Use of the femoral artery route for placement of temporary catheters for emergency haemodialysis when all usual central venous access sites are exhausted.

Nephrol Dial Transplant. 2008 Oct 24;

Authors: Frampton AE, Kessaris N, Hossain M, Morsy M, Chemla ES

BACKGROUND: Urgent dialysis via a temporary central line may be impossible when all central veins are obstructed. METHODS: We report 10 patients (7 males and 3 females) over a 5-year period who lost all venous access sites, due to multiple peripheral venous thromboses with a superior vena cava obstruction or stenosis in 50%. These patients required urgent haemodialysis prior to general anaesthetic for a surgical intervention, but in all cases a traditional central venous line could not be used. They were therefore dialysed via a femoral artery catheter (FAC) before surgical rescue or creation of a more definite vascular access (VA). The median age of these patients was 64.7 years. None were suitable for peritoneal dialysis or urgent transplantation. Thirteen FACs (11F dual lumen dialysis catheter) were inserted into the common femoral artery. Both lumens were perfused continuously with heparinized saline (12 000 IU/24 h). All patients underwent a surgical procedure (rescue of previous access/creation of a new exotic one). First dialysis adequacy was assessed and compared to the rescued or new access. RESULTS: All patients had been on haemodialysis for a median period of 4.4 years. The mean number of previous access procedures was 17 (range 10-28). The duration of FAC use ranged from 1 to 12 days (mean 5 days). Dialysis adequacy was satisfactory for all patients. Seven patients had a complex vascular access formed and six had thrombectomy of their previous access. There were two complications related to FAC use, which were distal ischaemia and bleeding. Three patients died from access-related problems at 0, 4.6 and 15.0 months. Seven are still dialysed through their fistula or graft as outpatients with a mean follow-up of 14.0 months (range 0-50.9 months). CONCLUSION: Femoral artery dialysis is an effective means of haemodialysis as a method to bridge the gap before definitive vascular access formation when all other options have been exhausted.

PMID: 18952702 [PubMed - as supplied by publisher]

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Designing and implementing insulin infusion protocols and order sets.

J Hosp Med. 2008 Oct 24;3(S5):42-54

Authors: Ahmann AJ, Maynard G

Influential trials and guidelines supporting the value of glucose control in hospital settings, particularly in the intensive care and postoperative settings, has led to the widespread adoption of intravenous infusions of human regular insulin. As groups have attempted to study the outcomes or to explore improved methods for improved glucose control, a number of insulin infusion protocols (IIPs) have been reported and validated. Now, many institutions are attempting to translate this experience into clinical practice in a systematic manner. The intent of this discussion is to highlight the authors’ practical view of best practices in development and use of IIPs.As the implementation of IIPs has progressed, it has become apparent that this is not a simple process. It requires a carefully planned, inclusive, and continuous effort striving to attain effective glucose control while avoiding severe hypoglycemia. Whereas there are limitations in the literature comparing the IIPs, we identify design elements and implementation methods that increase the chances for staff acceptance and safe attainment of glycemic goals. Most importantly, this must be a team effort with attention to the numerous potential pitfalls that can disrupt the process and place patients at risk.In many cases, it is best to start more conservatively and methodically intensify the protocol. Continuous assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to overall success. Journal of Hospital Medicine 2008;(5 Suppl):42-54. (c) 2008 Society of Hospital Medicine.

PMID: 18951382 [PubMed - as supplied by publisher]

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Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia.

J Hosp Med. 2008 Sep;3(5):409-22

Authors: Wall RJ, Ely EW, Talbot TR, Weinger MB, Williams MV, Reischel J, Burgess LH, Englebright J, Dittus RS, Speroff T, Deshpande JK

BACKGROUND:: Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP. OBJECTIVE:: We recently conducted a national collaborative aimed at reducing health care-associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases. DESIGN:: This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections. SETTING:: The setting of the study was 110 ICUs at 61 HCA hospitals. INTERVENTION:: None. MEASUREMENTS AND RESULTS:: We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients. CONCLUSIONS:: We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem. Journal of Hospital Medicine 2008;3:409-422. (c) 2008 Society of Hospital Medicine.

PMID: 18951395 [PubMed - in process]

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Implementation of a physician assistant/hospitalist service in an academic medical center: Impact on efficiency and patient outcomes.

