Tuesday December 29, 2009
Association Between ICU Admission During Morning Rounds and Mortality

Background: No previous study has evaluated the association between admission to ICUs during round time and patient outcome. The objective of this study was to determine the association between round-time ICU admission and patient outcome.

Methods: This retrospective study included 49,844 patients admitted from October 1994 to December 2007 to four ICUs (two surgical, one medical, and one multispecialty) of an academic medical center. Of these patients, 3,580 were admitted to the ICU during round time (8:00 am to 10:59 am) and 46,264 were admitted during nonround time (from 1:00 pm to 6:00 am). The medical ICU had 24-h/7-day per week intensivist coverage during the last 2 years of the study. We compared the baseline characteristics and outcome of patients admitted to the ICU between the two groups. Data were abstracted from the acute physiology and chronic health evaluation (APACHE) III database.

Results: The round-time and non–round-groups were similar in gender, ethnicity, and age.

• The predicted hospital mortality rate of the round time group was higher (17.4% vs 12.3% predicted, respectively).
• The hospital length of stay was similar between the two groups.
• The round-time group had a higher hospital mortality rate (16.2% vs 8.8%, respectively).
• Most of the round-time ICU admissions and deaths occurred in the medical ICU.
• Round-time admission was an independent risk factor for hospital death (odds ratio, 1.321; 95% CI, 1.178 to 1.481). This independent association was present for the whole study period except for the last 2 years.

Conclusions: Patients admitted to the ICU during morning rounds have higher severity of illness and mortality rates.


Association Between ICU Admission During Morning Rounds and Mortality - CHEST December 2009 vol. 136 no. 6 1489-1495

Monday December 28, 2009
Tips on use of Atropine in AV conduction block

Atropine is useful in treating second-degree heart block Mobitz Type 1 (Wenckebach block), and also third-degree heart block with a high Purkinje or AV-nodal escape rhythm.

• It is usually not effective in second-degree heart block Mobitz type 2, and in third-degree heart block with a low Purkinje or ventricular escape rhythm.
• Atropine is contraindicated in ischemia-induced conduction block, because the drug increases oxygen demand of the AV nodal tissue, thereby aggravating ischemia and the resulting heart block.

Sunday December 27, 2009
About Dabigatran

Dabigatran is an anticoagulant from the class of the direct thrombin inhibitors. It is being studied for various clinical indications and may replace warfarin as the preferred anticoagulant in many cases. Unlike warfarin it works right away and does not require INR monitoring.

Phase 3 clinical trials are ongoing in treatment and prevention of secondary venous thromboembolism (VTE) in post-operative orthopedic patients; long-term prophylaxis in acute coronary syndrome and stroke patients with atrial fibrillation and symptomatic VTE because of various causes. Dabigatran at doses of 150 mg and 220 mg once daily when compared with the standard 40 mg dose of enoxaparin once daily, confirmed that dabigatran performed as well as enoxaparin in preventing thrombosis, with a similar risk profile.

Absorption is unrelated to food but may be decreased if taken with a proton pump inhibitor. Metabolism is slowed in people taking quinidine, verapamil, or amiodarone.

Approval from FDA is expected in 2010.

Saturday December 26, 2009
About Tolvaptan (Samsca)

Tolvaptan (Samsca) is the first oral dosage form in a class known as “selective vasopressin antagonists.” These drugs, also referred to as “vaptans,” cause renal elimination of water without increasing urinary excretion of sodium or potassium. An injectable vaptan, conivaptan (Vaprisol), has been available in the U.S. since 2006. Both conivaptan and tolvaptan are indicated for the treatment of hyponatremia. In addition, tolvaptan has been studied for treating heart failure.

Once-daily Samsca has been shown to significantly raise serum sodium concentrations in as early as 8 hours, and the change was maintained for 30 days. Exposure and response to Samsca are similar in patients with a creatinine clearance of 10-79 mL/min and in patients without renal impairment; thus no dosage adjustment is necessary.

The unique mechanism of action of Samsca selectively blocks the binding of vasopressin to the V2-receptors in the collecting duct of the kidney. If the V2-receptors are left unblocked, the binding of vasopressin with these receptors can cause water retention resulting in hyponatremia. By inhibiting the effects of vasopressin at the V2-receptor, Samsca increases the excretion of free water, while the excretion of sodium and other electrolytes is not directly affected (aquaresis).

Friday December 25, 2009


Merry Christmas

Thursday December 24, 2009


Q: What is the rule of thumb to select size of IABP (Intra Aortic Ballon Pump)?

Answer: The size of the balloon is dependent on the patients height to prevent occlusion of sub-clavian or renal arteries.

Less than 160 cm use 34 cc
Between 160 – 182 cm use 40 cc
More than 182 cm use 50 cc

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