Monday June 30, 2008
Do all patients need Foley Catheter in ICU?

See this interesting work: "The Effects of Criteria-Based Foley Catheter Guidelines in an ICU", from Morristown Memorial Hospital, NJ, USA.

Background: The prolonged use of indwelling urinary catheters in the hospital-setting can lead to many complications. In an effort to decrease Foley catheter related urinary tract infections (UTI's), our critical care unit (22-bed mixed medical/surgical/trauma adult ICU) focused on reducing the number of foley catheter device days in the critical care setting.

Measurement : The measurement metric utilized was Foley catheter device days (DD). A device day began when a patient was admitted to the intensive care unit (ICU) with an indwelling Foley catheter intact or one was placed in the ICU. A DD ended when the patient was discharged from the ICU with the Foley catheter intact or the Foley catheter was discontinued in the ICU.

Strategy: Nurse-driven surveillance of Criteria-Based Foley Catheter Guidelines (CFCG) was imlemented and an intense educational program was instituted over a 2-week period. A daily checklist for every patient with an indwelling Foley catheter was completed by the nurses. The checklist functioned as a trigger to determine the necessity of the catheter. If the patient did not fall into one of the criteria categories, the nurse contacted the physician to request an order for discontinuation of the catheter.

Results:

• The pre-intervention UTI infection rate for units was 6.4 (UTI's per 1000 device days). Post-intervention the UTI rates decreased by almost 70% to 1.9 (UTI's per 1000 device days.
• Pre-intervention only 6% of the Foley catheters were removed before the patient was transferred out of the ICU and post-intervention 20% of the Foley catheters were removed prior to ICU transfer.
• When a patient leaves the ICU without the Foley catheter, chances are the Foley catheter will not be reinserted on the general hospital floor and the potential to decrease hospital-wide Foley catheter related UTI's is very probable as well.

Conclusion: Although a large percentage of patients did meet the criteria for continued Foley catheter use, there was a subcategory that, prior to intervention, had a continued use of Foley catheters when they weren't warranted.


Previous related pearl: Urinary Catheter related UTIs in ICU


Reference: click to get abstract

1. The Effects of Criteria-Based Foley Catheter Guidelines in an ICU - presented at Sigma Theta Tau International, 38th Biennial Convention - Clinical Sessions, November 12-13, 2005Indianapolis, IN

Sunday June 29, 2008
Repairing a PFO (Patent Foramen Ovale)

Repairing a PFO once required open heart surgery, but via new devices and techniques a corrective procedure can be performed in the cardiac catheterization lab to seal the hole without surgery. A closure device is advanced through the catheter via femoral vein and inserted into the gap between the two heart chambers. Once in position, the ends of the device are opened toward each other, sealing the hole from either side.

Closing the PFO facilitates the heart lining to grow over it and do in-growth of tissue. Clinical data show that tissue in-growth is usually complete in about six months.While open heart surgery to close a PFO is also an option but closing via catheter is easy, safe and cost-efective.


First, one half of the seal device (trade name CardioSEAL) is opened in the left atrium.

Second, the other half of the seal device is opened on the right atrial side of the heart.

Saturday June 28, 2008


Q: What is called 'poor man's swan" ?

A: Urine output

Related previous pearl: How to write order for IVF bolus !!

(based on review article, "Fluid challenge revisited" from Vincent, Jean-Louis MD, PhD, FCCM - Critical Care Medicine. 34(5):1333-1337, May 2006)


Here is feedback on our pearl from yesterday on Botulism : "Botulism is interesting, we had two deaths locally last year, one was anesthesiologist. Read here "

Surindra J. Singh, M.D., Chief, Emergency Medicine VAMC, Salem, VA 24153, (Dr. Singh is also co-editor of this website)

Thursday June 26, 2008


Q; What is Catamenial pneumothorax?

A; Catamenial pneumothorax is a rare condition characterized by a pneumothorax coinciding with the onset of menses. It is almost always right-sided, and generally occurs in women in their thirties and forties.

Exact etiology is unknown but endometriosis is suspected with possible diaphragmatic fenestrations. Damage to endometriosis with air passes into the pleural space through these holes. It may accompany with hemothorax if blood from endometriosis enters pleural cavity.

Acute treatment is drainage of pneumo (air), Chest tube, Pleurodesis in recurrent cases and surgical closure of diaphragmatic fenestrations if required.
Referral should be made to Gyn. service for hormonal and related management of endometriosis.

