Predicting Fluid Responsiveness by Passive Leg Raise (PLR)

23 Jun
June 23, 2016

passive leg raiseBackground: The best way to resuscitate critically ill patients with fluids has been a hotly debated topic in the FOAMed and Critical Care worlds. Fluids are important to optimize stroke volume and distal tissue perfusion, however, the administration of excessive fluids for shock can increase a patient’s morbidity and mortality by causing volume overload, which may lead to tissue edema and subsequently inadequate blood flow to tissues [1]. Accurately predicting when, whom, and how much fluid to administer remains a very challenging clinical question as only half of critically ill patients increase their cardiac output in response to the administration of fluids (i.e. the patient is preload or fluid responsive) [1].

Clinical signs and pressure/volumetric static variables are unreliable predictors of fluid responsiveness [1]. Ventilator-induced dynamic variables such as stroke volume variation and pulse pressure variation, however, have been shown to be more accurate in predicating fluid responsiveness. These tests can only be applied when several criteria are present (e.g., sinus heart rate, mechanical ventilation with a tidal volume of 8-10cc/kg of ideal body weight).

Passive leg raise (PLR) is another method to assess preload responsiveness. PLR produces a temporary and reversible increase in ventricular preload through an increase in venous return from the lower extremities, which mimics fluid administration without actually having to give exogenous fluids. This sounds great in theory, but PLR requires a hemodynamic assessment to be made during the maneuver to determine if the patient is preload responsive or not. There are multiple techniques for assessing changes in stroke volume but the diagnostic performance of each method still remains unknown. The two most commonly described methods are changes in pulse pressure variation and variables of flow. Read more →

The PATCH Trial: Hold the Platelets in Spontaneous Intracerebral Hemorrhage?

15 Jun
June 15, 2016

PATCH TrialBackground: Hemorrhagic stroke accounts for 11 – 22% of strokes, half of all stroke deaths, and a significant amount of disability in many of the remaining survivors. Spontaneous, non-traumatic, intracerebral hemorrhage (ICH) accounts for 2/3 of hemorrhagic strokes; estimated at > 2 million ICHs each year. To date several studies have suggested that antiplatelet therapy use before ICH might worsen outcomes by increasing the risk of early ICH volume growth, due to platelet dysfunction, and pathophysiologically this makes sense. Platelet transfusion has been used therapeutically in many clinical settings for acute ICH, but there is a paucity of randomized trials investigating its effectiveness for reducing death or dependence.  Read more →

Forget the PediaLyte and Just use Dilute Apple Juice in Mild Gastroenteritis

02 Jun
June 2, 2016

Dilute Apple JuiceBACKGROUND: Every year in the United States there are an estimated 178.8 million episodes of acute gastroenteritis resulting in 473,832 hospitalizations.  Most of the evidence surrounding oral rehydration centers around Oral Rehydration Therapy (ORT) studies in low-income countries where children suffer from more extensive gastrointestinal losses.  Theoretically, electrolyte maintenance solutions are recommended in order to prevent increasing diarrheal losses through the osmotic diuresis that can occur with glucose-rich drinks like juice.  However, these electrolyte maintenance solutions can cost up to $10 for a 1-liter bottle and are unpalatable to some children.  Refusal to drink often results in the need for IV hydration and can potentially result in disease progression and hospitalization.  This study attempted to look at whether a dilute apple juice solution or preferred fluids was equal to, if not superior to oral hydration with an electrolyte maintenance solution. Read more →

The ENCHANTED Trial: Is Low-Dose the Right Dose for Intravenous tPA in Acute Ischemic Stroke?

26 May
May 26, 2016

The ENCHANTED TrialBackground: Despite continued debate on the efficacy of alteplase (tPA), it currently remains one of the major interventions directed at patients presenting with acute ischemic stroke. The current standard dose of the drug is 0.9 mg/kg given over 1 hour. It is unclear whether lower doses would be equally effective in increasing good neurologic outcomes after stroke while simultaneously decreasing the rate of intracerebral hemorrhage (ICH); the most serious side effect. Evidence showing that lower doses of tPA are non-inferior to standard-dose tPA could lead to a shift in treatment.  Read more →

Changing Arm Position for Ultrasound Guided Subclavian Central Lines?

