A Prerotational, Simulation-Based training of housestaff for central line insertion

Study is performed  to evaluate the effectiveness of a simulation-based workshop with ultrasonography instruction in reducing mechanical complications associated with central venous catheter(CVC) insertion.

56 medical house staff were trained prior to their rotations over a 6-month period. The data on mechanical complication rates after the implementation of the workshop were compared with previous experience when no structured educational program existed.

Results: There were 334 procedures in the preeducation period compared to 402 procedures in the posteducation period.

• The overall complication rate in the preeducation and posteducation period was 32.9% and 22.9%, respectively
• Placement failure rate decreased from 22.8% to 16.2%
• arterial punctures decreased from 4.2% to 1.5% Ultrasonography usage increased from 3.0% to 61.4%
• Multivariate analysis demonstrated that interns were more likely to cause overall mechanical complications compared with fellows and attending physicians in the preeducation period (P = .02); however, this trend was not observed in the posteducation period.
• Catheter site and ultrasonography usage significantly affected the overall complication rate in both periods, and ultrasound-guided femoral CVC was the safest procedure in the posteducation period.

It was concluded by authors that Implementation of a prerotational workshop significantly improved the safety of CVC insertion, especially for CVCs placed by inexperienced operators.

A Prerotational, Simulation-Based Workshop Improves the Safety of Central Venous Catheter Insertion Results of a Successful Internal Medicine House Staff Training Program - CHEST September 2011 vol. 140 no. 3 652-658  

Scenario: 28 year old male with history of sickle cell crisis presented with priapism. 6 hours past and despite adequate hydration and analgesia, there is no relief ! What is your next option?



Answer: In case of priapism, you have 2 options. Either call an urologist for aspiration of corpus cavernosum or consult a hematologist for exchange blood transfusion.

Exchange blood transfusion in sickle cell crisis should be consider in following situations:
No relief in crisis despite adequate hydration and analgesia

• Any sign of stroke
• Pregnancy
• Prophylactic exchange transfusion prior to major surgery. A single exchange transfusion reduces the risk of complications from the general anaesthetic and surgery.
• C/O loss of vision in one eye or visual symptoms
• Unresolved painful erection of the penis (priapism)

Q: Describe 7 basic properties of Midazolam (Versed) making it a good choice of use in ICUs?

Answer: Midazolam is

1. Fast (due to water solubility) and short acting,
2. anxiolytic,
3. Anterograde amnestic,
4. hypnotic,
5. anticonvulsant,
6. skeletal muscle relaxant, and
7. sedative

Introducing "Cardiophile MD"

Very informative educational website related to cardiology.

http://cardiophile.org is a blog site dedicated to medical professionals interested in learning cardiology. It aims to serve as a portal to understand all about cardiovascular system and its disorders. It is moderated by Johnson Francis, MD, DM, FCSI, FACC, FRCP, Professor of Cardiology, KMCT Medical College, India.

Topics/posts included

• Angiography and Interventions
• Cardiac CT scan
• Cardiology MCQ
• Cardiology X-ray
• Cardiovascular Biomarkers
• Cardiovascular Magnetic Resonance Imaging
• Cardiovascular Pharmacology
• Cardiovascular Surgery
• Clinical Cardiology
• ECGs
• Echocardiography
• Electrophysiology
• Ventricular Assist Devices

Q: What is the difference between Orthotopic and the Heterotopic heart transplant?

Answer:

In Orthotopic heart transplant, the failing heart is removed (The pulmonary veins are not transected; rather a circular portion of the left atrium containing the pulmonary veins is left in place). The donor heart is trimmed to fit onto the patient's remaining left atrium and the great vessels are sutured in place.

In Heterotopic heart transplant, the patient's own heart is not removed before implanting the donor heart. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a 'double heart'. The procedure can give the patients original heart a chance to recover, and if the donor's heart happens to fail (e.g. through rejection), it may be removed, allowing the patient's original heart to start working again.

Q: What is HTK solution?

