Sunday September 14, 2008
Digoxin Toxicity

Q: Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?

A: Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it may be misleading.

Thursday September 11, 2008
Does Restraint has any influence on unplanned Extubation

Background: Unplanned extubation commonly occurs in ICUs. Various physical restraints have been used to prevent patients from removing their endotracheal tubes. However, physical restraint not only does not consistently prevent injury but also may be a safety hazard to patients
.
Objective:To evaluate the effect of physical restraint on unplanned extubation in adult intensive care patients.

Methods:

• 100 patients with unplanned extubations and
• 200 age-, sex-, and diagnosis-matched controls

Results:The incidence rate of unplanned extubation was 8.7%. Factors associated with increased risk for unplanned extubation included

• Physical restraints: 3.11 times
• Nosocomial infection: 2.02 times
• Glasgow coma scale more than 9: 1.98 times

Episodes of unexplained extubation were also associated with increase ICU stay.

Conclusions: An impaired level of consciousness on admission to the intensive care unit and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used.


Reference: click to get abstract/article

Chang LY, Wang KWK, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study. American Journal of critical Care 2008; 17:408-415

Wednesday September 10, 2008
Amiodarone Neurotoxicity

Amiodarone neurotoxicity has been reported in up to 40% of patients and may easily get miss or misdiagnosed when an elderly patient presents with multiple symptoms. Major manifestation are peripheral neuropathy causing proximal motor weakness, ataxia and fine resting tremor. It may also present as neuromyopathy. A case has been described with autonomic dysfunction presented as incapacitating orthostatic hypotension. Cases has been reported with Amiodarone-Induced Delirium .

Most neurotoxicities are dose related and resolved with discontinuation of Amiodarone. Being an intensivist it may be important to keep this very common dose related toxicity in mind while evaluating patient with neurologic symptoms.

Related: Amiodarone pulmonary toxicity.


References: Click to see abstract/article

1. Amiodarone-Induced Neuromyopathy: Three Cases and a Review of the Literature - Journal of Clinical Neuromuscular Disease. 3(3):97-105, March 2002.

2. Severe Ataxia Caused by Amiodarone - Volume 96, Issue 10, Pages 1463-1464 (15 November 2005) - Am J of Card

3. Amiodarone toxicity presenting as pulmonary mass and peripheral neuropathy: the continuing diagnostic challenge - Postgraduate Medical Journal 2006;82:73-75

4. Amiodarone: Guidelines for Use and Monitoring - aafp.org - Vol 68, No. 11, Dec., 2003

5. Atypical pulmonary and neurologic complications of amiodarone in the same patient. Report of a case and review of the literature - Vol. 147 No. 10, October 1, 1987 - Archive of Int Med.

6. Amiodarone-Induced Delirium - Am J Psychiatry 156:1119, July 1999

Tuesday September 9, 2008
Procalcitonin, C-reactive protein and now Chromagranin A in Sepsis. JUST ADD IT ON

Dan Zhang from France studied the link between Chromagranin A (CGA) and systemic inflammatory response syndrome (SIRS). CGA is a stress marker released along with catecholamine by adrenal medulla.

They measured CGA, procalcitonin, and C-reactive protein level in 53 patients and 14 controls. They also assessed Simplified acute physiological score (SAPS).

Results: Serum CGA level was significantly elevated in patients where infection is associated with SIRS with a median value of 138.5mcg/L as compared to controls (p<0.001).
CGA concentration also positively with procalcitonin and C-reactive protein.

Conclusion: Patients with CGA concentration higher then 71 mcg/L have a significantly shorter survival and was independent of SAPS score.


Reference: Click to get abstract/article

Zhang D, Lavaux T, Lavigne T, Castelain V, et al. Serum concentration of chromogranin A at admission: An early biomarker of severity in critically ill patients. Annals of Medicine, 21 August 2008

Monday September 8, 2008
And we thought any free fluid in peritoneum is bad

Noriyuki and their colleague studied if peritoneum can be another oxygen storage organ??

They studied the role of peritoneum and its safety by infusing volume of oxygenated RBC and with oxygenated saline in Dogs and followed hemodynamic changes. The controls comprised of dogs that underwent sham operation.

Result: They found that intraperitoneal infusion of less than 1250 ml was hemodynamically safe. Oxygenation levels (PaO2) increased with intraperitoneal infusion of oxygenated RBC.

Conclusion: Peritoneum can potentially serve as an “artificial Lung” in critically ill patients.


Editors' comment: Watch out GI may be now playing as Pulmonalogist in future.


Reference: click to get reference/article

THE PERITONEUM AS A NOVEL OXYGENATION ORGAN: REVITALIZATION OF INTRAPERITONEAL OXYGENATION. Shock. 30(3):250-253, September 2008. Matsutani, Noriyuki; Takase, Bonpei; Nogami, Yashiro ; Ozeki, Yuichi ; Ishihara, Masayuki ; Maehara, Tadaaki

Sunday September 07, 2008
How Factor 7 works

Total video time (5:50 minutes)

Saturday September 06, 2008
Noise level in ICU !!

Unnecessary noise in ICU can mask vital alarms, verbal communications and may be an unseen added cause of mental stress for staff itself. There are 2 kinds of noise in ICU

• one you can't control like "ventilator and IV pump alarms"
• and one you can modify like "conversations and TV"

One interesting and landmark work was done by Kahn and coll. which showed that:

1. "Talking" and "TV" contribute to 49% of noise in ICU.
2. EPA (Enviromental Protection Agency) recommends noise level not to exceed beyond 45 dBA in hospitals but mean peak sound level in study (medical ICU) was 80 dBA !! (which showed mark decrease with behavior modification)

Do you know beepers contribute 1% to ICU noise pollution with 84 dBA - why not to turn it to vibrate mode !!


Click here to see various measures which can decrease noise pollution in ICU (from nursingspectrum.com)



References: click to get abstrat/article

1. Identification and modification of environmental noise in an ICU setting - Chest, Vol 114, 535-540 - full article available as pdf

2. Contribution of the Intensive Care Unit Environment to Sleep Disruption in Mechanically Ventilated Patients and Healthy Subjects - American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 708-715, (2003)

3. Noise in the postanaesthesia care unit - British Journal of Anaesthesia, 2002, Vol. 88, No. 3 369-373