Cryptococcal soft tissue infection serves as a marker of disseminated cryptococcosis in immunocompromised hosts. Owing to its rarity as a cause of soft tissue infections, diagnosis is difficult and mortality is high.
BACKGROUND Postoperative outpatient narcotic overprescription plays a significant role in the opioid epidemic. Outpatient opioid prescription ranges from 150 to 350 oral morphine equivalent (OME) for a laparoscopic cholecystectomy or appendectomy, with 75 OME (10 pills of 5 mg of oxycodone) being the lowest recommendation (National Institute on Drug Abuse, 2018). We hypothesized that the addition of nonopioid medications to the outpatient pain control regimen would decrease the need for narcotics. METHODS In this prospective, observational pilot study, we prescribed a 3-day regimen of ibuprofen and acetaminophen to patients after uncomplicated laparoscopic cholecystectomies and appendectomies. An additional opioid prescription for 5 pills of 5 mg of oxycodone (37.5 OME) was written for breakthrough pain. During their postoperative visit, we evaluated patients' adherence to the pain control regime, their postdischarge opioid use, and the adequacy of their pain control. RESULTS Sixty-five patients were included in the study (52% male). The majority (80%) of surgeries were performed urgently or emergently. The visual analog scale pain score at home was significantly better than upon discharge (3.7 vs. 5.5, p = 0.001). The average number of oxycodone pills taken postdischarge was 1.8 pills. Half (51%) of the patients did not take any opioids. All but four patients reported that their pain was adequately controlled. No patient required additional opioid prescriptions or visited the emergency department. CONCLUSION This study demonstrated that opioids can be eliminated in at least half of the patients and that five pills of 5 mg of oxycodone (37.5 OME) is sufficient for outpatient pain control when a 3-day course of ibuprofen and acetaminophen is prescribed. LEVEL OF EVIDENCE Therapeutic study, level V.
BACKGROUND: Patients intubated in the prehospital setting require quick and definitive confi rmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no defi nitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confi rmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confi rmed with disposable fi beroptic bronchoscopy. METHODS: Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, fl exible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identifi ed ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of diffi culty were measured. RESULTS: Residents accurately identifi ed the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very diffi cult). No tubes were damaged or dislodged. CONCLUSION: While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confi rmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.
BackgroundUsing finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock.MethodsCapillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an “investigational use only” study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods.Results40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p < 0.001). Capillary lactate measured slightly higher on average than paired arterial values, with a mean difference 0.99 mmol/L. In patients being resuscitated for septic and hemorrhagic shock, capillary and arterial lactate trended closely over time: rising, peaking, and falling in tandem. Clearance of capillary and arterial lactate mirrored clinical improvement, normalizing in all patients except two that expired.ConclusionFinger-stick capillary lactate both correlates and trends closely with arterial lactate in critically ill surgical patients, undergoing resuscitation for shock.
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