Nutrition 2019

I’m not one to make New Year’s Resolutions.  Why?  Because I used to make a list of 10 things and NEVER got any of them completed.  My goal these days is to constantly re-asses my goals daily.  Every day is a new day to accomplish something or try something new or go outside your comfort zone.  So, this year, my husband and I both want to work on our nutrition.  It’s more evident now (we’re in our 40s) than ever before that we really take responsibility not only for our own health, but the health of our littles.  Therefore, this is a top priority for both of us.  The more we learn about nutrition and what to put into our bodies, the more we can teach our kids the importance of health and nutrition.  I hope this knowledge continues to transfer down into our kids, grandkids, etc.  The gift of good health is more valuable to me now than before.   The older I get, the more I see my parents/family aging.  Luckily, my family has good genes are have lived into their 90s.  However, I want to take what I can into my own hands and make sure it stays that way.  I come across so many patients who either have bad genes, poor diet, poor access to nutrition, lack of knowledge of nutrition and exercise, or simple complacency with an “I’m gonna do what I’m gonna do” attitude.

Three Books that I’m tackling this year:

 

recommended-weekly-exercise
From CBHS Fund
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Thoracic surgery: PVB, SAPB, TEpi, ESP block, Precedex

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study.  JCVA February 2017. Volume 31, Issue 1, Pages 142–146.

To place the PV catheter at the T4-5 level, the authors used an in-plane transverse technique under ultrasound guidance, with the probe in a transverse orientation. After identifying the anatomic landmarks on ultrasound, a 17-gauge Tuohy needle was advanced in a lateral to medial direction, until the tip was beneath the transverse process. For all recipients in the study, the authors further confirmed correct PV catheter placement with real-time infusion of a local anesthetic (1-3 mL of 1.5% lidocaine with epinephrine 1:200,000); they were able to visualize on ultrasound the spread from the tip of the catheter.

Once it was confirmed that the tip remained in position, the PV catheter was secured with skin glue (Dermabond®, Ethicon, Inc.; Somerville, NJ). Next, at the PV catheter insertion site, the authors placed an occlusive dressing on a chlorhexidine-impregnated sponge (BioPatch®, Johnson & Johnson Wound Management, a division of Ethicon, Inc.; Somerville, NJ). The PV catheter was connected to an elastomeric pump (ON-Q®, Halyard Health, Alpharetta, GA), an infusion of 0.2% ropivacaine was started at a rate of 0.2 to 0.25 mL/kg/h; the maximum dose was 7 mL/h per side in bilateral lung transplant recipients and 14 mL/h in unilateral single-lung transplant recipients.

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From NYSORA

Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. JCVA February 2017. Volume 31, Issue 1, Pages 152–158.

Under sterile conditions and while patients still were in the lateral position with the diseased side up, a linear ultrasound transducer (10-12 MHz) was placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the ribs were counted down until the fifth rib was identified in the midaxillary line (Fig 1).18 The following muscles were identified overlying the fifth rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscles (deep and inferior). The needle (a 22-gauge, 50-mm Touhy needle) was introduced in plane with respect to the ultrasound probe, targeting the plane superficial to the serratus anterior muscle (Fig 2). Under continuous ultrasound guidance, 30 mL of 0.25% levobupivacaine was injected, and then a catheter was threaded. A continuous infusion of 5 mL/hour of 0.125% levobupivacaine then was started through the catheter.

Figure-17-Nagdev-2017-ACEP-Now-Ultrasound-Guided-Serratus-Anterior-Plane-Block-Can-Help-Avoid-Opioid-Use-for-Patients-with-Rib-Fractures-
From http://painandpsa.org/rnb/

Erector Spinae Plane Block


Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-Thoracotomy Pain Syndrome After Thoracotomy: A Randomized Controlled Trial. JCVA February 2017. Volume 31, Issue 1, Pages 159–165.

Adjuvants to prolong regional anesthesia

HIT and heparin alternatives

Took care of a patient who came to OR for a redo-sternotomy and triple valve replacement on ECMO.

Scroll down to see how we managed the patient’s possible HIT.  The patient had a low score on her 4Ts assessment.  Therefore, we opted to move forward before the functional assay came back with results as the patient was in dire need of triple valve replacement.

