• Ischemic liver: “shock” from systemic hypoperfusion, obstruction (ie, Budd-Chiari, etc.)
• Acute viral hepatitis (hepatitis A or B, acute hepatitis C, HSV)
• Drug-induced: Tylenol toxicity by far!
• Autoimmune hepatitis exacerbation

Although these are the common diagnoses, management and therapeutic options vary considerably based on the acuity, comorbidities, etiology, and institution’s capabilities. Furthermore, transaminitis in the thousands doesn’t exclude other diagnoses like biliary obstruction, Wilson’s disease, etc.

Cardiothoracic anesthesiologists routinely place lumbar drains for these procedures to facilitate the controlled removal of cerebrospinal fluid (CSF). These drains are placed similar to epidural catheters which are often used to control labor or post-operative pain. However, a key difference is a larger Tuohy needle (14 gauge!) is used to access the subarachnoid space where the CSF lives. After this space is entered, a flexible, multiorifice catheter is threaded into the space and connected to a pressure transducer and collection bag system. I use a silk tie to reinforce the connection between the catheter and pressure tubing. I also use Tegaderm and tape to make sure the catheter skin insertion entry point is visible but protected!

Spinal cord perfusion pressure (SCPP) is determined by the gradient between mean arterial pressure (MAP) and intraspinal pressure (ISP). In other words: SCPP = MAP – ISP. With the lumbar drain in place, I can decrease ISP by intermittently draining CSF (usually no more than 5-10 cc/hr) or using pharmacologic therapy to increase the MAP. These techniques will help improve spinal cord perfusion; however, they’re no substitute for performing lower extremity motor exams post-operatively!

Drop me a comment below with questions! 🙂

Patients were excluded if they received the aforementioned treatments > 48 hours after testing positive, received remdesivir, or were already on mechanical ventilation. The authors found that each of the four treatment arms were independently associated with an increased risk of in-hospital mortality AND de-novo ventricular arrhythmias when compared to the control.

Naturally, one would be skeptical given the observational nature of this study coupled with the fact that many institutions were selecting for the “sickest patients” (ie, those requiring ICU admission) to receive the therapies in question. Perhaps many of these individuals would have died regardless of the therapy they received? However, the authors used a Cox proportional hazard model to account for many of the confounding variables (patient demographics, comorbidities, other medications, disease severity, etc.) in addition to propensity score matching to support the results.

Limitations include a lack of randomization and consideration for more granular data (no description of how treatment regimens were dosed/timed in the first 48 hours, etc.). Given the observational design, one CANNOT infer causation either; however, the authors should be lauded for performing such a large, comprehensive review of international data registries regarding this controversial topic.

So yes, in conclusion, we really don’t have a great alternative currently. Plenty of work is being done regarding vaccine development, but in the interim, prevention is the best therapy.

LINK TO ARTICLEhttps://rk.md/wp-content/uploads/2020/05/hcq-cq-macrolide-covid-19.pdf

After receiving the Magic Keyboard for my iPad Pro, I began to realize that Safari on the iPadOS offers many advantages, namely that it requests the desktop version of a site by default. Fortunately, using Chrome flags, I can accomplish the same with my favorite browser! 🙂

First, open Chrome and navigate to: chrome://flags. Next, search for “desktop” and enable the request desktop version by default flag as shown in the image below.

Then, swipe up with one finger from the bottom edge of the screen and hold in the middle of the screen until the app switcher appears. Find the Chrome app and swipe up over it to end the process. Now simply restart Chrome and the flag will be invoked. 🙂

Drop me a comment with your thoughts and questions!

As a cardiac anesthesiologist, I most often use procainamide when coming off cardiopulmonary bypass if patients are in a stable atrial fibrillation/flutter (often times I can see the right atrium fibrillating in the operative field) since procainamide slows the atrial rate and has a direct vagolytic effect on the AV node. The net effect is that more atrial impulses are actually conducted through the AV node resulting in normal A-V firing.

