This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.
This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.
Top causes for hospital readmission in patients with cirrhosis were acute complications of cirrhosis (especially hepatic encephalopathy), substance abuse, and cancer complications.
A historical myth in procedural medicine is the operator should limit removal of pleural fluid to 1.5 L during thoracentesis because of the risk of re-expansion pulmonary edema or pneumothorax. New evidence supports safety of large volume thoracentesis until no fluid remains.
This meta-analysis analyzed 20 studies and nearly 3,500 patients. The study found that, on the average, a pleural cholesterol level of 55 mg/L or more had an 88% sensitivity, 96% specificity and positive likelihood ratio for an exudate of 20.3. On the other hand, a pleural cholesterol level below 55 mg/L has a negative likelihood ratio of 0.12 suggesting a transudate. In addition a pleural fluid/serum cholesterol ratio of 0.3 or more has 94% sensitivity and 87% specificity for a pleural exudate. A P/S cholesterol ratio less than 0.3 has a negative likelihood ratio of 0.07.3
Central line malposition occurs between 3.3-6.7% of the time according to studies but complications from central line malpositioning is very rare.
This prospective randomized study of complications related to central line location favors subclavian lines over internal jugular lines and femoral lines.
The internal jugular or subclavian veins have fewer combined mechanical or infectious complications for central venous catheter insertions compared with femoral vein CVC placements.
The standard tests to assess bleed risk do not accurately predict bleed risk in cirrhotic patients during bedside procedures.
This blog summarizes the current understanding on the management of hepatic hydrothorax
This blog will summarize the recommendations by the Difficult Airway Society guidelines on Awake Intubation
After an initial failure, emergency department intubators were more successful with video laryngoscopy than with a direct laryngoscopy, regardless of which device was used initially.
This blog summarizes the recent European Association for the Study of the Liver (EASL) guidelines on the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS) in patients with cirrhosis.
According to AASLD Practice Guidelines, all patients with cirrhotic ascites admitted to the hospital should have a diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP).
This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesiologists (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.
The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891 This technique utilizes the...
This is a summary of clinical findings that help to predict the patient who may have a difficult intubation.
The optimal insertion site for tube thoracostomy is at the mid-axillary line in the triangle of safety. Ultrasound-guided localization of this site performed better than palpation
When a chest tube was inserted in a pleural space, secondary interventions were not necessary. Also, there is no significant difference between using a small or large chest tube in the setting of chest trauma.
Ultrasound-guided thoracentesis has a low bleeding risk in mild-moderate coagulopathy or thrombocytopenia
Patients may have anatomically difficult airways or physiologically difficult airways. Both anatomical and physiological factors can lead to peri-intubation complications.
Ultrasound-guided central venous catheter insertion is safe to perform without preprocedural transfusions for platelet counts >20x10(9)/L or if INR<3.
Vasopressors are utilized for various forms of shock. The following summarizes the pharmacology of the most commonly used vasoactive medications
As a hospitalist who also works in the ICU, I am often the first responder to respiratory emergencies. Frequently under these circumstances, you have a chaotic environment and a less than optimal environment to intubate a patient.
New 2018 AHA/ASA Guidelines for the early management of acute ischemic stroke provides new evidence-based recommendations.
Rapid Influenza Diagnostic Tests (RIDTs) have a low sensitivity but a high specificity compared with PCR testing
Rapid Ultrasonography in Shock: Is this really useful? Caring for patients with undifferentiated hypotension, causes anxiety for most health...
This Mayo Clinic study demonstrated that intravenous contrast−enhanced computed tomography was not associated with acute kidney injury.
A non-rebreather mask provides equivalent preoxygenation compared with bag-valve mask ventilation prior to rapid sequence intubation.
This study supports that intravenous contrast−enhanced computed tomography was NOT associated with acute kidney injury.
Evidence-based guidelines and the Society of Hospital Medicine recommend against routine daily labs in hospitalized adults who are clnically stable.
