sedationstation

Heparin resistance is defined in terms of the context: A) in treatment of VTE, if more than 35,000 u / 24 hour period is required to prolong the aPTT to the therapeutic range, or B) in cardiac bypass surgery, if after heparinization, there is at least one ACT greater than 400 s or if exogenous antithrombin is required. In general, studies have sited heparin resistance to occur due to a multitude of factors in 22% of patients undergoing major surgery.  AT deficiency only accounts for one possible cause among many including increased clearance of heparin from the plasma, elevations of various heparin binding proteins (as mentioned above), elevations in FVIII and fibrinogen levels.  Medications such as aprotinin and nitroglycerin have also been sited as causal of heparin resistance.    In patients previously exposed to heparin or requiring an IABP,  resistance may arise.  In the surgical population it is likely that when resistance to heparin occurs, i...

The classic TRALI syndrome is an uncommon condition characterized by the abrupt onset of respiratory failure within hours of the transfusion of a blood product.  It is usually caused by anti-leukocyte antibodies, resolves rapidly, and has a low mortality.  A single unit of packed cells or blood component product is usually implicated in initiating this syndrome.  It has, however, recently been recognized that the transfusion of blood products in critically ill or injured patients increases the risk (odds ratio 2.13; 95% confidence interval 1.75-2.52) for the development of the ALI 6-72 hours after the transfusion.  This "delayed TRALI syndrome" is common, occurring in up to 25% of critically ill patients receiving a blood transfusion, and is associated with a mortality of up to 40%.  While the delayed TRALI syndrome can develop after the transfusion of a single unit, the risk increases as the number of transfused blood products increase....

Blindness post-TURP/hysteroscopy likely due to glycine toxicity. Treatment consists of magnesium therapy to correct plasma-magnesium levels and reassurance that blindness is transient and will resolve over next 24 hours

Heparin is the most commonly used anticoagulant during operative procedures due to its cost, rapid onset, safety, and short half life as well as its reversibility.  The heparin molecule is a negatively charged molecule .   It's mode of action is important in understanding its limitations and potential problems that may occur with its use.  Heparin can only function after it binds to a protein that circulates naturally in the blood stream by the name of antithrombin or AT III.   Once heparin binds to free circulating antithrombin, this complex is capable of it inhibiting thrombin as well as activated factor X.  Thrombin is the main coagulant protein in the coagulation cascade.   AT (formerly AT III) is a glycoprotein that functions normally as a natural anticoagulant, providing inhibition of coagulation enzymes in a slow progressive manner. In the presence of heparin, AT undergoes a conformational change that results in a 1000 fold increase in i...

It is  too common sequelae of difficult intubation are damage to soft tissues of the mouth and throat, and damage to the maxillary incisors of the patient. This  study evaluates the forces applied to the maxillary incisors when using various VLSs and a Macintosh blade. Methods Fifty consecutive surgery patients were randomly assigned to receive laryngoscopy from a pair of four blades investigated in the study – the VLSGlideScope ®   (Verathon Inc., Bothell, WA, USA), V-Mac™ Storz ®   (Karl Storz, Tuttlingen, Germany), and McGrath™ (Aircraft Medical, Edinburgh, United Kingdom); and the classic Macintosh blade also from Storz ®   (Karl Storz). An endotracheal tube (ETT) was brought into position anterior to the vocal cords, with actual intubation carried out only with the second of the laryngoscopes. Sensors measured the forces directly applied to the patient's maxillary incisors while inserting the ETT. Other common metrics of intubation difficulty (e.g...

Despite the absence of precise prevalence rates, overall trends and risk factors have been observed. Overall, the incidence of CIN is thought to be low in patients with normal renal function, but it can be much higher in patients with underlying renal disease. In the general population, the incidence of CIN is estimated to be 1% to 6%. Among patients with normal baseline renal function, the incidence of CIN is estimated to be < 2%. In chronic kidney disease (CKD), the incidence increases to 12% to 27%. In patients with both CKD and DM, the incidence of CIN may be as high as 50%. Patients with acute MI undergoing angioplasty are at higher risk of CIN than patients undergoing elective interventions. Incidence rates of 15% have been reported in patients undergoing cardiac catheterization.

