tag:blogger.com,1999:blog-38050184444376965642024-02-21T23:54:23.207-08:00March 2008 archiveUnknownnoreply@blogger.comBlogger23125tag:blogger.com,1999:blog-3805018444437696564.post-86859219019889992622008-03-23T21:18:00.000-07:002008-04-02T00:33:49.857-07:00<strong><span style="color:#000066;">Sunday March 23, 2008</span></strong><br /><strong><span style="color:#990000;">Dilantin in Torsade</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Q: </span><span style="color:#003333;"><em>Which anti-seizure drug can be use in the treatment of Torsade de pointes if conventional therapy fails?</em></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">A: Phenytoin (Dilantin).</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References:</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1996806&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Torsades de pointes therapy with phenytoin</span></a><span style="font-size:78%;color:#003333;"> - Ann Emerg Med.1991 Feb;20(2):198-200.</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.remarkablemedicine.com/Clinical/clinicaluses/cardiodisorders/torsade.html" target="_blank"><span style="font-size:78%;color:#003333;">Few case reports from literature</span></a><span style="font-size:78%;color:#003333;">: remarkablemedicine.com</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-6377285422557049192008-03-22T09:54:00.000-07:002008-03-22T21:27:52.399-07:00<strong><span style="color:#000066;">Saturday March 22, 2008</span><br /><br /></strong><a name="_MINI_MENTAL_STATUS"></a><strong><br /><span style="color:#660000;">Q:</span> <em>Once patient receive Digoxin Fragmented Antibody (DIGIFAB or Digibind), how frequent digoxin level should be measured ?</em><br /><br /><span style="color:#660000;">A:</span> <span style="color:#000000;">Digoxin level after giving Digibind will rise and will remain distorted for about 7 days. This is due to ability of Digibind to pull all of the digoxin into blood stream. These are inactive fragments and not toxic. There is no need to follow Dig level after administration of Digibind as it will be erroneously high and misleading.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-65985897807345203422008-03-21T07:21:00.000-07:002008-03-21T07:22:47.507-07:00<strong><span style="color:#000066;">Friday March 21, 2008<br /></span></strong><strong><span style="color:#990000;">"Locked-in" Syndrome (coma vigilante)</span></strong><br /><strong></strong><br /><strong><em><span style="color:#003333;">"patient is a silent and unresponsive witness to everything that is happening" - from story of Nick Chisholm</span></em> <span style="font-size:78%;">1</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">Patient with Locked-in syndrome is a fully conscious person, but all the voluntary muscles of the body are completely paralyzed, other than those that control eye movement. Term was first introduced about 25 years ago by Plum and Posner with complete occlusion of the basilar artery.</span><span style="font-size:78%;"> 3</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">Any catastrophy involving ventral pons can cause this syndrome like massive stroke, traumatic head injury, ruptured aneurysm, pontine infarction after prolonged vertebrobasilar ischaemia, haemorrhage, tumor, central pontine myelinolysis, pontine abscess or postinfective polyneuropathy. As all of the nerve tracts responsible for voluntary movement pass through the ventral pons but fortunately or unfortunately, consciousness are above the level of the ventral pons.</span> <span style="font-size:78%;">2</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">Only supportive rehabilitation is the answer. Being an intensivist, it is extremely important to educate staff and to protect patient from any physical or psychological harm (like procedure without adequate analgesia), with upmost understanding that it is an "imprisoned mind buried alive in a dead body’’ (as said for character with paralysis like locked-in syndrome in </span></strong><a href="http://us.penguingroup.com/nf/Book/BookDisplay/0,,0_0140449442,00.html" target="_self"><strong><span style="color:#660000;">Thérèse Raquin by Emile Zola</span></strong></a><strong><span style="color:#000000;"> - 1868).</span></strong><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get articles/abstract </span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://bmj.bmjjournals.com/cgi/content/full/bmj;331/7508/94" target="_blank"><span style="font-size:78%;color:#003333;">The patient's journey: Living with locked-in syndrome</span></a><span style="font-size:78%;color:#003333;"> - BMJ 2005;331:94-97 (9 July)<br />2. </span><a href="http://health.enotes.com/neurological-disorders-encyclopedia/locked-syndrome" target="_blank"><span style="font-size:78%;color:#003333;">Locked-in Syndrome</span></a><span style="font-size:78%;color:#003333;"> - enotes.com<br />3. Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: FA Davis, 1982; 377<br />4. </span><a href="http://bja.oxfordjournals.org/cgi/content/full/92/2/286" target="_blank"><span style="font-size:78%;color:#003333;">Locked-in syndrome: a catastrophic complication after surgery</span></a><span style="font-size:78%;color:#003333;"> - British Journal of Anaesthesia, 2004, Vol. 92, No. 2 286-288</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-11373398826735885572008-03-20T08:13:00.000-07:002008-03-20T08:20:38.986-07:00<strong><span style="color:#000066;">Thursday March 20, 2008</span> </strong>
<br /><strong><span style="color:#990000;">MINI MENTAL STATUS EXAM (MMSE)</span></strong>
