Jones & Bartlett Learning Medicine Blog

    Perioperative Statin Therapy Reduces Perioperative Cardiac Events and Hospital Length of Stay

    Posted by Joseph Esherick on Aug 28, 2012 9:47:52 AM

    Perioperative statin therapy has long been felt to confer cardiac protection during both cardiac surgery and major noncardiac surgery.  Until recently the data have been scarce to definitively make claims in support of this belief.  In 2004, Durazzo et al. conducted the first randomized trial examining the use of Perioperative statins in major noncardiac surgery.  They compared the use of atorvastatin 20 mg daily compared against placebo initiated 2 weeks prior to elective major vascular surgery and continued for 45 days post-operatively.  The investigators found that statins were associated with a 70% relative risk reduction of the combined end-point of death, nonfatal MI, unstable angina, or stroke. [1] Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. [2]

    Statins are thought to be beneficial for a myriad reasons:

    • They lower lipids and have additional pleiotropic effects.
    • The cardioprotective effects of statins during the perioperative period is more likely related to their pleiotropic effects than their lipid-lowering effects.
    • Statins inhibit the action of HMG-CoA Reductase which is the rate-limiting step in cholesterol synthesis, but effective lipid lowering takes months.
    • Perioperative studies have demonstrated that statins confer a cardioprotective benefit when started even 1-2 weeks in advance of major surgery.
    • These pleiotropic effects of statins include suppression of endothelial nitric oxide which promotes coronary vasodilation.
    • Statins also reduce lipopolysaccharide-induced tissue factor release, decrease plasminogen activator inhibitor levels, and increase tissue plasminogen activator; the combination of which reduces coronary thrombosis.
    • Statins also have anti-inflammatory properties which may provide more plaque stability. [3]
    Read More

    Topics: Stroke, cardiac surgery, cholesterol, Dr. Joseph Esherick, Authors, MI, atorvastatin, atrial fibrillation, beta-blockers, bypass grafting surgery, Cardiology, cardioprotective, coronary artery, Hospital Medicine Blog, lipids, myonecrosis, statin therapy, unstable angina

    Ultrasound is More Sensitive Than Chest X-ray for Detection of a Pneumothorax

    Posted by Joseph Esherick on Apr 24, 2012 4:26:04 PM


    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 patients.  A recent study of 225 trauma patients demonstrated that an AP chest x-ray had only 20.9% sensitivity for detecting a pneumothorax versus a CT scan of the chest.[1] A chest CT scan is the gold standard for the diagnosis of a pneumothorax, but a CT scan is extremely expensive and exposes a patient to about 7 mSv radiation (the equivalent of 70 chest x-rays).  Another modality that is gaining traction as the principal diagnostic modality to evaluate for post-traumatic pneumothoraces is a transthoracic ultrasound.  Thoracic ultrasound look for the presence or absence of lung sliding, comet tail artifacts, A line, a lung point, and a “Seashore sign” or “Bar code sign” on M Mode sonography to determine whether a pneumothorax is present.  A transthoracic ultrasound takes only a few minutes to perform and is performed as a part of the E-FAST exam right in the trauma bay of the ER.  It costs nothing, is associated with no radiation exposure, and requires no transport of the patient.

    Read More

    Topics: CT scan, Dr. Joseph Esherick, Authors, Pneumothorax, x-ray, Hospital Medicine Blog, E-FAST, sonography, thoracic

    Daily Aspirin Decreases the Development of Cancer

    Posted by Joseph Esherick on Mar 22, 2012 9:05:28 AM

    Dr. Joseph Esherick Monthly Blog – March 2012

    Read More

    Topics: oncology, Breast Cancer, colorectal cancer, Dr. Joseph Esherick, gastric cancer, Authors, lung adenocarcinoma, metastasis, pancreatic cancer, aspirin, biliary cancer, brain cancer, Hospital Medicine Blog, Dr. Peter Rothwell, esophageal adenocarcinoma, hospital medicine, Lancet

    Beta-Blockers: Beneficial For Older Patients with Chronic Obstructive Pulmonary Disease?

