Dr. Joseph Esherick Monthly Blog – March 2012
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
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. 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...
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.
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. 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.
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...
The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891This 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. 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. 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]
Topics: Dr. Joseph Esherick, emergency physician, Heinrich Quincke, Authors, bedside ultrasound, Hospital Medicine Blog, emergency medicine, hospital medicine, hospitalist, landmark-guided, lumbar puncture
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. 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.