Icuroom pearls - November 2006

2006-11-30T19:55:00.000-08:00

Thursday November 30, 2006
Let him stay overnight !!

Interesting study came out this month in Critical Care Medicine (Dec' 2006) on impact of ICU discharge time on patient outcome. It is an extensively large prospective study from 31 canadian community and teaching hospitals looking into 79,000 consecutive admissions.

Study found that: patients discharged (transferred to floor) from ICU at night had a 1.22-fold risk of dying in hospital compared with those discharged during the day. The mortality rate for those discharged during the day was 9.0% compared with 11.8% for those discharged at night. Night time is defined from 9 PM to 7 AM.

Multiple reasons from this and previous studies include:

lower staff and nurse-to-patient ratios at night both in ICU as well as at floor.
Demand for a bed for a new admission.
Possible inadequate patient assessment/observation.
Insufficient communication of transfer care plan.
Possible relationship between DNR order and decrease care.

Related previous pearls:

Sign-out Mortality !
Monday-Friday 9-5 ICUs ! (weekend Mortality)

Reference: click to get abstract

Impact of intensive care unit discharge time on patient outcome - Critical Care Medicine. 34(12):2946-2951, December 2006

2006-11-29T06:06:00.000-08:00

Wednesday November 29, 2006

Scenario: 52 year old male is back from cardiac angioplasty with abciximab (ReoPro) infusion. Pre-cath labs were normal. CBC was send per protocol after 4 hours of abciximab infusion and lab call with critical platelet level of 62. Abciximab was stopped and hematology consulted. Hematology made a trip to lab and advised to restart abciximab !!

Pseudothrombocytopenia:

Pseudothrombocytopenia is a common phenomenon with patients on abciximab (ReoPro). It is a benign condition and is not a real thrombocytopenia as platelets actually clump in collecting tubes containg EDTA. It is an important diagnosis to make as it may subject patient to unwanted treatments. Diagnosis can be made by reviewing peripheral blood film or drawing blood in citrated or heparinized tube. It is not clear why abciximab cause more EDTA-induced platelet clumping.

* EDTA (Ethylenediaminetetraacetic acid) is a commonly used anticoagulant in sampling tubes for blood counts.

References: click to get abstract/article

1. Occurrence and clinical significance of pseudothrombocytopenia during abciximab therapy J Am Coll Cardiol. 2000 Jul;36(1):75-83.
2. Abciximab-Associated Pseudothrombocytopenia - Circulation. 2000;101:938
3. EDTA dependent pseudothrombocytopenia caused by antibodies against the cytoadhesive receptor of platelet gpIIB-IIIA - Journal of Clinical Pathology 1994;47:625-630
4. Pseudothrombocytopenia Volume 329:1467 Nov. 11, 1993

2006-11-28T07:39:00.000-08:00

Tuesday November 28, 2006
Bedside trick - suspecting tracheal aspiration !!

One quick method of suspecting tracheal aspiration or atleast ruling out tracheal aspiration is checking glucose concentration by regular bedside glucose meters. A glucose concentration of more than 20 mg/dl of bloodless tracheal aspirate doesn't confirm but atleast enhance the suspicion of tracheal aspiration.

Though literature is full of conflicting data for this method but still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.

Related previous pearls:

Feed Critically Ill Mechanically Ventilated Patients early despite risk of VAP
Where is my food dude
Is post pyloric feeding absolute?
Non-radiological tests to confirm naso-gastric tube placement

References: click to get abstracts / articles

1. Clinical implications of the glucose test strip method for early detection of pulmonary aspiration in nasogastric tube- fed patients - Taehan Kanho Hakhoe Chi. 2004 Dec;34(7):1215-23
2. Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults - Chest, Vol 103, 117-121
3. Glucose content of tracheal aspirates: Implications for the detection of tube feeding aspiration. Crit Care Med 1994; 22:1557-1562
4. Glucose Content of Tracheal Aspirates - Letter to the Editor - Critical Care Medicine: Volume 23(8) August 1995 pp 1451-1452

2006-11-26T21:07:00.000-08:00

Monday November 27, 2006
Calcium infusion and thrombophlebitis !

One important factor while writing order for IV calcium infusion is of line availability. If central line is not available, it is better to write order for calcium gluconate instead of calcium chloride. Calcium infusion tends to cause thrombophlebitis and chances are higher with calcium chloride as it contains 3 times more elemental calcium in camparison to same dose of calcium gluconate.

