Reversal of INR - Guidelines

The American College of Chest Physicians (ACCP) updated their recommendations on the use of vitamin K in June of 2008.

• Oral vitamin K is preferred to subcutaneous (SC) for patients with elevated INRs in the absence of major bleeding. 

• INR ≥5.0 and <9.0 – may give oral vitamin K 1 to 2.5 mg if the patient is at an increased risk for bleeding; up to 5 mg oral vitamin K may be given if more rapid reversal is required. Additional doses may be required.

• INR ≥9.0 – give vitamin K 2.5 to 5 mg orally; additional doses may be required.

• If the patient is experiencing serious or life-threatening bleeding, intravenous vitamin K 10 mg along with blood products should be administered.

Q; Why "Bridging of warfarinization" is recommended?

Answer: 

For the first 48 to 72 hours of initiation of warfarin, the levels of protein C and protein S, usually known as proteins of anticoagulation, drop faster than pro-coagulation proteins such as factor II, VII, IX and X. Henceforth, bridging anticoagulant therapies (such as heparin) are recommended to be used during this temporary hypercoagulable state.

Q; What are the guidelines on new oral anticoagulants (NOACs) on holding before surgical procedures?

Answer: 

Warfarin remained the lone oral anti-coagulant for almost 40 years. The new anticoagulants (NOACs) are: 

1. Dabigatran - a direct thrombin inhibitor 

2. Rivaroxaban - a direct factor Xa inhibitor 

3. Apixaban - a direct factor Xa inhibitor 

They have relatively short half life and dissipate rapidly within 12-24 hours after a dose. 

In patients with normal renal function, the NOACs should be held for ≥24 hours before an elective surgical procedure associated with a minor bleeding risk, and for ≥48 hours before surgical procedures associated with a major bleeding risk.

ICU Sonography

Very informative website with detailed 14 tutorials on use of sonography in ICU, including heart, lung, vascular, abdomen and other generally encountered scenarios.

The site is an outstanding work from Dr. Kishore Pichamuthu at the Division of Critical Care at the Christian Medical College Hospital, Vellore, India.

http://www.criticalecho.com/

Q: 42 year male who developed acute Transverse Myelitis - failed treatment options with high dose steroids and plasma exchange . What could be your third salvage option?

Answer: Intravenous cyclophosphamide

If there is continued progression despite high dose IV steroid  and Plasma Exchange therapy, pulse dose of intravenous cyclophosphamide (800–1000 mg/m2) can be given with consultation of neurology and oncology services.

Q: 52 year old male with end stage liver disease - presented with shortness of breath. Patient is found to have massive right sided hydrothorax. Which one procedure should be avoided?

Answer: Inserting chest tube

Chest tube should almost never be inserted in hydrothorax unless there is an evidence of pyothorax or pneumothorax. 

Treatment option to be considered in clinically significant hydrothorax is TIPS (though it may transiently worsened hepatic encephalopathy). The ultimate treatment is a liver transplant. 

Q: What are the 2 ways of diagnosing Chylous Ascites?


Answer:  

Chylous ascites is diagnosed when the ascites triglyceride level is greater than 110 mg/dL. Other way is to have elevated ascites:plasma triglyceride ratio (somewhere between 2:1 and 8:1).

Also, color of ascites usually is white or milky.

Chylous Ascites may occur due to various reasons like abdominal surgery, blunt abdominal trauma, malignant neoplasms, spontaneous bacterial peritonitis, occasionally in cirrhosis, pelvic irradiation, peritoneal dialysis, abdominal tuberculosis and carcinoid syndrome.

Q: In DKA (Diabetic ketoacidosis), how much is the usual water deficit? - Rule of thumb to remember

Answer: About 6 Liters

The average adult DKA patient has a total body water deficit of about 6 liters or to be precise, about 100 mL/kg.

Q: Give at least 3 reasons of pseudo-hyponatremia?

Answer:

• Severe Hypertriglyceridemia
• Extreme elevation of immunoglobulins as in multiple myeloma, and
• Severe hyperglycemia

Q: Give at least 7 reasons of pseudo-hyperkalemia?

Answer:

1. Excessive vacuum of the blood draw (hemolysis)
2. A collection needle that is of too fine a gauge (hemolysis)
3. Excessive tourniquet time or fist clenching during phelobotomy, which leads to efflux of potassium from the muscle cells.
4. A delay in the processing of the blood specimen.
5. Thrombocytosis (Platelet count >500,000/mm³), 
6. Leucocytosis  (WBC count > 70 000/mm³), 
7. Erythrocytosis (hematocrit > 55%). 

Q: If patient requires long term Intra Aortic Balloon Pulsation (IABP), which vessel is desirable to use?


