Q: Why commonly use medicine in 'transplant ICUs' may cause acute attack of Gout?

Answer: Tacrolimus (Prograf)

Cyclosporin was one main culprit in transplant patients to cause hyperuricemia and Gout but it has been reported with Tacrolimus too.

Q: Why steroids are not favored as treatment choice in acute pericarditis?

Answer: They increase the chance of recurrent pericarditis.

References:

1. Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation. 2010;121:916–928.

2. Farand P, Belley-Côté ÉP. Give a bigger place for colchicine and a smaller place for corticosteroids in the algorithm for the treatment of acute and recurring pericarditis. MedActuel. 2010;10:1–5.

Q: What is the basic objective of administrating D-5 dextrose solution peri and post operatively?

Answer: Administering a 5% dextrose solution peri and postoperatively usually provides a good balance between starvation reactions and hyperglycemia caused by sympathetic activation.

On Acute Hypernatremia

Interesting case report

Survival of acute hypernatremia due to massive soy sauce ingestion

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.

Reference: 

Carlberg DJ, Borek HA, Syverud SA, Holstege CP. - Survival of acute hypernatremia due to massive soy sauce ingestion. - J Emerg Med. 2013 Aug;45(2):228-31. , Epub 2013 Jun 2.

Q: Why initiation of warfarin is always recommended with Heparin/LMW Heparins, particularly at higher doses?

Answer: Warfarinization (start of warfarin) initially and temporarily may promote clot formation. This is due to the fact that the level of protein C and protein S are also dependent on vitamin K activity. Warfarin causes drop in protein C levels in first 36 hours. Also, reduced levels of protein S lead to a reduction in activity of protein C, for which it is the co-factor. This leads to a prothrombotic state. Thus, when warfarin is loaded at greater than 5 mg per day, it is advisable  to co-administer heparin.

Reference:

Wittkowsky AK (2005). "Why warfarin and heparin need to overlap when treating acute venous thromboembolism". Dis Mon 51 (2–3): 112–5.

Q: What are the best places to obtain TCD (Trans Cranial Doppler)?

Answer: The bones of the skull block the transmission of ultrasound, so areas  with thinner walls, called insonation windows get used for procedure. For Most preffered  areas are the temporal region above the cheekbone/zygomatic arch, through the eyes, below the jaw, and from the back of the head.

 

The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.

BACKGROUND:

Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.

OBJECTIVE:

A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.

STUDY SELECTION:

Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.

DATA SYNTHESIS:

Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.

CONCLUSIONS:

Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.

  

Reference:

Marik PE, Flemmer M Harrison W: The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. - Crit Care Med. 2012 Aug;40(8):2479-85.

AxoTrack needle guided central line insertion

Link: http://youtu.be/aTwroYONy1o

 

MACOCHA score to determine difficult intubation

	Points
Factors related to patient
Mallampati score III or IV	5
Obstructive apnea syndrome	2
Reduced mobility of cervical spine	1
Limited mouth opening <3 cm	1
Factors related to pathology
Coma	1
Severe hypoxemia (<80%)	1
Factor related to operator
Non-anaesthesiologist	1
Total	12
Reference: Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9

Q: Name 3 commonly used drugs in ICU which may cause TTP (Thrombotic thrombocytopenic purpura)?

Answer:

1. Plavix (clopidogrel)

2. Acyclovir
3. Tacrolimus (FK506)

EKOS

                                         If video does not work,
                          link is http://youtu.be/ufPmm6BupqY


 

Q: Why Succinylcholine should be use with caution in Myasthenia Gravis patients?

Answer: Succinylcholine can have unpredictable effects in patients with myasthenia gravis.

Firstly, The relative lack of ACh receptors makes these patients somewhat resistant to succinylcholine

Secondly, higher doses may be required to achieve desirable effect.

Thirdly, Paralysis effect may be prolonged.

Reference:

Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. Semin Neurol. Mar 2004;24(1):75-81

Q: What is the equivalency of  fosphenytoin sodium to phenytoin sodium?

Answer:

Fosphenytoin sodium is a prodrug and its active metabolite is phenytoin.

1.5 mg of fosphenytoin sodium is equivalent to 1 mg phenytoin sodium, and is referred to as 1 mg phenytoin sodium equivalents (PE).

Q: Why calcium is the first line of treatment in hyperkalemia than Insulin/Dextrose or Albuterol treatment?

Answer: 

• Calcium takes immediate effect and last for 30-60 minutes
• Insulin/Dextrose peak effect occurs  in 30-60 minutes
• Albuterol peak effect occurs in 90 minutes

Q: What's the rate of removal of potassium via Kayexalate (Sodium Polystyrene) and hemodialysis?


