Monday, December 12, 2011

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines



Thursday, December 8, 2011

Picture Diagnosis


Answer: A Swan-Ganz catheter causing infarction.

A Swan-Ganz catheter has been inserted too far into the right pulmonary artery (A). Several hours later, an infiltrate is present in this region (B) as a result of lung infarction.

Wednesday, December 7, 2011

Q: What precaution should be taken while giving IV Ketorolac in post operative patients who is also getting IV Morphine?

Answer: When giving Ketorolac intravenously through the same IV catheter as morphine, the two drugs have been known to combine and form a precipitate. Line flushing with a can push the blockage through and may cause embolism. Different ports should be use for both drugs.

Tuesday, December 6, 2011

Q: What is the conversion of IV to PO Tylenol (Acetaminophen)?


Answer: 1:1

FDA has approved the IV form of Tylenol (Omfirmev). It has the advantage of opioid sparing effect and very useful in immediate post-op period. Peak serum levels are 70% higher with IV form, with onset of analgesia at 10 minutes, peak at 1 hour and last 4-6 hours.

Sunday, December 4, 2011

Q: What is the treatment (chelating agent) to treat arsenic poisoning?


Answer: Dimercaprol

Dimercaprol sequester the arsenic away from blood proteins and are used in treating acute arsenic poisoning. The most important side effect is hypertension.

It is also used in the treatment of mercury, gold and lead, and other toxic metal poisoning. In addition, it has in the past been used for the treatment of Wilson's disease.

Saturday, December 3, 2011



Outcomes of extubation failure in medical intensive care unit patients

Interesting article published this month in CCM Journal on debate of extubation failure. Objectives of study  were to evaluate the impact of failed extubation, whether planned or unplanned, on patient outcomes and to identify a patient subset at risk for extubation failure.
It was a prospective 1-yr observational study with daily data collection from a 13 bed medical intensive care unit in a teaching hospital.

Results: Of 168 planned extubations in 340 patients, 26 (15%) failed.
  • Of these 26 patients, seven (27%) had pneumonia and 13 (50%) died after reintubation. Compared with successfully extubated patients, the patients with failed extubation were not significantly different regarding disease severity, mechanical ventilation duration, or blood gas values.
  • Age and underlying diseases were the only factors associated with extubation failure, and extubation failure occurred in 34% of patients more than 65 yrs with chronic cardiac or respiratory disease compared with only 9% of other patients (p less than .01).
  • Unplanned extubation occurred in 9% of patients, and inadequate endotracheal tube position was a risk factor.
  • Failure of both planned and unplanned extubation was specifically associated with significant rapid worsening of daily organ dysfunction scores.
Authors concluded that patients more than 65 yrs with underlying chronic cardiac or respiratory disease are at high risk for extubation failure and subsequent pneumonia and death. Contrasting with successful extubation, failed planned or unplanned extubation was followed by marked clinical deterioration, suggesting a direct and specific effect of extubation failure and reintubation on patient outcomes.


Outcomes of extubation failure in medical intensive care unit patients - Critical Care Medicine: December 2011 - Volume 39 - Issue 12 - pp 2612-2618

Tuesday, November 29, 2011

Q: What are the absolute and relative contraindications to Extracorporeal membrane oxygenation (ECMO) in Patients with ARDS?



Answer:

Absolute contraindications to ECMO include:
  • Ongoing terminal disease that will not resolve or stabilize,
  • contraindication to anticoagulation,
  • intracranial hemorrhage,
  • refusal to receive blood products
Relative contraindications to ECMO (due to historically poor survival rates): 
  • Mechanical ventilatory support for more than 10 days and high pressure mechanical ventilatory support for more than 7 days

Extracorporeal membrane oxygenation (ECMO) in Patients with ARDS - Pauline K. Park M.D., James M. Blum M.D., Lena M. Napolitano, M.D., Gail Annich, M.D., Jonathan W. Haft, M.D., and Robert H. Bartlett, M.D. - University of Michigan Health System -http://www.thoracic.org/clinical/critical-care/refractory-ards/pages/ecmo.php

Friday, November 25, 2011

Q: How do you write the drip of soda bicarbonate in preventing contrast induced nephropathy ?


