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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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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New Classification of ARDS Predicts Hospital Mortality

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – Acute respiratory distress syndrome, ARDS, HPC updates, mechanical ventilation
Presently, the mortality of patients in the hospital with acute respiratory distress syndrome (ARDS) is higher than 40%.  A sixteen month long observational study was conducted to determine if certain cutoff points of PaO2/FiO2 (less than or equal to 200…
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What Size Catheter Should I Use For Needle Decompression For a Tension Pneumothorax?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, medical procedures, Needle Decompression, Respiratory diseases, Traumatology
More Tags – chest tube, Chest wall thickness, HPC updates, Needle decompression catheter, Pleural space, Tension pneumothorax, tube thoracostomy
A recent meta-analysis of 13 studies that were investigating needle decompression compared data of sample size, mean chest wall thickness, and decompression success rates. The meta-analysis concluded that the needle decompression catheter should be at least 6.5 cm in length…
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Differences Between Lumbar Punctures in Children Vs Lumbar Punctures in Adults

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Lumbar Puncture, Medical General, medical procedures
More Tags – CSF Lactate Level, HPC updates, lumbar puncture, Pediatric Lumbar Puncture
Pediatric lumbar punctures can have much higher success rates when proper positioning and technique are emphasized. The position should be the lateral decubitus position with hips flexed, but the neck does not need to be flexed. The spinal cord ends…
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Risk Factors for Difficult Ventilation with a Laryngeal mask Airway

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Laryngeal Mask Airway, Mechanical Ventilation, Medical General, medical procedures, Respiratory diseases
More Tags – Difficult LMA, HPC updates, laryngeal mask airway, LMA, PLAD Score, Predictive Laryngeal Mask Airway Difficulty Score, Risk Factors
Recently, a retrospective review of over 14,000 adult patients who underwent general anesthesia were assessed. A multivariable analysis was used to determine risk factors of difficult laryngeal mask airways (LMA). The following four risk factors were identified: male gender, age…
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Serum Procalcitonin Can Help to Differentiate CHF from Pneumonia in ED Patients Complaining of Dyspnea

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Emergency Procedures, Medical General, medical procedures, Nephrology, Respiratory diseases
More Tags – BNP, CHF, dyspnea in ER, Heart failure, HPC updates, pneumonia, procalcitonin
Previous trials have investigated the use of B-type natriuretic peptide (BNP) to assess patients with dyspnea in the ED. The sentinel trial was the BNP (Breathe Not Properly) trial that evaluated nearly 800 patients presenting to the ED with complaints…
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