Wednesday January 7, 2009


Scenario: 67 year old s/p colectomy patient in ICU, went into acute agitation and psychosis. He pulled all his IVs and not allowing nurses to insert any IV. What could be your option to 'cool him down' before further evaluation, but without any IV access and inability to use enteral route?

Answer: Orally disintegrating olanzapine (Zedis)

Zydis® (olanzapine) is an orally disintegrating tablets of formulation of ZYPREXA - that dissolves in the mouth on contact with saliva. It is available in 5-mg, 10-mg, 15-mg, and 20-mg tablets. Tablets can be taken without water. The mode of action of olanzapine's antipsychotic activity is unknown.

Tuesday January 6, 2009
WWHHHIMP

Q; Name few major etiologies for delirium?


Answer: Remember WWHHHIMP

W = Withdrawal (ETOH/drug)
W = Wernicke encephalopathy
H = Hypoxemia
H = Hypoglycemia
H = Hypertensive encephalopathy
I = Intracranial bleeding / CVA
M = Meningitis/encephalitis
P = Poisoning

Monday January 5, 2009
Decontamination of the Digestive Tract and Oropharynx in ICU Patients

Interesting study on this controversial topic published this week in NEJM 1

Background Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting.

Methods We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in the Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point.

SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach.

SOD consisted of oropharyngeal application only of the same antibiotics.

Monthly point-prevalence studies were performed to analyze antibiotic resistance.

Results A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively.

Conclusions In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD.


Reference: click to get abstract

Decontamination of the Digestive Tract and Oropharynx in ICU Patients - The New England Journal of Medicine, Volume 360:20-31, Number 1, January 1 2009

Sunday January 4, 2009


Q: Hyponatremia should be corrected slowly and extreme caution should be taken. Rapid correction of Na may lead to central pontine myelinolysis (CPM) characterized by focal demyelination in the pons and extrapontine areas associated with serious neurologic sequelae. Which four subgroups of patients are more prone to develop CPM and at higher risk?

Answer: Patients with

• hypokalemia,
• female gender,
• history of alcoholism and
• liver transplant
  
  

Reference: click to get abstract

Murase T, Sugimura Y, Takefuji S, et al. Mechanisms and therapy of osmotic demyelination. Am J Med. Jul 2006;119(7 Suppl 1):S69-73

Saturday January 3, 2009
Something which we have been doing, here is the data now

Intensivist have been using pig tail drainage catheter under ultrasound guidance for several years. Study by Liang in Intensive Care Medicine confirmed the findings.

On a retrospective review of 133 patients, pigtail drainage catheter yielded largest amount of fluid (5382 +/- 4844 ml) in massive transudative effusion with longest duration of drainage (9 +/- 7 days). It has the highest complication rate of 18%. The success rate was highest when used to treat traumatic hemothorax (100%) and postoperative pleural effusions (85%); drains inserted for empyema were more likely to fail (overall success rate, 42%). No significant insertion complications, such as hollow organ perforation, were caused by this procedure.


Editor’s Comment: This procedure is simple and safe to perform. In addition it helps us to prevent transfer critically ill patients to radiology department.



Laing SJ, Tu CY, Chen HJ, Chen W et al. Application of ultrasound-guided pigtail catheter for drainage of pleural effusions in the ICU. Intensive Care Medicine. Published online Oct 11 2008.

Friday January 2, 2009


Case: 52 year old male is admitted with frequent runs of ventricular tachycardia and was started on IV Lidocaine with 2mg/min drip. First lidocaine serum level is 8.5 micrograms/ml. To determine the time period to shut off Lidociane drip, do you know the half life of intravenous Lidocaine?

Answer: The elimination half-life of lidocaine is approximately 1.5–2 hours in most patients. But it may be prolonged in patients with liver insufficiency upto 6-8 hours. Also, in patients with congestive heart failure, it may be slightly prolonged upto 3 hours. Though Lidociane is excreted via urine but renal insufficiency doesn't effects its level much as 90% Lidocaine is metabolized in the liver by to the pharmacologically-active metabolites.

Lidocaine alters depolarization in neurons, by blocking sodium (Na+) channels in the cell membrane, leading to its anaesthetic effects. And toxic dosage may lead to nervousness, tingling, tinnitus, tremor, dizziness, blurred vision and seizures.

In above case, it would be appropriate to hold Lidocaine drip for 4-6 hours and drew the level again to determine the rate of infusion.

Happy New Year, 2009
New year resolution