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<br /><strong><span style="color:#000000;">Although older adults are at higher risk than the rest of the population, changes in cognitive function often call for prompt and aggressive action, particularly in hospital / ICU setting. The Mini Mental State Examination (MMSE) is a tool that can be used systematically. It is an 11-question measure that tests five areas of cognitive function:</span></strong>
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<br /><strong><ol><li><span style="color:#000000;">orientation, </span></li><li><span style="color:#000000;">registration, </span></li><li><span style="color:#000000;">attention and calculation, </span></li><li><span style="color:#000000;">recall, and </span></li><li><span style="color:#000000;">language </span></li></ol><span style="color:#000000;"></span>
<br /><span style="color:#000000;">The maximum score is 30. A score of 23 or lower is indicative of cognitive impairment. The MMSE takes only 5-10 minutes to administer and has been validated in clinical practice.</span>
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<br /><img id="BLOGGER_PHOTO_ID_5179843725600945522" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjiAkg-bgOl4qSbLaDS_YgT_UJBgm3h8ojoe7kUEmyZPAfeD3PATVBd4d87MJzKBCn9U6Y9WjdSUQVIOy1jfJKRqQ-EMvFzyF1utI7iwBjoVJv08erms_MFgsKVm-JNrWbxsdLWs78xzJ8/s400/mmse.jpg" border="0" />
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<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-80997458889317545962008-03-19T17:14:00.000-07:002008-03-19T17:19:42.092-07:00<strong><span style="color:#000000;"><span style="color:#660000;"><span style="color:#000066;">Wednesday March 19, 2008</span><br /></span><br /><span style="color:#660000;">Case:</span> <em><span style="color:#003333;">You inserted central line. While you were on your way to check CXR to confirm line placement, nurse request you to check KUB also to confirm enteral feeding tube placement (DHT). Interestingly, KUB shot this morning had IVC filter which is no more present there ?</span></em><br /><br /><br /><span style="color:#660000;">Answer:</span> </span><span style="color:#000000;">Guide wire during central line procedure probably travelled into inferior vena cava and dislodged IVC filter !!!</span></strong><br /><p><strong><span style="color:#660000;"></span></strong> </p><p><strong><span style="color:#660000;"><span style="color:#003300;">Related previous pearls:</span> </span></strong></p><p><strong><a href="http://january07-icuroom.blogspot.com/2007_01_21_archive.html"><span style="color:#660000;">Guide wire length</span></a></strong></p><p><strong><a href="http://icuroom-pearls.blogspot.com/2006/01/sunday-january-8-2006-peres-nomogram.html"><span style="color:#660000;">Peres Nomogram</span></a></strong></p><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference: click to get abstract / article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://ves.sagepub.com/cgi/content/abstract/31/5/587" target="_blank"><span style="font-size:78%;color:#003333;">Guidewire Dislodgment of Inferior Vena Cava Filters During Insertion of Central Venous Catheters,</span></a><span style="font-size:78%;color:#003333;"> Vascular and Endovascular Surgery, Vol. 31, No. 5, 587-593 (1997)</span><br /><span style="font-size:78%;color:#003333;"><br />2. </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/10667513?dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement</span></a><span style="font-size:78%;color:#003333;">. Crit Care Med 2000; 28: 138–42</span><br /></span><span style="font-size:78%;color:#003333;"><br />3. </span><a href="http://www.chestjournal.org/cgi/reprint/106/3/957.pdf"><span style="font-size:78%;color:#003333;">Greenfield Inferior Vena Cava Filter </span></a><a href="http://www.chestjournal.org/cgi/reprint/106/3/957.pdf"><span style="font-size:78%;color:#003333;">Dislodged During Central Venous Catheter placement</span></a><span style="font-size:78%;color:#003333;">, Chest 1994;106;957-959</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-40152169074329746192008-03-18T11:26:00.001-07:002008-03-18T11:28:35.051-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Tuesday March 18, 2008</span><br /><br /><span style="color:#990000;">Case:</span> </span><span style="color:#003333;"><em>57 year old female, newly hemodialysis patient, transferred from floor to ICU after she developed seizure at the end of her dialysis session. No significant risk factor could be find otherwise. Nurse reports patient appear irritable and restless before episode and complain of headache, nausea and blurred vision. While resident was called to evaluate as patient also noticed to have muscular twitching and confusion, symptoms progressed and seizure was witnessed.</em></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><strong>Answer: <span style="color:#990000;">Dialysis disequilibrium syndrome.</span></strong></span><br /><span style="color:#000000;"><strong></strong></span><br /><span style="color:#000000;"><strong>Dialysis disequilibrium syndrome is common during hemodialysis particularly patient’s first few dialysis sessions. It is characterized by neurologic symptoms of varying severity and actually may lead to herniation and death. The rapid reduction in BUN lowers the plasma osmolality, creating a transient osmotic gradient that promotes water movement into the cells, causing cerebral edema and consequently acute neurologic dysfunction. With better understanding of the process and newer dialysis techniques, severe form of syndrome is now not commonly seen. This not only explains that why our nephrology colleagues start with gentle but frequent sessions but also explains one of the several benefits of mannitol during dialysis.