See case report with discussion Catamenial pneumothorax - Mayo Clin Proc. • May 2005;80(5):677-680 - pdf file

Wednesday June 25, 2008
Is Acute Myocardial Infarction (AMI) and Community Acquired Pneumonia interrelated ?

A recently published retrospective observational study by Julio Ramirez shed some light on it.

Data for 500 consecutive patients admitted to hospital with community acquired pneumonia (CAP) was performed. Clinical failure was defined as the development of respiratory failure or shock. AMI was diagnosed on the basis of abnormal troponin levels and EKG findings. At hospital admission, AMI was present in 13 (15%) of 86 patients with severe CAP. During hospitalization, AMI was present in 13 (20%) of 65 patients who experienced clinical failures. Following risk adjustment, significant associations were discovered between AMI and the pneumonia severity index score and between AMI and clinical failure (p less than 0.05).

Conclusion: A combined diagnosis of CAP and AMI is common among hospitalized patients with severe CAP. In CAP patients whose clinical course is complicated by clinical failure, AMI should be considered as a possible etiology.

Editor’s comment: This study raises an important issue which we commonly observe in our ICU patients. This study suggests a need for prospective well designed trial.


Reference: click to get abstract

Ramirez J, Alibert S, Mirsaeidi M, Peyrani P, et al. Acute Myocardial Infarction in Hospitalized Patients with Community-Acquired Pneumonia. Clinical Infectious Diseases 2008;47:182–187

Tuesday June 24, 2008
Verification of Endotracheal Tube Placement via Esophageal detection devices

Esophageal detection devices are easily used, inexpensive, and have generally demonstrated good utility in detecting esophageal intubations. It is available as either a self-inflating bulb or a syringe device. The EDD relies on the anatomic differences between the trachea and the esophagus. Application of negative pressure, either through aspiration of the syringe plunger or the bulb, leads to the collapse of the esophagus around the end of the endotracheal tube. This is due to the fibromuscular structure of the esophagus, whereas the trachea is very rigid and remains open due to its cartilaginous rings. In an improperly placed endotracheal tube, the bulb will be unable to fully inflate, or the syringe plunger will not be able to completely (or nearly completely) pull back from the body of the syringe.

Advantages:
inexpensive,
portable,
easy to use,
not dependent on environmental conditions (such as good lighting etc).
Unlike the ETCO 2 detector, it works just as well and is just as accurate if the patient is in cardiac arrest

Disadvantages:
false negative can result in obese patients,
false positive can result with a large amount of air in the esophagus,
false negative can result with a large copious pulmonary secretions.
It does not provide an ongoing assessment of continued proper tube placement.

Monday June 23, 2008

Scenario; You have been called to psychiatric floor to intubate a patient, who was found unconscious on floor. You felt thready pulse. You successfully intubated the patient and confirmed endotracheal tube placement by listening to bilateral chest and bright color change on CO2 detector. While RT (respiratory therapist) was applying ETT-holder you noticed thar Color change on CO2 detector stopped and remained purple. What is your next step?


A) Change CO2 detector and watch for color change.

B) You are probably in GI tract - so remove ET tube and reintubate.

C) Check for pulse and if no pulse is palpable, start CPR

D) Hook ET-tube to ventilator and watch for exhaled tidal volume

E) Ask nurse to check blood pressure with cuff

Answer: Check for pulse and if no pulse is palpable, start CPR

Always remember, CO2 detector may not change color if their is cardio-respiratory collapse. The visible color change of carbon dioxide detection devices depends on a minimum concentration of the gas reaching the detector. Pulmonary gas exchange (blood flow and delivery of CO2 to the lungs is low) may be inadequate to deliver the required concentration of carbon dioxide to the detector device in cardio-respiratory collapse.

False-negative readings (failure to detect CO2 despite tube placement in the trachea) have also been reported in association with pulmonary embolus because pulmonary blood flow and carbon dioxide delivery to the lungs are reduced. Also note, elimination and detection of CO2 can be drastically reduced following an intravenous bolus of epinephrine or with severe airway obstruction (eg, status asthmaticus) and pulmonary edema.

Another interesting scenario is - CO2 detector may display a constant color rather than breath-to-breath color change. This happens, if the detector is contaminated with gastric contents or acidic drugs (eg, endotracheally administered epinephrine).

