Friday June 12, 2009 (pediatric pearl)
Necrotizing enterocolitis in children with cardiac disease is a unique and distinct entity

Necrotizing enterocolitis (NEC) is a disease predominantly of preterm neonates. The intestinal injury of NEC occurs in association with pathogenic enteric bacteria and leads to bowel ischemia, necrosis, perforation, sepsis, and, in severe cases, death. Although prematurity and the associated immaturity of the gut mucosa account for 90% of cases, 10% of NEC occurs in term infants.

There is a 10- to 100-fold increased risk of NEC in the population with CHD compared with the entire preterm and term neonatal population. Episodic or chronic decreased mesenteric perfusion with CHD contributes to the development of this clinical picture in the term infant.

Differences in initial severity, range of age at diagnosis, and prognoses between subjects with necrotizing enterocolitis with and without cardiac disease suggest that necrotizing enterocolitis in the cardiac patient is a distinct disease process and should be labeled cardiogenic necrotizing enterocolitis.

When controlling for birth weight and gestational age, the congenital heart disease group had decreased risk of perforation, need for a bowel operation, strictures, need for a stoma, sepsis, and short bowel syndrome compared with the non–congenital heart disease group.


Reference: click to get abstract

Short- and Long-Term Outcomes of Necrotizing Enterocolitis in Infants With Congenital Heart Disease - Pediatrics 2009;123:e901–e906

Thursday June 11, 2009
Value of Cardiac Troponin in PE

In patients with severe pulmonary embolism (PE), myocardial ischemia may lead to progressive right ventricular dysfunction. It was therefore the purpose of this study to test prognostic implications in patients with confirmed PE.

Methods : Fifty-six consecutive patients with confirmed PE were enrolled in this prospective study. PE was confirmed by pulmonary angiography, lung scan, or echocardiography and subsidiary analyses. Severity of PE was assessed by a clinical scoring system, and cTnT was measured within 12 hours after admission.

Results:

• cTnT was elevated in 18 (32%) patients with massive and moderate PE but not in patients with small PE.
• In-hospital death, prolonged hypotension and cardiogenic shock, and need for resuscitation were more prevalent in patients with elevated cTnT.
• cTnT-positive patients more often needed inotropic support and mechanical ventilation.
• After adjustment, cTnT remained an independent predictor of 30-day mortality.

Conclusions—cTnT may improve risk stratification in patients with PE and may aid in the identification of patients in whom a more aggressive therapy may be warranted.

Reference:

1. Independent Prognostic Value of Cardiac Troponin T in Patients With Confirmed Pulmonary Embolism (Circulation. 2000;102:211.)

Wednesday June 10, 2009
Therapeutic monitoring: Total phenytoin vs Free Phenytoin levels in Critical Care

Phenytoin remains one of the most frequently used medications in critical care to treat various seizure disorders, which also require close therapeutic monitoring to prevent toxicity.

Therapeutic range:

• Total 10-20 mcg/ml;
• Free 1-2 mcg/ml

Phenytoin is 90% protein bound. In critical illness, protein synthesis and binding affinity are altered for various reasons including decreased dietary intake, renal/hepatic impairment, and a catabolic state. Also, critically ill patients have numerous drug-drug and drug-food interactions. In these situations, free phenytoin levels may increase by 2-3 fold, potentially resulting in toxicity. Therefore, the monitoring of free phenytoin levels, not total levels, are the most accurate and strongly correlated with clinical toxicity in critical care.


Reference:

1. Von Winckelmann, SL. Pharmacotherapy 2008;28:1391

2. Evidence-based Implementation of Free Phenytoin therapeutic Drug Monitoring - Clinical Chemistry 46: 1132-1135, 2000

Tuesday June 9, 2009
EKG in Pulmonary Hypertension

Click to get larger view

Electrocardiogram demonstrating the changes of right ventricular hypertrophy (long arrow) with strain in a patient with primary pulmonary hypertension. Right axis deviation (short arrow), increased P-wave amplitude in lead II (black arrowhead), and incomplete right bundle branch block (white arrowhead) are highly specific but lack sensitivity for the detection of right ventricular hypertrophy.

Monday June 8, 2009

Q: Which has more risk of transmission via needlestick injuries - HIV or Hepatits C (HCV)?

Answer: Hepatitis C

HIV = 0.3%
HCV = 1.8%

Sunday June 7, 2009
Amiodarone induced optic neuritis !

