Monday May 10, 2010
Q: While starting treatment for DKA (Diabetes Ketoacidosis) how much time should be allowed between initiation of IVF (hydration) and Insulin infusion?
A: About one hour
Insulin should be started about an hour after intravenous fluid replacement is started to allow for checking potassium levels and because insulin may be more dangerous and less effective before some fluid replacement has been obtained. Danger of life-threatening hypokalemia due to aggressive insulin administration is possible, as well as there is no advantage in starting insulin prior to rehydration and evaluation of serum potassium levels.
Monday, May 10, 2010
Sunday, May 9, 2010
Sunday May 9, 2010
Q: Is Pregnancy contraindication (Exclusion criteria) for Hypothermia Protocol?
A: Yes
Standard exclusions for Hypothermia protocol:
Q: Is Pregnancy contraindication (Exclusion criteria) for Hypothermia Protocol?
A: Yes
Standard exclusions for Hypothermia protocol:
- Another reason to be comatose (e.g. convulsive status epilepticus)
- Pregnancy
- A known terminal illness preceding the arrest
- Known severe pre-existing coagulopathy or active bleeding (relative exclusion, esp for patients on warfarin)
- No limit on duration of resuscitation effort; however “down time” of less than 1 hour most desirable
- Pre-existing DO NOT INTUBATE code status and patient not intubated as part of resuscitation efforts
Saturday, May 8, 2010
Saturday May 8, 2010
Q: Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation and atrial flutter. Conversion rates is described upto 80% of cases. What is the half-life of Ibutalide?
A: 3-6 hours
Ibutilide (Corvert) is a Class III antiarrhythmic agent that is indicated for acute cardioconversion of atrial fibrillation and atrial flutter of a recent onset to sinus rhythm. Due to unknown reason, It show better results in atrial flutter as compared to atrial fibrillation.
Ibutalide should be use with caution as it may degenrate rhythm into sustained Torsade (polymorphic ventricular tachycardia) in 3% of cases. Also due to longer half life, its not recommended to repeat dose more than twice as it may take upto 90 minutes before normal sinus rhythm gets restored.
Dose is usually 1 mg over 10 minutes (may repeat once) but in post-cardiac surgery patients, one or two infusions of 0.5 mg is usually effective in terminating atrial fibrillation or atrial flutter.
Q: Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation and atrial flutter. Conversion rates is described upto 80% of cases. What is the half-life of Ibutalide?
A: 3-6 hours
Ibutilide (Corvert) is a Class III antiarrhythmic agent that is indicated for acute cardioconversion of atrial fibrillation and atrial flutter of a recent onset to sinus rhythm. Due to unknown reason, It show better results in atrial flutter as compared to atrial fibrillation.
Ibutalide should be use with caution as it may degenrate rhythm into sustained Torsade (polymorphic ventricular tachycardia) in 3% of cases. Also due to longer half life, its not recommended to repeat dose more than twice as it may take upto 90 minutes before normal sinus rhythm gets restored.
Dose is usually 1 mg over 10 minutes (may repeat once) but in post-cardiac surgery patients, one or two infusions of 0.5 mg is usually effective in terminating atrial fibrillation or atrial flutter.
Friday, May 7, 2010
Friday May 7, 2010
Case: 25 year old male is admitted to ICU with severe ethylene glycol toxicity. Patient is intubated and in severe acidosis. Hemodialysis is initiated to enhance elimination of ethylene glycol. Pharmacy call you with info. that they have located Fomepizole and now its available for patient. What adjustment in dosing is required for Fomepizole in patients already on "HD"?
Answer: Fomepizole is significantly (50-70%) removed through hemodialysis. Standard dose is loading dose of 15 mg/kg followed by 10 mg/kg every 12 hours for 4 doses and then 15 mg/kg every 12 hours until ethylene glycol levels fall below 20 mg/dl. In patient already on dialysis, reduction of the interval between doses to 4-6 hours is recommended or to just start drip with infusion rate of 1-1.5 mg/kg/hour.
The cost of Fomepizole per vial is around $1000, and therefore is not widely stocked in most hospital pharmacy. One vial contains 1500 mg of fomepizole.
