Monday May 31, 2010


Q; What is the five (5) "P" Philosophy before doing any Critical Care procedure?

A: Proper Preparation Prevents Poor Performance

Sunday May 30, 2010
5 Grades of SAH (Subarachnoid Hemorrhage)

Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process (traumatic and nontraumatic hemorrhages).





Grade I - Mild headache with or without meningeal irritation

Grade II - Severe headache but nonfocal examination, with or without mydriasis

Grade III - Mild alteration in neurologic examination, including mental status

Grade IV - Obviously depressed level of consciousness or focal deficit

Grade V - Patient either posturing or comatose

Friday May 28, 2010
Post-Dural Puncture Headache (PDPH) -
Part 2 (Blood Patch)

If conservative measures are ineffective in ameliorating PDPH, another intervention is the epidural blood patch - in practice since last 50 years with success. The epidural blood patch consists of injecting 5-20 mLs of autologous blood into the epidural space, in the region of the suspected dural 'hole.' Once the epidural space is located, autologous blood is drawn from an intravenous (IV) line, and then injected as a bolus into the epidural space. In 90% of cases, the response is positive and immediate. And, long-term relief of PDPH occurs in the almost all cases.

Thursday May 27, 2010
Post-Dural Puncture Headache (PDPH) -
Part 1 (conservative measures)

After Lumbar Puncture (LP) larger hole in the dura are associated with a greater likelihood of CSF leakage and non-sealage. As CSF leaks out of the subarachnoid space, structures within the cranium(skull) gradually shift downwards. This mechanism stretches sensitive fascial and ligamentous structures, that are attached to cerebral tissue, and dilates cerebral vessels; thus, producing a typical postural headache. Termed "Post-Dural Puncture Headache," (PDPH) it is characterized by headache that dissipates while supine, but reoccurs when upright. Other symptoms include neck stiffness and pain across the upper back. Although the headache itself is harmless, it can be very severe and very debilitating. Most cases of PDPH are short-lived, resolving within 24 hours. However, when persisting for more than 24-36 hours, additional measures are needed. Conservative measures to reduce PDPH includes

1. Bedrest - Since the symptoms of PDPH are alleviated by assuming the horizontal position, keeping a patient horizontal for a period of time (eg. 24 hours) after an intervention is thought to enable spontaneous closure of the dural 'hole.' Unfortunately, it rarely works.

2. Hydration - Extra hydration is thought to facilitate increased CSF production. This, too, rarely works.

3. Analgesics - Narcotic analgesics and, in some instances, non-steroidal anti-inflammatory agents are often administered for symptomatic treatment of the headache. Other agents that have been used include; ACTH, theophylline, vasopressin, and sumatriptan.

4. Caffeine - Caffeine has been suggested as a mode of therapy to help constrict the vasodilated cerebral vessels. It is best administered early in the day so that the patient can sleep at night. The dose of caffeine sodium benzoate is 500 mg intravenously which can be repeated once; two hours later, if the first dose does not have the desired effect.

5. Epidural saline injection - Boluses or infusions of epidural normal saline can help to transiently increase the epidural pressure; thus, slowing the speed at which CSF leaks through the dural hole. This may facilitate spontaneous closure of the dural 'hole.' The bolus dose is 30-60 mls given every 6 hours for 4 doses. The rate of infusion is 1000 mls administered over a 24 hour period.

Wednesday May 26, 2010

Following Pearl contributed by:

Peggi Guenter, PhD, RN, CNSN
Director of Clinical Practice, Advocacy, and Research Affairs
American Society for Parenteral and Enteral Nutrition
peggig@aspen.nutr.org
(610) 649-7994
www.nutritioncare.org


Nutrition Guidelines 2009

Would like to bring your attention to the following nutrition and critically ill guidelines developed by the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine published in 2009. We also have a set of pediatric ICU and nutrition guidelines as well. These can be obtained by visiting this link for our guidelines and standards library:

http://www.nutritioncare.org/Library.aspx

These are open access but one needs to create an account to download them.

Tuesday May 25, 2010

Q: What is the modus operandi of Subdural Hematomas (SDH)?

Answer: Contrary to popular belief that SDH happens due to direct trauma, Subdural hematomas actually are most often caused by rapidly changing velocities within the skull which may stretch and tear small bridging veins. In other words, subdural hematomas generally result from shearing injuries due to various rotational or linear forces.

Due to above modus operandi, SDH is a classic finding in shaken baby syndrome, in which similar shearing forces classically cause intra- and pre-retinal hemorrhages. Cerebral atrophy - commonly seen in the elderly and in alcoholics - increases the length the bridging veins have to traverse between the two meningeal layers, hence increasing the likelihood of shearing forces causing a tear.

