icuroom pearls - September 2006

2006-09-30T09:03:00.000-07:00

Saturday September 30, 2006

Q; You admitted a patient with acetaminophen (Tylenol) overdose and started on 21 hour regimen of IV acetylcysteine / mucomyst (Acetadote). After a while as passing through the bedside, you noticed the color of liquid in bottle is changed to pink. What would be your next step ?

A; Nothing

Acetadote changes color from colorless to light pink / purplish once the stopper is punctured. This is a benign and expected effect and doesn't require any intervention. Some hospital pharmacies prepare their own generic IV acetylcysteine and this color change may not be always apparent.

Caution: Keep IV benadryl and steroid handy as flushing, urticaria and angioedema are frequent side effects of IV acetylcysteine, mostly during first hour of loading and particular caution is advised in patients with asthma and bronchospasm.

2006-09-29T08:35:00.000-07:00

Friday September 29, 2006
Phlebotomy and anemia in ICU

Phlebotomy in ICU is a major cause of anemia. With each draw of 100 ml of blood, Hb level drop by 0.7 gram/dl.

In latest report 1, "Anemia, transfusion and phlebotomy practices in critically ill patients with prolonged ICU length-of-stay" - study found that:

"In patients who are in ICU more than 21 days, blood draw of just 3.5 mL/day above average (average = 13.3 ml/day), was associated with a doubling of the odds of being transfused".

What it suggests: even very small reductions in phlebotomy volume, may significantly reduce the number of pRBC transfusions.

Do we really need blood counts, electrolytes, ABGs and other tests everyday in long-stayed ICU patients?

Related previous pearl: Phlebotomy and anemia in ICU

Reference: Click to get absract

Anemia, transfusion and phlebotomy practices in critically ill patients with prolonged ICU length-of-stay: a cohort study Critical Care 2006, 10:R140

2006-09-28T08:13:00.000-07:00

Thursday September 28, 2006
Erythropoetin and replacement of Iron

Although use of erythropoetin (and its long acting cousin - darbepoetin) are usually not part of acute treatments in ICU but are in considerable use for long term, kidney failure, Jehovah's Witnesses and other patients. We all are aware that erythropoetin will not work if patient is deficient in iron storage. But there are 3 points to remember.

Simply checking Fe level may not provide reliable answer to Fe storage 1.
Erythropoetin, by stimulating erythropoiesis to greater than physiologic level, may induce iatrogenic functional iron deficiency.
Oral iron may take longer and may not satisfy the requirement and extra dose of IV iron may be needed.

The simple formula to see if a supplemental iron is required:

Transferrin saturation less than 25%
Or/And
Ferritin less than 100 g/dl

Related previous pearls:

Intravenous(IV) Iron with dose calculations
ICU anemia score
Phlebotomy and anemia in ICU

Reference: Click to get absract
Diagnosis and management of iron-related anemias in critical illness. Critical Care Medicine. 34(7):1898-1905, July 2006

2006-09-27T10:35:00.000-07:00

Wednesday September 27, 2006
Red blood cell transfusions and nosocomial infections in ICUs

Unnecessary blood transfusions are harmful for patients and has multiple reasons for it. Significant study of about 2100 patients published in Critical Care Medicine in september 2006 regarding 'Red blood cell transfusions and nosocomial infections in critically ill patients'. Out of 2,085 patients, 21.5% received red blood cell transfusions.

Nosocomial infections, mortality rates, ICU and hospital length of stay were the main outcome measures. Study found that

The posttransfusion nosocomial infection rate was 14.3% in transfused patients but only 5.8% in nontransfused patients.
In a multivariate analysis the number of transfusions was independently associated with nosocomial infection.
Leukoreduction tended to reduce the nosocomial infection rate but not significantly.

Mortality and length of stay (both ICU and hospital) were significantly higher in transfused patients.

