Sunday September 21, 2008
What's the right length of endotracheal tube (ETT) for oral intubation?
As a gold standard the only way to make sure that tip of ETT is atleast 2 cm away from carina (or at appropriate place) is via chest X-ray. But there are many bedside quick tricks/formulae described in literature. One such formula 1 which also found to have good clinical correlation, is
ETT length (incisors to midpoint of trachea, cm) = patient's height (cm)/10+5
Like, if patient's height is 170 cm, ETT should be taped at
170/10 + 5 = 22 cm
Another trick is to have ETT's cuff palpable at sternal notch, a technique described about 40 years ago ! 2 .
Reference:
1. Anaesthesia Intensive Care 1992; 20:156;
2. Anesthesiology 1964; 25:169
Sunday, September 21, 2008
Saturday, September 20, 2008
Saturday September 20, 2008
Diagnostic criteria of Delirium
Q: What are 4 basic criteria to label patient as having Delirium?
A: Per American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV), Patient is having delirium if
1. Disturbance of consciousness (eg, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition such as memory deficit, disorientation, language disturbance (or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia).
3. The disturbance develops over a short period of time (usually hours) and tends to fluctuate during the course of the day.
4. Disturbance caused by a general medical condition or substance intoxication or medication use.
References: click to get abstract/article
1. An Empirical Study of Different Diagnostic Criteria for Delirium Among Elderly Medical Inpatients - J Neuropsychiatry Clin Neurosci 15:200-207, May 2003
2. Delirium in Elderly Patients - Focus 3:320-332 (2005)
3. Delirium in Older Persons - N. Engl. J. Med., March 16, 2006; 354(11): 1157 - 1165
4. Delirium - emedicine.com
5. Delirium - American Family Physician® Vol. 67/No. 5 (March 1, 2003)
Diagnostic criteria of Delirium
Q: What are 4 basic criteria to label patient as having Delirium?
A: Per American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV), Patient is having delirium if
1. Disturbance of consciousness (eg, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
2. A change in cognition such as memory deficit, disorientation, language disturbance (or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia).
3. The disturbance develops over a short period of time (usually hours) and tends to fluctuate during the course of the day.
4. Disturbance caused by a general medical condition or substance intoxication or medication use.
References: click to get abstract/article
1. An Empirical Study of Different Diagnostic Criteria for Delirium Among Elderly Medical Inpatients - J Neuropsychiatry Clin Neurosci 15:200-207, May 2003
2. Delirium in Elderly Patients - Focus 3:320-332 (2005)
3. Delirium in Older Persons - N. Engl. J. Med., March 16, 2006; 354(11): 1157 - 1165
4. Delirium - emedicine.com
5. Delirium - American Family Physician® Vol. 67/No. 5 (March 1, 2003)
Friday, September 19, 2008
Friday September 19, 2008
Case: 52 year old male is back from cardiac angioplasty with abciximab (ReoPro) infusion. Pre-cath labs were normal. CBC was send per protocol after 4 hours of abciximab infusion and lab call with critical platelet level of 62. Abciximab was stopped and hematology consulted. Hematology advised to restart abciximab !!
Pseudothrombocytopenia
Pseudothrombocytopenia is a common phenomenon with patients on abciximab (ReoPro). It is a benign condition and is not a real thrombocytopenia as platelets actually clump in collecting tubes containg EDTA. It is an important diagnosis to make as it may leave patient without an appropriate treatment. Diagnosis can be made by reviewing peripheral blood film or drawing blood in citrated or heparinized tube. It is not clear why abciximab cause more EDTA-induced platelet clumping.* EDTA (Ethylenediaminetetraacetic acid) is a commonly used anticoagulant in sampling tubes for blood counts.
References: click to get abstract/article
1. Occurrence and clinical significance of pseudothrombocytopenia during abciximab therapy J Am Coll Cardiol. 2000 Jul;36(1):75-83.
2. Abciximab-Associated Pseudothrombocytopenia - Circulation. 2000;101:938
3. EDTA dependent pseudothrombocytopenia caused by antibodies against the cytoadhesive receptor of platelet gpIIB-IIIA - Journal of Clinical Pathology 1994;47:625-630
4. Pseudothrombocytopenia Volume 329:1467 Nov. 11, 1993
Case: 52 year old male is back from cardiac angioplasty with abciximab (ReoPro) infusion. Pre-cath labs were normal. CBC was send per protocol after 4 hours of abciximab infusion and lab call with critical platelet level of 62. Abciximab was stopped and hematology consulted. Hematology advised to restart abciximab !!
