Tuesday, June 30, 2009

Tuesday June 30, 2009
Gastrointestinal Beriberi: A Previously Unrecognized Syndrome

I read your recent pearl about thiamine and lactic acidosis (
here). I have attached another pearl about this which talks about the high Sv02 seen in such cases. Recently, I actually saw two cases of this and both improved after I gave 100 mg of IV thiamine.

Tony Halat, MD

Clinical Instructor in Medicine
Department of Medicine, The Methodist Hospital
Weill Medical College, Cornell University

Gastrointestinal Beriberi: A Previously Unrecognized Syndrome

"In the 1940s, several separate experiments induced thiamine deficiency in humans; almost all participants reported nausea, vomiting, and abdominal pain. These early observations were not translated into a clinical syndrome and have essentially been forgotten. A case series documented the occurrence of "fulminant beriberi" in intensive care unit patients who were deprived of thiamine during administration of total parenteral nutrition. Eleven patients in that series had undergone laparotomy for abdominal pain; surgical findings were negative. All patients given intravenous thiamine recovered.... The current report of 2 cases is the first to recognize a primary gastrointestinal syndrome secondary to thiamine deficiency. Both patients were critically ill and recovered rapidly after receiving thiamine as the only therapeutic intervention. In patient 1, the abdominal pain was severe enough to warrant an operation. Both patients also displayed severe venous hyperoxia (central venous oximetry 93%), which indicates a mitochondrial defect in oxygen utilization consistent with thiamine deficiency. The rapid recovery from such profound venous hyperoxia and lactic acidosis (in the absence of other treated causes) can be explained only by thiamine repletion......Thiamine deficiency may lead to a gastrointestinal syndrome of nausea, vomiting, abdominal pain, and lactic acidosis. Further delineation of this potential syndrome is of paramount importance—failure to recognize and treat it may lead to unnecessary morbidity and death. Thiamine administration should be considered for all inadequately nourished patients who present with gastrointestinal symptoms and lactic acidosis 1."

References: Click to get abstract

1. Gastrointestinal Beriberi: A Previously Unrecognized Syndrome - 7 December 2004 Volume 141 Issue 11 Pages 898-899 (need registration to have access)

2. Observations on induced thiamine deficiency in man. Arch Intern Med. 1940;66:785-99

3. TPN-induced fulminant beriberi: a report on our experience and a review of the literature. Surg Today. 1996;26:769-76

Monday, June 29, 2009

Monday June 29, 2009

Q: Why D-5 is a poor choice of resuscitation at cellular level in septic shock?

At cellular level, in hypoperfused patients most D-5 get diverted to lactate production making acidosis worse !

Also, as we know - at vascular level - it has no resuscitation effect.

Sunday, June 28, 2009

Sunday June 28, 2009

52 year old male after emergent exploratory laparotomy is admitted to ICU. Patient has Lactated Ringer's solution going at 125 cc/hr. 2 units of pRBC were ordered. Why it is a bad idea to mix Lactated Ringer's solution and pRBC through same IV line?

Answer: Lactated Ringer's solution contains calcium which may bind to the citrate (use as anticoagulant) in blood products. This promotes clot formation in donor blood (bag).

Normal Saline contains (per litre)

  • 154 mEq/L of Na+ and
  • 154 mEq/L of Cl−

Lactate Ringer contains (per litre)

  • 130 mEq/L of Na+ (but total cations of 137 mEq/L , so still is isotonic)
  • 109 mEq/L of Cl−
  • 28 mEq/L of lactate
  • 4 mEq/L of potassium
  • 3 mEq/L of calcium

Lactate converts to bicarbonate in liver. Patients with lactic acidosis usually have inadequate liver metabolism of lactate so conversion to HCO3- from the infused lactate of LR is impaired and may give false readings of serial lactate measurements.

Saturday, June 27, 2009

Saturday June 27, 2009

Strictly speaking from 'Base Excess' point of view, what is the target value while doing volume resuscitation ?

*Please note, in clinical practice all factors and markers should be considered. This is purely an academic exercise.

Answer: 2 mmol

Base excess is defined as the amount of protons (H+ ions) required to return the pH of blood to atleast 7.35 if the partial pressure of carbon dioxide was adjusted to normal. It is a parameter which indicates the acid-base balance in the body. Base excess is affected by blood lactate, with which it has a high correlation. Normal base excess values are between −2.3 and +2.3 mmol.