1 gram of Calcium chloride contains 13.6 mEq of elemental Calcium while 1 gram of Calcium gluconate contains 4.65 mEq of elemental Calcium

2006-11-25T21:51:00.000-08:00

Sunday November 26, 2006

Q; Do you need to adjust Cefepime in CVVHD. Yes OR No ?

A: No

Cefepime is dialysable. In patients on CVVHD (Continuous venovenous haemodiafiltration), no dosage adjustment for cefepime is required and the dosage regime as with normal renal function should be administered.

In patients on HD (hemodialysis), dose of 1 gram every 24 hours is recommended. A supplemental dose of cefepime is advisable at the end of a HD session due to the fact that cefepime is dialysable.

Related previous pearl: Vancomycin dosing in CRRT

2006-11-24T20:30:00.000-08:00

Saturday November 25, 2006

Q; What is the main purpose of trendelenburg position during upper body central line insertion? (choose one)

1. To increase blood flow to vessels.
2. To increase ease of anatomical landmarks.
3. To prevent venous air embolism
4. To counteract hypotension by sedative medicines if used.

Answer : To prevent venous air embolism

Venous Air Embolism is a rare but potentially fatal complication of central line insertion in upper body area and could be prevented with trendelenburg position (atleast 15 degrees), given no orthopnea. In case, Venous Air Embolism is suspected during line procedure with symptoms of sudden occurrence of cardiopulmonary dysfunction like hypotension, hypoxia or churning murmur over left sternal border ( "millwheel murmur" ) - following 7 immediate maneuvers are essential:

1. Clamp the line (do not withdraw) - to prevent further air.

2. Rotate patient to left lateral decubitus position - to decrease air leaving through RV outflow tract.

3. Enhance (or do if not done yet) Trendelenburg position - to help air trap in the apex of the ventricle.

4. Increase oxygen to 100% - Supplemental oxygen reduces the size of embolus. (Avoid High PEEP as it may increase the risk of paradoxical emboli).

5. Advance the catheter little, unclamp the line and aspirate from the 'distal port' to attempt to remove air. (PA-catheter is not as effective as triple lumen catheter in aspirating air).

6. If hypotension occurs - start IVF wide open and add pressor if needed (catecholamines are prefered).

7. Continue supportive treatment till air is absorbed or further management for complications like paradoxical emboli or hyperbaric oxygen therapy is planned.

Refrences: Click to get abstract/article

1. An Infrequent but Life-Threatening Complication of a Simple Procedure - Journal of Intensive Care Medicine, Vol. 17, No. 2, 92-94 (2002)
2. Venous Air Embolism - emedicine.com
3. Gas Embolism - NEJM, feb. 2000, Volume 342:476-482
4. Venous air embolism: a review. J Clin Anesth 1997;9:251-257

2006-11-23T21:30:00.000-08:00

Friday November 24, 2006
What is Mortality Index?

One extra value which intensivist brings is his ability to improve core measures of quality improvement of ICU in particular and hospital in general. Out of those many core measures one is mortality index.

Mortality Index tracks "unexpected" mortalities based on how sick the patients are when they come to the hospital. (An unexpected mortality is one in which the patient did not come to the hospital with a fatal disease).

A score of "1.0" would equal the expected number of patient mortalities given the medical condition of the patients upon arrival. A number lower than 1.0 would indicate success and a number higher than 1.0 would indicate less success.

Mortality index get calculated on a risk score using a national sample. Usually a third party vendor has been hired by hospital who analyse data against data from hospitals nationally.

Keeping mortality Index below 1 should be one of the goal of intensivist team. So, your mortality rate may be high if you are working in an institution getting sicker patients but your mortality index may be low.

2006-11-22T20:19:00.000-08:00

Thursday November 23, 2006
Adenosine and Digoxin !

Adenosine is relatively a safe medicine in treatment of PSVT (paroxysmal supraventricular tachycardia) due to its short half life of 7-10 secs. It is quickly metabolise via cellular uptake by erythrocytes and vascular endothelial cells.

But some anecdotal reports show that if digoxin (or digoxin and verapmil in combination) is already on board, there are chances of culminating into fatal ventricular fibrillation. FDA advise use of adenosine with digoxin or digoxin and verapamil (in combination) with crash cart available at bedside.

