Q: Should PO amiodarone be given with food or empty stomach?

Answer:  With food

It is well known that PO amiodarone has variable bioavailability ranging from 22 to 95%. Interestingly, it has shown to have better absorption if it is taken with food.

Reference:

Siddoway LA (2003). "Amiodarone: guidelines for use and monitoring" - American Family Physician 68 (11): 2189–96. (http://www.aafp.org/afp/2003/1201/p2189.html)

Q: What one precaution should be taken before giving rTPA to patient with acute ischemic stroke?

Answer:  Insert another large bore IV

Once decision is made to administer rTPA to a patient with ischemic CVA, another large-bore intravenous line (in addition to their dedicated TPA line), should be inserted.

For 24 hours after infusion, venipuncture, arterial lines, and insertion of nasogastric tubes should be avoided because of the increased risk of bleeding.

Reference:

Adams H.P. Jr., del Zoppo G., Alberts M.J., et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke 2007;38:1655-711.

Q: In Catheter-Directed Thrombolysis for Acute Limb Ischemia, what is the threshold to transfuse FFP (Fresh Frozen Plasma) for low fibrinogen level to avoid bleeding complication?

Answer:  100 mg/dL

Some vascular services monitor fibrinogen levels during catheter-directed thrombolysis for acute limb ischemia,  and may halt thrombolysis or give fresh frozen plasma if the value drops below 100 mg/dL. There is no strong evidence that it may decrease bleeding risk, so, many other vascular services do not monitor fibrinogen. Also, Fibrinogen level can be artificially high or normal in rtPA infusion due to accumulation of fragment X, one of several fibrin degradation products.

References: 

1. Catheter-Directed Thrombolysis for Acute Limb Ischemia - Semin Intervent Radiol. 2006 September; 23(3): 258–269.

2. The STILE Investigators Results of a prospective randomised trial evaluating surgery versus thrombolysis for ischaemia of the lower extremity. The STILE trial. Ann Surg. 1994;220:251–268. 

Q: Following is the usual layout of an arterial line setup. How much fluid is usually push through the pressure bag line towards transducer to keep it open?

Report photo

Answer:

The pressure bag is a way of keeping the right amount of fluid flowing thru the A-line. It pushes HARD against the transducer and the transducer allows 3cc/hr of Normal Saline thru the transducer into the A-Line. This is like a TKO IV Fluid for the A-Line. Also,  pressure bag's pushing against the transducer keeps the wire getting the right signal.

Q: Which one added step is recommended to decrease the trauma complication from Paracentesis

Answer:  Either request patient to urinate before the procedure; or insert a a foley catheter to empty the bladder.

Coupled plasma filtration adsorption combined with continuous veno venous hemofiltration treatment in patients with severe acute pancreatitis

BACKGROUND: Severe acute pancreatitis (SAP) still has a high mortality rate. Coupled plasma filtration adsorption (CPFA) and continuous veno-venous hemofiltration (CVVH) are 2 extracorporeal blood purification techniques. We hypothesized that CPFA combined with CVVH could preferentially improve prognosis and suppress clinical manifestations of SAP.

METHODS: In this observational cohort study, 25 patients with SAP were enrolled, in which 12 received CPFA plus CVVH treatment (group 1), and 13 received CVVH therapy (group 2). All the patients underwent a successive 10-day intervention. Clinical indicators were detected before or after the intervention and the results were compared between the 2 groups. The feasibility and the survival rate were evaluated on day 28.

RESULTS: Compared with group 2, oxygenation index (PaO(2)/FiO(2)), mean arterial pressure, serum amylase, and blood urine nitrogen showed significant differences (all P<0.01) and serum TNF-α, IL-1β, IL-6 were reduced and IL-10 was elevated with time in group 1 (all P<0.01). Liver functions, electrolyte, and acid-base balance did not show significant difference before and after the 10-day treatment with CPFA plus CVVH compared with CVVH (P>0.05). No therapy-related adverse reactions were noted in both groups. Twenty-eight-day survival rate of group 1 was higher than that in group 2 [91.7% (11/12) vs. 53.8% (7/13), P<0.05].