Amiodarone is one of the most commonly used medicine in ICU. In past, we have done many pearls related to IV amiodarone.One of the other unusual and common presentation of Amiodarone toxicity is optic neuritis. Optic neuritis may occur at any time following initiation of therapy. If any symptoms of visual impairment appear, like change in visual acuity or decrease in peripheral vision, prompt ophthalmic consult is recommended.

Saturday June 6, 2009

Scenario: To perform a central venous catheter insertion - you applied sterile gloves, mask with eye protection, cap and full length gown. You applied full area chlohexidine at procedure site and covered patient from head to toe with sterile drape. What did you miss?


Answer: Handwashing

It may sound silly but handwashing is still required before and after fully sterile prep for any procedure.

Friday June 5, 2009 (pediatric pearl)
Concurrent use of intravenous ceftriaxone and calcium-containing solutions in the newborn and young infant may result in a life-threatening adverse drug reaction

The concurrent use of intravenous ceftriaxone and calcium-containing solutions in the newborn and young infant may result in a life-threatening adverse drug reaction. On September 11, 2007, the US Food and Drug Administration (FDA) issued an alert that highlighted important revisions to the prescribing information for ceftriaxone (Rocephin; Roche Pharmaceuticals, Nutley, NJ) for young infants.

Ceftriaxone is known to form precipitates when administered with
calcium-containing solutions such as Ringer’s Lactate

. Currently the exact mechanism is unknown but it is biologically plausible, however, to assume that ceftriaxone given to a young infant at higher than a routinely prescribed dose and administered intravenously together with a calcium-containing solution could also cause precipitate formation. These calcium precipitates might act as emboli, resulting in vascular spasm or infarction. It is this precaution that is being shared with clinicians.

Eight of the reported 9 cases (7 were less than/= 2 months of age) represented possible or probable adverse drug events. There were 7 deaths. None of the cases were reported from the United States. The dosage of ceftriaxone that was administered to 4 of 6 infants for whom this information was available was between 150 and 200 mg/kg per day. The rate of occurrence of these serious adverse drug reactions cannot be accurately determined from available data. Contributing factors for infants in this report may include the use of ceftriaxone at dosages higher than those approved by the Food and Drug Administration, intravenous “push” administration, and administration of the total daily dosage as a single infusion.


Intravenous Ceftriaxone and Calcium in the Neonate: Assessing the Risk for Cardiopulmonary Adverse Events - Pediatrics 2009;123:e609–e613

Thursday June 4, 2009


Q: Toradol (keterolac) is a very effective pain killer due to its non-steroidal anti-inflammatory property. What is another interesting use of Toradol beside its analgesic and antipyretic properties?



Answer: It can be use as a tocolytic agent to arrest pre-term labor!

Since prostaglandin synthetase inhibitors are known to have tocolytic effect, and because short term use of less than 48 hours is of little risk to the fetus at less than 32 weeks gestation, parenteral ketorolac appears to be a viable alternative for acute tocolysis since it more rapidly leads to uterine quiescence without increasing maternal/fetal adverse effects.

Dose is intramuscularly administered ketorolac 60 mg as a loading dose followed by 30 mg every 6 hours for a maximum of 24 hours.



Reference: Click to get abstract

A Comparative Study of Ketorolac (Toradol) and Magnesium Sulfate for Arrest of Preterm Labor. - Southern Medical Journal. 91(11):1028-1032, November 1998.

Wednesday June 3, 2009

Picture Quiz
What is your diagnosis

Answer: Air in the billiary tree (see Arrow)

One of the classic complications of gallstones. Mechanical blockage of the small bowel by a large gallstone. Air in the biliary tree can sometimes indicate recent passage of the stone.

Tuesday June 2, 2009
Is There a Real Role of Pneumococcal Vaccine ?

Administrating pneumococcal vaccine has been the part of core measure as mandated by JCAHO and several other regulatory agencies. Efforts have been initiated by several centers to ensure pneumococcal vaccine resulting in several doses over a period of few years in patients who are poor historian and have received that vaccination at their physician’s office. Metaanalysis by Huss helped once again to clarify the over-exaggerated efforts.

Introduction: Clinical trials and meta-analyses have produced conflicting results of the efficacy of unconjugated pneumococcal polysaccharide vaccine in adults.

METHODS: Meta-analyses for clinical trials that compared pneumococcal polysaccharide vaccine with a control. They examined rates of pneumonia and death, taking the methodological quality of the trials into consideration. They included 22 trials involving 101 507 participants: 11 trials reported on presumptive pneumococcal pneumonia, 19 on all-cause pneumonia and 12 on all-cause mortality. The current 23-valent vaccine was used in 8 trials.

