Tuesday April 7, 2009
Q; 32 year old male - recently immigrated from Africa - presented with hypotension and left flank pain and "Milky Urine". What are treatment options beside resuscitation?
Answer: Chyluria (Milky Urine) is common in many parts of the world, where Wuchereria bancrofti, the main agent of filariasis, is endemic. It occurs, on average, 5–10 years after the worm has died, and so there may be no evidence of active filariasis.
Treatment includes therapeutic trial of diethylcarbamazine should be considered before undertaking surgery for lymphatic urinary fistula.
Reference:
1. Filarial chyluria: Long-term experience of a university hospital in India - International Journal of Urology, Volume 11 Issue 4, Pages 193 - 198, Published Online: 16 Mar 2004
Tuesday, April 7, 2009
Monday, April 6, 2009
Monday April 6, 2009
Q; What amount of air is usually needed to cause clinical symptoms in Venous Air Emboilsm (VAE)?
Answer: Around 50 ml
But again, all precautions should be taken to avoid even any small amount of air to get introduce into vascular system as there are case reports in literature showing lethal effect with as little as 20 mL of air (the length of an unprimed IV infusion set) or even 0.5 mL of air in the left anterior descending coronary artery causing ventricular fibrillation. Related previous pearl: Venous Air Embolism - VAE - immediate maneuvers Reference: Venous Air Embolism - emedicine.com Most occurrences of VAE go unreported because they are asymptomatic due to very small amount of air entering system, but entrapment of large quantities of intravascular gas may lead to severe neurologic injury, cardiovascular collapse, or even death. The factors that determine the subsequent morbidity and mortality include the rate of air entrainment, the volume of air introduced, and the position of the patient at the time of the embolism. Although very small volumes of air can lead to severe sequelae, generally it is accepted that atleast 50 mL of air is required to cause clinical symptoms.
Sunday, April 5, 2009
Sunday April 5, 2009
Q; You inserted a central venous line in a patient with hypoxemic respiratory failure. Procedure went uneventful. Post-procedure CXR is below. What's your concern?
Answer: Arterial Cannulation
Notice - the catheter is taking a sharp left turn just distal to the clavicle.
The best approach in such situation is to obtain radial ABG and ABG from central line to compare. Also to hook central line to monitor to see waveform which may clearly show arterial waveforms.
Q; You inserted a central venous line in a patient with hypoxemic respiratory failure. Procedure went uneventful. Post-procedure CXR is below. What's your concern?
Answer: Arterial Cannulation
Notice - the catheter is taking a sharp left turn just distal to the clavicle.
The best approach in such situation is to obtain radial ABG and ABG from central line to compare. Also to hook central line to monitor to see waveform which may clearly show arterial waveforms.
Saturday, April 4, 2009
Friday, April 3, 2009
Friday April 3, 2009 (pediatric pearl)
Q: Does sustained meropenem use have effect on the pattern of Gram-negative bacillus colonization in patients admitted to a tertiary care PICU?
Answer: No
In a prospective study, after a 6-mo baseline period, all children with serious infections admitted to the PICU during the subsequent 2 yrs were administered meropenem
.
During the period of preferred meropenem use, the amount of meropenem used increased me than orseven-fold, whereas the use of other advanced generation beta-lactams was reduced by nearly 80%.
Conclusion:
1. There was no statistically detectable effect on the prevalence of colonization by Gram-negative organisms resistant to one or more classes of broad-spectrum parenteral antibiotics
2. or to colonization by organisms resistant specifically to meropenem, when meropenem was the preferred antibiotic in a PICU.
3. The incidence of nosocomial infections did not change, and the prevalence of nosocomial infections caused by meropenem-resistant organisms was always less than 1% of all admissions during the period of meropenem preference.
Reference: click to get abstract
Meropenem use and colonization by antibiotic-resistant Gram-negative bacilli in a pediatric intensive care unit - Pediatric Critical Care Medicine:Volume 10(1)January 2009pp 49-54
Q: Does sustained meropenem use have effect on the pattern of Gram-negative bacillus colonization in patients admitted to a tertiary care PICU?
Answer: No
In a prospective study, after a 6-mo baseline period, all children with serious infections admitted to the PICU during the subsequent 2 yrs were administered meropenem
.
During the period of preferred meropenem use, the amount of meropenem used increased me than orseven-fold, whereas the use of other advanced generation beta-lactams was reduced by nearly 80%.
Conclusion:
1. There was no statistically detectable effect on the prevalence of colonization by Gram-negative organisms resistant to one or more classes of broad-spectrum parenteral antibiotics
2. or to colonization by organisms resistant specifically to meropenem, when meropenem was the preferred antibiotic in a PICU.
