Tuesday January 12, 2010
Q: Adenosine can cause
A) Asystole
B) Atrial fibrillation
C) Ventricular fibrillation
D) All of the above
Answer: D
Certain SVTs can be successfully terminated with adenosine. This includes any re-entrant arrhythmias - AV reentrant tachycardia(AVRT), AV nodal reentrant tachycardia (AVNRT) - by causing transient heart block in the AV Node. This is mediated via the A1 receptor, inhibiting adenylyl cyclase, reducing cAMP and so causing cell hyperpolarization by increasing outward K+ flux.
Adenosine has an indirect effect on atrial tissue causing a shortening of the refractory period and may initiate atrial fibrillation. In individuals with accessory pathways, the onset of atrial fibrillation can lead to a life-threatening ventricular fibrillation.
Tuesday, January 12, 2010
Monday, January 11, 2010
Monday January 11, 2010
A note on Terlipressin
Terlipressin is an analogue of vasopressin with longer half life. Over the past few years there has been much interest in the use of terlipressin both in adults and children. Vasopressin mediates vasoconstriction via V1 receptors and increases intracellular calcium concentration. Terlipressin (triglycyl lysine vasopressin) is a long-acting vasopressin analog. In part, it is a prodrug that is slowly cleaved in vivo to lysine vasopressin by endo- and exopeptidases in the liver and kidney over 4-6 hrs, thereby allowing prolonged effects by intermittent intravenous injections rather than continuous intravenous infusion.
Terlipressin is administered as a single bolus of 1 mg (the dosage used in gastroenterological indications) in patients with septic shock refractory to catecholamine/hydrocortisone/methylene blue. A significant improvement in blood pressure can be seen during the first 5 hours. Partial or total weaning from catecholamines is possible.
Terlipressin (1 or 2 mg intravenously) is able to reverse the intractable hypotension, with a concomitant decrease in heart rate and CI. With Terlipressin renal function and gastric mucosal perfusion are improved.
One serious concern is raised by the high incidence of ischaemia during terlipressin administration (skin and/or limb ischaemia).
In conclusion, use of terlipressin may be considered in patients with (truly) refractory septic shock despite adequate fluid resuscitation and high-dose conventional vasopressors.
A note on Terlipressin
Terlipressin is an analogue of vasopressin with longer half life. Over the past few years there has been much interest in the use of terlipressin both in adults and children. Vasopressin mediates vasoconstriction via V1 receptors and increases intracellular calcium concentration. Terlipressin (triglycyl lysine vasopressin) is a long-acting vasopressin analog. In part, it is a prodrug that is slowly cleaved in vivo to lysine vasopressin by endo- and exopeptidases in the liver and kidney over 4-6 hrs, thereby allowing prolonged effects by intermittent intravenous injections rather than continuous intravenous infusion.
Terlipressin is administered as a single bolus of 1 mg (the dosage used in gastroenterological indications) in patients with septic shock refractory to catecholamine/hydrocortisone/methylene blue. A significant improvement in blood pressure can be seen during the first 5 hours. Partial or total weaning from catecholamines is possible.
Terlipressin (1 or 2 mg intravenously) is able to reverse the intractable hypotension, with a concomitant decrease in heart rate and CI. With Terlipressin renal function and gastric mucosal perfusion are improved.
One serious concern is raised by the high incidence of ischaemia during terlipressin administration (skin and/or limb ischaemia).
In conclusion, use of terlipressin may be considered in patients with (truly) refractory septic shock despite adequate fluid resuscitation and high-dose conventional vasopressors.
Sunday, January 10, 2010
Sunday January 10, 2010
Googling Ourselves — What Physicians Can Learn from Online Rating Sites
"......My patients often Google a medication I've recommended or a disease I've diagnosed, despite the fact that I give them medication data sheets and patient education pamphlets. I figure it is not inconceivable that they would Google me too, and I'm curious to see what they will find.....
