Podcast # 469: Go PO

Author: Dave Rosenberg, MD

Educational Pearls:

  • Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
  • However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
  • Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 465: As easy and 1, 2, 10 – Capillary Refill and Sepsis

Author: Ryan Circh, MD

Educational Pearls:

  • The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
  • Capillary refill time was standardized (this is not straightforward):
    • A glass microscope slide was pressed on the ventral side of the right index finger
    • Pressure was increased until the skin was blanched
    • This pressure was sustained for another 10 seconds
    • After pressure was removed, the time to return to normal skin color was timed
    • Greater than three seconds was considered abnormal.
  • No difference between the two groups for mortality at 28-days

Editor’s note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 456 Hypoglycemia: Not feeling so sweet

Author: Jared Scott, MD

Educational Pearls:

 

  • Beta-blockers can mask the effects of hypoglycemia
  • Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
  • Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
  • Octreotide can be used as an antidote with sulfonylurea ingestion 

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O’Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 428: Severe Hypothyroidism

Author: Gretchen Hinson, MD

Educational Pearls:

  • Clinical manifestations of severe hypothyroidism may include:
    • Pale, cool, diaphoretic skin
    • Myxedema is the non-pitting edema seen in hypothyroidism
    • Hypothermia, heart failure, hypotension and shock
    • Shortness of breath
    • Cholestasis, constipation
    • Encephalopathy and coma

 

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

 

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 421: Sweet DKA Pearls

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diabetic ketoacidosis patients are subject to electrolyte derangements
  • Potassium should be monitored closely:
    • K < 3.3 = Do not give insulin and replete K first
    • 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF
    • K > 5.3 = delay potassium replacement
  • Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
  • Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

 

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 417: Water Balance

Author: Katie Sprinkle, MD

Educational Pearls:

  • Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
  • Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness,  lightheadedness, general malaise)
  • With severe hyponatremia patients can progress to seizure, coma, and death
  • Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast # 371: EKG changes of Hyperkalemia

Author:  Jared Scott, MD

Educational Pearls:

  • EKG changes do not necessarily correlate to degree of hyperkalemia
  • Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole

References

Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

Podcast # 346: Pediatric DKA

Author: Chris Holmes, MD

Educational Pearls:

  • There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
  • Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
  • Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).

 

References

Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435?446. http://doi.org/10.1111/pedi.12027

Podcast #310: Bicarb in DKA

Author: Gretchen Hinson, M.D.

Educational Pearls:

  • Controversial topic.
  • Pathophysiology – acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
  • 3 risk of giving bicarb in DKA – alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and  increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
  • 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.

References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Podcast #292: Hypercalcemia

Author: John Winkler, M.D. 

Educational Pearls

  • Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut.
  • Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers.
  • Hypercalcemia can lead to poor bone quality and pathological fractures. It can also cause heart arrhythmias.
  • It is important to order an ionized calcium to quantify the level of hypercalcemia, since calcium binds to albumin.
  • Treatment for hypercalcemia includes fluids and loop diuretics.

References:  https://emedicine.medscape.com/article/766373-treatment