Reference: click to get article
1. Adenocard IV - fda.gov

2006-11-21T19:55:00.000-08:00

Wednesday November 22, 2006
Bedside tip - Where is Subclavian vein ?

The easiest way to visualize the exact location of subclavian vein is to find the junction of lateral (clavicular) head of sternocleidomastoid muscle and clavicle. Even in obese neck, this junction can be find with little deep palpation. Subclavian vein lies just behind clavicle.

In infraclavicular approach - go below the clavicle at this junction

In supraclavicular approach - go from above the clavicle at the angle of this attachment/junction. Supraclavicular approach carries slightly higher risk of hitting subclavian artery.

2006-11-20T21:06:00.000-08:00

Tuesday November 21, 2006
Ultrasound guided central venous catheterization.

All new studies point towards the fact that bedside ultrasound guided venous catheter placement would be the thing of future, mostly for IJ placement. Ultrasound does not help much in subclavian placement and use in femoral placement is limited due to its easy compressibility and less recommended use in ICUs. Are we too negative about femoral vein cannulation? - another debate.

A study just published at ccforum.com where 450 patients who underwent real-time ultrasound-guided cannulation of the internal jugular vein were prospectively compared with 450 patients in whom only the landmarks were used. Have a look at results:

Cannulation of the internal jugular vein was achieved in all 450 patients by using ultrasound but in 425 of the patients by using the landmark technique.
Average access time - skin to vein - was 17.1 secs (11.5 to 41.4) vs 44 secs (33.2 to 77.5)
Number of attempts were 1.1 vs 2.6.
Puncture of the carotid artery occurred 1.1% vs 10.6% of patients
Haematoma was 0.4% vs 8.4%,
haemothorax was 0% vs 1.7%,
pneumothorax was 0% vs 2.4%
Additional equipment and manipulation associated with the ultrasound method did not increase the rate of catheter-related infection. Actually, central venous catheter-associated blood stream infection was 16% in landmark technique significantly increased compared with the ultrasound group (10.4%).
The number of CVC-BSIs (Blood stream infections) was positively correlated to the number of needle passes in the total study population.

You may read the full provisional draft of article (pdf) here 1 - (article also carries ultrasound images).

Note: For those who are interested, The Society of Critical Care Medicine is arranging a pre-congress course to be held in February, 2007 at Orlando, Florida, USA. See here

Related previous pearl: Ultrasound guided insertion of radial artery catheters

Reference: click to get abstract

1. Real-time ultrasound guided catheterization of the internal jugular vein: a prospective comparison to the landmark technique in critical care patients - Critical Care 2006, 10:R162

2006-11-19T22:04:00.000-08:00

Monday November 20, 2006
Sulfonylurea overdose

Anti-diabetic pills overdose remained one of the leading cause of drug overdose worldwide. Among anti-diabetic pills sulfonylureas are the most dangerous and hard to correct. Overdose of metformin rarely causes clinically evident hypoglycemia (It has its own danger of cardiovascular collapse and renal failure, due to severe lactic acidosis).

Unfortunately very few clinicians use the real antidote for sulfonylurea which is Octreotide (Sandostatin) in resistant hypoglycemia. Infusion of glucose to achieve euglycemia in the early phase is an appropriate treatment but there is some literature available which argues that prolong infusion of dextrose in sulfonylurea overdose may make hypoglycemia longer and worse by stimulating insulin release. The dose for Octreotide is 50 mcg SC every 8 hours with adjustment of dose according to blood glucose level. Octreotide is a somatostatin analogue, which activates G-protein K channel and hyperpolarization of the beta cell results in inhibition of Ca influx and insulin release.

Another antidote for sulfonylurea overdose beside octreotide is Diazoxide. Exact mechanism is unknow but probably it increases blood glucose by inhibiting pancreatic insulin release. It is found to be effective within 60 minutes of administration. The usual dose is 5 mg/kg/day intravenously and should be divided every 8 hours. Dose can be increased if needed but still its experience in comparison to octreotide is limited.

References: click to get abstracts/articles

1. Octreotide for sulfonylurea-induced hypoglycemia following overdose - The Annals of Pharmacotherapy: Vol. 36, No. 11, pp. 1727-1732
2. Clinical spectrum of sulfonylurea overdose and experience with diazoxide therapy - Archives of Internal Medicine Vol. 151 No. 9, September 1, 1991

2006-11-19T07:24:00.000-08:00

Sunday November 19, 2006

Q: Which 3 major clinical signs may help in differentiate propofol infusion syndrome (PRIS) from other conditions particularly septic shock?

