Sunday December 13, 2009
Q: Describe relationship between Hypoxemia and acute Decompensated Right Ventricular Failure?
Answer: Oxygen is the most potent pulmonary vasodilator and liberal oxygen administration will reduce pulmonary vascular resistence and improve cardiac output.
Sunday, December 13, 2009
Saturday, December 12, 2009
Saturday December 12, 2009
The influence of white noise on sleep in subjects exposed to ICU noise
Background and purpose: There is disagreement in the literature about the importance of sleep disruption from intensive care unit (ICU) environmental noise. Previous reports have assumed that sleep disruption is produced by high-peak noise. This study aimed to determine whether peak noise or the change in noise level from baseline is more important in inducing sleep disruption. We hypothesized that white noise added to the environment would reduce arousals by reducing the magnitude of changing noise levels.
Patients and methods: Four subjects underwent polysomnography under three conditions: (1) baseline, (2) exposure to recorded ICU noise and (3) exposure to ICU noise and mixed-frequency white noise, while one additional subject completed the first two conditions. Baseline and peak noise levels were recorded for each arousal from sleep.
Results: A total of 1178 arousals were recorded during these studies. Compared to the baseline night (13.3±1.8arousals/h) the arousal index increased during the noise (48.4±7.6) but not the white noise/ICU noise night (15.7±4.5). The change in sound from baseline to peak, rather than the peak sound level, determined whether an arousal occurred and was the same for the ICU noise and white noise/ICU noise condition (17.7±0.4 versus 17.5±0.3DB, P=0.65).
Conclusions: Peak noise was not the main determinant of sleep disruption from ICU noise. Mixed frequency white noise increases arousal thresholds in normal individuals exposed to recorded ICU noise by reducing the difference between background noise and peak noise.
The influence of white noise on sleep in subjects exposed to ICU noise - Sleep Medicine, Volume 6, Issue 5, Pages 423-428 (September 2005)
The influence of white noise on sleep in subjects exposed to ICU noise
Background and purpose: There is disagreement in the literature about the importance of sleep disruption from intensive care unit (ICU) environmental noise. Previous reports have assumed that sleep disruption is produced by high-peak noise. This study aimed to determine whether peak noise or the change in noise level from baseline is more important in inducing sleep disruption. We hypothesized that white noise added to the environment would reduce arousals by reducing the magnitude of changing noise levels.
Patients and methods: Four subjects underwent polysomnography under three conditions: (1) baseline, (2) exposure to recorded ICU noise and (3) exposure to ICU noise and mixed-frequency white noise, while one additional subject completed the first two conditions. Baseline and peak noise levels were recorded for each arousal from sleep.
Results: A total of 1178 arousals were recorded during these studies. Compared to the baseline night (13.3±1.8arousals/h) the arousal index increased during the noise (48.4±7.6) but not the white noise/ICU noise night (15.7±4.5). The change in sound from baseline to peak, rather than the peak sound level, determined whether an arousal occurred and was the same for the ICU noise and white noise/ICU noise condition (17.7±0.4 versus 17.5±0.3DB, P=0.65).
Conclusions: Peak noise was not the main determinant of sleep disruption from ICU noise. Mixed frequency white noise increases arousal thresholds in normal individuals exposed to recorded ICU noise by reducing the difference between background noise and peak noise.
The influence of white noise on sleep in subjects exposed to ICU noise - Sleep Medicine, Volume 6, Issue 5, Pages 423-428 (September 2005)
Friday, December 11, 2009
Friday December 11, 2009
Q: What is the easy (and quick) way of knowing ideal body weight at bedside?
Answer: Ideal weight can be calculated as follows:
- Men = 106 lb for 5 feet in height plus 6 lb for each additional inch.
- Women = 100 lb for 5 feet in height plus 5 lb for each additional inch.
Nutrition Management in the ICU - CHEST May 1999 vol. 115 no. suppl 2 145S-148S
Thursday, December 10, 2009
Thursday December 10, 2009
Q: Name few treatment modalities in Status Asthmaticus if all conventional treatments including mechanical ventilation fails?
Answer:
Ketamine: has been shown to improve airway resistance, particularly the lower airways, as well as improve lung compliance. Dose: loading dose of 1 mg/kg (IV), followed by a continuous infusion of 1 mg/kg/hr for 2h. Peak airway pressure, PaCO2 and PaO2 should be monitored.
Deep anesthesia: such as with halothane or enflurane in combination with propofol or ketamine, may also be effective treatment as potent bronchodilators.
Nitric oxide: has also been used in isolated case reports.
Nebulized lidocaine: in combination with albuterol or levalbuterol is effective in helping the vocal cord dysfunction that may accompany status asthmaticus.
ECMO: Extracorporeal life support in patients with status asthmaticus when everything fails.
Reference: Click to get abstract
Use of ketamine in severe status asthmaticus in intensive care unit. Iran J Allergy Asthma Immunol. Dec 2003;2(4):175-80
Anaesthetic management in asthma. Minerva Anestesiol. Jun 2007;73(6):357-65.
Q: Name few treatment modalities in Status Asthmaticus if all conventional treatments including mechanical ventilation fails?
Answer:
Ketamine: has been shown to improve airway resistance, particularly the lower airways, as well as improve lung compliance. Dose: loading dose of 1 mg/kg (IV), followed by a continuous infusion of 1 mg/kg/hr for 2h. Peak airway pressure, PaCO2 and PaO2 should be monitored.
Deep anesthesia: such as with halothane or enflurane in combination with propofol or ketamine, may also be effective treatment as potent bronchodilators.