I anxiously scan the first 10 results, which offer a variety of promises to provide the reader with priceless information about Shaili Jain, M.D.: "free doctor profile report," "check her ratings and credentials," "detailed background report," "comparisons with physicians in similar specialties." Then my anxiety turns to fear as I find what I was looking for: patients' ratings of me on the many online physician-rating sites.
These sites, such as RateMDs, Vimo, and RevolutionHealth, offer patients an opportunity to rate physicians on their helpfulness, knowledge base, interpersonal skills, and punctuality..... Critics find the sites defamatory and fundamentally flawed. How can one be sure the person posting a review is really a patient and not someone with a grudge against the physician? If a physician disagrees with a particular comment, there is no opportunity for rebuttal: physicians are bound by privacy laws and a duty to preserve the confidentiality of patient information. Also, most rated physicians average a handful of ratings, which can hardly reflect the full range of impressions of a physician who sees hundreds of patients each year....
I find one score for me on Vitals.com — a pathetic 2.5 out of 5 — but I don't see any comments and can't figure out whether this is an aggregate score. It looks as if I have to pay for further information, so I scan the results for my colleagues. Most are not rated, some got 1 out of 5, and one got 4 out of 5. I exit the site, deciding its offerings are not meaningful. A few more minutes of surfing reveals that my Internet reputation is intact. I am relieved.
.......................
As I log off and prepare for a day of doctoring, I realize that despite the anxiety it has provoked since medical school, I should adapt to having my scores available for public inspection — it will clearly continue to be a fact of my professional life. Whether publicly available performance evaluations will actually result in better care and service for patients or just more bureaucracy and wasted energy remains to be seen."
Read full article from Shaili Jain, M.D. at The New England Journal of Medicine (january 7, 2010) here
Googling Ourselves — What Physicians Can Learn from Online Rating Sites
"......My patients often Google a medication I've recommended or a disease I've diagnosed, despite the fact that I give them medication data sheets and patient education pamphlets. I figure it is not inconceivable that they would Google me too, and I'm curious to see what they will find.....
I anxiously scan the first 10 results, which offer a variety of promises to provide the reader with priceless information about Shaili Jain, M.D.: "free doctor profile report," "check her ratings and credentials," "detailed background report," "comparisons with physicians in similar specialties." Then my anxiety turns to fear as I find what I was looking for: patients' ratings of me on the many online physician-rating sites.
These sites, such as RateMDs, Vimo, and RevolutionHealth, offer patients an opportunity to rate physicians on their helpfulness, knowledge base, interpersonal skills, and punctuality..... Critics find the sites defamatory and fundamentally flawed. How can one be sure the person posting a review is really a patient and not someone with a grudge against the physician? If a physician disagrees with a particular comment, there is no opportunity for rebuttal: physicians are bound by privacy laws and a duty to preserve the confidentiality of patient information. Also, most rated physicians average a handful of ratings, which can hardly reflect the full range of impressions of a physician who sees hundreds of patients each year....
I find one score for me on Vitals.com — a pathetic 2.5 out of 5 — but I don't see any comments and can't figure out whether this is an aggregate score. It looks as if I have to pay for further information, so I scan the results for my colleagues. Most are not rated, some got 1 out of 5, and one got 4 out of 5. I exit the site, deciding its offerings are not meaningful. A few more minutes of surfing reveals that my Internet reputation is intact. I am relieved.
.......................
As I log off and prepare for a day of doctoring, I realize that despite the anxiety it has provoked since medical school, I should adapt to having my scores available for public inspection — it will clearly continue to be a fact of my professional life. Whether publicly available performance evaluations will actually result in better care and service for patients or just more bureaucracy and wasted energy remains to be seen."