Monday May 24, 2010

Q: 54 year old male with end stage liver disease may require large volume paracentesis. Patient is labeled as allergic to Albumin. What is your alternative to prevent circulatory dysfunction after large-volume paracentesis?

Answer: Use of terlipressin

The removal of 5 litres of fluid or more is considered large-volume paracentesis. The AASLD (American Association for the Study of Liver Diseases) suggests that postparacentesis albumin infusion may not be necessary for a single paracentesis of less than 5 litres; however, for large-volume paracenteses consider an albumin infusion of 8-10 g per liter of fluid removed.

Another alternative is to use terlipressin (1 mg every 4 hours for 48 hours) rather than albumin for prevention of circulatory dysfunction after large-volume paracentesis. Studies suggest that terlipressin is as effective as albumin.

References: Click to get abstract

1. The efficacy of terlipressin in comparison with albumin in the prevention of circulatory changes after the paracentesis of tense ascites --a randomized multicentric study. Hepatogastroenterology. Oct-Nov 2007;54(79):1930-3.

2. Terlipressin versus albumin in paracentesis-induced circulatory dysfunction in cirrhosis: a randomized study. J Gastroenterol Hepatol. Jan 2006;21(1 pt 2):303-7.

Sunday May 23, 2010
Relationship Between ICU Design and Mortality

Architectural design of health-care facilities can influence patient safety; however, it is unknown whether patient outcomes are significantly affected by ICU design.

Methods: Six hundred sixty-four patients admitted to the medical ICU (MICU) of Columbia University Medical Center during 2008 were included in this retrospective study. Patient outcome measures, which included hospital mortality, ICU mortality, ICU length of stay (LOS), and ventilator-free days, were compared based on random room assignment. Rooms that were not visible from the MICU central nursing station were designated as low-visible rooms (LVRs), whereas the remaining rooms were designated as high-visible rooms (HVRs).

Results:

• Overall hospital mortality did not differ among patients assigned to LVRs vs HVRs
• Severely ill patients (those with APCHE II scores more than 30) had significantly higher hospital mortality when admitted to an LVR than did similarly ill patients admitted to an HVR (82.1% and 64.0%, n = 39 and 75, respectively; P = .046). ICU mortality showed a similar pattern.
• ICU LOS and ventilator-free days did not differ significantly between groups.

Conclusions: Severely ill patients may experience higher mortality rates when assigned to ICU rooms that are poorly visualized by nursing staff and physicians.


Relationship Between ICU Design and Mortality - CHEST May 2010 vol. 137 no. 5 1022-1027

Saturday May 22, 2010
Ice test - Poor man's test for Myasthenia Gravia

Most of the Myasthenia patients along with other symptoms of weakness usually exhibits ptosis. While at bedside place an ice cube over eye lids for 2 minutes. Cooling improves neuromuscular transmission. Resolution of ptosis with cooling is a positive test for Myasthenia Gravis and reported upto 80% reliable to diagnose ocular myasthenia.

Friday May 21, 2010


Q: 30 year old pregnant female admitted with Hyperemesis Gravidarum(HG). patient is hypotensive, dehydrated and hypoglycemic. Before writing IVF orders what would be your concern and which additional order you will consider?


Answer: Wernicke's Encephalopathy (WE)


There is a high risk of WE in HG after 3-4 weeks of persistent vomiting. Thiamine should be given prior to glucose and dextrose infusion.

Thursday May 20, 2010
Insulin in TPN - a bad idea?

Adding insulin to the TPN bag itself - this is chemically compatible and has been done for years. The debate comes in when we start to discuss how much actually makes it to the patient. Study results have been variable. The amount of insulin adsorbed (i.e. stuck to) the glass bottle, plastic bag, or plastic IV tubing can be as high as 80%. Some factors affecting this adsorption include type of container, solution, administration set, previous exposure of tubing to insulin, etc. The binding appears to happen within the first 30-60 minutes. Some in vitro studies have been conducted to assess the effect of "priming" the line with a dilute insulin solution. Priming the tubing with a dilute solution or running through and wasting the first aliquot of the insulin-containing solution increases delivery of insulin from 38% to 85% at 2 hours. Once the priming is done, the amount of insulin delivered remains pretty constant.

Other options - although costly and controversial, adding albumin in small concentrations may help deliver higher amount of insulin by decreasing the amount of insulin available to bind to the container and/or tubing. Adding 0.3 gram/100ml seems to decrease adsorption. Flushing the tubing with the insulin-containing solution two hours before administration seems to saturate the binding sites and minimizes further adsorption. Giving the insulin as a separate IV infusion is another delivery option but adsorption should be considered in this setup as well.

Wednesday May 19, 2010

Case: 27 year old diabetic male is admitted to hospital and get diagnosed with osteomyelitis. After surgical intervention long term antibiotics are planned and PICC line is inserted. Following image is obtained after PICC insertion (arrows showing PICC path). What could be your concern?

