Q: Which type of lung cancer is mostly associated with lung abcess?

Answer: Squamous Cell Carcinoma

When a pulmonary abscess doesn’t improve with appropriate medical management, there  should be  a suspicion of lung cancer.

References:

L.E.L. Hendriks and co. - A pulmonary abscess, beware of lung cancer! Respiratory Medicine CME - Volume 4, Issue 4, 2011, Pages 157–159

IABP

Link: http://youtu.be/RU1gEBNK1pY


 

Q: What is the treatment of unresolved hepatic encephalopathy following transjugular intrahepatic portosystemic shunt (TIPS)?

Answer: Insertion of ePTFE stent-graft inside the original shunt

In usual cases, post-TIPS encephalopathy symptoms get better with  the use of rifaximin or lactulose. In profound or unresolved Post-TIPS Hepatic Encephalopathy, placement of an hourglass-shaped balloon-expandable polytetrafluoroethylene (ePTFE) stent-graft inside the original shunt resolves symptoms within a day.

Reference:

Fanelli F, Salvatori FM, Rabuffi P, et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol. Dec 2009;193(6):1696-702

Q: Methylene Blue can be use as a treatment in which infectious disease? 


 Answer: Malaria 

 Actually Methylene Blue has been used as an anti-malarial for almost a century. It has been shown to play role again in malarial treatment with increasing resistance of P. falciparum to front line treatments. 

Mechanism of action: Methylene Blue, a specific inhibitor of P.falciparum glutathione reductase has the potential to reverse CQ resistance and it prevents the polymerization of haem into haemozoin similar to 4-amino-quinoline antimalarials. 

Dose: A dose of 36-72mg/kg over 3 days. 



 Reference:

 Meissner Peter E, Germain Mandi, Boubacar Coulibaly, et al. - Methylene blue for malaria in Africa: results from a dose-finding study in combination with chloroquine. Malaria Journal. 2006;5:84.

Thromboelastogram

Link: http://youtu.be/SjH05uGSGv0

Q: Coumadin (warfarin) is contraindicated in pregnancy, except in one condition. Which one

Answer: prosthetic mehanical heart valves.

In pregnancy, warfarin can be continued after the first trimester in women with prosthetic heart valves.

Current guidelines recommend that the decision whether to use heparin during the first trimester or to continue oral anticoagulation throughout pregnancy should be made after full discussion of the aforementioned facts with the patient. The 2008 ACC/AHA guidelines recommend that patients who elect to stop warfarin between weeks 6 and 12 of gestation, to decrease the risk of fetal defects, should receive continuous IV, or dose adjusted subcutaneous (SQ) UFH or dose-adjusted SQ LMWH.

Reference:

1. Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med 2000;160:191–6.

2. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1.

A Note of Proton Pump Inhibitors (PPIs) use in ICU

"There is increasing concern that IV PPI is being prescribed inappropriately in the hospital and community setting. The use of IV PPI as prophylaxis against stress-related mucosal injury needs to be judicious. Routine prophylaxis is not cost-effective, and may subject patients to unnecessary side effects. It should be reserved for patients who are at higher risk of developing stress related ulcers. Acid-suppressive therapy is often inappropriately continued post ICU discharge, and even beyond hospital discharge in the community. Physicians should review and discontinue the use of IV PPI when the risk factors responsible for stress related mucosal injury are no longer present, and ensure that there is adequate communication with the treating team upon a patient's transfer out of ICU, and also with the community medical care provider upon hospital discharge."

Reference: 

Sandy H. Pang, David Y. Graham - A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers- Therap Adv Gastroenterol. Jan 2010; 3(1): 11–22.

Q: What causes Transfusion-Related Acute Lung Injury (TRALI) via pRBC transfusion?

Answer: TRALI is mostly associated with plasma components, means platelets and Fresh Frozen Plasma. TRALI with packed red blood cells (pRBCs) occur due to residual plasma in the packed cells. TRALI occurs due to the presence of leukocyte antibodies in transfused plasma. Leukoagglutination and pooling of granulocytes in the recipient's lungs causes release of the contents of leukocyte granules, and resulting injury to cellular membranes, endothelial surfaces, and potentially to lung parenchyma. 

