An evolving role for endobronchial ultrasonography in the intensive care unit.

Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.

A Basic Therapy Gone Awry.

Baking soda (sodium bicarbonate) is a common household item that has gained popularity as an alternative cancer treatment. Some have speculated that alkali therapy neutralizes the extracellular acidity of tumor cells that promotes metastases. Internet blogs have touted alkali as a safe and natural alternative to chemotherapy that targets cancer cells without systemic effects. Sodium bicarbonate overdose is uncommon, with few reports of toxic effects in humans. The case described here is the first reported case of severe metabolic alkalosis related to topical use of sodium bicarbonate as a treatment for cancer. This case highlights how a seemingly benign and readily available product can have potentially lethal consequences.

The management and outcome of documented intraoperative heart rate-related electrocardiographic changes.

OBJECTIVES: The authors analyzed surgical cases in which electrocardiographic (ECG) signs of cardiac ischemia were noted to be precipitated by increases in heart rate (ie, heart rate-related ECG changes [REC]). The authors aimed to find REC incidence, specificity for coronary artery disease (CAD), and the outcome associated with different management strategies. DESIGN: A retrospective review. SETTING: A university hospital, tertiary care. PARTICIPANTS: Patients undergoing surgery under anesthesia. INTERVENTIONS: A chart review. MEASUREMENTS: The authors searched 158,252 anesthesia electronic records for comments noting REC (ie, ST-segment or T-wave changes). After excluding cases with potentially confounding conditions (eg, hypotension, hyperkalemia, and so on), 26 cases were analyzed. RESULTS: REC commonly was precipitated by anesthesia-related events (ie, intubation, extubation, and treatment of bradycardia). In 24 cases, REC was managed by prompt heart rate reduction using ß-blocker agents, opioids, and/or cardioversion in the addition to the removal of stimulus. Only 1 case had a copy of the ECG printed. Two cases were aborted, 1 was shortened and 23 proceeded without change. Postoperative troponin T levels were checked, and cardiology consultation was obtained in selected cases and led to further cardiac evaluation in 6 cases. Postoperative myocardial infarction developed in only 1 patient in whom the ECG changes were allowed to persist throughout the case. CONCLUSIONS: This incidence of reported REC was much lower than the previously reported incidence of ischemia-related ECG changes, suggesting that the largest proportion of events go unnoticed. In many patients, subsequent cardiology workup did not confirm the existence of clinically significant CAD.