Thershold for Blood Transfusion

In my series of EBM, I was talking on our grand rounds regarding restrictive vs liberal strategies for blood transfusion! I have already posted the evidence for it. But NEJM published a study in septic shock patient that will really change practice: This is a multi-center, parallel-group trial, they randomly assigned 998 patients in the ICU who had septic shock and they did transfusion when the hemoglobin level was 7 g per deciliter or less (lower threshold) versus when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization. As other study showed their conclusion is” patients with septic shock who underwent transfusion at a hemoglobin threshold of 7 g per deciliter, as compared with those who underwent transfusion at a hemoglobin threshold of 9 g per deciliter, received fewer transfusions and had similar mortality at 90 days, use of life support, and number of days alive and out of the hospital; the numbers of patients with ischemic events and severe adverse reactions to blood in the ICU were also similar in the two intervention groups.”

 

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Cavity Lesion

Very nice mnemonic for Cavity lesion DDx in cxray: Cavity, C: Cancer or Mets, A: autoimmune; granulomas from, V: vascular (both bland and septic pulmonary embolus), I: infection(TB, fungall), T: trama (pneumatocoeles), Y: youth (congenital pulmonary airways malformation) Reference

 

Angioedema to Treat or Not to Treat

We are very familiar with the term of Angioedema. Mostly comes from ACE-In but has a large ddx from NSAIDS to hereditary to idiopathic. There is an article in Academic EM that is discussing the treatment options for Angioedema. They categorize Angioedema to  histaminergic-mediated vs Bradykini-meiated. In ED usually we do not know the underline disease of patient . we may find with history that patient has hereditary angioedema(HAE), but we can not diagnose the pathology in an acute setting specifically with a patient with airway concern. I recommend you to read this article in AEM.

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Morphine delays Clopidogrel effects!

Morphine can affect functionality of Clopidogrel. There is an article in JACC, March 2014, that showed “Morphine delays clopidogrel absorption, decreases plasma levels of clopidogrel active metabolite, and retards and diminishes its effects, which can lead to treatment failure in susceptible individuals”. This will bring a problem with patient that the pain is not controlled with Nitro and now the choice of pain meds is….

 

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Alpha Blocker as a treatment for Ureteral Stone!

Alpha blocker (Tamsulosin , Flomax) originally is used for medical treatment of BPH. There are growing concerns that alpha blocker can be used in treatment of ureteral stone due to same affect on bladder and prostate, relaxation of muscle fiber. The recent Cochrane database review showed that compare with Nifedipine (ca channel blocker), alpha blocker has higher stone-free rate and a shorter time to stone expulsion. They recommended this medication to adjunct pain meds for patients with ureteral stone.

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