Q: 53 year old male in ICU is complaining of  "acidity". One of the veteran nurse ask you to try "Green Goddess". As you look confuse to him, he further explained it as "Green Lizard"?

Answer:   "The Green Goddess," or "Green Lizard" is a slang for GI  (gastrointestinal) cocktail - consisting of 

• 10-30 ml Mylanta,
• 10 ml Donnatal and
• 10 ml viscous lidocaine

Anecdotally, this mixture is said to be most effective for the treatment of dyspepsia.

Q: What advantage propofol has as an induction agent in intubation?

Answer:  Propofol reduces airway resistance and can be a useful induction agent for intubation in patients with bronchospasm.

References:

Eames WO, Rooke GA, Wu RS, Bishop MJ. Comparison of the effects of etomidate, propofol, and thiopental on respiratory resistance after tracheal intubation. Anesthesiology 1996; 84:1307.

Conti G, Ferretti A, Tellan G, et al. Propofol induces bronchodilation in a patient mechanically ventilated for status asthmaticus. Intensive Care Med 1993; 19:305.

Q: 64 year old male with significant past medical history of end stage congestive heart failure with ejection fraction of 10-15% - awaiting left ventricular assist device (LVAD) - admitted to ICU with coma. Lab rechecked and call you with critical value of calcium level  of 16.5 mg/dL. On exam, patient is markedly in anasarca and fluid overload. What is your treatment option here?

Answer: Hemodialysis

Hemodialysis with no calcium in the dialysis fluid is an effective therapy for hypercalcemia in patients where IV hydration is not an option and immediate management is required. Nephrology service should be consulted to tailor  composition of dialysis solution.

Reference:

Koo WS, Jeon DS, Ahn SJ, et al. Calcium-free hemodialysis for the management of hypercalcemia. Nephron 1996; 72:424.

Q: 42 year old female with no significant past medical history except for hypertension, presented to ER with dizziness and  palpitations. Initial rhythm showed runs of V.Tach. Only significant description given in history is recent episode of UTI (urinary tract infection) for which she was prescribed antibiotics by an urgent care physician. Which drug interaction is suspected?

Answer: Bactrim (Trimethoprim-sulfamethoxazole) and ACE-Inhibitor (ACE-I)

Among patients treated with ACEIs or ARBs, the use of Bactrim is associated with a life threatening hyperkalemia, in comparison to other antibiotics. Alternate antibiotic therapy should be considered in such situation.

Q: 52 year old female with ESRD (End Stage Renal Disease) - on PD (Peritoneal Dialysis) for many years is admitted to ICU post-op after orthopedic surgery. Patient is requiring fair amount of narcotics for pain relief. Nurse call you to report outflow problem with her peritoneal dialysis catheter. What could be the most probable cause

Answer: Constipation

Constipation in peritoneal dialysis patient is a very common cause of outflow problem, particularly in patients who have otherwise  stabilized catheter (late complication). Use of laxatives to relieve constipation usually takes care of problem. Obviously, proper physical exam and other causes should be ruled out.

Q: What is the dose of Fentanyl in blunting the sympathetic response to laryngoscopy and intubation?

Answer: 3 mcg/kg

Recommended doses for pretreatment for intubation is 3 mcg/kg to avoid hypotension in patients dependent on sympathetic tone. Fentanyl has been described to cause thoracic and abdominal muscular rigidity but the incidence is extremely low and usually only happens when doses higher than 15 mcg/kg are used.

Steroids equivalency

Q: How fast Etomidate works after injection?

Answer:  “one arm-brain circulation time”

“one arm-brain circulation time”  is the time taken for the drug to travel from the site of injection (usually the arm) to the brain.

Q: How many days usually it takes for Clopidogrel (Plavix) hypersensitivity to manifest?

