Friday May 8, 2009 (pediatric pearl day)
Outcome of septic shock in the neonatal period

Septic shock in the neonatal period has a very poor outcome.

Study n = 48

The 28-day mortality was 40%. Adverse outcome at 18 months of corrected age was observed 52% cases (death = 19, severe sequelae = 5). 28% of the infants were alive and had a normal examination at 18 months.

Significant predictors (multivariate analysis) of 28-day mortality and of adverse outcome at 18 months of corrected age were:

• Weight (kg) at the onset of sepsis
• Gram-negative infection

Conclusions: Data underscore the extreme vulnerability of very low birth weight infants to septic shock, particularly to Gram-negative species.




Reference:

Outcome and prognostic factors in neonates with septic shock - Pediatric Critical Care Medicine. 9(2):186-191, March 2008

Thursday May 7, 2009
Influence of positive end-expiratory pressure (PEEP) on left ventricular regional wall motion in patients with acute respiratory distress syndrome (ARDS)

Regional left ventricular wall motion abnormalities have been described with positive end-expiratory pressure (PEEP). Study was conducted to assess global and regional LV performance in response to PEEP by transoesophageal echocardiography (TOE) in patients with ARDS. Study was conducted on eight critically ill patients with normal systolic LV function requiring mechanical ventilation (tidal volume 6-8 ml/kg, PEEP 12 ± 2 cmH2O) due to ARDS.

Measurements: Regional and global LV performance were assessed at PEEP levels of 5, 10, 15, 20 and 25 cmH2O.

Results: PEEP =15 cmH2O produced a significant reduction in systolic septal wall motion (hypokinesia) and a significant augmentation of lateral systolic wall motion (hyperkinesia). Global LV performance - measured as fractional area change - was not significantly affected.



Reference: Click to get abstract

Influence of positive end-expiratory pressure (PEEP) on left ventricular regional wall motion in patients with acute respiratory distress syndrome (ARDS): from 22nd International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium. 19–22 March 2002 Critical Care 2002, 6(Suppl 1):P14

Wednesday May 6, 2009

Q; EKG below shows characteristics of which electrolyte abnormality?

Answer: Hypokalemia

This EKG shows

• a long QT interval,
• ST depression,
• low T waves, and
• TU wave fusion

all characteristics of Hypokalemia.

Tuesday May 5, 2009


Q; What are 2 types of Atrial flutter?

Answer:

Type I atrial flutters (tricuspid valve isthmus dependent): Catheter ablation is typically successful and recurrence is less than 5%. Postprocedure anticoagulation with warfarin is usually continued for 4-6 weeks.

Type II atrial flutters (non—tricuspid valve isthmus dependent): These circuits are amenable to catheter ablation but require advanced mapping systems. Recurrence is more common and may also require the use of antiarrhythmic agents for suppression.

Monday May 4, 2009
Transdermal patch burn and MRI

Certain transdermal patches contain aluminum or other metals in the backing of the patches. Patches that contain metal can overheat during an MRI scan and cause skin burns in the immediate area of the patch. Patches usually contain metal in the layer of the patch that is not in contact with the skin (the backing).
Following patches have been identified by FDA.

Catapres TTS

(Clonidine)

Neupro

(Rotigotine)
Lidopel

(Lidocaine HCl and epinephrine)
Synera

(Lidocaine/Tetracaine)
Transderm-Scop

(Scopolamine)
Prostep

(Nicotine transdermal system)

Habitrol

(Nicotine transdermal system)

Nicotrol TD

(Nicotine transdermal system)
Androderm

(Testosterone transdermal system)
Fentanyl

(Fentanyl)

Salonpas Power Plus

(Methyl Salicylate/Menthol)

Reference:

1. FDA Public Health Advisory Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings - fda.gov

Sunday May 3, 2009
Drug -Drug interaction / cardiology

Q: Which two commonly use drugs in CHF (congestive heart failure) - may oppose each other's action?

Answer: Aspirin and Furosemide (Lasix)

Lasix has a direct vasodilator effect and this effect begins within a few minutes after an administration of IV Lasix. This added effect is very useful in treatment of acute pulmonary congestion. But this desirable action can be blocked by nonsteroidal anti-inflammatory drugs including aspirin.

Mechanism of action is not clear but salicylates may inhibit the renal effects of loop diuretics that are mediated by prostaglandins, including increases in sodium excretion, renal blood flow, and plasma renin activity.

Read interesting commentary on this issue: Aspirin Use in Chronic Heart Failure, What Should We Recommend to the Practitioner? (Barry M. Massie, MD - J Am Coll Cardiol, 2005; 46:963-966


References:

1. Jhund PS, Davie AP, McMurray JJ. Aspirin inhibits the acute venodilator response to furosemide in patients with chronic heart failure. J Am Coll Cardiol. 2001;37:1234-1238

2. Effect of combined administration of furosemide and aspirin on urinary urate excretion in man - Journal of Molecular Medicine, Volume 57, Number 23 / December, 1979, 1299-1301

Saturday May 2, 2009
Dermatology

Q: What is the medical term for "cool, clammy, and mottled skin" in cardiogenic shock due to vasoconstriction and subsequent hypoperfusion of the skin?

Answer: Cutis Marmorata

Friday May 1, 2009
Use of Nebulized Lidocaine for Nasogastric Tube Insertion - Pros and cons

A double-blind, placebo-controlled, randomized clinical trial of adult patients was conducted in the EDs of 2 university hospitals. 29 participants were administered nebulized lidocaine (4 mL 10%), and 21 participants received nebulized normal saline solution *. Patient discomfort was measured using a 100-mm visual analog scale. The difficulty of nasogastric tube insertion was evaluated using a 5-point Likert scale.

Results:

• There was a clinical and statistical significant difference in patient discomfort associated with the passage of the nasogastric tube between nebulized lidocaine and placebo groups (mean visual analog scale score 37.7 versus 59.3 mm, respectively).
• There was not a detectable difference in difficulty with the passage of the nasogastric tube between the 2 groups
• Epistaxis occurred more frequently in the lidocaine group

Conclusion: Nebulized lidocaine decreases the discomfort of nasogastric tube insertion and should be considered before passing a nasogastric tube. An increased frequency of epistaxis, however, may be associated with its use.

* Four milliliters of the trial solution was administered using a face mask and a compressed gas-powered jet nebulizer with an oxygen flow rate of 6 L/min. The patient was instructed to breathe through his or her nose and mouth while the solution was being nebulized. Immediately after the nebulization was completed, the nurse removed the mask and inserted the nasogastric tube with the usual lubrication gel (KY Jelly) in the normal manner.



Reference: Click to get abstract

Nebulized Lidocaine Decreases the Discomfort of Nasogastric Tube Insertion: A Randomized, Double-Blind Trial - [Ann Emerg Med. 2004;44:131-137.]