Persistent Left Superior Vena Cava (SVC)

0.3% of normal population have Left Superior Vena Cava (SVC). In most cases, the right SVC is also present (i.e. double SVC). Left SVC courses lateral to the aortic arch, main pulmonary artery, anterior to the left hilum and typically enters the coronary sinus that drains into the right atrium. In some cases, left SVC enters the left atrium. The variation, in isolation, is considered benign but but may be very frequently associated with cardiac abnormalities. Left SVC draining into the left atrium is highly associated with commonly ASD.

Tuesday May 18, 2010
Coagulopathy Does Not Protect Against Venous Thromboembolism in Hospitalized Patients With Chronic Liver Disease

Background: It is uncertain whether pathologically prolonged international normalized ratio (INR) seen in chronic liver disease (CLD) protects against venous thromboembolism (VTE). Previous studies reported VTE incidence of 0.5% to 1.9% in patients with CLD. We sought to evaluate VTE incidence among hospitalized patients with CLD according to INR levels.

Methods: This was a retrospective cohort study performed at a tertiary university hospital. We included all adult patients admitted with a primary diagnosis of CLD over a 7-year period. The primary outcome was the development of VTE during hospital stay. Patients were divided into quartiles according to their highest admission INR. VTE events and prophylaxis rates were compared among INR quartiles.

Results: During the allotted 7-year period, we included 190 patients.

• 12 developed VTE events, yielding a VTE incidence of 6.3%.
• There was no significant difference in the incidence of VTE between INR quartiles.
• Hospital mortality rates were higher in the higher INR quartiles than in the lower ones, but hospital length of stay was not significantly different.
• VTE prophylaxis was not used in 75% of patients.

Conclusions: An elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. The notion that “auto-anticoagulation” protects against VTE is unfounded. Use of DVT prophylaxis was extremely low in this population.


Coagulopathy Does Not Protect Against Venous Thromboembolism in Hospitalized Patients With Chronic Liver Disease - CHEST May 2010 vol. 137 no. 5 1145-1149

Monday May 17, 2010
Hypocapnia and the injured brain: More harm than benefit

Objectives: Hypocapnia is used in the management of acute brain injury and may be life-saving in specific circumstances, but it can produce neuronal ischemia and injury, potentially worsening outcome. This review re-examines the rationale for the use of hypocapnia in acute brain injury and evaluates the evidence for therapeutic and deleterious effects in this context.

Data Sources and Study Selection: A MEDLINE/PubMed search from 1966 to August 1, 2009, was conducted using the search terms “hyperventilation,” “hypocapnia,” “alkalosis,” “carbon dioxide,” “brain,” “lung,” and “myocardium,” alone and in combination. Bibliographies of retrieved articles were also reviewed.

Data Extraction and Synthesis: Hypocapnia—often for prolonged periods of time—remains prevalent in the management of severely brain-injured children and adults. Despite this, there is no proof beyond clinical experience with incipient herniation that hypocapnia improves neurologic outcome in any context. On the contrary, hypocapnia can cause or worsen cerebral ischemia.

• The effect of sustained hypocapnia on cerebral blood flow decreases progressively because of buffering;
• subsequent normocapnia can cause rebound cerebral hyperemia and increase intracranial pressure.
• Hypocapnia may also injure other organs.

Accidental hypocapnia should always be avoided and prophylactic hypocapnia has no current role.

Conclusions: Hypocapnia can cause harm and should be strictly limited to the emergent management of life-threatening intracranial hypertension pending definitive measures or to facilitate intraoperative neurosurgery. When it is used, Paco2 should be normalized as soon as is feasible. Outside these settings hypocapnia is likely to produce more harm than benefit.



Hypocapnia and the injured brain: More harm than benefit Critical Care Medicine: May 2010 - Volume 38 - Issue 5 - pp 1348-1359

Sunday May 16, 2010


Q: What is the equivalent strength of PO vs IV of Lopressor (Metoprolol)?


Answer: Equivalent maximal beta-blocking effect of Lopressor is achieved with oral and intravenous doses in the ratio of approximately 2.5:1. But be aware - this is not the standard by any means. Literature shows coversion effect ranging anywhere from 2:1 to 5:1.


Previous related pearls:

Labetolol and Hyperkalemia

Ratio of alpha and beta blockade in Labetalol

Atenolol & Renal Failure

Carvediol (Coreg)

Guided dose of labetalol in hypertensive emergency

Saturday May 15, 2010

Q: What is the conversion (or equivalent) of propranolol to Nadolol in portal hypertension?


Answer: Decrease the dose to half and give once a day.