Nitric oxide: has also been used in isolated case reports.
Nebulized lidocaine: in combination with albuterol or levalbuterol is effective in helping the vocal cord dysfunction that may accompany status asthmaticus.
ECMO: Extracorporeal life support in patients with status asthmaticus when everything fails.
Reference: Click to get abstract
Use of ketamine in severe status asthmaticus in intensive care unit. Iran J Allergy Asthma Immunol. Dec 2003;2(4):175-80
Anaesthetic management in asthma. Minerva Anestesiol. Jun 2007;73(6):357-65.
Life-threatening status asthmaticus treated with inhaled nitric oxide - The Journal of Pediatrics, Volume 137, Issue 1, Pages 119-122
Emergency extracorporeal life support for asphyxic status asthmaticus. Respir Care. Nov 2007;52(11):1525-9.
Tuesday, December 8, 2009
Tuesday December 8, 2009
Life-threatening sodium valproate overdose: A comparison of two approaches to treatment
Objectives: To describe two identical cases of severe sodium valproate overdose treated with two different approaches.
Design: Case report and review of the literature.
Patients: Two cases of identical life-threatening valproate (VPA) overdose with high VPA blood levels, markedly elevated ammonia levels and coma.
Interventions:
Measurements and Main Results: The first patient remained critically ill with elevated VPA and ammonia levels until the development of seizures and life-threatening cerebral edema. After the delayed application of hemofiltration, the patient slowly recovered to be discharged from intensive care on day 11. In contrast, the second patient's VPA and ammonia levels rapidly declined with hemodialysis and hemodiafiltration with rapid clinical improvement and intensive care discharge on day 3.
Conclusions: In severe VPA overdose, early intervention with blood purification of suitable intensity was associated with a rapid reduction in VPA and ammonia levels and clinical improvement. This improvement was not seen with supportive therapy alone.
Life-threatening sodium valproate overdose: A comparison of two approaches to treatment - Critical Care Medicine: December 2009 - Volume 37 - Issue 12 - pp 3161-3164
Life-threatening sodium valproate overdose: A comparison of two approaches to treatment
Objectives: To describe two identical cases of severe sodium valproate overdose treated with two different approaches.
Design: Case report and review of the literature.
Patients: Two cases of identical life-threatening valproate (VPA) overdose with high VPA blood levels, markedly elevated ammonia levels and coma.
Interventions:
- One patient was treated with supportive therapy alone until the development of cerebral edema and seizures;
- the other was treated with immediate extended hemodialysis followed by high-volume hemodiafiltration.
Measurements and Main Results: The first patient remained critically ill with elevated VPA and ammonia levels until the development of seizures and life-threatening cerebral edema. After the delayed application of hemofiltration, the patient slowly recovered to be discharged from intensive care on day 11. In contrast, the second patient's VPA and ammonia levels rapidly declined with hemodialysis and hemodiafiltration with rapid clinical improvement and intensive care discharge on day 3.
Conclusions: In severe VPA overdose, early intervention with blood purification of suitable intensity was associated with a rapid reduction in VPA and ammonia levels and clinical improvement. This improvement was not seen with supportive therapy alone.
Life-threatening sodium valproate overdose: A comparison of two approaches to treatment - Critical Care Medicine: December 2009 - Volume 37 - Issue 12 - pp 3161-3164
Monday, December 7, 2009
Monday December 7, 2009
Q: What percentage of patients may experience post extubation stridor (PES)?
Answer: About 15%
A low cuff-leak volume (less than 130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.
Racemic Epinephrine, Heliox and and Decadron has been used as treatment for PES. It may require re-intubation in severe cases.
Q: What percentage of patients may experience post extubation stridor (PES)?
Answer: About 15%
A low cuff-leak volume (less than 130 ml or 12%) around the endotracheal tube prior to extubation is useful in identifying patients at risk for post-extubation stridor.
Racemic Epinephrine, Heliox and and Decadron has been used as treatment for PES. It may require re-intubation in severe cases.
Sunday, December 6, 2009
Sunday December 6, 2009
Q: 54 year old asian male presented to ED with cough and left sided chest pain. CXR showed pleural effusion. Radiologist call you with the result adding "there is relative enlargement of the left sided ribs". What does it imply?
Answer: Chronic pleural effusion
The most common cause is tuberculosis and require close workup and possible isolation. Changes in the ribs of patients with tuberculosis as well as the other patients with chronic effusion are due to local hyperemia from an adjacent inflammatory process. In advanced cases, the affected side of the thorax is also contracted, so gravitational and postural factors might also play a role.
Remember these rib changes are not case of direct or metastisize skeletal tuberculosis as there is no destruction of bone.
Reference: Click to get article
Rib Enlargement in Patients with Chronic Pleural Disease - AJR:167, October 1996
Q: 54 year old asian male presented to ED with cough and left sided chest pain. CXR showed pleural effusion. Radiologist call you with the result adding "there is relative enlargement of the left sided ribs". What does it imply?
Answer: Chronic pleural effusion
The most common cause is tuberculosis and require close workup and possible isolation. Changes in the ribs of patients with tuberculosis as well as the other patients with chronic effusion are due to local hyperemia from an adjacent inflammatory process. In advanced cases, the affected side of the thorax is also contracted, so gravitational and postural factors might also play a role.
Remember these rib changes are not case of direct or metastisize skeletal tuberculosis as there is no destruction of bone.
Reference: Click to get article
Rib Enlargement in Patients with Chronic Pleural Disease - AJR:167, October 1996
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