A: In the presence of propofol infusion, if following triad is present, its propofol infusion syndrome - proved otherwise.

Bradycardia
Hyperlipidemia
Rhabdomyolysis

Editors' note: In last one week, this is 3rd pearl related to propofol (see this and this. This is to emphasize the dangers of widely used propofol in ICUs)

2006-11-18T09:43:00.000-08:00

Saturday November 18, 2006
Sympathetic storming

Sympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units. It occurs due to episodes of uncontrolled sympathetic surge with a diminished or unmatched parasympathetic response. Acording to Baguley criteria, 5 out of the 7 clinical features should be present -

tachycardia,
tachypnea,
hyperthermia,
hypertension,
dystonia,
posturing, and
diaphoresis.

Various agents have been used for symptomatic treatment including versed, morphine, propranolol etc (see review article below) but one thing need to remember: Haloperidol (Haldol) makes symptoms worse.

Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004 2.

See great review article here on Sympathetic Storming from Denise M. Lemke, published in J Neurosci Nurs 36(1):4-9, 2004.

References: click to get abstract/article
1. Dysautonomia after traumatic brain injury: a forgotten syndrome? - J Neurol Neurosurg Psychiatry 1999;67:39-43 ( July )
2. Pa roxysmal autonomic instability with dystonia (PAID) - Arch Neurol. October 2004;61:1625.
3. Paroxysmal Autonomic Instability with Dystonia After Brain Injury - Arch. Neurol. March 2004;61:321-328

2006-11-17T07:05:00.000-08:00

Friday November 17, 2006
Iatrogenic induced Brugada syndrome !!

Scenario: You admitted a patient in ICU with COPD exacerbation, requiring mechanical intubation. You started patient on cocktail of nebulizer treatments, IV steroid, antibiotic coverage, standard ICU prophylaxes and propofol for short term sedation as you expected recovery and extubation within 48-72 hours. Next day, nurse noticed ST elevation in V2 lead. You ordered EKG (ECG) and indeed new ST elevations noted in leads V1 to V3 changes along with Right-Bundle-Branch-Block (RBBB). You acquired cardiology consult and cardiologist was excited to report you that this is a Brugada syndrome. As far as you remember, Brugada syndrome is a hereditary and a genetic disease. And you are wondering - isn't the EKG was normal on admission ?

A; Propofol induced EKG findings look like Brugada syndrome.

The Brugada syndrome is a genetic syndrome said to be autosomal dominant associated with SCN5A gene. Clinically, it appears as EKG findings of right bundle branch block and ST segment elevation in V1 to V3 (J point elevation) with a structurally normal heart. It goes unnoticed and cause either syncopal episodes or sudden death. Mean age of death is 40 years but can happen at any point in life time. It is very common in asian people and acquired different names as Lai Tai (death during sleep) in Thailand, Bangungut (scream followed by sudden death during sleep) in Philippines and Pokkuri (unexpected sudden death at night) in Japan.

Recently, it has been reported in HeartRhythm that Brugada syndrome like EKG findings may be the earliest finding of propofol infusion syndrome (PRIS) and early recognition with discontinuation of propofol may save lives as mortality of PRIS is more than 80%.

Related site: www.brugada.org

Reference: click to get abstract

1. Electrocardiographic changes predicting sudden death in propofol-related infusion syndrome - HeartRhythmVolume 3, Issue 2, Pages 131-137 (February 2006)

2006-11-16T06:22:00.000-08:00

Thursday November 16, 2006
Anemia in ICU

Q: If you admit a patient with Hb of 10 g/dL and draw 100 ml of blood, how much will be the drop in Hb ?

A; Hb will drop from 10 to 9.3 g/dL. With each 100 ml of blood draw(s), Hb drop by 0.7 g/dL 1. Remember ! phlebotomy is one of the major cause of anemia in ICUs.

Related previous pearl: ICU anemia score

Reference:

Blood testing causes anemia - J Gen Intern Med 2005; 20:520–524

2006-11-14T19:19:00.000-08:00

Wednesday November 15, 2006

Q: Use of steroid along with propofol ... (choose one)

A) prevents propofol infusion syndrome
B) Increase the chance of propofol infusion syndrome
C) Can have erratic effect on sedation
D) Can increase infection rate
E) has no association

Answer: B

Propofol when combined with steroids, acts as a triggering factor for propofol infusion syndrome 1.