23 May
May 23, 2016

Changing Arm Position for Ultrasound Guided Subclavian Central Lines?The subclavian route is known to be the site for central line placement with the lowest risk of infection, but can also lead to many mechanical complications [2]. The biggest risk of subclavian line placement is an iatrogenic pneumothorax. The use of ultrasound for subclavian line placement can greatly reduce this risk by watching the needle enter the vein. But does arm position matter for ultrasound guided subclavian central lines? Read more →

Benzodiazepine-Refractory Alcohol Withdrawal

28 Apr
April 28, 2016

Alcohol WithdrawalBackground: Severe alcohol withdrawal syndrome (AWS) accounts for only 10% of the roughly 500,000 annual cases of AWS episodes that require pharmacologic treatment. AWS is characterized by an imbalance between inhibitory GABA and excitatory NMDA receptor stimulation secondary to chronic ethanol intake. Treatment is typically centered around supportive care and symptom-triggered benzodiazepines. However, some patients are refractory to benzodiazepines, defined as > 10 mg lorazepam equivalents in 1 hour or > 40 mg lorazepam equivalents in 4 hours. Doses exceeding this threshold provide little benefit and put patients at risk for increase morbidity and mortality, over sedation, ICU delirium, respiratory depression and hyperosmolar metabolic acidosis.  Read more →

ALPS: Amiodarone, Lidocaine or Placebo Study in OHCA

25 Apr
April 25, 2016

ALPSBackground: Many Out-of-Hospital Cardiac Arrest (OHCA) are attributable to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Both are said to be treatable presentations of OHCA, due to their responsiveness to defibrillation. VF and VT can persist or recur after defibrillation with an inverse relationship between the duration of OHCA, the recurrences of arrhythmias, and ultimately resuscitation outcomes.

Amiodarone and lidocaine are both recommended by the advanced cardiovascular life support (ACLS) guidelines to help promote successful defibrillation in refractory ventricular fibrillation or pulseless ventricular tachycardia and to prevent recurrences. In previous randomized controlled trials patients receiving amiodarone vs placebo or lidocaine in OHCA were more likely to have return of spontaneous circulation (ROSC) and to survive to hospital admission. However the effects of amiodarone on survival to hospital discharge or neurologic outcome still remain uncertain. Should we be using anti-dysrhythmic drugs in out-of-hospital cardiac arrest? Read more →

Succinylcholine vs Rocuronium for RSI in Traumatic Brain Injury

21 Apr
April 21, 2016

Succinylcholine vs Rocuronium v2Background: Airway management is a critical part of the management of patients presenting with traumatic brain injury (TBI). Emergency Physicians (EPs) have no ability to change the primary injury once it has occurred and so our focus is on preventing secondary brain injury. Hypoxemia and hypercarbia are major contributors to morbidity and mortality and management must focus on preventing them. Patients with TBI and depressed mental status frequently require definitive airway management in order to avoid these secondary insults. Rapid sequence intubation (RSI) with serial administration of a neuromuscular blocking agent (NMBA) and an induction agent is common practice. The most commonly used NMBAs are the depolarizing agent succinylcholine and the non-depolarizing agent rocuronium. There are strong proponents arguing for the dominance of one agent over the other based on qualities of the drugs but scant data investigating the question has led to clinical equipoise. Read more →

Advice to the Graduating Resident – Victoria Brazil

18 Apr
April 18, 2016

Advice to the Graduating ResidentSo this is the third installation of Advice to the Graduating Resident. Again, many 3rd year residents will be graduating in just a few short months and taking on their first jobs as attending physicians. I was lucky enough to sit down with the amazing Victoria Brazil and pick her brain. She gave some valuable words of wisdom, which I will try and summarize in this post, but for the full advice, be sure to checkout the podcast. Read more →

Hemophilia: What’s so Bloody Funny?

13 Apr
April 13, 2016

HemophiliaToday, I gave a lecture on Hemophilia to our residents in San Antonio, TX.  Now this was a core content lecture that I have actually never given before. As I was preparing the lecture I realized that this is a diagnosis that comes up frequently enough that it is important to know about, but also so infrequently that I always have to look up the factor replacement options and calculations.  So instead of being our typical evidence based evaluation of literature, this post will serve as a reminder of the basics of hemophilia and what are the essential elements one needs to know to appropriately treat a patient with Hemophilia. Read more →

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