Fentanyl-Based Ventilator Sedation Decreased Ventilator Days in ICU Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Mechanical Ventilation, Medical General, medical procedures, Respiratory diseases
More Tags – Fentanyl-Based Ventilator, HPC Blog Updates, HPC updates, ICU, intubation, mechanical ventilation, RASS, Richmond Agitation-Sedation Scale
Complications from long-term deep sedation and the lack of adequate pain control for mechanically ventilated intensive care unit (ICU) patients has resulted in the development of sedation protocols emphasizing pain control over sedation. These protocols use either remifentanyl or fentanyl.…
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MRSA antibiotics are overprescribed in patients hospitalized for community-acquired pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Infections, medical procedures, Respiratory diseases
More Tags – antibiotic stewardship, community-acquired pneumonia, HPC updates, mechanical ventilation, MRSA, pneumonia
Are MRSA Antibiotics Overprescribed for Community-Acquired Pneumonia? – NEJM Journal Watch Nearly 30% of hospitalized CAP patients received antibiotics for MRSA, even though fewer than 1% had MRSA-associated CAP. A recent multicenter, prospective, active-surveillance study of 2259 patients hospitalized with…
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How to Manage Patients with Atrial Fibrillation and Prior Intracranial Hemorrhage

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, medical procedures
More Tags – atrial fibrillation, CHADS2-VASc score, HPC updates, intracranial hemorrhage
It has always been a therapeutic dilemma whether to anticoagulate patients with Afib and a history of prior intracranial hemorrhage (ICH).  This study used a Taiwanese national database to identify 12,917 patients with an ICH history and new AF and…
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Correction for CSF protein in traumatic lumbar punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Lumbar Puncture, medical procedures, Neurological diseases, Traumatology
More Tags – HPC updates, lumbar puncture, meningitis
Traumatic lumbar puncture (LP) is fairly common and occurs when the needle causes bleeding into the subarachnoid space. Introduction of peripheral red blood cells (RBCs) in cerebrospinal fluid (CSF) increases CSF protein levels, thereby complicating diagnosis of bacterial meningitis. This…
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Factors that influence Pleural Fluid pH after Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, HPC updates, pleural fluid analysis, thoracentesis, tube thoracostomy
Pleural fluid pH is an important measure for determining the clinical management of pleural diseases. For example, a pleural fluid pH <7.2 in patients with suspected pleural infection should mandate the placement of a chest tube. However, pleural fluid pH…
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The Risk that Chest Pain Represents Acute Coronary Syndrome

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, medical procedures, Thoracentesis, Traumatology
More Tags – acute coronary syndrome, chest pain, HPC updates, unstable angina
This meta-analysis examined 58 prospective ED studies that involved diagnostic test accuracy among patients with suspected Non-ST elevation ACS. The meta-analysis found that the following clinical findings predicted excess ACS risk in patients presenting with chest pain: hypotension (systolic blood…
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Chronic corticosteroid use increases the risk of some infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Dermatology, Emergency Procedures, Endocrinology, Ginecology, Infections, Traumatology
More Tags – bloodstream infections, candidiasis, corticosteroids, HPC updates, respiratory tract infections, steroids, zoster
This population-based cohort study between 2000 and 2012 from the UK’s Health Improvement Network database compared diagnoses between 275,000 adults who had been prescribed corticosteroids and 626,000 who had not been prescribed corticosteroids.  The query was whether corticosteroid recipients had…
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Obesity Hypoventilation Syndrome Is Associated with Serious Postoperative Respiratory Complications

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Medical General, medical procedures, Respiratory diseases
More Tags – Bilevel noninvasive positive pressure ventilation, BiPAP, CPAP, HPC updates, Nocturnal continuous positive airway pressure, Obesity hypoventilation syndrome, Obstructive sleep apnea, OHS, OSA, Sleep-disordered breathing
Obesity hypoventilation syndrome (OHS) is defined by the triad of obesity (BMI >30 kg/m2), daytime hypoventilation (Paco2 >45 mm Hg), and sleep-disordered breathing in the absence of other causes of hypercapnia, such as severe obstructive lung disease, severe interstitial lung…
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Lower Oxygen Saturation Goals Are Safe in Mechanically Ventilated Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Medical General, medical procedures, Respiratory diseases
More Tags – Goal peripheral oxygen saturation, HPC updates, Oxygenation goals, PEEP, Positive end expiratory pressure
Targeting to 88%–92% did not cause harm. There is little data on ventilator weaning when it comes to oxygenation goals.  Many intensivists adjust the ventilator to maintain an oxygen saturation of at least 95% to buffer against desaturation.  However, there…
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Fondaparinux appears to be superior to enoxaparin for patients with an NSTEMI

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, medical procedures
More Tags – Anti-coagulant, HPC updates, Non–ST-segment elevation myocardial infarction, NSTEMI
The anti-Xa anticoagulant lowers bleeding and death rates in a routine clinical care setting. In patients with non–ST-segment elevation myocardial infarction (NSTEMI), the factor Xa inhibitor fondaparinux was noninferior to enoxaparin in reducing ischemic outcomes in the OASIS-5 study. In…
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Differences in Intracerebral Hemorrhage Between Warfarin and New Oral Anticoagulants

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Hematology, Laryngeal Mask Airway, medical procedures, Neurological diseases
More Tags – HPC updates, ICH, Intracerebral Hemorrhage, New Oral Anticoagulants, NOACs
In prior randomized trials, the incidence of intracerebral hemorrhage (ICH) was significantly lower with the new oral anticoagulants (NOACs) than with warfarin (Blood 2014; 124:1968).  However, it remains unclear if clinical outcomes are similar when ICH does occur with different…
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The Insertion Site for a Thoracentesis Should not be Close to the Spine

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Medical General, medical procedures, Thoracentesis
More Tags – Catheter, Guidelines, HPC updates, Saftey techniques, thoracentesis, Ultrasound-guided thoracentesis
Recent studies have determined the best technique for improving the safety of thoracentesis. The patient should be sitting as upright as possible. Then, ultrasound the posterior back and locate a catheter insertion point at least 6 cm lateral to the…
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Conservative Fluid Management Decreases Ventilator Days but not Mortality Compared with Liberal Fluid Management in ARDS

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Respiratory diseases
More Tags – ARDS, Central venous pressure, Conservative fluid management, CVP, FACTT, FACTT Conservative, FACTT Liberal, FACTT Lite, Fluid and Catheter Treatment Trial, HPC updates, mechanical ventilation, Pulmonary artery occlusion pressure
A retrospective study compared the performance of Fluid and Catheter Treatment Trial (FACTT) Lite, FACTT Conservative, and FACTT Liberal. The prior FACTT demonstrated that conservative fluids is superior to liberal fluids for ARDS. A simplified conservative fluid protocol (FACTT Lite)…
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New Guidelines for Chest Tube Removal

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures
More Tags – chest tube, Chest tube removal, Guidelines, HPC updates, tube thoracostomy
A collection of recent studies has helped determine the best protocol for removing chest tubes. For instance, a trial of water seal for at least six hours is recommended before discontinuation. The water seal reduces the need for another chest…
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First Pass Success Rate is Better for Ultrasound-Guided Radial Artery Line Placement vs Palpation-Guided Placement

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, medical procedures
More Tags – Arterial Line, First-attempt success rate, HPC updates, Palpation-guided placement, Ultrasound-guided radial artery line placement
In 2015 a meta-analysis found that when an ultrasound was used during a radial arterial catheter placement the first pass success rate improved. In the eleven trials that met inclusion criteria over 800 patients were enrolled. Compared to the palpation-guided…
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