A: Use 154meq/L of sodium bicarbonate (3 amps) in 1 litre of D5W.

Give 3ml/kg/hr one hr prior to the exam.

Give 1ml/kg/hr during the exam and for 6 hours after the exam.

Thursday, November 24, 2011

Wednesday, November 23, 2011

Q: What is Diabetes innocence?

Answer: Diabetes innocence also known as renal glucosuria, is a condition in which the simple sugar glucose is excreted in the urine, despite normal or low blood glucose levels. This is due to improper functioning of the renal tubules. In most affected individuals, it is asymptomatic. Condition is thought to be inherited as an autosomal recessive trait.

Tuesday, November 22, 2011

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.

Sunday, November 20, 2011

Fecal Bacteriotherapy for the Treatment of Recurrent Clostridium Difficile Infection in Adults

We found following thorough work on above topic on internet from  Julie L. Cramer as a Clinical Graduate Project Submitted to the Faculty of the School of Physician Assistant Studies, Pacific University, Hillsboro, OR for the Masters of Science Degree program.

Fecal Bacteriotherapy for the Treatment of Recurrent Clostridium Difficile Infection in Adults

Thursday, November 17, 2011

On Takotsubo Cardiomyopathy



Females are seven to nine times more likely to suffer "broken heart syndrome," when sudden or prolonged stress like an emotional breakup or death causes overwhelming heart failure or heart attack-like symptoms, the first nationwide study of this finds. Usually patients recover with no lasting damage.....

Japanese doctors first recognized this syndrome around 1990 and named it Takotsubo cardiomyopathy; tako tsubo are octopus traps that resemble the unusual pot-like shape of the stricken heart.

It happens when a big shock, even a good one like winning the lottery, triggers a rush of adrenaline and other stress hormones that cause the heart's main pumping chamber (Left ventricle).

Dr. Abhishek Deshmukh of the University of Arkansas reported study results Wednesday at an American Heart Association conference in Florida. Using a federal database with about 1,000 hospitals, Dr. Deshmukh found 6,229 cases in 2007. Only 671 involved men. After adjusting for high blood pressure, smoking and other factors that can affect heart problems, women seemed 7.5 times more likely to suffer the syndrome than men. It was three times more common in women over 55 than in younger women. And women younger than 55 were 9.5 times more likely to suffer it than men of that age....

One theory is that hormones play a role. Another is that men have more adrenaline receptors on cells in their hearts than women do, "so maybe men are able to handle stress better" and the chemical surge it releases, Deshmukh said.

About 1 percent of such cases prove fatal, the new study shows. About 10 percent of victims will have a second episode sometime in their lives. And although heart attacks happen more in winter, broken heart syndrome is more common in summer.

Full report here

Previous related pearl here


Tuesday, November 15, 2011

Angioplasty without surgical backup


"Balloon angioplasty, has become so safe that surgical backup is no longer needed when treating low-risk, simple cases." Study leader Dr. Thomas Aversano of Johns Hopkins University presented results Monday at an American Heart Association conference in Florida.

The study was the first large experiment to see if doing it without surgical backup was safe. About 4,500 were given angioplasty at hospitals that had heart surgeons available, and 14,000 others had it at facilities without one. Hospitals without heart surgeons on duty had to complete special training to make sure experienced doctors were doing the angioplasty procedures. And patients were carefully selected to avoid especially troublesome types of blockages.

Six weeks after angioplasties were done, success rates, complications and deaths did not differ between the two groups of patients. Emergency surgery was needed in only 30 cases - patients were transferred to hospitals with that capacity if the one treating them lacked it.


Full report here





Monday, November 14, 2011

Q: Abdomen can hold upto how much  of Ascitic fluid?


Answer: 25 Litre

Abdomen can hold 25 Litre of Ascitic fluid but care should be taken to avoid large volume paracentesis

Sunday, November 13, 2011

Ultrasound Guidance for Paracentesis

Friday, November 11, 2011

Q: What is "Paradoxical undressing"?


Answer: Relatively unknown phenomenon but 20-50% of hypothermia deaths are associated with paradoxical undressing. In moderate to severe hypothermia, as the person becomes disoriented, they may begin undressing their clothing, which, in turn, increases the rate of heat loss.

