Tuesday September 30, 2008



Q: Why its not a good idea to give "amp. of bicarb" via same line from where LR (Lactate Ringer) is infusing?


A: Reason, its not a good idea to mix "bicarb" with LR (Lactated Ringer) as LR contains calcium which will bind bicarbonate and will make the whole management ineffective.


Related previous pearls: LR and NS

Sunday September 28, 2008
CURB-65 Score

Lim and colleagues have designed a score called CURB-65 to rate mortality in community acquired pneumonia (CAP) - based on information available at initial hospital assessment. Give one point each for following values

C = Confusion
U = Urea (BUN) if more than 20 mg/dl (7 mmol/l)
R = Respiratory rate if more than / = 30/min,
B = BP if SBP less than 90 or DBP less than/= 60,
65 = If age more than / = 65 years

With score 0 expected mortality is 0.7%,
With score 1 expected mortality is 3.2%,
With score 2 expected mortality is 13%,
With score 3 expected mortality is 17%,
With score 4 expected mortality is 41.5% and
With score 5 expected mortality is 57%



Reference: click to get abstract

1.Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study - W S Lim, M M van der Eerden, R Laing, W G Boersma, N Karalus, G I Town, S A Lewis and J T Macfarlane - Thorax 2003;58:377-382

Saturday September 27, 2008
An important score card to remember !

TIMI RISK SCORE FOR STEMI

Category = Points
Age more than 75 yrs = 3
Age 65-74 yrs = 2
DM or HTN or Angina = 1
SBP less than 100 mm hg = 3
HR more than 100 bpm = 2
Killip II-IV = 2
Weight less than 67 kg (150 lbs) = 1
Anterior STE or LBBB = 1
Time to treatment more than 4hrs = 1
Total points (0-14)


TIMI RISK SCORE AND 30 DAY MORTALITY

Risk Score = 30 day mortality
0 = 0.8
1 = 1.6
2 = 2.2
3 = 4.4
4 = 7.3
5 = 12
6 = 16
7 = 23
8 = 27

more than 8 = 36

Morrow et al. , TIMI Risk Score for ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clinical Score for Risk Assessment at Presentation, Circulation 2000; 102:2031-2037

Friday September 26, 2008
KILLIP Classification

The Killip classification (designed about 40 years ago) is a system used in individuals with an acute myocardial infarction (heart attack), in order to risk stratify them. Individuals with a low Killip class are less likely to die within the first 30 days after their myocardial infarction than individuals with a high Killip class.

Patients were ranked by Killip class in the following way:

Killip class I includes individuals with no clinical signs of heart failure
Killip class II includes individuals with rales or crackles in the lungs an S3 gallop, and elevated jugular venous pressure.
Killip class III describes individuals with frank acute pulmonary edema.
Killip class IV describes individuals in cardiogenic shock or hypotension (measured as SBP lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosisor sweating).


Mortality rate based on Killip classification

Killip class I: 81/250 patients; 32% (27 to 38%). Mortality rate was found to be at 6%.
Killip class II: 96/250 patients; 38% (32 to 44%). Mortality rate was found to be at 17%.
Killip class III: 26/250 patients; 10% (6.6 to 14%). Mortality rate was found to be at 38%.
Killip class IV: 47/250 patients; 19% (14 to 24%). Mortality rate was found to be at 81%.



Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two year experience of 250 patients. Am J Cardiol 1967; 20: 457-464.

Thursday September 25, 2008


Q: Does Phenytoin (Dilantin) get cleared by hemodialysis or hemoperfusion?

A; No (clinically insignificant removal)


Clinical significance:

1. In Phenytoin toxicity/overdose, Hemodialysis or hemoperfusion are ineffective for enhancing elimination.

2. Hemodialysis patients do not require extra dosing post dialysis though require frequent monitoring due to lower albumin level.

Wednesday September 24, 2008
Is there any change in criteria for identifying exudative pleural effusion

Heffner and Steven Sahn did the study to determine multilevel likelihood ratios for pleural fluid tests that are commonly used to discriminate between exudative and transudative pleural effusions. Studies were identified by searching MEDLINE and related bibliographies. Data were obtained for 1,448 patients from seven primary investigators led to modified Light criteria. These incorporate the test combination of the value of LDH of pleural fluid to serum ratio, PF/serum protein ratio, PF/serum LDH ratio, LDH of pleural fluid alone. If any of these being positive that indicates exudative effusion.


Pleural fluid Test/ Metaanalysis cut Points
Pleural fluid protein = more than 2.9 g/dl
PF/serum protein ratio = more than .5
Pleural fluid LDH = more than 0.45 upper limit of normal
PF/serum LDH ratio = more than 0.6
Pleural fluid cholesterol = more than 45 mg/dl


Conclusion: Multilevel likelihood ratios combined with a clinician’s estimation of the pretest probability of an exudative effusion improve the diagnostic accuracy of discriminating between exudative and transudative pleural effusions. Likelihood ratios avoid the use of confusing terms, such as “pseudoexudates,” that derive from the use of single cutoff points for pleural fluid tests.



Reference: click to get abstract

Heffner JE, Sahn SA, Brown LK. Multilevel Likelihood Ratios for Identifying Exudative Pleural Effusions. CHEST 2002; 121:1916–1920

Tuesday September 23, 2008
Mortality in Acute Lung Injury due to Pulmonary vs. Nonpulmonary Sepsis

Janothan Sevransky from John Hopkins studied 288 patients with sepsis induced ALI and prospectively classified as having pulmonary vs. non pulmonary sources of sepsis.

Result: Unadjusted analysis revealed, lower in hospital mortality for pulmonary sepsis vs. nonpulmonary sepsis (42% vs. 66%, p less than 0.0001).

Adjusted analysis several factors predicted the mortality:

• Age: OR 1.03
• Charlson co morbidity index: OR 1.15
• ICU length of stay prior to ALI diagnosis: OR 1.19
• APACHE II score: OR 1.07
• Lung injury score: OR 1.64
• SOFA score: OR 1.15
• Cumulative fluid balance in first 7 days after ALI diagnosis: OR 1.06

A pulmonary vs. non pulmonary source of sepsis was not independently associated with mortality: OR 0.72

Conclusion: Although lower mortality was observed for ALI patients with a pulmonary vs. non pulmonary source of sepsis, this finding was due to lower severity of illness in those with pulmonary sepsis.



Reference: click to get abstract

Sevransky JE, Martin GS, Mendez-Tellez P, Shanholtz C, Brower R, Pronovost PJ, Needham DM. pulmonary vs nonpulmonary sepsis and mortality in acute lung injury. Chest 2008; 134: 534-538