Q: TandemHeart can provide Cardiac Index up to what level?


Answer:  Cardiac index of 2.62 L/min/m2

The pump flow rate ranged from 1.5 to 3.5 L/min, which resulted in an average cardiac index of 2.62 L/min/m2. IABP flow rates are limited to approximately 1.5 L/min. TandemHeart can provide up to 4 L/min. The higher level of support provided by the TandemHeart results in better hemodynamics and metabolic parameters, although it may not improve the survival rate.

Q: What are the three levels of BPF (Broncho-pleural Fistula)?

Answer: 

The severity of the air leak is generally measured into 3 levels from least to most severe:

●Bubbling during inspiration only
●Bubbling during both inspiration and expiration
●Bubbling during both inspiration and expiration, as well as a detectable difference in the inspired and expired tidal volumes

The last category suggests that there is an air leak greater than 100 to 150 mL per breath.

Q: How much Talc powder is needed for pleurodesis?

Answer: 3 to 5 grams

For pleurodesis, 3 to 5 grams of talc are insufflated into the pleural space. For pneumothorax pleurodesis, 3 grams of talc are sufficient.

Q: How frequent tubing for propofol infusion should be changed?

Answer: 12 hours

Recommended time period to change tubing for prolong propofol infusion is about 12 hour. This is due to propofol's lack of preservatives and its ability to support the growth of microorganisms.

                            

Q: Risk of re-feeding syndrome increases after how many days of NPO status or poor intake?

Answer: 5 days

It is not uncommon in ICUs for patients to go without feed for few days. It is important to understand that any patient who has had negligible nutrient intake for more than 5 consecutive days is at risk of refeeding syndrome. And, refeeding syndrome usually occurs within four days of starting to feed.

Q: Which one electrolyte should be replaced with Thiamine infusion in Wernicke's encephalopathy?

Answer:  Mg

Magnesium is a co-factor in many thiamine dependent enzymes involved in carbohydrate metabolism. Thaimine may not work in the presence of low magnesium. This is clinically an extremely important point as alcoholics usually lack magnesium.

Q: Which 2 common conditions in ICU may give falsely elevated Pre-Albumin level?

Answer:

1. Alcohol intake
2. Steroid administration

In acute alcohol intoxication, a leakage of proteins from damaged hepatic cells may cause a rise in the prealbumin level. Consequently, alcoholics may have elevated levels of prealbumin after binge drinking. It takes about 7 days when levels return to baseline. Also, serum prealbumin levels may rise during prednisone/steroid therapy.

References:

Staley MJ, Naidoo D, Pridmore SA. Concentrations of transthyretin (prealbumin) and retinol-binding protein in alcoholics during alcohol withdrawal [Letter]. Clin Chem. 1984;30:1887.

Oppenheimer JH, Werner SC. Effect of prednisone on thyroxine-binding proteins. J Clin Endocrinol Metab. 1966;26:715–21.

AIMS65 Score

●Albumin less than 3.0 g/dL (30 g/L)

●INR greater than 1.5

●Altered Mental status

●Systolic blood pressure of 90 mmHg or less

●Age older than 65 years

the mortality rate predicted

●Zero risk factors: 0.3 percent

●One risk factor: 1 percent

●Two risk factors: 3 percent

●Three risk factors: 9 percent

●Four risk factors: 15 percent

●Five risk factors: 25 percent

Q: Name 3 conditions where PT, PTT and platelet count is not affected - but only the bleeding time increase?

Answer:

1. ASA

2. Uremia

3. Glanzmann's Thromboasthenia

Q: Intestinal bacteria synthesize a large amount of Vitamin K. Taking broad spectrum antibiotics can destroy how much of that capacity?

Answer: 2/3rd

Taking broad-spectrum antibiotics can reduce vitamin K production in the gut by nearly 75% in people compared with those not taking these antibiotics.

Reference

Conly, J; Stein K (1994). "Reduction of vitamin K2 concentrations in human liver associated with the use of broad spectrum antimicrobials". Clinical and investigative medicine. Médecine clinique et experimentale 17 (6): 531–539.

Q: What is the rule of thumb to diagnose Rhabdomyolysis using CPK level?