<br /><br /><br />Read interesting article from University of Calgary, Alberta, Canada : </strong></span><a href="http://www.biomedcentral.com/content/1471-2369/5/9" target="_blank"><span style="color:#660000;"><strong>Dialysis Disequilibrium Syndrome: Brain death following hemodialysis for metabolic acidosis and acute renal failure</strong></span></a><span style="color:#000000;"><strong> </strong><em>- A case report followed with discussion and different management modalities (Ref.: BMC Nephrol. 2004; 5: 9.)</em></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-12734597643483011842008-03-17T12:22:00.000-07:002008-03-17T12:25:04.835-07:00<p><span style="color:#000000;"><strong><span style="color:#000066;">Monday March 17, 2008</span><br /></strong><strong><span style="color:#990000;">DVT prophylaxis - our poor record card !!<br /></span><br /><span style="color:#000000;"><br />Dr. Alpesh Amin and coll. from School of Medicine, University of California, Irvine, looked into thromboprophylaxis rates in US medical centers: and guess what? We failed miserably !<br /><br /><span style="color:#660000;">Methods:</span> Patients included were </span></strong></span></p><ul><li><span style="color:#000000;"><strong><span style="color:#000000;">40 years old or more, </span></strong></span></li><li><span style="color:#000000;"><strong><span style="color:#000000;">with a length of hospital stay of 6 days or more, and </span></strong></span></li><li><span style="color:#000000;"><strong><span style="color:#000000;">had no contraindications for anticoagulation<br /></li></ul></span></strong></span><p><span style="color:#000000;"><span style="color:#000000;"><em><strong>A total of 196,104 discharges from 227 hospitals met the inclusion criteria.</strong></em><br /><strong><br /><br /><span style="color:#660000;">Results:</span></strong></span></span></p><span style="color:#000000;"><span style="color:#000000;"><ul><li><strong>The overall VTE thromboprophylaxis rate was 61.8%, although the appropriate thromboprophylaxis rate was only 33.9%. </strong></li><li><strong>Of the 66.1% discharged patients who did not receive appropriate thromboprophylaxis, 38.4% received no prophylaxis, </strong></li><li><strong>4.7% received mechanical prophylaxis only, </strong></li><li><strong>6.3% received an inappropriate dosage, and </strong></li><li><strong>16.7% received an inappropriate prophylaxis duration </strong></li></ul><p><br /><em>(based on ACCP recommendations)<br /></em><strong><br /><br /><span style="color:#660000;">Conclusions:</span> This study highlights the low rates of appropriate thromboprophylaxis in US acute-care hospitals, with two-thirds of discharged patients not receiving prophylaxis in accordance with the 6th ACCP guidelines. More effort is required to improve the use of appropriate thromboprophylaxis in accordance with the ACCP recommendations.</strong></span><br /><strong><br /><br /></strong><span style="font-size:78%;"><br /><span style="color:#003333;">Reference: click to get article / abstract<br /><br /></span></span></span><a href="http://www.blackwell-synergy.com/doi/abs/10.1111/j.1538-7836.2007.02650.x" target="_blank"><span style="font-size:78%;color:#003333;">Thromboprophylaxis rates in US medical centers: success or failure? </span></a><span style="font-size:78%;color:#003333;">- Journal of Thrombosis and Haemostasis, Volume 5 Issue 8 Page 1610-1616, August 2007</span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-72010995437147271052008-03-16T21:22:00.000-07:002008-03-15T21:25:00.292-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday March 16, 2008
<br /></span><span style="color:#990000;">Propofol lipidic infusion promotes resistance to antifungals !</span>
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<br />See this interesting study explaining why sometime antifungals do not work ! and why there are discrepancies between in vitro and in vivo susceptibility to antifungals. </span></strong>
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<br /><strong>During study, Candida and Aspergillus were studied regarding the ability to grow and its susceptibility profile to antifungals in the presence of propofol infusion and its lipidic vehicle. </strong>
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<br /><em><span style="font-size:85%;">The intensity of fluorescence after staining with FUN1, in the presence and absence of propofol infusion, was determined by flow cytometry. Radioactivity assays were also performed in order to quantify the input of [3H]- itraconazole into the fungal cell in the presence of propofol. Assays were repeated after addition of sodium azide, in order to block efflux pumps.
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<br /><span style="color:#660000;">Results</span></strong>
<br /><strong><ul><li>Propofol infusion promoted budding of Candida and the germination of Aspergillus, latter forming a lipid layer around the hypha.</li><li>An increase of minimal fungicidal concentrations regarding both Candida and Aspergillus strains was found for all antifungals when incubated simultaneously with propofol infusion. </li><li>A decrease of the intensity of fluorescence of Candida cells was systematically observed, as well as a significant reduced intracellular uptake of [3H] itraconazole in cells treated with propofol infusion, even after the blockade of efflux pumps. </li></ul>
<br /><span style="color:#660000;">Conclusion
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<br />Propofol infusion, due to its lipidic vehicle, increased the fungal germination and promoted resistance to antifungals. This effect seems to be related to the reduced access and/or permeabilization to fungal cells by antifungals</strong></span>.