Q: How Transfusion-Associated Circulatory Overload (TACO) can be clinically distinguished from Transfusion-Related Acute Lung Injury (TRALI)?

Answer: TACO typically responds to diuretics with symptomatic improvement, while TRALI is usually unresponsive to diuretics. Moreover, TRALI usually presents with hypotension and TACO with hypertension, given other cardiovascular and renal conditions stable.

Q: No adjustment is needed for Linezolid in ESRD (Renal failure) patients. But what is the recommendation for patients on Hemodialysis (HD)?

Answer: Though there is no adjustment needed for Linezolid (Zyvox) in ESRD patients, it should be administrated after HD session as linezolid clearance is increased by 80% during intermittent hemodialysis.

Fifty percent of a linezolid dose is metabolized in the liver to 2 inactive metabolites, and 30% of the dose is excreted in the urine as unchanged drug. There is no adjustment recommended for patients with renal failure; however, it should be administrated after HD.

No linezolid dosage adjustment is recommended for patients receiving CRRT.

Procalcitonin versus C-reactive protein for guiding antibiotic therapy in sepsis

Study was sought to evaluate whether procalcitonin was superior to C-reactive protein in guiding antibiotic therapy in intensive care patients with sepsis.

DESIGN: Randomized open clinical trial.

SETTING: Two university hospitals in Brazil.

PATIENTS: Patients with severe sepsis or septic shock.

INTERVENTIONS: Patients were randomized in two groups: the procalcitonin group and the C-reactive protein group. Antibiotic therapy was discontinued following a protocol based on serum levels of these markers, according to the allocation group. The procalcitonin group was considered superior if the duration of antibiotic therapy was at least 25% shorter than in the C-reactive protein group. For both groups, at least seven full-days of antibiotic therapy were ensured in patients with Sequential Organ Failure Assessment greater than 10 and/or bacteremia at inclusion, and patients with evident resolution of the infectious process had antibiotics stopped after 7 days, despite biomarkers levels.

MEASUREMENTS AND MAIN RESULTS:  Ninety-four patients were randomized: 49 patients to the procalcitonin group and 45 patients to the C-reactive protein group. The mean age was 59.8 (SD, 16.8) years. The median duration of antibiotic therapy for the first episode of infection was 7.0 (Q1-Q3, 6.0-8.5) days in the procalcitonin group and 6.0 (Q1-Q3, 5.0-7.0) days in the C-reactive protein group (p=0.13), with a hazard ratio of 1.206 (95% CI, 0.774-1.3; p=0.13). Overall, protocol overruling occurred in only 13 (13.8%) patients. Twenty-one patients died in each group (p=0.836).

CONCLUSIONS: C-reactive protein was as useful as procalcitonin in reducing antibiotic use in a predominantly medical population of septic patients, causing no apparent harm.

Reference:

Oliveira CF, Botoni FA, Oliveira CR, Silva CB, Pereira HA, Serufo JC, Nobre V. - Procalcitonin versus C-reactive protein for guiding antibiotic therapy in sepsis: a randomized trial. - Crit Care Med. 2013 Oct;41(10):2336-43.

Q: Which factors may give false positive higher HbA1C level?

Answer: 

Higher than actual  level of HbA1C can be seen in people with a longer red blood cell lifespan, such as with Vitamin B12 or folate deficiency.

Reference:

Kilpatrick ES, Bloomgarden ZT, Zimmet PZ (2009). "Is haemoglobin A1c a step forward for diagnosing diabetes?". BMJ 339: b4432.

Q: Why Tacrolimus  (FK/prograf) level should always be drawn peripherally, if patient is on intravenous Tacrolimus?

Answer:   The IV prograf seems to “stick” to the IV line and can falsely elevate any levels that are drawn from the same IV line.  Patients on IV Prograf really need to have the levels drawn from a peripheral venous stick or from an A-line.

Reference:

Jain AB, Pinna A, Fung JJ, Warty V, Singhal AK, Lever J, Venkataramanan R.- Capillary blood versus arterial or venous blood for tacrolimus monitoring in liver transplantation. - Transplantation. 1995 Sep 15;60(5):512-4.