Rescuers usual first thought is - victims of hypothermia have been subjected to a sexual assault.

Several explanations have been proposed including cold-induced malfunction of the hypothalamus. Another explanation is that the muscles contracting peripheral blood vessels become exhausted, loss of vasomotor tone and relax, leading to a sudden surge of blood to the extremities, fooling the person into feeling overheated.


Wedin B, Vanggaard L, Hirvonen J (July 1979). ""Paradoxical undressing" in fatal hypothermia". J. Forensic Sci. 24 (3): 543–53

Thursday, November 10, 2011

Q: Which finding in CBC is highly suggestive of Adrenal crisis? (Select one)


A) Neutrophilia
B) Eosinophilia
C) Thrombocytopenia
D) Neutropenia
E) Polycythemia


Ans: Eosinophilia


Hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia may be present along with anemia and lymphocytosis, but eosinophilia with above serum chemistry findings is highly suggestive of Adrenal Crisis.

Wednesday, November 9, 2011

Q: 32 year old male preparing for London 2012 summer olympics in "Competitive Weightlifting" - complained of severe chest pain during training session which was radiating to back. What could be your first concern?



Answer: Aortic Dissection

There are increasing evidence that weight lifting related acute aortic dissection is a real phenomenon. Routine  screening echocardiography is recommended in such sports competition. Person with known aortic dilatation should be advised against weight lifting.


Weight lifting and aortic dissection: more evidence for a connection - Cardiology. 2007;107(2):103-6.

Tuesday, November 8, 2011

Q: What is the disadvantage of using steroids in Acute Pericarditis?


Answer: Steroids increases the chance of recurrent pericarditis. Colchicine is a very effective treatment. If Aspirin and NSAIDs are not sufficient, colchicine should be added to the regimen.


Corticosteroids for Recurrent PericarditisHigh Versus Low Doses: A Nonrandomized Observation - Circulation. 2008; 118: 667-671


Monday, November 7, 2011

Q: Which vitamin deficiency may cause life threatening lactic acidosis?



Answer: Thiamine (Vitamin B1) deficiency

Thiamine is part of the pyruvate-dehydrogenase (PDH) complex. Its deficiency inhibits pyruvate entry into mitochondria.

Clinical implication: It is important to add Thiamine on patients requring long term parentral nutrition (TPN)


Reference: Click to get references

1. Thiamine deficiency as a cause of life threatening lactic acidosis in total parenteral nutrition - Klin Wochenschr. 1991;69 Suppl 26:193-5.

2. Metabolic acidosis and thiamine deficiency - Mayo clinic Proceedings, March 1999 vol. 74 no. 3 259-263

3. Severe Lactic Acidosis Related to Acute Thiamine Deficiency - Journal of Parenteral and Enteral Nutrition, Vol. 15, No. 1, 105-109 (1991)

Saturday, November 5, 2011

A note on Megace (Megestrol) and Adrenal insufficiency

Megestrol can induce alterations of the pituitary-adrenal axis in some patients. It is important to consider a diagnosis of adrenal insufficiency in patients with symptoms of fatigue, hypotension, and asthenia who have been treated with megestrol. Patients who require more than 12 weeks of treatment should have their morning free cortisol levels checked at 12 weeks and biweekly thereafter.





Megestrol acetate in cachexia and anorexia - Int J Nanomedicine. 2006 December; 1(4): 411–416. Published online 2006 December

Friday, November 4, 2011

Q: Fomepizole and ethanol are both use as treatment in Ethylene Glycol toxicity. What other medicines should be considered as adjuvant therapy in Ethylene Glycol toxicity?
Answer: Pyridoxine and Thiamine Pyridoxine (Vitamin B6) and Thiamine are cofactors in ethylene glycol metabolism and may be administered parenterally. On side note, while preparing antidotes early treatment with sodium bicarbonate should be initiated essential to correct acidosis. It may require upto 500-1000 mmol of bicarbonate within the first hours, especially if antidotal therapy is delayed.

