Comments on: EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema http://blog.emcrit.org/podcasts/test-podpost/ Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation Sat, 20 Mar 2010 16:26:56 +0000 http://wordpress.org/?v=2.9.2 hourly 1 By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-523 emcrit Sat, 30 Jan 2010 06:02:07 +0000 http://blog.emcrit.org/?p=17#comment-523 Salman, Thanks for commenting. I used to give them up front, but now I get them stabilized and see where their blood pressure winds up. Sometimes, surprisingly they are low after the acute catecholamines fade. If they are still hypertensive, I then give the ACEI. scott Salman,

Thanks for commenting. I used to give them up front, but now I get them stabilized and see where their blood pressure winds up. Sometimes, surprisingly they are low after the acute catecholamines fade. If they are still hypertensive, I then give the ACEI.

scott

]]> By: salman http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-522 salman Sat, 30 Jan 2010 03:03:26 +0000 http://blog.emcrit.org/?p=17#comment-522 any place for ACE inhibitors in acute management? any place for ACE inhibitors in acute management?

]]> By: Medora Pashmakova (DVM) http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-519 Medora Pashmakova (DVM) Sun, 24 Jan 2010 01:33:23 +0000 http://blog.emcrit.org/?p=17#comment-519 Scott, We see relatively profound bradycardia. Maybe due to the nature of how we use this drug (sometimes for chemical restraint, at doses of 10-15 mcg/kg IV) and also for sedation of instrumented patients (at CRI of 1-2 mcg/kg/hr) we see heart rates in the 40's. With the higher doses the peripheral vasoconstriction is very significant (mucous membranes turn white initially) and I imagine the reflex bradycardia can only support the increased afterload and initial hypertension. I do like this drug a lot and we can perform minimal surgical procedures (i.e. laceration repairs) with this alone. My preferred recipe is Dexdomitor + a pure mu agonist + a local block. I have not measured initial blood pressure after administration - I suspect a direct arterial line would be the most accurate way to monitor hemodynamic effects. Interesting exchange of info, thanks! Medora Scott,
We see relatively profound bradycardia. Maybe due to the nature of how we use this drug (sometimes for chemical restraint, at doses of 10-15 mcg/kg IV) and also for sedation of instrumented patients (at CRI of 1-2 mcg/kg/hr) we see heart rates in the 40’s. With the higher doses the peripheral vasoconstriction is very significant (mucous membranes turn white initially) and I imagine the reflex bradycardia can only support the increased afterload and initial hypertension. I do like this drug a lot and we can perform minimal surgical procedures (i.e. laceration repairs) with this alone. My preferred recipe is Dexdomitor + a pure mu agonist + a local block. I have not measured initial blood pressure after administration – I suspect a direct arterial line would be the most accurate way to monitor hemodynamic effects. Interesting exchange of info, thanks!

Medora

]]> By: A Dabz http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-518 A Dabz Sat, 16 Jan 2010 23:28:15 +0000 http://blog.emcrit.org/?p=17#comment-518 We typically slap on the bipap, get the drip going (albiet at lower dosages) and see the improvement, although I wonder how many intubations/ICU admissions we'd mitigate. BTW, where's the data? Any upcoming studies? We typically slap on the bipap, get the drip going (albiet at lower dosages) and see the improvement, although I wonder how many intubations/ICU admissions we’d mitigate. BTW, where’s the data? Any upcoming studies?

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-516 emcrit Sat, 16 Jan 2010 21:57:55 +0000 http://blog.emcrit.org/?p=17#comment-516 Medora, Great to have a vet. listener! I think you are talking about the possible initial elevation of pulse and blood pressure at the very start of a dexmedetomidine infusion, yes? If so, I have not witnessed this in clinical practice in these patients, probably b/c they are already experiencing great sympathetic stimulation and I have potent vasodilators infusing. What has been you experience in 4-legged patients? scott Medora,

Great to have a vet. listener! I think you are talking about the possible initial elevation of pulse and blood pressure at the very start of a dexmedetomidine infusion, yes? If so, I have not witnessed this in clinical practice in these patients, probably b/c they are already experiencing great sympathetic stimulation and I have potent vasodilators infusing. What has been you experience in 4-legged patients?

scott

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-515 emcrit Sat, 16 Jan 2010 20:41:53 +0000 http://blog.emcrit.org/?p=17#comment-515 Thanks so much for your kind comments. I'm going to have to get permission from one of patients to video the change from arrival to 15 minutes later, because in this case seeing is believing. Scott Thanks so much for your kind comments. I’m going to have to get permission from one of patients to video the change from arrival to 15 minutes later, because in this case seeing is believing.