Answer:

In patients with severe peripheral vascular disease or where femoral approach is not desirable like in patients awaiting heart transplantation - Left axillary artery approach is a great alternative preferably with Dacron graft interposition. Use of TEE should be utilize during insertion for proper catheter placement.

Intra-aortic Balloon Pump Aortic Pressure Curve

If video below does not work, click at link below

http://youtu.be/naEaPo7PPJE

Q: What is the occurance of PFO (Patent foramen Ovale) in general population, and what is it clinical significance

?

Answer:  

In general population, PFO is present in 10–20% of adults but usually remain asymptomatic. With advancement of clinical care, and availability of ventilators - these PFOs may become symptomatic under positive pressure as 'shunt' with refractory hypoxia.

Any patient under positive pressure ventilation, whose hypoxia remain unexplained or whose hypoxia get worse with increase in PEEP - should be evaluated for PFO.

Reference:

Patent Foramen Ovale and Mechanical Ventilation - Rev Esp Cardiol. 2010;63:877-8 - Vol. 63 Num.07 (http://www.revespcardiol.org/en/patent-foramen-ovale-and-mechanical/articulo/13154121/)

Q: What are anatomic Pulmonary and Cardiac shunting?


Answer:  

Pulmonary anatomical shunting: The bronchial circulation provides oxygenation to the lung and is not oxygenated before it returns to the left heart. 

Cardiac anatomical shunting: Some of the blood which flows through some small cardiac veins empty back into the left heart directly without oxygenation.

Capnography in CPR

Capnography, which indirectly measures cardiac output, is a great tool during "codes" to measure effectiveness of CPR and also can be as an early indication of return of spontaneous circulation (ROSC). When a patient experiences return of spontaneous circulation, the first indication cn be a sudden rise in the ETCO2. Similarly, a sudden drop in ETCO2 may indicate the patient has 'lost pulse' and CPR may need to be restarted.

Q: Name at least 4 conditions where "Asterixis" can be a clinical sign?

Answer: Asterixis

is a tremor of the hand when the wrist is extended. It can be a clinical sign of

• Hepatic encephelopathy
• Uremia
• Severe Hypercarbia, and
• Wilson's disease

Q: Technically, when Renal Failure is called "End Stage Renal Failure or ESRD?

Answer: When patient requires renal replacement therapy (RRT) for more than 3 months.

Glasgow criteria For acute pancreatitis

Glasgow criteria For acute pancreatitis can be remembered as mnemonic PANCREAS:

• P02 Oxygen < 60mmHg
• Age > 55
• (Neutrophilia) White blood cells > 15
• Calcium < 2 mmol/L
• Renal Urea > 16 mmol/L
• Enzymes Lactate dehydrogenase (LDH) > 600iu/L Aspartate transaminase (AST) > 200iu/L
• Albumin < 32g/L
• Sugar Glucose > 10 mmol/L

Octreotide for the Management of Chylothorax

Several case reports have shown that octreotide is safe and effective for the management of chylothorax due to various reasons. The property of Octreotide (somatostatin) to induce leak closure is due its decelerating effect on lymph flow, although exact mechanism of action is not well defined.

Treatment usually lasts for 1-2 weeks (mean 11 days). Octreotide may be given subcutaneously at 20 to 70 mcg/kg/day, divided as three doses, or as an IV infusion starting at a dose of 1 to 4 mcg/kg/hr and titrating as needed up to 10 mcg/kg/hr. Infusion can be weaned by the reduction in the volume of pleural drainage.


References:

1. Dalokay Kilic, MD, Octreotide for Treating Chylothorax after Cardiac Surgery - Tex Heart Inst J. 2005; 32(3): 437–439.

2. Kalomenidis I., Octreotide and chylothorax. - Curr Opin Pulm Med. 2006 Jul;12(4):264-7.

3. Cheung Y, Leung MP, Yip M. Octreotide for treatment of postoperative chylothorax. J Pediatr 2001;139:157-9.

4.Rosti L, Bini RM, Chessa M, et al. The effectiveness of octreotide in the treatment of post-operative chylothorax. Eur J Pediatr 2002;161:149-50.

5. Al-Zubairy SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother 2003;37:679-82.

Q: 64 year old male, admitted to ICU for unrelated reason, found to have about 10%  of pneumothorax (PTX) after subclavian central venous line placement. Patient is hemodynamically stable, alert, oriented and saturation is 98% on room air. You decided to observe the patient. What amount of oxygen should be applied at least via nasal canula to increase the absorption of pneumothorax?

