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Archive for December, 2008

2008-2009 MSSM Influenza Recommendations

Available as a pdf here.

Written by reuben

December 30th, 2008 at 8:47 pm

Posted in ID

Pediatrics Fast Track Schedule

Monday 2-12

Tuesday 2-12

Wednesday 4-12

Thursday 4-12

Friday 2-8

Sat 2-8

Sun 2-10

Written by reuben

December 26th, 2008 at 9:14 pm

Posted in Peds,Schedule

December M&M Tips

Teaching points summary:

* Testing the gag reflex is no longer thought to be an appropriate maneuver for assessing airway reflexes as it is neither sensitive nor specific and can provoke vomiting.

* Patients likely to desaturate quickly after pre-oxygenation include the obese, kids, pregnant women, and any patient with an oxygenation insult (pneumonia, pulmonary edema, asthma/COPD, pneumo/hemothorax, pulmonary contusion, etc).

* Although RSI with conventional laryngoscopy is safe and effective for most intubations, its appropriateness must be explicitly considered in every case. The less urgent the intervention, and the more difficult airway features present (difficult laryngoscopy, difficult bag-valve-mask, difficult cricothyrotomy) the more suitable is an awake technique.

* When in the midst of an intubation, the response to hypoxia is ventilation, not repeat laryngoscopy.

* Bag-valve-mask ventilation should routinely be performed with nasal and oral airways in situ as well as a two hands-down technique.

* If BVM ventilation is ineffective, the response should not be repeat laryngoscopy but rather the optimization of BVM ventilation. The most important interventions to perform are to re-position the patient, insert two nasal airways and an oral airway if not already placed, replace dentures if out, use a larger mask size, and change to a more experienced BVM operator. The use of airway adjuncts that may be blindly and quickly inserted, such as an LMA or combitube, is also appropriate to effect ventilation in an otherwise difficult to bag patient.

* Continuous capnography should be used as a tube confirmation technique when possible. If colorimetric capnography is used, a bright yellow response should be sought after six breaths.

* Have a low threshold to use the gum elastic bougie.

* Think of laryngoscopy as epiglottoscopy, as the purpose is to first control the tongue and then to find and control the epiglottis. Perform bimanual laryngoscopy by using your right hand to manipulate the thyroid cartilage to optimize glottic view.

* Patients being bagged with high FiO2 require surprisingly little ventilation to fully oxygenate. Bag slowly and gently to minimize gastric insufflation.

* For all intubations, consider using the intubation checklist, overflowing with handy reminders and pearls. Use the Sinai EM Updates page and click on “airway.”

Process Results:

* The glidescope handle, previously behind a key, is now in an easily-opened drawer and should be immediately available when needed.

* Airway equipment, including difficult airway adjuncts and implements for performing awake intubation, will soon be organized on a cart so as to provide immediate and reliable access.

* Airway management strategies were reviewed this morning and residents were trained in the two-hands down method of bag-valve-mask ventilation.

Written by reuben

December 24th, 2008 at 11:48 pm

Posted in Airway,Pearls

Influenza 2008 – 2009

The CDC issued interim recommendations for use of antiviral medications for the treatment of influenza during the 2008-2009 influenza season due to a high rate of resistance to oseltamivir (Tamiflu) among circulating influenza A (H1N1) strains.   The information below (and in the attached document) provides updated recommendations for the diagnosis and treatment of influenza at the Mount Sinai Medical Center that have been developed by the Pharmacy, Clinical Microbiology Laboratory, and the Divisions of Infectious Diseases and Pediatric Infectious Diseases.  Additional updates will be provided as needed throughout the course of influenza season.

Thank you.

David P. Calfee, MD, MS

Hospital Epidemiologist and Infection Control Officer


Revised Recommendations for Treatment of Influenza: 2008-2009

Mount Sinai Hospital

On December 19, 2008 the CDC issued interim recommendations for use of antiviral medications for the treatment of influenza during the 2008-2009 influenza season due to a high rate of resistance to oseltamivir (Tamiflu) among circulating influenza A (H1N1) strains.   These oseltamivir-resistant viruses have remained susceptible to other antiviral agents, including zanamivir (Relenza), rimantadine, and amantadine.  Circulating H3N2 influenza A viruses and influenza B viruses have been susceptible to oseltamivir and zanamivir but resistant to rimantadine and amantadine.  In response to this new information, the following recommendations have been developed by the Department of Pharmacy, the Clinical Microbiology Laboratory, and the Divisions of Infectious Diseases and Pediatric Infectious Diseases.

1. Laboratory testing: Confirmatory testing for influenza is strongly recommended, especially during the early part of influenza season.  The DFA test is the preferred rapid diagnostic test and it is available 7 days per week during the dayshift.  Rapid antigen testing is available at all other times but it has lower sensitivity and specificity than the DFA.   Both of these tests are able to distinguish influenza A from influenza B.  The preferred specimen for both testing methods is a nasopharyngeal aspirate or wash. A nasopharyngeal (not nasal) swab is an alternative.  The techniques for collecting these specimens are described below. Culture is also available and should be considered when the rapid tests are negative and the index of suspicion for influenza is high. In addition, you may be contacted to order a viral culture for your patients with a positive rapid test result so that the Department of Health laboratory can determine which subtype(s) of influenza are circulating in the community.  In very young patients and in older adults, testing for respiratory syncytial virus (RSV) should also be included in the initial evaluation.

2. Vaccination:  Vaccination remains the primary approach to influenza prevention and early data indicates that there is a good match between vaccine strains and circulating strains.  Efforts to vaccinate patients and healthcare workers should continue.   Employee Health Service continues to offer the influenza vaccine at no charge to all employees, faculty, and volunteers.  No appointment is necessary.