J Hosp Med. 2008 Sep;3(5):361-8

Authors: Roy CL, Liang CL, Lund M, Boyd C, Katz JT, McKean S, Schnipper JL

BACKGROUND:: Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services. OBJECTIVE:: To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services. DESIGN:: Retrospective cohort study. SETTING:: Inpatient general medicine service of a 747-bed academic medical center. PATIENTS:: A total of 5194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4202 patients on a traditional house staff service. INTERVENTION:: A geographically localized service staffed with physician assistants and supervised by hospitalists. MEASUREMENTS:: Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction. RESULTS:: Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] -7.5% to -0.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, -0.4% to +10%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. CONCLUSIONS:: For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency. Journal of Hospital Medicine 2008;3:361-368. (c) 2008 Society of Hospital Medicine.

PMID: 18951397 [PubMed - in process]

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Amiodarone hepatotoxicity.

Curr Vasc Pharmacol. 2008 Jul;6(3):228-36

Authors: Babatin M, Lee SS, Pollak PT

Potential hepatotoxicity related to amiodarone therapy is often a concern when deciding whether to initiate or continue treatment with this medication. While mostly associated with long-term oral administration of the drug, toxicity has also been reported early during intravenous administration and months after discontinuation of therapy. In the majority of patients, it is discovered incidentally during routine testing of liver biochemistry and rarely do the hepatic effects develop into symptomatic liver injury or failure. Despite the widespread use of amiodarone, prospective clinical studies have been sparse and there has been little consensus among experts in the field regarding optimum monitoring for adverse effects in patients receiving this drug. In order to examine the current state of knowledge surrounding the incidence, pathogenesis and mechanism of liver effects associated with amiodarone, the existing literature was reviewed, with particular emphasis on clinical recommendations for monitoring.

PMID: 18673162 [PubMed - indexed for MEDLINE]

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Review article: the modern management of portal hypertension–primary and secondary prophylaxis of variceal bleeding in cirrhotic patients.

Aliment Pharmacol Ther. 2008 Jul;28(2):178-86

Authors: Garcia-Pagan JC, De Gottardi A, Bosch J

BACKGROUND: Variceal bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. AIM: To provide an overview of the current knowledge on the best evidence-based therapeutic options to prevent first or recurrent bleeding from oesophageal varices in patients with cirrhosis. METHODS: For the preparation of this narrative review, we sought to analyse randomized controlled trials that examined the efficacy and side effects of pharmacological or endoscopic therapy for the primary and secondary prophylaxis of oesophageal variceal bleeding. RESULTS: Endoscopic band ligation (EBL) and nonselective beta-blockers are both effective in preventing first bleeding. Until more long-term data are available, nonselective beta-blockers should be the first treatment option because of less severe side effects. EBL is an alternative when beta-blockers are contraindicated or not tolerated. Patient preference may also be considered. For prevention of rebleeding, nonselective beta-blockers (preferably in association with isosorbide-5-mononitrate) or EBL are both effective and good alternative treatments. A combination of both treatments may be the best alternative. CONCLUSIONS: A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

PMID: 18462268 [PubMed - indexed for MEDLINE]

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Liver in systemic disease.

World J Gastroenterol. 2008 Jul 14;14(26):4111-9

Authors: Shimizu Y

Potential causes of abnormal liver function tests include viral hepatitis, alcohol intake, nonalcoholic fatty liver disease, autoimmune liver diseases, hereditary diseases, hepatobiliary malignancies or infection, gallstones and drug-induced liver injury. Moreover, the liver may be involved in systemic diseases that mainly affect other organs. Therefore, in patients without etiology of liver injury by screening serology and diagnostic imaging, but who have systemic diseases, the abnormal liver function test results might be caused by the systemic disease. In most of these patients, the systemic disease should be treated primarily. However, some patients with systemic disease and severe liver injury or fulminant hepatic failure require intensive treatments of the liver.

PMID: 18636653 [PubMed - indexed for MEDLINE]

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Short- and long-term outcomes following atrial fibrillation in patients with acute coronary syndromes with or without ST-segment elevation.

Heart. 2008 Jul;94(7):867-73

Authors: Lopes RD, Pieper KS, Horton JR, Al-Khatib SM, Newby LK, Mehta RH, Van de Werf F, Armstrong PW, Mahaffey KW, Harrington RA, Ohman EM, White HD, Wallentin L, Granger CB

