sedationstation

The traditional text book of anesthesia tells us about the the interaction between aminoglycoside and the non depolarizing muscle relaxants... It is true ...the aminoglycoside prolong the action of muscle relaxants..... But it is not only o for aminoglycoside .....Colistin also... You may not be be familiar with Colistin...it highly used in many areas (Lebanon one of these countries).. Here is the Colistin issue and its implications on anesthesia practice..(report from the anesthesia safety news letter) Colistin, otherwise known as Polymyxin E, is a drug seeing a resurgence in use against multi-drug-resistant Gram negative bacteria, in particular Acinetobacter, E-coli, Klebsiella , and P. aeruginosa .  This drug, initially developed in the 1950s, was supplanted by the aminoglycosides because of the concern for significant nephrotoxicity and neurotoxicity associated with Polymyxin E. Of particular concern to anesthesiologists is the neuromuscular blockade due to ...

Rethinking Opioid Prescribing to Protect Patient Safety and Public Health. Alexander GC et al.  JAMA  2012 Nov 13;308:1865-1866. The authors of this “Viewpoint” piece begin by noting that the rates of death and complication from prescription drug abuse have been increasing astronomically: The annual number of fatal drug overdoses in the United States now surpasses the annual number of motor vehicle deaths, and overdose deaths attributable to prescription opioids — nearly 15000 in 2008 — exceed those attributable to cocaine and heroin combined. This marked increase has coincided with “ Pain as the 5th Vital Sign ” campaign, a push  that  some have suspected  was encouraged and supported by pharmaceutical companies as a marketing tool. The authors recommend “changes to clinical guidelines to treat chronic pain that are less reliant on opioids”. This would involve re-evaluation of the role of opioids in treating chronic pain: Grater cli...

Next time you get endocrine question.... Check endobible.com A very interesting site to help you answering these  questions.....

Identify the antihypertensive agent: 1. Rapid acting systemic and coronary artery vasodilator with minimal effects on cardiac conductivity or inotropy. Well studied in pregnancy. Caution in patients with left ventricular failure, liver cirrhosis 2. Predominantly dilates the venous system. Useful in patients with cardiac ischemia, pulmonary edema, or congestive heart failure. Caution in patients with right ventricular failure 3. Drug of choice in eclampsia, pre-eclampsia, and aortic dissection. Contraindicated in patients with congestive heart failure and heart block   4. Decreases peripheral vascular resistance and increases collateral coronary blood flow in an uncontrolled and unpredictable manner and may result in serious complications. Drug of choice during pregnancy 5. Direct arterial vasodilator that increases cardiac output and heart rate (Reflex response). Patient may develop lupus like syndrome. Not to be used as first line in the ED 6. Arterial vasodilator that...

EtCO 2 can be measured by colorimetry and capnography. Colorimetric devices provide continuous, semi-quantitative EtCO2 monitoring. A typical device has the following three color ranges: Purple—EtCO 2 is less than 0.5% Tan—EtCO 2 is 0.5–2% Yellow—EtCO 2 is greater than 2% Normal EtCO 2 is greater than 4%; hence, the device should turn yellow when the endotracheal tube is inserted in patients with intact circulation.(1) False positives may occur when the device is contaminated with acidic substances, such as gastric acid, lidocaine or epinephrine. The device will not provide an accurate reading if it is expired or if the tube is clogged with secretions. 1- Galvagno SM, Kodali BS. Critical monitoring issues outside the operating room. Anesthesiology Clin . 2009;27(1):141–156

The Eastern Association for the Surgery of Trauma recently released an update of their practice guideline for screening for blunt cardiac injury.  Although the bulk of the guideline remains the same, a few areas have been updated to reflect advances since its original 1998 release. Here is a quick summary of the new guidelines. Level 1 (best data): If blunt cardiac injury is suspected, an EKG should be obtained (no change) Level 2 (good  data ): If a new arrhythmia is seen on EKG, admit for monitoring. If not new, compare with an old EKG to determine need for admission. (updated) If the EKG is normal and troponin I is normal, BCI is ruled out. If the EKG is normal and troponin I is abnormal, admit for monitoring. (new) If the patient is unstable or the arrhythmia persists, obtain a cardiac echo. (updated) Sternal fracture is not predictive of BCI (moved from level 3) CPK should not be obtained (modified and moved from level 3) Nuclear medicine studies should ...

Delirium in the Critically Ill Delirium has been shown to be an independent predictor of mortality and can occur in up to 75% of critically ill patients. Whether preventing or treating delirium in the critically ill patient, consider the following: Minimize the use of anticholinergic medications (i.e. diphenhydramine, chlorpromazine) Ensure pain is adequately controlled (avoid meperidine and tramadol) Be careful with sedative medications; consider bolus dosing and daily interruption of continuous infusions Additional measures to treat delirious patients include reducing sensory deprivation, promoting normal sleep-wake cycles, early physical rehabilitation, and treating psychosis