Reference: Click to get absract

Red blood cell transfusions and nosocomial infections in critically ill patients - Critical Care Medicine: Volume 34(9) September 2006 pp 2302-2308

2006-09-26T07:16:00.000-07:00

Tuesday September 26, 2006
INSLUIN SLIDING SCALE

Patients in the ICU with hyperglycemia should be managed by protocolized insulin infusion. However, when patients are improving, and ready to be discharged from the ICU, insulin sliding scale is a very common switch over. A few important points to remember on the insulin switch over!

a) Each unit of insulin decreases the blood glucose level by 30 – 50 mg/dl.

b) Type 1 and type II patients have different insulin requirements. Type 1 patients require less insulin (about 0.5 U/kg/day) than type II’s (1.0 U/kg/day and up depending on resistance). Remember type 1 patients need basal insulin even when NPO (i.e. approximately 1/2 - 1/3 their usual dose).

c) Think about basal insulin levels with long acting insulins such as NPH, glargine, or ultralente.

d) For BG less than 80 mg/dl, give a patient that can take PO’s 20 grams of fast acting carbohydrate (6 oz. fruit juice or soda, 4 glucose tabs, or 12 oz. low fat milk). If the patient cannot take PO’s, give 25 cc of D50 IV push. Check the finger stick glucose q15 minutes until BG more than 100 mg/dl.

e) May need to decrease doses in renal failure (insulin is not as rapidly cleared).

f) May need to increase doses for patients who are septic or treated with steroids (insulin resistance).

g) Patients on TPN/PPN may need an insulin drip (insulin can be added to TPN).

h) On the floor, Mild hyperglycemia is better than hypoglycemia.

Related previous pearl: IV insulin dose

The best precise article we found with all insulin related protocols is
Hospital management of diabetes: Beyond the sliding scale written by Dr. Etie Moghissi, Co-chair, American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. ( Reference: CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71: NUMBER 10 OCTOBER 2004. Page 801).

2006-09-25T20:31:00.002-07:00

Monday September 25, 2006
CO-OXIMETRY

Interpretation of ABG can be divided into measured and calculated values. The PH, PaO2 and PaCO2 are the measured values and HCO3 and SaO2 are calculated values. As the SaO2 is a calculated value, it does not reflect Methemoglobin and Carboxyhemoglobin levels and can misguide the management.

The most accurate method of tracking the Methemoglobin and Carboxyhemoglobin is the Co-oximetry. The principle of operation is related to the Beer-Lambert law, which states that the amount of light absorbed by a substance is directly related to the concentration of the substance. The co-oximeter uses various wavelengths of light to measure the concentration of oxyhemoglobin, reduced hemoglobin, Methemoglobin and Carboxyhemoglobin.
.

2006-09-23T18:35:00.000-07:00

Sunday September 24, 2006
Topics you can't afford to miss for Critical Care Board exams - Part 1

Editors' note: Internal Medicine's Critical Care board exam is approaching fast and we are sure fellows are preparing for it. With our experiences, we will post list of those areas (few today) which have been frequently asked in Critical Care board exams. Remember ! Taking a test is an art. Prepare for those topics which you suppose to know as an intensivist. Critical Care board exams are unique in the sense that most questions are from your day to day practice at bedside. No big magic or unusual things. We request all readers to share topics they feel our fellows should prepare. This is first in series and once a week we will try to post important topics. Good luck !!. And do as many MCQS as you may find.

1. Ethylene Glycol overdose case with osmolal gap and basic chemistry calculation (Somehow this topic and to distinguish Ethylen Glycol from other ETOHs remained all time favourite in board exams) .

2. Formula for SVR calculations

3. PWP wave form in intubated and non-intubated patient

4. Indications and contra-indications of TPA in CVA

5. Clinical manifestations of Auto-PEEP

6. Treatment of Auto-PEEP

7. ARDS and application of low tidal volume

8. PAC findings in cardiac tamponade

9. Algorithm of Dr. Rivers' Early Goal Directed Theapy

10. Adrenal insufficieny - lab and clinical findings

11. Management of fresh tracheostomy (like what if it comes out).

12. Heparin Induced Thrombocytopenia (types and clinical findings).

13. Side effects of different neuro-muscular blockers

14. Propofol infusion syndrome

15. Weaning parameters

2006-09-22T22:03:00.000-07:00

Saturday September 23, 2006
Preventing sympathetic surge during head injury patient's intubation

Orotracheal intubation cause sympathetic surges resulting in increase ICP (intracranial pressure). Despite no definite answer, endeavours continue to minimize iatrogenic expansion of hematoma. 3 drugs have shown some neuroprotective benefit during intubation of spontaneous or traumatic brain injury although they remained controversial and their benefit never get purely established.

1. Lidocaine: One study 25 years ago (but later studies were negative) showed that about 100 mg of Lidocaine (1.5 mg/kg), blunt ICP by approximately 15 mm Hg with tracheal suctioning 1. Mechanism of action is not entirely clear but probably lidocaine decreases cough reflex and dysrhythmias. No studies document any harmful effects of prophylactic lidocaine 2.