Answer:  About one week

Interestingly, it takes few days before Clopidogrel manifests its hypersensitivity. Usually, it presents as an erythematous, macular, morbilliform rash which usually begins on the face, chest, or abdomen, and slowly spreads to the proximal and then distal extremities. It may even involve palms and soles. It is rarely but can be pruritic. The median time from drug introduction to appearance of symptoms is between 5 and 10 days.

Hypersensitivity can be managed without discontinuation of drug. (see references). 

References:

1. Cheema AN, Mohammad A, Hong T, et al. Characterization of clopidogrel hypersensitivity reactions and management with oral steroids without clopidogrel discontinuation. J Am Coll Cardiol 2011; 58:1445.

2. von Tiehl KF, Price MJ, Valencia R, et al. Clopidogrel desensitization after drug-eluting stent placement. J Am Coll Cardiol 2007; 50:2039.

3. Campbell KL, Cohn JR, Fischman DL, et al. Management of clopidogrel hypersensitivity without drug interruption. Am J Cardiol 2011; 107:812.

Q: Beside CSF drainage, what other modality of treatment has shown some beneficial effect in acute postoperative paraplegia complicating with emergency graft replacement of the ascending aorta for the Type A Dissection?

Answer: Hyperbaric Oxygen (HBO)

Usual dose of oxygen to patient is to breath 100% oxygen for 90 minutes at a pressure of 2.4 atmospheres absolute.

References:

1. . Puttaswamy V, Bennett M, Frawley JE. Hyperbaric oxygenation treatment of acute paraplegia after resection of thoracoabdominal aortic aneurysm. J Vasc Surg 1999; 30: 1158–61.

2. Gharagozloo F, Larson L, Dausmann MJ, Neville RF, Gomes MN. Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta. Chest 1996; 109: 799–809.

3. Fleck T, Hutschala D, Weissl M, Wolner E, Grabenwoger M, Austria V. Cerebrospinal fluid drainage as a useful treatment option to relieve paraplegia after stent-graft implantation for acute aortic dissection type B. J Thorac Cardiovasc Surg 2002; 123: 1003–5.

4. Narayana PA, Kudrle WA, Liu SJ, Charnov JH, Butler BD, Harris JH Jr. Magnetic resonance imaging of hyperbaric oxygen treatment rats with spinal cord injury: preliminary studies. Magn Reson Imaging 1991; 9:423-8.

Propofol induced priapism

Priapism following the infusion of propofol has been reported in literature - which may last for hours. Actual mechanism is not known but various theories has been proposed. It may be secondary to lipid content of the drug causing fat emulsion-related increased thrombin, erythrocyte aggregation and/or fat embolism. Vasodilatation, well know with propofol, has also been speculated as a cause of priapism. Another possibility described is the anesthetic effect in the spinal cord that might have blocked the sympathetic vasoconstrictor action or that might have enhanced the parasympathetic vasodilatory action causing an abnormal erection. Propofol-induced alteration of nitric oxide-mediated smooth muscle relaxation might have also had a contributory effect. The modulating effect on GABAa and adrenal steriodogenesis effects of propofol might have also played an additional role.

References:

1. Vesta, Kimi; Shaunta' Martina, Ellen Kozlowski (25 April 2009). "Propofol-Induced Priapism, a Case Confirmed with Rechallenge". The Annals of Pharmacotherapy 40 (5): 980–982.

2. Fuentes, Ennio; Silvia Garcia, Manuel Garrido, Cristina Lorenzo, Jose Iglesias, Juan Sola (July 2009). "Successful treatment of propofol-induced priapism with distal glans to corporal cavernosal shunt". Urology 74 (1): 113–115.

Q: Which commonly use drug in ICU may provide synergistic effect to ondansetron (Zofran) in preventing postoperative nausea and vomiting?

Answer:  Dexamethasone (Decadron)

Dexamethasone and Ondansetron, together are 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

Q: Which one test may help in distinguishing Epilepsy from a psychogenic non-epileptic seizure?