Answer: 3 L/min

By applying oxygen, you may be able to treat stable, low volume, PTX by process called "Nitrogen washout". On room air, most of the air volume trapped in the pleural space is Nitrogen. By breathing higher amount of oxygen, you lower the level of Nitrogen within the alveoli and, thus, the nitrogen in the pleural space will diffuse across (down the gradient).

Though it would not harm to apply 100% non-rebreather mask (NRM) in a patient who has no contraindication, oxygen administration at 3 L/min nasal canula or higher flow is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone.




Moore FO, Goslar PW, Coimbra R, et al. Blunt Traumatic Occult Pneumothorax: Is Observation Safe?-Results of a Prospective, AAST Multicenter Study. J Trauma. May 2011;70(5):1019-1025

Albumin reminder in large volume paracentsis

Abstract

Albumin infusion reduces the incidence of postparacentesis circulatory dysfunction among patients with cirrhosis and tense ascites, as compared with no treatment. Treatment alternatives to albumin, such as artificial colloids and vasoconstrictors, have been widely investigated. The aim of this meta-analysis was to determine whether morbidity and mortality differ between patients receiving albumin versus alternative treatments. The meta-analysis included randomized trials evaluating albumin infusion in patients with tense ascites.

Primary endpoints: were postparacentesis

• circulatory dysfunction,
• hyponatremia, and
• mortality

Eligible trials were sought by multiple methods, including computer searches of bibliographic and abstract databases and the Cochrane Library. Results were quantitatively combined under a fixed-effects model. Seventeen trials with 1,225 total patients were included. There was no evidence of heterogeneity or publication bias.

Compared with alternative treatments, albumin reduced the incidence of postparacentesis circulatory dysfunction (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.27-0.55). Significant reductions in that complication by albumin were also shown in subgroup analyses versus each of the other volume expanders tested (e.g., dextran, gelatin, hydroxyethyl starch, and hypertonic saline). The occurrence of hyponatremia was also decreased by albumin, compared with alternative treatments (OR, 0.58; 95% CI, 0.39-0.87). In addition, mortality was lower in patients receiving albumin than alternative treatments (OR, 0.64; 95% CI, 0.41-0.98).

Conclusions: This meta-analysis provides evidence that albumin reduces morbidity and mortality among patients with tense ascites undergoing large-volume paracentesis, as compared with alternative treatments investigated thus far.

Bernardi M., Caraceni P, Navickis RJ, Wilkes MM. - Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. - Hepatology. 2012 Apr;55(4):1172-81.

http://www.ncbi.nlm.nih.gov/pubmed/22095893

Q: What disadvantage Lactate Ringer (LR) has when it comes to compatibility while using IV lines?

Answer:

LR contains calcium in lactated Ringer’s in amount of 1.5 mmol/L. While using same IV lines or as a 'drip line', Ca+ in LR can bind to some drugs and may reduce their efficacy.

Another under-appreciated effect in surgical ICUs is calcium binding to the citrated anticoagulant in blood products. This can inactivate the anticoagulant and may promote the formation of clots in donor blood.

Q: How DKA is categorized as per its level of severity?

Answer:

The American Diabetes Association categorizes DKA in adults into one of three stages of severity according to blood PH, Bicarbonate level and mental status.

Mild: pH 7.25 and 7.30; serum bicarbonate 15–18 mmol/l; the patient is alert

Moderate: pH 7.00–7.25, bicarbonate 10–15, mild drowsiness

Severe: pH below 7.00, bicarbonate below 10, stupor or coma

Varicella pneumonia and pregnancy 

 "Acyclovir is not currently licensed for use in pregnancy, however, the risks from withholding treatment, particularly in the second half of pregnancy when severe complicated chicken pox are more common, probably outweigh the risks of adverse drug effects on the foetus or mother". 

Read most updated review on 

 Varicella pneumonia in adults - from European Respiratory Journal - ERJ, May 1, 2003, Vol. 21, No. 5, 886-891 

 http://erj.ersjournals.com/content/21/5/886.long

Q: 28 year old male is admitted to hospital with shortness of breath. Lab. workup showed elevation of alkaline phosphatase. Further lab. inquiry for specific isozyme showed it of placental type. What is the diagnosis?

Answer:  Seminoma

In humans, alkaline phosphatase is present in all tissues but is particularly concentrated in intestine, liver, bone and the placenta.  Following are the alkaline phosphatase isozymes:

• ALPI – intestinal
• ALPL – liver/bone/kidney
• ALPP – placental

Placental alkaline phosphatase is elevated in seminomas and active form of Rickets.

Q: What is the clinical significance of rising AST and ALT after initiation of Heparin

Answer:  None

Elevation of serum aminotransferase levels are very common and reported in as many as 80% of patients receiving heparin. To note, this abnormality is not associated with liver dysfunction, and it disappears after the drug is discontinued.