 


HIT Basics

Heparin Induced Thrombocytopenia and Cardiac Surgery: A Comprehensive Review. J Blood Disord Transfus 2011, S2.

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From https://www.omicsonline.org/open-access/heparin-induced-thrombocytopenia-and-cardiac-surgery-a-comprehensive-review-2155-9864-S2-003.pdf

The goals of treatment for HIT are threefold: Interrupt the pathological immune response, inhibit the uncontrolled generation of thrombin, and minimize the complications.

Cessation of heparin alone does not sufficiently reduce the risk of thrombosis. The next step in management targets the uncontrolled generation of thrombin with the use of direct thrombin inhibitors (DTIs).  Argatroban is preferred in patients with renal insufficiency, whereas lepirudin is the drug of choice for patients with liver disease.  Bivalirudin is another hirudin analog that differs from lepirudin in that it is hemodialyzable and primarily undergoes enzymatic elimination. Its half-life is the shortest, 20-25 minutes, making bivalirudin the safest option since there are no reversal agents available.

All three agents can be monitored using the activated partial thromboplastin time (aPTT) to levels of 1.5 to 2.0 above baseline. Once the platelet count has increased to a minimum of 150,000/µL bridging therapy to warfarin is essential for the safe transition from DTIs.

Iloprost is a prostacyclin analogue that reversibly inhibits platelet aggregation.  Plasma exchange was successful in reducing anti-P4/heparin antibodies and allowed for the restoration of a normal platelet count, essentially reversing the disease.

A-suggested-approach-to-diagnosis-and-initial-management-of-patients-with-suspected-HIT
From https://www.researchgate.net/figure/A-suggested-approach-to-diagnosis-and-initial-management-of-patients-with-suspected-HIT_fig1_236255402

HIT/HITT and alternative anticoagulation: current concepts. BJA: British Journal of Anaesthesia, Volume 90, Issue 5, 1 May 2003, Pages 676–685.

Heparin-induced thrombocytopenia and cardiac surgery. Curr Opin Anaesthesiol, 2010; 23:74–79.

Perioperative care in cardiac anesthesia and surgery.  Chapter 19: HIT and heparin alternatives.  

Handbook of patient care in cardiac surgery. Chapter 2: Operative management.


Prostacyclins in Cardiac Surgery: Coming of Age.  Seminars in Cardiothoracic and Vascular Anesthesia 22(3):108925321774929 · December 2017.

Intraoperative infusion of epoprostenol sodium for patients with heparin-induced thrombocytopenia undergoing cardiac surgery. The Japanese Journal of Thoracic and Cardiovascular Surgery. Volume 54, Issue 8, pp 348–350.

Cardiac Surgery With Cardiopulmonary Bypass in Patients With Type II Heparin-Induced Thrombocytopenia. Ann Thorac Surg 2001;71:678–83.

HIT and urgent open heart surgery: a sticky situation. Grand Rounds, Hematology. UW 2015. 


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From https://www.omicsonline.org/open-access/percutaneous-coronary-intervention-in-patients-with-heparin-inducedthrombocytopenia-case-report-and-review-of-literature-2329-6607-1000202.php?aid=82752

Bivalirudin for Cardiopulmonary Bypass in the Setting of Heparin-Induced Thrombocytopenia and Combined Heart and Kidney Transplantation— Diagnostic and Therapeutic Challenges. Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) 354–364.

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From https://www.jcvaonline.com/article/S1053-0770(16)30273-7/fulltext

Cardiac Bypass Surgery in the Setting of Heparin Induced Thrombocytopenia.  BIDMC guidelines.

Anticoagulation during Cardiopulmonary Bypass in Patients with Heparin-induced Thrombocytopenia Type II and Renal Impairment Using Heparin and the Platelet Glycoprotein IIb–IIIa Antagonist Tirofiban. Anesthesiology 2 2001, Vol.94, 245-251. 

Management of anticoagulation in patients with subacute heparin-induced thrombocytopenia scheduled for heart transplantation. BLOOD, 15 NOVEMBER 2008 VOLUME 112, NUMBER 10; 4024-4027.