In case, patient appears hemodynamically intact but if CO2 color change is not detected, a second method should be used to confirm endotracheal tube placement, such as direct visualization or the esophageal detector device.

Reference:
[Advanced Cardiovascular Life Support] Part 7.1: Adjuncts for Airway Control and Ventilation Circulation: Volume 112(24) Supplement13 December 2005pp IV-51-IV-57

Sunday June 22, 2008
Tip to identify prolong QT interval on EKG

The QT interval is measured from the onset of the Q wave until the termination of the T wave. Various drugs can cause QT Prolongation like antiarrhythmic drugs, tricyclic antidepressants or electrolytes abnormalities such as hypokalemia, hypocalcemia or hypomagnesemia. Some clinical conditions like stroke, seizure, coma, intracerebral or brainstem bleeding, bundle branch block, infarction, and ischemia may also cause QT prolongation.

One easy way to determine QT prolongation on EKG is to find - if it clearly measures more than half the R-R interval (see diagram below)

Note: This tip may not be reliable if heart rate is more than 100 beats/minute

Saturday June 21, 2008

Q; After successful completion of Transjugular Intrahepatic Porto-systemic Shunt (TIPS) for variceal bleeding - hepatic encephalopathy __________ ?

A) tends to get better
B) tends to get worse
C) It has nothing to do with TIPS


Answer is B

Hepatic encephalopathy tends to get worse after successful completion of TIPS as due to shunting, blood flow to the liver is reduced, which might result in increase toxic substances reaching the brain without being metabolized first by the liver. It can be treated medically such as diet, lactulose or by narrowing of the shunt by insertion of a reducing stent.


References: click to get abstract/article

1. Treatment for hepatic encephalopathy: tips from TIPS? - Journal of Hepatology 42 (2005) 626–628
2. Hepatic encephalopathy after TIPS-- retrospective study - Vnitr Lek. 2002 May;48(5):390-5
3. TIPS for Prevention of Recurrent Bleeding in Patients with Cirrhosis: Meta-analysis of Randomized Clinical Trials - Radiology. 1999;212:411-421

Friday June 20, 2008
CORRECTING ANION-GAP FOR ALBUMIN

Hypoalbuminaemia is common in critically ill patients with shock. Fail to consider this component, may associated with a low or normal observed anion gap despite clinically significant amounts of lactate and other occult tissue anions. Ideally, albumin corrected anion gap should be used.

Correcting the ANION-GAP for changes in albumin would be a better predictor of mortality than an uncorrected ANION-GAP.

The measured ANION-GAP is corrected for changes (usually decreases) in albumin by using following simple formula


adjusted AG = observed AG + 0.25 x ([normal albumin]-[observed albumin])

AG = Anion Gap



Reference: click to get abstract

Anion gap and hypoalbuminemia. Critical Care Medicine. 26(11):1807-1810, November 1998

Thursday June 19, 2008

Q; You have been approached by a resident, who accidentally stuck himself while doing central line in a known Hepatitis C patient. He wants to know, what are his chances of getting Hepatitis C?


A; about 2%

After needle stick or sharps exposure to HCV positive blood, about 2 healthcare workers out of 100 will get infected with HCV.

Immediately wash the site well with water(squeezing or milking the site is of little benefit). Interferon or immune globulin should not be used for postexposure prophylaxis. Activate hospital policy for post occupational exposure. Following steps should be taken:

1. Baseline testing of patient for anti-HCV.
2. For the person exposed to an HCV-positive source, baseline and follow-up testing including­ baseline testing for anti-HCV and ALT activity; and­ follow-up testing for anti-HCV (e.g., at 4-6 months) and ALT activity. (If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4-6 weeks.)
3. Confirmation by supplemental anti-HCV testing of all anti-HCV results reported as positive by enzyme immunoassay.

Wednesday June 18, 2008
Another use of Flolan !


Flolan (Epoprostenol sodium) is a common IV infusion used for pulmonary hypertension. Another less known use of Flolan is in Cardiac bypass surgery for patients already known (pre-operatively) to have HIT type II (type II heparin-induced thrombocytopenia ).

Epoprostenol sodium, a prostaglandin (PGI2), vasodilator, used in patients with pulmonary hypertension, is also a potent platelet inhibitor. Epoprostenol sodium is successfully used in association with heparin in patients with type II HIT requiring anticoagulation for hemodialysis, or vascular or cardiac surgery.