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<br /></span><span style="font-size:78%;color:#003333;">Reference: click to get article / abstract
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<br /></span><a href="http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2258299&blobtype=pdf" target="_blank"><span style="font-size:78%;color:#003333;">Propofol lipidic infusion promotes resistance to antifungals by reducing drug input into the fungal cell</span></a><span style="font-size:78%;color:#003333;"> - BMC Microbiol. 2008; 8: 9. - pdf non-pdf version is available </span><a href="http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2258299" target="_blank"><span style="font-size:78%;color:#003333;">here</span></a>
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<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-46062030158595535362008-03-15T15:15:00.000-07:002008-03-15T15:18:14.525-07:00<strong><span style="color:#000066;">Saturday March 15, 2008</span><br /></strong><br /><strong><span style="color:#990000;">Ultrasound for LP !<br />and<br />Ultrasound tricks to find collapsed IJ vein !!</span></strong><br /><br /><br /><object width="425" height="355"><param name="movie" value="http://www.youtube.com/v/Ha56rsZ1IVA&hl=en"></param><param name="wmode" value="transparent"></param><embed src="http://www.youtube.com/v/Ha56rsZ1IVA&hl=en" type="application/x-shockwave-flash" wmode="transparent" width="425" height="355"></embed></object>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-56824764022112327822008-03-14T21:45:00.000-07:002008-03-14T21:46:40.262-07:00<strong><span style="color:#000066;">Friday March 14, 2008<br /></span><span style="color:#990000;">Four generations of Quinolones</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">The classification of the fluoroquinolones on the basis of generations (imitating from cephalosporins) is not officially standardized, but it is now commonly use to classify them by their spectrum of action.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">1st generation</span> - Gram negative coverage but not pseudomonas (example: Nalidixic acid)</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">2nd generation</span> - Gram negative coverage with pseudomonas and some gram postive coverage including s.aureus but not strep pneumoniae. (example: Ciprofloxacin, Ofloxacin, Norfloxacin)</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">3rd generation</span> - Gram negative coverage with pseudomonas. More gram postive coverage including penicillin sensitive and resistant s. pneumoniae. (example: Levofloxacin, Sparfloxacin, Gatifloxacin (tequin), Moxifloxacin (avalox)). Avalox has been said to be the most effective in this generation.</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;"><span style="color:#660000;">4th generation</span> - Same as 3rd generation but with anaerobic coverage (example: Trovafloxacin (Trovan) ).</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><strong><span style="color:#000000;">Read </span></strong><a href="http://www.aafp.org/afp/20020201/455.pdf" target="_blank"><strong><span style="color:#660000;">comprehensive review on Quinolones</span></strong></a><span style="color:#000000;"><span style="color:#660000;"> </span><span style="font-size:85%;">(Source: Am Fam Physician 2002;65:455-64, authors: CATHERINE M. OLIPHANT, PHARM.D., University of Wyoming School of Pharmacy and GARY M. GREEN, M.D., Kaiser Permanente, California)</span></span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-31665541383850268432008-03-13T11:19:00.000-07:002008-03-13T11:22:40.629-07:00<span style="color:#000000;"><strong><span style="color:#000066;">Thursday March 13, 2008</span><br /><span style="color:#990000;">Feeding tube in Brain !</span></strong></span><br /><br /><span style="color:#000000;"><strong>Any procedure, how simple it sounds, may turn into a nightmare. See following images where feeding tube travelled upward in brain.</strong></span><br /><br /><span style="color:#000000;"><strong>See important read: </strong></span><a href="http://www.aacn.org/AACN/practiceAlert.nsf/Files/VOFTP/$file/Verification%20of%20Feeding%20Tube%20Placement%2005-2005.pdf" target="_blank"><span style="color:#660000;"><strong>VERIFICATION OF FEEDING TUBE PLACEMENT</strong></span></a><span style="color:#000000;"> <em><span style="font-size:85%;">(Ref; American Association of Critical-Care Nurses ) - pdf file</span></em></span><br /><br /><br /><img id="BLOGGER_PHOTO_ID_5177292785744325282" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhen6X_o_aFkjn2EHJ9CTzyyso8PTDp9p4rToOEetriht1-2nGnmhrYkzPKwkKZBP5gLGpAeGgbJC_aSsXsfdSgg76NrDAxjYVYC77DJTNVsa9VlMvHqPP2heAmJ9TvHzT-BfNovF7yNrQ/s400/1.bmp" border="0" /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhstZ-YjPhTIanETJizBbR6btEtt6z0xas_mYiawzqTranRck0szqBMxv_DfE50GWP_4lOYx_4yDlWjf5k68ZyP7T1eFnZ_5_7rJOzD13NM7B06AWh9TzY-GjfaRYuXf_ACWULScPrZAvc/s1600-h/2.bmp"><img id="BLOGGER_PHOTO_ID_5177292790039292594" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhstZ-YjPhTIanETJizBbR6btEtt6z0xas_mYiawzqTranRck0szqBMxv_DfE50GWP_4lOYx_4yDlWjf5k68ZyP7T1eFnZ_5_7rJOzD13NM7B06AWh9TzY-GjfaRYuXf_ACWULScPrZAvc/s400/2.bmp" border="0" /></a><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgJQJEI23jytegBLuArQuMvDsKrEuv5VAs04TkhFze3Tx-Ba70KyZBp0xQMjlwLe8D9_sff3553i9GGw8rmI0tJFMOlmpO5a_hdLLe9yCf3kGhIC3TgPyLQHQ6eMmhnF6wtwkhWpK6m1s/s1600-h/3.bmp"><img id="BLOGGER_PHOTO_ID_5177292794334259906" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgJQJEI23jytegBLuArQuMvDsKrEuv5VAs04TkhFze3Tx-Ba70KyZBp0xQMjlwLe8D9_sff3553i9GGw8rmI0tJFMOlmpO5a_hdLLe9yCf3kGhIC3TgPyLQHQ6eMmhnF6wtwkhWpK6m1s/s400/3.bmp" border="0" /></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-44460678866016041072008-03-12T06:36:00.000-07:002008-03-12T06:37:47.983-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Wednesday March 12, 2008</span>