Answer:

• Kayexalate (Sodium Polystyrene) = 1 mEq/gram
•  Hemodialysis = 25 -  50 mEq per hour

Q: What is "ABCDE" Bundle/approach for Delirium?

Answer:

Awakening and 

Breathing (minimize sedation)
Coordination (among various teams),
Delirium Monitoring (and Management),
Early Mobility 

Reference:

Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: The ‘ABCDE’ approach. Curr Opin Crit Care. 2011;17(1):43–49

Q: Which commonly use Antibiotic in ICU may cause black discoloration of tongue?

Answer: Linezolid

Fortunately its not very common and is reversible!

Reference:

Black tongue associated with linezolid - Am J Ther. 2010 Jul-Aug;17(4):e115-7

Q: What are the 2 major differences on clinical exam between Myasthenia Gravis (MG) and Lambert-Eaton syndrome?

Answer:

1. Weakness gets worse on exercise with MG but improves with Lambert-Eaton (Call Lambert's sign)

2. Reflexes are normal in MG but decrease or absent in Lambert-Eaton.

One relatively less known fact on NRM (Non-Rebreather Mask)

Non-rebreather masks are designed to capture the first 150ml of the exhaled breath into the reservoir bag for inhalation during the subsequent breath. 

 Clinical significance: This portion of the breath was initially delivered at the end of inhalation and was therefore delivered to the "deadspace" anatomy where gas exchange does not occur. Therefore, there would be no depletion of oxygen nor gain of carbon dioxide during the rebreathing component.

Something to keep in mind with plasmaphresis in cardiac transplant patient

Persistent hypocalcemia associated with therapeutic plasma exchange performed to reduce HLA antibody levels in cardiac transplant recipients

Background

Patients who receive heart transplants may undergo therapeutic plasma exchange to reduce high levels of HLA antibodies which may increase the risk of allograft rejection. Plasma exchange may predispose to hypocalcemia because of chelation of calcium by sodium citrate, used as an anticoagulant both during the procedure and in thawed fresh frozen plasma often used for replacement.

Methods

We report three adults with dilated cardiomyopathy who underwent cardiac transplantation and serial plasma exchange for high levels of HLA antibodies. We followed these patients’ pre-exchange serum calcium levels and the quantity of calcium supplementation they received. Further, we examined myocardial tissue sections post-transplantation for calcium deposition.

Results

Our patients’ serum calcium levels were initially normal, but, despite aggressive calcium repletion, remained low (nadirs for pre-exchange ionized calcium in two patients 4.48 and 3.8 mg/dL, respectively, reference range 4.6–5.4 mg/dL). For patient 3, pre-exchange total calcium on day 2 was 7.9 mg/dL (reference range 8.4–10.2 mg/dL). Two patients had intermittent symptoms of hypocalcemia. Studies of cardiac tissue sections (available only from these two patients) were consistent with the presence of calcium deposition post transplantation. In comparison, six patients who underwent lung transplantation and plasma exchange for high levels of HLA antibodies did not manifest significant hypocalcemia.

Conclusions

We emphasize the need for prompt and sufficient calcium replacement, monitored by serum ionized calcium levels, in the early post-cardiac transplantation period when plasma exchange is performed with thawed fresh frozen plasma replacement. The persistently low serum calcium levels we observed post heart transplantation were possibly contributed to by increased myocardial calcium influx.

Reference:

Persistent hypocalcemia associated with therapeutic plasma exchange performed to reduce HLA antibody levels in cardiac transplant recipients - Transfusion and Apheresis Science, Volume 44, Issue 3, June 2011, Pages 243–248

Q: What is Todd's Paresis?

Answer: Todd's paresis is focal paralysis which occurs after seizure, and usually resolves within a day or two. Usually, it presents as hemiplegia. Todd's paresis may also presents difficulty in speech, gaze problems or blurred vision. It affects around 10% of seizures.

The most challenging part is to determine whether seizure is the cause of motor weakness or is the result of CVA. Fortunately, in most cases it resolves quickly.

Q: What is the pathophysiology of playtpnea in Hepatopulmonary syndrome?

Answer: In hepatopulmonary syndrome, there is a shunting and V/Q mismatch due to arteriovenous malformations in the lung. Platypnea and orthodeoxia occur because the pulmonary AVMs occur predominantly in the bases of the lung. Therefore, when sitting up or standing, blood pools at the bases of the lung with resultant  increased AV shunting.

ASV Ventilation mode - video

 http://youtu.be/Exqua1pExno