Sunday September 07, 2008
How Factor 7 works
How Factor 7 works
Total video time (5:50 minutes)
Sunday, September 7, 2008
Saturday, September 6, 2008
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 interesting and landmark work was done by Kahn and coll. which showed that:
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
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:
- "Talking" and "TV" contribute to 49% of noise in ICU.
- 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
Friday, September 5, 2008
Friday September 05, 2008
Regarding fenoldopam
Case: 39 year old male admitted with hypertensive emergency after he ran out of his prescriptions. "ED Doc" started patient on IV cardene (nicardipine) drip and resumed patient's home med for BP which consist of Toprol (metoprolol) XL - first dose given in ER. On review of CXR you noticed some pulmonary edema and decide to switch to Fenoldopam to get dual effect of lowering BP as well as dopaminergic effect to resolve pulmonary edema. Patient dropped his BP precipitously and coded.
Probable cause: It is not advisable to start fenoldopam on patients with B-blocker or atleast close caution should be maintained. Concomitant use of beta-blockers in conjunction with fenoldopam may cause life threatening hypotension from beta-blocker's inhibition of the sympathetic reflex response to fenoldopam 1.
Related previous pearl: Renal dose Fenoldopam ?
Click to get abstract/article
1. Corlopam - fda.gov
2. Fenoldopam — A Selective Peripheral Dopamine-Receptor Agonist for the Treatment of Severe Hypertension - Volume 345:1548-1557, Number 21, Nov. 22,2001
Regarding fenoldopam
Case: 39 year old male admitted with hypertensive emergency after he ran out of his prescriptions. "ED Doc" started patient on IV cardene (nicardipine) drip and resumed patient's home med for BP which consist of Toprol (metoprolol) XL - first dose given in ER. On review of CXR you noticed some pulmonary edema and decide to switch to Fenoldopam to get dual effect of lowering BP as well as dopaminergic effect to resolve pulmonary edema. Patient dropped his BP precipitously and coded.
Probable cause: It is not advisable to start fenoldopam on patients with B-blocker or atleast close caution should be maintained. Concomitant use of beta-blockers in conjunction with fenoldopam may cause life threatening hypotension from beta-blocker's inhibition of the sympathetic reflex response to fenoldopam 1.
Related previous pearl: Renal dose Fenoldopam ?
Click to get abstract/article
1. Corlopam - fda.gov
2. Fenoldopam — A Selective Peripheral Dopamine-Receptor Agonist for the Treatment of Severe Hypertension - Volume 345:1548-1557, Number 21, Nov. 22,2001
Thursday, September 4, 2008
Thursday September 04, 2008
Bedside tip ! - Tracheal Tube Tolerance
Some intubated patients wake up and cough on the tracheal tube, but may not be ready for extubation and you may be reluctant to re-sedate them. Consider a trial of intravenous Lidocaine. Administer 1 mg/Kg slowly over about two minutes. There is a good chance that the patient will experience immediate and dramatic relief from irritation caused by the tracheal tube (some may even sleep for a while). If the patient has a good response to the bolus, you may even start an intravenous infusion of Lidocaine at 2mg/ min. This can buy you the 1 – 3 hours the patient may need to be able to extubated safely.
Bedside tip ! - Tracheal Tube Tolerance
Some intubated patients wake up and cough on the tracheal tube, but may not be ready for extubation and you may be reluctant to re-sedate them. Consider a trial of intravenous Lidocaine. Administer 1 mg/Kg slowly over about two minutes. There is a good chance that the patient will experience immediate and dramatic relief from irritation caused by the tracheal tube (some may even sleep for a while). If the patient has a good response to the bolus, you may even start an intravenous infusion of Lidocaine at 2mg/ min. This can buy you the 1 – 3 hours the patient may need to be able to extubated safely.
Wednesday, September 3, 2008
Wednesday September 03, 2008
Do we need to start thinking about extracorporeal life support in cardiopulmonary resuscitation?
A study by Chen from national Taiwan University hospital evaluated the role of cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest.
Study Design: 3 year prospective observational study with 113 enrolled in the conventional CPR and 59 enrolled in the extracorporeal CPR group out of total 975 patients with in-hospital cardiac arrest.
Results:
Between the propensity matched group, there was a significant difference to survival to discharge hazard ratio (HR=0.51), and a 30 days and one year survival (HR 0.53)
Reference: Click to get abstract/article
Chen Y, Lin J, Yu H, Ko W et al. Cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008; 372(9638): 554-561
Do we need to start thinking about extracorporeal life support in cardiopulmonary resuscitation?
A study by Chen from national Taiwan University hospital evaluated the role of cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest.
Study Design: 3 year prospective observational study with 113 enrolled in the conventional CPR and 59 enrolled in the extracorporeal CPR group out of total 975 patients with in-hospital cardiac arrest.
Results:
Conclusion: In patients with in hospital cardiac arrest, extracorporeal CRP had a short and long term benefit over conventional CPR.