As far as “board questions”, procainamide is associated with bone marrow toxicity and drug-induced lupus (as are medications like isoniazid and hydralazine). Furthermore, in patients with atrioventricular accessory pathways as seen in Wolff-Parkinson-White (WPW) syndrome, atrial arrhythmias should be treated with procainamide or cardioversion rather than traditional rate control meds like beta-blockers or calcium channel blockers as these may promote conduction through the accessory pathway.

Drop me a comment with questions! 🙂

Based on the equation, as the bicarbonate concentration increases, so does the pH (more basic/alkaline), and as the pCO2 increases, the pH will decrease (more acidotic). This relationship is rooted in the carbonic anhydrase equilibrium: [H2O] + [CO2] ⇆ [H2CO3] ⇆ [HCO3-] + [H+]. In the equation, ‘6.1’ represents the dissociation constant of carbonic acid and ‘0.03’ the solubility constant of carbon dioxide. Plug in the “normal” values of 24 mmol/L and 40 mmHg for HCO3- and pCO2, respectively, and you’ll arrive at the “normal” pH of 7.4.

Remember that the pH and pCO2 are directly measured on an arterial blood gas (ABG), but the bicarbonate value on that same ABG is CALCULATED using the H-H equation. You’d need a BMP or CMP to obtain a directly measured bicarbonate value.

Drop me a comment below with questions! 🙂

This post was last updated 5/17/2020.

PASSWORD MANAGER

In my opinion, the single most important way to improve one’s digital security is by using strong passwords. I’ve been using Bitwarden, an open source password manager, across all of my devices since 2019. This software is where I store important information like my family’s identity information, login/passwords, credit card numbers, etc. With this utility, every single one of my passwords is different and theoretically impossible to guess with a “brute force” attack given the complexity. If you’re going to make one change to improve your digital security, go through all your browser’s stored passwords, change them to something created by a password manager like Bitwarden, and delete the stored information from your browser.

When I first embarked on this task, I had well over 150 sites ranging from utility companies and social media to school/work-related pages that were password protected. At that time, I used variations of the same password base for the sake of memory. Navigating to each site and changing the passwords one-by-one took all day, but with each passing day, I’m so glad I did!

VIRTUAL PRIVATE NETWORK (VPN)

A few months ago, I purchased a three year NordVPN subscription (my affiliate link) for ~$125 that allows me to connect up to six devices simultaneously to a virtual private network (VPN). VPNs add privacy and security by encrypting data transfers, masking your IP address/location, etc. This is especially important if you’re using public wifi networks, for example. All my devices are connected to this secure network by default; however, because the VPN serves as a “middle man”, speed is somewhat compromised. For that reason, if I’m gaming on my PC, I’ll disconnect from the VPN to take advantage of my gigabit Internet connection. 😉

SOCIAL MEDIA

Besides a strong, Bitwarden-based password, I use two factor authentication whenever possible. If I leave a platform or unsubscribe entirely from a website, I explore options to delete all my user data. I also periodically browse services I’ve authorized through Google, Facebook, Twitter, Instagram, Dropbox, LinkedIn, Microsoft, etc. and revoke any unnecessary permissions. Although it’s easier to log into new websites/apps with existing social media accounts, I’ve transitioned into creating separate profiles (again, through my password manager) to keep everything sandboxed.

Finally, as someone who accesses many web/file servers across the Internet, I do so via secure, SSH file transfer protocol (SFTP)… something which most hosts support and only takes a few minutes to set up with popular FTP clients. If you run the backend of your website, I highly encourage you do the same!

APPLICATIONS

If you can’t trust the applications you install due to poor coding and security vulnerabilities, then you’re leaving yourself wide open for attacks. Delete any unused programs, and update your applications/operating system whenever possible. Check out the applications I use on MacOS and iOS/iPadOS as well as the plugins that power this site.

SMART HOME

When it comes to smart homes, much of the concern stems from secure WiFi connections. Figure out how to obtain access to your router to disable broadcasting of your SSID (the network’s name) and ensure you are using wireless protected access (WPA/WPA2) security with, again, a strong password.