Answer:  A prolactin level

A high blood prolactin level within the first 20 minutes following a seizure may be useful to differentiate an epileptic seizure as opposed to psychogenic non-epileptic seizure.

1.  Luef, G (October 2010). "Hormonal alterations following seizures.". Epilepsy & behavior : E&B 19 (2): 131–3.

2. Ahmad S, Beckett MW (2004). "Value of serum prolactin in the management of syncope". Emergency medicine journal : EMJ 21 (2): e3

Q: How strikingly different is pleural effusion finding in Acute Eosinophilic Pneumonia (AEP)?

Answer:  The presence of eosinophils in the pleural effusion is usually considered nondiagnostic. But if the pleural fluid is exudative with an increased percentage of eosinophils, AEP should be strongly considered. It makes diagnosis very susceptible with hypoxemia, pulmonary infiltrates, eosinophils in bronchoalveolar lavage fluid, and prompt response to steroid therapy.

Other reasons for eosinophillia in pleural fluid is previous thoracentesis with air or blood  in contact with the effusion.

Reference:

1. Pope-Harman AL, Davis WB, Allen ED, Christoforidis AJ, Allen JN. Acute eosinophilic pneumonia. A summary of 15 cases and review of the literature. Medicine (Baltimore) 1996; 75 (6) 334–342

2. Fitzgerald DJ1, Chaudhary BA, Davis WB. - Eosinophilic pleural effusion: is it always nondiagnostic? - J Fam Pract. 1996 Apr;42(4):405-7.

Q: Why it is important recognize Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome?

Answer: The mortality rate associated with DRESS syndrome is approximately 10%, the majority due to fulminant liver failure. It is very important to recognize DRESS Syndrome as treatment is curative with steroids otherwise can be highly fatal.

.

A Brief Story of Mannitol

Mannitol remains a standard therapy for reducing intracranial pressure. The initial dose of mannitol is 1 g/kg and can be given emergently without intracranial pressure monitoring as long as the patient is normotensive.

Mannitol is particularly useful if the patient is showing any signs or symptoms of impending herniation. Subsequent dosing to a serum osmolality up to 320 mosm/l is usually recommended as needed. Dosing to higher levels has not been shown to improve outcome and increases the risk of acute renal failure.

Mannitol reduces intracranial pressure through two mechanisms. The immediate mechanism is expansion of intravascular volume which reduces blood viscosity. This results in an increase in cerebral blood flow in the areas of the brain where cerebral autoregulation remains intact and ICP falls. The second mechanism, which occurs later, involves the establishment of osmotic gradients between the serum plasma and the brain cells. This ultimately decreases intracellular volume and reduces intracranial pressure.

Since mannitol also functions as a diuretic there is always a risk of reducing blood pressure and therefore cerebral perfusion pressure if the patient is not adequately volume resuscitated. For this reason, hypertonic saline has gained favor as an osmotic agent for increased ICP since it is less likely to cause hypotension.

    Hepatorenal syndrome

Hepatorenal syndrome is quite common in the cirrhotic population and is found in approximately 10% of individuals admitted to the hospital with ascites.

It is characterized by azotemia, oliguria (500mL per day), low urinary sodium excretion (10mEq per liter), and increased urine-plasma osmolality ratio (U:P 1.0) in the absence of urinary sedimentation.

Histology of renal tissue from patients with hepatorenal syndrome is normal.

Hepatorenal syndrome occurs in patients with pre-existing parenchymal liver disease after a precipitating event such as surgery or a hypotensive episode (e.g., GI bleed, dialysis, sepsis).

The etiology of hepatorenal syndrome is not completely understood but appears to involve vasodilation, decreased effective arterial volume, and further reduction of glomerular filtration by the reninangiotensin- aldosterone system.

Hepatorenal syndrome progress over days to weeks after the precipitating event. While initially partly responsive to volume expansion, it is ultimately refractory to all interventions except liver transplantation.