Alcohol septal ablation is not very different in technique from regular coronary angioplasty except here artifical occlusion is performed. After localizing the septal artery feeding the hypertrophied muscle, a small amount of absolute alcohol is infused into the artery to produce infarction.  Resulting c hest pain can be treated with analgesics and sedatives.  About 5-10% of patients may require permanent pacemaker.

In an epidemiologic study of 19,982 adults admitted to an urban academic medical center, Chertow et al. reported that increases in SCr of 0.3 to 0.4 mg/dl were   significantly associated with in-hospital mortality (multivariable OR 1.7;   95% CI, 1.2 to 2.6).  These individuals experienced a roughly 70% increase in the risk of death compared with patients with   little or no change in SCr. Note that the significance of a change of 0.3 mg/dL depends on the baseline Cr.  For a given change in creatinine, the change in creatinine reflects a greater change in GFR at lower Cr levels compared with higher levels, i.e. early changes in Cr are more signficant. For example, an increase in Cr from 1 to 1.5 roughly correlates with a 33% drop in GFR.  An increase in Cr from 4 to 4.5 roughly correlates with a 5% drop in GFR.   The gross relationship is GFR ≈ 1/Cr . Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mort...

Many clinical studies have demonstrated that the arterial pulse pressure variation (PPV) and the stroke volume variation (SVV) are accurate predictors of fluid responsiveness. A recent meta-analysis showed that the average sensitivity and specificity of these two parameters is 85%, which is indeed not perfect, but quite impressive when compared with all other clinical indicators. However, these dynamic parameters have limitations precluding their use in several clinical situations. The main limitations to the use of dynamic parameters in surgical patients have been recently summarized as ‘SOS’. The first ‘S’ stands for small tidal volume and spontaneous breathing activity; the ‘O’ stands for open chest. In these conditions, changes in intrathoracic pressure are usually too small to induce significant changes in venous return. As a result, a false-negative may be observed, that is a small PPV or SVV in flu...

Cuff Pressures and the Prevention of VAP  Ventilator-associated pneumonia (VAP) is the second most common nosocomial infection in the US and is associated with increases in ICU length of stay and mortality. With increasing PACU lengths of stay for many critically ill patients receiving mechanical ventilation, measures to prevent VAP should be initiated in the PACU. In addition to elevating the head of the bed to 30-45 degrees, another low cost intervention is the measurement of endotracheal tube cuff pressures. Cuff pressures below 20 cm H 2 O   increase the risk of VAP. Measure cuff pressure within 4 hours of inflation and maintain between 20-30 cm H 2 O. Grap MJ, et al. Ventilator-associated pneumonia: The potential critical role of emergency medicine in prevention.  JEM  2012; 42:353-362  

I like it, so i wanna share it with you, This is a term used to describe an acute abdomen due to intussusception with syncope. Numerous case reports, retrospective studies, and clinical reviews document prominent neurologic features in the absence of common gastrointestinal symptoms of intussusception. Although lethargy is most common, other neurologic symptoms include apathy, listlessness, hypersomnolence, impaired reaction to painful stimuli, and fluctuating levels of consciousness.   Neurologic intussusception is particularly common in infants. The pathophysiology of neurologic intussusception is not well understood. Proposed mechanisms include release of neuropeptides from strangulated bowel, absorption of toxic metabolites, dehydration and electrolyte imbalance as a result of vomiting, and progressive bowel obstruction. It is also possible that neurologic impairment is simply a normal behavioral reaction of an infant to severe abdominal pain.

Know the sulcus sign  and make the pneumothorax Diagnosis... Pneumothorax is frequently difficult to diagnose in the operating room or PACU . Sometimes it   is   obvious, with a hypoxic patient and absent breath sounds. But not usually. Most of the time we rely on a chest xray to help make the diagnosis. Unfortunately, the good old   chest xray only shows a pneumothorax about 30-50% of the time . A big part of the problem is that our patients are usually supine.A small pneumothorax make float anteriorly in the supine position, and if it is not big enough to wrap around the lateral edge of the lung, it may remain invisible. So you need to look for gross   and   subtle signs on the image that will help make the diagnosis. The deep sulcus sign is one of the more subtle signs.  Simply stated, the deep sulcus sign is a radiolucent (dark) lateral sulcus where the chest wall meets the diaphragm. The amount of lung in this...