Q: Although Lactated Ringers (LR) has PH of 6.5, it is an alkalizing solution. How?

Answer: Although LR has pH of 6.5, it is an alkalizing solution.

The lactate in LR is metabolized into bicarbonate (HCO3-) by the liver. Though lactate itself contributes a strong anion, lactated Ringer's solution alkalinizes via the sodium cations it leaves behind. They increase the strong ion difference in solution, leading to proton consumption and an overall alkalinizing effect.

Normal Saline Vs Lactated Ringers in Hemorrhagic Shock

Choice of crystalloid as a resuscitation fluid in the face of known hemorrhagic shock remains one of the most highly debated topics in the trauma literature at this time. While many clinicians consider lactated Ringer’s and normal saline interchangeable, they are not.

Multiple studies in the swine model compare the use of various crystalloid solutions, focusing on lactated Ringer’s solution and normal saline. The swine model demonstrates that if shock is induced and maintained for 30 min, followed by resuscitation with either normal saline or lactated Ringer’s solution, the animals resuscitated with Ringer’s lactate have better improvement in markers of shock, pH, and extracellular lung water. In this study neutrophil activation contributes to cellular damage. Other studies support the neutrophil activation phenomenon; dextran is the biggest activator, followed by normal saline and then lactated Ringer’s

·         Phillips CR, Vinecore K, Hagg DS, Sawai RS, Differding JA, Watters JM, Schreiber MA. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics. Crit Care. 2009;13(2):R30. Epub 2009 Mar 4.

·          Scultetus A, Alam HB, Stanton K, et al. Dextran and Hespan resuscitation causes neutrophil activation in swine after hemorrhagic shock. Shock. 2000;13(Suppl):52.

Lactated Ringer’s, as a resuscitation fluid, yields less acidosis and less coagulopathy than seen with similar volumes of normal saline

·          Todd SR, Malinoski D, Muller PJ, Schreiber MA. Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007;62(3):636–9.

Normal saline causes a well-recognized metabolic hyperchloremic acidosis; patients resuscitated with lactated Ringer’s do not achieve such levels of acidosis. Furthermore, normal saline-resuscitated patients demonstrate more blood loss than those resuscitated with lactated Ringer’s

·        Kiraly LN, Differding JA, Enomoto TM, Sawai RS, Muller PJ, Diggs B, Tieu BH, Englehart MS, Underwood S, Wiesberg TT, Schreiber MA. Resuscitation with normal saline (NS) vs. lactated ringers (LR) modulates hypercoagulability and leads to increased blood loss in an uncontrolled hemorrhagic shock swine model. J Trauma. 2006;61(1):57–64. discussion 64–5.

What are the possible Bioterrorism Agents that might be used in an attack?

The CDC classifies six pathogens as class A bioterrorism agents:

·         Smallpox

·         Plague

·         Botulism

·         Tularemia

·         Viral hemorrhagic fever (VHF)

·         Anthrax.

These agents are considered to have the greatest potential for mass casualties, large-scale dissemination, and public panic and social disruption. All of them except VHF have been developed as biological weapons. They are stable in aerosol form and would be most likely delivered in this manner. Most of the civilian population remains susceptible to them, and most cause illnesses not typically seen by providers, causing delayed or missed diagnoses.

Does Diaphragmatic Inactivity during mechanical ventilation lead to disuse atrophy?

Studies have demonstrated that the combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragmatic fibers, and that there is increased diaphragmatic proteolysis during inactivity. Compared with diaphragm-biopsy specimens from control subjects, specimens from case subjects showed decreased cross-sectional areas of slow-twitch and fast-twitch fibers, decreased glutathione concentration, and increased activity of proteolytic enzymes.

·          Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358(13):1327-1335.

·          Kondili E, Alexopoulou C, Xirouchaki N, et al. Estimation of inspiratory muscle pressure in critically ill patients. Intensive Care Med 2010; 36(4):648-655.

·          Petrof BJ, Jaber S, Matecki S. Ventilator-induced diaphragmatic dysfunction. Curr Opin Crit Care 2010; 16 (1):19-25.