Thursday, November 3, 2011

Q: Caspofungin may cause which electrolyte abnormality?
Answer: Hypokalemia
Beside increase liver enzymes, other rare but life threatening side effects reported so far includes severe thrombophlebitis (require a greater dilution and infusion over an extended period) and severe hypokalemia, with serum potassium levels as low as 1.7 mg/dl.
Experience with Caspofungin in the Treatment of Persistent Fungemia in Neonates - Journal of Perinatology (2005) 25, 770–777; published online 13 October 2005

Wednesday, November 2, 2011

Holiday Heart Syndome

Holiday Heart Syndome was originally defined as "arrhythmias of the heart, sometimes apparent after a vacation or weekend away from work, following excessive alcohol consumption; usually transient". Same has been reported with recreational use of marijuana. The most common rhythm disorder is atrial fibrillation, which usually converts to normal sinus rhythm within 24 hours. It occurs in patients without structural heart disease and its clinical course is usually benign. Even modest alcohol intake may trigger paroxysmal atrial fibrillation.

Most patients with no evidence of structural heart disease can be discharged without further treatment once arrhythmia has stabilized with advise against the excessive use of alcohol. Patients with sustained tachyarrhythmia require treatment if the ventricular rate is excessive. Patients with structural heart disease needs further workup

Monday, October 31, 2011



 







Hematemesis

Hemoptysis


  • Dark red or brown
  • In clumps
  • Mixed with food
  • Acidic pH
  • Abdominal discomfort
  • Nausea, retching before and after episode

    • Bright red
    • Foamy, runny
    • Mixed with mucous
    • Alkaline pH
    • Chest pain,
    • warmth or gurgling over the chest
    • Persistent cough

    Sunday, October 30, 2011

    A note on Ambien and GERD association!

    Zolpidem (Ambien) dramatically increases the new event and duration of gastroesophageal reflux (GERD)., Patients with established diagnosis of GERD had reflux events measured to be significantly longer when taking zolpidem than on placebo.

    Proposed mechansim of action: This is assumed to be due to suppression of arousal during the reflux event, which would normally result in a swallowing reflex to clear gastric acid from the esophagus.

    Long term effect includes development of  esophageal cancer.


    Reference: Gagliardi GS, Shah AP, Goldstein M, Denua-Rivera S, Doghramji K, Cohen S, Dimarino AJ (September 2009). "Effect of zolpidem on the sleep arousal response to nocturnal esophageal acid exposure". Clin. Gastroenterol. Hepatol. 7 (9): 948–52.

    Saturday, October 29, 2011

    IV Benadryl as local anesthetic - interesting case report and discussion

    Reference:  J Clin Aesthetic Dermatol. 2009;2(10):37–40.

    Diphenhydramine hydrochloride (DPH) has numerous pharmacological uses in medicine. It is a first-generation, sedating, oral antihistamine. When topically applied, DPH has excellent anesthetic and antipruritic effects. DPH has also been shown to be an effective injectable drug for local anesthesia. This may be due to its three-dimensional structure, which is similar to other anesthetic drugs. The authors present a patient whose history of a severe “allergic” reaction to a “caine” local anesthetic prompted the use of 1% DPH to allow same-day surgery and avoid any possibility of a potentially life-threatening reaction."

    Read full article here

    Thursday, October 27, 2011

    Q: What is Sepsis 6?

    The sepsis six is following intervention in one hour

    1. Deliver high-flow oxygen.
    2. Take blood cultures.
    3. Administer empiric intravenous antibiotics.
    4. Measure serum lactate and send full blood count.
    5. Start intravenous fluid resuscitation.
    6. Commence accurate urine output measurement.
    Five years after the international Surviving Sepsis Campaign (SSC) care bundles were published, care standards in the management of patients with severe sepsis are achieved in fewer than one in seven patients! Application of sepsis six along with SSC resuscitation bundle showed remarkable improvement.

    Study data from 567 patients showed that 84.6% of those receiving the sepsis six (n=220) achieved the resuscitation bundle compared with only 5.8% of others!

    Tuesday, October 25, 2011

    Q: What is Talcosis?




    A: Talcosis refers to emboli of talc, starch, and cellulose, and are seen almost invariably in chronic intravenous drug users. When injected, talc produces a giant cell granulomatosis of the pulmonary arterioles, thats why also known as Talc granulomatosis.


