Journal of community hospital internal medicine perspectives
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J Community Hosp Intern Med Perspect · Jan 2015
A widened pulse pressure: a potential valuable prognostic indicator of mortality in patients with sepsis.
Sepsis is one of the leading causes of death in the United States and the most common cause of death among critically ill patients in non-coronary intensive care units. Previous studies have showed pulse pressure (PP) to be a predictor of fluid responsiveness in patients with sepsis. Additionally, previous studies have correlated PP to cardiovascular risk factors and increase in mortality in end-stage renal disease patients. ⋯ Based on our findings, we suggest that PP could be a valuable clinical tool in the early assessment of patients admitted with sepsis and could be used as a prognostic factor to assess and implement management therapy for the patients with sepsis.
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J Community Hosp Intern Med Perspect · Jan 2015
A new approach to the prevention and treatment of delirium in elderly patients in the intensive care unit.
The pronounced prevalence of delirium in geriatric patients admitted to the intensive care unit (ICU) and its increased morbidity and mortality is a well-established phenomenon. The purpose of this review is to explore the potential use of dexmedetomidine in preventing or managing ICU delirium in older patients. Articles used were identified and selected through multiple search engines, including Google Scholar, PubMed, and MEDLINE. ⋯ Dexmedetomidine has also been shown to be effective in limiting risk factors associated with ICU delirium such as length and depth of sedation. As opposed to benzodiazepines or opiates, dexmedetomidine provides effective analgesia, sympatholysis, and anxiolysis without causing respiratory depression and allows a patient to more effectively interact with practitioners. The review of these nine articles indicates that these favorable attributes and overall decreased duration and incidence of delirium make dexmedetomidine a viable option in preventing or reducing ICU delirium in high-risk geriatric patients and as a palliative adjunct to help control symptoms and stressors.
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J Community Hosp Intern Med Perspect · Jan 2015
Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital.
Severe adverse events such as cardiac arrest and death are often heralded by abnormal vital signs hours before the event. This necessitates an organized track and trigger approach of early recognition and response to subtle changes in a patient's condition. The Modified Early Warning System (MEWS) is one of such systems that use temperature, blood pressure, pulse, respiratory rate, and level of consciousness with each progressive higher score triggering an action. Root cause analysis for mortalities in our institute has led to the implementation of MEWS in an effort to improve patient outcomes. Here we discuss our experience and the impact of MEWS implementation on patient care at our community academic hospital. ⋯ Implementation of MEWS in our institute has led to higher rapid response system utilization but lower cardiopulmonary arrest events; this is associated with a lower mortality rate, and improved patient safety and clinical outcomes. We recommend the widespread use of MEWS to improve patient outcomes.
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J Community Hosp Intern Med Perspect · Jan 2015
Thrombus entrapped in patent foramen ovale: a rare form of thrombus in transit.
In rare cases, thrombus in transit can be entrapped in a patent foramen ovale (PFO). A patient with this condition is at high risk of embolic stroke and death. ⋯ The decision between medical versus surgical treatment should be made individually for each patient. We present a case of thrombus in transit entrapped in a PFO that was treated medically by lifelong anticoagulation.
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J Community Hosp Intern Med Perspect · Jan 2015
Case ReportsKey clinical features a general internist needs to know about Brugada syndrome: a case-based discussion.
Brugada syndrome (BrS) is an autosomal dominant genetic disorder involving the abnormal function of cardiac voltage-gated sodium ion channels. Sodium channel loss of function can lead to early repolarization and loss of the Phase 2 action potential dome in cardiomyocytes. In BrS, this sodium channelopathy occurs in some, but not all, epicardial cells thus creating 1) juxtaposition of depolarized and repolarized cells in the epicardium and 2) a transmural voltage gradient. Together, these conditions can set up a Phase 2 reentry and resultant malignant cardiac arrhythmia. Of the three types of electrocardiogram (EKG) changes seen in BrS, only the Type 1 EKG is considered diagnostic. In a controlled setting, sodium channel blockers and Brugada EKG leads may be used to unmask this diagnostic EKG finding. Fever and certain medications that interfere with the sodium channel can also trigger these changes, which can be catastrophic. ⋯ Due to the gravity of symptoms that can manifest in the BrS patient, it is important to recognize and treat this condition promptly and effectively. BrS patients require admission for continuous cardiac monitoring when febrile and certain medications interfering with the sodium channel should be avoided in this population. Although medications may be used as one treatment modality, definitive therapy is placement of an ICD device.