Among other choices, D) is worth mentioning as improper unsterile handling of propofol may increase the infection rate, though not associated with steroid. Steroid may independently increase the rate of infection.

When continued at rates higher than 5 mg/kg/h for more than 48 hours, propofol may cause rhabdomyolysis, acute renal failure, metabolic acidosis, hyperkalemia, bradycadia, arrhythmia and hyperthermia. Mortality is very high at more than 80%. Syndrome is called 'propofol infusion syndrome' or PRIS. Recently PRIS has been reported even at lower dose or in less than 48 hours time. 2, 3

Bonus Pearl: Propofol may turn color of urine green. It is a benign effect of Propofol. Recognition of this side effect is important as it averts unnecessary workup and limits medical expenditures.

References: click to get articles/abstracts

1. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome - Volume 29, Number 9 / September, 2003, Intensive Care Medicine
2. Propofol Infusion Syndrome—A Fatal Case at a Low Infusion Rate - Anesth. Analg., Vol. 103, Issue 4, 1050 October 1, 2006
3. Propofol Infusion Syndrome Associated with Short-Term Large-Dose Infusion During Surgical Anesthesia in an Adult - Anesth Analg 2005;100:1804-1806

2006-11-13T20:13:00.000-08:00

Tuesday November 14, 2006

Q: After how many attempts to intubate you should stop and call for help?

A: 3

ASA (American Society of Anesthesiologists)Task Force on the Management of the Difficult Airway recommends to limit laryngoscopic attempts to 3 in lieu of the considerable injury that may occur including hypoxemia, regurgitation and aspiration of gastric contents, bradycardia and cardiac arrest.

Historical Trivia: Orotracheal intubation in difficulty of breathing was first suggested about 1000 years ago by a persian doctor Avicenna (also called Ibne-Sina) 1. First oral intubation in modern medicine was performed by British surgeon McEwen in 1878 when he preoperatively intubated a patient to prevent the aspiration of blood during extirpation of a tumour from the base of the tongue.

Reference:
1. History of intubation - Laryngol Rhinol Otol (Stuttg).1986 Sep;65(9):506-10

2006-11-12T18:21:00.000-08:00

Monday November 13, 2006

Q: Once you decide to give Digibind (Digoxin Fragmented Antibody) to patient, how you decide the number of vials to be given?

A: # of Digibind vials = Digoxin level in ng/mL x wt. in kg / 100

Example: If patient's Dig. level is 4.2 ng/ml and his wt. is 70 kg, you need: 4.2 x 70/100 = 2.94 or about 3 vials.

Digibind is an expensive medicine and saving of one vial is even worthed.

* Each vial contains 40 mg of Digoxin immune Fab protein

Bonus Pearl: Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it may be misleading.

2006-11-11T18:28:00.000-08:00

Sunday November 12, 2006
Assessment of cirrhosis !! - Part 3 - CPS vs MELD score

Editors' note: This is 3rd pearl in series to assess prognosis in cirrhosis. See

Part 1 - The Child-Turcotte-Pugh score (CPS) here and
Part 2 - "model for end stage liver disease" (MELD) score here

Many experts believed that Child-Pugh score to allocate liver for transplantation was subject to misjudgement due to level of clinical subjectiveness for ascites and hepatic encephalopathy. Also, there were public allegations that liver allocation is not transparent and fair. In february, 2002 a new method for allocating livers for transplantation, known as the Model for End-Stage Liver Disease (MELD) score, is institutated to leave no room for subjective criteria favoritism, as it was based on a mathematical equation. The equation calculates a patient’s likelihood of dying within three months and measures the level of sickness. In other words, the sickest patient gets the liver transplant.

Since than many attempts have been made to compare both the score but literature failed to prove superiority of MELD over CP score. They both have their own strengths and weaknesses.The overall trend at this point and take home message is to keep using the CP score for individual assessment of liver disease in daily clinical practice. And, the MELD score in prioritizing candidates for liver transplant.

We are putting here a reference article comparing both scores.