Overall results seems effective and safe with acceptable postoperative blood losses. On cautious side, epoprostenol sodium may induce hypotension and may require use of a vasoconstrictor like norepinephrine.


Protocol: One recommended protocol is continuous infusion of epoprostenol sodium started after induction of anesthesia at a rate of 5 ng/kg/min, infusion rate increased by stages of 5 µg/kg every 5 minutes, and when the infusion rate reached 30 ng/kg/min, a bolus of 300 U/kg of heparin was intravenously administered. When required, norepinephrine (0.05 to 0.1 µg/kg/min) was infused to maintain mean arterial pressure greater than 75 mmHg. CPB was started when ACT exceeded 480 seconds. After emergence from CPB, heparin was reversed with protamine (3 mg/kg). Fifteen minutes after protamine reversal, epoprostenol sodium infusion was reduced by stages of 5 ng/kg until stopped.



Reference : click to get abstract

1.Cardiac surgery with cardiopulmonary bypass in patients with type II heparin-induced thrombocytopenia Ann Thorac Surg 2001;71:678-683

Tuesday June 17, 2008
accidental succinylcholine in pseudocholinesterase deficiency


Q: You have been called emergently to intubate patient with impending respiratory failure. You successfully intubate patient with rapid sequence using succinylcholine. While writing procedure note, you noticed patient has documented pseudocholinesterase deficiency. Now what is your other option beside waiting as respiratory muscle paralysis spontaneously resolves?



A: Use of succinylcholine should better be avoided in patients with pseudocholinesterase deficiency. But in situations, where reversal is intended, there are 3 options

1. Waiting - Recovery eventually occurs as a result of passive diffusion of succinylcholine away from the neuromuscular junction.
2. Transfusion of fresh frozen plasma. FFP can augment the patient's endogenous plasma pseudocholinesterase activity.
3. Administration of cholinesterase inhibitors, such as neostigmine, is controversial for reversing succinylcholine-related apnea in patients who are pseudocholinesterase deficient. The effects may be transient, possibly followed by intensified neuromuscular blockade.

Monday June 16, 2008
Photo Quiz

Hint: Patient presents with progressive abdominal distension





Answer: Sister Mary Joseph Nodule

The finding of a hard subcutaneous nodule at the umbilicus secondary to metastatic carcinoma is referred to as Sister Mary Joseph's Nodule. This is a sign of metastatic intra-abdominal malignancy and signals advanced disease with a poor prognosis. The most common malignancies associated with a Sister Mary Joseph Nodule are adenocarcinoma of the stomach, colon, pancreas and ovary.

In critical Care, Umblicus should be examined in patients with Ascites. This is an easy and quick clinical sign.



Reference:

Powell FC, Cooper AJ, Massa MC, Goellner JR, Daniel WP: Sister Joseph's nodule: a clinical and histologic study. J Am Acad Derm 1984, 10:610-615

Dubreuil A, Dompmartin A, Barjot P, Louvet S, Leroy D: Umbilical metastasis or Sister Mary Joseph's nodule.Int J Dermatol 1998, 37:70-73.

Sunday June 15, 2008
Severe Tissue Injury with IV Promethazine (FDA warning)

Saturday June 14, 2008
C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge


Purpose: To assess the ability of potential clinical predictors and inflammatory markers to predict in-hospital mortality after patient discharge from the intensive care unit.

Setting and participants: 1272 patients who survived their index admission to a 22-bed multidisciplinary ICU of a university hospital.

Results: There were 29 unexpected in-hospital deaths after ICU discharge (2.3%). C-reactive protein (CRP) concentrations within 24 hours of ICU discharge were available for 14 of these 29 patients and 22 concurrent control patients.

• CRP concentration at ICU discharge was associated with subsequent mortality (mean CRP concentrations: cases, 204 mg/L v controls, 63mg/L; P = 0.001).
• CRP concentration remained significantly associated with post-ICU mortality after adjustment with other potential predictors of mortality.

The destination and timing of ICU discharge, SOFA (Sequential Organ Failure Assessment) score, white cell count and fibrinogen concentration at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge.


Conclusions: A high CRP concentration at ICU discharge is an independent predictor of subsequent in-hospital mortality.