Answer: HTK stands for Histidine-tryptophan-ketoglutarate. It is a preservation solution used for organ transplantation, intended for perfusion and flushing of donor liver, kidney, heart, lung and pancreas prior to removal from the donor and for preserving these organs during hypothermic storage and transport to the recipient.

The composition of HTK is similar to that of extracellular fluid. It also contains Histidine which does intensive buffering of the extracellular space, so as to prolong the period during which the organs will tolerate interruption of oxygenated blood. It also contains Mannitol and its Osmolarity is 310 mOsm/L.


Reference: click to get article

Transplantation: HTK solution: should it replace UW solution for kidney preservation? , Nature Reviews Nephrology 5, 429 (August 2009)

A note on Portal Hypertension and development of Varices

Normal portal pressure is about 9 mmHg and a normal inferior vena cava pressure is about 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12 mmHg, th gradient rises to more than 5 mm Hg. A gradient greater than 5 mmHg is defined as  portal hypertension. Once gradient becomes greater than 10 mmHg, blood flowing though the hepatic portal system gets redirected from the liver into areas with lower venous pressures. This creates collateral circulation in the lower esophagus, abdominal wall, stomach, and rectum.

AWV = abdominal wall vein, GEV = gastroesophageal vein, IMV = inferior mesenteric vein, IVC = inferior vena cava, LGV = left gastric vein, LPV = left portal vein, LRV = left renal vein, MV = mesenteric vein, PDV = pancreaticoduodenal vein, PEV = paraesophageal vein, PV = portal vein, RPPV = retroperitoneal-paravertebral vein, SMV = superior mesenteric vein, SRV = splenorenal vein, SV = splenic vein, UV = umbilical vein.

A note on PPIs and Arrhythmias

At least one study 1 has so far suggested link between Proton Pump Inhibitors (PPIs) and cardiac arrhythmias. Interestingly, study suggested a nearly four-fold increase in heart arrhythmias like focal atrial tachycardia and right ventricular outflow tract (RVOT) tachycardia).

Possible Mechanism of Action: Proton pump inhibitors (PPIs) are potent inhibitors of the gastric H+/K+-adenosine triphosphatase (ATPase) pump. H+/K+-ATPase is expressed in myocardium, and both animal and human tissue studies have shown that PPIs have electrophysiologic effects, potentially by increasing intracellular calcium concentrations.

  

Marcus, GM, Smith LM et al. (2010). "Proton Pump Inhibitors are Associated with Focal Arrhythmias". The Journal of Innovations in Cardiac Rhythm Management 1 (4): 85–89.

Q: What is the off label use of Levetiracetam (Keppra) beside its usual role as an anti-seizure?


Answer: To treat neuropathic pain

Llike gabapentin (Neurontin), it is also sometimes used to treat neuropathic pain.

Price MJ., Levetiracetam in the treatment of neuropathic pain: three case studies., Clin J Pain. 2004 Jan-Feb;20(1):33-6.

 Q: Combining which 2 epileptic drugs may increase the risk of  Stevens–Johnson syndrome?

Answer:  lamotrigine (lamictal) with sodium valproate (Depakote)

Stevens-Johnson syndrome is a rare but life-threatening acute mucocutaneous hypersensitivity reaction, well known during treatment with antiepileptic drugs (AEDs).

Kocak S, Girisgin SA, Gul M, Cander B, Kaya H, Kaya E. - Stevens-Johnson syndrome due to concomitant use of lamotrigine and valproic acid.  Am J Clin Dermatol. 2007;8(2):107-11.

Q: Which anti-psychotic drug has shown efficacy in preventing severe Nausea-Vomitting?


Answer: Zyprexa

Olanzapine (Zyprexa) has has been shown off-label use as an antiemetic, particularly for the control of chemotherapy-induced nausea and vomiting. It is said to be very effective if use with palonosetron and dexamethasone.

Q: Which of the following is side effects of Selective serotonin reuptake inhibitors (SSRIs)?

anhedonia (inability to experience pleasure)

apathy

bruxism

strange dreams

mydriasis

increased risk of bone fractures

autonomic dysfunction

Syndrome of inappropriate antidiuretic hormone hypersecretion

Answer is all of the above

Many side effects disappear after 6-8 weeks but their durations are highly individual and drug-specific.