2. Fentanyl: Idea is to achieve sympatholysis and block hypertension and tachycardia. Dose of 2.5-3 μg/kg has been found to be without risk of hypotension.

3. Esmolol: Here again, goal is to achieve sympatholysis. Esmolol with dose of 100-200 mg has effect said to be superior to fentanyl and markedly superior to lidocaine 3, 4.

Combinations of above drugs have been described to have synergestic and better effect than using them alone, either esmolol and fentanyl or fentanyl and lidociane.

Related previous pearl: ICP (Intracranial pressure) wave forms

Related Link: Airway Management of the Critically Ill Patient (Chest. 2005;127:1397-1412)

References:

1. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology 1980;52:516-8
2. Prophylactic lidocaine use preintubation: a review - J Emerg Med. 1994 Jul-Aug;12(4):499-506.
3. Attenuation of hemodynamic responses to rapid sequence induction and intubation in healthy patients with a single bolus of esmolol. J Clin Anesth 1990;2:343-52.
4. A comparison of lidocaine, fentanyl, and esmolol for attenuation of cardiovascular response to laryngoscopy and tracheal intubation. Acta Anaesthesiol Sin 1996;34(2):61-7.

2006-09-22T03:55:00.000-07:00

Friday September 22, 2006
PEG-J tube

PEG-J is a modification of standard percutaneous endoscopic gastrostomy (PEG). It is a dual tube - 2 ports PEG with a jejunal extension (9F jejunal extension with 20F PEG tube). The tip is positioned distal to the ligament of Treitz.

Advantage: It may decrease aspiration rate. (Doesn't eliminate completely).

Disadvantage: It has similar complications as has standard PEG tube including bleeding, perforation, peritonitis, cellulitis or organ damage but "J extension" may have added complications with migration of J-extension back into the stomach, kinking or clogging.

If jejunal feeding is desired, literature favors direct percutaneous endoscopic jejunostomy (20F tube directly into jejunum) instead of PEG with smaller 9F jejunal extension 1.

Reference:
1. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension Gastrointest Endosc. 2002 Dec;56(6):890-4.

2006-09-21T07:08:00.000-07:00

Thursday September 21, 2006

Q; During lumbar puncture (LP), what is the normal rate of cerebrospinal fluid (CSF) escape via needle into collecting tube ?

A; 1 drop per second

While performing LP, CSF should drop into tube with approximate rate of one drop/sec. A continuous stream of CSF indicates raised intrameningeal pressure.

2006-09-20T06:27:00.000-07:00

Wednesday September 20, 2006

Q; What's the last resort of treating clostridium difficile when all other therapies fail and patient continue to have relapsing severe clostridium difficile infection ?

A; Stool Donation !!

Infusion of healthy stool (from donor) in patient's bowel via colonoscope, enema or a naso-jejunal tube. Sounds weird but idea is to restore human bowel flora. Actually, published reports shows that stool donation kills and eradicates C. diff. spores with a very high cure rate.

References:

Treatment of Recurrent Clostridium difficile-Associated Diarrhea by Administration of Donated Stool Directly Through a Colonoscope - Am J Gastroenterol. 2000 Nov;95(11):3283-5.

The effect of faecal enema on five microflora-associated characteristics in patients with antibiotic-associated diarrhoea. Scand J Gastroenterol 1999;34:580-6.

2006-09-19T14:28:00.000-07:00

Tuesday September 19, 2006
Phosphate level in acetaminophen-induced acute liver failure

Case: You transferred a patient from nearby community hospital with acetaminophen-induced acute liver failure. ALT / AST reported in thousands and last PT-INR of 2.7. On clinical exam patient is alert and oriented. Hemodynamics are stable. You alerted the hepatology team and send STAT labs. After 45 minutes you received a call from lab with 'critical value' of phosphate with 0.9 mg/dl. Is it a good sign or a bad sign?

Answer: Good Sign

Hypophosphatemia in the setting of acetaminophen-induced acute liver failure is a good sign. It indicates regeneration of hepatocytes and reversal of acute liver failure. You may have to replace it aggressively.

Conversely, hyperphosphatemia suggest impaired regeneration and is a poor prognostic sign and actually also said to be a sign of impending hepato-renal failure due to kidney's lost ability of lowering of serum phosphate 1.

Related previous pearl:

Is serum phosphate level better than King’s College Hospital criteria in Tylonol Toxicity ?

