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The incidence of bicuspid aortic valve is 1-2%, making it the most common congenital cardiovascular anomaly. It often occurs in multiple members of the same family, suggesting autosomal dominance. It has a male predominance and it is associated with coartation of the aorta. The most common complication of bicuspid aortic valve is aortic stenosis and severe stenosis is a frequent indication for aortic valve replacement in young patients (<60 years of age). The features of aortic stenosis associated with a bicuspid aortic valve are similar to degenerative calcification of tricuspid aortic valves, although degeneration occurs at a much younger age. Bicuspid aortic valves are also at risk of developing aortic regurgitation and at risk of endocarditis

Intraventricular haemorrhage occurs in 25% of very low birth weight infants, mostly within the first 72 hours of life . Intraventricular haemorrhage may be complicated by ventricular dilation, which can progress to hydrocephalus, parenchymal infarction, or cystic periventricular matter injury.   The risk factors include RDS, hypotension, aggressive fluid resuscitation, fluctuating blood pressure and hypertonic infusions. Periventricular leucomalacia describes changes in white matter associated with hypoxia, hypotension, severe hypocarbia, large PDA, toxic injury or infection. It is a strong predictor for later cerebral palsy. Research has shown pain receptors develop by 20 weeks GA and pain pathways develop by 26 weeks. A foetus of 26 weeks may demonstrate a stress response in response to stimulation.   There has been recent concern about that anaesthetic agents may have an effect on the developing brain leading to later memory and learning impairment. ...

Central lines offer good vascular access for the infusion of pressors and inotropes. It is important to mention that central access is preferred for infusion of those medications because of the concern for peripheral vascular and tissue damage. The problem with pressors delivered peripherally is with infiltration . A long peripheral IV placed in a good vein could certainly be used to deliver pressors but the risk of skin necrosis and its implications (infection, need for grafting) is just too high. Some institutions however have been using more dilute formulations of certain pressors for peripheral use. There is no data supporting this but institutional records have shown it to be safe. Please keep in mind you should make sure to stay within your institution’s guidelines for the use of pressors. Your pharmacy needs to be on board with this as they are responsible for mixing/diluting the meds and dispensing them. The dilution would also have to be compatible with pump pr...

Most anesthesiologists are aware of the adverse effects associated with mild hypothermia in the perioperative period (e.g. increased risk of wound infection, cardiac morbidity, and PACU stay). However, in the ICU population, some of whom are exposed to environmental extremes, the manifestations of hypothermia become more numerous. Hypothermia is classified as mild (core temperature 32-35C), moderate (28-32C), and severe (< 28C), and leads to multiple physiologic derangements, including in the CNS (fatigue, ataxia, reduced gag reflex, coma, decreased EEG activity), cardiovascular system (hypovolemia [secondary to diuresis], arrhythmias [including asystole]), pulmonary system (respiratory depression, apnea, pulmonary edema), kidneys (“cold diuresis”), and immune system (immunosuppression). The mortality rate of hypothermic patients is approximately 17% (based on a multicenter review of over 400 non-operative cases) In 2002, two large, prospective trials demonstra...

Once the fluid and fetal cells enter the maternal pulmonary circulation, usually AFE presents as 2 phases . First phase: The patient experiences acute shortness of breath which may lead to hypotension and cardiac arrest. It is said that half of women does not provide beyond this phase. Second phase : S urvivors of first phase will pass onto the second phase. This is known as the hemorrhagic phase and may be accompanied by severe shivering, coughing, vomiting, and the sensation of a bad taste in the mouth. This is accompanied by excessive bleeding due to DIC. Regardless the phase the treatment is mostly supportive.

For the first time, doctors have imaged a live birth using a special MRI machine, hoping to illuminate the birthing process and understand how complications may develop. The mother and baby — who was born Nov. 20 — are both doing fine, according to doctors at Berlin's Charité hospital, who announced the results today. The mother agreed to give birth inside the MRI machine, which was specially designed to be larger than the typical narrow cylinder. She still had to wear earmuffs to block out the high-frequency noise, as CNET points out . To protect the baby’s hearing, the machine was shut off just before the amniotic sac opened.