A study in Resuscitation looking at the efficacy of LMA’s in neonatal resuscitation. Usually we use a face mask and bag them. This study shows a tiny LMA might be a better choice. So get your LMA size 1 ready for the newborn resus trolley. Objective : To study the feasibility, efficacy and safety of using the laryngeal mask airway (LMA) in neonatal resuscitation. Methods : In total, 369 neonates (gestational age≥34 weeks, expected birth weight≥2.0 kg) requiring positive pressure ventilation at birth were quasi-randomised to resuscitation by LMA (205 neonates) or bag-mask ventilation (164 neonates). Results : (1) Successful resuscitation rate was higher with the LMA compared with bag-mask ventilation (P < 0.001) and the total ventilation time was shorter with the LMA than with bag-mask ventilation (P < 0.001). Seven of nine neonates with an Apgar score of 2 or 3 at 1 min after birth were successfully resuscitated in the LMA group, while in the BMV group all six...

Traditionally balanced salt solutions  like LR were avoided in Renal failure patients  because of concerns regarding accumulation of potassium in renal failure.Keep in mind LR contains only 4 meq of potassium.... However, a study by O’Malley et al. demonstrated a 20% absolute risk increase (number needed to treat: 5) for hyperkalemia in patients undergoing renal transplantation who were administered saline rather than lactated Ringer solution. Moreover, there was a 30% incidence of metabolic acidosis, requiring treatment, in the saline group, versus 0% in the lactated Ringer group. Chloride is involved with regulation of renal vascular tone. Hansen demonstrated that potassium induced contraction of smooth muscle cells in the afferent arteriole is highly sensitive to chloride. Thus Chloride is a functional renal vasoconstrictor. Hyperchloremia has been shown to produce dose dependent renal vasoconstriction and a reduction in glomerular f...

Diagnosis of AKI is based on elevation of creatinine or the presence of oliguria.  Serum creatinine is a biomarker of little value because it is influenced by several extra-renal factors. Advanced renal tissue damage is required to demonstrate AKI and this increasn occurs after 48 h of the injury. Biomarkers are tools frequently used in the ICU for diagnosis, monitoring and decision making. Neutrophil Gelatinase-Associated Lipocalin (NGAL) one of the most studied and promising biomarkers for early diagnosis of AKI. There is increasing evidence that NGAL is not only a marker of AKI but also a predictive factor for severity, mortality and hospital stay and also useful to determine time to initiate renal replacement therapy. Studies in critically ill patients with AKI showed a 10-fold increase above the reference range of the NAGL in plasma and up to 100 times in urine. Both were correlated with serum creatinine levels. Kidney biopsies showed an accumulation ...

Doctors Luscombe and Owens tell us in a recent article that we need a new formula for estimating kids’ weight, They suggest (age x 3)+7.  Apparently that formula is more precise than the old  (age x 2 + 8 ) which is so nineties. click here to access the article in PDF format                                                                              Click here please

From the May issue 2007 of Anesthesiology is a systematic review and meta-analysis on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women. Nine articles met the inclusion quality criteria (3,320 participants). Cesarean delivery (odds ratio, 1.00; 95% confidence interval, 0.82-1.23) and instrumental vaginal delivery (odds ratio, 1.00; 95% confidence interval, 0.83-1.21) rates were similar in the early NA and control groups. Neonates of women with early NA had a higher umbilical artery pH and received less naloxone . In the early NA group, fewer women were not compliant with assigned treatment and crossed over to the control group. Women receiving early NA for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status , worse indices of neonatal wellness, and a ...

Ceftobiprole is a fifth-generation cephalosporin antibiotic with activity against MRSA, penicillin-resistant, Pseudomonas aeruginosa, and enterococci. It is on Fast track for FDA approval. Ceftobiprole has already been approved for use in Canada and Switzerland. Ceftobiprole is the first, broad-spectrum, anti-MRSA cephalosporin. It is also the first of antimicrobials to include anti-MRSA and anti-Pseudomonas activity in the spectrum of its coverage - providing single coverage for both.  The dosing is 500 mg IV every 8 hours or every 12 hours.  Dosing adjustments may be necessary in patients with renal insufficiency.

