patient.</span></strong><br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-38438294209175925512007-10-15T23:31:00.000-07:002007-10-16T21:41:16.570-07:00<p><strong><span style="color:#000066;">Monday October 15, 2007<br /></span><span style="color:#990000;">Look for leukoreduced RBCs ?</span></strong></p><p><br /><strong><span style="color:#000000;">Studies after studies are now pointing towards conservative practice of transfusion in ICU. This month "Chest" has published another study to assess effect of RBC transfusion on in-hospital mortality in 248 consecutive patients with already having ALI.<br /><br /><span style="color:#003333;">Results:</span> </span></strong></p><ul><li><strong><span style="color:#000000;">Overall in-hospital mortality rate was 39.5% (Of these patients, 207 of 248 patients received atleast 1 unit of packed RBCs</span></strong></li><li><strong><span style="color:#000000;">The transfusion of any packed RBCs was associated with an increased risk of death. </span></strong></li><li><strong><span style="color:#000000;">The overall OR (odds ratio) per unit was 1.06</span></strong></li><li><strong><span style="color:#000000;">Transfusion after ALI onset was associated with an adjusted OR of 1.13, while transfusion before ALI onset was not associated with higher risk </span></strong></li><li><strong><span style="color:#000000;">The adjusted OR per unit of nonleukoreduced RBC transfused was 1.14, while the adjusted OR for leukoreduced cells per unit transfused was 1.06</span></strong></li></ul><p><strong></strong><br /><strong><span style="color:#000000;"><span style="color:#003333;">Conclusions:</span> </span></strong></p><ul><li><strong><span style="color:#000000;">Transfusion of RBCs in patients with ALI was associated with increased in-hospital mortality. </span></strong></li><li><strong><span style="color:#000000;">This risk was greater for nonleukoreduced than for leukoreduced RBCs.</span></strong> </li></ul><p><br /><span style="font-size:78%;color:#003333;"></span></p><p><span style="font-size:78%;color:#003333;">Reference: click to get abstract</span></p><p><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.chestjournal.org/cgi/content/abstract/132/4/1116" target="_blank"><span style="font-size:78%;color:#003333;">Association of RBC Transfusion With Mortality in Patients With Acute Lung Injury</span></a><span style="font-size:78%;color:#003333;"> - Chest. October 2007; 132:1116-1123</span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-34047462504866696232007-10-14T17:17:00.000-07:002007-10-14T17:20:43.519-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday October 14, 2007<br /></span></span><span style="color:#990000;">LASA drugs</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">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 </span></strong><br /><strong><ul><li><span style="color:#000000;"><em>dopamine and dobutamine, </em></span></li><li><span style="color:#000000;"><em>phenylephrine and norepinehrine, </em></span></li><li><span style="color:#000000;"><em>heparin and hespan, </em></span></li><li><span style="color:#000000;"><em>primacor and primaxin, </em></span></li><li><span style="color:#000000;"><em>diflucan and diprivan</em><br /></span><span style="color:#000000;"></span></li></ul><p><span style="color:#000000;">Institutions are taking initiatives like</span></p><ul><li><span style="color:#000000;"><em>computer based drug entry,</em></span></li><li><span style="color:#000000;"><em> verbal read backs, </em></span></li><li><span style="color:#000000;"><em>automated alerts, </em></span></li><li><span style="color:#000000;"><em>advise to prescribers to write both the brand and generic name on problematic drugs or </em></span></li><li><span style="color:#000000;"><em>to include the intended purpose of the medication</em></span></li></ul><span style="color:#000000;"><br /> 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</span><span style="color:#003333;"> </span></strong><a href="http://www.accp.com/position/pos28.pdf" target="_blank"><strong><span style="color:#003333;">here</span></strong></a><strong><span style="color:#000000;"> 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.</span></strong><br /></span></strong><br /><br /><br /><strong><span style="color:#003333;">Related previous Pearls:</span></strong><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong>1. </strong></span><a href="http://icuroom-pearls.blogspot.com/2005/11/isp.html" target="_blank"><strong><span style="color:#660000;">ICU satellite pharmacy</span></strong></a><br /><span style="color:#000000;"><strong>2. </strong></span><a href="http://icuroom-pearls.blogspot.com/2005/12/pivde.html" target="_blank"><strong><span style="color:#660000;">Preventing intra-venous (IV) drip errors</span></strong></a><br /><span style="color:#000000;"><strong>3.