    Posted by Joseph Esherick on Jan 26, 2012 10:32:42 AM

    Dr. Joseph Esherick Monthly Blog – January 2012

    When I was in medical school in the early 1990’s, one of the principles that I learned was to never prescribe beta-blockers to patients with chronic obstructive pulmonary disease (COPD).  We knew that stimulation of beta-2 receptors caused bronchodilation and therefore the belief was that beta-blockers would cause bronchospasm and lead to COPD exacerbations.  This practice was analyzed in a Cochrane review by Salpeter et al. in 2005 which concluded that, “cardioselective beta-blockers, given to patients with COPD do not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations. “[1] Another study focusing on the treatment of systemic hypertension in patients with pulmonary disease also concluded that cardioselective beta-blockers (β1-selective antagonists) were safe to use in patients with stable COPD.[2] One final review of the available evidence came to the same conclusion that, “the use of cardioselective beta-blocker therapy in patients with cardiovascular disease and comorbid COPD [appears safe].”[3]

    These previous reviews attested to the safety of beta-blocker therapy in patients with stable, mild-moderate COPD.  However, a recent study analyzed the question whether beta-blockers in patients with COPD are beneficial if there is an indication for their use?[4]

    Read More

    Topics: cardiovascular disease, Dr. Joseph Esherick, Authors, Tarascon Medical Procedures Pocketbook, Tarascon Primary Care Pocketbook, beta-blocker therapy, beta-blockers, bronchospasm, Cardiology, chronic obstructive pulmonary disease, COPD, Hospital Medicine Blog, Tarascon Hospital Medicine Pocketbook

    Ultrasound-guided Thoracentesis Reduces the Rate of Pneumothorax and Tube Thoracostomy

    Posted by Joseph Esherick on Nov 28, 2011 11:16:57 AM

    Dr. Joseph Esherick Monthly Blog – November 2011

    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, and ultrasound-guided lumbar punctures in obese patients.  This essay will focus on ultrasound-guided thoracentesis which has a decreased rate of pneumothorax and need for tube thoracostomy compared with the blind approach.

    Pleural effusions affect nearly 1.5 million people each year in the United States.  Many of these people require thoracentesis for pleural fluid analysis to either determine the etiology of their pleural effusions or as a therapeutic procedure to relieve dyspnea and hypoxia.  Examination of the pleural space with sonography is best carried out using a convex array 3.5- to 5 MHz probe.[1]   Ideally, the patient is in the sitting position and sonography should identify the uppermost extent of the pleural effusion and the location of the diaphragm.  The depth of insertion can also be approximated by using the depth markers on the ultrasound screen.  At this point, a mark can be made on the posterior thorax just above the rib at the optimal site for thoracentesis.  The thoracentesis can then be carried out in standard fashion with the patient in the same sitting position.   Alternatively, the convex array probe can be placed in a sterile sheath and the thoracentesis can be performed using real-time ultrasound guidance.  The complication rate is identical with either technique for ultrasound-guided thoracentesis...

    Read More

    Topics: Dr. Joseph Esherick, paracentesis, pleural effusion, thoracentesis, ultrasound-guided, Hospital Medicine Blog, hospital medicine, lumbar puncture, pneumothroax, ultrasound

    The Rise and Fall of Xigris (Drotrecogin-alfa)

    Posted by Joseph Esherick on Oct 31, 2011 3:10:09 PM

    Dr. Joseph Esherick Monthly Blog – October 2011

    Drotrecogin-alfa (DrotAA) has been an integral part of the care bundle for adult patients hospitalized with severe sepsis or septic shock and a high risk of death since 2002.  DrotAA is a synthetic activated Protein C (APC) which has good scientific evidence for why it may be beneficial in patients with severe sepsis and septic shock.  Patients with severe sepsis have abnormal activation of their coagulation pathways and inflammatory system and impaired fibrinolysis, which lead to a procoagulant state.  Normally, APC acts with Protein S to degrade clotting factors Va and VIIa to promote anticoagulation.  However, intrinsic levels of APC are diminished in patients with severe sepsis because of impaired APC synthesis and increased degradation by neutrophil elastases.  Therefore, the theory was that a synthetic APC could benefit patients by decreasing the abnormal clotting which occurs in the micro-circulation.