Read full article from Shaili Jain, M.D. at The New England Journal of Medicine (january 7, 2010) here
Saturday, January 9, 2010
Saturday January 9, 2010
Central Venous Access on Same Side of Hemothorax
A 25-yr-old man is admitted to the emergency room after motor vehicle accident on new year night. CXR showed a right-sided hemothorax. You inserted right chest tube draining 2 litres of blood. Thinking as chest tube is already placed you inserted subclavian vein central line on same side (right) with good return on all 3 ports. You started volume resuscitation. Repeat CXR shows full resolution of the hemothorax and central line in lower SVC. Despite continuous volume replacement with multiple pRBCs and 4 liters of LR and colloid blood pressure continues to deteriorate and increased drainage of blood from the chest tube noted. For faster resuscitation you placed large bore (cordis) line in left femoral vein. More volume is given through the new femoral line and patient seems to stabilize. Repeat CXR showed reaccumulation of hemothorax. Patient taken to OR but found to have a diagnosis of laceration of major vessel due to central line placement instead of original trauma. New left IJ line placed and patient stabalized.
Central Venous Access on Same Side of Hemothorax
A 25-yr-old man is admitted to the emergency room after motor vehicle accident on new year night. CXR showed a right-sided hemothorax. You inserted right chest tube draining 2 litres of blood. Thinking as chest tube is already placed you inserted subclavian vein central line on same side (right) with good return on all 3 ports. You started volume resuscitation. Repeat CXR shows full resolution of the hemothorax and central line in lower SVC. Despite continuous volume replacement with multiple pRBCs and 4 liters of LR and colloid blood pressure continues to deteriorate and increased drainage of blood from the chest tube noted. For faster resuscitation you placed large bore (cordis) line in left femoral vein. More volume is given through the new femoral line and patient seems to stabilize. Repeat CXR showed reaccumulation of hemothorax. Patient taken to OR but found to have a diagnosis of laceration of major vessel due to central line placement instead of original trauma. New left IJ line placed and patient stabalized.
Friday, January 8, 2010
Friday January 8, 2010
Electronic ICU - does it work?
Objective: To determine the impact of a telemedicine system, the electronic intensive care unit (eICU), on ICU, and non-ICU mortality, total mortality, total and ICU-specific length of stay, and total hospital cost at two community hospitals.
Design: Observational study with one baseline period and two comparison periods (eICU wave one and eICU wave two). Each time period was 4 months in duration.
Setting: Four ICU from two community hospitals in the metropolitan Chicago area. Hospital one is a 610-bed teaching hospital with three adult ICU (ten-bed medical ICU, ten-bed cardiac ICU, and 14-bed surgical ICU). Hospital two is a 185-bed nonteaching hospital with a ten-bed mixed medical/surgical ICU.
Patients: All patients 18 yrs or older with an ICU stay of at least 4 hrs during the specified time period were included.
Interventions: The eICU was implemented at both hospitals in April 2003.
Measurements and Main Results: Mortality, length of stay, and total cost were measured. Age, gender, race/ethnicity, trauma status, Acute Physiology and Chronic Health Evaluation III score, and physician utilization of the eICU were included as covariates. Included in the analysis were 4088 patients (1371 at baseline, 1287 in eICU wave one, and 1430 in eICU wave two).
Clinical and economic outcomes of the electronic intensive care unit: Results from two community hospitals - Critical Care Medicine: January 2010 - Volume 38 - Issue 1 - pp 2-8
Electronic ICU - does it work?
Objective: To determine the impact of a telemedicine system, the electronic intensive care unit (eICU), on ICU, and non-ICU mortality, total mortality, total and ICU-specific length of stay, and total hospital cost at two community hospitals.
Design: Observational study with one baseline period and two comparison periods (eICU wave one and eICU wave two). Each time period was 4 months in duration.
Setting: Four ICU from two community hospitals in the metropolitan Chicago area. Hospital one is a 610-bed teaching hospital with three adult ICU (ten-bed medical ICU, ten-bed cardiac ICU, and 14-bed surgical ICU). Hospital two is a 185-bed nonteaching hospital with a ten-bed mixed medical/surgical ICU.
Patients: All patients 18 yrs or older with an ICU stay of at least 4 hrs during the specified time period were included.