</strong></span><a href="http://icuroom-pearls.blogspot.com/2005/12/fr.html" target="_blank"><span style="color:#000000;"><strong> <span style="color:#660000;">"Five Rights"</span></strong></span></a><br /><br /><span style="color:#003333;"><br /><span style="font-size:78%;">Reference:</span></span><br /><br /><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199708000-00014.htm;jsessionid=DW7XXcTFbXF7xIRWqMSLkgBuS32I26SYeN8Vwut2MzKUqswwkOG2!-2109904337!-949856144!9001!-1" target="_blank"><span style="font-size:78%;color:#003333;">Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units</span></a><span style="font-size:78%;color:#003333;"> Critical Care Medicine. 25(8):1289-1297, August 1997.</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-57280039544317758622007-10-13T19:16:00.000-07:002007-10-12T19:26:23.573-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Saturday October 13, 2007<br /></span><span style="color:#990000;">Dopamine dosing on pump !</span><br /><br /><br /></strong><em><span style="color:#003333;">Beauty of Critical Care Medicine is in details</span></em><br /><br /><br /><span style="color:#000000;"><strong>In contrast to dosing of other vasopressors, it is important to dose Dopamine on "ideal" body weight instead of actual body weight.<br /><br />Unexpected tachycardia or hypertension may occur due to overdosing, if actual body weight instead of "ideal" body weight punched on pump. This is important to understand as in ICU it is very frequent to have high actual body weight due to fluid resuscitation. The right way to write dopamine dosing is like,<br /><br /><em>Start Dopamine drip with 2 mcg/kg/min of "Ideal" body weight and titrate as needed upto 20 mcg/kg/min. Call physician if heart rate more than 120 or Mean Blood Pressure more than 100.</em></strong></span><br /></span><br /><br /><br /><span style="font-size:78%;color:#003333;">Further recommended reading</span><br /><br /><span style="font-size:78%;color:#003333;">1. Dopamine administration - Intensive Care Medicine , Volume 10, Number 5 / September, 1984<br />2. The ICU Book - 3rd edition, Paul L. Marino, Page 301</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-42476334738676737132007-10-12T01:59:00.000-07:002007-10-12T19:51:55.978-07:00<strong><span style="color:#000066;">Friday October 12, 2007<br /></span><br /><span style="color:#660000;">Scenario:</span> <em><span style="color:#003333;">Nurse call you as patient 's SVRI (Systemic Vascular Resistance Index) is only 372. As you asked further hemodynamics data, you were given following info: </span></em></strong><br /><strong><br /><em><span style="color:#003333;">MAP (Mean Arterial Pressure) = 80 ,<br />CI (Cardiac Index) = 4.0,<br />CVP = 10 </span></em><br /><br /><em><span style="color:#003333;">What what be your response? </span></em><br /><ol><li><em><span style="color:#003333;">Do Nothing - you are happy with this number</span></em></li><li><em><span style="color:#003333;">Recalibrate and recheck the SVRI again as it appears to be an error. </span></em></li><li><em><span style="color:#003333;">Titrate the vasopressor up.</span></em></li><li><em><span style="color:#003333;">Give fluid.</span></em></li><li><em><span style="color:#003333;">Give Lasix.</span></em> </li></ol><p><br /><span style="color:#660000;">Answer:</span> <span style="color:#000000;">B </span></p><p><br /><span style="color:#000000;">This is probably an error as formula for SVRI is </span></p><p align="center"><br /><span style="color:#003333;">SVRI = (MAP - CVP) / CI x 80 </span></p><p align="center"><br /><span style="color:#003333;">so SVRI in above case should be: </span></p><p align="center"><span style="color:#003333;">(80 - 10)/4 x 80 = 1400</span></p><p><span style="color:#000000;"><br />Objective of above question is to emphasize the point that, with high dependence on technology and computer chips, errors are common and its very important to obtain full picture when things appear out of normal for no reason and does not fit with full picture. It is more important to know "What not to do" than to know "what to do" ! </span></p><p><span style="color:#000000;">It is very frequent in board exams to have questions with objective to identify erroneous data !