Q; Which supplement intake may help in preventing Coronary artery vasospasm (Prinzmetal Angina)?

Answer: Magnesium

Magnesium deficiency heighten sensitivity to acetylcholine- and hyperventilation-induced coronary artery spasm. Magnesium supplementation may help as a useful therapy.

Q; Each 15 mL unit of Cryoprecipitate typically contains how much of fibrinogen? 

Answer: Each 15 mL unit of Cryoprecipitate typically contains 250 mg of fibrinogen. 

It also contains 100 IU of factor VIII, von Willebrand factor (vWF) and factor XIII.

FDA standards requires that the product must have an average of 150 mg or more of fibrinogen and 80 IU of factor VIII.

PICCS?

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients 

Introduction

In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters.

Method

We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance.

Results

We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications during management were not clinically significant. There was one episode of symptomatic thrombosis during the stay in ICU and one episode after transfer of the patient in a non-intensive ward.

Conclusions
Power injectable PICCs have many advantages in the ICU: they can be used as multi-purpose central lines for any type of infusion including high flow infusion, for hemodynamic monitoring, and for high-pressure injection of contrast media during radiological procedures. Their insertion is successful in 100% of cases and is not associated with significant risks, even in patients with coagulation disorders. Their maintenance is associated with an extremely low rate of infective and non-infective complications.

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients - Critical Care 2012, 16:R21, Published: 4 February 2012

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

Click Here

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.

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

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

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.

Happy Thanksgiving

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.

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.

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

The Impella cardiac device

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

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

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

Ultrasound Guidance for Paracentesis

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.

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 Published oline before print July 21, 2008

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)

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

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.

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

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

 

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

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.

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

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!

The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study - Emerg Med J 2011;28:507-512

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.

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.

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.

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.