Systematic Review: The Model for End-Stage Liver Disease - Should it Replace Child-Pugh's Classification for Assessing Prognosis in Cirrhosis? - Aliment Pharmacol Ther. 2005;22(11):1079-1089. Available via free registration with medscape.com

Another good reference article is Assessment of the prognosis of cirrhosis: Child–Pugh versus MELD - Journal of Hepatology Volume 42, Issue 1, Supplement 1, April 2005, Pages S100-S107 but is subject to subscription.

We are thankful to Dr. Richard Saval, Associate Director, Surgical Intensive Care Unit, Maimonides Medical Center and Assistant Professor of Medicine, Mt. Sinai School of Medicine, NY in helping us out in this series of pearl.

2006-11-10T19:55:00.000-08:00

Saturday November 11, 2006
Assessment of cirrhosis !! - Part 2 - MELD score

Editors' note: Yesterday we did The Child-Turcotte-Pugh (CPS) score (click here to see). Today we are doing "model for end stage liver disease" (MELD) score for assessment of cirrhosis.

Evaluating prognosis in Cirrhosis via "model for end stage liver disease" (MELD) score

In february 2002, a new methodology for allocating livers for transplantation has been introduced to avoid any subjective criteria favoritism with 100% based mathematical equation. The equation calculates a patient’s likelihood of dying within three months from their liver disease and so the sickest patient gets the liver transplant.

3.8 x log (e) (bilirubin mg/dL) + 11.2 x log (e) (INR) + 9.6 log (e) (creatinine mg/dL)

Another version is

0.957 loge (creatinine [mg/dl]) +0.378 loge (bilirubin [mg/dl]) + 1.120 loge (INR) +0.643 (cause of cirrhosis).

‘Cause of cirrhosis’ is 0 if alcoholic or cholestatic and 1 for all other causes.

Online quick calculator is

here (www.unos.org)

Interpretation: Scores range from 6-40. A score of 6 means the least ill and a score of 40 means the sickest patient. Patient continue to get re-configured his MELD score periodically while on the transplant waiting list. It may go up or down depending upon the patient’s health.

Addendum: Patients with liver cancer will be assigned a MELD - TNM score together with his cancer stage.

2006-11-09T22:42:00.000-08:00

Friday November 10, 2006
Assessment of cirrhosis !! - Part 1 - Child-Pugh score

Editors' note: We will run this pearl on assessment of cirrhosis in 3 parts.

Part 1 - The Child-Turcotte-Pugh (CPS) score.
Part 2 - "model for end stage liver disease" (MELD) score and
Part 3 to compare both scores.

We are thankful to Dr. Richard Saval, Associate Director, Surgical Intensive Care Unit, Maimonides Medical Center and Assistant Professor of Medicine, Mt. Sinai School of Medicine, NY in helping us out in this series of pearl.

Evaluating prognosis in Cirrhosis via Child-Turcotte-Pugh (CPS) score

In 1964 Dr C.G. Child and Dr J.G. Turcotte from the University of Michigan first proposed the scoring system of prognosis in Cirrhosis. In 1972, it was modified by Dr. Pugh as he replaced criterion of nutritional status with the INR.

1 point to lower value
2 points to middle value and
3 points to highest value

1. Total Bilirubin (mg/dL) less than 2 or 2-3 or more than 3

2. Albumin (g/L) more than 35 or 30-35 or less than 30

3. INR 1.7 or 1.7- 2.2 or more than 2.2

4. Ascites None or Controlled with medication or Refractory

5. Hepatic encephalopathy None or Grade I-II (or controlled with medication) or Grade III-IV(coma)

Interpretation

Class A - if Points are 5-6, life expectancy is 15-20 years and Perioperative mortality is about 10%.

Class B - if Points are 7-9, life expectancy is 10-15 years and Perioperative mortality is about 30%.

Class C - if Points are 10-15, life expectancy is 1-3 months and Perioperative mortality is about 82%

2006-11-09T07:04:00.000-08:00

Thursday November 9, 2006
Oral Narcan for opioid induced constipation !

Constipation / ileus is a major issue in ICU since many intubated patients stays on narcotic drips for analgesia. Different meds like dulcolex (bisacodyl), lactulose, enema etc. can be used but if patient on narcotic drip like fentanyl, morphine or dilaudid doesn't get relief from conventional constipation relief agents, oral Narcan (naloxone) can be tried. It provides only local effect - without systemic effect. It is found to have a pretty good margin of safety as when given orally, hepatic metabolism limits systemic bioavailability.