This is a real world study that shows that antibiotics first is a viable option for the treatment of appendicitis, confirming previous RCTs. Complications were less for those receiving primary antibiotics compared to those receiving primary surgery. A difficulty is that not all cases were ‘confirmed appendicitis’ – ‘early appendicitis’ can be hard to confirm.                                                   Click here for the abstract

Today I was covering the acute pain service...i had a case of 81 y/o female patient with ESRD and Lymphoma...she was maintained on Duragesic patch 25mcg..we are consulted because she is suffering of severe chest and back pain during dialysis.."yes it is Rebound pain"..a well known phenomenon that occurs when opioids get dialyzed ...SO i thought How to manage..and what opioid that will stay in during dialysis... Here is what I found: The factors that determine whether or not a drug is filtered during dialysis are the molecular weight (MW) of the compound and its degree of protein binding, volume of distribution (VD), and solubility (WS) Molecules less likely to be removed by dialysis have low MW and WS, are highly protein bound, and have a high VD.   Using these criteria, one would anticipate that morphine , a drug of relatively low protein binding and moderate WS, would be removed by dialysis   Whereas methadone...

A couple decades ago, a patient was considered at high risk for Post Operative  cardiac complication(PCC) for 6 months after an MI, and at some increased risk forever. Today, advances in treatment of acute coronary syndrome have improved the prognosis after MI. However, as shown by Van Belle ’ s angiography study of 56 post-MI patients, plaques remain unstable and vulnerable to reocclusion for at least 4 weeks, even after thrombolysis. Now the high-risk period is 6 weeks, with a period of relative risk from 6 – 12 weeks. In this relative-risk period, cardiac function is more important than time Van Belle E, Lablanche J-M, Bauters C, Renaud N, McFadden EP, Bertrand ME. Coronary angioscopic findings in the infarct- related vessel within 1 month of acute myocardial infarction: natural history and the effect of thrombolysis. Circulation 1998;97(1):26 – 33.

Photos show the Migration of IVC to the Heart                                           lateral CXR showing the IVC filter in the Heart   Apical, four-chamber, echocardiogram showing the presence of an IVC filter in right ventricle (arrow). The right atrium (RA), left ventricle (LV), and left atrium (LA) are labeled . Excision of the IVC filter from the right ventricle (arrow). The right atrium (RA) is labeled. Wait the details tomorrow....

A very interesting case report Published in Pediatr Emerg Care  highlights the difference between the Pharmacokinetics of  Transdermal fentanyl and the Pharmacokinetics of  IV route...Beside this it highlights the management of Transdermal fentany Overdose... Here is the case : The case is of a 15-year-old girl found apneic at home after having applied five of her stepfather’s fentanyl patches (100 μg/h each) to her body in a suicide attempt. She required multiple doses of intramuscular and intravenous naloxone to maintain respiratory drive and level of consciousness, and then a naloxone drip for 36 hours after presentation. Here is the Lesson learned : Because fentanyl is so short-acting (duration of IV dose 0.5 – 1.0 hours), it is easy to underestimate how long the effects of transdermal fentanyl will last. However, because of the concentration gradient, when a fentanyl patch is applied a depot of the drug is taken up by skin layers and slowly r...

T he aim of surgical positioning is to allow good surgical access while minimising risk of harm to the patient. An unconscious surgical patient is reliant on the anaesthetist to be attentive to their safe positioning throughout the procedure. Safe patient positioning includes ensuring that; 1-The patient is secure on the operating table 2-All limbs are placed in natural positions without stretch to nerves/muscles/tendons/vessels 3-All pressure areas are padded and eyes are protected

Cesarean Section is about 20% of all deliveries. Severe pain for 48 hrs. Two components; Visceral and Somatic Possible chronicization of pain (10-15%) Multimodol analgesia :neuroaxial morphine,paracetamol,NSAIDs,Tramal TAP Block is effective..But maybe intrathecal morphine is superior(Kanazi et al).. TAP is probably interesting in CS under General anesthesia. More abstracts: www.lsanesthesia.org

Intrathecal Morphine for post operative pain : Doses from 0.075 mg to 5 mg have been tested . limited effectiveness of doses less than 0.1mg ceiling effect at 0.2 mg and more. Duration of analgesia is 27 hours..(11-29 hrs) Dose dependent side effects: pruritis  ,Nausea,Vomiting..significantly decreased with dose of 0.1mg Clinically significant respiratory depression rarely if dose < 0.2mg..Obesity is a risk factor  For more abstracts...                                                www.lsanesthesia.org

Generally, calcium is administered to hyperkalemic patients to stabilize the cardiac myocytes by restoring their normal resting membrane potential ( Fisch, 1973 ). It is generally reserved for moderate to severely hyperkalemic patients with cardiac instability. Although there are no clear guidelines or evidence demonstrating the exact point to administer calcium, many clinicians will administer it if:  (1) the EKG shows evidence of cardiac destabilization such as widening QRS or loss of p-waves on EKG (be advised that EKG findings in patients with hyperkalemia can vary from patient to patient, and patients with severely elevated serum potassium levels may not manifest concomitant EKG findings);  (2) Serum potassium levels above 6.5-7mEq/L regardless of the presence of EKG changes (3) rapid rises in serum potassium levels.  As a general rule, however, have a low threshold to administer calcium. There are two options when administering calcium: calcium gluc...

