Background: Many providers and health care workers place oxygen on patients as a way to overcome hypoxemia or for patient comfort. Also in STEMI patients, many of us have learned the mnemonic “MONA” to remember the treatments for acute coronary syndrome. MONA stands for morphine, oxygen, nitroglycerin, and aspirin. It is however important to remember that oxygen is a drug; just like any other drug, there are side effects. Some of the best known side effects of hyperoxia are direct lung toxicity, peripheral vasoconstriction, and increase in production of reactive oxygen species. The PROXI Trial (Perioperative Oxygen Fraction-Effect on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery) and the AVOID Trial (Air Versus Oxygen in Myocardial Infarction) showed increased long-term mortality and larger myocardial infarction size respectively in patients with supra-normal oxygen levels (hyperoxia). In this episode we will explore the effect of higher oxygen levels through in ICU and STEMI patients by reviewing two trials:
Tag Archive for: REBELCast
The Oxygen ICU Trial
Every few years we get updates in the guidelines based on new evidence. Guidelines give us a framework to work with in the treatment of disease processes, such as pneumonia. The last Infectious Disease Society of America (IDSA) guidelines update on the treatment of pneumonia came from 2005, but recently, the new 2016 guidelines were just published. This was a massive 51 page summary that starts off by saying:
“It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be VOLUNTARY, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.” Read more →
Background: Welcome back to the September 2016 REBEL Cast. We are back with another episode and I am super excited about this episode because we are going to talk about two papers just published in the Resuscitation Journal on management of refractory ventricular fibrillation. It is a well known fact that the cornerstones for survival from Out-Of-Hospital Cardiac Arrest (OHCA) have always been early, high quality CPR and early defibrillation in patients with shockable rhythms (i.e. Ventricular Fibrillation/Ventricular Tachycardia). Some patients with shockable rhythms may be refractory to standard defibrillation therapy (i.e. refractory VF). Even more frustrating, there is truly a dearth of data on what to do with these patients. One strategy that has been reported more and more in the literature is double sequential defibrillation (DSD).
Another issue in cardiac arrest patients is we frequently give boluses of 1mg epinephrine every 3 – 5 minutes as is outlined in the ACLS guidelines. When patients have minimal cardiac output, the buildup of catecholamines may potentially cause refractory ventricular fibrillation (RVF). This could be due to an increase myocardial oxygen consumption causing an increase in myocardial ischemia, and ultimately more difficulty in successful defibrillation. But maybe by blocking the beta-adrenergic receptors in the myocardium, we can block the beta effects of the catecholamines and potentially increase the chances of successful sustained ROSC.
REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Background: In the ACLS guidelines stable Ventricular Tachycardia (VT) can be treated with either IV amiodarone or IV procainamide, as the drugs of choice. This has been given a class II recommendation, but there has not been a controlled prospective trial to base the use of one drug over the other in the clinical setting. Despite both medications having a class II recommendation, both clinically and anecdotally it appears that amiodarone is the preferred agent in clinical practice. Read more →
So 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 →