OBJECTIVE: To assess variables associated with the occurrence of atrial fibrillation (AF) and the relation of AF with short- and long-term outcomes and with other in-hospital complications in patients with acute coronary syndromes (ACS) with and without ST-segment elevation. DESIGN: Pooled database of 120 566 patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation (NSTE) ACS enrolled in 10 clinical trials. Multivariable logistic regression and Cox proportional hazards modelling were used to identify factors associated with AF and its relation with clinical outcomes. SETTING: ACS complicated by AF. PATIENTS: 120,566 patients with STEMI and NSTE-ACS in 10 clinical trials. INTERVENTIONS: None evaluated. MAIN OUTCOME MEASURE: Short- and long-term mortality. RESULTS: Occurrence of AF was 7.5% in the overall population (STEMI 8.0% (n = 84 161); NSTE-ACS = 6.4% (n = 36,405)). Seven-day mortality was higher for patients with AF (5.1%) than for those without (1.6%). After adjusting for confounders, association of AF with 7-day mortality was present in STEMI (hazards ratio (HR) = 1.65; 95% CI 1.44 to 1.90) and NSTE-ACS (HR = 2.30; 95% CI 1.83 to 2.90; p interaction = 0.015). Risk of long-term mortality (day 8 to 1 year) was also higher in STEMI (HR = 2.37; 95% CI 1.79 to 3.15) and NSTE-ACS (HR = 1.67; 95% CI 1.41 to 1.99). AF had a larger impact in NSTE-ACS on risk of short-term mortality (p<0.001), stroke (p<0.001), ischaemic stroke (p<0.001) and moderate or severe bleeding (p<0.001). CONCLUSIONS: AF is more common in patients with STEMI. An association of AF with short- and long-term mortality among patients with STEMI and NSTE-ACS was found. Understanding these findings may lead to better care of patients with this common arrhythmia.

PMID: 18332062 [PubMed - indexed for MEDLINE]

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Clinical features and management of primary sclerosing cholangitis.

World J Gastroenterol. 2008 Jun 7;14(21):3338-49

Authors: Silveira MG, Lindor KD

Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the bile ducts, resulting in cirrhosis and need for liver transplantation and reduced life expectancy. The majority of cases occur in young and middle-aged men, often in association with inflammatory bowel disease. The etiology of primary sclerosing cholangitis includes immune-mediated components and elements of undefined nature. No effective medical therapy has been identified. The multiple complications of primary sclerosing cholangitis include metabolic bone disease, dominant strictures, bacterial cholangitis, and malignancy, particularly cholangiocarcinoma, which is the most lethal complication of primary sclerosing cholangitis. Liver transplantation is currently the only life-extending therapeutic alternative for patients with end-stage disease, although recurrence in the allografted liver has been described. A PSC-like variant attracting attention is cholangitis marked by raised levels of the immunoglobulin G4 subclass, prominence of plasma cells within the lesions, and steroid responsiveness.

PMID: 18528931 [PubMed - indexed for MEDLINE]

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Encephalopathy and cerebral edema in the setting of acute liver failure: pathogenesis and management.

Neurocrit Care. 2008;9(1):97-102

Authors: Wendon J, Lee W

Cerebral edema is a potential life-threatening complication in patients with acute liver failure who progress to grade III/IV encephalopathy. The incidence is variably reported but appears to be most prevalent in those patients with hyperacute liver failure as opposed to subacute forms of liver failure. In those patients who are deemed at risk of cerebral edema and raised intracranial pressure, insertion of an intra-cranial pressure monitoring device may be considered to optimize treatment and interventions. The pathogenesis of cerebral edema in this setting remains controversial, although recent work suggests a pivotal role for arterial ammonia, whose effects appear to be potentiated by the presence of systemic inflammation. Recent work has also suggested the import of free radical formation occurring at a mitochondrial level as being the potential mediator of cellular dysfunction as opposed to ammonia per se. Treatment of such patients requires a multi-disciplinary approach incorporating both hepatology and critical care. In a significant proportion of such cases, consideration of liver transplantation may be required. Treatment should be focused at optimizing liver function and regenerative capacity and minimizing the inflammatory milieu. Controlled studies are lacking and much of the management has been extrapolated from neurocritical care. Sustained elevation of intracranial pressure may be responsive to mannitol or hypertonic saline bolus, and in those with hyperemia indomethacin has been reported as beneficial in case series. Recently, interest has developed into the use of cooling in the management of patients with acute liver failure and raised intracranial pressure. Animal studies support this treatment option as do case series, although randomized trials are still awaited.

PMID: 18688582 [PubMed - indexed for MEDLINE]

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Survival after in-hospital cardiopulmonary resuscitation.