Interventions: The eICU was implemented at both hospitals in April 2003.
Measurements and Main Results: Mortality, length of stay, and total cost were measured. Age, gender, race/ethnicity, trauma status, Acute Physiology and Chronic Health Evaluation III score, and physician utilization of the eICU were included as covariates. Included in the analysis were 4088 patients (1371 at baseline, 1287 in eICU wave one, and 1430 in eICU wave two).
- The eICU did not have a significant effect on ICU/non-ICU/total mortality or hospital length of stay.
- ICU length of stay increased over time and was associated with higher physician utilization of the eICU.
- Although total hospital costs increased over time, the rate of increase was steeper for those patients whose physicians permitted only a low level of eICU involvement.
Clinical and economic outcomes of the electronic intensive care unit: Results from two community hospitals - Critical Care Medicine: January 2010 - Volume 38 - Issue 1 - pp 2-8
Thursday, January 7, 2010
Thursday January 7, 2010
A note on hyperkalemic response after succinylcholine administration
Not all patients have an exaggerated hyperkalemic response after succinylcholine administration. However, patients with conditions involving central and peripheral motor neurons, such as encephalitis, stroke, intracranial tumors, cerebral aneurysms, head trauma, spinal cord injuries, Guillain-Barré syndrome, and myopathies, may develop severe hyperkalemia after succinylcholine administration. Hyperkalemia has also been observed during the prolonged immobility of patients with burns or intraabdominal infections and in patients receiving other nondepolarizing neuromuscular blocking agents. Also, preexisting hyperkalemia may be exacerbated in patients with chronic renal insufficiency.
A note on hyperkalemic response after succinylcholine administration
Not all patients have an exaggerated hyperkalemic response after succinylcholine administration. However, patients with conditions involving central and peripheral motor neurons, such as encephalitis, stroke, intracranial tumors, cerebral aneurysms, head trauma, spinal cord injuries, Guillain-Barré syndrome, and myopathies, may develop severe hyperkalemia after succinylcholine administration. Hyperkalemia has also been observed during the prolonged immobility of patients with burns or intraabdominal infections and in patients receiving other nondepolarizing neuromuscular blocking agents. Also, preexisting hyperkalemia may be exacerbated in patients with chronic renal insufficiency.
Wednesday, January 6, 2010
Wednesday January 6, 2010
Omentum in the management of complex cardiothoracic surgical problems
Vascularized, pedicled tissue flaps are often used for cardiothoracic surgical problems complicated by factors that adversely affect healing, such as previous irradiation, established infection, or steroid use. Use of omentum was prophylactic to aid in the healing of closures or anastomoses considered to be at high risk for failure. Overall, omental transposition is successful in its prophylactic or therapeutic purpose. Complications of omental mobilization are rare. Omentum's unique properties render it an excellent choice of vascularized pedicle in the management of the most complex cardiothoracic surgical problems.
Omentum is highly effective in the management of complex cardiothoracic surgical problems. J Thorac Cardiovasc Surg. 2003 Mar;125(3):526-32.
Omentum in the management of complex cardiothoracic surgical problems
Vascularized, pedicled tissue flaps are often used for cardiothoracic surgical problems complicated by factors that adversely affect healing, such as previous irradiation, established infection, or steroid use. Use of omentum was prophylactic to aid in the healing of closures or anastomoses considered to be at high risk for failure. Overall, omental transposition is successful in its prophylactic or therapeutic purpose. Complications of omental mobilization are rare. Omentum's unique properties render it an excellent choice of vascularized pedicle in the management of the most complex cardiothoracic surgical problems.
Omentum is highly effective in the management of complex cardiothoracic surgical problems. J Thorac Cardiovasc Surg. 2003 Mar;125(3):526-32.
Tuesday, January 5, 2010
Tuesday January 5, 2010
Glutamine (GlutaSolve)
Emerging literature in Critical Care nutrition shows that Glutamine supplement improves survival from Multi Organ Failure. Low plasma glutamine has been shown to be an independent predictive factor for a poor outcome.