Zofran (ondansetron): New FDA warning

Zofran (ondansetron) is a class of medications called 5-HT3 receptor antagonists. It is used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy and surgery.

FDA has issued a new warning against Zofran (Ondansetron) as it may increase the risk of developing prolongation of the QT interval, which can lead to Torsade de Pointes. Patients at particular risk are with underlying heart conditions, such as congenital long QT syndrome, with electrolyte imbalance like hypokalemia and hypomagnesemia, and those taking other medications that lead to QT prolongation.

Gestational diabetes insipidus

During pregnancy, all women produce vasopressinase in placenta, which breaks down ADH. Women with Gestational DI is thought to have excessive vasopressinase production. It can be treated as usual with desmopressin. Before starting treatment, care should be taken first to rule out pregnancy induced Dipsogenic DI where desmopressin is contraindicated.

Clinical Significance: Gestational Diabetes insipidus may be a warning sign of some serious underlying pathophysiology including pre-eclampsia, HELLP Syndrome or acute fatty liver of pregnancy. Delay in diagnosis and treatment may lead to maternal or perinatal mortality.

LOLA

Lola is an adjuvent treatment in hepatic encephelopathy. It is a solution of L-ornithine and L-aspartate (LOLA). It increases the generation of urea through the urea cycle, a metabolic pathway that removes ammonia by turning it into the neutral substance urea. It may be combined with lactulose and/or rifaximin to control symptoms of hepatic encephelopathy. See following video

Q: Out of following, in which only bleeding time is prolonged (PT, PTT and Platelet count remains normal)

A) Uremia

B) DIC

C) Aspirin

D) Hemophillia

E) Von Willebrand disease

Answer: Uremia and Aspirin

In uremia and in ASA intake, only bleeding Time (BT) is prolonged  but PT, PTT and Platelet count remains normal.

In DIC, PT, PTT  and bleeding time - all becomes prolonged and Platelet counts decrease.

In Hemophillia, only PTT gets prolonged but PT, BT and Platelet counts remain normal.

In Von Willebrand disease, PTT and BT gets prolonged but PT and Platelet counts remain normal.

A note on Factor 7 (rVIIa) and thrombocytopenia

Factor 7 (rVIIa - Novoseven) is now significantly use as off label in uncontrolled bleeding. It may not be efective in the presence of severe thrombocytopenia and should be corrected prior to its administration. Although there are case reports of the successful use of rVIIa in severe thrombocytopenia, a low platelet count is likely to predict a poor or partial response to rVIIa therapy.

Its haemostatic effects are mediated by the thrombin it generates by both tissue factor (TF) dependent and independent mechanisms. The TF independent mechanism requires platelets for the direct activation of Factor X on their surface by rVIIa

Q: How quickly IV Vitamin K starts working?

Answer: Somewhere around 2-6 hours.

IV Vitamin K should be given very slowly over 20-30 minutes. It may cause hypersensitivity. Symptoms may include facial flushing, diaphoresis, chest pain, hypotension, dyspnea, cardiac arrest and death. Very low dose (1-2 mg) is mostly enough.

Q: How Hemothorax is defined on the basis of Hematocrit?

Answer: A pleural effusion with a hematocrit value of more than 50% of that of the circulating hematocrit is considered a hemothorax.

Q: Which one immunization status should be checked in burn patients?

Answer: Tetanus

Burn patients are very prone to tetanus. A tetanus booster shot is required if patient has not been immunized within the last 5 years.

Click here for recommended Tetanus Booster (from The California Department of Public Health)

Q: Beside Renal failure, name at least 5 conditions which may be risk factors for hyperkalemia with succinylcholine?

Answer: Conditions beside renal failure having susceptibility to succinylcholine-induced hyperkalaemia are

• burns,
• closed head injury and CVAs,
• acidosis,
• Guillain–Barré syndrome,
• drowning and
• massive trauma

 etomidate speech and memory test (eSAM)

Another less known use for etomidate is to determine speech lateralization in patients prior to performing lobectomies to remove epileptogenic centres in the brain. 