Reference: click to get abstract

1. Serum Phosphate Is an Early Predictor of Outcome in severe Acetaminophen-Induced Hepatotoxicity , Hepatology, Volume 36, Issue 3 , Pages 659 - 665

2006-09-18T12:59:00.000-07:00

Monday September 18, 2006
Resistant (uncontrolled bleeding) / Life-threatening diffuse alveolar hemorrhage

Diffuse alveolar hemorrhage remained a condition with high mortality. Usual treatment is high dose IV metilprednisolone (1g/day) for three to five days and in more severe cases to add IV cyclophosphamide (cyclophosphamide has a delayed effect, but may provide synergistic action with steroid). Plasmapheresis has been described to be effective particularly in diffuse alveolar hemorrhage associated with Goodpasture syndrome.

But what if bleeding is non-stop and life-threatening ?

Answer is off label use of activated Factor VII. In 3 cases reported from University of North Carolina at Chapel Hill - bleeding stops and oxygenation improved within minutes 1.

Reference: click to get abstract

Successful Treatment of Diffuse Alveolar Hemorrhage with Activated Factor VII - 16 March 2004 Volume 140 Issue 6 Pages 493-494

2006-09-17T11:38:00.000-07:00

Sunday September 17, 2006
Why PO Demerol is not a good idea !!

Overall, demerol (meperidine) is falling out of favor and has been referred by many as 'demon' due to neurotoxicity of its metabolite normeperidine. Fortunately PO (by mouth) demerol is not as popular as IV but it should be avoided at all. PO demerol is way more dangerous than IV demerol. 50% of PO demerol get metabolized first pass via liver and give high level of normeperidine in blood which has long half life of 15-30 hours even with normal kidney function and may accumulate to cause tremors, myoclonus, hallucinations and seizure. Hemodialysis has been described to help in normeperidine toxicity 1.

See nice review at medscape.com - free registration required: Meperidine is Alive and Well in the New Millennium: Evaluation of Meperidine Usage Patterns and Frequency of Adverse Drug Reactions (Dr. Seifert and Dr. Kennedy, Ref: Pharmacotherapy 24(6):776-783, 2004)

Reference: click to get abstract

Successful treatment of normeperidine neurotoxicity by hemodialysis - Am J Kidney Dis. 2000 Jan;35(1):146-9.

2006-09-16T06:45:00.000-07:00

Saturday September 16, 2006
A-line Tip !!

Suturing of arterial line particularly at femoral site may be tricky as catheter may get twist, turn and kink as they are relatively smaller catheter, both in length and diameter, than central venous catheter. Not only you may loose hardly obtained arterial placement but may cause significant bleeding.

Answer is simple. After you pass catheter over wire - suture first than remove the wire (if you are positive about right placement) or reinsert the wire once good pulsation of bright red blood confirmed. Some A-line kits (like arrow) have extra short wire (with J-shaped curve at back) to pass till you obtain secure placement. You must suture femoral A-lines as simple dressing will not secure it. Radial A-lines may be dressed tightly without sutures but it is preferable to secure it with sutures.

Related previous pearls: click to get

Potassium level via A-line

A-line is here but where is Allen test !!

Ultrasound guided insertion of radial artery catheters

2006-09-15T11:50:00.000-07:00

Happy 1st Anniversary - icuroom.net
September 15, 2006

Message from editors:

Today is the first anniversary of icuroom.net. We started this project one year ago with sole purpose of sharing our experiences from ICU floor. Educating critical care fellows and sharing of knowledge was the driving force for this project. This web site, as we desired remained non-commercial, educational and practical. Our aim was to share day to day related issues and to bridge knowledge and practice of Critical Care Medicine.

This project was made possible only with the team work of editors and many intensivists across the globe who continue to share their tips from bedside and encouraged us in this endeavour. We did not have a single day without a pearl in last 365 days ! Interestingly, review of our web site log shows that our major traffic originates from overseas (thats why we try to send pearl a night before).

We apologize for website's amateur look and maintenance, frequent spelling mistakes and sometimes incoherent sentences from tired minds but we hope our colleagues will understand and continue to be part of this project.

Future objectives of the website is to make it more accessible to fellows via direct email and departmental communication and to involve our overseas colleagues. Also, to include search of topics/pearls at front page. Again, anyone who is interested in joinging our team can reach editors via emails from our editors' section area.

