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Background : We investigated acetaminophen use and identify factors contributing to supratherapeutic dosing of acetaminophen in hospitalized patients. Methods : We retrospectively reviewed the electronic health records of adult patients who were admitted to 2 academic tertiary care hospitals (hospital A and hospital B) from June 1, 2010, to August 31, 2010, and who received acetaminophen during their hospitalization. Patients’ acetaminophen administration records (includ- ing drug name, dose, administration time, hospital units, etc), demographic data, diagnoses, and results from liver function tests were obtained. The main outcome measures included acetaminophen exposure rate and supra- therapeutic dosing rate among hospitalized patients, hazard ratios (HRs) and 95% confidence intervals (CIs) for risk factors for supratherapeutic dosing, and changes in liver function test before and after supratherapeutic dosing. Resu...

Cricoarytenoid joint may be affected by rheumatoid arthritis.  Cricoarytenoid arthritis may result in shortness of breath and snoring.  RA patients have been misdiagnosed as having sleep apnea when in fact they have cricoarytenoid arthritis.  Patients with cricoarytenoid arthritis may present with stridor on inspiration.  This may present in the postanesthesia care unit (PACU) while the patient is recovering from anesthesia.  Acute subluxation of the cricoarytenoid joint, as a result of tracheal intubation, can cause stridor as well, and it is not responsive to racemic epinephrine

Nondepolarizing neuromuscular blocking drugs have very limited lipid solubility. This is due to the highly ionized state of nondepolarizing neuromuscular blocking drugs at physiologic pH. This limits their accessibility to the various tissues and results in a small volume of distribution.  The small volume of distribution implies that neuromuscular blocking drugs are limited primarily to the extracellular fluid. Physiologically, the highly ionized state of nondepolarizing neuromuscular blocking drugs minimizes their transfer across lipid membrane barriers. This includes lipid membranes such as the blood-brain barrier, renal tubular epithelium, gastrointestinal epithelium, and placenta.  Clinically, nondepolarizing neuromuscular blocking drugs therefore produce minimal central nervous system effects, undergo minimal renal tubular absorption, are ineffective when administered orally, and do not affect the fetus when administered to a parturient.   miller anesthesia ...

Proportioning Systems a)  Limit N 2 O flow to 3 times O 2 flow b)  Link vs. pressure operated systems • Link system: mechanically turns down N 2 O needle valve if O 2 flow reduced - N 2 O flow will NOT return to initial value if O 2 flow increased • Pressure system: pneumatically decreases N 2 O flow if O 2 flow reduced - N 2 O flow will return to initial value if O 2 flow increased 

Published data and guidelines are mixed about whether epidural steroid injections benefit patients with sciatica. Researchers performed a meta-analysis of 23 randomized trials (>2000 patients) in which steroid injections were compared with placebo injections. The placebo arms included injection of inert substances (such as saline) or short-acting anesthetics. Both acute and chronic cases were included in the trials; patients with histories of surgery or potential spinal canal stenosis were excluded. Short- (>2 weeks but  3 months) and long-term (>12 months) efficacy was measured on a scale from 0 to 100 points (difference of 10–30 points is clinically significant). Epidural steroid injections were associated with less short-term leg pain (mean difference, –6.2 points) and disability (mean difference, –3.1 points) but not with less back pain relative to placebo. In the long term, no significant differences were found in leg pain, disability, or back pain. Comment: ...

Anesthesia practice is associated with polypharmacy ....polypharmacy is highly linked to anaphylaxis...all of us know that adrenalin is the drug of choice....but maybe still contraversial which route is the best......here is the answer.. The therapeutic algorithm for anaphylaxis should begin with epinephrine 0.3-0.5 mg IM, which can be repeated every 5-15 minutes.  The intramuscular route has been shown to have better absorption and more rapid peak plasma concentrations than the subcutaneous route and is therefore the route of choice.  If the patient is still in extremis, then a diluted solution of epinephrine 0.1mg should be given intravenously.  Extreme caution should be used when giving epinephrine intravenously as most adverse effects are from this route.

Transient neurologic symptoms (TNS) is a syndrome of pain/dysesthesia in the lower back, posterior thighs, or buttocks that generally occurs within 24 hours of recovery from a spinal anesthetic.  Full recovery from the symptoms most often occurs within 3 days. Importantly, TNS is not associated with sensory loss, motor weakness, or bowel or bladder dysfunction.  Risk factors for TNS following spinal anesthesia include the use of lidocaine, lithotomy position during surgery, and outpatient status. Indeed, when these three risk factors are combined, the incidence rate has been found to be 24%. Similar to lithotomy, positioning for knee arthroscopy appears to dramatically increase risk. 

One of the more serious complications of central venous catheter (CVC) placement involves arterial puncture and cannullation with a large caliber dialator and catheter.  This occurs in up to 5% of all CVC placement attempts.   Depending on the location of  CVC placement, inadvertent arterial placement may lead to bleeding, embolism, neurologic injury, airway loss and even death.  Verifying venous placement prior to dilatation, cannulation and infusion of vasoactive agents is essential. One method of doing so in situations where placement is equivocal by standard methods is with the less-publicized but highly useful bedside echocardiography bubble test. In order to employ this method during CVC placement, after the target vessel has been entered with the finder needle, insert the finder needle catheter.  Have an assistant place the echo probe in a subcostal position.  Through the finder needl...