Glutamine is linked to improved immune function and fewer infections.Glutamine is a dietary non-essential amino acid, however during situations of extreme stress a deficiency develops. Ideally, it needs 20-40 gram glutamine per day to restore plasma glutamine levels to normal.
A major demand for glutamine via glutamate is for the production of the major cellular anti-oxidant glutathione. Low intramuscular glutathione levels are correlated with low glutamine and glutamate levels in the critically ill patients. Glutamine has been shown protective to intestinal cells. Patients with severe burns, who were nevertheless fed enterally, showed a significant reduction in septicemia.
Delivery of 30 g/day of glutamine jejunally in multiple-trauma patients led to a significant reduction in pneumonia, bacteraemia, and severe sepsis.
Practically, Glutamine (GlutaSolve) can be given via enteral route 1 packet (15 gram) twice a day after mixing in 100 cc of water.
Contraindications are acute renal failure without dialysis and moderate to severe hepatic failure.
Reference: Click to get article
Glutamine in the critically ill , Richard D Griffiths, Professor of Medicine (Intensive Care), University of Liverpool, UK. , lecture in Paris, June 9-10, 2005 - pdf file
Glutamine (GlutaSolve)
Emerging literature in Critical Care nutrition shows that Glutamine supplement improves survival from Multi Organ Failure. Low plasma glutamine has been shown to be an independent predictive factor for a poor outcome.
Glutamine is linked to improved immune function and fewer infections.Glutamine is a dietary non-essential amino acid, however during situations of extreme stress a deficiency develops. Ideally, it needs 20-40 gram glutamine per day to restore plasma glutamine levels to normal.
A major demand for glutamine via glutamate is for the production of the major cellular anti-oxidant glutathione. Low intramuscular glutathione levels are correlated with low glutamine and glutamate levels in the critically ill patients. Glutamine has been shown protective to intestinal cells. Patients with severe burns, who were nevertheless fed enterally, showed a significant reduction in septicemia.
Delivery of 30 g/day of glutamine jejunally in multiple-trauma patients led to a significant reduction in pneumonia, bacteraemia, and severe sepsis.
Practically, Glutamine (GlutaSolve) can be given via enteral route 1 packet (15 gram) twice a day after mixing in 100 cc of water.
Contraindications are acute renal failure without dialysis and moderate to severe hepatic failure.
Reference: Click to get article
Glutamine in the critically ill , Richard D Griffiths, Professor of Medicine (Intensive Care), University of Liverpool, UK. , lecture in Paris, June 9-10, 2005 - pdf file
Monday, January 4, 2010
Monday January 4, 2010
Trivia on Urokinase
Urokinase is a physiologic thrombolytic agent that is produced in renal parenchymal cells. Unlike streptokinase, urokinase directly cleaves plasminogen to produce plasmin. When purified from human urine, approximately 1500 L of urine are needed to yield enough urokinase to treat a single patient.
In plasma, urokinase has a half-life of approximately 15 minutes. Allergic reactions are rare, and the agent can be administered repeatedly without antigenic problems.
Urokinase is also commercially available in a form produced by tissue culture, and recombinant DNA techniques have been developed for urokinase production in E coli cultures.
Trivia on Urokinase
Urokinase is a physiologic thrombolytic agent that is produced in renal parenchymal cells. Unlike streptokinase, urokinase directly cleaves plasminogen to produce plasmin. When purified from human urine, approximately 1500 L of urine are needed to yield enough urokinase to treat a single patient.
In plasma, urokinase has a half-life of approximately 15 minutes. Allergic reactions are rare, and the agent can be administered repeatedly without antigenic problems.
Urokinase is also commercially available in a form produced by tissue culture, and recombinant DNA techniques have been developed for urokinase production in E coli cultures.
Sunday, January 3, 2010
Saturday, January 2, 2010
Friday, January 1, 2010
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