Lastly, but not the least: Today's pearl

"Only one thing is inevitable in ICU. Trash can always lies beneath the glove box !"

Happy Birthday !

Iqbal Ratnani M.D.
Mohammed Aziz M.D.

Editors

Our first pearl was: "Try to avoid using Demerol with Zyvox (even prescribed within last 2 weeks). It may induce 'symptom cluster' which include fever, agitation, seizure, coma or even death."

2006-09-13T21:14:00.000-07:00

Thursday September 14, 2006
Z - technique

We try to share bedside tips and techniques which have not been tested scientifically but have been used by physicians with various success. During paracentesis, using the 'z technique' has shown to decrease leaking of ascitic fluid after the procedure.

Z-technique: Retract / pull the skin down relative to the abdominal wall and go in with the angiocath, then release the skin (this creates a skin track to stop ascitic fluid from leaking out after the procedure).

Related previous pearls:

How much intavenous albumin should be given to patient while removing ascitic fluid via paracentesis?

Paracentesis with seldinger technique / with central venous catheter kit

2006-09-12T21:26:00.000-07:00

Wednesday September 13, 2006
VAP and CPIS

Q; This is a very common scenario in ICUs. You have an intubated patient who starts having low grade fever and increase secretion through respiratorty tract. CXR has mild infiltrate. You suspect Ventilator-associated pneumonia (VAP) and started emperic antibiotic. Indeed, patient is showing signs of improvement in next 2/3 days but LRT (lower respiratory tract) specimen, blood cultures and UA remained negative. CXR unchanged. No other source of infection apparent. What would be your next step ?

A; Consider stopping antibiotics.

If patient's clinical pulmonary infection score (CPIS) - click here to see - remained 6 (maximum 12) or less for three days in suspected VAP - consideration should be given to stop antibiotics 1.

Click here to see one algorithm proposed by Dr. Singh and co. from Veterans Affairs Medical Center and University of Pittsburgh, Pittsburgh, Pennsylvania 2.

References: click to get abstract / article

1. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia - American Thoracic Society
2. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit: a proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med 2000;162:505–511
3. Ventilator-associated Pneumonia - Am. J. Respir. Crit. Care Med., Volume 165, Number 7, April 2002, 867-903
4. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic "blind" bronchoalveolar lavage fluid. Am Rev Respir Dis 1991;143:1121–1129.

2006-09-11T21:26:00.000-07:00

Tuesday September 12, 2006
Clonidine Toxicity !!

Q; The treatment of clonidine toxicity is mostly supportive. Which antidote has shown (only anecdotal reports) to reverse altered mental status and associated hypotension with clonidine toxicity ?

A; Naloxone (Narcan).

There are few case reports in literature describing naloxone to improve the altered mental status associated with clonidine toxicity. It also reverses hypotension but may induce severe hypertension while reversing clonidine effect and should be use with caution. Dose should be initiated from 0.2 IV and can be titrated upto 2 mg IV. Doses upto 5-10 mg have been reported but again caution should be exercise.

Another antidote described in literature for clonidine toxicity is yohimbine. (Yohimbine is a central alpha2-adrenergic antagonist) .The dose is a single 5.4 mg tablet via enteral route.

Dopamine is the choice of vasopressor in clonidine induced hypotension after IVF boluses. And, atrpoine to counteract bradycardia associted with it.

References: click to get abstract / article

1. Reversal of clonidine toxicity by naloxone - Ann Emerg Med. 1986 Oct;15(10):1229-31.
2. Clonidine toxicity revisited - J Toxicol Clin Toxicol. 2002;40(2):145-55.
3. Yohimbine as an antidote for clonidine overdose - Am J Emerg Med.1996 Nov;14(7):678-80.
4. Clonidine overdose: report of six cases and review of the literature - Ann Emerg Med. 1981 Feb;10(2):107-12.
5. Toxicity, Clonidine - emedicine.com

2006-09-10T20:28:00.000-07:00

Monday September 11, 2006
Do you really need IV potassium replacement ?

This is important to know that PO (by mouth) potassium replacement is as effective as IV replacement ans should be use if enteral route is available. Actually, correction of K level could be faster with oral supplementation due to limitation of slow rate needed for IV potassium.

40 meq of PO KCl increases serum K by 0.5 - 0.7 meq/L in 1 - 2 hours, means K level may rise from 3 to 3.5 meq/L with one PO dose of 40 meq KCl elixir.

