Leon Chen

Follow me down the K-hole: ketamine and its modern applications.

Ketamine is a versatile anesthetic agent that has been in use since the Vietnam War. Its popularity grew in war time due to its unique pharmacological properties, yet its use dwindled because of some of its adverse effects. However, in specialty areas, ketamine remains the drug of choice and its benefit far outweighs its risk. In our review, we outline the history of ketamine, its pharmacological properties, and its modern applications in various arenas.

Factors Influencing Weaning Older Adults From Mechanical Ventilation: An Integrative Review.

This study aim was to describe the influences that affect weaning from mechanical ventilation among older adults in the intensive care unit (ICU). Adults older than 65 years comprised only 14.5% of the US population in 2014; however, they accounted up to 45% of all ICU admissions. As this population grows, the number of ICU admissions is expected to increase. One of the most common procedures for hospitalized adults 75 years and older is mechanical ventilation. An integrative review methodology was applied to analyze and synthesize primary research reports. A search for the articles was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases; using the keywords and Boolean operators “older adults,” “weaning,” “mechanical ventilation,” and intensive care unit. Although physiologic changes that occur with aging place older adults at higher risk for respiratory complications and mortality, there are many factors, other than chronological age, that can determine a patients ability to be successfully weaned from mechanical ventilation. Of the 6 studies reviewed, all identified various predictors of weaning outcome, which included maximal inspiratory pressure, rapid shallow breathing index, fluid balance, comorbidity burden, severity of illness, emphysematous changes, and low serum albumin. Age, in and of itself, is not a predictor of weaning from mechanical ventilation. More studies are needed to describe the influences affecting weaning older adults from mechanical ventilation.

Stuck inside a cloud: Optimizing sedation to reduce ICU-associated delirium in geriatric patients

Elderly population account for more than 50% of all intensive care admissions, and during their stay, up to 87% of them suffer from delirium. There is a large body of evidence demonstrating increased mortality and worse cognitive function for elderly patients who become delirious during their intensive care unit stay. Although the cause of delirium is multifactorial, inappropriate and outdated sedation methods are preventable causes. We review the current best evidences and provide what we believe are the best sedation strategies that are in line with the Society of Critical Care Medicines Pain, Agitation and Delirium best practice guideline to reduce the incidence of intensive care unit-associated delirium.

Managing hypocalcemia in massive blood transfusion

MR. P, 56, had a history of cirrhosis, pancreatitis, and peptic ulcer disease. He was admitted to the ED with hematemesis (estimated at about 1 L). On presentation, he was responsive to painful stimuli only. He was immediately placed on a cardiac monitor. His initial vital signs were: BP 70/40, hear

A Patient on Airway Pressure Release Ventilation With Sudden Hemodynamic Collapse

We present a case of a man in his 50s with past medical history significant for schizophrenia and hypertension who was recently diagnosed with mycosis fungoides vs primary cutaneous T-cell lymphoma with extensive metastasis. Patient was admitted to the medical ICU and treated for sepsis of unknown source, likely pneumonia. Wound cultures grew Pseudomonas, methicillinresistant Staphylococcus aureus, and Proteus. Laboratory results were notable for the following: WBC count, 88,000/mL; uric acid, 10.6 mg/dL; potassium, 5.3 mEq/L; phosphate, 6.5 mg/dL; lactate dehydrogenase, 693 U/L. The patient was started on broad-spectrum antibiotics and treated for sepsis and tumor lysis syndrome. An official echocardiogram on admission showed unremarkable results. The patient’s clinical condition improved and he was transferred to the ward.

Glycocalyx in Sepsis Resuscitation.

Starlings forces are fundamental to our understanding of physiology. Based on his findings, hydrostatic pressure and oncotic pressure are crucial factors in the movement of intravascular and extravascular fluid. However, new literatures on endothelial glycocalyx, a layer of protective glycoprotein within the vasculature that was first discovered in the 1980s, are reshaping our standard models of Starlings forces. This article examines the nature of the endothelial glycocalyx and why understanding it may change the way we resuscitate patients with sepsis.

The myth of 0.9% saline: neither normal nor physiological.

Normal saline is the crystalloid of choice for fluid resuscitation with its utility born out of the cholera epidemic of 1832. However, its ubiquitous usage is being challenged because of a growing body of evidence suggesting that a large volume infusion of normal saline does in fact have deleterious effects on multiple body systems. Careful considerations should be given to the physiological effects of using large amounts of normal saline as one would with another pharmacological agents.

A study in scarlet: restrictive red blood cell transfusion strategy.

Anemia due to various etiologies occurs in critically ill patients requiring blood transfusion. Traditional transfusion goals guide our transfusion to achieve a hemoglobin goal of at least 10 g/dL. However, it is becoming increasingly evident that a restrictive transfusion goal of 7 g/dL may improve survival outcome, reduce infection, and reduce health care expenditure. Moreover, this strategy has been proven to be effective in a variety of patient population, including those who are critically ill, septic patients, those with a history of cardiac disease, those with gastrointestinal bleed, or those who suffered traumatic injury. This article reviews some of the evidence supporting the restrictive transfusion strategy.

Hepatic portal venous gas from nonischemic cause: a case report.

A 65-YEAR-OLD obese man with uncontrolled diabetes, uncontrolled hypertension, chronic renal insufficiency, and bladder cancer diagnosed in May 2014 status-post multiple transurethral resection of bladder tumors with incomplete resection of tumor and chemotherapies. He was admitted to a large urban cancer medical center in November for a radical cystectomy with ileal-conduit creation and bilateral peritoneal lymph node dissection. Intraoperative and postoperatively, his course was significant for labile blood pressure, hyperglycemia, and fever with leukocytosis attributed to postoperative atelectasis. On postoperative day 3, he was able to start a regular diet and ambulate with assistance. However, during ambulation he had mild emesis and when he went back to his room and sat down, he was noted to become unresponsive. The hospital emergency response team was activated. On arrival of the emergency response team, the patient was found