UMEM Educational Pearls - By Robert Brown

Category: Critical Care

Title: Do Little People Have Little Lungs?

Keywords: Achondroplasia, vertebral arteries, mechanical ventilation (PubMed Search)

Posted: 6/11/2019 by Robert Brown, MD (Updated: 6/25/2019)
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Takeaways

Little people (patients with achondroplasia or "dwarfism") have little lungs. Even though the trunk may appear to be a normal size with small limbs, the vital capacity is actually about 75% the predicted value based on the patient's sitting height. Macrocephaly and a decreased anterior-posterior depth are the cause for this. When you want to mechanically ventilate a little person, you can estimate their height based on a typical person with the same sitting height, but their actual volume will be about 3/4 the tidal volume predicted.

When intubating, remember these patients also have a high risk of basicranial hypoplasia (the foramen magnum may be small and key-hole shaped). These patients will be predisposed to compress the vertebral arteries when you tilt the head back and this itself can cause ischemia of the medulla and pons leading to central apnea.

Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52

Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1): 

 

 

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Category: Critical Care

Title: Alarms responsible for alarm fatigue

Keywords: Alarm fatigue (PubMed Search)

Posted: 5/21/2019 by Robert Brown, MD (Updated: 6/25/2019)
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Takeaways

In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.

While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.

Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229

 

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Takeaways

Gallstones account for 35-40% of cases of pancreatitis and the risk increases with diminishing stone size. Bile reflux into the pancreatic duct can form stones there, beyond where they can be visualized by ultrasound. Biliary colic may precede the pancreatitis, but not necessarily. The pain typically reaches maximum intensity quickly but can remain for days.

Alanine aminotransferase (ALT) > 3x normal is highly suggestive of biliary pancreatitis.

Abdominal ultrasound is not sensitive to common bile duct stones but may find dilation.

In the absence of cholangitis, endoscopic ultrasound or MRCP are sensitive tests and permit intervention. Patients who recover are much more likely to develop cholangitis, therefore cholecystectomy is indicated in patients after they recover from gallstone pancreatitis.

Bottom Line: a patient presenting with days of abdominal pain but an absence of gallstones or cholangitis may still suffer from gallstone pancreatitis which requires further intervention, including cholecystectomy.

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Category: Critical Care

Title:

Keywords: Alarm Fatigue (PubMed Search)

Posted: 5/20/2019 by Robert Brown, MD (Emailed: 6/25/2019) (Updated: 6/25/2019)
Click here to contact Robert Brown, MD

Takeaways

In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.

While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.

Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229

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