Chest tube placement, or tube thoracostomy, can be an anxiety-provoking procedure for both the patient AND the operator. It can also be a...
A two probe technique for ultrasound-guided paracentesis can identify abdominal wall vessels and to minimize the risk of vessel injury during procedure.
Open Lung recruitment maneuvers using PEEP titration based on respiratory system compliance increased mortality compared with ARDSNet PEEP titration in moderate-severe ARDS.
Protocolized sedation compared with usual care led to decreased mortality, decreased ICU length of stay, decreased hospital length of stay, and decreased tracheostomy rates.
Recommendations to manage Staph aureus bacteremia and decrease mortality from this serious condition.
Hospital inpatients admitted during weekends have a significantly higher rate of mortality compared with patients admitted on a weekday.
Ultrasound in experienced hands can help diagnose bone fractures and can aid in fracture reductions prior to splinting.
For pediatric procedural sedation, ketamine monotherapy has fewer serious adverse events compared with propofol, fentanyl or combinations of these.
These are five recommendations by ACEP that allows for safely avoiding unnecessary testing.
Many articles of clinician clothing can become colonized with bacteria and act as fomites spreading bacteria between patients.
The 2017 Global Initiative for Obstructive Lung Disease provides these recommendations for COPD exacerbations
Endotracheal intubation during in-hospital CPR resulted in a decreased rate of survival and good functional outcome compared with Bag-Mask ventilation.
This systematic review and meta-analysis of mechanically ventilated patients demonstrates that prophylactic corticosteroids decrease the rate of post-extubation stridor and reintubation.
A shock from an automated external defibrillators can save lives in cardiac arrests from ventricular fibrillation or ventricular tachycardia if delivered early. Drones might be a solution to get an AED to cardiac arrest victims especially in rural America.
Blood cultures rarely change empiric antibiotic management and can lead to unnecessary increased costs and length of stays for patients admitted for non-severe cases of urinary tract infections, community-acquired pneumonias and cellulitis
This meta-analysis shows higher portal vein recanalization, lower cirrhosis progression, and no excess bleeding risk with anticoagulant treatment for portal vein thrombosis in patients with cirrhosis.
A D-dimer of 1000 ng/mL or less and the absence of three Wells score risk factors safely excluded PE.
This single-center study demonstrated that septic cancer patients had a lower 90-day mortality rate with a transfusion threshold <9 g/dL than a threshold <7 g/dL.
This study showed that a rise in serum creatinine (SCr) of 0.7 mg/mL from baseline had 68% sensitivity and 80% specificity for predicting 30-day mortality in hospitalized patients with cirrhosis. This level of acute kidney injury (AKI) also doubled the chance of mortality within 30 days compared with cirrhotic patients without AKI.
This meta-analysis demonstrates that a negative high-sensitivity cardiac troponin measured at least 3 hours after symptom onset in association with an EKG with no evidence of ischemia or injury can effectively rule out an acute myocardial infarction (AMI).
This large meta-analysis evaluating over 15,000 patients demonstrates that antipyretic therapy does not reduce 28-day mortality.
A serum neutrophil-lymphocyte ratio of less than 4.0 can rule out subarachnoid hemorrhage with 97% specificity.
2017 consensus syncope guidelines from American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS), in collaboration with the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine, and endorsed by the Pediatric and Congenital Electrophysiology Society
Extended cardiac rhythm monitoring, repeated three times in 6 months, significantly increased detection of paroxysmal atrial fibrillation in elderly patients with cryptogenic strokes.
First attempt success rates are higher with more upright positioning for emergent intubations compared with supine positioning.
Many physicians prescribe antibiotics for a much longer duration than guideline recommendations to treat community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP).
Continuous infusion of beta-lactam antibiotics decreases 30-day mortality compared with intermittent dosing in septic patients.
In this study, 1 in 7 elderly patients hospitalized with syncope had a pulmonary embolism.