Conventional cardiopulmonary resuscitation (CPR) Vs compression-only CPR

 
Bystanders who perform chest-compression-only CPR instead of traditional CPR with mouth-to-mouth resuscitation (rescue breathing) save more lives, Researchers found that adults who experienced cardiac arrest in a non-hospital setting, such as a restaurant or mall, were 60% more likely to survive if they received compression-only CPR than if they received traditional CPR or no CPR until an emergency medical services (EMS) crew arrived at the scene. The survival edge may occur because interrupting chest compressions --- even just for rescue breathing-- may further hamper blood flow, and it takes longer to get that blood flow back when it is time for more chest compressions.

·          Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from out of- hospital cardiac arrest. JAMA 2010; 30(13):1447-1454.

What is Damage Control Resuscitation?

The concept of damage control resuscitation (DCR) was proposed in the mid 2000s as an alternative resuscitation approach to hemorrhagic shock. A key component of this damage control approach is early hemorrhage control. Another core concept is that resuscitation fluids should resemble what the trauma patient loses—warm fresh whole blood. In civilian settings, fresh whole blood is not available for transfusion, and blood components in appropriate ratios should be used toward this goal. A number of studies suggest that FFP and platelets should be given early and in high ratios (e.g., PRBCs/FFP/ platelets in a ratio of 1:1:1) in patients who require massive transfusion (>10 units PRBCs).

Damage control resuscitation involves:

·         Rapid control of surgical bleeding

·         Early and increased use of red blood cells, plasma and platelets in a 1:1:1 ratio

·         Limitation of excessive crystalloid use

·         Prevention and treatment of hypothermia, hypocalcemia and acidosis

·         Hypotensive resuscitation strategies

Which biomarker provides the earliest detection of acute kidney injury?

Acute kidney injury (AKI) is a common complication among ICU patients and its incidence has been increasing in recent years. Currently the diagnosis of AKI requires serial assessment of laboratory tests over a period of several days, and is based mainly on serum creatinine (sCr) as supported by Risk, Injury, Failure, Loss, and End-Stage Kidney Disease (RIFLE) criteria. As a consequence, the use of biomarkers of acute kidney damage could be of great utility at the time of ICU admission in order to distinguish AKI from volume responsive renal dysfunction, chronic kidney disease (CKD) or normal renal function.

Neutrophil gelatinase-associated lipocalin (NGAL) is expressed in immature neutrophil precursors and in epithelial cells during both inflammation and neoplastic transformation.

Neutrophil gelatinase-associated lipocalin (NGAL) is a promising novel biomarker that correlates with the severity and outcome of acute kidney injury (AKI).

Double lumen tube

(2 Parts - Total time 10:20)

Links: 
http://www.youtube.com/watch?v=w1cgx2AVC6k 
http://www.youtube.com/watch?v=JZkOiy4PXxg

Q: What is the bedside trick to facilitate left lung intubation, assuming no other tools are available?

Answer: To facilitate left lung intubation, place the patient in right lateral decubitus and curving the tube to the left.

Deep Brain stimulation

Link: 

http://youtu.be/abHuHFt_izI

.

Can a patient make a movement and still meet criteria for brain death?

Yes!

Spinally mediated reflexes and automatisms can be present in the setting of brain death. These movements are often misinterpreted by laypersons as signs of purposeful brain function. Careful neurologic examination can differentiate between reflexive movements and purposeful motor movements.

These are non-purposeful movements released by lack of descending inhibition of primitive spinal motor reflex pathways.

·         Deep-tendon reflexes: For example, Achilles, patellar, and biceps are by definition monosynaptic spinally mediated reflexes and hence often preserved despite brain death.

·         Abdominal reflexes: Deviation of the umbilicus toward a light stroking of the skin. Often preserved in brain-dead patients, it may be absent in normal or obese patients.

·         Triple flexion response or limb posturing: Stereotyped, non-purposeful flexion or extension and internal rotation in response to noxious stimulus. (A movement may be purposeful if the limb reliably moves away from, rather than toward, an applied noxious stimulus.)