2006-09-10T05:33:00.000-07:00

Sunday September 10, 2006

Q; Which vasopressor can suppress TSH (Thyroid Stimulating Hormone) secretion, and may be a pitfall in TSH screening ?

A; 3 major things in ICU may suppress TSH and may give misleading result.
Dopamine
High dose steroid
Caloric deprivation (malnutrition) or NPO status

Word of wisdom is not to check thyroid function test in ICUs as it takes only few hours for patient to ‘abnormalize’ thyroid function test under stress but if clinically indicated send full "Thyroid Function Test” including TSH, Total T3, Total T4, Free T4 and rT3 (reverse T3) - and read your diagnoses carefully preferably with the help of endocrine service or by consulting reference.

Related: Read nice roundup: Sick euthyroid syndrome - Jennifer Best M.D - Harborview Medical Center, seattle, Washington - University of Washington, Div. of General Internal Medicine.

2006-09-09T22:34:00.000-07:00

Saturday September 09, 2006
Non-radiological tests to confirm naso-gastric tube placement

We use different bedside techniques to confirm NG tube placement before xray is done. The most popular one is air insufflation and auscultation. Another refined version is immersing the end of the tube in water to check for bubbling.

One of the simple quick bedside confirmatory test in talking patient is his ability to continue to phonate. Some studies suggest measurement of bilirubin and enzyme content of the aspirate but naturally it is not feasible at bedside. Also bedside ultrasound has been utilized too.

One other technique whis is very under utilized and found to be more reliable than other bedside tests is to test PH of aspirate. This test is more reliable in NPO patient. Remember, the pitfalls of PH test are feeding formulas, medications like H2 blockers , PPI and patients with GERD (may have higher pH) .

Overall consencus is to combine PH with visual inspection. Here is a quick guideline

An aspirate from a gastric tube often has a pH of 5 or less and is usually grassy-green or clear.

An aspirate from a small bowel tube often has a pH of 6 or greater and is usually bile-stained, light to golden yellow or brownish-green in color.

An aspirate from a tube inadvertently positioned in the tracheobronchial track or the pleural space has a pH of 6 or greater. Obviously, an aspirate from a tube in the tracheobronchial track has the appearance of fluid obtained during tracheal suctioning. An aspirate from a tube in the pleural space is usually straw-colored and watery and mostly tinged with bright-red blood caused by perforation of the pleura.

2006-09-08T09:39:00.000-07:00

Friday September 08, 2006
Give break to housestaff !!

Q: Why we call our housestaff 'residents' in USA ?

A: About 100 years ago when formal medical training was introduced in USA, doctors in training actually lived in the hospital and were called "residents".

This week, JAMA (september 6, 2006) has published studies related to residents' hours of work and other related issues. We will give synopses of 2 studies.

1. Percutaneous injuries (like getting prick with needle) were reported to be associated with lapse in concentration and fatigue. Also, they were more frequent during extended work hours (nighttime) 1.

2. 34% of residents reported making at least 1 major medical error during the study period. Self-perceived medical errors were associated with worsened measures in all domains of burnout, depression, depersonalization, emotional exhaustion, and lower personal accomplishment 2.

Reference: get abstract by clicking

1. Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns - JAMA. 2006;296:1055-1062

2. Association of Perceived Medical Errors With Resident Distress and Empathy: A Prospective Longitudinal Study - JAMA. 2006;296:1071-1078.

2006-09-07T08:19:00.000-07:00

Thursday September 07, 2006
Eye care in ICU

Not exotic interventions but simple things make difference in patients' outcome in ICU and one of the most ignored aspect of patient care in ICU is opthalmic care. Sedatives, NMB (neuro-muscular blockers) and other meds in ICU cause eye to loose tonic contraction of the orbicularis oculi muscle, random eye movements and blink reflex. These factors interfere with tear protection of eyes as well as increase in tear evaporation by inadequate eyelid closure. Many drugs in ICU decrease secretions. All these lead to superficial or infectious keratitis.

Local hygiene play important role in eye care. One interesting study done 23 years ago found that 9 of their 10 patients have infection only in left eye because Right-handed nurses pulled the suctioning catheter away over the left side of the patient’s face 1. Another study done about 20 years ago found same organism (Pseudomonas aeruginosa) from sputum, the conjunctiva, and later the cornea 2.

