Wednesday October 21, 2009
Statin prophylaxis and inflammatory mediators following cardiopulmonary bypass: a systematic review shows evidence is still missing!


Introduction: Induction of an inflammatory response is thought to have a significant role in the complications that follow cardiopulmonary bypass (CPB). The statin drugs are increasingly being recognized as having potent anti-inflammatory effects and hence have potential to influence an important mechanism of injury in CPB. Our objective was to systematically review if pre-operative prophylactic statin therapy, compared with placebo or standard of care, can decrease the inflammatory response in people undergoing heart surgery with CPB.

Results: Eight RCTs were included in the review, with the number of trials for each inflammatory outcome being even more limited.

• Pooled data demonstrated benefit with the use of statin to attenuate the post-CPB increase in interleukins 6 and 8 (IL-6, IL-8), peak high sensitivity C-reactive protein (hsCRP), and tumor necrosis factor-alpha (TNF-a) post-CPB.
• Very limited RCT evidence suggests that prophylactic statin therapy may also decrease adhesion molecules following CPB including neutrophil CD11b and soluble P (sP)-selectin.

Conclusions: Although the RCT evidence may suggest a reduction in post-CPB inflammation by statin therapy, the evidence is not definitive due to significant limitations. Several of the trials were not methodologically rigorous and statin intervention was highly variable in this small number of studies. This systematic review demonstrates that there is a significant gap that exists in the current literature in regards to the potential anti-inflammatory effect of statin therapy prior to CPB.



Reference: click to abstract

Statin prophylaxis and inflammatory mediators following cardiopulmonary bypass: a systematic review: Critical Care 2009, 13:R165 (19 October 2009)

Tuesday October 20, 2009
3 preparations of Propofol

Propofol has 3 products available in market. They each contain different preservatives.

• The Hospira brand has Benzyl Alcohol,
• the Teva product has Sodium Metasulfite, and
• the APP product contains Edetate Disodium

Clinical significance: Some patients have allergies to sulfites so using the Teva product could be of concern in these instances.

Monday October 19, 2009


Question: What is Empyema necessitans?

Answer: Empyema necessitans is a rare complication of pleural space infections and occurs when the infected fluid dissects spontaneously into the chest wall from the pleural space. This process may result from bronchopleural extension of a peripheral lung infection. These cases result from inadequate treatment of an empyema and usually occur after a necrotizing pneumonia or pulmonary abscess.

XX-year-old male intravenous drug user with "empyema necessitans".
CT image shows empyema and draining chest wall abscess

Sunday October 18, 2009
Clipping of Cerebral Aneurysm

Saturday October 17, 2009
Mechanism of Thrombocytopenia and Thrombosis in HIT (Heparin induced Thrombocytopenia)

Friday October 16, 2009
Bedside trick - suspecting tracheal aspiration!

One quick method of suspecting tracheal aspiration or atleast ruling out tracheal aspiration is checking glucose concentration by regular bedside glucose meters. A glucose concentration of more than 20 mg/dl of bloodless tracheal aspirate doesn't confirm but atleast enhance the suspicion of tracheal aspiration.

Though literature is full of conflicting data for this method but still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.



References: click to get abstracts / articles

1. Clinical implications of the glucose test strip method for early detection of pulmonary aspiration in nasogastric tube- fed patients - Taehan Kanho Hakhoe Chi. 2004 Dec;34(7):1215-23

2. Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults - Chest, Vol 103, 117-121

3. Glucose content of tracheal aspirates: Implications for the detection of tube feeding aspiration. Crit Care Med 1994; 22:1557-1562

4. Glucose Content of Tracheal Aspirates - Letter to the Editor - Critical Care Medicine: Volume 23(8) August 1995 pp 1451-1452

Thursday October 15, 2009


Q: How Hextend is different from regular 6% hetastarch in 0.9% NS?

Answer: 6% hetastarch in 0.9% NS contains 154 mEq/L of Sodium and 154 mEq/L of chloride along with 6% hetastarch.

Hextand is 6% Hetastarch in Lactated Electrolyte solution with following amounts of electrolytes

• Sodium (mEq/L) = 143
• Chloride (mEq/L) = 124
• Calcium (mEq/L) = 5
• Potassium (mEq/L) = 3
• Magnesium (mEq/L) = 0.9
• Dextrose/ Glucose Units (g/L) =0.99

Hextend also contains 28mEq/L lactate, which acts as a source of bicarbonate in patients with unimpaired lactate metabolism.

Related previous pearls:

Normosol is NOT just Normal Saline
Difference between Lactate Ringer's and Normal Saline solutions