Vitamin K (phytonadione) is an essential, fat-soluble cofactor for γ-carboxylation of clotting factors II, VII, IX, and X, as well as proteins C and S. This post-translational modification allows these proteins to bind calcium and participate in coagulation. In vitamin K deficiency or during warfarin therapy, the liver continues to…
Olanzapine (Zyprexa) and quetiapine (Seroquel) are often discussed as if they are interchangeable sedating antipsychotics used to help with addressing facets of delirium (insomnia, emotional lability, etc.). It often feels like dealer’s choice when deciding which one to use. Here are some of my considerations as an intensivist. Olanzapine is…
Andexanet alfa (Andexxa) will leave the US market on December 22, 2025, after AstraZeneca withdrew its biologics license application for commercial reasons. For a drug that costs as much as a car (~$25-50K per dose) and carries meaningful safety concerns… good riddance! Andexanet entered practice as the only FDA-approved reversal…
Tramadol (Ultram) is often prescribed for analgesia because it’s easy to write for (especially at hospital discharge); however, its pharmacology makes it unreliable for pain control. The parent compound has only weak affinity for the mu opioid receptor, so most of the meaningful opioid effect comes from its active metabolite…
Acetaminophen (Tylenol) is routinely administered in IV and PO (pill) forms in perioperative and critical care medicine, but the debate of which route of administration is superior comes up all the time, despite the evidence being consistent for years. TLDR – once both formulations are absorbed, the analgesic effect is…
Isopropyl alcohol (IPA) aromatherapy by means of inhaling the vapors from an IPA pad has been a simple bedside practice used to relieve nausea. Several studies suggest that IPA inhalation can provide a quick, modest reduction in nausea severity in an inexpensive, safe, and easy-to-administer intervention. However, other trials and…
As a cardiac anesthesiologist and intensivist, vasoplegia following cardiopulmonary bypass is an issue I often face in the OR and ICU. This distributive shock phenotype is characterized by low systemic vascular resistance, despite preserved or elevated cardiac output, primarily driven by dysregulated nitric oxide (NO) and guanylate cyclase signaling, which…
A eutectic mixture refers to a combination of two or more substances that, when mixed in a specific ratio, form a mixture with a lower melting point than any of the individual components alone. As a cardiac anesthesiologist and intensivist, I occasionally use a eutectic mixture of local anesthetics (EMLA)…
Dexmedetomidine (Precedex) is a selective alpha-2 agonist I frequently use as a cardiac anesthesiologist and intensivist to provide analgosedation before extubation. Beyond its sedative and sympatholytic effects, dexmedetomidine has been increasingly implicated in drug-induced fever. Although listed in the FDA label, recent literature provides a clearer picture. A post hoc…
Fondaparinux is a synthetic pentasaccharide that exerts its anticoagulant effect by binding to antithrombin III, inducing a conformational change that selectively inhibits activated factor X (Xa). Unlike unfractionated heparin or low molecular weight heparins, fondaparinux does not inhibit thrombin (factor IIa) and is too small to promote platelet activation, making the risk…