    Some of the oral medications such as amphetamines, methylphenidate, hydromorphone, and dextropropoxyphene are ground by drug users, mixed in liquid, and injected IV. Talc (as magnesium trisilicate), starch, and cellulose, are used as fillers in these drug and causes Talcosis. Talc and other particles reach small pulmonary arterioles and capillaries where a foreign body giant cell granulomatous reaction occurs. Chronic use causes Pulmonary hypertension and right heart failure.

    Monday, October 24, 2011

    Q: Propofol should be given with caution in which common allergy?


    A: Egg allergy

    Originally propofol was launched 32 years ago but was withdrawn from the market due to reports of anaphylactic reactions. It was re-launched in 1986 by AstraZeneca with the brand name Diprivan with preparation containing 10% soybean oil and 1.2% purified egg lecithin, a phosphatidylcholine found in egg yolk.

    A history of egg allergy does not necessarily contraindicate the use of propofol. Most egg allergies are related to a reaction to the egg white (albumin) and not to the egg yolk (lecithin). This could explain why 'propofol' is only very rarely a problem. However, a patient who has an egg allergy should be carefully questioned.

    Sunday, October 23, 2011

    Q: 32 year old female with 12 weeks of pregnancy presented with right lower quadrant pain with rebound tenderness. There is a huge clinical suspicion of Acute appendicitis. What should be the management approach beside starting full coverage antibiotics?



    Answer:  According to the 2010 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline, laparoscopic appendectomy is suitable in suspected appendicitis in pregnant women. Overall, The SAGES guideline states that the laparoscopic approach should be preferred in women of childbearing age with presumed appendicitis.

    Diagnostic laparoscopy can be performed only to confirm the diagnosis of appendicitis. If findings are positive, definitive surgical treatment should be performed. Perforation may increase the fetal and maternal morbidity. Therefore, aggressive management of the appendix is warranted in pregnant patients.

    Advantages of laparoscopic appendectomy include increased cosmetic satisfaction, a decrease in the postoperative wound-infection rate, shortens hospital stay and convalescent period compared with open appendectomy. Disadvantages of laparoscopic appendectomy are increased cost and an operating time approximately 20 minutes longer than that of an open appendectomy.

    Saturday, October 22, 2011

    Q: 62 year old male with history of Acute Intermittent Porphyria (AIP) presented to ER with chest pain. While awaiting to go to cardiac cath. patient went  into ventricular fibrillation. Which one antiarrhythmic medicine is contra-indicated or at least should be given with extreme caution?



    Answer: Lidocaine

    Contraindications for the use of lidocaine include history of Porphyria, especially acute porphyria. Lidocaine is known to be porphyrogenic.

    Friday, October 21, 2011

    Q: Ventricular fibrillation caused by Digitalis toxicity is best responsive to(Choose one)?

    A) cardioversion
    B) Amiodarone
    C) Lidocaine
    D) Digibind


    Answer: Lidocaine

    Interestingly, electrical cardioversion is generally not indicated in ventricular fibrillation caused by digitalis toxicity. On the contrary it is found to increase the dysrhythmia in digitalis toxicity. Similarly, is the case with amiodarone. Lidocaine is a better choice in known ventricular fibrillation caused by digitalis toxicity.

    Digibind is an antidote for Digitalis but not an antiarrhythmic agent.

    Thursday, October 20, 2011

    Q: 52 year old male with ESRD presented to hospital with Respiratory failure and hypotension. Patient was intubated in field. In ER patient found to have complete heart block. ER physician emergently inserted intravenous pacemaker which stabalizes hemodynamics. On clinical exam, patient is unresponsive and have lost of reflexes. Labs showed abnormalities but most pronounced was Magnesium level of 17.0 mEq/L. You gave intravenous calcium. What should be the next step?



    Answer: Emergent Dialysis

    Magnesium has fairly good therapeutic margin but hypermagnesemia is a risk in some patients particularly Renal failure. Mild hypermagnesemia may cause weakness, nausea, vomiting and mild hypotension but progressively it can become life threatening. Following is the ballpark clinical signs/symptoms depending on magnesium level.