<br /></span><span style="color:#990000;">Restless Legs syndrome</span></strong>
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<br /><strong><span style="color:#000000;">Restless legs syndrome is a common condition in non-intubated patients which may get aggravated by ICU enviroment. Major factors associated with Restless Leg Syndrome in ICU are</span></strong>
<br /><strong><ul><li><span style="color:#000000;">Iron-deficiency anemia </span></li><li><span style="color:#000000;">Peripheral neuropathy </span></li><li><span style="color:#000000;">Withdrawal from vasodilator drugs and sedatives </span></li><li><span style="color:#000000;">Cigarette smoking, alcohol and caffeine withdrawal </span></li><li><span style="color:#000000;">Various drugs including phenytoin, antidepressant drugs, H2 blockers, lithium, beta-blockers and antipsychotics </span></li><li><span style="color:#000000;">Hypomagnesemia </span></li><li><span style="color:#000000;">Renal insufficiency (uremia)</span></li></ul><span style="color:#000000;"></span>
<br /><span style="color:#000000;">Various pharmacological agents have been described and used with success including benzodiazepines, carbamazepine and clonidine. In ICU situation, one useful drug in this regard is Ropinirole which is a Dopamine agonist. One of the effect of Ropinirole is heavy sleepiness, which can be use as a bonus benefit in ICU. Dose can be initiated from .25 mg PO QHS upto 4 mg PO QHS.</span></strong>
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<br /><span style="font-size:78%;color:#003333;">References: (click to get abstract)</span>
<br /><span style="font-size:78%;color:#003333;"></span>
<br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.aafp.org/afp/20000701/108.html" target="_blank"><span style="font-size:78%;color:#003333;">Restless Legs Syndrome: Detection and Management in Primary Care - NATIONAL HEART, LUNG, AND BLOOD INSTITUTE WORKING GROUP ON RESTLESS LEGS SYNDROME</span></a><span style="font-size:78%;color:#003333;"> - Vol. 62/No. 1 (July 1, 2000) - American Family Physician.</span>
<br /><span style="font-size:78%;color:#003333;"></span>
<br /><span style="font-size:78%;color:#003333;">2. </span><a href="http://www.ncbi.nlm.nih.gov//entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15390050" target="_blank"><span style="font-size:78%;color:#003333;">Ropinirole is effective in the treatment of restless legs syndrome. TREAT RLS 2: a 12-week, double-blind, randomized, parallel-group, placebo-controlled study</span></a><span style="font-size:78%;color:#003333;"> - Mov Disord. 2004 Dec;19(12):1414-23.</span>
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-65552353859051365562008-03-11T12:46:00.000-07:002008-03-11T12:48:44.837-07:00<strong><span style="color:#000066;">Tuesday March 11, 2008</span><br /><span style="color:#990000;">Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery</span><br /><br /></strong><span style="color:#000000;"><strong>Interesting study particularly for folks working in cardio-thoracic ICUs. This randomised, double-blinded, placebo-controlled study was primarily aimed to evaluate the potential of risperidone to prevent postoperative delirium following cardiac surgery with cardiopulmonary bypass. The secondary objective was to explore clinical factors associated with postoperative delirium.<br /><br /><span style="color:#660000;">Number:</span> 126 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomly assigned to receive either 1 mg of risperidone or placebo sublingually when they regained consciousness.<br /><br /></strong><em>The confusion assessment method for intensive care unit was used to assess postoperative delirium.</em><br /><strong><br /><br /><span style="color:#660000;">Results:</span></strong></span><br /><span style="color:#000000;"><strong><span style="color:#660000;"></span><ul><li>The incidence of postoperative delirium in the risperidone group was lower than the placebo group (11.1% vs. 31.7% ). </li><li>Other postoperative outcomes were not statistically different between the groups.</li><li>Many factors were associated with postoperative delirium. However multiple logistic regression analysis showed <em>a lapse of 70 minutes from the time of opening eyes to following commands and postoperative respiratory failure were independent risk factors.</em> </li></ul><p><span style="color:#660000;">Conclusion:</span> A single dose of risperidone administered soon after cardiac surgery with cardiopulmonary bypass reduces the incidence of postoperative delirium. Multiple factors tended to be associated with postoperative delirium, but only the time from opening eyes to following commands and postoperative respiratory failure were independent risk factors in this study.