Reference: click to get abstract

C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a nested case–control study - Crit Care Resusc 2007; 9: 19–25


Above pearl is contributed by

Anthony Halat M.D.
ICU Physician
The Methodist Hospital,
Texas Medical Center, Houston, Texas

Friday June 13, 2008


Q: You have been called to ED to evaluate 46 year old male with probable exacerbation of Myasthenia gravis (MG). Patient is still protecting his airway. Though you arrange intubation at bedside, you decide to give Tensilon (edrophonium) challenge test. As soon as you administer 3 mg of edrophonium, patient develops increase salivation, bronchopulmonary secretions, became diaphoretic, and smelled to have flatus (symptoms of SLUDGE syndrome *). You required to intubate the patient. What's your diagnosis?


Answer: Cholinergic crisis

One of the confusing factors in treating patients with Myasthenia gravis is that insufficient medication (ie, myasthenic crisis) or excessive medication (ie, cholinergic crisis) ?

In patient with myasthenic crisis, muscular strength will improve with edrophonium, otherwise there will be no response or weakness will increase along with unmasking symptoms of cholinergic crisis (SLUDGE syndrome *).

Cholinergic crisis is seen in patients with myasthenia gravis who take too high a dose of their cholinergic treatment medications. As a result of cholinergic crisis, muscles stop responding to the bombardment of ACh, leading to flaccid paralysis, respiratory failure, increased sweating, salivation, bronchial secretions and miosis.

Tensilon (edrophonium) challenge test is good way of differentiating between myasthenic crisis (insufficient medication) and cholinergic crisis (excessive medication).



SLUDGE = Salivation, Lacrimation, Urinary Incontinence, Diarrhea, GI hypermotility, Emesis


Related previous Pearls:

Iodinated IV contrast and myasthenia gravis

Ice test - Poor man's test for Myasthenia Gravis

Thursday June 12, 2008

Before today's pearl, here is one comment on our pearl Evidence based medicine: Is it like changing wind (Commentary on recently published article in Ann Intern Med regarding intensivists feasibility): "I had the honor of doing a podcast interview with Dr. Levy about this paper. It should hopefully be posted soon at www.sccm.org/podcast. I agree completely with your evaluation of this article. It could be easily misinterpreted by the media".

Richard H. Savel, MD, FCCM (Medical co-director, surgical intensive care unit, Montefiore Medical Center, New York City, NY)

Today's Pearl

Q: Why (Dexamethasone) decadron is not a good choice of steroid in septic shock?

Answer: Reasons which render dexamethasone a poor choice in sepsis:

1. It has very minimal (almost negilgible) mineralocorticoid activity. Advantage of performing ACTH stimulation test, while on decadron is there but again its no more recommended to perform in septic shock per updated guidelines of Surviving Sepsis Campaign 1. It is suggested to give IV hydrocortisone to adult septic shock patients if blood pressure remains poorly responsive to fluid resuscitation and vasopressor therapy (grade 2C) - without ACTH stimulation test. Potency of Hydrocortisone and Dexamethasone is 20:1 - means 1 mg of dexamethasone is equal to 20 mg of hydrocortisone.

2. It has prolog half life of 36-54 hours. In updated guidelines of Surviving Sepsis Campaign 1, it is Grade 2B recommendation that patients with septic shock should not receive dexamethasone if hydrocortisone is available. As dexamethaxone has no mineralcorticoid activity, in case if used, should be use with florinef (fludrocortisone).

3. Dexamethasone can lead to immediate and prolonged suppression of the hypothalamic-pituitary-adrenal axis after administration 2.

Reference: click to get abstract

1. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 - Critical Care Medicine:Volume 36(1)January 2008pp 296-327

2. The hypothalamic-pituitary-adrenal axis in critical illness: Response to dexamethasone and corticotropin-releasing hormone. J Clin Endocrinol Metab 1993; 77:151-156

Wednesday June 11, 2008
Pulmonary hypertension and electrolytes: Does sodium tells us any story

With aging and overweight population we are seeing an increasing number of patients in our ICU with severe secondary pulmonary hypertension. As we are aware that hyponatremia is associated with decompensated cardiac failure and poor prognosis in patient with left ventricular systolic dysfunction.

A recent study by Forfia [1] also concluded that hyponatremia is strongly associated with right heart failure and poor survival in Pulmonary Arterial Hypertension (PAH), thus emphasizing the importance of associated hyponatremia further.

