Q: Why it is important to look at CXR for a patient presenting with symptoms consistent with Myasthenia Gravis?


Answer:  To Rule out Lambert-Eaton Myasthenic syndrome.

Lung cancer has strong association with this syndrome.

Q: Which vaptan is contraindicated in liver failure during treatment of hyponatremia? 


 Answer: Conivaptan

Quinton Hemodialysis catheter insertion, use and care

Q: What could be the 4 life threatening side effects of Neupogen (Filgrastim)?


Answer:

1. Neupogen may bring sickle cell crisis after receiving it in patients with sickle cell disorders.

2. Spleen Rupture has been reported after the administration of Neupogen. Patients receiving Neupogen who report left upper abdominal pain should be evaluated for it.

3. ARDs (Acute respiratory distress syndrome) has been reported secondary to an influx of neutrophils to sites of inflammation in the lungs.

4. Alveolar Hemorrhage and Hemoptysis.

Q: What is Libman-Sacks endocarditis?



Answer: Libman-Sacks endocarditis is the most characteristic cardiac manifestation of systemic lupus erythematosus. The condition most commonly involves the mitral valve.

The vegetations are formed from strands of fibrin, neutrophils, lymphocytes, and histiocytes. It rarely produce significant valve dysfunction and rarely embolize.

No specific therapy is required for Libman-Sacks endocarditis. In clinical manifestations, standard treatment is required.

Q: Is Daptomycin dialyzable?


Answer: No

In renal failure patients on CRRT and HD - every 48 hour dosing is recommended.

On Chylothorax

Chylothorax is defined as triglycerides more than 113 mg/dl (1.24 mmol/L) in pleural cavity.

A number of therapeutic interventions have been used to reduce chyle production and promote resolution of a chylothorax. Initial management typically includes restriction or temporary cessation of enteral feedings. Enteral feedings high in medium-chain triglycerides (MCT), or parenteral nutrition may be used. Total parenteral nutrition typically results in resolution in 75 to 80% of cases by that time. In resistant cases, pleurodesis, ligation of the thoracic duct, or placement of drains and pleuroperitoneal shunts may be considered.

Octreotide has become another option for management of patients with chylothorax. Although the exact mechanism by which the drug exerts its effects has not been defined, it is believed that the multiple effects of octreotide on the gastrointestinal tract and the reduction in splanchnic blood flow reduce thoracic duct flow and decrease the triglyceride content of chyle.

Q: Why it is not a good idea to add Sorbitol while administrating Katexalate for Hyperkalemia ?



Answer:  Concern for Bowel Necrosis

In 2010, the FDA has already issued a warning of increased risk for GI Necrosis.

Q: 57 year old male severe diabetes and ESRD, 'coded' in cath lab. Patient is now in ICU after VA-ECMO (inserted by surgeon after cut down). Looking at previous record you found that patient is extremely vasculopath and putting dialysis catheter would be "next to impossible". Nephrology wrote orders to start CVVHD. What would be your option?



Answer: Doing CRRT via ECMO cannulation

If situation arise, CRRT can be performed simultaneouly via same cannulas.

Q: Though lately Etomidate has become unpopular due to its side effect of adrenal insufficiency in ICU patients - but still it has an unique advantage in traumatic brain injury patient?


Answer: Etomidate has an interesting characteristics for patients with traumatic brain injury because simultaneously it decreases intracranial pressure but maintain a normal arterial pressure.

One relatively unknown use of DDAVP (Desmopressin)
Desmopressin (DDAVP) can be use in treatment of sleep apnea. Patients prescribed DDAVP are found to have 4.5 times more likely to sleep without disruption than with placebo. FDA has banned the treatment of sleep apnea with desmopressin, particularly nasal sprays due to reported deaths, hyponatremia and seizures.
Desmopressin tablets are still use for sleep apnea. Side effects are as above along with severe vomiting, diarrhea, fever and flu like symptoms.

Q: What is Gray platelet syndrome? 


Answer: Gray platelet syndrome is a congenital bleeding disorder caused by a reduction or absence of alpha-granules in blood platelets. Not only, it causes thrombocytopenia but also releases of protein normally contained in these granules into the marrow, which in turn causes myelofibrosis. It poses a risk of increase bleed, which can be life threatening. 

Grey Platelet Syndrome is named for the greyish appearance of these platelets when viewed with a microscope.

