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