RESULTS:

• The relative risk (RR) was 0.64 (95% confidence interval [CI] 0.43-0.96) for presumptive pneumococcal pneumonia and 0.73 (95% CI 0.56-0.94) for all-cause pneumonia.
• There was significant heterogeneity between the trials reporting on presumptive pneumonia (I(2) = 74%) and between those reporting on all-cause pneumonia (I(2) = 90%).
• The RR for all-cause mortality was 0.97 (95% CI 0.87-1.09), with moderate heterogeneity between trials (I(2) = 44%, p = 0.053). Trial quality, especially regarding double blinding, explained a substantial proportion of the heterogeneity in the trials reporting on presumptive pneumonia and all-cause pneumonia.
• There was little evidence of vaccine protection in trials of higher methodologic quality (RR 1.20, 95% CI 0.75-1.92, for presumptive pneumonia; and 1.19, 95% CI 0.95-1.49, for all-cause pneumonia in double-blind trials).
• The results for all-cause mortality in double-blind trials were similar to those in all trials combined.
• There was little evidence of vaccine protection among elderly patients or adults with chronic illness in analyses of all trials (RR 1.04, 95% CI 0.78-1.38, for presumptive pneumococcal pneumonia; 0.89, 95% CI 0.69-1.14, for all-cause pneumonia; and 1.00, 95% CI 0.87-1.14, for all-cause mortality).
  

Conclusion: Pneumococcal vaccination does not appear to be effective in preventing pneumonia, even in populations for whom the vaccine is currently recommended.


Reference: Click to get abstract

Huss A; Scott P; Stuck AE; Trotter C; Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009; 180(1): 48-58

Monday June 1, 2009
MOBILIZING PATIENTS WITH FEMORAL ARTERIAL CATHETHERS DURING PHYSICAL THERAPY

This post is contributed by:

Christiane Perme, PT CCS
Board Certified Cardiovascular and Pulmonary Clinical Specialist
Senior Physical Therapist
The Methodist Hospital, Houston, TX 77030

Rationale: Patients with femoral arterial catheters are on bed rest in intensive care units(ICU) throughout the United States and abroad. Early mobility in ICU increases level of consciousness, improves the psychological well-being, reduces the adverse aspects of immobilization, optimizes functional status and has shown to decrease length of ICU stay.1,2, 3, 4

Methods:This retrospective,single-center, study was conducted in a 40 bed CardioVascular ICU(CVICU) in a teaching hospital. From June 2005 to December 2005,a retrospective chart review was conducted and 30 patients were identified as receiving physical therapy with femoral arterial catheters. All the patients mobilized were alert and hemodynamically stable.

Five activity events were identified: sitting on the side of bed, standing at the bedside, transfer to a stretcher chair, transfer to a regular chair, and walking.

The activity related adverse events included: bleeding at the femoral arterial catheter site, accidental femoral arterial catheter dislodgement and/or removal, non-functioning catheter after activity event, and acute limb ischemia within 24 hours.

Results: There were 134 activity events in the 30 patients identified for this study. The activity events included:

• sitting on the side of bed: 46 (34.3%),
• standing at the bedside: 15 (11.2%),
• transfers to a stretcher chair: 17(12.7%),
• transfers to a regular chair: 28(20.9%), and
• walking: 28 (20.9%).

There were no activity related adverse events documented.

Conclusion: MOBILIZING PATIENTS WITH FEMORAL ARTERIAL CATHETHERS DURING PHYSICAL THERAPY INTERVENTIONS DID NOT LEAD TO CATHETER RELATED COMPLICATIONS. Physical therapy interventions in ICU with focus on early mobility and walking for selected patients with a femoral arterial catheter appears to be feasible. The results of this study have the potential to affect outcomes by reducing the risks associated with bed rest for patients with femoral arterial catheters.


(Presented as abstract at ATS 2009 · San Diego - C S Perme, PT CCS and F N. Masud, MD, FCCP. The Methodist Hospital, Houston, TX, United States)


References:

Perme C, Chandrashekar R. Early mobility and walking program for patients in the intensive care unit:: Creating a standard of care. American Journal of Critical Care. 2009 (in press)

Perme C et al. Early mobilization of LVAD recipients who require prolonged mechanical ventilation. Texas Heart Institute Journal 2006; 33; 130-133

Morris PE et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008 Aug;36(8):2238-43

Needham DM. Mobilizing patients in the intensive care unit. JAMA.2008;300(14): 1685-1690.