</strong></span><br /><br /><br /><span style="font-size:78%;"><br /><span style="color:#003333;">Reference:<br /><br />Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery - Anest. and Intensive care, Volume 35, No. 5, 2007, 714-719</span></span></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-11879996738802089452008-03-10T10:48:00.000-07:002008-03-10T10:51:37.801-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Monday March 10, 2008<br /></span></span><span style="color:#990000;"> Percutaneous tracheostomy with Blue Rhino (2nd video is Bronchoscopic view)</span></strong><br /><br /><br /><object width="425" height="355"><param name="movie" value="http://www.youtube.com/v/6TVOSb6sqL8"></param><param name="wmode" value="transparent"></param><embed src="http://www.youtube.com/v/6TVOSb6sqL8" type="application/x-shockwave-flash" wmode="transparent" width="425" height="355"></embed></object><br /><br /><br /><object width="425" height="355"><param name="movie" value="http://www.youtube.com/v/PhasybkUrzk"></param><param name="wmode" value="transparent"></param><embed src="http://www.youtube.com/v/PhasybkUrzk" type="application/x-shockwave-flash" wmode="transparent" width="425" height="355"></embed></object>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-21761265508503905742008-03-09T14:25:00.000-07:002008-03-09T14:27:23.946-07:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday March 9, 2008<br /></span></span><span style="color:#990000;">Heparin Induced HyperKalemia</span></strong><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><span style="color:#000000;"><strong>Hyperkalemia from Heparin is a well know phenomenon and has been detected particularly on geriatric, renal insufficient and diabetic patients. Hyperkalemia can be anywhere from .3 to 1.7 mEq/Litre. It usually occurs around on day 3 with SQ heparin (as for DVT prophylaxis) but can occur early with IV heparin</strong></span> <span style="font-size:78%;">1,2,3,4.</span></span><br /><strong><span style="color:#000000;"></span></strong><br /><span style="color:#000000;"><span style="color:#000000;"><strong> Hyperkalemia has been reported with low- molecular weight heparins too but risk is low</strong></span> <span style="font-size:78%;">5, 6, 7.</span><strong> <span style="color:#000000;">Mechanism of action: Heparin induce hypoaldosteronism and can subsequently lead to hyperkalemia 6.Treatment: Best thing is to discontinue the culprit but if heparin is absolutely required, fludrocortisone (.1 mg/day) has been reported to be effective in heparin-induced hyperkalemia</span></strong></span> <span style="font-size:78%;">8.</span><br /><br /><br /><span style="font-size:78%;color:#003333;">References: Click to get abstracts/articles</span><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://ats.ctsnetjournals.org/cgi/content/full/74/5/1698" target="_blank"><span style="font-size:78%;color:#003333;">Case report - Heparin-induced hyperkalemia after cardiac surgery</span></a><span style="font-size:78%;color:#003333;"> - Ann Thorac Surg 2002;74:1698-1700<br />2. </span><a href="http://www.theannals.com/cgi/content/abstract/24/3/244" target="_blank"><span style="font-size:78%;color:#003333;">Heparin-induced hyperkalemia</span></a><span style="font-size:78%;color:#003333;"> -The Annals of Pharmacotherapy: Vol. 24, No. 3, pp. 244-246.<br />3. </span><a href="http://www.endocrine-abstracts.org/ea/0004/ea0004p26.htm" target="_blank"><span style="font-size:78%;color:#003333;">Heparin Induced HyperKalemia</span></a><span style="font-size:78%;color:#003333;"> - Endocrine Abstracts (2002) 4 P26<br />4. </span><a href="http://www.amjphysmedrehab.com/pt/re/ajpmr/abstract.00002060-200001000-00019.htm;jsessionid=EeI2wAT53phP4F3U0EMxZzYELAgaICWOuTNGLK1o3hzIEPFmWCha!-839643570!-949856144!9001!-1" target="_blank"><span style="font-size:78%;color:#003333;">Heparin-Induced Hyperkalemia Confirmed by Drug Rechallenge</span></a><span style="font-size:78%;color:#003333;">. American Journal of Physical Medicine & Rehabilitation. 79(1):93-96, January/February 2000.<br />5. </span><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&list_uids=15133781&dopt=Abstract" target="_blank"><span style="font-size:78%;color:#003333;">Early onset of hyperkalemia in patients treated with low molecular weight heparin: a prospective study </span></a><span style="font-size:78%;color:#003333;">- Pharmacoepidemiol Drug Saf.2004 May;13(5):299-302.<br />6. Effect of Low-Molecular-Weight Heparin on Potassium Homeostasis - Pathophysiology of Haemostasis and Thrombosis 2002;32:107-110<br />7. </span><a href="http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgg/vol2n2/heparin.xml" target="_blank"><span style="font-size:78%;color:#003333;">Low Molecular Weight Heparins Can Lead To Hyperkalaemia</span></a><span style="font-size:78%;color:#003333;"> The Internet Journal of Geriatrics and Gerontology . 2005. Volume 2 Number 2.<br />8. </span><a href="http://www.theannals.com/cgi/content/abstract/34/5/606" target="_blank"><span style="font-size:78%;color:#003333;">Fludrocortisone for the treatment of heparin-induced hyperkalemia</span></a><span style="font-size:78%;color:#003333;"> - The Annals of Pharmacotherapy: Vol. 34, No. 5, pp. 606-610</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-74592685339345591062008-03-08T15:10:00.000-08:002008-03-08T15:11:25.497-08:00<strong><span style="color:#000066;">Saturday March 8, 2008</span><br /> <span style="color:#990000;">Response to Warfarin during Initial Anticoagulation is genes dependent !</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">We all are aware of situations where warfarin (coumadin) takes forever to get upto therapeutic level despite escalating dose. One study of 297 patients who were starting warfarin therapy, is published this week in The New England Journal of Medicine.