In this retrospective study, 30% of patients hospitalized and treated for cellulitis were misdiagnosed.
This study of out-of-hospital cardiac arrest (OHCA) showed that resuscitation efforts should continue and patients should be transported to the hospital if there is ROSC (return of spontaneous circulation), a shock has been delivered, or if EMS witnessed the arrest.
This observational study suggests that intubation during inpatient cardiac arrest was associated with worse outcomes.
A shock index >1.2 was associated with a higher rate of admission and inpatient mortality
The 2016 Surviving Sepsis Guidelines have just been released and summarize the current international guidelines for the management of patients with sepsis and septic shock
Both the fractional excretion of sodium (FENa) and the fractional excretion of urea (FEUrea) have an established role as part of the work-up for determining if acute kidney injury (AKI) is due to a prerenal or intrarenal cause. Although both the FENa and FEUrea are helpful, they both have their limitations.
High-sensitivity troponin assays have improved the sensitivity of the test but the specificity for acute coronary syndromes (ACS) has decreased over time.
This meta-analysis demonstrates that continuous infusion beta-lactam antibiotics compared with traditional intermittent antibiotic dosing lowers 30-day mortality in septic patients.
Among patients hospitalized with their first syncopal episode, 1 in 7 had a pulmonary embolism (PE).
The HACOR score can predict failure of BiPAP and the need for intubation in patients with respiratory failure.
Ultrasound-guided lumbar puncture improved first-pass success rates compared with landmark-guided lumbar puncture in infants.
This is a summary of the epidemiology, diagnosis, and current management of acute pancreatitis
Propofol and ketofol are both suitable options for moderate-to-deep procedural sedation in properly monitored patients.
A systematic review suggests that lidocaine and amiodarone provide similar minor benefits compared with placebo.
An international team of researchers examined several decades' worth of data on worldwide attitudes toward euthanasia and PAS.
In a study of controlled intubations in the OR using acute-angled videolaryngoscopes, “sniffing” head position, reduced mouth opening, and attending intubators were associated with prolonged intubation times.
New NICE guideline recommend early, whole-body computed tomography for adults with major trauma; for trauma with suspected hemorrhage, use blood and tranexamic acid (TXA) instead of crystalloid for treatment.
Modern CT scans of the cervical spine alone is sufficient to rule out significant C-spine injury in patients without focal neurological deficits, even when they are intoxicated.
Abusive head trauma (AHT) is difficult to diagnose because history is unreliable and physical exam findings are insensitive. Now a new Pittsburgh Infant Brain Injury Score has been validated to help determine which infants should undergo neuroimaging for possible AHT.
This systematic review shows a high rate of pulmonary embolism (PE) in patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations.
Empiric antibiotics that cover methicillin-resistant staph aureus (MRSA) are overprescribed for adults admitted to the hospital for community-acquired pneumonia (CAP).
Patients with AF and prior ICH should undergo warfarin anticoagulation if they have valvular AF or non-valvular AF and a CHADS2-VASc score of 6 or more. On the other hand, patients with AF, diabetes and vascular disease but have a CHADS2-VASc score of 5 or less should probably have no antithrombotic therapy due to a high risk of recurrent ICH.
Early administration of antibiotics within 8 hours and use of objective criteria to transition from intravenous to oral therapy when patients reach clinical stability is best practice for patients hospitalized for community-acquired pneumonia (CAP).
Leaving air or lidocaine in the syringe or analyzing pleural fluid more than one hour after collection led to significant changes in pleural fluid pH levels.
In traumatic LPs, every 1000 cell increase in CSF red blood cell count will cause the CSF protein to increase by 1.1 mg/dL
This large cohort study documents the degree to which chronic corticosteroids increase certain types of infections
Chest pain is a leading cause of ED admissions and hospital admissions. This meta-analysis isolates certain risk factors and prognostic scoring systems that are best at predicting whether chest pain represents ACS
Obesity hypoventilation syndrome (OHS) is associated with a high incidence of postoperative respiratory failure. OHS is often detected by preoperative hypercapnia in obese patients.
