Wednesday December 06, 2006
Q: Which procedure can be use both as diagnostic as well as therapeutic in acute colonic pseudo-obstruction (Ogilvie syndrome) ?
A; Gastrografin enema
Gastrografin is a contrast medium which is water-soluble but has a high osmolarity and so causes a fluid shift into the colon and subsequently increases colonic motility. A Gastrografin enema may be both diagnostic and therapeutic for this disorder.
Medical treatment of acute colonic pseudo-obstruction (ogilvie syndrome) is 2 mg IV Neostigmine but if diagnosis is suspected on KUB and further workup is underway Gastrografin enema is a good choice. It may relieve pseudo-obstrution without the need of Neostigmine.
Tuesday December 05, 2006
Changing Endotracheal tube (ETT) with Endotracheal Tube Exchangers
Changing Endotracheal tube (ETT) with Endotracheal Tube Exchangers, mostly for large air leaks, seems to be a harmless, easy and relatively a benign procedure but literature speaks against it. Hypoxemia has been reported in 60% during such exchanges and 8% of patients become bradycardic. Proper setup with all backup medications should be available and should be treated as a new intubation procedure.
Read related article: Mishaps With Endotracheal Tube Exchangers In ICU: Two Case Reports And Review Of The Literature - The Internet Journal of Anesthesiology. 2001. Volume 5 Number 1.
Monday December 04, 2006
Q; 65 year old female admitted to ICU 9 days ago with small bowel obstruction. Pt. is now stable and actually is about to get transferred out of unit. Patient suddenly start complaining of choking sensation with two hands on neck. Monitor shows oxygen desaturation. Patient intubated emergently. No laryngeal or vocal edema seen on laryngoscope but vocal cord paralysis noted.
A; Nasogastric tube syndrome
Nasogastric tube syndrome was described about 25 years ago by Sofferman and coll. It is a life-threatening complication of an indwelling (more than a week) nasogastric tube. The syndrome may present as complete vocal cord abductor paralysis. The syndrome is thought to result from perforation of the NG tube-induced esophageal ulcer and infection of the posterior cricoid region (postcricoid chondritis) with subsequent dysfunction of vocal cord abduction. Unilateral paralysis of cord is also described. Treatment is protection of airway, removal of NG tube and antibiotics. Some advocates antireflux therapy too. Another variant is described with no esophageal ulcer but possibly because of ischemia of the laryngeal abductor muscle secondary to physical compression of the postcricoid blood vessels by NG tube.
References: Please click to get abstract
1. The nasogastric tube syndrome: two case reports and review of the literature. Head Neck. 2001 Jan;23(1):59-63.
2. A variant form of nasogastric tube syndrome. Intern Med. 2005 Dec;44(12):1286-90.
3. Case Report - Nasogastric Tube Syndrome: The Unilateral Variant - Medical Principles and Practice Vol. 12, No. 1, 2003
4. Sofferman, R.A. and Hubbell, R.N., "Laryngeal Complications of Nasogastric Tubes," ANNALS OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, 90:465-468, 1981.
Sunday December 3, 2006
What if plasma exchange is not available as treatment of TTP
Q: You just diagnosed a patient with thrombotic thrombocytopenic purpura (TTP) but you were informed by the nursing supervisor that plasma exchange with fresh frozen plasma is not available in hospital due to technical reason and it will take time before patient can be transferred to a facility where the said services are available. What would be your alternate plan to bridge that time?
A; High-dose plasma infusion with rate of 25-30 mL/kg per day. When immediate plasma exchange with fresh frozen plasma is not available, simple plasma infusion can be performed until transfer to a higher care facility is available. There is always a substanial risk of fluid overload with such high plasma infusion and you have to weigh risks and benefits of the clinical decision or to watch patient closely while plasma is infusing.
Reference: click to get abstract/article
High-dose plasma infusion versus plasma exchange as early treatment of thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome - Medicine. 82(1):27-38, January 2003.
Saturday December 02, 2006
Room temperature or Iced Saline ?
Critical Care literature is not clear, actually controversial, regarding the suitable temperature of the solution use as injectable to measure cardiac output via thermodilution. Let see what is the major pro & con of iced saline.
Advantage: Iced injectate gives a higher signal/noise ratio and more reliability in the measured cardiac output. Signal-to-noise ratio is an engineering term for the power ratio between a signal (meaningful information) and the background noise.
Disadvantage: Iced injectate may affect heart rate and cardiodynamics 5.Iced solution may not be as cold as we think after it passes through the operator's hand and long port.Overall literature favors room temperature or atleast does not show any major advantage of using iced saline 1-4.
Related: Thermodilution Cardiac Output Measurement Protocol (sample from Univ. of Carolina Hospitals)
References: click to get abstract/article
1. Cardiac output measured by thermal dilution of room temperature injectate. - Evonuk E, Imig CJ, Greenfield W, et al: J Appl Physiol 1961; 16:271-2752.
2. Cardiac output by thermodilution technique. Effect of injectate's volume and temperature on accuracy and reproducibility in the critically Ill patient - Chest, Vol 84, 418-422, 1983
3. Effect of injectate volume and temperature on thermodilution cardiac output determination - Anesthesiology.1986 Jun;64(6):798-801.
4. Iced versus room temperature injectate for assessment of cardiac output, intrathoracic blood volume, and extravascular lung water by single transpulmonary thermodilution - J Crit Care. 2004 Jun;19(2):103-7.
5. The slowing of sinus rhythm during thermodilution cardiac output determination and the effect of altering injectate temperature. Anesthesiology 1985; 63:540-541
posted by icupearls.org archive @ 6:45 PM
0 comments