A note on Factor 7 (rVIIa) and thrombocytopenia

Factor 7 (rVIIa - Novoseven) is now significantly use as off label in uncontrolled bleeding. It may not be efective in the presence of severe thrombocytopenia and should be corrected prior to its administration. Although there are case reports of the successful use of rVIIa in severe thrombocytopenia, a low platelet count is likely to predict a poor or partial response to rVIIa therapy.

Its haemostatic effects are mediated by the thrombin it generates by both tissue factor (TF) dependent and independent mechanisms. The TF independent mechanism requires platelets for the direct activation of Factor X on their surface by rVIIa.

Q: Despite its logistic concerns, prone positioning in severe ARDS still keeps it role. What 3 things have shown to benefits patients in recent literature, when applying prone position in ARDS?


Answer:

1. Prone positioning offers benefits in the most hypoxemic (P/F less than 100-130) ARDS patients.

2. It is beneficial when applied early.

3. It is beneficial if given for long session (more than 12 hrs).

Q: 53 year old female post-operatively developed propofol induced dystonia. What could be a possible treatment beside stopping propofol?

Answer:  prone position!

See following case report and discussion at:

Novel management of propofol induced dystonia in the post anaesthesia care unit - Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists - Feb, 2007 Source Volume: 35 Source Issue: 1 URL link: http://www.biomedsearch.com/article/Novel-management-propofol-induced-dystonia/188796766.html

Q: What is the half life of Precedex (dexmedetomidine), when it is fully on board?


Answer: About 2 - 3 hours!

Q: What is "Whoosh test"? 


Answer: The whoosh test is done by rapidly injecting air down the NasoGastric tube while auscultating over the epigastrium. Gurgling indicates probability of NGT in the stomach, whilst its absence suggests NGT is elsewhere (lung, oesophagus, pharynx etc).

Tandem Heart

Q: Ischemic colitis remained a clinical diagnosis. Despite normal labs or no bloody stools, which one clinical sign should promptly lead to diagnosis of Ischemic colitis?

Answer: "pain out of proportion to physical findings", specifically excruciating abdominal pain despite limited focal tenderness. Labs and other clinical signs may lag behind.

Q: ID service advise you to consider Octreotide for a patient with Aids related diarrhea. What is the dosing?


Answer: 100 to 500 mcg SC tid


Though evidence is weak but Octrotide has been used in AIDS related refractory chronic diarrhea. Octreotide is a candidate drug for the treatment of these patients as it inhibits gastrointestinal motility and increase the transit time.

Q: 58 year old male with Renal failure, but not yet on dialysis, is admitted with ST elevation MI and taken to cath lab for PCI and stent placement. Patient is back in unit and has been written to be started on glycoprotein IIb/IIIa inhibitor. What would be your choice?


Answer: Reopro Eptifibatide gets renal elimination and in such patients Abciximab (Reopro) would be a better choice.

In case Integrilin has to be given, renal dosing should be provided.

Update on platelet inhibition assay (for Plavix monitoring) 

 The VerifyNow P2Y12 assay is used for monitoring platelet inhibition for patients on medications like clopidogrel (plavix). The company has modified the assay so that, from now on, the instrument will only report out in “P2Y12 Reaction Units” or PRU, % inhibition will no longer be reported. 

The normal reference range is 194-418 PRU. Based on a review of the literature, the optimal P2Y12 result for patients on clopidrogrel is approximately 240 – 180 PRU. 

•  above 240 PRU the patient is at increased risk of thrombosis, 
•  below 180 PRU the patient is at increased risk of bleeding.

Q: While working in ICU you over heard on hospital paging system "Code Silver". What does it mean?

Answer: A person with weapon in hospital!

Hospitals may use their own codes but few codes are universally and informally shared by all.

Animation of TIPS

Q: Why steroids remain mainstay of treatment in Neurocysticercosis?


Answer: Albendazole and Praziquantel are both effective in treatment of Neurocysticercosis. They are given under cover of steroids. Steroids are essentially needed as inflammatory reactions to the dying parasite could be life threatening with mental status changes and convulsions.

Also, Albendazole when co administered with a steroid (to treat inflammation) results in increased absorption of albendazole.

Both Albendazole and Praziquantel are recommended to give with fatty meal.

Earplugs in ICU

"The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception."

Read interesting article recently published at ccforum.com

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients: Critical Care 2012, 16:R73

URL: http://ccforum.com/content/16/3/R73

Q: Inverted sleep-wake pattern (i.e sleeping by day and being awake at night), is the hallmark or at least sign of which encephelopathy?



