Will This Patient Be Difficult to Intubate?

A previously healthy 27-year-old woman was scheduled for elective cholecystectomy. Examination of her airway demonstrated a modified Mallampati score of 2; however, she was unable to bite her upper lip with her lower incisors.

Is she a difficult airway ? Which test has the best +LR?

As a non- anesthesiologist , I definitely learned something new here. The widely used modified Mallampati score (>or equal then 3) had only a +LR= 4.1. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test, +LR = 14

In this systematic review in the September JAMA LN issue, several physical findings increased the likelihood of difficult intubation. The best predictors were an inability to bite the upper lip with the lower incisors, a short hyomental distance, retrognathia, or a combination of findings based on the Wilson score. No risk factor or physical finding consistently ruled out a potentially difficult intubation.

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 An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient

Silent left ventricular apical ballooning and Tako-tsubo cardiomyopathy and it's prevalence in the ICU

I have published already on Tako - tsubo cardiomyopathy (LVAB or TCC ) . If you go in the search engine you will find that post  , it was presented as a MC question.( Differentiating between the three morphological types.

I know, I may be boring you to death, but my suspicion after looking at multiple echos of various institutions, I was surprised on the high prevalence of this disorde , without its classic risk factors, consistent with what's being reported in the literature

Recent studies have reported a variable, but surprisingly high,incidence of undiagnosed LVAB in some intensive care settings. An incidence of 28% in medical ICU patients was reported in a South Korean study that screened 92 consecutive patients by echocardiography and 5.6% of the medical ICU patients who required echocardiography for clinical and hemodynamic reasons. Harm was caused by using inotropes with worse outcomes.

A more recent study in  the September issue of  The European Society Cardiology Heart Failure .the incidence of silent LVAB suggestive of TCC was substantially lower in this study than recently reported in other international ICU settings .A total of 116 patients were enrolled of whom four had LVAB (3.5%,95% confidence interval 0.9–8.6%). The authors conclusion was: a larger, multi-centre study, prospectively screening for LVAB may help understand any variation between centers and regions, with important implications for ICU management.

I think this number is probably to low and as shown on the diagram,  so many risk factors now are identified that most likely none of the studied population groups are similar in risk factor pofile;  they will have a different pre- test probabilities for risk of LVAB. Also regional /geographic /ethnic factors may play a role.It's a little bit of a similar story with ATTR- amyloidosis,  which is grossly under diagnosed, and patient are not being treated with new drugs directed at transthyretin tetramer folding and deposition in the myocardium.

Nevertheless, when I was still doing bedside medicine no patient came in the ICU/CCU  without getting an immediate echocardiogram ( complete study with TDI) ,  particularly if there was any evidence of hemodynamic instability. It's truely not all about fluids and vaspressors only.

We know there is a substantial population we will harm with blindly throwing them on vasopressors/inotropes as discussed above  . One specific example  were excessive doses of epinephrine causes harm, for  example is the Kounis Syndrome  ( Kounis syndrome and Epinephrine; the ATAK Complex )  ATAK constitutes a challenging contemporary complex in anaphylaxis associated with TCC. It is vital to use epinephrine correctly and monitor vital signs and ECGs for patients with acute anaphylaxis.(see Kounis syndrome link above)

It also makes me wonder if high and repeated doses of epinephrine are truly the right therapy for example in PEA arrest  or could they be more harmful ?

Reference images :Current state of knowledge on Tako-tsubo syndrome: a position statement from the task force on Takotsubo syndrome of the Heart Failure Association of the European Society of
Cardiology

Cardiac amyloidosis increasingly common in US

New research suggests the incidence of cardiac amyloidosis in the U.S. is trending up, bringing with it high rates of morbidity and mortality.

Scientists have long assumed the instance of cardiac amyloidosis—the deposition and buildup of immunoglobulin light chains (AL) or transthyretin (ATTR) in heart tissue—is on the rise, Brett W. Sperry, MD, and colleagues wrote in the American Journal of Cardiology. Recent years have seen a rise in awareness of the disease, more novel treatment options and improved noninvasive diagnostic imaging modalities, but the hospitalization trends for amyloidosis remain unclear, especially for AL type.

Sperry, of the Mid America Heart Institute at Saint Luke’s Hospital and University of Missouri-Kansas City in Kansas City, Mo., combed National Inpatient Sample data with his team to identify 156,914 patients hospitalized with amyloidosis between 2005 and 2014. Patients were on average 70 years old and more often white men, and 34.7% of the pool presented with concomitant heart failure.

The researchers noted the overall number of hospital admissions in patients with amyloidosis more than doubled during the study period—from 9,296 in 2005 to 21,740 in 2014. During the peak in 2014, 62 of every 100,000 hospital admissions was related to amyloidosis.

“The explanation for the more than doubling of the rate of hospitalization in those with amyloidosis is likely multifaceted,” Sperry et al. wrote in AJC. “One possibility is that the incidence and prevalence of amyloidosis are increasing due to a growing awareness of the disease. Alternatively, the aging of the population may contribute to these observed trends.”

Over time, patients admitted with amyloidosis tended to be older and have more medical comorbidities, the authors said. They also had longer lengths of stay than those without the disease (7.5 vs. 6.2 days), were less likely to be discharged home (43.6% vs. 48.7%) and were more likely to die while hospitalized (7.4% vs. 4.9%). Patients with concomitant heart failure fared worse in terms of mortality, too.