If ABG is not available (which usually provides automated BE), you can quickly calculate Base Excess with HCO3 and PH from venous blood

B.E. = (HCO3 - 24 + 15 (PH - 7.4)

Friday, June 26, 2009

Friday June 26, 2009

Q: Which vitamin deficiency may cause life threatening lactic acidosis?

Answer: Thiamine (Vitamin B1) deficiency

Thiamine is part of the pyruvate-dehydrogenase (PDH) complex. Its deficiency inhibits pyruvate entry into mitochondria.

Clinical implication: It is important to add Thiamine on patients requring long term parentral nutrition (TPN)

Reference: Click to get references

1. Thiamine deficiency as a cause of life threatening lactic acidosis in total parenteral nutrition - Klin Wochenschr. 1991;69 Suppl 26:193-5.

2. Metabolic acidosis and thiamine deficiency - Mayo clinic Proceedings, March 1999 vol. 74 no. 3 259-263

3. Severe Lactic Acidosis Related to Acute Thiamine Deficiency - Journal of Parenteral and Enteral Nutrition, Vol. 15, No. 1, 105-109 (1991)

Thursday, June 25, 2009

Thursday June 25, 2009

Q: What is "wedged blood PO2" and what is the clinical implication?

Answer: "Wedged blood Po2" is the level of PO2 while Pulmonary artery catheter baloon is inflated (wedging).

Wedge blood Po2 should be atleast 20 mm Hg higher than arterial PO2 (ABG) to confirm that you are measuring Pulmonary artery occlusion pressure at right level/spot.


Paul L. Marino - The little ICU book of facts and Formulas, 2009 - Page 119

Wednesday, June 24, 2009

Wednesday June 24, 2009
Metformin-associated lactic acidosis in an intensive care unit

Introduction: Metformin-associated lactic acidosis (MALA) is a classic side effect of metformin and is known to be a severe disease with a high mortality rate. The treatment of MALA with dialysis is controversial and is the subject of many case reports in the literature. We aimed to assess the prevalence of MALA in a 16-bed, university-affiliated, intensive care unit (ICU), and the effect of dialysis on patient outcome.

Methods: Over a five-year period, we retrospectively identified all patients who were either admitted to the ICU with metformin as a usual medication, or who attempted suicide by metformin ingestion. Within this population, we selected patients presenting with lactic acidosis, thus defining MALA, and described their clinical and biological features.

  • MALA accounted for 0.84% of all admissions during the study period (30 MALA admissions over five years)
  • Associated with a 30% mortality rate.
  • The only factors associated with a fatal outcome were the reason for admission in the ICU and the initial prothrombin time.
  • Although patients who went on to haemodialysis had higher illness severity scores, as compared with those who were not dialysed, the mortality rates were similar between the two groups (31.3% versus 28.6%).

Conclusions: MALA can be encountered in the ICU several times a year and still remains a life-threatening condition. Treatment is restricted mostly to supportive measures, although haemodialysis may possess a protective effect.

Metformin-associated lactic acidosis in an intensive care unit - Critical Care 2008, 12:R149 - pdf file

Tuesday, June 23, 2009

Tuesday June 23, 2009

Q: For cardiac output measurement via thermodilution method, cold (or room temerature) saline should be injected through which port?

Answer: Proximal port

The idea is very simple. Thermodilution method of cardiac output measurement involves injection of a small amount (10ml) of cold saline/dextrose (or room temperature) into the pulmonary artery via proximal port into right ventricle and measuring the temperature (after it is mix with blood) a known distance away while it pass through the same catheter at thermistor near distal port.

The time-temperature curve is made through electronic instrument. The curve is called Q wave. High Q means temperature is changing rapidly (high CO), and low Q means change in temperature is slow (Poor CO). Usually three or four repeated measures are averaged to improve accuracy.

Modern catheters are fitted with a heating filament which intermittently heats and measures the thermodilution curve providing serial Q measurement.

Monday, June 22, 2009

Monday June 22, 2009
Gone would be the days of nice smelling shampoo

Recent work by Michael Climo et al. studied the effect of bathing with chlorhexidine on the acquisition of MRSA and VRE, and health care blood stream infections (BSI).

Design: Six ICU at four academic centers. They measured the incidence of MRSA and VRE colonization and BSI during a period of bathing with routine soap for six months and then compared results with a 6 month period with bathing with chlorhexidine solution.

