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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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 EASL Guidelines on Ascites, SBP and HRS Management in Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Gastrointestinal diseases, Infections, medical procedures, Paracentesis
More Tags – ascites, featured, HPC updates, paracentesis, spontaneous bacterial peritonitis
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. Cirrhotic ascites occurs as a consequence of portal…
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Guidelines for Antiplatelet and Anticoagulation Discontinuation before a Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – anticoagulation, antiplatelets, epidural hematoma, featured, HPC updates, lumbar puncture
This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table…
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Ultrasound-guided Tube Thoracostomy Improves Optimal Insertion Site Selection

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Emergency Procedures, Featured, medical procedures
More Tags – chest tube, featured, HPC updates, tube thoracostomy, ultrasound
The optimal insertion site for tube thoracostomy is at the mid-axillary line in the triangle of safety.  This avoids any major nerves or arteries aside from the intercostal vessels.  Ultrasound-guided localization of this site performed better than palpation. In semi-elective…
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Predictors of and Pearls for Difficult Airway Management

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, Featured, King Tube, Laryngeal Mask Airway, Mechanical Ventilation, Medical General, medical procedures, Respiratory diseases
More Tags – cricothyroidotomy, difficult airway management, endotracheal intubation, featured, HPC updates, intubation, King tube, laryngeal mask airway, supraglottic airway, surgical airway
Patients may have anatomically difficult airways or physiologically difficult airways.  Both anatomical and physiological factors can lead to peri-intubation complications.  My goal for this blog is to describe the factors that may contribute to an anatomically difficult airway and clinical…
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Bleeding Risk of Central Line Insertion in Coagulopathic Patients

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, Hematology, medical procedures
More Tags – central lines, featured, HPC updates, thrombocytopenia
The evidence base for the safety of ultrasound-guided central line placement with thrombocytopenia or in patients with a bleeding diathesis is not robust.  Nevertheless, based on the data available most procedural experts feels that an ultrasound-guided central venous catheter insertion…
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Safety of Lumbar Puncture in Adults and Children with Thrombocytopenia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – HPC updates, lumbar puncture, procedure, thrombocytopenia
Traditionally, it has been promulgated by anesthesiologists that you need a platelet count of 100,000 to safely perform neuraxial regional anesthesia (spinal and epidural anesthesia).  This practice pattern has continued even though Children’s Hospitals routinely perform intrathecal injections for prophylactic chemotherapy with…
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2018 Guidelines for Acute Ischemic Stroke Provides New Recommendations

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, Medical General, medical procedures
More Tags – featured, HPC updates, stroke
The 2018 AHA/ASA guidelines for the early management of acute ischemic stroke provides some important new evidence-based recommendations.  Some important new recommendations described in these guidelines include: The DAWN and DEFUSE 3 trials selected patients for mechanical thrombectomy within an extended time…
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Rapid Influenza Diagnostic Tests Have High False Negative Rates

Patient Sleeping with Nurse in Mechanical Ventilation Cours
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, Medical General, medical procedures, Respiratory diseases
More Tags – ARDS, featured, HPC updates, influenza
We are in the midst of an aggressive influenza season right now that should continue into March, so it is nice to review the testing accuracy of standard influenza point-of-care tests that are commonly used.  There are many Rapid Influenza Diagnostic…
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IV Contrast CT Scans Do Not Significantly Increase the Risk of Acute Kidney Injury

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hospital Procedures, medical procedures, Nephrology
More Tags – acute kidney injury, CT scan, featured, HPC updates
Researchers from the Mayo Clinic Rochester performed a retrospective study of data from 5758 adults with chronic kidney disease (CKD; stages 1−5) who underwent either noncontrast CT or iodixanol-enhanced contrast CT and who had pre- and post-CT serum creatinine measurements. All of…
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Early Transexamic Acid Decreases Severe Bleeding in Major Trauma Patients or After Childbirth

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, Gastrointestinal diseases, Ginecology, medical procedures, Traumatology
More Tags – HPC updates, Major trauma, postpartum hemorrhage, TXA
Tranexamic acid (TXA) has been shown to decrease deaths from acute severe bleeding. To determine if time to treatment is associated with the effectiveness of TXA, these authors conducted a systematic review and only two trials met their criteria: the…
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Steroids of No Benefit for Severe Alcoholic Hepatitis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endocrinology, Featured, Gastrointestinal diseases, Hospital Procedures
More Tags – alcoholic hepatitis, hepatitis, HPC updates, steroids
Severe alcoholic hepatitis as defined by a Maddrey’s Discriminant Function [MDF] score, >32 can carry risk for 1-month mortality of greater than 50%. Current AASLD guidelines recommend corticosteroids (prednisolone 40 mg daily for 28 days) for patients with severe acute…
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Non-rebreather Mask for Preoxygenation During Rapid Sequence Intubation

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, medical procedures, Respiratory diseases
More Tags – featured, HPC updates, intubation, preoxygenation, rapid sequence intubation
With flush-rate oxygen, a non-rebreather mask was at least as good as a bag-valve-mask ventilation for intubation preoxygenation. Many intubators using the rapid sequence intubation protocol use a bag-valve-mask (BVM) for preoxygenation. But in the absence of a good mask…
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