CONCLUSIONS: CPFA combined with CVVH was an effective and safe method for treatment of SAP patients, the mechanism being related to its effect on regulating the level of cytokines and serum amylase

Reference:

He C., and coll., Coupled plasma filtration adsorption combined with continuous veno-venous hemofiltration treatment in patients with severe acute pancreatitis - J Clin Gastroenterol. 2013 Jan;47(1):62-8.

http://www.ncbi.nlm.nih.gov/pubmed/23090044

Plasmapheresis and heparin re exposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia 


 BACKGROUND: Heparin-induced thrombocytopenia (HIT) complicates the management of patients presenting for cardiac surgery, because high-dose heparin anti-coagulation for cardiopulmonary bypass is contraindicated in these patients. Alternative anticoagulants are available, but there are concerns about dosing, efficacy, monitoring, thrombosis, and hemorrhage. 


 METHODS: A retrospective chart review between November 2004 and March 2008 retrieved perioperative clinical and laboratory data for 11 adult cardiac surgical patients with a preoperative history of HIT and a current positive antiheparin/platelet factor 4 (anti-HPF4) antibody titer, who were managed with plasmapheresis and heparin anticoagulation. 

RESULTS: The median (interquartile range) preoperative anti-HPF4 antibody titer was 0.8 (0.7-2.2). Three of the 11 patients (27%) died of causes unrelated to HIT and 1 of these patients (9%) developed an ischemic foot, in the setting of cardiogenic shock, not thought to be HIT-related. A single plasmapheresis treatment reduced titers by 50%-84%, and 6 patients had negative titers after treatment; none of the 3 patients with reduced titers developed clinical HIT. 

 CONCLUSIONS: This case series describes an alternative management strategy using intraoperative plasmapheresis for patients presenting for cardiac surgery with acute or subacute HIT. Reducing antibody load can potentially decrease the thrombotic risk associated with high anti-HPF4 titers and decrease the urgency to initiate postoperative anticoagulation in this patient group at high risk of postoperative bleeding.


Reference: 

 Anesth Analg. 2010 Jan 1;110(1):30-5. Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia.

 http://www.ncbi.nlm.nih.gov/pubmed/20023181

Prone positioning is back!

May 20, 2013 issue of NEJM has newest study published on Prone Positioning in Severe Acute Respiratory Distress Syndrome. Many previous trials involving patients with the acute respiratory distress syndrome (ARDS) have failed to show a beneficial effect of prone positioning during mechanical ventilatory support on outcomes. 

In this multicenter, prospective, randomized, controlled trial, of 466 patients with severe ARDS, patients were assigned to either go prone-positioning sessions of at least 16 hours or to be left in the supine position.

Severe ARDS was defined P/F ratio less than 150 mm Hg, with an FiO2 of at least 0.6, a PEEP of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. 

The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion.

A total of 237 patients were assigned to the prone group, and 229 patients were assigned to the supine group. 

• The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P less than 0.001).
• The hazard ratio for death with prone positioning was 0.39 (95% confidence interval [CI], 0.25 to 0.63).
• Unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group (P less than 0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67).
• The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group.
  
  
  Study concluded that In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.

Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013.

http://www.nejm.org/doi/full/10.1056/NEJMoa1214103

Pigtail Catheter insertion

 If video doesn't work, click or cut n paste 

http://youtu.be/nrxuZwFpigI

Hyponatremia and non-cardiogenic pulmonary edema

 

 

One less paid attention during management of hyponatremia is to non-cardiogenic pulmonary edema, which can develop at Sodium level below 121 ± 3 mmol/L. In these settings usually EKG and echocardiograms are normal. CXR shows pulmonary edema with a normal heart. Also, cardiac enzymes are normal, and pulmonary wedge pressure not elevated. Cerebral edema may simultaneously may be present. Situation is usually reversible with reversal of hyponatremia.

 

 

 

Reference:

 

 

1. J. Carlos Ayus, MD; Joseph Varon, MD; and Allen I. Arieff, MD Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in Marathon Runners, Ann Intern Med. 2000;132(9):711-714

 

2. Ayus JC, Arieff AI., Pulmonary complications of hyponatremic encephalopathy. Noncardiogenic pulmonary edema and hypercapnic respiratory failure., Chest. 1995 Feb;107(2):517-21.

Q: Which diuretic can have antimineralocorticoids effects?

Answer: Spironolactone

Spironolactone decreases the effects of mineralocorticoids including aldosterone and corticosterone by competing for intracellular mineralocorticoid receptors in the cortical collecting duct. 

On Relative Bradycardia!