</span></strong></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-88749692726110072442007-10-11T21:00:00.000-07:002007-10-11T11:46:28.864-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Thursday October 11, 2007</span><br /></span><span style="color:#990000;">Carbon Dioxide Angiography</span></strong><br /><strong><span style="color:#000000;"><br />Carbon dioxide (CO2) gas is used as an alternative contrast to iodinated contrast material. When injected into a blood vessel, carbon dioxide bubbles displace blood, allowing vascular imaging. Because of the lack of nephrotoxicity and allergic reactions, CO2 is increasingly used as a contrast agent for diagnostic angiography and vascular interventions.<br /><br />CO2 is particularly useful in patients with renal insufficiency or a history of hypersensitivity to iodinated contrast medium. Also, it is safe as CO2 is effectively eliminated by means of respiration.<br /><br /><span style="color:#660000;">Disadvantage:</span> CO2 is less dense than iodinated contrast medium, and the overall quality of the CO2 vascular image is less than the contrast medium.<br /><br /><br /><span style="color:#660000;">Cautions:</span><br /><ul><li>CO2 should not be used as a contrast agent in the coronary and cerebral circulations because of the possibility of adverse effects secondary to a gas embolism. Safely, CO2 should be avoided in vessels above the diaphragm.</li><li>In patients with pulmonary insufficiency or pulmonary hypertension because of amount diagnostic doses of CO2 pulmonary arterial pressure may increase. </li><li>In right-to-left shunts Co2 may cause paradoxical gas embolism.<br /><br /></li></ul></span></strong><strong><span style="color:#000000;">See slide presentation </span></strong><a href="http://www.miit.com/PDF/MIIT%202002/CARBON%20DIOXIDE%20Angiography%20and%20Intervention%20-%20Slides.pdf" target="_blank"><strong><span style="color:#000000;"><span style="color:#660000;">CARBON DIOXIDE ANGIOGRAPHY AND INTERVENTION CARBON DIOXIDE</span> </span></strong></a><strong><span style="color:#000000;">(Jim Caridi MD. University of Florida. Gainesville, FL)<br /></span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference: click to get article</span><br /><br /><a href="http://www.emedicine.com/radio/topic870.htm" target="_blank"><span style="font-size:78%;color:#003333;">Carbon Dioxide Angiography</span></a><span style="font-size:78%;color:#003333;"> - emedicine.com</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-6720882072802521632007-10-10T21:59:00.000-07:002007-10-09T22:00:52.196-07:00<strong><span style="color:#000066;">Wednesday October 10, 2007<br /></span><span style="color:#990000;">Significance of venous blood gas</span></strong><strong><br /></strong><strong><br /><span style="color:#000000;">Venous blood gasses are easy to obtained but very under-utilized in ICUs.<br /><br />In ICU setting where hypotension and hypoperfusion are very common, it is very important to know that although information about arterial blood gases is needed to assess pulmonary gas exchange, in the presence of severe hypoperfusion, the hypercapnia and acidemia at the level of the tissues are detected better and correlate more in central venous blood.</span></strong><span style="color:#000000;"><br /></span><br /></strong><br /><span style="color:#003333;"><br /><span style="font-size:78%;">References: click to get abstracts</span></span><br /><br /><a href="http://content.nejm.org/cgi/content/abstract/320/20/1312" target="_blank"><span style="font-size:78%;color:#003333;">Assessing acid-base status in circulatory failure. Differences between arterial and central venous blood </span></a><span style="font-size:78%;color:#003333;">- Volume 320:1312-1316, , May 18. 1989</span><br /><br /><span style="font-size:78%;color:#003333;">Comparison of Blood Gas and Acid-Base Measurements in Arterial and Venous Blood Samples in Patients with Uremic Acidosis and Diabetic Ketoacidosis in the Emergency Room - American Journal of Nephrology 2000;20:319-323</span><br /><br /><a href="http://emj.bmj.com/cgi/content/abstract/23/8/622" target="_blank"><span style="font-size:78%;color:#003333;">Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate.. </span></a><span style="font-size:78%;color:#003333;">Emerg. Med. J. 23: 622-624</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-29049807028474355282007-10-09T14:49:00.000-07:002007-10-09T14:55:30.098-07:00<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitonngPEa2F86Y_ZZX2HYjZTELZtoq59cObK6YmepMo7PcN4cRpdXMFNwQZ5tQsdvBB2h28i-g76SGxMMfSNjv9WKkGA6-7eG1_IrlMwFKRwNZ9tlXz0dwG-HV0QIdE9OyDuVakTkkePqO/s1600-h/bvartery.jpg"><strong><img