Screen Shot 2018-12-19 at 8.56.04 PM
From http://www.bloodjournal.org/content/bloodjournal/112/10/4024.full.pdf?sso-checked=true

 

What we did:

  • Prior to giving heparin, we started alprostadil (PGE1) infusion at 1mcg/min and increased the doseage as tolerated to 5mcg/min.  We did offset the hypotension with levophed and vasopressin.
  • We gave our routine dose of heparin.
  • No heparin resistance noted.  Because this would be a long pump run, we opted to give an antifibrinolytic infusion as well as bolus.
  • This patient required higher than normal amounts of pressors and ultimately received methylene blue to help with vasoplegia.
  • We reversed the heparin with protamine and stopped the PGE1 at that time.

Adjuvants to prolong regional anesthesia

For my single shot blocks, I’m always looking for ways to prolong my regional anesthetic effect.  For awhile, Exparel was the most talked about drug to have a 72 hour blockade.  We don’t have this medication available to us at the hospital.  Therefore, it’s time to get creative and hit the literature to see what has worked for prolonging our blocks.

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Prolonging blockade with adjuvants:

 

  • Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia 110 (6): 915–25 (2013).
    • Sensory block duration was prolonged by 150 min [95% confidence interval (CI): 96, 205, P,0.00001] with intrathecal dexmedetomidine. Perineural dexmedetomidine used in brachial plexus (BP) block may prolong the mean duration of sensory block by 284 min (95% CI: 1, 566, P¼0.05), but this difference did not reach statistical significance. Motor block duration and time to first analgesic request were prolonged for both intrathecal and BP block. Dexmedetomidine produced reversible bradycardia in 7% of BP block patients, but no effect on the incidence of hypotension. No patients experienced respiratory depression.
    • Considerable differences existed in the doses of perineural dexmedetomidine; doses varied between 3, 5, 10, or 15 mcg for the intrathecal route, and 30, 100, 0.75, 1 mcg/kg for the peripheral route.

 

 

 

 

 

 

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Other useful links:

 

Easy BBQ Instant Pot Ribs

From time to time, I get a craving for meat. More specifically, Texas BBQ. As much as I’d love to learn the secrets of a pitmaster or master griller/smoker, life and job get in the way of tackling it all.

However, I did find a delicious recipe to curtail that craving that’s tender, juicy, flavorful and brings me back to my Texas roots!


EASY BBQ INSTANT POT RIBS
Original Recipe: please visit their website to send the love!

Make this no fuss 4 ingredients Easy BBQ Instant Pot Ribs in 40 mins! Tender baby back ribs are finger lickin’ good. Perfect weeknight dinners! Perfect weeknight meal, last minute dinners, or cook them for your next BBQ. 😀

Recipe type: Dinner, Lunch, Main Course, Meat, Quick Meals, Super Easy
Cuisine: American
PREP: 1 MIN | COOK: 40 MINS | TOTAL: 41 MINS
SERVING: 2 – 3
RATED 5.0/5 FROM 26 REVIEWS
INGREDIENTS
  • 1 rack baby back ribs
  • Kosher salt
  • Ground black pepper
INSTRUCTIONS
Support us & Pay it forward by sharing this recipe & tips on Facebook & Pinterest, so others can enjoy it too! Thank you 🙂
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  1. Prepare the Baby Back Ribs: Remove the membrane from the back of the ribs with a paper towel.

    Season the Baby Back Ribs: Season the Baby Back Ribs with generous amount of kosher salt and ground black pepper.

  • Pressure Cook the Baby Back Ribs: Place 1 cup of cold running tap water and a trivet into the pressure cooker. Place the baby back ribs on top of the trivet. Close lid and pressure cook at High Pressure for 16 – 25 minutes. Adjust the timing according to your preference: 16 minutes (Tender with a bit of chew) to 25 minutes (Fall off the bone). Turn off the heat and full Natural Release. Open the lid carefully.
  • Preheat Oven: While the baby back ribs is cooking in the pressure cooker, preheat the oven to 450F.
  • Apply Sauce and Finish in the Oven: Brush your favorite BBQ sauce all over the baby back ribs on all sides including the bones. Place the baby back ribs with the baking tray in the oven for 10 – 15 minutes.
  • Serve: Remove the ribs from the oven and serve!