</span></strong><br /><span style="color:#000000;"><strong> <br /></strong><em>2 genotypes were assessed CYP2C9 genotypes VKORC1 haplotypes</em></span><br /><br /><strong><span style="color:#000000;">Study found that initial variability in the INR response to warfarin was more strongly associated with genetic variability in the pharmacologic target of warfarin, VKORC1, than with CYP2C9.</span></strong> <br /><br /><br /><br /><span style="font-size:78%;color:#003333;">Reference: click to get abstract/article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://content.nejm.org/cgi/content/abstract/358/10/999" target="_blank"><span style="font-size:78%;color:#003333;">Genetic Determinants of Response to Warfarin during Initial Anticoagulation</span></a><span style="font-size:78%;color:#003333;"> - Number 10, Volume 358:999-1008, March 6, 2008, The New England Journal of Medicine</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-79069255822324417512008-03-07T10:37:00.000-08:002008-03-07T10:38:31.802-08:00<strong><span style="color:#000066;">Friday March 7, 2008</span><br /><span style="color:#990000;">Ice test - Poor man's test for Myasthenia Gravis</span></strong><br /><strong></strong><br /><strong><span style="color:#000000;">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.</span></strong><br /><br /><span style="color:#000000;"><strong>Related: Click </strong></span><a href="http://www.jaoa.org/cgi/content/full/104/9/377" target="_blank"><span style="color:#660000;"><strong>here</strong></span></a><strong><span style="color:#000000;"><span style="color:#660000;"> </span>to read good review article on Myasthenia Gravis</span> </strong><em>( Dr. Milind J. Kothari The Journal of the American Osteopathic Association.Vol 104 • No 9 • Sept. 2004 • 377-384)</em>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-11686632787883034842008-03-06T06:38:00.000-08:002008-03-06T06:39:38.542-08:00<strong><span style="color:#000066;">Thursday March 6, 2008</span>
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<br /><span style="color:#660000;">Q;</span> <span style="color:#003333;"><em>While you prescribe 15 mmol of intravenous (IV) potassium phosphate to patient, what amount of potassium is received by patient ?
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<br /><span style="color:#660000;">A;</span> <span style="color:#000000;">About 20 meq</span></strong>
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<br /><span style="color:#000000;">To be precise, 1 mmol of intravenous phophate delivers 1.46 meq of potassium in "K-phos rider".
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<br /><span style="color:#000000;">To make it in round figure, 7.5 mmol of phosphate is equal to about 10 meq of potassium. </span>
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<br /><span style="color:#000000;">By mouth repletion of phosphate is preferable but if used, intravenous phosphate should be given very slowly. Usual recommended infusion rate is 5 mmol/hour. Rapid phosphate infusion may lead to precipitous fall in serum calcium, hypotension, and acute renal failure. Also, it may lead to hypomagnesemia, metastatic soft tissue calcifications, hypernatremia and volume loss from osmotic diuresis.
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<br /><span style="font-size:78%;color:#003333;">Reference: click to get article / abstract</span>
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<br /><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199507000-00009.htm;jsessionid=HPJcwWGGVQmfqwv1j7jLLJ6WG2Tm4Fpsgz7G4Pvy80vf8JKzJCWx!1253064403!181195628!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Intravenous phosphate repletion regimen for critically ill patients with moderate hypophosphatemia</span></a><span style="font-size:78%;color:#003333;"> - Critical Care Medicine. 23(7):1204-1210, July 1995.</span>
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-56581280950940914642008-03-05T14:04:00.000-08:002008-03-05T14:05:35.712-08:00<strong><span style="color:#000066;">Wednesday March 5, 2008</span><br /><span style="color:#990000;">Bedside precaution</span></strong><br /><strong><br /><span style="color:#000000;">If patient is recieving Lactate Ringer's solution, than lactate level should not be drawn from same infusion catheter to avoid erroneously high level of lactate. It should be drawn from catheter at any other site of body or peripherally.</span></strong><br /><br /><span style="color:#000000;"><strong>Though, once inside circulation lactate ringer does not have any clinically significant effect on serum lactate level.</strong><br /></span><br /><br /><span style="font-size:78%;color:#003333;"></span><br /><span style="font-size:78%;color:#003333;">Reference: click to get abstract / article</span><br /><br /><span style="font-size:78%;color:#003333;">1. </span><a href="http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199711000-00022.htm;jsessionid=HThGyGs7T17v1lBG5Ly2lklRZzVBRJNnCYv3Jpyf4y0Y4wn2yFmV!-667243907!181195629!8091!-1" target="_blank"><span style="font-size:78%;color:#003333;">Effects of crystalloid solutions on circulating lactate concentrations: Part 1. Implications for the proper handling of blood specimens obtained from critically ill patients</span></a><span style="font-size:78%;color:#003333;"> - Critical Care Medicine. 25(11):1840-1846, November 1997</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-24521447155744640592008-03-04T14:07:00.000-08:002008-03-05T14:08:34.155-08:00<strong><span style="color:#000066;">Tuesday March 4, 2008<br /></span><br /><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">One bag unit of cryoprecipitate is expected to raise fibrinogen by what level?