For additional security, I keep my smart home devices (thermostat, lights, etc.) on a different SSID just in case my primary network becomes compromised. Oh, and just for fun, I use webcam covers. 🙂

PUBLIC LOGINS

If you’re accessing password-protected accounts (email, social media, etc.) on a public computer, be mindful, sign out, and delete any files you may have downloaded. I can’t tell you how many times I’ve been at a public computer, gone through the “Downloads” folder, found important documents (social security numbers, scanned credit cards/driver’s licenses, etc) which I proceed to delete to protect other individuals. This is one of the easiest ways to scam someone!

So with that, I’m sure some of you are thinking: “Man, this guy is paranoid.” 😛

Haha, honestly, I’m not! The aforementioned measures are relatively easy to implement involving free software and some minor reconfigurations in work flow. In my opinion, they are essential practices for anyone leveraging the Internet.

Drop me a comment with your recommendations and thoughts regarding “best practices” for protecting oneself against cyber attacks.

The kit comes with three pieces: a guidewire, a needle, and an introducer. The benefit of this guidewire is that it has a flexible tip that I can sneak beyond venous narrowing, device leads, etc. Once I’ve accessed the vein with the included needle and successfully passed the guidewire (confirmed with TEE in the OR or with ultrasound in the ICU), I’ll make a small skin nick and pass in the introducer. I’ll then remove the inner stylet and pass my traditional guidewire (for a MAC, Cordis, Trialysis, etc.) to proceed with line placement in the usual fashion.

This technique has saved me a few times and is something I’m going to increasingly start teaching my residents/fellows to have in their arsenal when confronted with difficult line placements.

Drop me a comment below with your questions/experiences regarding the micropuncture kit!

This study used a national registry of perioperative data with more emphasis placed on ICD 9/10 codes more clearly linked to PPCs (acute respiratory failure following trauma and surgery, acute pulmonary insufficiency following nonthoracic surgery, etc.); however, there is always room for error when dealing with codes.

Besides matching for more obvious variables like patient demographics and comorbidities/procedures associated with increased PPCs, the authors adjusted for other factors such as blood loss, opioids, vent driving pressure, and time from last NMBA dose. They excluded outpatient cases, emergencies, heart/lung/liver transplantation, ASA V/VI, renal failure (GFR < 30 cc/min), combined sugammadex/neostigmine administration, and institutions with a historically low use of sugammadex.

Ultimately, 22,856 sugammadex and neostigmine patients were matched to each other across 12 hospitals from 1/2014 to 8/2018. Multivariate analysis demonstrated a 30% reduction in composite PPCs primarily from a 47% and 55% relative reduction of pneumonia and respiratory failure, respectively.

I encourage you to read the article (sorry it’s not free!) paying attention to how the authors matched patients and accounted for confounders. Drop me a comment with your thoughts and questions!

Article Citation: Kheterpal S, Vaughn MT, Dubovoy TZ, et al. Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis [published online ahead of print, 2020 Apr 8]. Anesthesiology. 2020;10.1097/ALN.0000000000003256.

Oropharyngeal candidiasis (“thrush”) is the most common opportunistic infection in those with HIVs. Fluconazole has shown to be just as effective (and better tolerated) than topical antifungals when used for this specific indication. In those with persistent candidemia (remember, fungemia carries a high morbidity/mortality rate!!), I often times jump straight to echinocandins like micafungin or caspofungin (not to mention amphotericin B for overwhelming infections in critically ill patients).

As a cardiac anesthesiologist, I most often administer fluconazole as a prophylactic measure in patients receiving durable left ventricular assist devices (LVADs). The data on what constitutes the “best surgical prophylaxis” for LVAD implantation is all over the place, but do we know that a subset of these patients have recurrent driveline/pocket infections, and we really don’t want these to track back to the heart.

Drop me a comment with your experiences and questions!