    • 4.0 mEq/L hyporeflexia
    • 5.0 mEq/L Prolonged atrioventricular conduction
    • 7.0-10.0 mEq/L - loss of patellar reflex
    • 10.0-13.0 mEq/L - respiratory depression and various heart block
    • Above 13.0 mEq/L - cardiac arrest/Asystole.
    Mainstay of treatment is withdrawing magnesium supplementation, Intravenous calcium, diuretics and in severe cases dialysis.

    Wednesday, October 19, 2011

    Q: Which anti-seizure medicine could be an adjuvant treatment in Central DI (Diabetes Insipidus)?


    Answer: Carbamazepine

    Primary treatment for Central DI is desmopressin. Carbamazepine, an anti-convulsive medication, has also shown some postive effect in this type of DI. Though the data is old but it is still a valid option, if required 1. It can also be used in gestational DI.


    Related posts:

    Hydrochlorothiazide in Diabetes Insipidus

    Gestational diabetes insipidus





    1. Wales JK.,  Treatment of diabetes insipidus with carbamazepine. Lancet. 1975 Nov 15;2(7942):948-51.

    Tuesday, October 18, 2011

    A quote from history on discovery of cryoprecipitate

    Cryoprecipitated is the cold-insoluble portion of plasma that precipitates when FFP has been thawed between 1-6C. It is extremely rich in fibrinogen and factor VIII. It also contains von Willebrand factor (vWF) and factor XIII.

    "I made a mistake in an experiment, and instead of putting frozen plasma back in the freezer at the end of the day's experiment, I instead stuck it in the refrigerator. When I came in the next morning, there was all this junk in the bottom of the tube which I spun out, and I used the plasma for my experiment. My experiment didn't work because there was no Factor VIII in it. And I went back and fished the junk out of the trash and assayed the junk and got these outrageously high values for Factor VIII in the junk, and neither Charlie nor I believed it, and so it was one of those things. And sure enough, about a year later Judith Graham Pool discovered cryoprecipitate". 1


    1. Reference: Resnik, Susan (1999). Blood Saga: Hemophilia, AIDS, and the Survival of a Community. Berkeley: University of California Press. pp. 40–41

    Monday, October 17, 2011

    On Pradaxa (dabigatran)


    Dabigatran (Pradaxa) is an direct thrombin inhibitors oral anticoagulant. It is an alternative to warfarin. It has huge advantage as it does not require frequent blood tests for INR monitoring. Half life of Dabigatran is 12-17 hours. In event of bleeding, f extreme aggressive treatment is needed, Dabigatran is dialyzable.

    Sunday, October 16, 2011

    Early Tracheostomy in Trauma patients?

    Background:  The influence of tracheostomy timing on outcome after severe head injury remains controversial.

    Methods: The investigation was based on data prospectively collected by the Pennsylvania Trauma Society Foundation statewide trauma registry from January 1990 until December 2005.

    Results: 3,104 patients met criteria for inclusion in the study (GCS less than/= 8 and tracheostomy). Early Tracheostomy Group (ETG) patients, defined as tracheostomy performed during hospital days 1–7, were more likely to be functionally independent at discharge (adjusted odds ratio (OR) 1.45, 95% confidence interval (CI), 1.16–1.82, P = 0.001) and have a shorter length of stay (adjusted OR 0.23, 95% CI, 0.20–0.28, P less than 0.0001). However, Late Tracheostomy Group (LTG) patients, defined as tracheostomy performed  more than 7 days after admission, were approximately twice as likely to be discharged alive (adjusted OR 2.12, 95% CI, 1.60–2.82, P less than 0.0001). Using a Composite Outcome Scale, which combined these three measures, there was a non-significant trend toward a higher likelihood of a poor outcome in LTG patients. When this analysis was repeated using only those patients in relatively good condition on admission, LTG patients were found to be approximately 50% less likely to have a good outcome (adjusted OR 0.46, 95% CI, 0.28–0.73, P = 0.001) when compared to ETG patients.

