Friday, September 30, 2005

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Friday, 30 September 2005
Betadine in procedures


Before starting procedure, make sure that Betadine stays in skin contact for atleast 2/3 minutes - as Iodine inside the complex need some time to get release from the carrier molecule (polyvinylpyrrolidone) and act. Slow release of iodine from carrier molecule is a desired effect as it prolongs the action as well as decrease irritation of skin. (Reason to bring this point is to discourage the practice of quickly wipe betadine and "get rid of" procedure). Residents have been seen to wipe off site after procedure with Saline or ETOH to make procedure look 'clean' but this decreases the antimicrobial effect of Betadine.

(chlohexadine is superior for anti-septic use than Betadine).



Thursday, 29 September 2005
Hagen-Poiseuille equation and IVF bolus lines


Technically Central line (TLC or PICC line) is not ideal for IVF bolus due to longer length and smaller radius. 2 Large bore (say 18 gauge) peripheral IVs or one large bore central IV (cordis) are real placements for aggressive resuscitation (due to bigger radius and shorter length). [As per Hagen-Poiseuille equation just 2 fold increase in radius increase flow by 16 fold but 2 fold increase in length decrease flow by 50%].



Wednesday, 28 September 2005
Propofol and Green urine


Propofol infusion is noticed to turn colour of urine green. It is a benign potential side effect of Propofol. Recognition of this side effect is important as it averts unnecessary further workup and limits medical expenditures.



Tuesday, 27 September 2005
Propylene Glycol and Ativan


Being an intensivist it is imperative to understand the dangers of propylene glycol with Lorazepam drip - particularly if it is continued beyond 48 hours and dose > 10 mg/hr. Any unexplained high anion gap metabolic acidosis with elevated osmol gap, should prompt the diagnosis of propylene gylcol toxicity. It may also cause CNS depression, arrhythmias and renal dysfuntion. Propylene glycol is a viscous, colorless liquid solvent used for many drugs with poor aqueous solubility including lorazepoam, diazepam, esmolol, nitroglycerin, pentobarbital, phenytoin, trimethoprim/sulfamethoxazole and others.



Monday, 26 September 2005
Advantage of fondaparinux


Advantage of fondaparinux (Arixtra) over Heparin and LMW-Heparin is no reported complication of Heparin-Induced Thrombocytopenia (HIT) so far. Usual dose for DVT prophylaxis including hip fracture, hip replacement, or knee replacement surgeries is 2.5 mg SQ QD and 7.5 mg SQ QD for treatment of DVT and PE.(Dose adjustement is required in weight below 50 kg or over 100 kg and also in renal insufficiency).



Sunday, 25 September 2005
Ecstasy


Ecstasy (MDMA) may cause Hyponatremia (SIADH), leading to cerebral edema and seizures. In the ED/ICU, always consider this possibility in any patient with known or suspected MDMA ingestion who presents with an altered mental status as it may progress quickly.



Saturday, 24 September 2005
Digibind and hypokalemia


With administration of DigiFab (Digibind), serum potassium concentration should be followed very closely. Because it shifts potassium back into the cell and life threatening hypokalemia may develop rapidly.(Actually, Digoxin causes a shift of potassium from inside to outside of the cell, sometime causing a life-threatening hyperkalemia. At end, patient may have severe hyperkalemia but a whole body deficit of potassium and with administration of Digifab, actual hypokalemia may manifest which could be equally life threatening).



Friday, 23 September 2005
Work Ethics


3 Basic Principles of work Ethics:
Non-Malfeasance: Do no harm.
Beneficence: Advance the good.
Autonomy: Pt. has right to choose treatment.



Thursday, 22 September 2005
Xigris and DVT prophylaxis.


DVT Prophylaxis: Concomitant use of SQ low dose heparin (upto 5000 units q8) did not appear to affect safety with Xigris and may be continued while Xigris is on. Age: is not an any contraindication to administration of Xigris. Pregnancy: is also not a contraindication but Xigris should be given to pregnant women only if clearly needed.



Wednesday, 21 September 2005
ABGs in DKA


Obtaining "Arterial" ABG has no significant clinical role in diagnosis or mangement of suspected DKA patients - except it is a painful procedure. "Venous" pH correlates well to serve as a substitute. Also, administration of Bicarbonate has virtually no role in DKA. Actually, it has been correlated with cerebral edema in children.



Tuesday, 20 September 2005
Etomidate


"Single dose" Etomidate (.3mg/kg) is still a valid choice for intubation due to its minimal effect on hemodynamic changes, faster effect (15 sec) and short duration (3-7 mins). Adrenocortical suppression after single dose is transient and has not shown any significant clinical effect. (It may lowers seizure threshold ).



Monday, 19 September 2005
Thyroid storm and steroid

Addition of steroid (Hydrocotisone 100 mg q8 or Decadron 2 mg q6) has shown better outcome in management of Thyroid storm along with Tylenol, Propranolol, PTU/Methimazole and KI. Also note: 1.Aspirin is relatively contraindicated for control of pyrexia in thyroid storm. 2. First dose of KI should be given atleast one hour after first dose of Anti-thyroid drug.




Sunday, 18 September 2005
Pseudo-hypokalemia


If Pseudo-hypokalemia is suspected, real potassium level can be measured by sending specimen quickly (preferably taking manually to lab as soon as drawn) and requesting to measure potassium level in separated plasma or serum.(Pseudo-hypokalemia is usually seen with very high WBC count, when the drawn sample is allowed to sit at room temperature for longer period of time. It happens due to uptake of plasma potassium by high leukocytes in the sample).



Saturday, 17 September 2005
Acetadote


As we may see higher use of IV Mucomyst (with FDA approval of Acedadote) for Tylenol overdose, its not a bad idea to keep IV Benadryl and Steroid at bedside as flushing, urticaria and angioedema are frequent side effects. Also caution is advised in patients with Asthma and Bronchospasm.



Friday, 16 September 2005
Epogen and Iron

epoetin alfa (Epogen/Procrit) will not work if patient's Iron level is low. (Role of epoetin alfa in ICU setting is controversial and generally judicious use is recommended).



Thursday, 15 September 2005
Demerol and Zyvox

Try to avoid using Demerol with Zyvox (even prescribed within last 2 weeks). It may induce 'symptom cluster' - fever, agitation, seizure, coma or death.