This recent drug trial and editorial  click here published in NEJM September 2010 show the outcome of too much analgesia when treating osteoarthritis of the knee. The study drug was Tanezumab , a monoclonal antibody that blocks nerve growth factor which then produces pain relief. Unfortunately the drug was too effective, which caused some patients to wear out their knees so badly they needed knee replacements. Consequently the FDA has put a halt on the studies with Tanezumab.

In one of largest studies to date (3,121 cardiac arrests included in the study) of prehospital capnography in cardiac arrest, an initial EtCO2 >10 mmHg (1.3 kPa) was associated with an almost five-fold higher rate of return of spontaneous circulation (ROSC). In addition, a decrease in the EtCO2 during resuscitative events of >25% was associated with a significant increase in mortality, independent of other variables known to affect outcome. The authors conclude: “ EtCO2 values should be included as important variables in protocols to terminate or continue resuscitation in the prehospital setting “. The link to Study Lives Here... JUST CLICK Prehosp Disaster Med. 2011 Jun;26(3):148-50

According to a study in J Trauma dec 2011 , the prescence of a skull fracture increases mortality in severe TBI by about 30%. The study Retrospective study of a total of 197 patients who had isolated severe TBI (GCS<9 at ED triage). The site was an university hospital. Paeds, multitrauma, traumatic cardiac arrest and no available CT images were exclusion criteria. Out of the 197 patients 46,7% had a skull fracture in the ED. 92 patients had a fractured skull while 105 patients comprised the non fractured group. These groups were compared for hospital mortality. Results Mortality in the skull fracture group was 64,1%. Mortality in the non skull fracture group was 31,4% Conclusion Skull bone fracture might double mortality in severe TBI. Not surprising. Skull fractures imply the head was hit with energy high enough to break skull bones. Consequently, one would expect more severe tissue injury. J Trauma. 2011 Dec;71(6):1611-4; discussion 1614

In addition to its diuretic effect, furosemide may acutely relieve congestive symptoms by increasing venous capacitance and decreasing pulmonary artery pressures within minutes of a bolus intravenous infusion.  This is before and independent of any diuretic effect. Bumetanide  ( Bumex ) is another   loop diuretic .  In the brain, bumetanide blocks the   NKCC1   cation-chloride co-transporter, and thus decreases internal chloride concentration in   neurons . In turn, this concentration change makes the action of   GABA   more hyperpolarizing, which may be useful for treatment of   neonatal   seizures , that quite often are not responsive to traditional GABA-targeted treatment, such as   barbiturates . Bumetanide is currently under evaluation as a prospective antiepileptic drug. Loop Diuretics interactions: When loop diuretics are administered in conjunction with some antiarrhythmic drugs or cardiac glycosi...

P roper positioning of Cental line  is imperative. Improperly placed tips of catheters can create significant morbidity and in some cases mortality. Specifically, catheter tips located in the right atrium or right ventricle can cause arrhythmias or perforate the heart, leading to tamponade and death. Catheter tips placed too proximally, in the subclavian vein or brachiocephalic vein, are associated with higher rates of thrombus formation and central stenosis. Central catheters placed in either the subclavian or internal jugular veins should be positioned with the tip at the cavoatrial junction. The cavoatrial junction is located approximately 5 cm below the tracheobronchial angle, a reliable fluoroscopic landmark.  This distance is reproducible in all patients independent of gender and body habitus. Most central venous catheters are manufactured with marks denoting the length of the catheter. In general to reach the cavoatrial junction, catheters should be ...

Step 1: Early antibiotics- broad spectrum/tailored for source (if known) Popular broad spectrum combo: Tazocin or Zosyn (piperacillin/tazobactam)- 3.375 or 4.5 grams IV Vancomycin- 15-20 mg/kg IV (usually capped at 1 gram per dose but latest guidelines recommend giving full weight based dose up to 2 grams IV for the first dose) Antibiotics for other clinical situations Healthcare associated pneumonia (patients at risk for drug resistant organsims- long term care facility resident, admitted to the hospital for 2 or more days in the past 3 months dialysis patient outpatient IV antibiotics or chemo in the past month In any of these cases Please add Levofloxacin  or  levaquin to zosyn/vanc Levaquin (levofloxacin)- 750mg IV “double covers pseudomonas” Step 2: Aggressive fluid resuscitation Start with a 2 liter normal saline bolus Insert a central line above the diaphragm (subclavian, supraclavicular, internal jugular) Measure central venous pressure (CV...