Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Featured, Gastrointestinal diseases, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Ultrasound-Guided Peripheral IV
More Tags – Arterial line placement, central line placement, chest tubes, cirrhosis, featured, HPC updates, lumbar puncture, paracentesis, thoracentesis, tube thoracostomy
This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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Why are Patients with Cirrhosis Readmitted to the Hospital?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Gastrointestinal diseases, Hospital Procedures, Medical General, medical procedures
More Tags – Alcoholic liver disease, cirrhosis, featured procedure, HPC updates, Nonalcoholic liver disease, readmission
Patients diagnosed with cirrhosis are regularly admitted and readmitted to the hospital. Statistics show that the 90-day readmission rate is approximately 50%. A recent study analyzed the rate of readmission at 30-days and 90-days and the relevant causes among patients…
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Safety of Draining Patients Dry During Large Volume Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured, medical procedures, Respiratory diseases, Thoracentesis
More Tags – featured, HPC updates, pneumothorax, re-expansion pulmonary edema, thoracentesis
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…
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Alternative Tests to Differentiate Pleural Effusion Exudates from Transudates

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Mechanical Ventilation, medical procedures, Thoracentesis
More Tags – featured procedure, HPC updates, Pleural cholesterol, pleural effusion, pleural exudate, pleural transudate
How to Differentiate Pleural Effusion Exudates from Transudates   Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a…
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Does the Location of the Central Line Tip Make a Difference?

Ultrasound-Guided Central Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, medical procedures
More Tags – central lines, central venous catheters, featured, HPC updates
Based on several studies, central line malposition occurs between 3.3-6.7% of the time.1  The historical recommendation is that malpositioned central lines should not be used for long periods of time, if at all.  The basis for these recommendations is based…
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Featured Procedure, Infections
More Tags – central line complications, central line placement, central lines, featured procedure, HPC updates
Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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In plane ultrasound-guided central line placement is preferred over out-of-plane technique

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Central line, medical procedures
More Tags – central line, HPC updates, internal jugular line, subclavian line, ultrasound-guided procedures
A study from an urban EM residency program determined that in-plane ultrasound-guided central venous catheterization is superior to out-of-plane ultrasound-guided central line placement. This study was only a single center study that was a randomized crossover study of ER residents…
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Where Should I Place My Central Line?

Ultrasound-Guided Central Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, Medical General, medical procedures
More Tags – central lines, central venous catheters, featured, femoral lines, HPC updates, IJ lines, subclavian 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.  Numerous organizations have proposed guidelines or central line bundles that have advocated preferential use of the…
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In plane ultrasound-guided central line placement is preferred over out-of-plane technique

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, medical procedures
More Tags – central line, featured procedure, HPC updates, internal jugular line, subclavian line, ultrasound-guided procedures
A study from an urban EM residency program determined that in-plane ultrasound-guided central venous catheterization is superior to out-of-plane ultrasound-guided central line placement. This study was only a single center study that was a randomized crossover study of ER residents…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured Procedure, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Thoracentesis
More Tags – Bleed risk, central line, HPC updates, paracentesis, Procedures in Cirrhotic Patients, thoracentesis
How do we assess a cirrhotic patients bleed risk prior to a planned bedside procedure?  Can our standard platelet count and coagulation studies, prothrombin time (PT/INR) and partial thromboplastin time (aPTT), accurately predict bleed risk in cirrhotic patients?  The quick…
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Review of the Management of Hepatic Hydrothorax

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured, Gastrointestinal diseases, medical procedures, Thoracentesis
More Tags – ascites, cirrhosis, featured, hepatic hydrothorax, HPC updates, pleural effusion, thoracentesis
This blog summarizes a recent update reviewing current management recommendations for hepatic hydrothorax (HH).  Hepatic hydrothorax is a complication of decompensated cirrhosis with portal hypertension.  Sixty percent of patients accumulate both ascitic fluid and pleural fluid as a result of portal…
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Transfuse Plasma, Platelets and Red Blood Cells in a 1:1:1 Ratio in Severely Injured Trauma Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, medical procedures, Traumatology
More Tags – HPC updates, massive transfusion protocol, transfusions, trauma
In recent years, the dogma regarding large-volume crystalloid resuscitation in trauma patients has changed, with increased emphasis on including plasma and platelets in addition to red blood cells in the immediate resuscitation protocol. The long-awaited PROPPR trial compared the safety and…
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Video Laryngoscopy after Failed Intubation Attempt in the ER

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Glidescope Intubation, medical procedures, Respiratory diseases
More Tags – direct laryngoscopy, featured procedure, HPC updates, intubation, video laryngoscopy
Video Laryngoscopy Is Superior to Direct Laryngoscopy for Failed Intubation Attempts in the ER Although video laryngoscopy has repeatedly been shown to be superior to direct laryngoscopy, there has not yet been any specific directive instructing emergency department (ED) intubators…
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Summary of New Difficult Airway Society Awake Intubation Guidelines

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, Featured, Glidescope Intubation, King Tube, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – awake intubation, difficult airway management, featured, HPC updates, intubation, video laryngoscopy
The Difficult Airway Society (DAS) has recently published new guidelines for awake tracheal intubation (ATI) in adults.  When performed correctly, ATI has a favorable safety profile for patients with an anticipated difficult airway.  The guidelines cover the indications for ATI,…
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Summary of AASLD Practice Guidelines on Cirrhotic Ascites – Paracentesis Indicated for all Hospitalized Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Infections, Medical General, medical procedures, Paracentesis
More Tags – Cirrhotic ascites, featured procedure, Guidlelines, HPC updates, paracentesis, SBP, spontaneous bacterial peritonitis
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). Treatment of SBP requires cefotaxime plus albumin 1.5 gm/kg on the first day and…
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