Answer: Hepatic Encephelopathy

Mild to moderate hepatic encephalopathy is characterized by forgetfulness, confusion, irritability, inverted sleep-wake pattern, irritability, tremors etc.

Q: 52 year old male patient has been overdosed in ICU with Ambien (Zolpidem) due to medication error. What intervention may help to diagnose as well as reverse the effect of Ambien?


Answer: Flumazenil

Zolpidem's (ambien) hypnotic effects are similar to those of the benzodiazepine, though molecularly it is distinct from the classical benzodiazepine. But due to similarlity in their hypnotic effects, Flumazenil which is a benzodiazepine receptor antagonist, also reverses zolpidem's sedative/hypnotic effect.

Q: Which drug overdose may present as ST elevation MI?




Answer: Eszopiclone (lunesta)

Lunesta is unique in a sense that its overdose may presents as ST elevation MI with increase Troponin due to coronary vasospasm. It may lead to V. Fib. as well as cardiac arrest.



Lunesta overdose: ST-elevation coronary vasospasm, troponemia, and ventricular fibrillation arrest.- Am J Emerg Med. 2006 Oct;24(6):741-6.

Q: Which ACE Inhibitor is well known to cause taste disturbances?


Answer: Captopril

Taste disturbance, infrequent with most ACE inhibitors, is more prevalent in captopril and is attributed to its sulfhydryl moiety. Though captopril is not in much use in USA, it is still very much in use in developing countries due to its cost effectiveness.

Q: In Ascites, if patient requires both spironolactone and furosemide - what combination minimize the danger of hypokalemia?


Answer: Generally, patients with ascites respond well to spironolactone. For nonresponders, a loop diuretic may also be added.

The ratio of 100 mg : 40 mg reduces risks of hypokalemia.

Q: 23 year old male is admitted to ICU after severe Abdominal pain. CT scan reports foreign body obstruction. GI service performed upper and lower GI scope and advised surgical consult. Their diagnosis was Rapunzel syndrome?


Answer: The Rapunzel syndrome is a rare intestinal condition resulting from condition called trichophagia (eating hair).

Trichophagia is a severe form of condition called Trichotillomania (also known as "trichotillosis"). It is the compulsive urge to pull out one's own hair leading to noticeable hair loss. In trichophagia, people with trichotillomania may also ingest the hair that they pull; which can lead to a hair ball formation in GI tract called trichobezoar, and may cause GI obstruction.

Rapunzel syndrome, is an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed. Because the human gastrointestinal tract is unable to digest human hair, the trichobezoar may require surgical treatment.

The syndrome is named after the long-haired girl Rapunzel in the fairy tale.

Neurology


Q: What is Ribot's law of retrograde amnesia?



Answer: Ribot's Law of retrograde amnesia states that there is a time gradient in retrograde amnesia, so that recent memories are more likely to be lost than the more remote memories.

Some examples are, in which bilingual patients recovered different languages with differential progress. In some cases, aphasics recover or preferentially improve only the first-acquired language.

Please note, in Neurology, Ribot’s Law is not universally accepted.

Q: What are the 3 major causes of false or factitious or pseudo hyponatremia?


Answer:

1. Severe hypertriglyceridemia,
2. Massive elevation of immunoglobulins as in multiple myeloma,
3. Severe hyperglycemia.

Q: Kernig's sign and Brudzinski's sign are well known in Meningitits. What is Jolt test or "jolt accentuation maneuver" to rule out meningitis?

Answer: The "jolt accentuation maneuver" helps to rule out meningitis in patients with fever and headache. The patient is told to rapidly rotate head horizontally; if this does not make the headache worse, meningitis is unlikely.

Q: Is Verapmil an anti- malarial drug?

Answer: Sort of !!

Verapamil has shown potential use in the treatment of malaria as an adjuvant treament with chloroquine particularly in resistance. Resistance to chloroquine is caused by the parasite cell's ability to expel the drug outside of its digestive vacuole. Verapamil, when used in combination with chloroquine, enhances the accumulation of chloroquine within a parasitic cell's digestive vacuole, rendering it incapable of detoxifying itself and making it more susceptible to death.

Recent resistance to the anti-malarial drug chloroquine has hindered the treatment of malaria in Southeast Asia, South America and Africa. Adjuvant use of verapamil may be useful in such circumstances.