Answer: Once CPK levels reach above 5 times the upper limit of normal, it can be label as rhabdomyolysis.

Q: 72 year old male, nursing home resident, admitted to ICU for Pneumonia and getting treated with Linezolid start having fever, agitation and myoclonus which is more pronounced in the lower limbs than in the upper limbs. What is your concern?

Answer: Serotonin Syndrome

One of the clinical diagnostic clue of Serotonin Syndrome is hyperreflexia and clonus more prononuced in the lower extremities than upper, at least in the moderate cases.

Reference:  Boyer, EW; Shannon, M (2005). "The serotonin syndrome". N Engl J Med 352 (11): 1112–20.

Q: Which 2 commonly used drugs in ICU may cause non-infectious Leucocytosis beside steroids?

Answer:

1. Lithium

2. Beta Agonists

Reference

NEIL ABRAMSON, M.D., and BECKY MELTON, M.D., - Leukocytosis: Basics of Clinical Assessment - Am Fam Physician. 2000 Nov 1;62(9):2053-2060.

Q: What are the 2 major different risk factors in Acute Eosinophilic pneumonia (AEP) and chronic Eosinophilic pneumonia (CEP)?

Answer:

In AEP men are affected approximately twice as frequently as women - and - AEP has been associated with smoking. 

CEP occurs more frequently in women and does not appear to be related to smoking. But, an association with radiation for breast cancer has been described.

Q: What is the cutoff point for the thickening of the gallbladder in acalculous cholecystitis on ultrasound?


Answer: 3 to 3.5 mm

Ultrasound is preferable in patients suspected of having acalculous cholecystitis as it is noninvasive, can be done at the bedside, and has good sensitivity and specificity. Thickening of the gallbladder wall is the most reliable feature seen in patients with acalculous cholecystitis. Using a cutoff of 3.5 mm, ultrasonography has a sensitivity of 80 percent and a specificity of 99 percent for detecting acalculous cholecystitis. If a cutoff of 3 mm is used, the sensitivity is 100 percent with a specificity of 90 percent.

Q: Which condition is abbreviated as "SILENT"?

Answer:  "Syndrome of Irreversible Lithium-Effectuated Neurotoxicity" (SILENT)

Neurotoxicity from Lithium acute or chronic overdose is irreversible and causes  cerebellar dysfunction.


Reference:

Adityanjee; Munshi, Thampy (2005). "The syndrome of irreversible lithium-effectuated neurotoxicity.". Clinical Neuropharmacology 28 (1): 38–49.

Q: Name at least 3 commonly used drugs in ICU - which should not be infuse via same infusion/port line as furosemide infusion?

Answer:

• labetalol
• ciprofloxacin 
• milrinone 

Furosemide drip is usually prepared in the weakly alkaline to neutral range. Above drugs are usually prepared in acid solutions. They must not be administered concurrently in the same infusion because they may cause precipitation of the furosemide. Also, furosemide injection should not be added to a running intravenous line containing any of these acidic products.

Q:  Indomethacin is one of the NSAID which is used in nephrogenic DI (Diabetes Insipidus). What is the mehansim of action?


Answer: NSAIDs are used as an adjuvant treatment in DI. NSAIDs may act by inhibiting prostaglandin synthesis in Diabetes Insipidus. Inhibition of prostaglandin synthesis reduces the delivery of solute to distal tubules, reducing urine volume and increasing urine osmolality.

Q:  How Desmopressin is different from Vasopressin?


Answer: Desmopressin, 1-deamino-8-O-arginine-vasopressin (DDAVP) is a synthetic analogue of arginine vasopressin. It has 10 times the antidiuretic action of vasopressin, but 1500 times less vasoconstrictor action. These modifications make metabolism slower with half-life of 158 min.

Q:  What different options are available, in case patient develops life-threatening bleeding as a complication of fibrinolytic therapy?


Answer: If a patient treated with fibrinolytic develops serious bleeding, the first step is to stop the fibrinolytic agent and any anticoagulants. Hemodynamic stability with volume and pressors as suppoprtive therapy is vital.

