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