Martin, S.; Oduola, A.; Milhous, W. (1987). "Reversal of chloroquine resistance in Plasmodium falciparum by verapamil". Science 235 (4791): 899–901

Q: 74 year old with previous history of CHF developed atrial fibrillation with RVR (rapid ventricular rate) pre-operatively which was controlled with IV cardizem drip. Cardizem was continued. Patient developed signs and symptoms of Malignant Hyperthermia during surgery. IV dantrolene was administerated. Patient became hypotensive, developed V.Tach., collapsed and died?



Answer: Calcium channel blockers such as diltiazem (Cardizem) or verapamil may cause severe hemodynamic problems if concomittently administerated with Dantrolene. It may lead to severe cardiovascular collapse, arrhythmias, myocardial depressions, and hyperkalemia.

Q: 24 year old hiker is brought to ER after snakebite. Patient is reporting severe symptom of mint taste in his mouth. which snake is a likely culprit?


Answer: Rattlesnake

Victims complain of a "rubbery," "minty," or "metallic" taste if bitten by certain species of rattlesnake, after 30 to 90 minutes of attack.


Clinical significance: Rattlesnake bites can be poisonous and need rapid treatment i.e. administration of antivenin.

Q: What is Prothrombin complex concentrates (PCC)?


Answer: Prothrombin complex concentrates (PCC) are derived from human plasma and contain the vitamin K dependent coagulation factors II, VII, IX, and X at varying concentrations. Several international guidelines as well as American College of Chest Physicians, now recommends PCC for warfarin reversal in patients with serious bleeding. The use of PCC in the United States (US) is still not widespread.


Prothrombin Complex Concentrate Versus Standard Therapies for INR Reversal in Trauma Patients Receiving Warfarin - Ann Pharmacother July/August 2011 vol. 45 no. 7/8 869-875

Q: Thyrotoxic patients with atrial fibrillation

A) require a lower maintenance dose of warfarin than euthyroid patients

or

B) require a higher maintenance dose of warfarin than euthyroid patients

(Select one)

Answer: A Thyrotoxic patients may require a lower maintenance dose of warfarin than euthyroid patients in atrial fibrillation because of increased clearance of vitamin K–dependent clotting factors.



Fadel BM, Ellahham S, Ringel MD, et al. Hyperthyroid heart disease. Clin Cardiol 2000;23: 402–8.

Q: Cipro associated seizure can occur with

A) thyrotoxicosis
B) high doses of the drug, old age,
C) renal insufficiency,
D) drug interactions
E) electrolyte abnormalities,
F) history of seizure
G) Allof the above



Answer: All of the above

Objective of this question is to enhance the relatively less known risk factor of seizure associated with ciropfloxacin intake i.e, thyrotoxicosis. Unrelated to it, cipro itself can cause unexplained hypothyroidism.

Q: 44 year old male with history of seizure is admitted with breakthrough seizure and has been loaded with phenytoin. His regular dose has been increased. Since morning patient is complaining of vision problem. On examination he has opthalmoplegia. What is your concern?


Answer: Phenytoin overdose

One of the side effect of Phenytoin intoxication is ophthalmoparesis, also know as opthalmoplegia. This opthalmoplegia may take weeks to resolve.

Q: What is the pitfall of PO amiodarone (oral)?


Answer: When given orally, the bioavailability of amiodarone is very variable. Absorption ranges from 22 to 95%.

Amiodarone may better absorp when it is given with food.

Amiodarone induced optic neuritis!

Amiodarone is one of the most commonly used medicine in ICU. In past, we have done many pearls related to IV amiodarone.One of the other unusual and common presentation of Amiodarone toxicity is optic neuritis. Optic neuritis may occur at any time following initiation of therapy. If any symptoms of visual impairment appear, like change in visual acuity or decrease in peripheral vision, prompt ophthalmic consult is recommended.

Picture diagnosis

Q: 76 year old male is seen in ER with this x-ray after fall to rule out cranial fracture. Is this an artifact or real? 

Answer: It is deep brain stimulator surgically inplanted

Q: 76 year old male is admitted in ICU for Bradycardia secondary to beta-blocker prescribed for his essential tremor. You received nursing call at night that patient is now requesting alcohol to abort his symptoms of essential tremor as it is always helpful to him?


Answer: It is true that Alcohol decrease the synptoms of essential tremor. The mechanism of tremor reduction by alcohol is unknown.

The recommeded treatment is propranolol. And if propranolol is contraindicated, primidone is an alternative choice. Other drugs which have shown effects include Gabapentin, Clonazepam or Topiramate.