Tracheal extubation is a high risk procedure in anaesthesia and critical care. Until now most guidelines have focused on intubation, with little to guide the process of extubation. Complications may relate to the following issues: Exaggerated reflexes – laryngospasm (which can lead to both hypoxia and negative pressure pulmonary oedema) and bronchospasm Reduced airway reflexes Dysfunctional laryngeal reflexes Depletion of oxygen stores at extubation Airway injury Physiological compromise in other systems Human factors The goal is to ensure uninterrupted oxygen delivery to the patient’s lungs, avoid airway stimulation, and have a back-up plan, that would permit ventilation and re-intubation with minimum difficulty and delay should extubation fail. The Difficult Airway Society has now published guidelines for the management of tracheal extubation, describing four steps: Step 1: plan extubation. Step 2: prepare for extubation. Step 3: perform extubation. Ste...

LR is a roughly isotonic solution with potassium, calcium, lactate, and reduced amounts of sodium and chloride compared with normal saline. The calcium can bind with drugs such as amphotericin and ampicillin and thus may reduce drug effectiveness.    " Calcium may also bind citrated anticoagulant in blood products causing clot formation in the donor " This statement is a MYTH..Many papers came out challenge this.. It is safe to mix LR with PRBCs..it is proven.(1) In healthy subjects, a liter of LR over one hour does not raise serum lactate levels. In critically ill patients, lactate clearance may be impaired but it is generally thought that LR has minimal impact on serum lactate levels. One reason is that only a quarter of the volume of crystalloid remains in the vasculature. As a precaution, lactate measurements for patients receiving intravenous LR should be interpreted with attention to the site of the blood draw; the sample should be obtained from sites ot...

Great review of novel oral anticoagulants, from ‘what’ to ‘how to’.. Published in BLOOD March 2012 issue... Click on the following Link..                                                                                                         Click Here please

The BP-lowering effect of labetalol begins within 2 to 5 minutes after its IV administration, reaching a peak at 5 to 15 minutes, and lasting for about 2 to 4 hours. Because of its beta blocking effects ,heart rate is either maintained or slightly reduced. This is contrary to frequent teaching or apprehensive tendencies held by many clinicians and nurses to not administer or withdraw labetalol for concerns of both bradycardia and myocardial depression. Unlike pure beta blocking agent, which decrease CO, labetalol maintains CO. Labetalol reduces systemic vascular resistance without reducing total peripheral blood flow. In addition, cerebral, renal, and coronary blood flows are maintained. Pearce CJ, Wallin JD. Labetalol and other agents that block both alpha- and betaadrenergic receptors Cleve Clin J Med . 1994;61:59–69.

Simply,Nasal prongs can’t deliver much oxygen due to their drying effect on the nasal mucosa . Hudson masks or non-rebreather masks are sometimes not that well tolerated. Patients many times  get restless and combative with a face mask, or simply wear it on forehead HUMIDIFIED NASAL HIGH-FLOW OXYGEN seems a little too much, or you don’t have it. NASOPHARYNGEAL OXYGEN could be the solution for the mentioned artifacts in oxygen therapy tools... NPO is achieved by insertion of a size 10 gauge oxygen catheter (for adults) passed through the nares and advanced to the depth of the nasopharynx. The depth of insertion is determined by the distance from the ala nasi to the tragus… Oxygen flow rates for NPO are generally provided at 2-6 L/min ” NPO gives equivalent oxygenation to a mask oxygen delivered at higher flows. A study from Anaesthesia and Intensive Care reports NPO’s halved the needed oxygen flow rate. It also helps the patient drink, feed and talk more easily wh...

Protamine for enoxaparin overdose Protamine may be used to treat severe cases of hemorrhage in enoxaparin overdose Protamine reverses the prolonged aPTT, but fails to completely reverse the anti-Xa effect (reverses about 60%) Administer protamine by slow IV to equal the dose of enoxaparin injected: (1:1 ratio) if < 8 hours after last dose enoxaparin, give 1 mg protamine per 1 mg enoxaparin; if 8-12 hours after last dose enoxaparin, give 0.5 mg protamine per 1 mg enoxaparin; if >12 hours after last dose of enoxaparin, protamine is not required Ellen Lemkin,University of Maryland Emergency department