Appropriate temperature–pulse relationships
Temperature	Beats/min
41.1 °f.f.s.C (106 °F)	150
40.6 °f.f.s.C (105 F)	140
40.7 °f.f.s.C (104 F)	130
39.4 °f.f.s.C (103 F)	120
38.9 °f.f.s.C (102 F)	120
38.3 °f.f.s.C (101 F)	110

Patient must be an adult, i.e. ≥ 13 years, with temperature ≥ 102 °F. Pulse must be taken simultaneously with the temperature elevation. Patient should be in Normal Sinus Rhythm without arrhythmia, second/third- degree heart block or pacemaker-induced rhythm. Patient must not be on β-blocker medication.

Fidaxomicin - a new kid in the block to treat C.Diff.

Fidaxomicin is a narrow spectrum macrocyclic non-systemic antibiotic drugs. It is bactericidal, and causes selective eradication of pathogenic Clostridium difficile  with minimal disruption of the other bacteria that make up the normal, healthy intestinal flora. As evident, the maintenance of normal physiological conditions in the colon is the best defense against the probability of Clostridium difficile infection recurrence.

Dose is 200 mg tablet every 12 hours for the duration of 10 days. 

 On dangers of Rectal Tubes
Abstract

The management of fecal incontinence is a struggle to maintain patient hygiene and limit the transmission of nosocomial infections. Intrarectal devices that cause diversion and collection of the fecal stream have been used with increasing frequency. This method can effectively control patient waste if used in an appropriate setting.

We examine a series of 3 patients in whom rectal trauma resulting in life-threatening hemorrhage was associated with use of the ConvaTec Flexi-Seal fecal management system.

In 2 patients there was a history of traumatic removal, and the third developed a rectal pressure ulcer associated with use of this device. All 3 patients required surgical or endoscopic intervention to achieve hemostasis.

Although effective, the Flexi-Seal fecal management system should be used with caution to avoid rectal trauma. Injury is most likely to occur because of traumatic removal or rectal ulceration secondary to pressure necrosis.

Reference:

Sparks D and coll.  - Rectal trauma and associated hemorrhage with the use of the ConvaTec Flexi-Seal fecal management system: report of 3 cases. , Dis Colon Rectum. - 2010 Mar;53(3):346-9

Q: Initiation of ACE-inhibitors and ARBs (angiotensin receptor blockers), may cause approximately what level of increment in baseline creatinine - and it should be OK!?

Answer:  ACEIs and ARBs could result in a 25% "permissible" increment of baseline serum creatinine and should not become an indication to stop these families of drugs.

But, a persistent upward trend of serum creatinine while on ACEIs and ARBs should be an alert to the possibility of bilateral renal artery stenosis or renal artery stenosis in solitary functioning kidney.

 

 

Q: 44 year obese male admitted with PE is now on Heparin and transitioniing to warfarin therapy. On 9th day of treatment, patient is diagnosed with HIT (Heparin induced Thrombocytopenia) with platelet count of 72. INR is reported to be 2.9. What would be your next step beside stopping Heparin?

Answer: Stop Warfarin and  reverse Warfarin effect with Vitamin K.

There is a very high risk of warfarin necrosis in people with HIT who have low platelet counts. Warfarin, should not be used in HIT until the platelet count is at least 150 x 10^9/L. Warfarin necrosis is marked by skin gangrenes. If the patient was receiving warfarin at the time when HIT is diagnosed, the activity of warfarin should be reversed with vitamin K.

Another important decision to make is need of use of 'direct thrombin inhibitors'.

Metoprolol and CNS effect

 One less know side effect of Metoprolol (Lopressor) is CNS effect, which may be of importance in ICU. Lopressor's CNS effect is dose dependent. It has high penetration across the blood brain barrier due to its lipophilic nature. In return, it may cause sleep disturbances, vivid dreams, nightmares, depression, and vision problems.

Q: 28 year old male is transferred from floor to ICU. Patient was admitted to floor 6 days ago with acute exacerbation of Multiple Sclerosis (MS). Patient did not show much improvement after high dose of steroid treatment. What could be your next step?



Answer:  Plasmapheresis

High doses of steroids (like 1000 mg of solumedrol) remained the mainstay of therapy for acute relapses in MS. Please note oral and IV corticosteroids have a similar efficacy.

Severe attacks of MS which do not respond to steroids are recommended to be treated by plasmapheresis.