Surgical treatment is reserved for the severe cases include thalamotomy and deep brain stimulation.

Q: What is Dopamine dysregulation syndrome? 

 Answer: It is an interesting syndrome, may seen on people on long term Dopamine replacement therapy (DRT) like Levadopa in Parkinson's Disease. It is characterized by addiction to DRT medication (taking extra doses), gambling, hypersexuality, shopping, eating disorder, euphoria, psychosis etc. marked by periods in between of dysphoria, sadness, psychomotor slowing, fatigue, apathy etc., reulting from DRT withdrawal. One interesting symptom during euphoria phase is punding, repetition of complex motor behaviors such as collecting or arranging objects. 

Management is drug dose stratification.

Q: 22 year old male in ICU is admitted for unrelated reason, continue to show prolonged PTT but normal PT, Bleeding Time and Platelet count. Which disease process only prolonges PTT but all other normal basic coagulation profile?


Answer: Factor X11 deficiency

Factor X11 deficiency is also known as Hageman factor deficiency. It is very rare with evidence of about 1 in 1 million. Fortunately its a benign process, does not cause bleeding and normally do not need treatment. Even with major surgery, bleeding manifestations are extremely rare. Usually, it is diagnosed accidently by a prolonged activated partial thromboplastin time (aPTT) test.

PICC line insertion

PICC line under ultrasound

(2 parts)

Truvada

Truvada (Tenofovir/emtricitabine), is a fixed-dose combination of two antiretroviral drugs, consisting of 300 milligrams of tenofovir and 200 milligrams of emtricitabine. The drug has been just approved for use as a pre-exposure prophylaxis against HIV infection. It significantly decreased the risk of contracting HIV. It is approved for non-infected men who have sex with multiple male partners.

Side effects include nausea, vomiting, dizziness and renal toxicity. Also, Lactic acidosis, steatosis and post treatment exacerbation of Hepatitis B.

Q: What level of d-dimer along with clinical signs is predictive of Acute Aortic dissection?


Answer: In acute aortic dissection, usually level more than 500ng/ml is significant. In most cases, in acute aortic dissection this level is reported to be more than 2000ng/ml. D-dimer levels is useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

CXR clue for PE

CXR clue for PE

Note the uneven distribution of pulmonary blood flow between the two lungs with open vessels on Right. This patient had massive pulmonary embolism obstructing the left main pulmonary artery.

Q: 52 year old male presented to ER with massive PE. Diagnosis is confirmed with CT Angio and bedside Echo showed RV strain. You decided to use Thrombolytics. Pharmacy informed you that none of the FDA approved thrombolytics are available (Alteplase, Urokinase and Streptokinase). Only available thrombolytic is Reteplase? 


Answer: Although Reteplase has not been approved by the FDA for PE (only approved for AMI), but it is widely used off label for life threatening PE. The dosing used is the same as for patients with AMI: 2 IV boluses of 10 U each, administered 30 minutes apart. No adjustment is required for patient's weight. 

Actually, Reteplase work more rapidly and tends to have less bleeding risk than alteplase.

6 "Ps" of compartment syndrome

• Pain out of proportion,
• Paresthesia,
• Pallor,
• Paralysis,
• Pulselessness (+/-),
• Poikilothermia (failure to thermoregulate)

Neuroleptic Malignant Syndrome (NMS)

Mnemonic used to remember the features of NMS is FEVER.

• F – Fever
• E – Encephalopathy
• V – Vitals unstable
• E – Elevated enzymes – CPK
• R – Rigidity of muscles

Q: 52 year old male in ICU is under treatment for MRSA pneumonia with Zyvox (Linezolid). Patient was taken for "I n D" (incision and drainage) by surgery. Post-op patient has symptoms of shivering. Resident wrote order for Demerol. Pharmacy called you to confirm the order. What would be their concern? 



Answer: serotonin syndrome 

 Meperidine (Demerol) with linezolid (Zyvox) may cause serotonin syndrome with symptoms of confusion, hallucination, tachycardia, fever, sweating, muscle spasm etc.

Q: How much pleural fluid drainage is the indicator of successful Pleurodesis? 


Answer: less than 100-150 cc/24 hours

Q: Which artery is called "mother of all end arteries"?


Answer: Brachial artery

Due to its designation of sole supplier around elbow for downward areas, Brachial artery is called "mother of all end arteries". Before advent of ultrasound, arterial line insertion was highly discouraged in brachial artery, due to possible hematoma and nerve injury.