Pseudothrombocytopenia
Pseudothrombocytopenia is a common phenomenon with patients on abciximab (ReoPro). It is a benign condition and is not a real thrombocytopenia as platelets actually clump in collecting tubes containg EDTA. It is an important diagnosis to make as it may leave patient without an appropriate treatment. Diagnosis can be made by reviewing peripheral blood film or drawing blood in citrated or heparinized tube. It is not clear why abciximab cause more EDTA-induced platelet clumping.* EDTA (Ethylenediaminetetraacetic acid) is a commonly used anticoagulant in sampling tubes for blood counts.
References: click to get abstract/article
1. Occurrence and clinical significance of pseudothrombocytopenia during abciximab therapy J Am Coll Cardiol. 2000 Jul;36(1):75-83.
2. Abciximab-Associated Pseudothrombocytopenia - Circulation. 2000;101:938
3. EDTA dependent pseudothrombocytopenia caused by antibodies against the cytoadhesive receptor of platelet gpIIB-IIIA - Journal of Clinical Pathology 1994;47:625-630
4. Pseudothrombocytopenia Volume 329:1467 Nov. 11, 1993
Thursday, September 18, 2008
Thursday September 18, 2008
Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection
The patients who have Pseudomonas aeruginosa colonization do worse compared to patients who have ventilator associated pneumonia, according to this prospective study in Journal of CCM 1.
Objective: To investigate the frequency and outcomes of ventilated patients with newly acquired large burdens of Pseudomonas aeruginosa and to test the hypothesis that large quantities of bacteria are associated with adverse patient outcomes. It was a prospective, single-center, observational, cohort study in a medical-surgical intensive care units in a tertiary care university hospital.
Patients: All adult patients requiring more than/ =48 hrs of mechanical ventilation and identified as having newly acquired P. aeruginosa in their lower respiratory tracts.
Results:
Furthermore, more patients with high P. aeruginosa burdens secreted the type III secretion facilitator protein, PcrV (p = 0.01).
Conclusions: A group of patients with large burdens of P. aeruginosa who did not meet clinical criteria for ventilator-associated pneumonia had an increased risk of death when compared with patients who had high P. aeruginosa burdens and met ventilator-associated pneumonia criteria. Patients with high P. aeruginosa burden seemed to possess more virulent strains.
Trivia: Do you know that P. aeruginosa is capable of growth in Diesel and Jet fuel where it is known as a hydrocarbon utilizing microorganism ("HUM bug") and also has the ability to grow at 42 degree Celsius?
References: Please click to get abstract
1. Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection - Critical Care Medicine. 36(9):2495-2503, September 2008
Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection
The patients who have Pseudomonas aeruginosa colonization do worse compared to patients who have ventilator associated pneumonia, according to this prospective study in Journal of CCM 1.
Objective: To investigate the frequency and outcomes of ventilated patients with newly acquired large burdens of Pseudomonas aeruginosa and to test the hypothesis that large quantities of bacteria are associated with adverse patient outcomes. It was a prospective, single-center, observational, cohort study in a medical-surgical intensive care units in a tertiary care university hospital.
Patients: All adult patients requiring more than/ =48 hrs of mechanical ventilation and identified as having newly acquired P. aeruginosa in their lower respiratory tracts.
Results:
- Of 45 patients with high P. aeruginosa burdens ( more than/=1,000,000 cfu/mL in endotracheal aspirates; more than/=10,000 cfu/mL in bronchoalveolar-lavage), 17 (37.8%) patients did not meet clinical criteria for ventilator-associated pneumonia and had a statistically significant higher risk of death (p = 0.002) when compared with the patients who had P. aeruginosa ventilator-associated pneumonia.
- When excluding the ten patients who had ventilator-associated pneumonia attributed to bacteria other than P. aeruginosa or attributed to multiple bacteria including P. aeruginosa, the risk of death remained statistically significant (p = 0.006).
Furthermore, more patients with high P. aeruginosa burdens secreted the type III secretion facilitator protein, PcrV (p = 0.01).
Conclusions: A group of patients with large burdens of P. aeruginosa who did not meet clinical criteria for ventilator-associated pneumonia had an increased risk of death when compared with patients who had high P. aeruginosa burdens and met ventilator-associated pneumonia criteria. Patients with high P. aeruginosa burden seemed to possess more virulent strains.
Trivia: Do you know that P. aeruginosa is capable of growth in Diesel and Jet fuel where it is known as a hydrocarbon utilizing microorganism ("HUM bug") and also has the ability to grow at 42 degree Celsius?
References: Please click to get abstract
1. Increased mortality of ventilated patients with endotracheal Pseudomonas aeruginosa without clinical signs of infection - Critical Care Medicine. 36(9):2495-2503, September 2008
Tuesday, September 16, 2008
Monday, September 15, 2008
Sunday, September 14, 2008
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.
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.
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