In all honesty, instead of doing steps 4 and 5, my husband fired up the grill and got some great grill flavoring on the ribs while also rebasting them with BBQ sauce. That’s how we served up the ribs! And it was a crowd pleaser!!! This would be perfect for your next summer picnic or Super Bowl party!

From PressureCookRecipes.com

Methylene Blue

Case: 65 yo male with septic endocarditis and septic emboli with + valve vegetations.  Severe MR, mod AI, mod TR, no PFO, EF 60-70%. Mild pericardial effusion. Large bilateral pleural effusions.

 

Vasoplegic syndrome—the role of methylene blue. European Journal of Cardio-Thoracic Surgery, Volume 28, Issue 5, 1 November 2005, Pages 705–710.

OpenAnesthesia: Methylene Blue

Dose:
2 mg/kg bolus –> 0.5 mg/kg/hr x 12 hours
Worked wonderfully for vasoplegia unresponsive to levophed or vasopressin.

Whole30 Instant Pot Chicken Tortilla-Less Soup

Continuing on my cold weather craze of some comforting hot soup, I came across this recipe.  I was looking for something quick and easy to store if I didn’t get a chance to make it during the week.  This is what I stumbled upon and after making it… it doesn’t disappoint!!  The hubs and 10 month old baby loved it!

Here’s the original recipe: 40 Aprons –  Whole30 Instant Pot Chicken Tortilla-Less Soup (Paleo)

whole30-instant-pot-chicken-tortilla-less-soup-low-carb-6-500x500

Whole30 Instant Pot Chicken Tortilla-Less Soup

This Whole30 Instant Pot chicken tortilla less soup is full of flavor and so easy to make! Super quick and filling, this Mexican soup is creamy, spicy, healthy, and low carb.
 Course: Soup
 Cuisine: American, Mexican
 Keyword: instant pot, soup, whole30
 Prep Time: 5 minutes
 Cook Time: 20 minutes
 Time to Pressure: 20 minutes
 Total Time: 45 minutes
 Servings: 4  servings
 Calories: 324 kcal

Ingredients

Soup:

  • 2 boneless skinless chicken breasts (about 1 1/2 pounds)
  • 1 1/2 teaspoon salt
  • 2 10-ounce cans cans tomatoes with green chiles
  • 1 medium onion chopped
  • 2 teaspoons garlic powder
  • 1 teaspoon onion powder
  • 1-3 teaspoons chipotle pepper powder if on Whole30. 1 teaspoon for mild, 3 teaspoons for hot. I used 1 tsp.
  • 1 teaspoon cumin
  • 2 teaspoons chili powder
  • 1 teaspoons dried oregano
  • 1 teaspoon smoked paprika
  • 2 zucchinis chopped or cut into 1/2″ half moons
  • 1 red bell pepper cubed (my addition)
  • 1 14-ounce can can full-fat coconut milk or coconut cream whisked until smooth
  • 1 small can diced green chiles (my addition)

Garnishes:

  • fresh avocado slices
  • red onions , sliced thin
  • fresh cilantro , chopped
  • coconut cream or greek yogurt or sour cream
  • lime juice
  • shredded cheese , if not paleo or on Whole30
  • tortilla strips or chips, if not paleo or on Whole30

Equipment Needed

Instructions

  1. Sprinkle boneless skinless chicken breasts with salt. Add the chicken breasts to the Instant Pot. Sear both sides.  Add the remaining ingredients in order, through zucchini.
  2. Secure the lid on the pot. Cook at high pressure for 18 minutes. Allow the pressure to naturally release for ten minutes, then use the manual release. Pull out the chicken breasts and add coconut milk and diced green chiles. Switch Instant Pot to Sauté mode and stir to combine. Dice chicken, then return to soup. Serve hot, topped with garnishes of choice.

Recipe Notes

If you don’t have an Instant Pot, you can make this Whole30 chicken tortilla-less soup in the slow cooker. Add all ingredients, except coconut milk, in order listed. Cook on low heat for 7 hours or on high heat for 4 hours. Remove chicken breasts and dice. Stir in coconut milk, then return chicken to slow cooker. Serve with garnishes.
If you’re not on a Whole30, use 2 chipotle peppers in adobo sauce and 2 teaspoons adobo sauce in place of the chipotle pepper powder. It’s better than the powder – trust me!