Still Radial and femoral artery are preferable over brachial artery for A-line insertion.

Lung Isolation

A note on Allen's test and Cardiac bypass surgery (CABG)


The radial artery is occasionally used as a conduit for bypass surgery, and its patency lasts longer in comparison to the saphenous veins. Prior to heart bypass surgery, Allen's test is performed to assess the suitability of the radial artery to be used as a conduit. A result of less than 3 seconds is considered as good and suitable. A result of between 3-5 seconds is equivocal, whereas the radial artery will not be considered for grafting if the result is longer than 6 seconds. A negative Allen’s test is safe to harvest the radial artery.


Is the Allen test reliable enough? - Eur J Cardiothorac Surg (2007) 32 (6): 902-905.

Q: What is "wedged blood PO2" and what is the clinical implication?

Answer: "Wedged blood Po2" is the level of PO2 while Pulmonary artery catheter baloon is inflated (wedging).

Wedge blood Po2 should be atleast 20 mm Hg higher than arterial PO2 (ABG) to confirm that you are measuring Pulmonary artery occlusion pressure at right level/spot.

Reference:
Paul L. Marino - The little ICU book of facts and Formulas, 2009 - Page 119

Q: What very essential piece of caution, seems missing most of the time, in femoral arterial line cannulation?

Answer: The femoral artery should always be accessed approximately 1 inch below the inguinal ligament, where it can be easily compressed. Unfortunately, many femoral arterial lines are placed/entered very high - near the inguinal ligament. In case of supra-inguinal bleed/injury, it becomes hard to control the bleeding by compression.

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Q: Nurse call you to evaluate the tongue of patient who is admitted with diagnosis of urosepsis?

Answer: Geographic Tongue!

Geographic tongue, also known as benign migratory glossitis, is an inflammatory condition of the tongue. It is characterized by discolored regions of taste buds. The condition usually manifests after eating exacerbating foods, or during times of stress, illness, or in women during menstruation. It is benign, appears and disappears frequently. It may cause some discomfort but no pain.

Q: What is the right time to check Anti-factor Xa levels in a renally impaired patients who is on q24 dosing?


Answer: Anti-Xa levels should be checked at their peak at 4 hours in all patients irrespective of dosing variations (both q12 and q24).

On Belviq (lorcaserin)

Belviq is a new anti obesity pill approved by FDA and expected to have a huge demand.

The drug works by activating brain receptors for serotonin, a neurotransmitter that triggers sense of satiety and satisfaction. Makers of Belviq (Arena) claims that drug is designed to seek out only the serotonin receptors that affect appetite - But - central side effects are expected including headache, dizziness, fatigue, nausea, dry mouth and constipation. Diabetic patients may get encounter with hypoglycemia.

It would be interesting to watch from Intensive Care Medicine perspective any incident of Serotonin Syndrome. Also, cardiac valvular defect remains a concern as happened with fenfluramine in past. FDA has asked Arena to conduct studies once the drug reaches the market to determine whether it causes heart attacks or stroke in people who take it.

Something to be aware about Pradaxa (Dabigatran) 

 According to FDA guidelines, Dabigatran potency get highly effected by enviromental humidity. Dabigatran is available both in bottles and in blister packs. Once a bottle of dabigatran is opened, the medication expires after four months. In commercially supplied Dabigatran the bottle-cap contains a humectant to reduce the humidity and prevent degradation of the medicine. Similarly, once the blister pack is open, drug degenrates in about 4 months.

A note on Phenytoin (Dilantin) stability

Phenytoin is very unstable when diluted even in normal saline. Precipitation may occur which is not visible. It is recommended to administer solutions immediately upon preparation.

Q: What is the dose of Methylene blue in treatment of Methemoglobinemia? 


Answer: Methylene blue 1% solution (10 mg/ml) 1 to 2 mg/kg given intravenously slowly over five minutes followed by IV flush with normal saline. 

 In any case supplemental Oxygen should be administrated. 

 Methylene blue restores the iron in hemoglobin to its normal (reduced) oxygen-carrying state.

Q: What is the formula to convert S/F ratio to P/F ratio? 

 - PaO2/FiO2 and SpO2/FiO2 ratio 


Answer: S/F = 64 + 0.84*(P/F) 

 An S/F value of 235 corresponded with P/F ratio of 200 while S/F value of 315 corresponded with P/F ratio of 300. Study shows that validation database from 2031 measurements produced a linear relationship.