id="BLOGGER_PHOTO_ID_5119458166642801794" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitonngPEa2F86Y_ZZX2HYjZTELZtoq59cObK6YmepMo7PcN4cRpdXMFNwQZ5tQsdvBB2h28i-g76SGxMMfSNjv9WKkGA6-7eG1_IrlMwFKRwNZ9tlXz0dwG-HV0QIdE9OyDuVakTkkePqO/s400/bvartery.jpg" border="0" /></strong></a><strong><span style="color:#000066;">Tuesday October 9, 2007</span></strong><br /><strong><span style="color:#990000;">"Locked-in" Syndrome (coma vigilante)</span></strong><br /><br /><em><span style="color:#003333;"><strong>Patient is a silent and unresponsive witness to everything that is happening" -</strong></span></em><span style="color:#003333;"> from story of Nick Chisholm</span> <span style="font-size:78%;">1</span><br /><br /><br /><span style="color:#000000;"><strong>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.</strong> <span style="font-size:85%;">3</span></span><br /><br /><span style="color:#000000;"><strong>Locked-In syndrome can be caused by stroke at the level of the basilar artery denying blood to the ventral part of the pons, among other causes. 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.</strong> 2</span><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Only supportive rehabilitation is the answer.</span></strong><br /><br /><strong><span style="color:#000000;">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 an 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 </span></strong><a href="http://us.penguingroup.com/nf/Book/BookDisplay/0,,0_0140449442,00.html" target="_self"><strong><span style="color:#000066;">Thérèse Raquin by Emile Zola</span></strong></a><strong><span style="color:#000000;"> - 1868).</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get articles/abstract </span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://bmj.bmjjournals.com/cgi/content/full/bmj;331/7508/94" target="_blank"><span style="font-size:78%;color:#003333;">The patient's journey: Living with locked-in syndrome</span></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOj_TLaKjxxygkgmIxRkBCZP8s9jbergMgnlJM0XfNBsC3tPGhJ7IyjrORcMCNG4TLCAtf5ITsIICyvo9qdCKjLEbWhhj0y51wwe0htMN198GVnVLh_dw1WmlwhzMwgQb5jF1sxCXnF_LK/s1600-h/brainpons.jpg"><span style="font-size:78%;color:#003333;"> - BMJ 2005;331:94-97 (9 July)<br />2. </span></a><a href="http://health.enotes.com/neurological-disorders-encyclopedia/locked-syndrome" target="_self"><span style="font-size:78%;color:#003333;">Locked-in Syndrome</span></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOj_TLaKjxxygkgmIxRkBCZP8s9jbergMgnlJM0XfNBsC3tPGhJ7IyjrORcMCNG4TLCAtf5ITsIICyvo9qdCKjLEbWhhj0y51wwe0htMN198GVnVLh_dw1WmlwhzMwgQb5jF1sxCXnF_LK/s1600-h/brainpons.jpg"><span style="font-size:78%;color:#003333;"> - enotes.com<br />3. Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: FA Davis, 1982; 377<br />4. </span></a><a href="http://bja.oxfordjournals.org/cgi/content/full/92/2/286" target="_self"><span style="font-size:78%;color:#003333;">Locked-in syndrome: a catastrophic complication after surgery</span></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOj_TLaKjxxygkgmIxRkBCZP8s9jbergMgnlJM0XfNBsC3tPGhJ7IyjrORcMCNG4TLCAtf5ITsIICyvo9qdCKjLEbWhhj0y51wwe0htMN198GVnVLh_dw1WmlwhzMwgQb5jF1sxCXnF_LK/s1600-h/brainpons.jpg"><span style="font-size:78%;color:#003333;"> - British Journal of Anaesthesia, 2004, Vol. 92, No. 2 286-288</span></a><br /><br /><br /> <img id="BLOGGER_PHOTO_ID_5119458046383717490" style="FLOAT: left; MARGIN: 0px 10px 10px 0px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOj_TLaKjxxygkgmIxRkBCZP8s9jbergMgnlJM0XfNBsC3tPGhJ7IyjrORcMCNG4TLCAtf5ITsIICyvo9qdCKjLEbWhhj0y51wwe0htMN198GVnVLh_dw1WmlwhzMwgQb5jF1sxCXnF_LK/s400/brainpons.jpg" border="0" />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-35565838549978868472007-10-08T22:44:00.000-07:002007-10-08T16:58:32.273-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Monday October 8, 2007</span><br /><span style="color:#990000;">Comparison of two dose regimens of arginine vasopressin in advanced vasodilatory shock.</span> </span></strong><br /><strong><span style="color:#000000;"><br /><span style="color:#000000;"></span><br /><span style="color:#000000;">Even though not an establish part of guidelines and literature is not plenty either, vasopressin has fastly become an integral pressor in most ICUs across USA. Usual acceptable dose is 0.04 units/min.