3. The incidence of nosocomial infections did not change, and the prevalence of nosocomial infections caused by meropenem-resistant organisms was always less than 1% of all admissions during the period of meropenem preference.
Reference: click to get abstract
Meropenem use and colonization by antibiotic-resistant Gram-negative bacilli in a pediatric intensive care unit - Pediatric Critical Care Medicine:Volume 10(1)January 2009pp 49-54
Thursday, April 2, 2009
Wednesday, April 1, 2009
Wednesday April 1, 2009
LOW DOSE VITAMIN K: DOES IT DECREASES RISK OF BLEEDING
Recent article published in Annals of Internal Medicine by Crowther helps to sort this practice. Low-dose oral vitamin K decreases the international normalized ratio (INR) but its effects on bleeding events are uncertain.
OBJECTIVE: To see whether low-dose oral vitamin K reduces bleeding events over 90 days in patients with warfarin-associated coagulopathy.
DESIGN: Multicenter, randomized, placebo-controlled trial with 14 anticoagulant therapy clinics in Canada, the United States, and Italy.
Method: Nonbleeding patients with INR values of 4.5 to 10.0 either received oral vitamin K, 1.25 mg (355 patients randomly assigned; 347 analyzed), or matching placebo (369 patients randomly assigned; 365 analyzed). Bleeding events (primary outcome), thromboembolism, and death (secondary outcomes) were measured.
Results: 56 patients (15.8%) in the vitamin K group and 60 patients (16.3%) in the placebo group had at least 1 bleeding complication. Major bleeding events occurred in 9 patients (2.5%) in the vitamin K group and 4 patients (1.1%) in the placebo group (absolute difference, 1.5 percentage points [CI, -0.8 to 3.7 percentage points]). Thromboembolism occurred in 4 patients (1.1%) in the vitamin K group and 3 patients (0.8%) in the placebo group (absolute difference, 0.3 percentage point [CI, -1.4 to 2.0 percentage points]). The day after treatment, the INR had decreased by a mean of 1.4 in the placebo group and 2.8 in the vitamin K group.
Limitation: Patients who were actively bleeding were not included, and warfarin dosing after enrollment was not mandated or followed.
CONCLUSION: Low-dose oral vitamin K did not reduce bleeding in warfarin recipients with INRs of 4.5 to 10.0.
Reference: click to get abstract
Crowther MA, Ageno W, Garcia D, Wang L et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009; 150(5):293-300
LOW DOSE VITAMIN K: DOES IT DECREASES RISK OF BLEEDING
Recent article published in Annals of Internal Medicine by Crowther helps to sort this practice. Low-dose oral vitamin K decreases the international normalized ratio (INR) but its effects on bleeding events are uncertain.
OBJECTIVE: To see whether low-dose oral vitamin K reduces bleeding events over 90 days in patients with warfarin-associated coagulopathy.
DESIGN: Multicenter, randomized, placebo-controlled trial with 14 anticoagulant therapy clinics in Canada, the United States, and Italy.
Method: Nonbleeding patients with INR values of 4.5 to 10.0 either received oral vitamin K, 1.25 mg (355 patients randomly assigned; 347 analyzed), or matching placebo (369 patients randomly assigned; 365 analyzed). Bleeding events (primary outcome), thromboembolism, and death (secondary outcomes) were measured.
Results: 56 patients (15.8%) in the vitamin K group and 60 patients (16.3%) in the placebo group had at least 1 bleeding complication. Major bleeding events occurred in 9 patients (2.5%) in the vitamin K group and 4 patients (1.1%) in the placebo group (absolute difference, 1.5 percentage points [CI, -0.8 to 3.7 percentage points]). Thromboembolism occurred in 4 patients (1.1%) in the vitamin K group and 3 patients (0.8%) in the placebo group (absolute difference, 0.3 percentage point [CI, -1.4 to 2.0 percentage points]). The day after treatment, the INR had decreased by a mean of 1.4 in the placebo group and 2.8 in the vitamin K group.
Limitation: Patients who were actively bleeding were not included, and warfarin dosing after enrollment was not mandated or followed.
CONCLUSION: Low-dose oral vitamin K did not reduce bleeding in warfarin recipients with INRs of 4.5 to 10.0.
Reference: click to get abstract
Crowther MA, Ageno W, Garcia D, Wang L et al. Oral vitamin K versus placebo to correct excessive anticoagulation in patients receiving warfarin: a randomized trial. Ann Intern Med. 2009; 150(5):293-300
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