Case: 25 year old male is admitted to ICU with severe ethylene glycol toxicity. Patient is intubated and in severe acidosis. Hemodialysis is initiated to enhance elimination of ethylene glycol. Pharmacy call you with info. that they have located Fomepizole and now its available for patient. What adjustment in dosing is required for Fomepizole in patients already on "HD"?
Answer: Fomepizole is significantly (50-70%) removed through hemodialysis. Standard dose is loading dose of 15 mg/kg followed by 10 mg/kg every 12 hours for 4 doses and then 15 mg/kg every 12 hours until ethylene glycol levels fall below 20 mg/dl. In patient already on dialysis, reduction of the interval between doses to 4-6 hours is recommended or to just start drip with infusion rate of 1-1.5 mg/kg/hour.
The cost of Fomepizole per vial is around $1000, and therefore is not widely stocked in most hospital pharmacy. One vial contains 1500 mg of fomepizole.
Thursday, May 6, 2010
Thursday May 6, 2010
Intermittent intravenous urokinase for critical limb ischemia as a salvage therapy in diabetic foot ulceration
Background: Patients with diabetic foot ulceration and critical limb ischemia have a high risk of major amputation, especially if limbs can not be revascularized. Urokinase is effective in improving microcirculation in critical limb ischemia and might improve outcomes.
Method: An open, prospective, non-controlled, multicenter phase II cohort study in 77 type-2 diabetic patients with critical limb ischemia and diabetic foot ulceration. Patients had no surgical or endovascular treatment option based on interdisciplinary consensus. Urokinase (1 Mio IU if plasma fibrinogen more than or=2.5 g/l, 0.5 Mio IU if fibrinogen less than 2.5 g/l) was administered for 21 days as an intravenous infusion over 30 minutes. Each patient was followed up for 12 months.
Results: Treatment for a median of 21 days resulted in 33% of patients being alive, having no major amputation and completely healed ulcers after 12 months. Total survival rate was 84.6%, amputation-free survival 69.2% and rate of major amputation 21.1%. Eighty-two percent of patients experienced at least once a complete ulcer healing within the course of study. Three serious adverse events were urokinase-related.
Conclusion: Urokinase treatment in diabetic patients with critical limb ischemia appears to be effective, feasible and safe. Although this calls for a larger, randomized and controlled trial, the results are highly relevant for clinical practice to prevent these patients from receiving major amputation due to diabetic foot syndrome.
Intermittent intravenous urokinase for critical limb ischemia in diabetic foot ulceration - Thromb Haemost. 2008 Sep;100(3):475-82.
Intermittent intravenous urokinase for critical limb ischemia as a salvage therapy in diabetic foot ulceration
Background: Patients with diabetic foot ulceration and critical limb ischemia have a high risk of major amputation, especially if limbs can not be revascularized. Urokinase is effective in improving microcirculation in critical limb ischemia and might improve outcomes.
Method: An open, prospective, non-controlled, multicenter phase II cohort study in 77 type-2 diabetic patients with critical limb ischemia and diabetic foot ulceration. Patients had no surgical or endovascular treatment option based on interdisciplinary consensus. Urokinase (1 Mio IU if plasma fibrinogen more than or=2.5 g/l, 0.5 Mio IU if fibrinogen less than 2.5 g/l) was administered for 21 days as an intravenous infusion over 30 minutes. Each patient was followed up for 12 months.
Results: Treatment for a median of 21 days resulted in 33% of patients being alive, having no major amputation and completely healed ulcers after 12 months. Total survival rate was 84.6%, amputation-free survival 69.2% and rate of major amputation 21.1%. Eighty-two percent of patients experienced at least once a complete ulcer healing within the course of study. Three serious adverse events were urokinase-related.
Conclusion: Urokinase treatment in diabetic patients with critical limb ischemia appears to be effective, feasible and safe. Although this calls for a larger, randomized and controlled trial, the results are highly relevant for clinical practice to prevent these patients from receiving major amputation due to diabetic foot syndrome.
Intermittent intravenous urokinase for critical limb ischemia in diabetic foot ulceration - Thromb Haemost. 2008 Sep;100(3):475-82.
Wednesday, May 5, 2010
Wednesday May 5, 2010
Q: What is Posttransfusion purpura (PTP)?