  If child is <6 months think: laryngomalacia and    if >6y-3y/o think croup   - The differential of child with stridor <6m:  laryngomalacia vocal cord paralysis subglottic stenosis  vascular ring structures - Other causes of stridor: tracheitis, epiglottitis, trauma, foreign body, deep neck space infection   - Tips for the treatment of croup:   Dexmethasone is superior to prednisolone. Start dexmethasone  at 0.15-0.6 mgkg. Typically one time dosing is sufficient. PO/IM forms are considered equivalent. A 2011 Cochrane review found no difference in the type of nebulized epinephrine used.  If regular epinephrine dosing is 0.5 ml/kg of 1:1000. If 2.25% racemic epinephrine, give 0.05 ml/kg

I just Got my ipad...and I looked for the best Medical Applications. here is one of the Top 10 ranked Med-Apps,as per imedicalapps.com Surley it is good for anesthesiologists and intensivists iLarynx.... iLarynx has to be one of the most ingenious iPad medical apps we’ve seen in the App Store. The idea itself is the focal point, whereas the practicality of the app needs more work. The premise of the the app is you are about to intubate with fiberoptic laryngoscopy — and you have to use the iPad’s accelerometer as well as on screen buttons to manipulate the scope in order to secure the airway. one of the users said: " I’ve used a fiberoptic scope to intubate before, and I must admit, this app does offer a relatively accurate description of how the scope manipulates. However, there are a massive amount of variables not taken into account: namely, not everyone intubates with fiberoptic scopes at the head of the bed. These things as an aside, it should again be emphasized...

There have been a number of publications looking at the pre-operative optimisation of oxygen delivery for high risk patients. They are based on studies showing that high-risk patients surviving major surgery achieved consistently higher postoperatrive oxygen delivery and cardiac index compared with non-survivors. Shoemaker showed the following values to be associated with survival: Cardiac Idex (CI)                    4.5 l/min/m2 Oxygen delivery (DO2)            600 ml/min/m2 Oxygen consumption (VO2)     170 ml/min/m2 Shoemaker et al . in 1987 and Boyd et al . in 1993 showed that producing supranormal values of oxygen delivery(>600 ml/min/m2) resulted in a reduction in pot-operative mortality in high risk surgical patients. A paper in Critical Care Medicine in 2000 (prospective, randomized controlled trial of 412 patients undergoing major abdominal surgery in 13 hospitals from ...

Three subtypes of HIT:  1.  Typical or classical onset HIT. Typically, the platelet count falls gradually starting 5 to 10 days (up to 2 weeks) after the initiation of heparin.  Thrombocytopenic levels may not occur until several days later. 2. Early or rapid-onset HIT.   In some cases, thrombocytopenia may occur abruptly within 5 days of heparin therapy.  The rapid onset suggests exposure to heparin within the past 3 months and the presence of circulating HIT antibodies.  Since the antibodies are already present, thrombocytopenia may occur promptly with heparin administration. 3.     Delayed-onset HIT.  Although rare, thrombocytopenia may occur from several days to more than a month after cessation of heparin.  Such patients may have high titers of HIT antibody.

Blood pressure (BP) = Cardiac output (CO) x systematic vascular resistance (SVR)  IS CO REDUCED?  Yes No BP 90/70 mm Hg 90/40 mm Hg Skin Cool, blue Warm, pink Nail bed return Slow Rapid Heart sounds Muffled Crisp History/lab Hypervolemic or cardiogenic etiology or WBC and/or temperature Source of infection Immune compromise Severe liver disease Working diagnosis See next question Septic shock/endotoxemia   IS THE HEART TOO FULL? Yes No Presentation Angina, dyspnea Hemorrhage, dehydration Signs Cardiomegaly Dry mucous membranes Extra heart sounds tissue turgor JVP Stool, gastric blood Lab ECG, x-ray hematocrit Echocardiogram BUN/creatinine Working diagnosis Cardiogenic shock   Hypovolemic shock   WHAT DOES NOT FIT? Cardiac tamponade Anaphylaxis Acute pulmonary hypertension Spinal shock Right ventricular infarction Adrenal insufficiency Overlapping multiple etiologies

First don't give Bicarb based on PH Give Bicarb based on HCO3 level,if HCO3 <5 If HCO3 < 5 ,give 1 or two vials..enough and reasses the ABGs If you found the PCO2 > 1.5 (HCO3) + 8,then ventilate the patient ,don't give HCO3 As U notice there are a lot of Don'ts ....yes don't use BICARB liberally ,Bicarb has its own risks: Risk One: Bicarb when adminstered it will release the CO2 Molecules that  it holds -(HCO3...did use ce the CO2)-into the circulation ,which diffuse intracelluraly causing significant intracellular acidosis. Risk two: Bicarb ,it is Sodium bicarb...yes there is sodium,the questio is How much sodium? 1L of 0.9% NSS contains 154 Meq of Sodium 1L of NaBicarb,contains 1000 Meq of sodium,thus the the 50 cc ampule contains 50 Meq..which is 1/3 the amount of sodium in 1L of NSS.... This huge amount of Sodium may cause uninetntional increase in sodium levels causing hypernatremia and then fluid overload... This High sodium content...

Vial contanaining orange powder 20 mg per vial 3 g of mannitol (to improve solubility) Sodium hydroxide (to give pH of 9.5) Reconstitute with 60 ml of water Protect from light