</span><br /><br /><span style="color:#000000;">Very recently, a retrospective controlled study of 78 patients published, to evaluate the effects of two vasopressin dose regimens (0.033 vs. 0.067 IU/min) on treatment efficacy, hemodynamic response, prevalence of adverse events, and changes in laboratory variables. </span><br /><br /><span style="color:#000000;">78 patients with vasodilatory shock (mean norepinephrine dosage, 1.07 mcg//min were given supplementary infusion of vasopressin. 2 groups were</span><br /><ul><li><span style="color:#000000;"> 0.033 (n = 39) and </span></li><li><span style="color:#000000;">0.067 IU/min (n = 39)</span></li></ul><br /><span style="color:#000000;">Cardiocirculatory, laboratory, and clinical variables were evaluated and compared between groups before and at 0.5, 1, 4, 12, 24, 48, and 72 hrs after initiation of Vasopressin (AVP). </span><br /><br /><span style="color:#000000;">Treatment efficacy was assessed by the increase in mean arterial blood pressure and the extent of norepinephrine reduction during the first 24 hrs of vasopressin therapy.</span><br /><br /><span style="color:#660000;"></span><br /><span style="color:#660000;">Results:</span><br /><ul><li><span style="color:#000000;">Although the relative increase in mean arterial pressure was comparable between groups (16.8 +/- 18.4 vs. 21.4 +/- 14.9 mm Hg), norepinephrine could be reduced significantly more often in patients receiving 0.067 IU/min. </span></li><li><span style="color:#000000;">AVP at 0.067 IU/min resulted in a higher mean arterial pressure (p < .001), lower central venous pressure (p = .001), lower mean pulmonary arterial pressure (p = .04), and lower norepinephrine requirements (p < .001) during the 72-hr observation period. </span></li><li><span style="color:#000000;">Increases in liver enzymes occurred more often in patients treated with 0.033 IU/min (71.8% vs. 28.2% - p < .001) ! </span></li><li><span style="color:#000000;">The prevalence of a decrease in cardiac index, decrease in platelet count, and increase in total bilirubin was not significantly different between groups. </span></li><li><span style="color:#000000;">Base deficit were lower and arterial lactate concentrations higher in patients receiving 0.033 IU/min.</span> </li></ul><br /><br /><span style="color:#660000;">Conclusions:</span> </span><span style="color:#000000;">Vasopressin dosages of 0.067 IU/min seem to be more effective to reverse cardiovascular failure in vasodilatory shock requiring high norepinephrine dosages than 0.033 IU/min.</span></strong><br /><br /><br /><span style="color:#003333;"><br /></span><span style="font-size:78%;color:#003333;">Reference: click to get abstract/article<br /><br /></span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200710000-00008.htm;jsessionid=HJyGLzkGyfypl0lpdfh6vS1ZXn2xyMRGDPSdJyhvjyjwFxJH00XL!872513869!181195628!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Comparison of two dose regimens of arginine vasopressin in advanced vasodilatory shock</span></a><span style="font-size:78%;color:#003333;">. - Critical Care Medicine. 35(10):2280-2285, October 2007.</span><br /></span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-2368084355119072409.post-11681996508288795082007-10-07T12:24:00.000-07:002008-05-07T15:08:06.755-07:00<strong><span style="color:#000066;">Sunday October 7, 2007</span><br /><span style="color:#990000;">Carvedilol (Coreg)</span></strong><br /><strong></strong><br /><br /><strong></strong><br /><strong><span style="color:#660000;">Q:</span> <em><span style="color:#003333;">How Carvedilol (Coreg) is different from other B-blockers?</span></em><br /></strong><br /><strong><span style="color:#660000;">A;</span> <span style="color:#000000;">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</span></strong><a name="uscarvedilol"><strong><span style="color:#000000;"> </span></strong></a><span style="color:#000000;"><strong>with 1094 patients showed 65% lower risk of death than placebo patients</strong> <span style="font-size:78%;">1.</span><strong> 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</strong></span> <span style="font-size:78%;">2.</span><br /><strong></strong><br /><span style="color:#000000;">FDA approves only Toprol-XL and Coreg for CHF.</span><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get article/abstract</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://content.nejm.org/cgi/content/abstract/334/21/1349" target="_blank"><span style="font-size:78%;color:#003333;">The Effect of Carvedilol on Morbidity and Mortality in Patients with Chronic Heart Failure</span></a><span style="font-size:78%;color:#003333;"> - N Engl J Med. 1996;334:1349-1355.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">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</span>Unknownnoreply@blogger.com0