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DSI works. Weingart’s original article was descriptive. Now he follows with a prospective observational study. I actually haven’t read the whole article yet because like a good book, I just don’t want it to be over. Everyone needs to read this.
Also we all need to quit being slackers on room9er. Lets try to get a few more posts in before the holidays hit us.
I think I’ve shown this to a few of you, but this is an interesting article Droperidol Article
Kind of amazing how some extremely dubious data can affect clinical practice for years, and take a great medicine out of our hands.
Also, do you think these QT concerns that we are now hearing about with Zofran have anything to do with the fact that its now waaaay cheaper than it used to be? No one seemed worried when it was raking in the cash.
Below is the LITFL summary of another look at the importance of early ABx administration in septic patients. Septic and especially severely septic patients should be taken to room 9, obtain blood cultures promptly, and initiate antibiotics as early as possible.
Ferrer R et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-55. PMID: 24717459
Can’t get pain meds after KASPER exposed your nasty habit, so you turned to your old friend heroin? Or you can still get your pain meds, just haven’t learned when enough is enough? Is the fear of stopping breathing really putting a damper on your narcotic addiction? Have no fear, Evzio is here.
This is old news as it was FDA approved in April, and my friend from NY says it is already being used there, but I hadn’t heard anyone talking about it. Evzio is similar to an EpiPen, but delivers a single dose of 0.4mg of naloxone instead. Once it is turned on, it gives verbal instructions in how to use it. It is now available by prescription only.
Has anyone written a prescription for this, or do you see yourself doing so in the near future? Obs your heroin addictions, give them a prescription, and out the door? Not sure how much it costs, but I saw one report that it may cost as much as $500. Goodrx.com lists the price as $591 for one kit of 2 autoinjectors, with a coupon.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm
http://www.nytimes.com/2014/04/04/health/fda-approves-portable-drug-overdose-treatment.html
Here is nice summary post by FOAMed guru Anand Swaminathan with evidence-based discussion of the role (or lack thereof) for diuretics in acute pulmonary edema. Trust me it works. See also the first Emcrit podcast on the topic.
Bottom line: minimal role for diuretics in the pulmonary edema patient in extremis. This is not the mildly fluid overloaded patient with normal respiratory status, they can use a little diuresis once BUN/Cr are determined.
I witnessed the third patient to have apnea as a side effect of ketamine administration. As in the other two cases ketamine was infused as a push, rather than the slow administration. This was not the resident, but typically and to be by the book, MDs should be the ones pushing ketamine. SLOWLY.
In this case our resident did well managing the sedation. Hypoventilation was diagnosed well before desaturation. Painful stimuli did not induce respirations as the ketamine is too good of an analgesic. We began to BVM ventilate, placed nasal trumpet, sat was never lower than 85%. Took about 8 minutes to get spontaneous respirations. We gave narcan as the patient had fentanyl prior to ketamine. As in one other case of ketamine apnea the narcan did not help, but should be attempted.
So learning point. NEVER SLAM ketamine into the patient. Dilute the 1cc (50mg-100mg) of ketamine in 10cc of saline if it will help the temptation to push it.
Also follow the algorithm below for PSA intervention. We will have the sedation review sheet and reference card finished soon.
Here is a very practical algorithm. I recommend using it every shift.
Source: life in the fast lane?