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A ratio of P aO 2 to fraction of inspired oxygen (P aO 2 / F IO 2 )   200 mm Hg is one criteria used to identify ARDS, and in severe cases the P aO 2 /F IO 2 may be 75 mm Hg and mortality risk exceeds 80%—a point when ECMO is considered. It is important to note that ECMO is supportive and not therapeutic, and that the most important criteria when considering ECMO are that the underlying disease process is reversible and that the risks associated with ECMO do not worsen the patient’s condition. 

Diagnosis 1. The diagnosis of AP is most often established by the presence of two of the three following criteria: (i) abdominal pain consistent with the disease, (ii) serum amylase and/or lipase greater than three times the upper limit of normal, and/or (iii) characteristic findings from abdominal imaging (strong recommendation, moderate quality of evidence). 2. Contrast-enhanced computed tomographic (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first 48–72 h after hospital admission (strong recommendation, low quality of evidence). Etiology ...

There are many studies that address the quality of CPR.  Here, we discuss a multicenter, observational study of in-hospital and out-of-hospital cardiac arrests.  While we prefer randomized trial data, it would not have been ethical to conduct the following study as a trial. Edelson et al. analyzed 60 VF arrests to identify predictors of successful shocks.  A shock was deemed successful if VF was terminated for at least 5 seconds (a common definition in the literature). Using logistic regression, the study reported that successful defibrillation was associated with deeper compressions and shorter pre-shock pauses.   Each 5 mm increase in compression depth and each 5 second decrease in pre-shock pause was associated with an approximate two-fold increase in the likelihood of shock success.  Note, however, that the study was not powered to predict “harder” outcomes, such as  survival  or  neurological recovery. Below is another way to look a...

Calcium-Channel Blocker–Clarithromycin Drug Interactions and Acute Kidney Injury Sonja Gandhi, BSc; Jamie L. Fleet, BHSc; David G. Bailey, BScPhm, PhD; Eric McArthur, MSc; Ron Wald, MD; Faisal Rehman, MD; Amit X. Garg, MD, PhD  JAMA . doi:10.1001/jama.2013.282426 Published online November 9, 2013. Calcium-channel blockers are a popular class of antihypertensive drugs that are metabolized by the CYP3A4 enzyme. In pharmacokinetic studies, coadministration of various inhibitors of this enzyme (eg, erythromycin, antifungals, protease inhibitors, and grapefruit juice) raised plasma calcium-channel blocker concentrations by up to 500%. As a result, there is the possibility of excessive systemic calcium-channel blocker concentration and associated toxicity with concurrent use of a CYP3A4 inhibitor. Enhanced blood pressure lowering was observed in several studies (up to 12 healthy volunteers) after a CYP3A4 inhibitor was administrated with ...

Long-acting insulins Long acting insulins have a relatively peakless profile and, when properly dosed, should not result in hypoglycemia when a patient is fasting. Preoperatively, the patient should take it as close as possible to the usual time of injection. This could be at home either at bedtime the night before surgery or the morning of surgery. If there is concern for hypoglycemia, the injection can be given when the patient is at the hospital. • If the patient does not tend to have hypoglycemic episodes and the total daily basal insulin dose is roughly the same as the total daily mealtime (prandial) dose (eg, 50% basal, 50% prandial ratio), the full dose of basal insulin can be given. Example: If the patient is on insulin glargine 30 U at bedtime and insulin lispro 10 U with each meal and does not have hypo- glycemic episodes, then insulin glargine 30 U should be taken at bedtime. If the patient has hypoglycemic episodes at home, then the basal insulin can be reduced by...