Noninvasive continuous arterial pressure monitoring using finger photoplethysmography is not quite ready for prime time.  This technology is comparable to cuff pressures, but this technology is far too variable compared with invasive arterial blood pressure monitoring using an arterial line.…
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Arterial lines are not completely benign.  They can definitely cause catheter-related bloodstream infections.  This study shows that arterial lines have a rate of bloodstream infection of about 1 in 1,000 catheter days.  Femoral arterial lines have a higher rate of…
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The American College of Emergency Physicians (ACEP) just published a new clinical policy on procedural sedation and analgesia in the emergency department, which revised the previous policy from 2005.1  Procedural sedation (conscious sedation) is extremely common in the ED and…
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Lungs normally empty by passive recoil and the pressure in the alveoli at end-expiration is the intrinsic positive end-expiratory pressure (PEEP).  During spontaneous respirations and with normal lungs, the PEEP is equal to atmospheric pressure.  On a ventilator, auto-PEEP occurs…
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I am frequently asked by my residents, “What elements are needed for informed consent?”  The first place to start is the definition of informed consent.  Applebaum defined informed consent as “the process by which the treating health care provider discloses…
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Is Aseptic Technique for Ultrasound Guided Peripheral Lines Enough? Widespread use of ultrasound guided peripheral intravenous catheters will reduce reliance on central lines, thus decreasing the central line device utilization ratios (DUR).  In theory and practice, high DURs correlate with…
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Ultrasound for Radial Arterial Line?   Do I really need to use an ultrasound for radial arterial lines?  For years I have used ultrasound guidance for brachial and femoral arterial line placement because the risk associated with puncturing or lacerating…
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Mortality Prediction Model for Patients with Prolonged Mechanical Ventilation One of the most difficult tasks for critical care physicians is approaching the patient and their families about end-of-life issues.  One scenario that often arises is the scenario of decision making…
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Endotracheal Intubation When You Can’t See the Cords: the Bougie is Your Friend This is a problem that every emergency physician or hospitalist faces on occasion and if you haven’t encountered this problem then you haven’t done enough intubations.  There…
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Pneumothoraces are a common problem in the ER and the ICU.  The traditional screening test for a pneumothorax in the hospital is the chest radiograph; however, chest radiographs are not very sensitive in the setting of trauma and in ventilated…
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One of the most common indications for placing a central venous catheter is “no IV access”.  I certainly have placed numerous central lines for this reason.  Unfortunately, this practice is not without consequences.  In addition to patient discomfort and mechanical…
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Are you a hospitalist who would like to incorporate procedures into your practice but don’t feel competent or confident in your skills?  Are you a hospitalist who does procedures so infrequently that you feel more comfortable referring your patients to…
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Numerous studies have shown that ultrasound guidance lowers the rate of complications and increases the success rate for virtually every hospital procedure compared with traditional landmark-based techniques. This has proved to be the case for ultrasound-guided central lines, ultrasound-guided paracentesis,…
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