Aminocaproic acid: Aminocaproic acid is a specific antidote to fibrinolytic agents. Loading dose is 4-5 g of aminocaproic acid over one hour, followed by a continuing infusion at the rate of 1 g / hour. Infusion is continued for about 8 hours or until the bleeding situation has been controlled. Aminocaproic acid should not be given unless hemorrhage is life-threatening, because it inhibits intrinsic fibrinolytic activity.

Blood products: FFP, cryoprecipitate, or both may be used to replenish fibrin and clotting factors.

Q:  How you define trophic enteral feeding?

Answer: Trophic feeding is a small volume of balanced enteral nutrition insufficient for the patient's nutritional needs but produce positive gastrointestinal and some systemic benefit. If less than 25% of the patient's nutritional needs are administered enterally, the feeding is considered trophic. The commonly identified benefits of trophic feeding are improved feeding tolerance, maintenance of intestinal function, and prevention of intestinal bacterial overgrowth and bacterial translocation.

Q:  In which 3 clinical conditions Anti-XA Assay can be misleading?


Answer:

1. Hemolysis

2. Hyperbilirubinemia

3. High lipids

Q:  What is the formula to calculate fibrinogen to be infused via cryoprecipitate to patient?

Answer:

Number of bags = 0.2 x weight (kg) to provide about 100mg/dL fibrinogen

Usually, pack of 10 units given together.

Fibrinogen levels should be monitored to adjust dosing.

Q:  What is Platypnea-orthodeoxia?

Answer: Platypnea-orthodeoxia is a clinical syndrome characterized by dyspnea and deoxygenation accompanying a change to a sitting or standing from a recumbent position.

Two conditions must coexist to cause platypnea-orthodeoxia:

an anatomical component - in the form of an interatrial communication such as PFO or ASD and

a functional component - that produces a deformity in the atrial septum and results in a redirection of shunt flow with the assumption of an upright posture. This includes pericardial effusion, constrictive pericarditis, emphysema, pneumonectomy, cirrhosis, ileus, aortic aneurysm etc.

Standing upright could stretch the interatrial communication, allowing more streaming of venous blood from inferior vena cava through the defect. This redirection of flow caused by an anatomic distortion of the right atrium or the atrial septum get clinically enhanced by functional component present.



Reference:

Cheng TO. - Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Cathet Cardiovasc Interv. 1999; 47: 64–66..

Q:  What percentage of patients may require permanent pacemaker (PPM) after transcatheter aortic valve implantation (TAVI)(Corvalve)?


Answer:  About 1/3rd

One third of patients undergoing a (CoreValve) transcatheter aortic valve implantation procedure may require a PPM. Followin factors may effect the need:

• Periprocedural atrioventricular block,
• balloon predilatation,
• use of the larger CoreValve prosthesis,
• increased interventricular septum diameter and
• prolonged QRS duration

References:

Permanent Pacemaker Insertion After CoreValve Transcatheter Aortic Valve Implantation
Incidence and Contributing Factors (the UK CoreValve Collaborative) M.Z. Khawaja, MBBS; and co.  -  Circulation.2011; 123: 951-960

Q:  52 year old male is admitted to ICU as "Pre-op" CABG patient. Previous admission record showed patient with diagnosis of HIT (Heparin Induced Thrombocytopenia) 2 years ago. You rechicked HIT test and OD (optimal density) for HIT is reported as 0.2. What would be your advise on use of Heparin?


Answer:  Patients with previous history of HIT but now with negative antibodies can have heparin during CBP but it should be avoided pre or post surgery.




References:

1. Follis F, Schmidt CA. Cardiopulmonary bypass in patients with heparin-induced thrombocytopenia and thrombosis. Ann Thorac Surg. 2000;70:2173-2181.

2. Warkentein TE. Heparin-induced thrombocytopenia: pathogenesis, frequency, avoidance and management. Drug Safety. 1997;17:325-341.

Q:  What is the most common cause of "false-negative" D-Dimer test?

Answer:  inappropriate collection of specimen

D-Dimer test may give "false-negative" result if the specimen collection tube is not sufficiently filled (undefiled). This is due to the dilutional effect of the anticoagulant. The blood should be collected in a 9:1 blood to anticoagulant ratio, in specimen tube.