REFERENCE:

rroyo, V, Guevara M, Gin`es P, et al. (2002) Hepatorenal syndrome in cirrhosis: pathogenesis and treatment. Gastroenterology 122 (6), 1658–76.

Mulholland MW, Lillemoe KD, Doherty G et al. (2010) Greenfield’s Surgery: Scientific Principles and Practice, Lippincott Williams & Wilkins, Philadelphia, PA.

                    All You Need to Know About ...TIPS

Transjugular intrahepatic portosystemic shunts (TIPS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein using angiographic techniques.

The indications for TIPS include bleeding refractory to endoscopic and medical management, refractory ascities, Budd–Chiari syndrome, and hepatorenal syndromes.

The stent is expanded to a diameter that reduces the porto-sytemic gradient to less than 12 mm Hg.

TIPS is associated with post-procedure encephalopathy rates of approximately 25%, and patients with renal insufficiency are at risk for worsened renal function.

The long-term problem with TIPS is stenosis of the shunt, which is reported in as many as two thirds of patients. Most centers advocate an aggressive Doppler ultrasound monitoring program with prompt balloon dilation for identified stenosis of the stent.

REFERENCE:

Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases (2010) The role of transjugular intrahepatic portosystemp shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 51, 306.

Mulholland MW, Lillemoe KD, Doherty G et al. (2010) Greenfield’s Surgery: Scientific Principles and Practice, Lippincott Williams & Wilkins, Philadelphia, PA.

            Acute Kidney Injury from Traumatic Rhabdomyolysis

Rhabdomyolysis is most commonly caused by trauma but may also be due to medications, exercise, toxins, infections, muscle enzyme deficiencies or endocrinopathies.

Rhabdomyolysis is associated with elevated levels of creatine kinase. Levels above 5000 U/L are associated with acute kidney injury; and treatment is recommended above this level.

Neither mannitol nor urinary alkalinization with sodium bicarbonate have been convincingly shown to reduce the need for dialysis or mortality from this condition.

The only effective treatment seems to be aggressive intravenous fluid replacement early in the course of the disease. This may require invasive monitoring with either a central line or a pulmonary artery catheter to prevent fluid overload.

REFERENCE:

Brown CV, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? Journal of Trauma 56 (6), 1191–6.

 Huerta-Alard´ın AL, Varon J, Marik PE (2005) Benchto- bedside review: Rhabdomyolysis—an overview for clinicians. Critical Care 9 (2), 158–69.

Lumber Puncture Headache

Lumber puncture is a frequently performed procedure in the ICUs. One of the nagging problem is post-lumbar puncture headache.

Lumbar puncture headache is believed to result from leakage and depletion of cerebrospinal fluid, causing traction on or distortion of anchoring pain-sensitive structures in the brain resulting in orthostatic headache. There may also be an effect of physical changes in the cerebral veins and venous sinuses.

Treatment options for post–lumbar puncture headache include hydration, caffeine, adrenocorticotropic hormone, sumatriptan, pregabalin, epidural saline, and epidural patches.

According to the results of a small study, IV theophylline promptly relieves the common problem of headache after lumbar puncture. In the study, mean pain scores were reduced by half within 30 minutes of treatment without adverse effects, researchers reported in a poster presentation at the 24th Meeting of the European Neurological Society (ENS).

Researchers administered theophylline, 200 mg in 100 mL of IV 5% dextrose, over 40 minutes. Patients in a sitting position reported pain on a 10-point visual analogue scale (VAS) at time 0 and at 30 and 60 minutes after the beginning of the infusion. All patients reported relief of pain at 30 and 60 minutes, with the greatest percentage decrease seen at 30 minutes.

 REFERENCES:

24th Meeting of the European Neurological Society (ENS): Abstract PP1104. Presented May 31, 2014.

Should critically ill patients in shock and/or receiving vasopressors receive Enteral Nutrition (EN)?

