Transaminitis refers to an increase in circulating levels of transaminases (ie, AST and ALT) classically indicative of liver injury. Hepatobiliary disease spans a wide breadth of various pathologies and should consider a patient’s physical exam, clinical context, imaging, other labs (GGT, bilirubin, alkaline phosphatase, etc); however, having AST and ALT levels in the thousands (yes, that’s bad) usually narrows the differential considerably. Ischemic liver: “shock” from systemic hypoperfusion, obstruction (ie, Budd-Chiari, etc.) Acute viral hepatitis (hepatitis A or B, acute hepatitis C, HSV ..read more

Lumbar drains are a mainstay for spinal cord protection when patients undergo operations like thoracoabdominal aortic aneurysm (TAAA) repairs and thoracic endovascular aortic repairs (TEVAR) with subclavian artery debranching. Why? Because the anterior spinal artery receives contributions from paired intercostal arteries that can be disrupted by the aortic pathology itself in addition to the operation (ie, not all the intercostals are re-anastomosed to grafts). So now we have an anterior spinal artery at risk for ischemia. Cardiothoracic anesthesiologists routinely place lumbar drains for thes ..read more

This observational Lancet study compared ~96,000 patients across 671 international hospitals with a positive COVID-19 diagnosis who received hydroxychloroquine (HCQ) +/- a macrolide (ie, azithro) or chloroquine +/- a macrolide (four total treatment arms) to a control arm that received none of the aforementioned therapies. The primary outcome was In-hospital mortality. The major secondary outcome was de-novo ventricular arrhythmias (we already know HCQ and azithro prolong the QT interval). Patients were excluded if they received the aforementioned treatments > 48 hours after testing positive ..read more

I’ve been a Chrome browser user since its inception in 2008. Over the years, I experimented with a wide variety of hardware ranging from Windows gaming rigs and Linux servers to MacOS laptops. Currently, Apple powers the majority of my life; however, I’ve stuck with Chrome as my browser of choice due to its massive market share and cross-platform availability. 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 ..read more

Procainamide is a type IA antiarrhythmic which prolongs repolarization via sodium channel blockade. This is achieved by slowing conduction through the ventricular His-Purkinje system thereby widening the QRS complex (and ultimately the QT interval). 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 mo ..read more

The Henderson-Hasselbalch (H-H) equation illustrates the incredibly important role of the bicarbonate buffer system comprised of the partial pressure of carbon dioxide (PaCO2, primarily regulated by the lungs) and bicarbonate (HCO3-, primarily regulated by the kidneys). It represents the largest buffer system in the extracellular space. 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 ..read more

We now rely on the Internet more than ever to communicate, learn, and manage various aspects of our lives. I decided to compile a list of things I’ve done to help ensure security in an increasingly volatile world of cyber attacks. In this post, I’ll list some techniques I use to remain secure. 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 in ..read more

As a cardiothoracic anesthesiologist and intensivist, my patients have significant comorbidities and have often times had prior instrumentation of their venous systems to place AICD leads, venous stents, temporary pacing wires, etc. This makes it more challenging to place lines that I might need for surgery or with acute decompensation in the ICU. Sometimes, the ‘J’ tip of a traditional central line guidewire meets resistance along indwelling devices. Enter the micropuncture kit! The kit comes with three pieces: a guidewire, a needle, and an introducer. The benefit of this guidewire is that i ..read more

Postoperative pulmonary complications (PPCs) come in a wide variety of flavors ranging from atelectasis and pulmonary congestion to respiratory failure and pneumonia. Not only do certain surgeries (upper abdominal and thoracic), age, case duration, and patient comorbidities (renal failure, longstanding respiratory disease, etc.) confer a higher incidence of PPCs, but so does inadequately reversing neuromuscular blocking agents (NMBA) like rocuronium or vecuronium. This multicenter, observational matched-cohort study evaluated whether reversing with neostigmine (an acetylcholinesterase inhibito ..read more

Fluconazole (Diflucan) is an intravenous and oral antifungal medication that inhibits ergosterol synthesis (an important component of fungal cell membranes). As an intensivist, I most often use this medication to cover Candida albicans infections (especially symptomatic cystitis given fluconazole’s excellent urine penetration); however, it doesn’t cover C. krusei and has variable coverage of C. glabrata at higher doses. Fluconazole also has wonderful bioavailability compared to most other drugs in this class. Oropharyngeal candidiasis (“thrush”) is the most common opportunistic infection in t ..read more