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
Wednesday, September 10, 2008
Tuesday, September 9, 2008
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
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
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
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 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.
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