(Limitations: small number of subjects)

Design: Prospective study

Methods: 40 patients with PAH were followed and examined the relationship between serum sodium and right heart function as well as survival.

Measurements and Main Results: Hyponatremia (Na less than/=136 mEq/L) patients were

• more symptomatic (11/13 World Health Organization [WHO] class III/IV vs. 12/27 WHO class III/IV; P = 0.02),
• had more peripheral edema (69 vs. 26%; P = 0.009),
• had higher hospitalization rates (85 vs. 41%; P = 0.009) than normonatremic subjects
• Hyponatremic subjects had higher right atrial pressure (14 ± 6 vs. 9 ± 3 mm Hg; P less than 0.001), lower stroke volume index (21 ± 7 vs. 32 ± 10 ml/m2; P less than 0.01), larger right ventricular: left ventricular area ratio (1.8 ± 0.4 vs. 1.3 ± 0.4; P less than 0.001), and lower tricuspid annular plane systolic excursion (1.4 ± 0.3 vs. 2.0 ± 0.6 cm; P = 0.001), despite similar mean pulmonary artery pressure.
• The 1- and 2-year survival estimates were 93% and 85%, and 38% and 15% for normonatremic and hyponatremic subjects, respectively (log-rank x2 = 25.19, P less than 0.001).
• The unadjusted risk of death (hazard ratio) in hyponatremic compared with normonatremic subjects was 10.16 (95% CI, 3.42–30.10, P less than 0.001)

Hyponatremia predicted outcome after adjusting for WHO class, diuretic use, as well as right atrial pressure and cardiac index.

Reference: click to get abstract

Abstract: Forfia PR, Mathai SC, Fisher MR, Housten-Harris T, et al. Hyponatremia Predicts Right Heart Failure and Poor Survival in Pulmonary Arterial Hypertension. AJRCCM 2008: (177); 1364-1369

Tuesday June 10, 2008
Early RRT !

A positive fluid balance is associated with a worse outcome in patients with acute renal failure


Another study showing that a positive fluid balance is associated with a worse outcome in patients with acute renal failure and favouring early renal replacement therapy (RRT).

Introduction : Despite significant improvements in intensive care medicine, the prognosis of acute renal failure (ARF) remains poor, with mortality ranging from 40 to 65%. The aim of the study was to analyze the influence of patient characteristics and fluid balance on the outcome of ARF in intensive care unit (ICU) patients.

Methods: The data were extracted from the Sepsis Occurrence in Acutely Ill patients (SOAP) study, a multicenter observational cohort study to which 198 ICUs from 24 European countries contributed. For the purposes of this substudy, patients were divided into two groups according to whether or not they had ARF.
The groups were compared with respect to patient characteristics, fluid balance, and outcome.

Results

• Sixty-day mortality was 36% in patients with ARF and 16% in patients without ARF
• Oliguric patients and patients treated with renal replacement therapy (RRT) had higher 60-day mortality rates than patients without oliguria or the need for RRT (41 vs 33% and 52 vs 32%, respectively)
• Independent risk factors for 60-day mortality in the patients with ARF were age, Simplified Acute Physiology Score (SAPS) II, heart failure, liver cirrhosis, medical admission, mean fluid balance, and need for mechanical ventilation.
• Among patients treated with RRT, length of stay and mortality were lower when RRT was started early in the course of the ICU stay.

Conclusions: A positive fluid balance was an important factor associated with increased 60-day mortality. Outcome among patients treated with RRT was better when RRT was started early in the course of the ICU stay.



Reference: click to get abstract

A positive fluid balance is associated with a worse outcome in patients with acute renal failure - Critical Care 2008, 12:R74 - Full provisional PDF article is available at abstract page

Monday June 9, 2008
Evidence based medicine: Is it like changing wind

Commentary on new article published in Ann Intern Med 1

In the recent years medicine has focused on evidence based care. Critical care medicine has also seen the influx of lot of studies pointing in the same directions, ranging from activated protein C in severe sepsis and it’s down fall, to tight glycemic sugar control in sepsis and it’s down fall, to the yo-yo swinging data on use of steroids in sepsis. Only one thing was holding steadfast in this time of ever changing and contradictory data on different issues over time, we clearly saw one thing holding strong was that Intensivist model with 24/7 coverage in ICU saves life. Even the Leapfrog data from April 2008 favors the role of intensivist in improving survival and decreasing mortality by 40% in ICU and 30% decrease in hospital mortality, but lets check the data out which got published in Annals of Internal Medicine on the basis of Project IMPACT data ( a national database of ICU patients) 1. The project IMPACT database is a large administrative database originally developed by Society of Critical Care Medicine in 1996).