Ischemic bowel is a very rare complication of EN but has been reported in critically ill patients and can be fatal. Therefore the general recommendation is that EN be avoided in patients who are in shock and in those patients in whom resuscitation is active, vasopressors are being initiated, or vasopressor doses are increasing.

Once patients are resuscitated and hemodynamically stable, EN may be initiated, even if they are receiving stable lower doses of vasopressors.

However, special attention should be paid to signs of enteral feeding intolerance such as abdominal distention or increasing gastric residual volumes.

There is something about 'Normal' Saline !!!

A 0.9% solution of saline is isotonic and is therefore called physiological or “normal.” The fluid contains a marked surplus of chloride ions and no buffer  and, hence, infusion of 2 liters or more of the fluid causes hyperchloremic metabolic acidosis. 

In adults, normal saline should be reserved for patients with hypochloremic metabolic alkalosis, as in disease states associated with vomiting. The fluid has a more accepted role for perioperative fluid therapy in children where the risk of subacute hyponatremia is a more serious concern than in adults.

When infused in healthy volunteers normal saline might cause abdominal pain, which is not the case for lactated Ringer’s. The fluid also has more undesired effects, including acidosis, when used during surgery.

 Normal saline is excreted more slowly than both lactated and acetated Ringer’s solution , increasing the volume effect (“efficiency”) of the fluid to be about 10% greater compared with the Ringer’s solutions.

 REFERENCES:

Scheingraber S, Rehm M, Sehmisch C, Finisterer U. Rapid saline infusion produces hyperchloremic acidocis in patients undergoing gynecologic surgery. Anesthesiology 1999; 90: 1265–70.

Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect of intravenous lactated Ringer´s solution vs. 0.9% sodium

chloride solution on serum osmolality in human volunteers. Anesth Analg 1999; 88: 999–1003.

Wilkes NJ, Woolf R, Mutch M, et al. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg 2001; 93: 811–16.

Drobin D, Hahn RG. Kinetics of isotonic and hypertonic plasma volume expanders. Anesthesiology 2002; 96: 1371–80.

Placement of the Blakemore Tube for Esophageal Varices

Q: Treatment of which infection found to show improvement in Idiopathic thrombocytopenic purpura (ITP)?

Answer: Helicobacter pylori

Interestingly, for mechanism not fully understood, particularly in adults who lives in areas with a high prevalence of Helicobacter pylori, diagnosis and treatment of Helicobacter pylori infection has shown to improve platelet counts in many patients.

Reference:

Stasi R, Sarpatwari A, Segal JB, Osborn J, Evangelista ML, Cooper N, Provan D, Newland A, Amadori S, Bussel JB (2009). "Effects of eradication of Helicobacter pylori infection in patients with immune thrombocytopenic purpura: a systematic review". Blood 113 (6): 1231–40.

Steroids and Delirium in ICU

Delirium is common in mechanically ventilated patients in the ICU and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury.

Design: Prospective cohort study.

Setting: Thirteen ICUs in four hospitals in Baltimore, MD.

Patients: Five hundred twenty mechanically ventilated adult patients with acute lung injury.

Results:

Delirium evaluation was performed by trained research staff using the validated Confusion Assessment Method for the ICU screening tool. A total of 330 of the 520 patients (64%) had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was noncomatose), with a total of 2,286 days of observation and a median (interquartile range) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior nondelirious, noncomatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio; 95% CI) were independently associated with transition to delirium:

older age (compared to < 40 years old, 40–60 yr [1.81; 1.26–2.62], and ≥ 60 yr [2.52; 1.65–3.87]) and

administration of any systemic corticosteroid in the prior 24 hours (1.52; 1.05–2.21).

Conclusions:

After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a nondelirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with acute lung injury.