Ultrasound Guidance for Thoracentesis

Parker Nasal Intubation

 

Q: 34 year old male patient had LP (lumbar punture) 4 days ago but continue to complaint of severe headache. Analgesics are not working. What would be other simple recommendation?



Answer: Caffeine - 300-500 mg q4-6h


In severe cases Caffeine sodium benzoate (500 mg) in 1 liter of fluid (D5LR) can be given intravenously over one and a half hour. The patients usually have complete resolution of symptoms and no recurrence of headache.

Caffeine sodium benzoate is a simple treatment of post-lumbar-puncture headaches. It should be considered as a safe alternative to an epidural blood patch for the treatment of post-lumbar-puncture headaches.


A simple treatment of post-lumbar-puncture headache. - J Emerg Med. 1989 Jan-Feb;7(1):29-31.

Sympathetic Storming
Sympathetic storming after traumatic brain injury remains one of the most dramatic clinical scene particularly in neurological units. It occurs due to uncontrolled sympathetic surge with a diminish or unmatch parasympathetic response. Acording to Baguley criteria 5 out of the 7 clinical features should be present - tachycardia, tachypnea, hyperthermia, hypertension, dystonia, posturing, and diaphoresis. Various agents have been used for treatment (see review article below) but haloperidol may worsen the symptoms.

Dr. Blackman and coll. coined the term "PAID" - paroxysmal autonomic instability with dystonia- in Archives of Neurology March 2004.
References: click to get abstract/article

1. Dysautonomia after traumatic brain injury: a forgotten syndrome? - J Neurol Neurosurg Psychiatry 1999;67:39-43 ( July )
2. Paroxysmal autonomic instability with dystonia (PAID) - Arch Neurol. October 2004;61:1625.
3. Paroxysmal Autonomic Instability with Dystonia After Brain Injury - Arch. Neurol. March 2004;61:321-328
4. Riding Out the Storm: Sympathetic Storming After Traumatic Brain Injury - Denise M. Lemke, MSN CS-RN ANP CNRN - J Neurosci Nurs 36(1):4-9, 2004.

A note on Factor 7 (rVIIa) and thrombocytopenia

Factor 7 (rVIIa - Novoseven) is now significantly use as off label in uncontrolled bleeding. It may not be efective in the presence of severe thrombocytopenia and should be corrected prior to its administration.

Although there are case reports of the successful use of rVIIa in severe thrombocytopenia, a low platelet count is likely to predict a poor or partial response to rVIIa therapy. Its haemostatic effects are mediated by the thrombin it generates by both tissue factor (TF) dependent and independent mechanisms. The TF independent mechanism requires platelets for the direct activation of Factor X on their surface by rVIIa.

Red urine during transfusion.
Q; You have been called to evaluate a patient who developed red-urine. At bedside, you noticed pRBC transufion in progress. What would be your first few immediate responses?


A; The first thing you need to determine is whether it is a transfusion reaction (hemolysis) or a pure hematuria. Send Urine or blood for centrifuge.

The onset of red urine during or shortly after a blood transfusion may represent hemoglobinuria from acute hemolytic reaction. To distinguish it from hematuria, if freshly collected urine is centrifuged, the urine sample remains clear red. If its pure hematuria, red blood cells settle at the bottom of the tube, leaving a clear yellow urine supernatant. Similarly patient's blood with centrifuge will turn free serum as a pink color from free hemoglobin in a clotted centrifuged specimen otherwise serum will be yellow if no transfusion reaction.

Other steps to take.

1. Halt the transfusion.

2. Send donor blood and patient's blood quickly to blood bank to make sure that right blood was transfused (repeat crossmatch and type) and for antibody screen, and direct and indirect Coombs tests.

If transfusion reaction is highly suspected:

3. Administer IV Benadryl, IV steroid, IV saline followed with IV lasix or with low dose dopamine to improve renal blood flow. Symptomatic treatment with acetaminophen.

4. Airway protection and if seems to be anaphylactic reaction, administer epinephrine (nebulizer treatment, SQ or IV drip depending on severity). Oxygen to keep saturation up.

5. Send complete lab workup including lytes, renal function (BUN/Cr), serum bilirubin level (peaks in 3-6 hours), Haptoglobin (binds to hemoglobin) , urine for hemoglobinuria, a repeat CBC (fails to show the rise in hematocrit because of intravascular or extravascular hemolysis) and DIC panel.