Usual dose noted in palliative literature is 2- 4 mg every 6 hours. Later, if needed either dose can be increased upto 8 mg or frequency can be increased upto every 4 hours. Another recommendation (only for morphine) is to give 10 - 20% of total morphine in previous 24 hours.

If you suspect systemic effect of narcane (consistent with opioid withdrawal) - hold narcane and increase narcotic dose.

It can similarly be used in opioid induce pruritis, common with epidural drips.

References: click to get abstract

1. Opioid antagonists in the treatment of opioid-induced constipation and pruritus. Ann Pharmacother. 2001;35(1):85–91
2. Opioid antagonists: a review of their role in palliative care, focusing on use in opioid-related constipation. J Pain Symptom Manage. 2002;24(1):71–90.
3. Oral naloxone reverses opioid-associated constipation. Pain. 2000;84(1):105–109
4. Low-dose oral naloxone reverses opioid-induced constipation and analgesia. J Pain Symptom Manage . 2002;23(1):48–53.

2006-11-08T08:43:00.000-08:00

l.Wednesday November 8, 2006
Sepsis Guidelines and bundle - Pro and Con

Con: In October 19, 2006 edition of The New England Journal of Medicine, an article published arguing that the whole sepsis guidelines are nothing but part of a commercial market strategy from company Eli Lilly to promote their drug "Xigris". In other words, it criticizes the whole surviving sepsis campaign and its major funding source, Eli Lilly as a business gimmick. This is a very strong provocative article and first time arguments have been brought against the whole idea of sepsis guidelines and bundle in a major journal and authors are none less but from Dept. of Critical Care, National institute of Health 1.

Pro: Dr. Mitchell M. Levy, M.D., Professor of Medicine at Brown Medical School and Medical Director of the Medical Intensive Care Unit at Rhode Island, and one of the vanguard of survivng sepsis guidelines answered these criticism while interviewing with Dr. Richard H. Savel, M.D., associte editor of SCCM podcast.

Being an intensivist, this is an important debate to be aware of. We are attaching here the link of the interview at SCCM podcast with courtesy and permission of Dr. Savel, Associate Director, Surgical Intensive Care Unit, Maimonides Medical Center and Assistant Professor of Medicine, Mt. Sinai School of Medicine, NY.
(Thanks Dr. Savel).

To listen to the interview click here. (SCCM pod # 49)
To download the interview click here.

(Total time 35 minutes)

Related sites:

iCritical Care (SCCM)

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Reference:

1. Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly - Volume 355:1640-1642, Number 16, October 19, 2006 - The New England Journal of Medicine.

2006-11-07T11:57:00.000-08:00

Tuesday November 7, 2006

Q; What is the advantage of Meropenem over Imipenem or Imipenem-Cilastatin (Primaxin)?

A; It doesn't carry the risk of seizures !!

Related previous pearl:

Imipenem and Primaxin

3 new antibiotics

2006-11-06T13:58:00.000-08:00

Monday November 6, 2006
Awareness of biggest port on venous catheter !

If central venous catheter is inserted, it is important to be aware of size of biggest lumen. Like in triple lumen, biggest port is of 16 G, and in quad lumen is of 14 G. In situations where IVF boluses are required as in septic patients, it is appropriate to write orders to infuse IVF bolus via biggest size port of catheter. As per Hagen-Poiseuille equation just 2 fold increase in radius increases flow by 16 fold. Although It is not always necessary that biggest port is the distal port but in most widely use TLCs - distal port is the largest bore port and as they are not positioned closely against the vessel wall, they may help in free flow of the IVF. Also, thrombus formation could be faster in the smaller ports causing obstruction to free flow of bolus.

It is true that distal port is mostly used and preferred for CVP monitoring but in a situation where IVF boluses are priority, it is not important which port is in use for CVP measurements, but adopt a consistent port so measurements can be 'trend'. One study compared CVP measurement via 3 ports and found clinically unsignificant mean difference of 1.12 - 1.28 mm Hg 1.

