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!