Design: Retrospective analysis of a large, prospectively collected database of critically ill patients in 123 ICUs in 100 US hospitals.

Patients: IMPACT project data base from 2000 to 2004 included 142,392 patients admitted to 123 ICUs. Of those 101,832 met criteria and qualified for analysis.

Measurements: Difference in hospital mortality between patients cared for entirely critical care physicians, and patients cared for entirely by non-critical care physicians.

An expanded Simplified Acute Physiology Score (SAPS) was used to adjust for severity of illness, and propensity score was used to adjust for difference in the probability of selective referral to critical care physicians.

Results: After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received care by Critical Care Management than for those who did not. Patient taken care by intensivist were sicker. They also end up in getting more procedures.


Limitations of the study:

1. Project Impact measures only ICU and hospital mortality. No information was collected after they left the hospital.
2. Process of identifying and management of patients has limitations.
3. Data elements for analysis are limited to those available in IMPACT database. Presence or absence of protocols, order sets, the length of experience of nursing staff, nurse patient ratio, how many group of critical care physicians, hand off procedures not known.
4. Percentage of patients managed by full time intensivist cannot be identified in IMPACT database, therefore cannot assess the benefit of full time, onsite management by ICU physicians.
   

our editors' Conclusion: Further well designed prospective study should be undertaken.

Reference: click to get abstract

Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit.

Ann Intern Med 2008; 148:801-809

Sunday June 8, 2008
Salmonella (Saintpaul strain) illnesses spread to 16 states

Salmonella food poisoning first linked to uncooked tomatoes has spread to 16 states, federal health officials said Saturday. Click to read more deatils http://www.cdc.gov/salmonella/saintpaul/


See here detailed ppt. presentation Salmonella (Seminar in Nucleic Acids-Spring 2004)

Read precise review article Salmonella Infection (emedicine.com)

Saturday June 7, 2008
Interesting study ! - Potentially helpful for the ICU

Methylnaltrexone(Relistor) for Opioid-Induced Constipation

Background: Constipation is a distressing side effect of opioid treatment. As a quaternary amine, methylnaltrexone, a µ-opioid–receptor antagonist, has restricted ability to cross the blood–brain barrier. The safety and efficacy of subcutaneous methylnaltrexone for treating opioid-induced constipation in patients with advanced illness is investigated.

Methods: A total of 133 patients who had received opioids for 2 or more weeks and who had received stable doses of opioids and laxatives for 3 or more days without relief of opioid-induced constipation were randomly assigned to receive

• subcutaneous methylnaltrexone (at a dose of 0.15 mg per kilogram of body weight) or
• placebo every other day for 2 weeks

Coprimary outcomes: laxation (defecation) within 4 hours after the first dose of the study drug and laxation within 4 hours after two or more of the first four doses.

Results

• In the methylnaltrexone group, 48% of patients had laxation within 4 hours after the first study dose, as compared with 15% in the placebo group, and
  52% had laxation without the use of a rescue laxative within 4 hours after two or more of the first four doses, as compared with 8% in the placebo group (P<0.001>
• The response rate remained consistent throughout the extension trial.
• The median time to laxation was significantly shorter in the methylnaltrexone group than in the placebo group.
• Evidence of withdrawal mediated by central nervous system opioid receptors or changes in pain scores was not observed.
• Abdominal pain and flatulence were the most common adverse events.

Conclusions: Subcutaneous methylnaltrexone rapidly induced laxation in patients with advanced illness and opioid-induced constipation. Treatment did not appear to affect central analgesia or precipitate opioid withdrawal.


Related previous pearl: Oral Narcan for opioid induced constipation !



References: click to get abstract/article

1. Methylnaltrexone for Opioid-Induced Constipation in Advanced Illness- The New England Journal of Medicine, Volume 358:2332-2343, May 29 2008, Number 22

Friday June 6, 2008
At last something favouring femoral access ! - Cathedia Study

A recent study (Cathedia Study) published in favour of femoral access 1. Study was a multicenter study of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007.