Results: Acquisition of MRSA decreased by 32% (5.04 vs. 3.44 cases/1000 patient days p=0.046), VRE decreased by 50% (4.35 vs. 2.19 cases/1000 patient days p=0.008). VRE-colonized patients bathed with chlorhexidine had a lower risk of developing VRE bacteremia (RR 3.35, 95% CI 1.13-9.87; p=0.035), suggesting that reduction in the level of colonization leads to the observed reductions in BSI

Conclusion: We conclude that daily chlorhexidine bathing among ICU patients may reduce the acquisition of MRSA and VRE. The approach is simple to implement and inexpensive and may be an important adjunctive intervention to barrier precautions to reduce acquisition of VRE and MRSA and the subsequent development of healthcare-associated BSI.

Reference: Click to get abstract

Climo M, Sepkowitz K, Zuccotti G, Victoria F et al.
The effect of daily bathing with chlorhexidine on the acquisition of MRSA, VRE and health care-associated bloodstream infections: Result of a quasi-experimental multicenter trial. Critical Care Medicine; 37(6): 1858-1865.

Sunday, June 21, 2009

Sunday June 21, 2009

Q: How much length of catheter should be cut distally to send catheter tip for culture?

Preferably about 2 inches (5 cm)

After removal of the catheter under aseptic conditions, the distal 2 inches of the catheter should be cut with sterile scissors into a sterile container for transport to the laboratory.

Saturday, June 20, 2009

Saturday June 20, 2009

Q: What does it mean when you say "7 french catheter" ?

Answer: "French" is the size of catheters in outside diameter.

1 French = 0.33 mm

and so,
2 French = 0.66 mm,
3 French = 0.99 mm

7 French = 7 x 0.33 = 2.31 mm in outside diameter

Friday, June 19, 2009

Friday June 19, 2009 (pediatric pearl day)
Late death occurred with similar frequency as early death associated with initial hospitalization with severe sepsis in children

Pediatric severe sepsis remains a significant health problem with hospital mortality up to 10%. However, there is little information about later health outcomes or needs of survivors. Therefore, our goal was to evaluate the rates of and risk factors for rehospitalization and late mortality among survivors of pediatric severe sepsis.

PATIENTS AND METHODS: This was a population-based retrospective cohort study of survivors of pediatric severe sepsis (age 1 month to 18 years) in Washington State over the years 1990–2004.

The sentinel admission was linked to subsequent death or episodes of hospitalization.
The main outcome measures were readmission and/or late death after surviving an initial hospitalization with severe sepsis.


  • Almost half (47%) of the survivors were readmitted at least once (median: 3) after a median of 3 months, and the majority of these readmissions were emergent.
  • Sentinel admission factors independently associated with both adverse outcomes were neurologic or hematologic organ dysfunction, government-based insurance, as well as several coexisting health conditions.
  • In addition, age less than 1 year at the time of sepsis and bloodstream and cardiovascular infections were highly associated with subsequent readmission.

CONCLUSIONS: Late death occurred with similar frequency as early death associated with hospitalization with severe sepsis. Almost half of the pediatric patients suffering from an episode of severe sepsis had at least 1 subsequent hospitalization, two thirds of which were emergent or urgent. These data suggest that late outcomes after an episode of severe sepsis are poor and call for the evaluation of interventions designed to reduce later morbidity and mortality.

Reference: Click to get abstract

Readmission and Late Mortality After Pediatric Severe Sepsis - Pediatrics 2009;123:849–857

Thursday, June 18, 2009

Thursday June 18, 2009
Picture Diagnosis

Hint: CT scan slice is at Right atrium level - so no its not liver!

Answer: Breast Hematoma

CT scan showed a large mass with a fluid-fluid level. The denser portion (star) is consistent with blood clot.The scan also revealed a very enlarged left atrium. The patient is on anticoagulant therapy for chronic atrial fibrillation.

Wednesday, June 17, 2009

Wednesday June 17, 2009
Alternatives for HIT patients on CRRT?

Critically ill patients with Heparin Induced Thrombocytopenia (HIT), requiring continuous renal replacement therapy(CRRT) are limited in their treatment options for anticoagulation to danaparoid and direct thrombin inhibitors (DTI). Danaparoid is no longer available in the US, thus leaving DTIs.

Argatroban and Lepirudin are the most commonly used DTIs. Given the renal elimination, potential accumulation in these patients and potential for antibody formation, Lepirudin is not a favorable choice in HIT patients requiring CRRT. Argatroban, on the other hand, is eliminated hepatically and does not require dose adjustments for CRRT or hemodialysis.