References:

1. Compston A, Coles A (October 2008). "Multiple sclerosis". Lancet 372 (9648): 1502–17.

2. Multiple sclerosis : national clinical guideline for diagnosis and management in primary and secondary care -  London: Royal College of Physicians. 2004. pp. 54–57.

 - (http://www.ncbi.nlm.nih.gov/books/NBK48919/pdf/TOC.pdf)

Q: 28 year old female, admitted to ICU with Urosepsis. Patient routine screening becomes positive for pregnancy. Patient was unaware of it. Her list of medications include methimazole for her hyperthyroidism. What would be your next step?


Answer:

If pregnancy occurs while taking methimazole, switching to propylthiouracil (PTU) is suggested, particularly in first trimester.

Both PTU and methimazole are classified as Drug Class D in pregnancy. PTU is preferred over methimazole in the first trimester of pregnancy. In the second and third trimester, methimazole is preferred.



References:

1. Bahn RS, Burch HS, Cooper DS, et al. (July 2009). The Role of Propylthiouracil in the Management of Graves' Disease in Adults: report of a meeting jointly sponsored by the American Thyroid Association and the Food and Drug Administration . Thyroid 19 (7): 673–4.

2. Abalovich M, Amino N, Barbour LA, et al. (August 2007). Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society Clinical Practice Guideline . J. Clin. Endocrinol. Metab. 92 (8 Suppl): S1–47

Q: In Tension pneumothorax, atelectasis, pulmonary edema, and pneumonia (Choose one)

A) Both static and dynamic compliance fall

B) Only dynamic compliance fall

C) Only static compliance fall

D) Both static and dynamic compliance remain unchanged

Answer is A

Formulae for compliances are as follows

Static compliance is based on plateau pressure (no air is flowing)

Cstat = Vt/(Pplat - PEEP)

Dynamic compliance is based on peak pressure (air is flowing)

Cdyn = Vt/(Ppeak - PEEP)

In tension pneumothorax, atelectasis, pulmonary edema, and pneumonia both peak and plateau pressures rise and so cause both compliances to fall.

kcentra

The FDA has approved the use of Kcentra for the urgent reversal of vitamin K antagonist anticoagulation in adults with acute major bleeding.

Unlike plasma, Kcentra can be administered rapidly because it does not require thawing, though Kcentra is made from the pooled plasma of healthy donors and is processed to minimize risk for transmitting viral and other diseases, according to the FDA press release. Kcentra (CSL Behring) is used in conjunction with the administration of vitamin K.

Study has demonstrated that Kcentra was similar to plasma in terms of stopping acute major bleeding.

Another advantage is, Kcentra is administered in a significantly lower volume than plasma at recommended doses, providing an alternative for those patients who may not tolerate the volume of plasma.

As expected, Kcentra is associated with some risk of arterial and venous thromboembolic complications.

See full prescribing info here

Q: In which organ dysfunction, Eptifibatide (Integrilin) should be used with caution?

Answer: Renal Dysfunction.

Eptifibatide (Integrilin)is an antiplatelet drug of the glycoprotein IIb/IIIa inhibitor class used in Acute Coronary Syndome and in patients undergoing Percutaneous Coronary Intervention (PCI).

Eptifibatide gets eliminated via renal route. Bolus dose remains same (180 µg/kg) but continuous infusion should be curtail back to half dose i.e. 1.0 µg/kg/min.

Patients undergoing, Percutaneous Coronary Intervention (PCI) - a second bolus dose of 180-µg/kg is given after 10 minutes of the first bolus.

Q; What is the mechanism of action, causing Hyperkalemia with Heparin therapy?

Answer: 5 to 10% of patients receiving heparin develops hyperkalemia. It is the result of heparin-induced aldosterone suppression.

Steroids Conversion Data

Glucocorticoid Approximate Equivalent dose (mg) Half-life (Biologic) hours Short-Acting Cortisone 25 8-12 Hydrocortisone 20 8-12 Intermediate-Acting Methylprednisolone 4 18-36 Prednisolone 5 18-36 Prednisone 5 18-36 Triamcinolone 4 18-36 Long-Acting Betamethasone 0.6 - 0.75 36-54 Dexamethasone 0.75 36-54

Q: What is the role of steroids in Thyroid storm?

Answer:

Glucocorticoids prevents further Thyroid Hormone secretion and peripheral conversion of T4 to T3. Interestingly, iodinated radiocontrast dyes can be use for same purpose.