How to Float a PA (Swan-Ganz) Catheter 1) Place an introducer catheter, usually 15 to 20cm, into a central vein, most commonly the RIJ. 2) Flush each port of the catheter and check the balloon integrity by inflating and deflating. Put on the swan cover. 3) With the balloon down, insert the catheter into the introducer to a depth about 2cm distal to the length of the introducer. (This ensures the balloon is outside of the introducer lumen when inflated). Be sure to maintain the natural curve of the PA catheter such that is curves towards the PA. 4) Inflate the balloon and begin to advance, watching the waveform as you go. As I mentioned, think of the balloon as a raft, and the blood flow carrying it to its destination! David Convissar, MD @countbackwardsfrom10 #SwanGanz #Catheter #Float #Pulmonary #Artery #instructions #cardiology

Epinephrine - Anesthesia Pharmacology Trade Name: Epinephrine Brand Name(s): Adrenalin Drug Type: Endogenous Catecholamine Time of Onset: Rapid Duration of Action: 1-2 minutes Mechanism of Action: Stimulates α and ß adrenergic receptors, sympathomimetic Cessation of Action: Metabolized by liver and other tissues via monoamine oxidase and catechol O-methyltransferase Cardiovascular Effects: - Activation of α-1 adrenergic receptors causes vasoconstriction - Activation of ß-1 receptors increases heart rate and contractility - Activation of ß-2 receptors causes relaxation of smooth muscle in the lungs leading to dilation and opening of airways - Marked increase in arrhythmogenicity Uses: Hypotension, Cardiac arrest, Heart failure, Airway edema, Bronchospasm, Anaphylaxis David Convissar, MD @countbackwardsfrom10 #Epinephrine #Adrenalin #Anesthesia #Pharmacology

Ephedrine - Anesthesia Pharmacology Trade Name: Ephedrine Brand Name(s): Akovaz Drug Type: Sympathomimetic Catecholamine Time of Onset: Rapid Duration of Action: 1 hour Mechanism of Action: Direct and indirect sympathomimetic, due to stimulation of a and ß adrenergic receptors along with increased release of norepinephrine at sympathetic nerve endings and inhibiting its reuptake Cessation of Action: Metabolized by liver minimally Cardiovascular Effects: Increases arterial blood pressure and heart contractility Uses: Hypotension David Convissar, MD @countbackwardsfrom10 #Ephedrine #Akovaz #Anesthesia #Pharmacology

Esmolol - Anesthesia Pharmacology Trade Name: Esmolol Brand Name(s): Brevibloc Drug Type: Cardio-Selective ß Antagonist Time of Onset: Rapid Duration of Action: 10-20 minutes after discontinuing Cessation of Action: Metabolized by RBC esterases Cardiovascular Effects: - Cardio-selective ß antagonist, with low doses blocking ß-1 receptors causing a decrease in heart rate, contractility, and of atrioventricular conduction. - Loses selectivity at higher doses, causing ß-2 receptor antagonism, resulting in bronchoconstriction and peripheral vasoconstriction Uses: Supraventricular tachydysrhythmias, Myocardial ischemia, Intraoperative and postoperative hypertension and tachycardia David Convissar, MD @countbackwardsfrom10 #Esmolol #Brevibloc #Anesthesia #Pharmacology

Phenylephrine - Anesthesia Pharmacology Trade Name: Phenylephrine Brand Name(s): Neo-Synephrine Drug Type: α-1 Agonist Time of Onset: Rapid Duration of Action: 5-20 minutes Cessation of Action: Hepatic metabolism Cardiovascular Effects: - Activation of α-1 receptors causes peripheral vasoconstriction and may cause reflex bradycardia - Other: Acts as a nasal decongestant and causes pupillary dilation Uses: Hypotension David Convissar, MD @countbackwardsfrom10 #Phenylephrine #NeoSynephrine #Anesthesia #Pharmacology

Dexmedetomidine - Anesthesia Pharmacology Trade Name: Dexmedetomidine Brand Name(s): Precedex Drug Type: Sedation Time of Onset: 30 minutes Duration of Action: N/A Mechanism of Action: Highly selective agonist of CNS alpha2-receptors Cessation of Action: Rapid hepatic metabolism Systems: - Central Nervous System - hypnotic agent due to stimulation of alpha2-receptors in the ceruleus, reducing its activity; sedative effect achieved by activation of endogenous sleep pathways; decreases CBF without significantly affecting CMRO2 and ICP - Cardiovascular - reduces heart rate and systemic vascular resistance, thus lowering systemic arterial blood pressure - Respiratory - moderately reduces tidal volume and to a lesser extent, respiratory rate David Convissar, MD @countbackwardsfrom10 #Dexmedetomidine #Precedex #Anesthesia #Pharmacology

Ketamine - Anesthesia Pharmacology Trade Name: Ketamine Brand Name(s): Ketalar Drug Type: Induction Time of Onset: Rapid Duration of Action: 5 - 10 minutes Mechanism of Action: Inhibition of the NMDA receptor complex Cessation of Action: Hepatic metabolism and redistribution to inactive tissue sites Systems: - Central Nervous System - Increases CBF and CMRO2 - Cardiovascular - large but transient increases in systemic arterial blood pressure, along with cardiac output and heart rate via inherent catecholamines. Otherwise, direct myocardia depressant. - Respiratory - relaxes bronchial smooth muscles but does not induce significant respiratory depression David Convissar, MD @countbackwardsfrom10 #Ketamine #Anesthesia #Pharmacology #Ketalar

Midazolam - Anesthesia Pharmacology Trade Name: Midazolam Brand Name(s): Versed Drug Type: Sedation Time of Onset: Rapid Duration of Action: 15 - 20 minutes Mechanism of Action: Enhancement of the GABA-A receptor complex Cessation of Action: Hepatic metabolism and redistribution to inactive tissue sites Systems: - Central Nervous System: decreases CBF and CMR02 - Cardiovascular: peripheral vasodilation leading to decrease in arterial blood pressure - Respiratory: minimal depression of ventilation David Convissar, MD @countbackwardsfrom10 #Midazolam #Anesthesia #Pharmacology #Versed

Propofol - Anesthesia Pharmacology Brand Name(s): Diprivan Drug Type: Induction and Maintenance Duration of Action: 3 - 8 minutes Mechanism of Action: Positive modulation of GABA-A receptor complex Cessation of Action: Hepatic and extrahepatic metabolism (lungs), redistribution to poorly perfused compartments Systems: - Central Nervous System: hypnotic with no analgesic properties; reduces CMR02 and the peripheral vasodilation results in decreased CBF - Cardiovascular: arterial and venous dilation reducing preload and afterload, blunts the baroreflex response, resulting in a lack of increased heart rate in response to a drop in blood pressure - Respiratory: reduces minute ventilation by markedly reducing tidal volume and somewhat decreasing respiratory rate; increases collapsibility of upper airway leading to apnea - Other: anti-emetic properties David Convissar, MD @countbackwardsfrom10 #Propofol #Anesthesia #Pharmacology #Diprivan

Prone Chest XRays in the setting of COVID19 Rishi Kumar, MD @rishimd #Proned #ChestXRay #CXR #clinical #radiology #labeled