In portal hypertension treatment, Beta-blockers are noncardioselective and reduce portal and collateral blood flow by 2 methods

• Reduction in cardiac output (blockade of beta1-adrenoreceptors) occurs.
• Splanchnic vasoconstriction (blockade of vasodilatory adrenoreceptors of the splanchnic circulation).

Most commonly used noncardioselective B-blockers are propranolol and Nadolol.

Propranolol is usually started at a dose of 20 mg every 12 hours, and increased or decreased every 3-4 days until a 25% reduction in the resting heart rate occurs or the heart rate is down to 55 beats per minute (bpm). The average dose of propranolol usually is 40 mg bid.

Nadolol dosing is half the daily dose of propranolol, administered once a day.

Friday May 14, 2010


Q: One dose of intravenous Vitamin K antagonize the effects of warfarin for how many days?



Answer: One week

High dose of Vitamin K (= 10 mg) produce rapid reversal; however, overcorrection and warfarin resistance complicate therapy. The effects of warfarin on clotting factor synthesis are antagonize for 7 days by a 10-mg dose of vitamin K. Low doses (0.5-2.5 mg) reversed anticoagulation within 24 hours (taking little longer but) with less risk of overcorrection or resistance to reinstitution of therapy.

Thursday May 13, 2010
On stroke


Q:What is Balint syndrome?


Answer: Balint syndrome is a triad of

• visual simultanagnosia,
• optic ataxia, and
• apraxia of gaze

Visual simultanagnosia: implies an inability to examine a scene and integrate its parts into a cohesive interpretation. A patient can identify specific parts of a scene but cannot describe the entire picture.

Optic ataxia: implies a loss of hand-eye coordination such that reaching or performing a motor task under visual guidance is clumsy and uncoordinated.

Apraxia of gaze: is a misnomer describing a supranuclear deficit in the ability to initiate a saccade on command.

This may occur with bilateral parieto-occipital infarction, most often in the watershed between the PCA and MCA territories.

Wednesday May 12, 2010
On Haldol


Q:Give at least 5 un-conventional uses of Haloperidol at bedside?

Answer:

1. Adjunctive treatment of alcohol and opioid withdrawal
2. Treatment of disorders such as tic, Tourette syndrome, and chorea
3. Treatment of severe nausea/emesis (postoperative, chemotherapy etc.)
4. Adjunctive treatment of severe chronic pain, (with analgesics)
5. Also used in the treatment of intractable hiccups

Tuesday May 11, 2010
Steroid controversy?

Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults - A Systematic Review


Context:The benefit of corticosteroids in severe sepsis and septic shock remains controversial.

Objective: We examined the benefits and risks of corticosteroid treatment in severe sepsis and septic shock and the influence of dose and duration.


Design: We searched the CENTRAL, MEDLINE, EMBASE, and LILACS (through March 2009) databases as well as reference lists of articles and proceedings of major meetings, and we contacted trial authors. All reviewers agreed on trial eligibility. One reviewer extracted data, which were checked by the other reviewers and by the trials' authors whenever possible. Some unpublished data were obtained from the trials' authors. The primary outcome for this review was 28-day mortality.


Results: We identified 17 randomized trials (n = 2138) and 3 quasi-randomized trials (n = 246) that had acceptable methodological quality to pool in a meta-analysis.

• Twenty-eight-day mortality for treated vs control patients was 35.3% vs 38.5% in randomized trials and 23.1% vs 19.2% in quasi-randomized trials
• In 12 trials investigating prolonged low-dose corticosteroid treatment, 28-day mortality for treated vs control patients was 37.5% vs 44%
• This treatment increased 28-day shock reversal 66.9% vs 58.6%; and reduced intensive care unit length of stay by 4.49 days without increasing the risk of gastroduodenal bleeding [8.1% vs 7.3%, superinfection [18.4% vs 17.9%], or neuromuscular weakness [1% 1.7%].
• Corticosteroids increased the risk of hyperglycemia [51.6% vs 46%] and hypernatremia (31.4% vs 19.2%]

Conclusions: Corticosteroid therapy has been used in varied doses for sepsis and related syndromes for more than 50 years, with no clear benefit on mortality. Since 1998, studies have consistently used prolonged low-dose corticosteroid therapy, and analysis of this subgroup suggests a beneficial drug effect on short-term mortality.


Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults - A Systematic Review - Djillali Annane, MD; Eric Bellissant, MD; Pierre-Edouard Bollaert, MD; Josef Briegel, MD; Marco Confalonieri, MD; Raffaele De Gaudio, MD; Didier Keh, MD; Yizhak Kupfer, MD; Michael Oppert, MD; G. Umberto Meduri, MD - JAMA. 2009;301(22):2362-2375.

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.

Sunday May 9, 2010


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

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


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
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


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


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
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
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


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.