EXPAREL...Is it the end of Post Operative Pain?

The US Food and Drug Administration today approved a novel long-acting nonopioid anesthetic/analgesic for postsurgical pain: bupivacaine extended-release liposome injection (Exparel, Pacira Pharmaceuticals).
Exparel consists of bupivacaine encapsulated in the multivesicular liposome DepoFoam, Pacira Pharmaceutical's extended drug-delivery technology that is the basis for 2 products already on the market: DepoCyte (cytarabine liposome injection) and DepoDur (morphine sulfate extended-release liposome injection).

The new product is designed to extend the duration of analgesia provided by bupivacaine. Based on clinical trial data, Exparel provides continuous and extended postsurgical analgesia for up to 72 hours compared with bupivacaine's analgesic time of 7 hours or less, the company notes.

Exparel has been shown safe in more than 1300 patients across 21 studies, the company says. Most recently, the product was shown to be safe and effective in 2 multicenter, randomized, double-blinded, placebo-controlled, pivotal phase 3 clinical trials in patients undergoing hemorrhoidectomy and bunionectomy.

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

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