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Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...

Rivaroxaban: Anti-FXa activity PT and aPTT modified according to the reagent (PT more sensitive) Apixaban: Anti-FXa activity PT and aPTT not really prolonged Dabigatran: Ecarin clotting time, Haemoclott or anti-IIa PT, aPTT and TT modified according to the reagent (aPTT more sensitive) Ref. MM Samama et al Clin Chem Lab Med 2011;49,761

                                                            click here to access may 2014 issue

Mechanical Ventilation in Pregnancy The indications for intubation of a pregnant patient are no different than the non-pregnant patient. The guiding principle of ventilating the pregnant patient is ensuring adequate oxygen delivery. The goal is a PaO2 of >90 mmHg. Positive end-expiratory pressure (PEEP) should be applied to keep the FiO2 <60%, but the patient should be kept in the left lateral decubitus position to minimize the effect of PEEP on venous return. Permissive hypercapnia, a strategy used in acute lung injury, may lead to fetal distress. If higher PaCO2 levels are being sustained in the pregnant patient, then continuous fetal monitoring is required. Sedation with propofol and opioid drugs are safe, though the fetus may need to be intubated on delivery as these drugs cross the placenta. Benzodiazepines should be avoided as they have been shown to increase the incidence of cleft palate. Higher than normal peak and plateau airway pressures can be expected on the venti...

- Use is encouraged when expected surgical blood loss > 800 ml. - It is indicated when Hemoglobin value is between 10 and 13 without iron deficiency anemia. - Dose approved is 600 U/kg/week subcutaneously. - It is given in 3 injections.  - It should be started 3 weeks prior to surgery without exceeding hemoglobin target level of 15. - Monitor blood pressure before each injection. Ref. MAPAR 2014

Delta 0-3 Hz Deep sleep or deep anesthesia; hypoxia, hypocapnea, ischemia, Electrolyte disturbances Theta 4-7 Hz Sleep and anesthesia Alpha 8-13 Hz Resting, awake with eyes closed

Hemolytic Reactions Reaction Response Treatment Acute Hemolytic Transfusion Reaction Antibody reaction  + Complement fixation to rbc A, B, Kell, Kidd, Duffy and Ss antigens Hemolysis, acute renal failure, hypotension, bronchospasm, DIC Supportive measures: inotropes and vasopressors to prevent shock, maintain intravascular volume and urine output with IVF and diuretics Delayed Hemolytic Reactions   Prior sensitization to donor antigens (kidd, kell, Rh) – low levels of antibodies over time such that they are not detected on routine screening. Transfusion exposure causes an anamnestic response. Usually rbc destruction occurs extravascularly and symptoms are less severe than AHTR. Low grade fever, ↑ indirect bilirubin, jaundice, anemia Supportive, hydration and transfusion of compatible rbc as necessary       Nonhemolytic reactions       Minor Allergic Reactions Allergic reaction to donor plasma proteins Rash, pruritus, swelling Diphenhydra...

Steroid Glucocorticoid Potency Mineralocorticoid Potency Equivalent Dose Hydrocortisone 1 1 20 Prednisone 4 0.8 5 Prednisolone 4 0.8 5 Methylprednisolone 5 0.5 4 Triamcinolone 5 0 4 Dexamethasone 30-40 0 0.75

Drugs considered  safe  in patients with porphyria Drugs to  avoid  in patients with porphyria Sedatives : propofol, etomidate, nitrous oxide Sedatives : barbituates, diazepam, chlordiazepoxide Analgesics : fentanyl, meperidine, morphine, droperidol, procaine Analgesics : pentazocine, lidocaine Others:  promethazine, chlorpromazine,succinylcholine, pancuronium, neostigme, atropine Anticonvulsants : phenytoin Antibiotics : sulfonamides, chloramphenicol   Hypoglycemic agents : tolbutamide, clorpropamide   Others : ethanol, ergot derivatives, amphetamines, methyldopa, oral contraceptives

Anion gap acidosis “MUDPILES” Non anion gap acidosis Methanol Renal Tubular Acidosis Uremia Diarrhea Diabetic Ketoacidosis Carbonic anhydrase inhibition Paraldehyde Ureteral Diversions/Fistulas INH toxicity Sodium chloride administration Lactic acidosis Early Renal failure Ethylene glycol   Salicylate poisoning  

EKG MASTER CLASS 2014: INTERPRETATION OF AN EKG:  What do you look for in an EKG? 1. VALIDITY : Name on EKG Indication for EKG Mirroring of Lead I and Lead aVR “R” Wave progression in precordial Leads  2. RHYTHM: Sinus or not, P present or not If P present sinus origin P or not  P married to QRS or not 3. RATE: Regular or not If irregular, pattern Same rate or variable rate 4. AXIS: Vertical axis normal. Left or right or intermittent Horizontal axis same as before or now more clockwise or less  5. INTERVAL: PR normal, short or long  RR constant or increasing QT normal or long 6. HYPERTROPHY: P waves tall, wide, bifid or normal Voltage criteria for RVH and LVH met or not 7. CONDUCTION : Normal QRS duration in V1 –V2 or not Normal QRS duration in V5-V6 or not Axis & hypertrophy compatible or not ,else should look for Hemi block .  8. PERFUSION: Ischemia or not (T Inversion) Injury or not ( ST depression) Infarction or not (ST elevation or q) Infarction ol...

Postdischarge Nausea and Vomiting As the number of surgeries performed on an outpatient basis  continues to grow, there is increasing interest in using  antiemetic agents to prevent and treat postdischarge nausea  and vomiting (PDNV).  Because outpatient procedures are  typically less invasive and shorter in duration than inpatient  procedures, the relatively lower exposure to emetogenic inha lational anesthetics and opioids predicts a relatively lower  incidence of PONV in the PACU.  However, a study in 2170  ambulatory patients in the United States found that the inci dence of nausea and vomiting after discharge from the hospi tal was 37%, even after intraoperative prophylaxis with  ondansetron or dexamethasone.  PDNV is particularly a  concern because it occurs when patients no longer have access  to fast-acting intravenous rescue treatment, and PDNV limits  their ability to tolerate oral antiemetics. Ideal antieme...

Studies in animal models suggest that dexa methasone acts on the glucocorticoid receptor-rich bilateral   nucleus tractus solitarius (i.e., the vomiting center), but not  the area postrema. However, like other   intravenous drugs containing phosphate esters, dexametha sone has been associated with perineal burning and itching  when injected in awake patients. Apepitant inhibits   CYP 3A4 activity. this doubles  the plasma concentration of dexamethasone. Given that dexamethasone has high (80%) oral bioavailability,  and that aprepitant also increases the peak plasma concentra tion and half-life of dexamethasone, aprepitant’s inhibition of  CYP 3A4 activity probably plays alarger rolein systemic rather   than first-pass clearance of dexamethasone. Therefore doses  of dexamethasone that are coadministered with aprepitant  should be reduced by half to maintain dexamethasone plasma  concentrations that are similar to regimens withou...

The transdermal formulation offers the following advantages : Does not require oral intake (especially useful in patients with dysphagia and NPO status) Does not depend on GI absorption Improved patient compliance Less frequent dosing Long steady state with less peaks and troughs Intravenous access is not required Transdermal administration is not associated with patient discomfort The disadvantages of the transdermal route include : Lack of efficacy for breakthrough pain given long steady state Difficulty delivering high doses Requires subcutaneous fat making it ineffective in cachectic patients Pharmacokinetics and pharmacodynamics are affected by body temperature (and blood flow to the skin) - Higher levels than expected may be absorbed during a febrile episode.