Sperry and colleagues said it’s impossible to differentiate between AL and ATTR amyloidosis in the NIS, but said it seems likely that ATTR is contributing more to the rise in amyloidosis given the increase in older and black patients over time with a decrease in concomitant multiple myeloma. AL amyloidosis diagnoses, on the other hand, have remained relatively stable for the past seven decades while prevalence has increased, likely because older patients are living longer.

Though their study was inherently limited by the possibility of NIS inaccuracies and human error, the authors said their study was able to shed light on some of the lesser-known characteristics of amyloidosis in the U.S.

“Given the increasing prevalence of hospitalizations in patients with amyloidosis, enhanced diagnostic and treatment options have the potential to improve care for a growing population of patients,” they wrote.

I will comment that almost every other shift , I am suspicious that I see at least once a patient that could have ATTR-wt amyloid  ( far more common then AL-amyloid) 

Use of Medication for Cardiovascular Disease During Pregnancy

CV Medications in Pregnancy

Table for Quick Review, I posted this article earlier in the year but not the Central Illustration 

Cardiovascular disease complicating pregnancy is rising in prevalence secondary to advanced maternal age, cardiovascular risk factors, and the successful management of congenital heart disease conditions. The physiological changes of pregnancy may alter drug properties affecting both mother and fetus. Familiarity with both physiological and pharmacological attributes is key for the successful management of pregnant women with cardiac disease. This review summarizes the published data, available guidelines, and recommendations for use of cardiovascular medications during pregnancy. Care of the pregnant woman with cardiovascular disease requires a multidisciplinary team approach with members from cardiology, maternal fetal medicine, anesthesia, and nursing.

Summary:

1. Labetalol and methyldopa are the agents of choice in treating pregnant patients with hypertension.
2. Although all antihypertensive agents cross the placenta, methyldopa and labetalol appear to be the safest antihypertensive agents in pregnant women.
3. ACE inhibitors (such as lisinopril), angiotensin receptor blockers (such as losartan), spironolactone, and direct renin inhibitors (aliskiren) are teratogenic and are therefore contraindicated during pregnancy. During the first trimester, these agents can cause central nervous system and cardiovascular malformations in the fetus. Second-trimester exposure can cause developmental malformations of the kidneys and genitourinary system.
4. A 2013 guideline published by the American College of Obstetricians and Gynecologists made a strong recommendation for initiation of pharmacologic therapy for pregnant women with persistent chronic hypertension at a systolic blood pressure of 160 mm Hg or higher or a diastolic blood pressure of 105 mm Hg or higher. However, other guidelines, including one from the European Society of Cardiology, continue to recommend initiation of pharmacologic therapy at a systolic blood pressure of 150 mm Hg or higher or a diastolic blood pressure of 95 mm Hg or higher in women without symptoms or evidence of end-organ damage due to hypertension

ESC Guidelines on the management ofcardiovascular diseases during pregnancy

Emergency Echocardiography in the ICU

This is a good video for basic 2D-echo at the bedside for patients in shock. Patients in septic shock and ARDS need frequent limited focused exams , probably every other day as LV (dys)funtion is an extremely dynamic process. Every patient admitted with shock to the ICU should get a baseline echo, which unfortunately does not happen very often.




Attached are a basic outline and summary of elementary echocardiography, the second title is more advanced with quantification of valvular lesions.

Remember that the IVC size and collapse during breathing only represent CVP and is prone to the same limitations as measuring CVP through a CVC. IVC  measurement in intubated patients is not reliable to assess CVP. Distensibility index on the other hand can be used in intubated patients.

Measurement of CVP is not without some merit, as long as the limitations are understood and what exactly is being  measured. Refuting the measurement altogether is not appropriate 

Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation

Fluoroquinolones (FQs) are one of the most prescribed classes of antibiotics and are favored over other agents for their broad spectrum of antibacterial activity and high oral absorption. In recent years, a number of adverse events have been linked to these drugs. Some of these adverse events include retinal detachment, which has produced mixed results , but others, including aortic aneurysm and dissection , peripheral neuropathy , and cardiac arrhythmias , are more consistent with a causal link with FQs and are now included in a warning from the U.S. Food and Drug Administration (FDA)

Mechanistically, FQs are known to damage connective tissue by inducing oxidative stress within the tendon cells , reducing collagen production , and stimulating the activity of metalloproteinases , all of which may lead to reduction in the integrity of the extracellular matrix . FQs can damage type I and III collagen  that is present in the Achilles tendons , aorta , and aortic valves . The putative chain of pathophysiological events would include FQs that, through their high bioavailability and chelating properties, bind to the collagen leading to eventual degradation of the collagen matrix of the aortic or possibly the mitral valve. This can lead to subsequent aortic or mitral valve regurgitation. This hypothesis has been observed in at least 1 case report where a patient who took ciprofloxacin (750 mg twice daily) for 2 days developed symptoms of decompensation as a result of aortic valve prolapse that, following a cardiac work-up, could only be linked to ciprofloxacin use . The acute onset of collagen damage with FQs has also been shown to lead to rupture of large tendons within hours  and aortic dissection within days .

The results of this study found an association between oral fluoroquinolones and an increased risk of mitral and aortic regurgitation. As such, it might be prudent to consider antibiotics that are chemically distinct to FQs in patients with a previous history of valvular regurgitation who require antibacterial therapy. Future studies are urgently required to confirm or refute these findings

Podcast

Master Class: Utility of the EKG and CXR in Clinical Cases

This week, Mayo Clinic is hosting the Cardiovascular Board Review for Internal Certification and Recertification
Join Rick A. Nishimura, M.D, Samuel J. Asirvatham, M.D., and Carole A. Warnes, M.D. for a free LIVE stream

This is an example why the Mayo Clinic is THE premier institution in the country !