6. Hematology consult.
Management is largely supportive.

Q: 32 year old otherwise healthy male with 2 weeks history of sinusitis presented with siezure. ER physician called you while he sent patient to CT scan. What would be your primary concern and line of action? 


 Answer: Neurological symptoms after prolong bout of sinusitis is highly suggestive of Subdural empyema.

 Subdural empyema is a neurosurgical emergency and beside instituting antibiotics and anti-seizure meds, it would be appropriate to ask neurosurgical service to review CT scan while patient is in neuroradiology department. It has a tendency to spread rapidly through the subdural space.

Q: What could be the supporting finding on lab in (Transfusion-related acute lung injury (TRALI)? 

 Answer: Laboratory findings may include unexpected haemoconcentration and a sudden fall in serum albumin.

Q: Name an epileptic drug which can be given rectally if required?


 Answer: Depakote (valproic acid) Dilute syrup 1:1 with water for use as a retention enema; loading dose: 17-20 mg/kg one time; maintenance: 10-15 mg/kg/dose every 8 hours

Q: Which of the following medicines can cause "Red Man Syndrome"? 

 A) Ciprofloxacin, 
 B) Amphotericin B, 
 C) Rifampcin 
 D) Vancomycin 
 E) All of the above 

 Answer: All of the above Antibiotics such as ciprofloxacin, amphotericin B and rifampcin can also potentially cause red man syndrome beside vancomycin. Like vancomycin, they are capable of causing direct degranulation of mast cells and basophils. Red man syndrome is amplified if these antibiotics are combined with vancomycin or with each other. Red man syndrome is also magnified in patients receiving vancomycin and opioid analgesics, muscle relaxants, or contrast dye because these drugs can also stimulate histamine release.

Ice test - Poor man's test for Myasthenia Gravia 

 Most of the Myasthenia patients along with other symptoms of weakness usually exhibits ptosis. While at bedside place an ice cube over eye lids for 2 minutes. Cooling improves neuromuscular transmission. Resolution of ptosis with cooling is a positive test for Myasthenia Gravis and reported upto 80% reliable to diagnose ocular myasthenia.

Q: What is the best way to follow on Amiodarone overdose? 

 Answer: Follow serial QT duration 

 Surprisingly, Overdose with amiodarone is usually benign as it is very poorly and variably absorbed. But all such patients should be admitted to ICU/CCU for close observation and serial EKGs. On EKG, Amiodarone leads to a prolonged QT interval due to its blocking of repolarising of. potassium channel. The QT duration is the best indicator of the extent of potassium channel blockade.

Q: 42 year male with no previous history known is brought to ER with mental status change, fever and nuchal rigidity. CT scan is not much of information. ER doc performed lumbar punture and transferred patient to ICU. You get STAT call from lab that there is a spiderweb clot in the collected CSF. What does it mean?


Answer: A spiderweb clot in the collected CSF is characteristic of TB meningitis though not always present. 

The CSF usually has a high protein, low glucose and a increase lymphocytes. Acid-fast bacilli commonly grown in culture but the culture of TB from CSF takes about two weeks, and therefore the majority of patients with TB meningitis are started on treatment before the diagnosis is confirmed.

Q: 47 year old male in ICU went into supraventricular tachycardia (SVT) and successfully converted to NSR with total of 18 mg of Adenosine. On strip total Asystole time was 8 seconds. Now patient is complaing of numbness in upper extremities. What should be your next step?

Answer: Observation

Adenosine may make patients' limbs feel numb for few minutes after administration intravenously. Usually it happens when patient requires more than 12 mg of Adenosine. It usually resolves without any complication.

A note on balloon inflation volume of Pulmonary Artery catheter in patients with Pulmonary Hypertension

Pulmonary artery occlusion pressure (PAOP) - commonly know as wedge - is used to differentiate patients having pulmonary hypertension (PH) due to left-sided heart disease from other etiologies. 

One interesting study published in 2010 (see reference), investigated the PAOP measurements obtained from both pulmonary arteries with balloon full (1.5 mL) and half (0.75 mL) inflation in patients with suspected PH.

Study showed that PAOP can be falsely elevated in patients with PH according to the balloon inflation volume. Balloon half inflation was safe and correlated with higher precision and lower bias in the PAOP measurements.

Effect of Balloon Inflation Volume on Pulmonary Artery Occlusion Pressure in Patients With and Without Pulmonary Hypertension - CHEST January 2011 vol. 139 no. 1 115-121