Answer: Post-transfusion purpura (PTP) is an adverse reaction to a blood transfusion that occurs when the body produces alloantibodies to the introduced platelets' antigens. Posttransfusion purpura typically occurs 7-10 days following a transfusion. This syndrome can be induced by platelet transfusion, a small amount of platelets contaminating a red blood cell transfusion or, occasionally, following fresh frozen plasma (FFP) transfusion. PTP is most common in women who have had multiple pregnancies, and men who have undergone previous transfusions.
The thrombocytopenia responds to intravenous immunoglobulin (IVIG).
See nice review on PTP here
Q: What is Posttransfusion purpura (PTP)?
Answer: Post-transfusion purpura (PTP) is an adverse reaction to a blood transfusion that occurs when the body produces alloantibodies to the introduced platelets' antigens. Posttransfusion purpura typically occurs 7-10 days following a transfusion. This syndrome can be induced by platelet transfusion, a small amount of platelets contaminating a red blood cell transfusion or, occasionally, following fresh frozen plasma (FFP) transfusion. PTP is most common in women who have had multiple pregnancies, and men who have undergone previous transfusions.
The thrombocytopenia responds to intravenous immunoglobulin (IVIG).
See nice review on PTP here
Tuesday, May 4, 2010
Tuesday May 4, 2010
Q: 35 year old male developed severe diarrhea, fever and abdominal pain after blood transfusion. Symptoms progressed very rapidly. CT scan of abdomen showed hepatic and splenic abscesses. Surgery back up is called and infectious diseases (ID) consult is obtained. Meanwhile blood bank confirmed contamination of stored blood. ID service started patient on Ciprofloxain. Which 'bug' they are suspecting?
Answer: Yersinia enterocolitica
Yersinia enterocolitica is a gram-negative bacillus and is a siderophilic (iron-loving) bacteria. Those with hereditary hemochromatosis are more susceptible to infection with Yersinia - and the most common contaminant of stored blood is Y. enterocolitica. Yersinia enterocolitica multiplies rapidly in whole blood or red blood cells stored at 4 to 8° C.
Other sources of infection are contaminated pork, milk, water, and tofu consumption. Infected individuals may shed Y enterocolitica in stools for 90 days after the symptom resolution.
Q: 35 year old male developed severe diarrhea, fever and abdominal pain after blood transfusion. Symptoms progressed very rapidly. CT scan of abdomen showed hepatic and splenic abscesses. Surgery back up is called and infectious diseases (ID) consult is obtained. Meanwhile blood bank confirmed contamination of stored blood. ID service started patient on Ciprofloxain. Which 'bug' they are suspecting?
Answer: Yersinia enterocolitica
Yersinia enterocolitica is a gram-negative bacillus and is a siderophilic (iron-loving) bacteria. Those with hereditary hemochromatosis are more susceptible to infection with Yersinia - and the most common contaminant of stored blood is Y. enterocolitica. Yersinia enterocolitica multiplies rapidly in whole blood or red blood cells stored at 4 to 8° C.
Other sources of infection are contaminated pork, milk, water, and tofu consumption. Infected individuals may shed Y enterocolitica in stools for 90 days after the symptom resolution.
Monday, May 3, 2010
Monday May 3, 2010
Vasoconstrictor extravasation
Antidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine) is PHENTOLAMINE. Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor. Keep yourself ready for fluid bolus post treatment.
Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent which inhibits vasoconstriction and allow improved blood circulation through the affected area.
Vasoconstrictor extravasation
Antidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine) is PHENTOLAMINE. Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor. Keep yourself ready for fluid bolus post treatment.
Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent which inhibits vasoconstriction and allow improved blood circulation through the affected area.
Sunday, May 2, 2010
Sunday May 2, 2010
Zinc Supplementation in Critically Ill Patients: - Just a Myth?
Introduction: The purpose of the paper is to provide a rationale for zinc supplementation as a potential therapeutic agent in critically ill patients by describing its role in health and disease, conducting a systematic review of current randomized trials in critical care, considering optimum route and dose of administration, and making recommendations for future research. Normal zinc homeostasis is required for a functional immune system, adequate antioxidant capacity, glucose homeostasis, and wound healing. In addition, zinc is a required cofactor for many enzymes, transcription factors, and replication factors. In non–critically ill patients, zinc supplementation has been associated with an improvement in markers of immune function.
