Monday March 8, 2010


Question: A standard dose of nebulized albuterol reduces serum potassium by what level?

Answer: A standard dose of nebulized albuterol reduces serum potassium by 0.2 to 0.4 mmol per liter (mEq/L).

Sunday March 7, 2010


Q: 26 year old female with recent history of abortion presented with hypotension, fever and severe abdominal pain. OB/Gyn service ordered intravenous urogram. Following abdominal film is obtained?

Answer: Uterine gas gangrene

Anaerobic infections with Clostridium perfringens (CP) occur rarely but are associated with considerable maternal mortality. Targeted antibiotics should be started ASAP. Surgery backup should be called to perform a hysterectomy and necrosis removal. Clostridium perfringens is ubiquitous and is found vaginally in 1 - 10 % of healthy women and usually does not cause a serious infection. Under the right conditions it can cause an endometritis leading to sepsis. Early recognition and interdisciplinary treatment are of extreme importance.

Saturday March 6, 2010


Q: What are Duret hemorrhages?

Answer: Duret hemorrhages of the midbrain and pons are small punctate hemorrhages that are often caused by arteriole stretching during the primary injury, as seen in the picture below (Duret hemorrhage in the splenium of the corpus callosum)

Friday March 5, 2010
TRALI - not very uncommon!


Objectives: To determine the incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of critically ill patients.

Design: In a retrospective cohort study, patients with transfusion-related acute lung injury were identified using the consensus criteria of acute lung injury within 6 hrs after transfusion. Inclusion criterion was a length of intensive care unit admission more than 48 hrs. Patients developing transfusion-related acute lung injury were matched (on age, sex, and admission diagnosis) to transfused control subjects and patients developing acute lung injury from another origin.


Measurements and Main Results:

• Of 5208 admitted patients, 2024 patients had a length of stay more than 48 hrs, of whom 109 were suspected transfusion-related acute lung injury cases.
• Compared with transfused control subjects, risk factors for transfusion-related acute lung injury were emergency cardiac surgery, hematologic malignancy, massive transfusion, sepsis , mechanical ventilation and high Acute Physiology and Chronic Health Evaluation II score
• The volume of platelets and plasma transfused was associated with transfusion-related acute lung injury in the univariate analysis. However, this association disappeared in the multivariate analysis.
• Compared with acute lung injury control subjects, risk factors for transfusion-related acute lung injury were sepsis and high Acute Physiology and Chronic Health Evaluation II score whereas pneumonia was a negative predictive factor.
• Patients with transfusion-related acute lung injury had a longer duration of mechanical ventilation compared with transfused control subjects and acute lung injury control subjects
• Also, 90-day survival of patients with transfusion-related acute lung injury was lower compared with transfused control subjects and acute lung injury control subjects

Conclusions: Transfusion-related acute lung injury is common in critically ill patients. Transfusion-related acute lung injury may contribute to an adverse outcome associated with transfusion. This study identifies transfusion-related acute lung injury risk factors, which may aid in assessing the risks and benefits of transfusion in critically ill patients.



Risk factors and outcome of transfusion-related acute lung injury in the critically ill: A nested case-control study - Critical Care Medicine: March 2010 - Volume 38 - Issue 3 - pp 771-778

Thursday March 4, 2010
Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty


Study Question: What is the relative safety and feasibility of the transradial versus transfemoral approach for coronary angiography and intervention?

Methods: The authors randomized a total of 1,024 patients undergoing coronary catheterization to the transradial or transfemoral approach. Patients with an abnormal Allen's test, history of CABG, simultaneous right heart catheterization, chronic renal insufficiency, or known difficulties with the radial or femoral access were excluded.

Results:

• Successful catheterization was more common in the femoral (99.8% vs. 96.5%) compared with the radial group.
• Procedure time (median procedural duration 37.0 minutes vs. 40.2 minutes, p = 0.046) and radiation exposure (median dose area product 38.2 Gycm2 vs. 41.9 Gycm2, p = 0.034) were significantly lower in the transfemoral group compared with the transradial access group.
• There was no difference in the amount of contrast media use between the two groups.
• Vascular access site complications were higher in the transfemoral group (3.71% vs. 0.58%, p = 0.0008).
  

Conclusions: The use of radial access is associated with an increased procedural duration and radiation exposure, and a marked reduction in vascular complications.

Editors' opinion: The reduction in groin complications and bleeding with the use of a radial approach has been highlighted in multiple studies. However, the increased radiation exposure to the patient and the operator is increasingly being recognized, and may translate into an increased late risk of malignancies. Better shielding strategies are needed to reduce this exposure so that the benefits of the radial approach can be obtained at minimal hazard to the patients or the operators.



JACC Cardiovasc Interv 2009;2:1047-1054

Wednesday March 3, 2010

Cardiac Tamponade on Echo

Tuesday March 2, 2010

Q: What is Redistributive hyponatremia?


Answer: Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. The TBW (Total Body Water) and total body sodium are unchanged. This condition occurs with hyperglycemia or administration of mannitol.

Monday March 1, 2010

Q: Which steroid is preferable during treatment of Thyroid storm?


Answer: Dexamethasone (Decadron)

Dexamethasone (2 mg every 6 hours during first 24 hours) not only inhibit hormone production but also decreases peripheral conversion from T4 to T3. After acute episode subsides and there is an indication or suspicion of adrenal insufficiency Hydrocortisone (Solu-Cortef) 100 mg IV every 8 hours should be given.