</span></em></strong><br /><strong><br /><span style="color:#660000;">A;</span> <span style="color:#000000;">A bag of transfused cryoprecipitate is expected to raise the fibrinogen level by a minimum of 30 mg/dL with a half life of 3 to 6 days. Fibrinogen levels of more than 100 mg/dL generally are considered adequate for hemostasis.</span></strong>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-50170443066663427712008-03-03T10:39:00.000-08:002008-03-03T10:40:35.339-08:00<p><span style="color:#000000;"><strong><span style="color:#000066;">Monday March 3, 2008</span><br /><br /><span style="color:#660000;">Q;</span> <span style="color:#003333;"><em>During lumbar puncture (LP), what is the normal rate of cerebrospinal fluid (CSF) escape via needle into collecting tube ?</em></span></strong></span></p><p><span style="color:#000000;"><strong><span style="color:#660000;">A;</span> <span style="color:#000000;">1 drop per second</span></strong></span></p><p><strong><span style="color:#000000;">While performing LP, CSF should drop into tube with approximate rate of one drop/sec. A continuous stream of CSF indicates raised intrameningeal pressure.</span></strong></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-52459465609948150142008-03-02T22:29:00.000-08:002008-03-03T10:39:39.522-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Sunday March 2, 2008
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<br /><span style="color:#660000;">Q;</span> <em><span style="color:#003333;">37 year old male admitted to ICU with inability to walk and severe pain in lower extremities. On examination in ER, he was found to have cold feet. No pulses were palpable even in femoral area. Previous record available in hospital computer shows outpatient visits to urology clinic for 'impotency' ?</span></em>
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<br /><strong><span style="color:#000000;"><span style="color:#660000;">Answer:</span> </span><span style="color:#000000;">Leriche's syndrome</span></strong>
<br /><strong><span style="color:#000000;">
<br /><span style="color:#000000;">Leriche's syndrome is a triad of </span>
<br /><span style="color:#000000;"></span>
<br /><ul><li><span style="color:#000000;">absent or diminished femoral pulses, </span></li><li><span style="color:#000000;">intermittent claudication (pain with walking) and </span></li><li><span style="color:#000000;">penile impotence. </span></li></ul><span style="color:#000000;"></span>
<br /></span><span style="color:#000000;">It usually affects males caused by atheromatous involvement or occlusion of the abdominal aorta by a thrombus just above the site of its bifurcation. Onset usually between 30 and 40 years of age. Treatment is surgical.</span></strong>
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<br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvjpyOLaHSsY5fPbJWvr49jCebFppwq8v7TKv66R-D3oyPKXXOTgcQcmeqz-xaiZX39H-aKwfzp3stOFcBuX_GuxovRo2XnfmPHJVmGz1_R0pdPJz8sR9JPulGJeQdSnLgzvqZzIHshlY/s1600-h/ls1.JPG"><img id="BLOGGER_PHOTO_ID_5173027797151464546" style="DISPLAY: block; MARGIN: 0px auto 10px; CURSOR: hand; TEXT-ALIGN: center" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvjpyOLaHSsY5fPbJWvr49jCebFppwq8v7TKv66R-D3oyPKXXOTgcQcmeqz-xaiZX39H-aKwfzp3stOFcBuX_GuxovRo2XnfmPHJVmGz1_R0pdPJz8sR9JPulGJeQdSnLgzvqZzIHshlY/s400/ls1.JPG" border="0" /></a>
<br /><div align="center"><span style="font-size:85%;color:#000000;">Leriche Syndrome: Coronal reconstruction from a contrast-enhanced abdominal CT scan shows complete occlusion of the infrarenal aorta (red arrow) by thrombus that extends into both common iliac arteries (yellow arrows). The white arrow points to calcification in the wall of the vessel.
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<br /></div><div align="center"> </div><div align="left"><span style="font-size:78%;color:#003333;">Reference: click to get abstract / article</span></div><div align="left"><span style="font-size:78%;">
<br /><span style="color:#003333;">1. </span></span><a href="http://www.ncbi.nlm.nih.gov/pubmed/9242162" target="_blank"><span style="font-size:78%;color:#003333;">Leriche syndrome. Surgical procedures and early and late results </span></a><span style="font-size:78%;color:#003333;">- Angiology. 1997 Jul;48(7):637-42</span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-3805018444437696564.post-89136729065731660902008-03-01T21:42:00.000-08:002008-02-29T21:54:12.111-08:00<strong><span style="color:#000000;"><span style="color:#000066;">Saturday March 1, 2008<br /></span></span><span style="color:#990000;">Palliative care - Death Rattle</span></strong><br /><br /><strong><span style="color:#000000;">Patients at end of life process, lose their ability to clear oral secretions. As air moves over the secretions, which have pooled in the respiratory tract, the resulting turbulence produces noisy ventilation, call Death rattle.</span></strong><br /><br /><strong><span style="color:#000000;">One easy bedside tip is to use 1% Atropine ophthalmic drops sublingually. Time of onset for action is about 30 minutes. It can be given every 2 hours PRN.</span></strong><br /><br /><strong><span style="color:#000000;">Other treatments are scopolamine patch placed behind the ear once every three days, Benadryl 25-100mg every 4 to 6 hours PRN or Robinul (glycopyrrolate) - 400 mcg SC every 8 hours PRN.</span></strong>Unknownnoreply@blogger.com0