·         Lazarus sign: Considered a variant of opisthotonus. It consists of extensor posturing of the trunk, which may look like chest expansion, simulating a breath. It may be accompanied by raising and crossing of the arms in front of the chest or neck. This sign most often occurs in the setting of apnea testing or disconnection from the ventilator. Hence it may be upsetting for family members or health care providers to witness this reflex.

A note on Isopropyl alcohol inhalation in Post operative Nausea Vomitting (PONV)

Isopropyl alcohol has been tried as an aroma-therapy in PONV. Couple of inhalations from a standard alcohol (70%) wipe has been said to be effective. There are few studies done in this regard leaning that isopropyl alcohol may be therapeutically equivalent, less costly and an useful trick in ICU.

References

1. Langevin RB, Brown MM. A simple, innocuous, and inexpensive treatment for postoperative nausea and vomiting. Anesth Analg. 1997; 84:A16.

2. Merritt BA, Okyere CO, Jasinski DM. Isopropyl alcohol inhalation: alternative treatment of postoperative nausea and vomiting. Nurs Res. 2002; 51:125-8.

3.Winston AW, Rinehart RS, Riley GP et al. Comparison of inhaled isopropyl alcohol and intravenous ondansetron for treatment of postoperative nausea. AANA J. 2003; 71(2):127-32.

4. Wang SM, Hofstadter MB, Kain ZN. An alternative method to alleviate postoperative nausea and vomiting in children. J Clin Anesth. 1999; 11:231-4.

Q: In severe nausea which drug may provide good synergism with ondansetron (zofran)?

Answer: Dexamethasone (Decadron)

Dexamethasone and Ondansetron (Zofran) may be more effective than Ondansetron alone in preventing postoperative nausea and vomiting.

Reference:

Song (2011). "The effect of combining dexamethasone with ondansetron for nausea and vomiting associated with fentanyl-based intravenous patient-controlled analgesia.". Anaesthesia 66 (4): 263–7

Picture Diagnosis

.

Answer: Cutaneous Leishmaniasis

Cutaneous Leishmaniasis is marked by itchy sores and swelling of lymph nodes on arms, legs or face. Over time, the sores develop a red raised border and a depression in the middle.

Leishmaniasis is found through much of the Americas from Argentina to Texas. The disease is also found across much of Asia and in the Middle East. Kabul is the largest center of cutaneous leishmaniasis in the world.

Leishmaniasis is diagnosed in the laboratory by direct visualization of the Leishman-Donovan bodies, from peripheral blood or aspirates from marrow, spleen, lymph nodes, or skin lesions.

Miltefosine is an oral medication that is effective against both visceral and cutaneous leishmaniasis. 

Q: Beside Erectile Dysfunction (ED) and Pulmonary Hypertension (PAH), Sildenafil is an acceptable treatment in which condition?

Answer: Altitude sickness

The phosphodiesterase 5 (PDE-5) inhibitors (both, sildenafil and tadalafil) have effectively shown to prevent hypoxic pulmonary hypertension. They have used for the prevention as well as treatment of high-altitude pulmonary edema occur in altitude sickness. Different doses have been described for sildenafil, from a single dose of 50 or 100 mg just prior to exposure for acute ascent, to 40 mg three times a day while at high altitude. For tadalafil, 10 mg every 12 hours is the described dose.

References: 

1. Richalet JP, Gratadour P, Robach P, et al. (2005). "Sildenafil inhibits altitude-induced hypoxemia and pulmonary hypertension". Am. J. Respir. Crit. Care Med. 171 (3): 275–81.

2.Perimenis P (2005). "Sildenafil for the treatment of altitude-induced hypoxaemia". Expert Opin Pharmacother 6 (5): 835–7. 

3.  Fagenholz PJ, Gutman JA, Murray AF, Harris NS (2007). "Treatment of high altitude pulmonary edema at 4240 m in Nepal". High Alt. Med. Biol. 8 (2): 139–46.

4. Ghofrani HA, Reichenberger F, Kohstall MG, et al. Sildenafil increased exercise capacity during hypoxia at low altitudes and at Mount Everest base camp: a randomized, double-blind, placebo-controlled crossover trial. Ann Intern Med 2004; 141:169.