    Conclusions: These results indicate a complex relationship between tracheostomy timing and outcome, but suggest that a strategy of early tracheostomy, particularly when performed on patients with a reasonable chance of survival, results in a better overall clinical outcome than when the tracheostomy is performed in a delayed manner.

    Impact of Tracheostomy Timing on Outcome After Severe Head Injury  - Neurocritical Care, DOI: 10.1007/s12028-011-9615-7 (online first)

    Saturday, October 15, 2011

    Q: Give 5 causes of "Nontraumatic" Chylothorax?

    Answer: L-CATS

    Lymphoma
    Cirrhosis,
    Amyloidosis
    Tuberculosis,
    Sarcoidosis

    Thursday, October 13, 2011

    Role of rTPA in Frostbite!



    Thrombolytic therapy will decrease the incidence of amputation when administered within 24 hours of exposure. One study published in 2007 from University of Utah, Salt Lake City 1. 32 patients with (frostbite) digital involvement (hands, 19%; feet, 62%; both, 19%) were identified. Seven patients received tPA, 6 within 24 hours of injury. The incidence of digital amputation in patients who did not receive tPA was 41%. In those patients who received tPA within 24 hours of injury, the incidence of amputation was reduced to 10%. Authors concluded that Tissue plasminogen activator improved tissue perfusion and reduced amputations when administered within 24 hours of injury.


    1. Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy - Arch Surg. 2007;142:546-553.

    Wednesday, October 12, 2011

    On Therapeutic Hypercapnia (HCA = Hypercapnic Acidosis)
    Interesting line from the following reference article - A very informative read
    "In experimental polymicrobial sepsis in female sheep, HCA improved tissue oxygenation and reduced lung edema formation more than dobutamine administration"1
    Bench-to-bedside review: Carbon dioxide - Gerard Curley, John G Laffey and Brian P Kavanagh - Critical Care 2010, 14:220 (click to read the article)
    1. Wang Z, Su F, Bruhn A, Yang X, Vincent JL: Acute hypercapnia improves indices of tissue oxygenation more than dobutamine in septic shock.  - Am J Respir Crit Care Med 2008, 177:178-183

    Tuesday, October 11, 2011

    Picture Diagnosis



    Answer: Moyamoya


    Moyamoya disease is a progressive cerebrovascular disease in certain arteries in the brain are constricted causing stroke. The name “moyamoya” means “puff of smoke” in Japanese. See the appearance above of Angiogram.

    Monday, October 10, 2011

    Q: Which lab is most reliable in following the effect of plasmapheresis in resolution of TTP (Thrombotic thrombocytopenic purpura)?


    Ans: LDH

    Declining LDH level is a pretty good indicator that plasma exchange is working to treat TTP.

    Sunday, October 9, 2011

    Q: What is the recommended dose of Solu-Medrol in DIFFUSE ALVEOLAR HEMORRHAGE?


    Answer: 500 mg every 6 hours

    Corticosteroids and immunosuppressive agents are the gold standard for this disease. Factor VII has recently shown promising results.

    Recommended dose of intravenous methylprednisolone (Solu-Medrol) is up to 500 mg every 6 hours for 5 days, followed by a taper to a maintenance dose. Though higher and lower doses have been described too.

    Also, Plasmapheresis and intravenous immunoglobulin therapy should be considered too in cases related to vasculitis.

    Saturday, October 8, 2011

    Airway evaluation - LEMON Rule

    Friday, October 7, 2011

    Q; Is Digoxin a diuretic?


    A: Yes it has direct diuretic property! Digoxin increases diuresis by at least 4 mechanisms
    • Direct vasodilation
    • Increased CO improves renal hemodynamics
    • Inhibition of tubular reabsorption of sodium, of renal Na+ -K+-ATPase, and of concentrating and diluting ability
    • Increased secretion of atrial natriuretic peptide
    Reference:

    1. Rahimtoola SH, Tak T. The use of digitalis in heart failure. Curr Probl Cardiol. 1996; 21: 781–756

    Thursday, October 6, 2011

    Q: What is postictal bliss?


    Answer: Postictal bliss (PB) is a highly blissful feeling associated with amnesia following seizures.