Etomidate is injected into the carotid artery and will anesthetize the ipisilateral brain hemisphere for 5–10 minutes. During such time, rudimentary speech and memory tasks are performed in order to determine if removal of a particular part of a hemisphere will affect the patients language abilities or induce severe memory impairments. 

Prior to the procedure the patient is shown a series of objects and during the procedure shown another series of objects. Once the injection has worn off, the patient is shown some of the same objects and asked whether or not they saw them that day. If the patient doesn't recognize the objects that were shown during the procedure, it is clear that the medial temporal structures that were left un-anesthetized during the procedure are not functioning properly.

Etomidate speech and memory test (eSAM) A new drug and improved intracarotid procedure - Neurology December 13, 2005 vol. 65 no. 11 1723-1729

A note on Acomprosate

Acomproste (Campra), is a drug used for treating alcohol dependence but effective only during abstinence from alcohol.

Withdrawal from alcohol induces a surge in release of excitatory neurotransmitters like glutamate, which activates N-methyl-D-aspartate receptors (NMDARs). Acamprosate reduces this glutamate surge.

Side effects include diarrhea, irregular heart beat, hypotension, headaches, insomnia, and impotence. It is relatively contraindicated in renal failure.

Recommended dose is 666 mg (taken as two 333-mg tablets) three times daily.

Acamprosate is also said to be an effective treatment for tinnitus.

 Interesting case report on Hypokalemia induced Nephrogenic DI 


Reference: Buridi A, Corman L, Redinger R., Hypokalemic nephropathy and nephrogenic diabetes insipidus due to excessive consumption of a soft drink. - South Med J. 1998 Nov; 91(11):1079-82.

"Chronic diarrhea commonly causes hypokalemia. However, life-threatening hypokalemia due to chronic diarrhea has not been reported in the adult caused by chronic ingestion of a fructose beverage. We report an adult patient who had severe hypokalemia from chronic osmotic diarrhea as a result of drinking 4 to 6 liters of Big Red daily for several months. This resulted in sustained hypokalemia, complicated by hypokalemic nephropathy and subsequent nephrogenic diabetes insipidus. All abnormalities cleared with potassium replacement, salt restriction, modest thiazide treatment, and abstinence from Big Red."

Procalcitonin Algorithms for Antibiotic Therapy Decisions

Reference: Procalcitonin Algorithms for Antibiotic Therapy Decisions - A Systematic Review of Randomized Controlled Trials and Recommendations for Clinical Algorithms - Arch Intern Med. 2011;171(15):1322-1331.

Previous randomized controlled trials suggest that using clinical algorithms based on procalcitonin levels, a marker of bacterial infections, results in reduced antibiotic use without a deleterious effect on clinical outcomes. However, algorithms differed among trials and were embedded primarily within the European health care setting. Herein, we summarize the design, efficacy, and safety of previous randomized controlled trials and propose adapted algorithms for US settings.

We performed a systematic search and included all 14 randomized controlled trials (N = 4467 patients) that investigated procalcitonin algorithms for antibiotic treatment decisions in adult patients with respiratory tract infections and sepsis from primary care, emergency department (ED), and intensive care unit settings. We found no significant difference in mortality between procalcitonin-treated and control patients overall (odds ratio, 0.91; 95% confidence interval, 0.73-1.14) or in primary care (0.13; 0-6.64), ED (0.95; 0.67-1.36), and intensive care unit (0.89; 0.66-1.20) settings individually. A consistent reduction was observed in antibiotic prescription and/or duration of therapy, mainly owing to lower prescribing rates in low-acuity primary care and ED patients, and shorter duration of therapy in moderate- and high-acuity ED and intensive care unit patients. Measurement of procalcitonin levels for antibiotic decisions in patients with respiratory tract infections and sepsis appears to reduce antibiotic exposure without worsening the mortality rate. We propose specific procalcitonin algorithms for low-, moderate-, and high-acuity patients as a basis for future trials aiming at reducing antibiotic overconsumption.