Related previous pearl: CVP via PICC

Reference:

Influence of Port Site on Central Venous Pressure Measurements From Triple-Lumen Catheters in Critically Ill Adults - American Journal of Critical Care - JANUARY 1998 - VOLUME 7 - NUMBER 1

2006-11-05T12:06:00.000-08:00

Sunday November 5, 2006
Uncontrolled diarrhea in C. diff. Colitis - what to do

If Diarrhea persists in C. diff. colitis despite treatment with metronidazole (flagyl) - add Cholestyramine 4 grams PO QID. Caution: Never add cholestyramine with PO vancomycin. It will render the whole treatment ineffective.

Bonus Pearl: Wash hands with soap and water if exposure to C.diff. is suspected. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against c. diff spores.

Related previous pearls:

Stool Donation in C. diff.

Epidemic of fluoroquinolone induced strain of C. Diff.

Metronidazole Induced Pancreatitis

2006-11-04T19:43:00.000-08:00

Saturday November 4, 2006
Posaconazole (Noxafil) - new big gun anti-fungal !!

6 weeks ago FDA approved new anti-fungal for treatment of life-threatening invasive Aspergillus and Candida infections resistant to currently available antifungal treatments, paricularly in immunosuppressed patients with organ transplants and chemotherapy.

Noxafil is found to be very effective in patients:

with febrile neutropenia or invasive fungal infections refractory to standard antifungal therapy.
with zygomycosis, a fatal fungal infection against which most pharmacotherapies have little activity.
with better clinical outcomes in patients with fungal infections that involve the central nervous system.
tends to work in patients with mycetoma or chromoblastomycosis, which are chronic fungal infections of the skin and soft tissues that do not respond well to current treatments.

Usual dose is 200mg 4 times a day (or 400 mg twice a day) with a meal. Major side effect include possible hepatotoxicity and prolong QT interval.

2006-11-03T07:14:00.000-08:00

Friday November 3, 2006
Bedside tip !! - ischemic bowels and legs

"As medicine is becoming more and more high-tech., physical exam is loosing its presence and in many instances like in ICU, whole management get done on availability of data. We rely on EEG, CT scans, MRIs, CXRs, EKG, ultrasounds, echo, swan, labs and monitor. But significance of physical exam remains as crucial as it was ever which herald changes even before any data available or before its too late.

The essential 5 physical exam of pupils, lungs, heart, abdomen and extremities can be done within 2-3 minutes. If you don't have time to do above 5 essentials, atleast make habit to put your hand on belly and lower extremities on each patient everyday - I promise, those 10 seconds will save you regrets of years ! Your palm is the first and the best scan of ischemic bowels and ischemic legs."

(From lecture of one of the old timer and experienced surgeon)

2006-11-02T07:52:00.000-08:00

Thursday November 2, 2006
tPA in PE

Q; What is the dose of tissue plasminogen activator (tPA) in PE ?

A; The approved dose of tPA (tissue plasminogen activator) from FDA is 100 mg as a continuous infusion over 2 hours. tPA administration should be followed with heparin infusion. In situations where you don't have luxury of even waiting for 2 hours and surgery backup is not available for thrombectomy, dose of 0.6 mg/kg over 15 minutes may be given.

Another thrombolytic which is not approved but may be use is Reteplase with single dose of 10 units as bolus. In code situation 20 units may be given as a single bolus.

If first round of thrombolysis doesn't improve clinical signs, second dose may be repeated but one recent trial (see related pearl below) showed that rescue surgical embolectomy is better than repeat thrombolysis in patients who do not respond to first dose of thrombolysis.

Related previous pearl:

What if even thrombolysis fails in massive PE ?

2006-11-01T15:48:00.000-08:00

Wednesday November 1, 2006
Amiodarone - Digoxin interaction !

Q; How Amiodarone effects the level of Digoxin? (choose one)

A) It increases Digoxin level
B) It decreases Digoxin level
C) It can have unpredictable erratic effect
D) There is no interaction between these 2 drugs
E) It all depends on potassium level

Answer is (A)

Amiodarone increases the digoxin level. From ICU perspective it is important as it may happen within 24 hours of simultaneous administration and it may be appropriate to decrease the dose of digoxin.
Different mechanisms of this interaction is proposed but it is not entirely known. Proposed reasons include reduction in renal clearance of digoxin, displacement of digoxin from tissue-binding sites and altered GI absorption. Amiodarone is known to have spasmolytic effect on the smooth muscle of the intestine and may prolong the intestinal transit time of digoxin and thus the absorption of digoxin.

Related previous pearls:

Why we call it Am-iod-arone !!

Amiodarone Neurotoxicity !!