Another less know eye problem in ICU is "conjunctival chemosis or edema". Increase in intraocular pressure leading to subconjunctival haemorrhage may occur with third space fluid loss which is universal in ICU patients. It gets exacerbated by positive pressure mechanical ventilation causing high intrathoracic pressure and in particular with high PEEP. Conjunctival edema also occur if the endotracheal tube is taped too tightly (due to venous congestion).

Broadly, there are 2 ways of eye care in ICU:

1. Open eye method which includes drops, gel and ointments

2. Close eye method which includes adhesive tape, saline soaked gauze, eye patches, eye shields/glasses, lower lid traction sutures etc.

Recently one study from India found that use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water providing a moisture chamber (creating close chamber, see image), is more effective than using a combination of ocular lubricants and securing tape over the eyelids (open chamber, see image) 3. But another study from UK found that Lacrilube is more effective than Geliperm or only basic eye care 4. Important thing is to be aware of dangers of exposure keratopathy.

See evidence based practice information Eye Care for Intensive Care Patients from Joanna Briggs Institute, an Affiliated Institute of the University of Adelaide, Australia.

Reference:

1. Nosocomial bacterial eye infections in intensive-care units. Lancet. 1983;1:1318-1320.

2. Eye infections caused by respiratory pathogens in mechanically ventilated patients. Crit Care Med. 1987;15:80-81.

3. Eye care in ICU - Indian J Crit Care Med 2006;10:11-14

4. Preventing exposure keratopathy in the critically ill: a prospective study comparing eye care regimes - British Journal of Ophthalmology 2005;89:1068-1069

5. A clear view: the way forward for eye care on ICU. Intensive care units. - Intensive Care Med.2000 Feb;26(2):155-6.

2006-09-06T05:39:00.000-07:00

Wednesday September 06, 2006
Where is my thyroxine doc ?

Q; What is the PO to IV conversion of thyroxine ?

A; 50% of patient's previous PO dose.

It may help to continue patient's baseline thyroxine replacement in ICU and if needed in IV form with 50% of PO dose 1. It gets more important if patient stay in ICU gets longer. Many times, it is the absence of baseline thyroxine replacement which prevents recovery of hemodynamics. Cases have been reported in literature with serious consequences that can potentially result from failure to provide adequate thyroid hormone therapy 2, 3.

Previous related pearls:

7 Pearls re. Myxedema Coma

Iodide in Thyroid Storm

Reference:

1. LEVOTHYROXINE SODIUM FOR INJECTION - bedfordlabs.com
2. Severe Myxedema After Cardiopulmonary Bypass - Anesth Analg 2003;96:62-64
3. Severe Hypothyroidism After Coronary Artery Bypass Grafting - Ann Thorac Surg 2005;80:714-716

2006-09-05T16:06:00.000-07:00

Tuesday September 05, 2006

Q; What is the physiologic amount of cortisol secreted by adrenals per day?

A; Adults secrete about 20 mg of cortisol daily.

We use anywhere from 200 - 300 mg of hydrocortisone as stress dose to encounter adrenal insufficiency. In USA, we prescribe it in divided doses and our european counterpart use it in a continuous drip and mostly along with fludrocortisone. But it may be of interest to know that physiologically, adrenal cortex in adults secrete only 20 mg of cortisol daily. It also secretes 2 mg of corticosterone which has similar activity. We use higher dose under presumption that due to stress body may require higher cortisol level. Usually, if its pure adrenal insufficiancy, restoration of BP and general improvement may be seen within 1 hour after the initial dose of hydrocortisone.

Some experts advise to leave the dose at 20 mg per day of hydrocortisone once hemodynamics are improved and stress is resolved and taper it later 1.

Related previous pearl:

Hypoproteinemia and cosyntropin test

Low dose steroid, yes or no ? - responder or non-responder ? - low-dose corticotropin stimulation test or high dose?

Hydrocortisone and Dexamethasone

Relevant study to know:

Corticus study (Corticosteroid Therapy of Septic Shock).

Reference:

1. The ICU Book : Paul L. Marino : 2nd edition: Page 770

2006-09-04T07:59:00.000-07:00

Monday September 04, 2006

Q; 62 year old male admitted to ICU with shortness of breath and found to be in exacerbation of congestive heart failure (CHF). Patient has past medical history of well controlled hypertension but uncontrolled type II diabetes mellitus (DM). Patient has stable New York Heart Association (NYHA) class 1 CHF since last many years with EF of 43%, on low dose lasix and ACE inhibitors. Patient echocardiogram done in ER showed no change from his previous echo available in file done about a year ago. Patient denied any change in his BP or CHF medicines but acknowledged that his primary care physician has added a new med. to control his DM ?