Below is the link of must read paper by every physician...the checklist.. It is not about novel diagnostic test...or magical therapeutic agent...it is about the simple checklist and how it made difference ans saved lives ....                                 Click here for the paper 

Jugular line access become easier by, putting patient head down,valsalva maneuver,lateral oration les than 45 degree. What about femoral line ....any way makeit easier ? This study was done in adult patients, with the knee straight and no abduction applied. External rotation is also helpful in kids, with  abduction up to sixty degrees . Simple external rotation of the leg increases the size and accessibility of the femoral vein Emerg Med Australas. 2012 Aug;24(4):408-13 Objective:  To determine if external rotation of the leg increases the size and accessibility of the femoral vein compared with a neutral position. Methods : One hundred patients presenting to a tertiary teaching hospital were prospectively recruited. The right common femoral vein of each subject was scanned with a linear probe (5–10 MHz) inferior to the inguinal ligament, with the leg in a neutral position and then in the externally rotated position. The transverse diamet...

 ETT should have a radiopaque line extending to the tip in order to identify the tube length.  Ideally the tip of the ETT (arrow) should be midway between the thoracic inlet (top dotted line) and the carina (bottom dotted line).  Some pointers: The thoracic inlet on chest XR is roughly at the level of the clavicles.  Anatomically it is the superior portion of the manubrium anteriorly.  This is the level of the subglottis area and upper trachea. The carina is usually located around T5-T7 and is usually easily identified on chest XR.  If you have difficulty draw a line from the inferior main bronchi and they intersect at the carina. The ETT in a normal adult can advance and retract up to 2cm with neck flexion and extension.  Therefore it is recommended that the ETT is at least 2cm from the carina and 2cm from the thoracic inlet.

There is a general belief that PN formulations require tapering. Rebound hypoglycemia is rarely seen but is often discussed in the clinical setting . The risk is very low, even in patients with diabetes mellitus, as they are somewhat “protected” by inherent insulin deficiency. Stopping PN is the same as stopping an independent insulin drip; remember, the half-life of regular insulin is only 5 minutes (although, somewhat longer if the patient is in renal failure). A taper down of PN is not needed, especially if the patient is receiving another dependable source of carbohydrate. If a particular patient is prone to hypoglycemia, tapering PN over 1–2 hours before discontinuation is justified and can avoid this problem. Eisenberg PG, Gianino S, Clutter WE, et al. Abrupt discontinuation of cycled parenteral nutrition is safe. Dis Colon Rectum, 1995; 38 (9):933-939. Krzywda EA, Andris DA, Whipple JK, et al. Glucose response to abrupt initiation and discont...

Diuretic resistance is multifactorial. Patients with heart failure often have some degree of chronic kidney disease.  As previously discussed, loop diuretics reached the tubular lumen by active secretion.  In renal insufficiency, secretion of loop diuretics is reduced.  This is in part because of accumulated, endogenous organic anions, which compete with loop diuretics at the transporter site.  Increased doses of loop diuretics are thus required to overcome this competitive inhibition.  Additionally, renal blood flow may be decreased in states of renal impairment, further interfering with diuretic secretion. Peak urinary concentrations of loop diuretics are reduced and delayed, resulting in a diminished diuretic effect. Non-adherence to sodium restriction can obviate the benefits of loop diuretics. Non-steroidal anti-inflammatory drugs interfere with prostaglandin synthesis and can antagonize the response to loop diuretics. Resistance managem...

Animal researchers are making remarkable progress in understanding the complex neurophysiologic interrelationships between the sensations of itch and pain. Recent discoveries in this area have the potential to transform the clinical management of human pain, especially for patients who experience intense itching in association with the in-hospital administration of epidural morphine. Among the most promising of these discoveries, in late 2011, using a mouse model, a group from the Washington University School of Medicine was successful in uncoupling the desired analgesic effect of morphine from the unwanted effect of itching. 1 The strategy employed by the researchers was a sequential series of molecular, cellular, biochemical, and behavioral experiments that culminated in blocking one variant of the μ-opioid receptor, MOR1D. 1  The group’s strategy built on earlier findings that showed MOR1 is the predominant receptor mediating the analgesic effects of morphine in the sp...

Functional capacity is an important consideration during pre-operative evaluation. Functional capacity can be expressed in metabolic equivalent (MET) level; the O2consumption (VO2) of a 70 kg, 40 yr old man in a resting state is 3.5 ml/kg/min or 1 MET. Perioperative cardiac and long-term risks are increased in patients unable to meet a 4-MET demand during most normal daily activities. Examples of leisure activities with less than 4 METs are baking, slow ballroom dancing, golfing with a cart, walking at a speed of approximately 2-3 mph. Activities requiring more than 4 METs include climbing hills, ice skating, running a short distance. More than 10 METs include participation in sports like swimming, football, single tennis, basketball and skating.

We always rely on the classical clinical picture of hypotension and tachycardia to make the diagnosis of hypovolemia .....but here is the two examples when the classical way may mislead you .... Beta-blockers or calcium channel blockers may blunt the usual heart rate response to severe bleeding. Among patients with chronic hypertension, a "normal" blood pressure may actually suggest relative hypotension.

1.Reduce initial dose of opioids by 50% 2. Increase intervals between boluses 3. Minimize medications 4. Monitor vitals signs 5. Consider supplemental oxygen 6. Consider significant comorbidities / complexity 7. Expect a potential longer recovery