NE and Dobutamine or Epinephrine alone?

In a recent study published from France compared epinephrine and norepinephrine-dobutamine in dopamine-resistant cardiogenic shock. It was an open, randomized interventional human study.

Thirty patients with a cardiac index of less than 2.2 and a mean arterial pressure of less than 60 mm Hg who were resistant to combined dopamine-dobutamine treatment and signs of shock were included. Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain a mean arterial pressure of between 65 and 70 mm Hg with a stable or increased cardiac index.

It was found that

• both regimens increased cardiac index and oxygen-derived parameters in a similar manner.
• Patients in the norepinephrine-dobutamine group demonstrated heart rates lower than those in the epinephrine group.
• Epinephrine infusion was associated with new arrhythmias in three patients.
• When compared to baseline values, after 6 hrs, epinephrine infusion was associated with an increase in lactate level, whereas this level decreased in the norepinephrine-dobutamine group.
• Tonometered PCO2 gap, a surrogate for splanchnic perfusion adequacy, increased in the epinephrine-treated group while decreasing in the norepinephrine group.
• Diuresis increased in both groups but significantly more so in the norepinephrine-dobutamine group, whereas plasma creatinine decreased in both groups.
  

It was concluded that when considering global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, epinephrine is associated with a transient lactic acidosis, higher heart rate and arrhythmia, and inadequate gastric mucosa perfusion. Thus, the combination norepinephrine-dobutamine appears to be a more reliable and safer strategy.

Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study - Critical Care Medicine: March 2011 - Volume 39 - Issue 3 - pp 450-455

Percutaneous Aortic Valve Replacement!!
(Corevalve)

Q: What is the quick way of suspecting Pancreatitis secondary to alcohol intake?


Answer: The lipase/amylase ratio. A lipase/amylase ratio of greater than 2 suggests alcoholic pancreatitis.

note: many sources question the reliability of this ratio.

Q: What is Fox's sign?

Answer: Fox's sign is ecchymotic patches seen over the inguinal ligament or the anterolateral surface of one or both thighs just below the inguinal ligament. The discoloration results from bloody fluid tracking extraperitoneally along the fascia of the psoas and iliacus muscles, becoming subcutaneous in the upper thigh. It occurs in patients with retroperitoneal bleeding, usually due to acute haemorrhagic pancreatitis. The sign is named after Dermatologist, Dr. Fox.

Case: 72 year old male presented after midnight when ancillary services (ultrasound or CT scan) are not available. Initial diagnosis is pneumonia with pleural effusion. What may help you in deciding "to tap or not to tap" (thoracentesis) the patient?



Answer: If there is a confusion about 'size of' pleural effusion, obtain lateral decubitus film. Measure the width of the layering pleural fluid. If the width of the fluid is less than 10 mm, the effusion can be managed medically or thoracentesis may be deferred. And if the effusion is wider than 10 mm, thoracentesis is recommended.

Case: 32 year old lean thin man presented to ED with 4 days of "Right" sided chest pain associated with shortness of breath. CXR showed sponteneous pneumothorax (PTX) on "Right" side. Chest tube is inserted with immediate resolution of PTX. 2 hours later patient complaint of shortness of breath again. Physical exam shows crackles on "Left " side?


Answer: "Contralateral" Reexpansion Pulmonary Edema

Reexpansion pulmonary edema (REPE) is a rare but known complication of evacuation of pleural effusion or pneumothorax. Usually it occurs on same side or both side but it may occur only in contralateral lung. Mechanism for this phenomenon is not known.

Risk for REPE is high if lung is collapsed for more than 3 days. If its secondary to pleural effusion it is recommended to remove no more than 1 liter of fluid. The treatment is supportive with supplemental oxygen, positive pressure ventilation, and diuresis.