Scott

]]> By: A Dabz http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-514 A Dabz Sat, 16 Jan 2010 18:21:30 +0000 http://blog.emcrit.org/?p=17#comment-514 I can't tell you how many cases of SCAPE we see at my program in the Bronx. Gonna pitch the afterload reduction dose of NTG to my attendings, see how they react. Enjoyed the lecture this past week at Mt. Sinai. EMCrit all the way. I can’t tell you how many cases of SCAPE we see at my program in the Bronx. Gonna pitch the afterload reduction dose of NTG to my attendings, see how they react.

Enjoyed the lecture this past week at Mt. Sinai. EMCrit all the way.

]]> By: Medora Pashmakova (DVM) http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-512 Medora Pashmakova (DVM) Fri, 15 Jan 2010 02:24:11 +0000 http://blog.emcrit.org/?p=17#comment-512 Found it very interesting that you recommended Dexdomitor for sedation as ideal in these patients - if you're fighting afterload, won't the peripheral vasoconstriction caused by dexdomitor be detrimental? I'm an ER veterinarian and a recent follower of the program and podcasts. Thanks! Found it very interesting that you recommended Dexdomitor for sedation as ideal in these patients – if you’re fighting afterload, won’t the peripheral vasoconstriction caused by dexdomitor be detrimental? I’m an ER veterinarian and a recent follower of the program and podcasts. Thanks!

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-509 emcrit Mon, 11 Jan 2010 23:03:41 +0000 http://blog.emcrit.org/?p=17#comment-509 Jose, Thanks for writing. In SCAPE patients, ALL of the chest x-ray findings are from too much afterload. X-ray will improve entirely if you vasodilate and give NIV. And, the patients will diurese as soon as you perfuse the kidneys. scott Jose,

Thanks for writing. In SCAPE patients, ALL of the chest x-ray findings are from too much afterload. X-ray will improve entirely if you vasodilate and give NIV. And, the patients will diurese as soon as you perfuse the kidneys.

scott

]]> By: Jose D. Torres, Jr. http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-507 Jose D. Torres, Jr. Mon, 11 Jan 2010 22:52:47 +0000 http://blog.emcrit.org/?p=17#comment-507 I wonder if I only use bipap and high dose nitro, will the cxr change remarkably? I know the patients I take care get better, usually gets hits with iv nitro, not as high as you have recommended , instead at 50-100mcg/min and bipap, and lasix, double the patient's daily use in iv form. I did once forget to give iv lasix, and more than 1.5 liter came out of the patient and he wanted to know if he could go home after 3 hrs of treatment. I know we usually diurese too much and leave them dehydrated/volume depleted. I wonder if I only use bipap and high dose nitro, will the cxr change remarkably? I know the patients I take care get better, usually gets hits with iv nitro, not as high as you have recommended , instead at 50-100mcg/min and bipap, and lasix, double the patient’s daily use in iv form. I did once forget to give iv lasix, and more than 1.5 liter came out of the patient and he wanted to know if he could go home after 3 hrs of treatment. I know we usually diurese too much and leave them dehydrated/volume depleted.

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-499 emcrit Tue, 05 Jan 2010 05:36:02 +0000 http://blog.emcrit.org/?p=17#comment-499 Brian, Thanks for writing. The data that have emerged in the past few years seems to indicate an increased risk of mortality when compared to standard care. In the reported trials, this seemed to be just a trend, but then two additional deaths seem not to have been reported in the natrecor group, which if you recalculate the p-values is actually a stat. sig. increased mortality. Even the original trial published in JAMA 2002 did not seem to have any clinically important effects when compared to minimal dose nitrites. I have found aggressive doses of nitrites to be the quickest and most effective way to go, but there are many ways to skin this cat. --Scott Brian,

Thanks for writing.

The data that have emerged in the past few years seems to indicate an increased risk of mortality when compared to standard care. In the reported trials, this seemed to be just a trend, but then two additional deaths seem not to have been reported in the natrecor group, which if you recalculate the p-values is actually a stat. sig. increased mortality.

Even the original trial published in JAMA 2002 did not seem to have any clinically important effects when compared to minimal dose nitrites.