Context: Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short term dialysis vascular access.

Objective: To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization.

Design: The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy.

Intervention: Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites.

End-point: Rates of infectious complications, defined as

1. Catheter colonization on removal (primary end point), and
2. Catheter-related bloodstream infection

Patient and catheter characteristics, including duration of catheterization, were similar in both groups.


Results:

• More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%]).
• The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days).
• A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI. Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days) in the lowest tercile (BMI less than 24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days) in the highest tercile (BMI>28.4)
• The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days)

Conclusion: Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma.



References: click to get abstract/article

1. Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy - A Randomized Controlled Trial , JAMA. 2008;299(20):2413-2422.

Thursday June 5, 2008


Q: How many units of platelets are required to avoid possible bleeding due to 300 mg dose of Plavix (clopidogrel)?


Answer: 10 units

According to one recent work 1, pre-operative transfusion of 10 platelet concentrate units after a 300-mg clopidogrel loading or 12.5 units after a 600 mg loading may adequately reverse clopidogrel-induced platelet disaggregation to facilitate postoperative hemostasis. An additional 2.5 units fully normalized platelet function. Roughly, each unit of platelet concentrate would incrementally increase platelet count by 10, 000 uL



Editors' note: Limitation of study - the study was performed under in vitro conditions and there is a lack of information regarding the correlation with in vivo clinical outcomes, which is acknowledged by authors.


References: click to get abstract/article

1. Normalization of platelet reactivity in clopidogrel-treated subjects - Journal of Thrombosis and Haemostasis, 5: 82–90

Wednesday June 4, 2008


Case: 58 year old female admitted to ICU with exacerbation of Asthma. Patient is on coumadin 5 mg per day due to previous DVT, which was continued in ICU. INR on admission was therapeutic with 2.6. Patient was intubated and started on IV steroid along with antibiotic (Ceftriazone) and other home meds. Standard ICU protocols for GI prophylaxis with esomeprazole, blood sugar control, enteral nutrion and head of bed elevation were also initiated. progressively INR continues to rise and on 6th ICU day, GI bleed developed. Which medicine may have interacted with coumadin to increase INR and subsequently GI bleed?


Answer: Esomeprazole (proton pump inhibitor)

Concomitant use of warfarin (coumadin) and esomeprazole therapy may increases INR, and supratherapeutic prothrombin time may lead to abnormal bleeding and even death. Patients treated with proton pump inhibitors and warfarin concomitantly may need to be monitored for increases in INR and prothrombin time.


References: click to get abstract/article

1. Nexium - Rxlist.com

Tuesday June 3, 2008
Time lag between Linezolid and Thrombocytopenia

Thrombocytopenia could be multifactorial in ICU. One of the relative new cause is Linezolid (Zyvox). But thrombocytopenia with Zyvox usually doesn't occur upto 2 weeks with the initiation of treatment and could help in ruling out atleast one reason. Relatively overall its mild, reversible and due to myelosuppression. there is no evidence for anti-platelet or interference with platelet function.


References: click to get abstract/article

1. Hematologic Effects of Linezolid: Summary of Clinical Experience - Antimicrobial Agents and Chemotherapy, August 2002, p. 2723-2726, Vol. 46, No. 8
2. Linezolid and reversible myelosuppression. - JAMA 285:1291
3. Safety, efficacy and pharmacokinetics of linezolid for treatment of resistant Gram-positive infections in cancer patients with neutropenia - Annals of Oncology 14:795-801, 2003

Monday June 2, 2008

Q; Patient with which poisoning presents with garlic odor?

A: Organophosphate poisoning.

Sunday June 1, 2008

Q; Name atleast 7 non-septic conditions which can cause low SVR (systemic vascular resistance) ?

1. Hemorrhagic (or necrotizing) Pancreatitis

2. Cirrhosis

3. Adrenal insufficiency

4. Head Injury ( initially increase SVR followed with low SVR)

5. Bactrim (TMP-SMX) in AIDS patient

6. Within 6 hours of postcardiopulmonary bypass (vasoplegic syndrome)

7. Spinal cord Injury above T6 (inhibited vagal tone)



Reference: click to get abstract/article

Low systemic vascular resistance: differential diagnosis and outcome - Critical Care 1999, 3:71-77