Argatroban dosing:
Initial infusion: 2 microgram/kg/min
Hepatic impairment: 0.5 microgram/kg/min - Titrated to 1.5-2.5 times initial aPTT baseline.

Reference: Click to get abstract

Link A, et al.
Argatroban for anticoagulation in continuous renal replacement therapy - Critical Care Medicine. 37(1):105-110, January 2009

Tang IY, et al.
Argatroban and Renal Replacement Therapy in Patients with Heparin-Induced Thrombocytopenia - Ann Pharmacother 2005;39:231-6

Tuesday, June 16, 2009

Tuesday June 16, 2009

Q: What does it mean by graded compression stockings for DVT (deep venous thrombosis) prophylaxis?

Answer: Compression stockings are made of strong elastic material and fit tightly at the feet and gradually become less tight at the knee/thigh. The pressure in the stockings is graded and this allows for the stockings to constantly squeeze the leg muscles. This pressure gradient (high pressure at ankle level minus low pressure level at thighs) helps to drive blood back to the heart, reduce swelling in the feet and prevent blood clot formation. They come in various strengths. 18 mm Hg at ankle level with 8 mm Hg at thigh level - giving gradient of 10 mm Hg is considered standard for DVT prophylaxis.

Related previous pearl: inflation and deflation cycle of intermittent pneumatic compression boots

Monday, June 15, 2009

Monday June 15, 2009
drug-drug interaction

Case; 74 year old male with chronic renal failure admitted to ICU after a seizure episode requiring intubation for airway protection. You started pepcid (femotidine) as GI prophylais. What should you watch closely?

Dilantin level

The mechanism of interaction is unknown. Elderly patients with renal failure seems to be on high risk though. Signs of dilantin toxicity includes ataxia, incoordination, tremor, nystagmus, hypotension, slurred speech, lethargy, nausea, vomiting, mental confusion, and psychosis.

Other medications which may affect phenytoin level beside H2-blockers includes carbamazepine, Depakote, phenobarbital, trazodone, isoniazid (INH), sulfonamides (a class of antibiotics), calcium containing antacids, H2 blockers, sucralfate, alcoholic beverages, amiodarone, chloramphenicol, and oral contraceptives.

Sunday, June 14, 2009

Sunday June 14, 2009
On Swan-Ganz Catheter

Very important and precise article is written by Dr. Kanu Chatterjee, from the Chatterjee Center for Cardiac Research, University of California, San Francisco, on importance of The Swan-Ganz Catheters. Despite all it flaws and criticism, it remains an important and essential tool of hemodynamics.

Its an essential read for all intensivists.

"Pulmonary artery catheterization with the use of balloon flotation catheters is an easy and rapid technique for bedside hemodynamic monitoring. However, its abuse has been associated with complications that can be avoided if it is used by experienced operators. The randomized clinical trials in patients with acute coronary syndrome, noncoronary high-risk patients (including noncardiac surgical patients and patients with sepsis and ARDS), and patients with chronic heart failure have established that its routine use is not necessary and may be associated with increased complications, including death. However, it is still necessary in patients with cardiogenic shock, for the differential diagnosis of pulmonary arterial hypertension, and for diagnosis and treatment of uncommon causes and complications of heart failure. In patients with severe chronic heart failure requiring inotropic, vasopressor, and vasodilator therapy, hemodynamic monitoring is essential. For heart and lung transplantation workup, hemodynamic monitoring is always necessary. In many institutions, hemodynamic studies are conducted before liver transplantation".


The Swan-Ganz Catheters: Past, Present, and Future - Circulation. 2009;119:147-152.

Saturday, June 13, 2009

Saturday June 13, 2009

Case: 24 year old male with no significant history presented with acute epigastric pain radiating to shoulders?

Answer: Free air under the diaphragm (both sides) secondary to perforated duodenal ulcer.

In patients presenting with complicated peptic ulcer disease, nearly half have no history of the disease! In younger patients, severe abdominal pain, which may radiate to the shoulder, may be the initial presentation.

Reference: click to get article

Perforated Peptic Ulcer - emadmag.com

Friday, June 12, 2009

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

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.

  • 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.


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

Wednesday, June 10, 2009

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.


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

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

Tuesday, June 9, 2009

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

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

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

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?


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

Friday, June 5, 2009

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

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?

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

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

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.


  • 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

Monday June 1, 2009

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)


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.