A; Avandia associated exacerbation of CHF

It was well established that Thiazolidinediones group of anti-diabetic medicines {Actos (pioglitazone), Avandia (rosiglitazone)}, should not be used in severe or NYHA class 3 and 4 cardiac status but recently it has been reported with Avandia (rosiglitazone) that this group may not be safe even in class 1 NYHA. Although there may not be any changes in EF, patient may experience increased rate of CHF worsening, new or worsening edema, and new or worsening dyspnea. Rosiglitazone-treated patients were reported to require increased doses of CHF medication and hospitalization. Also, ischemic adverse events, such as myocardial infarction and angina, were also more commonly reported in the rosiglitazone vs placebo group.

FDA has also recently revised safety labeling on rosiglitazone (Avandia) to warn of the increased risk for cardiovascular (CV) events associated with their use in patients with New York Heart Association (NYHA) class 1 and 2 cardiac status.

Note: Liver enzymes should be checked prior to the initiation of therapy and every 2 months with rosiglitazone in all patients.

References: click to get article

1. Avandia - rxlist.com

2006-09-02T22:09:00.000-07:00

Sunday September 03, 2006

Q; 74 year old male admitted with Alzheimer's related dementia to ICU with uncontrolled hypertension. Patient was initially started on Nitroprusside drip in ER and later weaned to oral antihypertensives. You decide to choose lopressor and cardizem as oral antihypertensives and noted to have good blood pressure control. Before transferring to floor you resumed his only home medication for his Alzheimer's related dementia - RAZADYNEtm ER (galantamine hydrobromide). 12 hours later, just before transfer, patient coded and on bedside note to be in 3rd degree AV block with barely palpable blood pressure ?.

A; RAZADYNE (galantamine hydrobromide), formerly known as Reminyl, is a commonly used drug for Alzheimer's related dementia. One of the major side effect of this medicine is bradycardia due to vagotonic effects on the sinoatrial and atrioventricular nodes. FDA has also issued warning for its use in patients with supraventricular cardiac conduction disorders and those receiving concomitant treatment with other drugs that significantly slow heart rate.

Objective of this question is to bring awareness of this side effect as this is a commonly used drug in geriatric population and B-blockers and calcium channel blockers always remained the first line of drug for BP control.

It is advisable to avoid or atleast be cautious of concomitant use of B-blockers and calcium channel blockers with RAZADYNE (galantamine hydrobromide).

Note: The company changed the drug's name from Reminyl to Razadyne in an effort to avoid confusion between it and glimepiride (Amaryl).

References: click to get article

1. razadyne - rxlist.com

2006-09-02T10:26:00.000-07:00

Saturday September 02, 2006
Prescribing vitamin B6 with linezolid

Linezolid is found to be associated with 2 major side effects: cytopenias and peripheral neuropathy 1. When Vitimain B6 (PYRIDOXINE) was prescribed for peripheral neuropathy, interestingly it was found to help in reversing cytopenias more than peripheral neuropathy 2 . Dose of vitamin B6 used was 50 mg PO once a day.

So far we have only few case reports but Vitamin B6 is safe and inexpensive and most experts don't see any harm in prescribing it along with linezolid.

References: click to get article

1. Severe sensory neuropathy associated with long-term linezolid use - Neurology.2005; 64: 926-927

2. Reversal of linezolid-associated cytopenias, but not peripheral neuropathy, by administration of vitamin B6 - Journal of Antimicrobial Chemotherapy 2004 54(4):832-835

2006-09-01T15:20:00.000-07:00

Friday September 01, 2006
Distal port of CVC

(Sender of this pearl has requested to hold his/her and institution's name).

Dear icuroom editors'

All kudos to your commitment for this site !! ..........

I have been in Critical Care practice for about 8 years and want to bring attention of my colleauges who are in practice for many years and some of like us, in teaching institutions, who unfortunately do not perform as many procedures due to presence of residents and fellows - to the fact that

'there is no standard color for distal port'

Over last few years, there are so many different central venous catheters made available in market that you better acquaint yourself with kit and catheter. Recently, while changing catheter over wire, I was looking for a "brown" port to insert wire but there was no brown port in this new exotic central venous catheter. I learned 2 lessons:

1. Know your kit before you open it.
2. Don't get deceived by color !

My 2 cents,
...............