South Med J. 2008 Oct;101(10):1007-11

Authors: Ferguson RP, Phelan T, Haddad T, Hinduja A, Dubin NH

BACKGROUND: The use of postarrest variables to predict survival after discharge following in-hospital cardiopulmonary resuscitation has not been definitive. This study evaluates whether the duration of cardiopulmonary resuscitation (CPR) and other variables affect discharge rates and survival rates after discharge. METHODS: Prospective cohort survival data and arrest variables were collected, including initial observed rhythm, duration of CPR, time of arrest, and number of arrests. Arrests on unmonitored general medical units, monitored telemetry units, and critical care units were included. Outcome measures were: survival after CPR, 24 hours post-CPR, survival to discharge, and to six months postdischarge. RESULTS: At both discharge and six months after discharge, ventricular fibrillation and ventricular tachycardia were associated with better survival rates than other initial rhythms (P < 0.001). There were significantly higher survival rates (P < 0.001) for those receiving CPR for < or =10 minutes as compared with those receiving CPR >10 minutes. Multiple versus single arrests and monitored versus unmonitored arrests approached significance. The time of day of the arrest was not a significant factor. CONCLUSIONS: Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge and six months postdischarge. Low six-month survival rates may reflect the relatively high proportion of initial rhythms other than ventricular in the study group.

PMID: 18791505 [PubMed - indexed for MEDLINE]

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Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

Arch Pathol Lab Med. 2008 Oct;132(10):1617-22

Authors: Wagar EA, Stankovic AK, Raab S, Nakhleh RE, Walsh MK

CONTEXT: Accurate specimen identification is critical for quality patient care. Improperly identified specimens can result in delayed diagnosis, additional laboratory testing, treatment of the wrong patient for the wrong disease, and severe transfusion reactions. Specimen identification errors have been reported to occur at rates of 0.1% to 5%. OBJECTIVE: To determine the frequency of labeling errors in a multi-institutional survey. DESIGN: Labeling errors were categorized as: (1) mislabeled, (2) unlabeled, (3) partially labeled, (4) incompletely labeled, and (5) illegible label. Blood specimens for routine or stat chemistry, hematology, and coagulation testing were included. Labeling error rates were calculated for each participant and tested for associations with institutional demographic and practice variable information. RESULTS: More than 3.3 million specimen labels were reviewed by 147 laboratories. Labeling errors were identified at a rate of 0.92 per 1000 labels. Two variables were statistically associated with lower labeling error rates: (1) laboratories with current, ongoing quality monitors for specimen identification (P = .008) and (2) institutions with 24/7 phlebotomy services for inpatients (P = .02). Most institutions had written policies for specimen labeling at the bedside or in outpatient phlebotomy areas (96% and 98%, respectively). Allowance of relabeling of blood specimens by primary collecting personnel was reported by 42% of institutions. CONCLUSIONS: Laboratories actively engaged in ongoing specimen labeling quality monitors had fewer specimen labeling errors. Also, 24/7 phlebotomy services were associated with lower specimen error rates. Establishing quality metrics for specimen labeling and deploying 24/7 phlebotomy operations may contribute to improving the accuracy of specimen labeling for the clinical laboratory.

PMID: 18834220 [PubMed - indexed for MEDLINE]

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Post-Cardiac Arrest Syndrome. Epidemiology, Pathophysiology, Treatment, and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.

Circulation. 2008 Oct 23;

Authors: Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T

PMID: 18948368 [PubMed - as supplied by publisher]

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Samuel A. Levine and the history of grading systolic murmurs.

Am J Cardiol. 2008 Oct 15;102(8):1107-10

Authors: Silverman ME, Wooley CF

Murmurs were described first by Laennec in 1819, after which the significance of a murmur became a matter of debate. By the late 19th century, many physicians regarded systolic murmurs as “organic,” whereas others believed that they were often “functional.” Samuel Levine became a central figure in separating functional from organic systolic murmurs. Freeman and Levine’s 1933 study of 1,000 “noncardiac” subjects determined the frequency, cause, and significance of systolic murmurs. Murmurs were rated on a scale of 1 to 6 grades of intensity. Approximately 20% of their patients had grade 1 or 2 systolic murmurs. Hypertension, fever, tachycardia, and anemia were common factors, and the murmurs were considered functional because they would often disappear when these causes were controlled. Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause, location, and effects of posture. They concluded that systolic murmurs often have an explanation and that their grade can be useful in the diagnosis and prognosis. They cautioned that a loud systolic murmur did not necessarily indicate a bad prognosis or even serious heart disease. Levine’s system of grading a systolic murmur is valuable and persists into the 21st century.

PMID: 18946930 [PubMed - in process]

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New treatments for type 2 diabetes–the DPP4 inhibitors.

Prim Care Diabetes. 2007 Dec;1(4):209-11

Authors: Gadsby R

Sitagliptin (brand name Januvia) the first of a new class of oral agents, the DPP4 inhibitors, which lower blood glucose in type 2 diabetes has recently been launched in UK. Another DPP4 inhibitor vildagliptin is due to be launched soon, and there are several others in the pipeline. This article gives an overview of this new class of medications.

PMID: 18632049 [PubMed - indexed for MEDLINE]

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