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.