I have found aggressive doses of nitrites to be the quickest and most effective way to go, but there are many ways to skin this cat.

–Scott

]]> By: Brian Hawkins http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-498 Brian Hawkins Tue, 05 Jan 2010 03:40:46 +0000 http://blog.emcrit.org/?p=17#comment-498 What about natrecor? I know it got bad press from its mortality statistics and it was overmarketed but I felt clinically that I have had good success in the past in particular in a crashing patient What about natrecor? I know it got bad press from its mortality statistics and it was overmarketed but I felt clinically that I have had good success in the past in particular in a crashing patient

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-117 emcrit Mon, 19 Oct 2009 05:22:58 +0000 http://blog.emcrit.org/?p=17#comment-117 When they are comfortable and the blood pressure is where you want, observe intravascular status. Then consider fixing it, usually the answer is they need fluid, not diuresis When they are comfortable and the blood pressure is where you want, observe intravascular status. Then consider fixing it, usually the answer is they need fluid, not diuresis

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-116 emcrit Mon, 19 Oct 2009 05:21:57 +0000 http://blog.emcrit.org/?p=17#comment-116 Bioavailability is pretty near IV b/v sublingual route avoids liver metabolism on first pass. 400 mcg of SL nitro is designed to be absorbed over 5 minutes so the dose is acutally ~80 mcg/min. THis is however predicated on having spit in your mouth. Most of these bad scape patients have bone dry mouths and don't absorb the pills well. Bioavailability is pretty near IV b/v sublingual route avoids liver metabolism on first pass. 400 mcg of SL nitro is designed to be absorbed over 5 minutes so the dose is acutally ~80 mcg/min. THis is however predicated on having spit in your mouth. Most of these bad scape patients have bone dry mouths and don’t absorb the pills well.

]]> By: jim http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-113 jim Sat, 17 Oct 2009 14:06:41 +0000 http://blog.emcrit.org/?p=17#comment-113 You're correct but what is the bioavailability of sl nitro compared to IV?? You’re correct but what is the bioavailability of sl nitro compared to IV??

]]> By: phil http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-110 phil Sat, 17 Oct 2009 10:07:36 +0000 http://blog.emcrit.org/?p=17#comment-110 Scott - the early management of SCAPE patients is BIPAP and NITRO - at what point do you start diuresing these patients? Scott – the early management of SCAPE patients is BIPAP and NITRO – at what point do you start diuresing these patients?

]]> By: phil http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-109 phil Sat, 17 Oct 2009 10:06:05 +0000 http://blog.emcrit.org/?p=17#comment-109 Correct me if I'm wrong, but 400 mcg is the dose of a slntg. We regularly give three of those in a row, with the same BP precautions. Correct me if I’m wrong, but 400 mcg is the dose of a slntg. We regularly give three of those in a row, with the same BP precautions.

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-57 emcrit Sat, 26 Sep 2009 07:26:13 +0000 http://blog.emcrit.org/?p=17#comment-57 1/2 life of nitro is between 1-4 minutes so even if they drop it won't be for long I have never seen a precipitous drop of of their pressure at the beginning of treatment when you are giving the bolus. They often drop as they are resolving, which is a function of underlying dehydration. If they did drop at the beginning, it should respond to a small fluid bolus. 1/2 life of nitro is between 1-4 minutes so even if they drop it won’t be for long
I have never seen a precipitous drop of of their pressure at the beginning of treatment when you are giving the bolus.
They often drop as they are resolving, which is a function of underlying dehydration.
If they did drop at the beginning, it should respond to a small fluid bolus.

]]> By: jim http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-56 jim Fri, 25 Sep 2009 23:02:20 +0000 http://blog.emcrit.org/?p=17#comment-56 Have you seen any cases where the BP has fallen precipitously with the use of the 400 mcg/min x 2 minutes of nitroglyerine? What is the half-life of iv nitroglycerine? Thanks, Jim Squires Canada Have you seen any cases where the BP has fallen precipitously with the use of the 400 mcg/min x 2 minutes of nitroglyerine? What is the half-life of iv nitroglycerine?

Thanks,

Jim Squires
Canada

]]> By: emcrit http://blog.emcrit.org/podcasts/test-podpost/comment-page-1/#comment-55 emcrit Sun, 20 Sep 2009 16:26:36 +0000 http://blog.emcrit.org/?p=17#comment-55 Dan, that's excellent! Dan, that’s excellent!

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