Reference: Click to get abstract/article
Chen Y, Lin J, Yu H, Ko W et al. Cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008; 372(9638): 554-561
Tuesday, September 2, 2008
Tuesday September 02, 2008
Alternatives to Fresh Frozen Plasma in Coagulopathy patients
Coagulopathy is generally treated with fresh frozen plasma in injured patients with coagulopathy. High dose recombinant factor VIIa has been used off label to treat severe coagulopathy following trauma. Deborah Stein from University of Maryland studied the use of Low-dose recombinant factor VIIa for trauma patients with coagulopathy.
Study design: Retrospective with 81 patients receiving 84 doses of low dose factor VIIa. Etiology of the coagulopathy patient in study population included:
- Traumatic brain injury (40%),
- warfarin use (22%)
- Cirrhosis (13%)
Results:
- Mean prothrombin time (PT) fell from 17s (+/-3.2) to 10.6 (+/- 1.4).
- All patients had a good clinical response with no bleeding complications.
- Utilization of packed red blood cells and fresh frozen plasma were significantly less in the 24 h after FVIIa administration as compared to the 24 h prior.
- Subsequent thromboembolic events were observed in 12 of the 81 patients (15%) and included; CVA (6), mesenteric thrombosis (2), myocardial infarction (1), pulmonary embolism/deep venous thrombosis (2), and atrial thrombus (1). Only four of these events were thought to be related to the FVIIa administration, with two of the four contributing to a lethal outcome.
Conclusions: The low dose (1.2mg) Factor VIIa rapidly and effectively treat mild to moderate coagulopathy following injury, and is felt to be cost effective.
Reference: Click to get abstract/article
Stein DM, Dutton RP, Hess JR, Scalea TM. Low-dose recombinant factor VIIa for trauma patients with coagulopathy. Injury 2008; 39 (9):1054-1061
Monday, September 1, 2008
Monday September 01, 2008
Early vs Late Tracheostomy !
It is a common understanding that all prolong ventilated patients eventually require tracheostomy but so far there is no strong evidence-based guidelines for early vs late tracheostomy, and the appropriate timing is still controversial.
Earlier, one study looked into a total of 163 relevant ICU patients and suggests that: "Tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality". 1
Another meta-analysis of five studies with 406 patients was published in BMJ and found that "In adult ICU patients, who require prolonged mechanical ventilation, performing an early tracheostomy, may shorten ventilator days and length of stay in ICU but does not alter mortality or the risk of pneumonia". 2
But one very large study failed to show marked benefit. This month a retrospective cohort analysis of about 11,000 patients from 114 acute care hospitals in Ontario, Canada has been published to determine whether earlier tracheostomy is associated with greater long-term survival. 3
Measurements: For crude analyses, tracheostomy timing was classified as early ( less than10 days) vs. late ( more than 10 days) with mortality measured at multiple follow-up intervals.
Results: A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) were early and two-thirds late (n = 7169)
Patients receiving early tracheostomy had little lower unadjusted 90-day (34.8% vs. 36.9%), 1 yr (46.5% vs. 49.8%), and study mortality (63.9% vs. 67.2%)
Conclusions: Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit.
Refrences: Click to get abstract/article.
1. Timing of Tracheostomy as a Determinant of Weaning Success in Critically Ill Patients: A Retrospective Study - Crit Care. 2005; 9 (1): R46-R52
2. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation - BMJ 2005;330:1243 (28 May)
3. The effect of tracheostomy timing during critical illness on long-term survival - Critical Care Medicine. 36(9):2547-2557, September 2008
Early vs Late Tracheostomy !
It is a common understanding that all prolong ventilated patients eventually require tracheostomy but so far there is no strong evidence-based guidelines for early vs late tracheostomy, and the appropriate timing is still controversial.
Earlier, one study looked into a total of 163 relevant ICU patients and suggests that: "Tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality". 1
Another meta-analysis of five studies with 406 patients was published in BMJ and found that "In adult ICU patients, who require prolonged mechanical ventilation, performing an early tracheostomy, may shorten ventilator days and length of stay in ICU but does not alter mortality or the risk of pneumonia". 2
But one very large study failed to show marked benefit. This month a retrospective cohort analysis of about 11,000 patients from 114 acute care hospitals in Ontario, Canada has been published to determine whether earlier tracheostomy is associated with greater long-term survival. 3
Measurements: For crude analyses, tracheostomy timing was classified as early ( less than10 days) vs. late ( more than 10 days) with mortality measured at multiple follow-up intervals.
Results: A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) were early and two-thirds late (n = 7169)
Patients receiving early tracheostomy had little lower unadjusted 90-day (34.8% vs. 36.9%), 1 yr (46.5% vs. 49.8%), and study mortality (63.9% vs. 67.2%)
Conclusions: Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit.
Refrences: Click to get abstract/article.
1. Timing of Tracheostomy as a Determinant of Weaning Success in Critically Ill Patients: A Retrospective Study - Crit Care. 2005; 9 (1): R46-R52
2. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation - BMJ 2005;330:1243 (28 May)
3. The effect of tracheostomy timing during critical illness on long-term survival - Critical Care Medicine. 36(9):2547-2557, September 2008
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