    Read More

    Topics: Dr. Joseph Esherick, DrotAA, sepsis, septic shock, Activated Protein C, APC, clotting, Hospital Medicine Blog, hospital medicine

    Antibiotic Stewardship with the Aid of Procalcitonin Measurements

    Posted by Joseph Esherick on Aug 23, 2011 4:37:43 PM

    Dr. Joseph Esherick Monthly Blog – August 2011

    There has been considerable interest in antibiotic stewardship programs over the past decade given the increase in drug-resistant bacteria.  The best way to combat the problem of drug-resistant bacteria is to develop systems which discourage the inappropriate initiation of antibiotics or the unnecessary prolongation of antibiotics.  The measurement of serum procalcitonin levels can aid sound clinical judgment for decisions regarding proper antibiotic use.

    Procalcitonin, the precursor peptide of calcitonin, is released in response to a body’s exposure to bacterial antigens or toxins.  Furthermore, the procalcitonin levels are suppressed by exposure to cytokines activated during viral infections, namely interferon gamma.  We know that the level of procalcitonin elevation is directly correlated with the severity of the bacterial infection.[1] In addition, procalcitonin levels rise within 6-12 hours after symptom onset of bacterial infections and decrease by about 50% per day once a bacterial infection is under control.[2]

    A number of randomized controlled trials have led to the development of procalcitonin guided clinical algorithms for various infections which have been used throughout Europe.  These protocols have led to a marked reduction in the use of antibiotics in adult patients treated in a variety of clinical settings with no increase in mortality or morbidity...

    Read More

    Topics: Dr. Joseph Esherick, Authors, Prescribing, viral infection, antibiotic, Hospital Medicine Blog, drug-resistant bacteria, hospital medicine

    Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

    Posted by Joseph Esherick on Jul 15, 2011 11:08:52 AM

    Dr. Joseph Esherick Monthly Blog – July 2011

    The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or the L2-3 interspinous spaces.  The landmark-guided technique of lumbar puncture is usually successful in experienced hands as long as the patient is not obese, pregnant, edematous, or have scoliosis, degenerative joint disease, or a history of lumbar spine surgery.  Patients who have any of these characteristics or conditions can lead to more difficult landmark-guided lumbar punctures.  It is in these cases when bedside ultrasound can increase the success rate of lumbar punctures.[2,3,4,5]    

    Ultrasound-guided regional neuraxial anesthesia has been described in the anesthesia literature since 1971.[6]   The literature reports a reduction in the number of attempts, need for repositioning, and interspaces accessed compared with landmark-guided spinal or epidural anesthesia.[7,8]  The use of bedside ultrasound to help guide difficult lumbar punctures has spread to the emergency room, ICU, and the hospital wards over the last 7 years.[9]   Observational studies have demonstrated that lumbar landmarks can be correctly identified using ultrasound about 76% of the time when they are difficult to palpate.[2,3,9]

    Read More

    Topics: Dr. Joseph Esherick, emergency physician, Heinrich Quincke, Authors, bedside ultrasound, Hospital Medicine Blog, emergency medicine, hospital medicine, hospitalist, landmark-guided, lumbar puncture

    A Simple Checklist for Central Lines Saves Lives and Money

    Posted by Joseph Esherick on Jun 28, 2011 8:28:07 AM

    Dr. Joseph Esherick Monthly Blog - June 2011

    Safety checklists have been adopted by numerous industries to prevent errors and save lives.  Checklists have been used for decades by industries as diverse as the aviation industry, construction companies, and professional chefs to prevent mistakes.  In medicine, checklists have been used in the operating room to prevent surgical errors and for central line placement to prevent catheter-related blood stream infections (CRBSIs).

    The pioneer of safety checklists in medicine is Dr. Peter Provonost who spearheaded the Michigan Keystone ICU Project that ended in 2006[1].   The checklist used for central venous catheter placement is simple and involves only five key steps that are rooted in evidence-based medicine:  wash your hands; cleanse the insertion site thoroughly with chlorhexidine; maximal barrier precautions (wear a mask covering the nose and mouth, a cap covering all your hair, sterile gown, sterile gloves and use a wide sterile drape over the patient); a nurse or observer is empowered to stop the procedure if there is any break in sterile technique; and there is a daily review of central line necessity.

    Read More

    Topics: medicine, Dr. Joseph Esherick, Authors, Keystone Project, CRBSI, Global Health Blog, Dr. Peter Provonost, hospital medicine, hospitalist, ICU, safety checklist

    Subscribe to Blog Email Updates

    Recent Posts

    Posts by Topic

    see all