Schreiber, Matthew P. MD, MHS; Colantuoni, Elizabeth PhD; Bienvenu, Oscar J. MD, PhD; Neufeld, Karin J. MD, MPH; Chen, Kuan-Fu MD, PhD; Shanholtz, Carl MD; Mendez-Tellez, Pedro A. MD; Needham, Dale M. MD, PhD - Corticosteroids and Transition to Delirium in Patients With Acute Lung Injury - Critical Care Medicine: June 2014 - Volume 42 - Issue 6 - p 1480-1486

Q: What precautions / tricks may help in good arterial cannulation of Axillary artery?

Answer:

1. Do under ulrasound guidance

2. Keep arm at 90 degree

3.  Go as proximal in axilla as possible to avoid brachial artery cannulation and to avoid stick to nerves.

Q: What is twiddler syndrome?

Answer:

Twiddler's syndrome is a known complication of pacemakers. It occurs when a patient manipulates and rotates the pulse generator that it results in lead dislodgment, diaphragmatic stimulation and loss of capture. Its  incidence is higher than as thought, around 0.07-7%. Possible causes include elderly age group, obesity, female gender, psychiatric illness, and the small size of the implanted device relative to its pocket. Most dramatic effect beside failure to pace is diaphragmatic contraction by phrenic nerve stimulation, vagus nerve, pectoral muscle, or brachial plexus stimulation resulting in rhythmic arm twitching.

Although originally described with pacemakers, the condition is also reported with implantable cardioverter-defibrillators.

References:

Fahraeus T, Hijer CJ. Early pacemaker Twiddler syndrome. Europace. 2003;5:279–81.

Gupta R, Lin E. Twiddler syndrome. J Emerg Med. 2004;26:119–20.

Castilo R, Cavusoglu E. Twiddler's syndrome: An interesting cause of pacemaker failure. Cardiology. 2006;105:119–21.

Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler's syndrome. N Engl J Med. 2003;348:1726–7.

Sharif M, Inbar S, Neckels B, Shook H. Twiddling to the extreme: Development of Twiddler syndrome in an implanted cardioverter-defibrillator. J Invasive Cardiol. 2005;17:195–6.

2 types of Amiodarone Induced Thyrotoxicosis (AIT)

Q: What are the 2 types of Amiodarone Induced Thyrotoxicosis (AIT)?

Answer:

Type 1 - Which usually affects patients with latent or previously known thyroid disorders and is more common in areas of low iodine intake. It is caused by iodine-induced excess thyroid hormone synthesis and release.

Type 2 - occurs in patients with a previously normal thyroid gland and is caused by a destructive thyroiditis that leads to the release of preformed thyroid hormones from the damaged thyroid follicular cells.

Clinical Significance: Type 2 thyrotoxicosis may respond to course of glucocorticoids, which has membrane-stabilizing and anti-inflammatory effects, as well as glucocorticoids reduce conversion of T4 to T3. Dose is prednisone to start with 30-40 mg/d and taper over a couple of months until free T4 levels are within the reference range. Patient symptoms may biochemically and clinically improve within 1 week following the start of therapy.

To note: some patients may have mixed forms of AIT.

A note on nebulized Lidocaine treatment in intractable cough in ICU

Nebulized lidocaine appears to be well tolerated and effective in the treatment of intractable cough particularly near the end of life. One advantage to nebulized lidocaine is the lack of significant side effects. Patients can be given 5 mL of 2% lidocaine solution with 4–6 L/min oxygen until completion of the nebulized therapy, typically over 3–5 minutes. Patients should be encouraged to maintain head elevation for at least 30 minutes post treatment and to refrain from eating or drinking for 40 minutes after the treatment completed.

Q: Nurse called you to evaluate an intubated patient, who is desaturating. Patient is admitted for community acquired pneumonia and required intubation. Patient is on FiO2 100% and PEEP of 7. You decided to slowly increase PEEP to get saturation more than 90%. As you increase PEEP progressively to 13, patient starts coughing. Is this a good sign or a bad sign?

Answer: Good sign

Any lung recruitment maneuvers followed by cough is a good sign. This is a good sign resulting from expansion of collapsed lung.