Wednesday December 23, 2009
Esophageal Perforation Associated With Noninvasive Ventilation - An interesting Case Report

"A 56-year-old man was admitted to our ICU after extensive nephrectomy with partial inferior vena cava resection for renal adenocarcinoma. He had a history of type 2 diabetes mellitus, and the cancer had been diagnosed on evaluation of recent-onset severe arterial hypertension.

The patient was extubated on the day of surgery. No respiratory, circulatory, or infectious complications occurred, but renal failure developed gradually, the suspected cause being intraoperative hypotension. No nausea or vomiting was noted. NIPPV was started via a facemask on day 4 because this morbidly obese patient (122 kg) could not be weaned from nasal oxygen and had persistent moderate hypoxemia with persistent basal atelectasis on the chest radiograph. NIPPV was initiated with a fraction of inspired oxygen of 0.5, a positive end-expiratory pressure of 5 cm H2O, and a pressure-support level of 15 cm H2O. When NIPPV was stopped after 1 h, the hypoxemia worsened, and marked tachypnea with agitation developed. NIPPV was immediately restarted and the pulse oximetric saturation dropped to 97%. After an additional 2 h of NIPPV, hypotension and loss of consciousness occurred, requiring orotracheal intubation, mechanical ventilation, and vasoactive drug therapy. The postintubation chest radiograph disclosed left-sided hydropneumothorax, which was confirmed by CT. A chest tube was inserted, and 1,000 mL of gastric-like fluid was recovered. A left thoracotomy was performed, and a 3-cm linear tear was seen in the lower esophagus. The tear was sutured, drains were placed in the pleural cavity and mediastinum, and a discharge gastrostomy was performed with a jejunostomy for enteral nutrition.

After a transient improvement in the hemodynamic status, multiple organ failure developed. There was no definitive evidence of infection. The patient died 12 days after the thoracotomy".


Source:

Esophageal Perforation Associated With Noninvasive Ventilation - A Case Report, CHEST November 2002 vol. 122 no. 5, 1857-1858

Tuesday December 22, 2009


Q: Define Hemothorax?

Answer: Even a very small quantity of blood can make pleural fluid apppears bloody but a hemothorax is the presence of blood in the pleural cavity such that the ratio of pleural fluid hematocrit to blood hematocrit is more than 0.5.

Monday December 21, 2009
2 CD VIP

In response to our yesterday pearl "WEANS NOW" we received following pearl from

MABULMAGD , MD, EDIC
Lecturer of critical care medicine, Cairo university
Consultant intensivist, Dar Alfouad Hospital


I found this mnemonics helpful for intensivist during daily clinical rounds (2 CDF VIP)

2C,2D,2F
2V,2I,2P

2C..consciousness-connections

2D…hemoDynamics-diuresis

2F..fluids-feeding

2V..ventilation-vasopressors

2I..investigations-drug Interactions

2P…dvt prophylaxis-ulcer prophylaxis

Sunday December 20, 2009
Famous "WEANS NOW" of Ventilator Weaning

W: weaning parameter - measure
E: endotracheal tube (too small ?, obstruction ? etc)
A: alkalosis (may cause apnea) or anxiety
N: nutrition
S: secretion

N: neuromuscular disease
O: obstruction, bronchospasm
W: wait !!!

Saturday December 19, 2009
The Impella - minimally invasive, catheter-based cardiac assist device

The Impella is a minimally invasive, catheter-based cardiac assist device designed to directly unload the left ventricle, reduce myocardial workload and oxygen consumption, and increase cardiac output and coronary and end-organ perfusion.

The Impella can be inserted into the left ventricle in a Cath Lab via a standard guidewire through the femoral artery, into the ascending aorta, across the valve and into the left ventricle.The tip of the catheter contains a “pigtail” that crosses the patient’s heart valve and rests in the left ventricle, generating flows up to 2.5 L/min. The Impella is hemocompatible, does no compromise to valve function. There is low hemolysis, bleeding, and stroke rates.

Friday December 18, 2009
Examination of the Neck Veins

Thursday December 17, 2009


Q: Lab call you with result that patient's pleural fluid has cholesterol level more than 45 mg/dL (1.16 mmol/L). What does it mean?


A; Pleural fluid is probably an exudate.

Using a cutoff point of 45 mg/dL for pleural cholesterol and/or LDH over 200 IU/L identified exudates with a sensitivity of 99% and a specificity of 98%.


Measurement of Pleural Fluid Cholesterol and Lactate Dehydrogenase - A Simple and Accurate Set of Indicators for Separating Exudates From Transudates - CHEST November 1995 vol. 108, no. 5 1260-1263