    Symptoms of his own post-ictal bliss is best described by famous Russian author Fyodor Dostoevsky (1821-1881) as: "For several instants I experience a happiness that is impossible in an ordinary state, and of which other people have no conception.  I feel full harmony in myself and in the whole world, and the feeling is so strong and sweet that for a few seconds of such bliss one could give up ten years of life, perhaps all of life. I felt that heaven descended to earth and swallowed me.  I really attained god and was imbued with him.  All of you healthy people don't even suspect  what happiness is , that happiness that we epileptics experience for a second before an attack."1


    1. From charge.org.uk

    Wednesday, October 5, 2011

    Half dose Succinylcholine?


    BACKGROUND: The authors reappraised the conventional wisdom that the intubating dose of succinylcholine must be 1.0 mg/kg and attempted to define the lower range of succinylcholine doses that provide acceptable intubation conditions in 95% of patients within 60 s.

    METHODS:  This prospective, randomized, double-blind study involved 200 patients. Anesthesia was induced with 2 mug/kg fentanyl and 2 mg/kg propofol. After loss of consciousness, patients were randomly allocated to receive 0.3, 0.5, or 1.0 mg/kg succinylcholine or saline (control group). Tracheal intubation was performed 60 s later. A blinded investigator performed all laryngoscopies and also graded intubating conditions.

    RESULTS: Intubating conditions were acceptable (excellent plus good grade combined) in 30%, 92%, 94%, and 98% of patients after 0.0, 0.3, 0.5, and 1.0 mg/kg succinylcholine, respectively. The incidence of acceptable intubating conditions was significantly greater (P  less than 0.05) in patients receiving succinylcholine compared with those in the control group but was not different among the different succinylcholine dose groups. The calculated doses of succinylcholine (and their 95% confidence intervals) that were required to achieve acceptable intubating conditions in 90% and 95% of patients at 60 s were 0.24 (0.19-0.31) mg/kg and 0.56 (0.43-0.73) mg/kg, respectively.

    CONCLUSIONS:  The use of 1.0 mg/kg of succinylcholine may be excessive if the goal is to achieve acceptable intubating conditions within 60 s. Comparable intubating conditions were achieved after 0.3, 0.5, or 1.0 mg/kg succinylcholine. In a rapid-sequence induction, 95% of patients with normal airway anatomy anesthetized with 2 mug/kg fentanyl and 2 mg/kg propofol should have acceptable intubating conditions at 60 s after 0.56 mg/kg succinylcholine. Reducing the dose of succinylcholine should allow a more rapid return of spontaneous respiration and airway reflexes.


    Optimal dose of succinylcholine revisited., Anesthesiology. 2003 Nov;99(5):1045-9.

    Tuesday, October 4, 2011

    Q: After inserting central venous catheter, you have hard time (resistance) to flush the distal lumen; Also you have poor venous backflow from the distal lumen; What should be your first thought?


    Answer: Lost guide wire


    The first thing before you cannot find guide wire or find it on CXR, would be a resistance to injection via the distal lumen and  poor venous backflow from the distal lumen.

    Lost guidewire during CVC insertion is a very under-appreciated complication and happens more frequently than thought.

    Loss of the guide wire: mishap or blunder? - Br. J. Anaesth. (2002) 88 (1): 144-146.

    Monday, October 3, 2011

    Q: Half life of Cisatracurium (Nimbex) is prolong in?


    A) Hepatic failure
    B) Renal failure
    C) Geriatric patients
    D) Hypothermia
    E) Both C and D




    Answer: E (Both C and D)


    Half life of Nimbex is approximately 22 to 29 minutes, following administration of a single intravenous dose. The half-life is not substantially affected by the duration of administration (approximately 26 ± 11 minutes in ICU patients receiving cisatracurium via intravenous infusion), type of anesthesia, or hepatic or renal function impairment, but is slightly longer in geriatric patients than in younger adults. In individuals undergoing induced hypothermia (body temperature of 25 to 28 °C), the half-life is prolonged as compared with the half-life during normothermia.

    Sunday, October 2, 2011

    Mnemonic to remember the causes of the oxygen dissociation curve to Right!
    CADET 
    • CO2,
    • Acid,
    • 2,3-DPG,
    • Exercise and
    • Temperature