Sister Mary Joseph Nodule
- 1928: Surgical assistant to Dr. William James Mayo first noted association between paraumbilical nodules observed during skin preparation for surgery and metastatic intra-abdominal malignancy.
- Painful umbilical nodule, with irregular margins, and a hard consistency.
- Metastasis to umbilicus typically via hematogenous spread
- May be first and only presenting sign of intra-abdominal malignancy (reported in ~30%).
Posted 02/27/17 09:10:28 AM by Matthew Cummings
Dynamic assessments of fluid responsiveness?
- Passive leg raise, pulse pressure/stroke volume variation, IVC dimension
- Passive leg raise -- most evidence-based support
Posted 02/27/17 09:14:34 AM by Matthew Cummings
Dopamine vs. norepinehprine as initial vasopressor of choice with central access (NEJM 2010)?
- Multicenter, double-blinded, parallel-group, RCT of patients ≥ 18 years w/ shock requiring a vasopressor (N=1,679)
- Septic 62%, Cardiogenic 17%, Hypovolemic 16%
- Hydrocortisone administered: 40.1% vs. 39.7%
- Activated protein C administered: 18.8% vs. 19.1%
- 28 day all-cause mortality (DA vs. NE): 52.5% vs. 48.5%, P=0.10
- Arrhythmia (DA vs. NE): 24.1% vs. 12.4% (P<0.001; NNH 9)
Posted 02/27/17 09:16:44 AM by Matthew Cummings
MAP resuscitation targets in septic shock (SEPSISPAM NEJM 2014)?
- Multicenter, randomized, open label, controlled trial of patients ≥ 18 with septic shock (N=776), randomized to MAP goal 65-70 mmHg vs. 80-85 mmHg
- All-cause 28-day mortality (high vs low): 34.0% vs. 36.6%, P=0.57
- Need for RRT (7 days) among patients with chronic HTN (high vs low): 42.2% vs. 31.7% P=0.046
Posted 02/27/17 09:17:40 AM by Matthew Cummings
When to initiate RRT in ICU patients (AKIKI NEJM 2016)?
- Multi-center, randomized, unblinded trial of early versus late RRT among ICU patients with AKI (serum Cr >3x baseline or ≥4) requiring vasopressors, IMV or both (N=620)
- Initial exclusion criteria: BUN > 112, K > 6 mmol/L , pH < 7.15 (and unable to increase ventilation), pulmonary edema with hypoxemia despite diuresis
- Early (N=311): immediate RRT following randomization (median 4.3 hours)
- Delayed (N=309): RRT initiated if 1+ of above criteria met (51%, median 57 hours)
- All-cause 60-day mortality (early vs late): 48.5% vs. 49.7%, P=0.79
- Increased risk of CLABSI in early arm: 10% vs. 5% P=0.03
Posted 02/27/17 09:20:09 AM by Matthew Cummings
For further reading...
Posted 02/27/17 09:22:33 AM by Matthew Cummings
Created by Christopher Kelly
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