Results: In critically ill patients, only 4 randomized trials have examined the effect of zinc supplementation on clinical outcomes.
Conclusion: Thus, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of high-dose zinc supplementation in the critically ill. A first step would be to determine the optimal dose that has a maximal positive effect on underlying inflammatory, immunologic, and metabolic processes yet is safe and tolerated by critically ill patients. Subsequently, large, rigorously designed, randomized trials are required to elucidate the efficacy of such doses of zinc supplementation in this patient population.
Zinc Supplementation in Critically Ill Patients: A Key Pharmaconutrient? - Journal of Parenteral and Enteral Nutrition, Vol. 32, No. 5, 509-519 (2008)
Editors' note: Negative studies are as important to look into as postive studies to prevent harm to patients!
Zinc Supplementation in Critically Ill Patients: - Just a Myth?
Introduction: The purpose of the paper is to provide a rationale for zinc supplementation as a potential therapeutic agent in critically ill patients by describing its role in health and disease, conducting a systematic review of current randomized trials in critical care, considering optimum route and dose of administration, and making recommendations for future research. Normal zinc homeostasis is required for a functional immune system, adequate antioxidant capacity, glucose homeostasis, and wound healing. In addition, zinc is a required cofactor for many enzymes, transcription factors, and replication factors. In non–critically ill patients, zinc supplementation has been associated with an improvement in markers of immune function.
Results: In critically ill patients, only 4 randomized trials have examined the effect of zinc supplementation on clinical outcomes.
- When all 4 studies were aggregated, zinc supplementation was associated with a nonsignificant reduction in mortality (relative risk = 0.63, 95% confidence intervals 0.25-1.59, P = .33) and length of stay in intensive care (–0.35 days, –0.85 to 0.15; P = .17)
Conclusion: Thus, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of high-dose zinc supplementation in the critically ill. A first step would be to determine the optimal dose that has a maximal positive effect on underlying inflammatory, immunologic, and metabolic processes yet is safe and tolerated by critically ill patients. Subsequently, large, rigorously designed, randomized trials are required to elucidate the efficacy of such doses of zinc supplementation in this patient population.
Zinc Supplementation in Critically Ill Patients: A Key Pharmaconutrient? - Journal of Parenteral and Enteral Nutrition, Vol. 32, No. 5, 509-519 (2008)
Editors' note: Negative studies are as important to look into as postive studies to prevent harm to patients!
Saturday, May 1, 2010
Saturday May 1, 2010
Scenario: 22 year male with multiple myeloma presented to ER with severe facial pain. He recently received a drug from his oncologist and was told its good for bones and actually he recommend the same drug for patient's mom once a year! You examined the patient and call for maxillo-facial surgical consult.
Answer: Zoledronate (Zometa)
Zoledronate (Zometa) is a bisphosphonate. Zometa is used to prevent skeletal fractures in patients with multiple myeloma, Paget's disease and other cancers, as well as for treating osteoporosis. The standard dose for zoledronate is 4 mg to be infused intravenously over 15 min every 4 weeks in cancer patients but has been approved as a once-yearly 5 mg infusion for treatment of osteoporosis!
A rare complication is osteonecrosis of the jaw. Risk is higher if such patients require dental workup. Jaw bone damage and death occurs as a result of reduced local blood supply (avascular osteonecrosis). Severe cases require surgical removal of the affected bone.
Scenario: 22 year male with multiple myeloma presented to ER with severe facial pain. He recently received a drug from his oncologist and was told its good for bones and actually he recommend the same drug for patient's mom once a year! You examined the patient and call for maxillo-facial surgical consult.
Answer: Zoledronate (Zometa)
Zoledronate (Zometa) is a bisphosphonate. Zometa is used to prevent skeletal fractures in patients with multiple myeloma, Paget's disease and other cancers, as well as for treating osteoporosis. The standard dose for zoledronate is 4 mg to be infused intravenously over 15 min every 4 weeks in cancer patients but has been approved as a once-yearly 5 mg infusion for treatment of osteoporosis!
A rare complication is osteonecrosis of the jaw. Risk is higher if such patients require dental workup. Jaw bone damage and death occurs as a result of reduced local blood supply (avascular osteonecrosis). Severe cases require surgical removal of the affected bone.
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