This study randomized 104 ventilated patients into two arms: a conservative strategy arm with a goal peripheral oxygen saturation of 88%–92% and a liberal strategy with a goal peripheral oxygen saturation of >95%.
The anti-Xa anticoagulant lowers bleeding and death rates in a routine clinical care setting.
This observational study suggested that intracerebral hemorrhages were less severe with the newer oral anticoagulants (NOACs) than with warfarin.
Following these procedural techniques will help reduce complications and improve safety during thoracentesis.
A retrospective study compared the performance of Fluid and Catheter Treatment Trial (FACTT) Lite, FACTT Conservative, and FACTT Liberal.
A collection of recent studies has helped determine the best protocol for removing chest tubes.
Ultrasound-guided technique showed significant improvement in the first-attempt success rate. Adults and pediatric patients both benefit from the ultrasound-guided technique.
Atraumatic spinal needles reduce the incidence and severity of post-dural puncture headaches, or spinal headaches, compared with traumatic spinal needles.
Hospital mortality increases steadily as the severity of acute respiratory distress syndrome (ARDS) increases. Presently, the mortality of patients in the hospital with ARDS is higher than 40%.
Needle decompression catheter should be at least 6.5 cm in length to ensure that 95% of patients would have penetration into the pleural space.
Pediatric lumbar punctures can have much higher success rates when proper positioning and technique are emphasized.
Using the PLAD Score can help clinicians take certain precautions in treatment plans, such as having alternate airway options available, to help reduce morbidity and mortality rates.
Two studies suggest that a serum procalcitonin level of 0.10-ng/mL or higher suggests pneumonia over heart failure as the cause of acute dyspnea in ED patients requiring hospitalization.
Ultrasound-guided thoracentesis is safe and associated with a very low rate of procedural complications.
Two recent trials confirm that an abnormal modified Allen's test does not preclude radial artery catheter placement.
A multidisciplinary group from 13 major organizations provides consensus recommendations on the appropriate radiologic imaging guidelines for four clinical scenarios presenting as chest pain in the ED.
Every four years the American College of Chest Physicians (ACCP) disseminates a new set of guidelines on the evaluation and management of venous thromboembolic disease (VTE).
A prospective cohort single center study was conducted to analyze the risk associated with patients undergoing thoracentesis or small-bore chest tube placement while taking clopidogrel.
The amendment of the Swedish guidelines to remove impaired mental status as a contraindication for lumbar punctures without prior CT scan led to more favorable outcomes.
The European Resuscitation Council and the European Society of Intensive Care Medicine have collaborated to produce these post-resuscitation care guidelines
For blunt trauma patients who are not evaluable because of depressed level of consciousness, an MRI is not needed if the CT scan of the C-spine is normal.
Many clinicians admit that they do not follow CDC guidelines for arterial catheter insertion even though the rate of bloodstream infections is similar between central lines and arterial lines.
Antimicrobial impregnated caps on IV ports reduce the incidence of central line-associated bloodstream infections in a high-risk cancer unit
The American College of Physicians has just released clinical practice guidelines on how to evaluate patients with a suspected acute PE.
Steroids appear to decrease mortality, need for mechanical ventilation, ARDS, and hospital length of stay for patients admitted for community-acquired pneumonia (CAP).
ABIMs Choosing Wisely campaign has 5 top recommendations of things not to do in the ICU.
More evidence suggests that prone positioning saves lives in severe ARDS compared with standard lung-protective ventilation
It is unequivocal that systemic thrombolysis is indicated for massive PE associated with obstructive shock. What is less clear is how to manage the patients with a submassive PE. This meta-analysis concludes that thrombolysis is associated with a lower all-cause mortality but an increased risk of major bleeding including intracranial hemorrhage.