3. Antiviral therapy for influenza infection:

a. Based on currently available data, two regimens can be considered for use in the empiric treatment of influenza:

i. zanamivir (Relenza)


ii. oseltamivir (Tamiflu) plus rimantadine (or amantadine).

b. If it is subsequently determined that the patient is infected with influenza A, then one of the empiric regimens should be continued for the full treatment course because the results of subtype testing to distinguish H1N1 from H3N2 will not be available in real-time.

c. If it is subsequently determined that the patient is infected with influenza B, treatment with either oseltamivir or zanamivir monotherapy is appropriate.

d. Comments regarding the use of anti-influenza medications:

i. Adult and pediatric dosing recommendations are provided below.

ii. The recommended treatment course is 5 days.

iii. Zanamivir will not be available from the Mount Sinai pharmacy until December 26, 2008.

iv. Rimantadine and zanamivir cannot yet be ordered via TDS.  Please call the Mount Sinai pharmacy to order these medications.

v. Zanamivir is available only as an oral inhalation.  The delivery system is different from common metered-dose inhalers.  Patients and healthcare personnel will need to be pay careful attention to the instructions for proper use of the delivery system.

vi. Zanamivir is not recommended for use in persons with underlying airway disease and should be discontinued in any patient who develops bronchospasm or decline in respiratory function.

4. Chemoprophylaxis:  Infectious Diseases should be consulted if chemoprophylaxis is being considered for persons at high risk who have been exposed to influenza.

Influenza Treatment Dosing Recommendations*

Adult Patients

Creatinine Clearance (mL/min)







100 mg Q12h

100 mg daily

100 mg Q48h

200 mg Qwk

Oseltamivir (Tamiflu®)

75 mg Q12h

75 mg daily

No data


100 mg Q12h

100 mg daily

Zanamivir2 (Relenza®)

10 mg (2 inhalations) Q12h

1Rimantadine dosing should also be adjusted to 100 mg daily for severe hepatic impairment

2Zanamivir doses on day 1 should be administered between 2-12 hrs apart; on day 2-5, give Q12h

Written by phil

December 24th, 2008 at 8:25 pm

Posted in ID

Q Tips

Greetings from the Peer Review Committee:

Here are the some “Q”uality tips from our recent meetings:

  • When you have a STEMI patient, use AMAC to activate the MI team.  The call should be initiated by either an attending or senior resident only.  If you choose to call the cath lab directly, be sure to document the time of notification in the chart.  This will help us ensure that STEMI cases are being identified & treated appropriately .
  • In reviewing sepsis cases, we found several patients that meet EGDT criteria but do not get all the indicated interventions in the pathway; most commonly, patients are appropriately getting central lines but CVP or ScVo2 are not being documented.
  • In patients with hemodynamically significant PE (documented or suspected), consider initial therapy with unfractionated heparin instead low molecular weight heparin – we have unfractionated heparin the department so there is no delay in medication administration; whereas lovenox needs to be sent from pharmacy thus adding significant delay in administration.
  • Be sure to wait for results of any tests that you order; seems obvious but there were several cases where an official urinalysis was ordered & the patient was discharged prior to results being obtained – in both of these cases they were positive & the patient was never treated.
  • If the CT scan that you are ordering is EMERGENT, call CT scan or the radiologist to facilitate the study.  Of course, all of our CTs are emergent but there are some that need to be done much more urgently than others so use your discretion.
  • When ordering lovenox, remember to document the patient’s weight in the notes section.  Pharmacy will not dispense lovenox until they confirm patient weight so this will decrease the turnaround time for getting the medication.
  • And lastly … always, remember to document any progress of the case in the doctors notes section of the chart.  This includes anything from “patient was seen by pmd” to “patient feels better after hydration, will d/c home”, etc.  If it’s not documented on the chart, then it didn’t happen.

Thanks for your attention!

Written by phil

December 11th, 2008 at 7:05 pm

Posted in Pearls

Chest Tube Drain Tutorial

Use this Tutorial to remind yourself how to set up the chest drain (pleur-evac) at Mount Sinai.

Written by reuben

December 4th, 2008 at 5:38 am

Posted in Trauma

Annual OSHA & NYS Infection Control Tests

Compliance with Infection Control training requirements is very important from both the patient safety and regulatory standpoints.  Compliance with these requirements is federally and/or state mandated and subject to review and enforcement by OSHA and accrediting agencies, including JCAHO.

1.  OSHA Bloodborne Pathogen Training:

All employees with the potential for exposure to blood and/or other body fluids (designated “category A” employees) are required to complete this training annually. The attached report indicates the date upon which each employee’s current certificate for OSHA Bloodborne Pathogen Training expires.  Employees with expired certificates are indicated by a comment in the far right column of the table.  Department administrators should notify these employees so that the renewal process can be completed immediately.

OSHA Training opportunities:

The OSHA retraining course lasts approximately one hour and is offered by the Department of Infection Control throughout the year.  The schedule of course dates, times, and locations is available on the Infection Control website (<> >>Medical Services>> Infection Control).  Pre-registration is not required.

Licensed health care professionals also have the option to complete the OSHA retraining course online.  The online course is available on the Infection Control website (<> >>Medical Services>>Infection Control).  In order to receive credit for the online course, the post-test must be successfully completed after review of the slide presentation.  The confirmation certificate generated after successful completion should be printed for the employee’s records.

2. New York State Infection Control Training:

New York State requires that certain healthcare professionals receive training in infection control every four years.  Information regarding an employee’s NYS certification status can be obtained from the appropriate Mount Sinai credentialing office.

For a list of other approved New York State Infection Control course providers, visit  Licensed health professionals can also fulfill the course requirements online at

Written by phil

December 2nd, 2008 at 3:35 pm

Posted in ID,JCAHO