Q:  What is the biggest pitfall of interpreting CRP (C-reactive protein) in suspected bacteremia?

Answer: Liver insufficiency

C-reactive protein (CRP) is a widely used marker of sepsis/bacteremia and is an independent predictor of mortality. CRP is synthesized in the liver due to inflammation. Since the CRP response in patients with liver disease is lower than in patients without liver disease, the prognostic information of initial CRP levels in patients with chronic liver disease is weak. And, the clinical management of patients with chronic liver disease and suspected infection should be based more on clinical, radiological and microbiological findings. The measurement of CRP in bacteremia is less helpful as compared with patients without liver disease.

Reference:

Janum SH, Søvsø M, Gradel KO, Schønheyder HC, Nielsen H. - C-reactive protein level as a predictor of mortality in liver disease patients with bacteremia. - Scand J Gastroenterol. 2011 Dec;46(12):1478-83.

Q:  Role of magnesium is not thoroughly known in treatment of eclampsia but what are the few mechanisms suggested?





Answer: MgSO4 has been shown to be a very effective treatment for the prevention and treatment of eclampsia. Its mechanism of action is multi-factorial,  and so has been found to be more effective than traditional anti-epileptics.

1. Being a calcium antagonist, it causes vasodilation 
2. MgSO4 via effect on the cerebral endothelium limits vasogenic edema 
3. MgSO4 may also act centrally to inhibit NMDA receptors, providing anticonvulsant activity by increasing the seizure threshold.

Q:  28 year old female presented with fever, urethral discharge, vesicular rash over body and c/o pain over right knee. What is the probable diagnosis?






Answer: Gonococcal arthritis (disseminated gonococcal infection).


Disseminated Gonococcal Infection (DGI) ia a systemic infection that follows the hematogenous dissemination of the gonococcus from infected mucosal sites to skin, tenosynovium, and joints and is characterized by fever, petechial or pustular acral lesions, asymmetric arthralgias, tenosynovitis, or septic arthritis. It affects women four times more often than men, and is most common among sexually active adolescent girls. There is also increased risk during menstruation and pregnancy.

Q: What is the good positioning of the operator while intubating a patient?


Answer: As the operator stands behind the patient's head, the patient's head should be around at the level of the operator's lower sternum. For ideal view, the operator should keep his or her back straight all the time and should resist any attempt  to  hunch over the patient. If required, any bending should occur in the knees of the operator.

Cricothyrotomy

Merry Christmas

Capillary refill - a basic exam often ignored

Capillary refill is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Ideally it should be measured by holding a hand higher than heart-level, pressing the soft pad of a finger until it turns white. Its the time needed for the color to return once pressure is released. Normal capillary refill time is usually less than 2 seconds but in clinically sick patients up to 5 seconds is acceptable. A prolonged capillary refill time is a sign of shock. Capillary refill should be read with other clinical signs.

Q: 28 year old female with 22 weeks of gestation is admitted to ICU with dehydration secondary to severe diarrhea. Patient has massive leucocytosis with abdominal pain. Patient was recently treated with antibiotics as out-patient  for her community acquired pneumonia. You want to cover her against C.diff. colitis. What would be the preferred agent?

Answer: Oral Vancomycin

Oral vancomycin is preferred over oral metronidazole for severe C.Diff. colitis anyway. Metronidazole has the potential to cause birth defects so during gestation oral vancomycin is preferred over metronidazole.

Reference:

Surawicz, Christina M; Brandt, Lawrence J; Binion, David G; Ananthakrishnan, Ashwin N; Curry, Scott R; Gilligan, Peter H; McFarland, Lynne V; Mellow, Mark et al. (26 February 2013). "Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections". The American Journal of Gastroenterology 108 (4): 478–498

Q: What are the recommendations after needlestick injury from HIV positive patient?

Answer: 

• The site of exposure should be washed liberally with soap and water but without scrubbing.
• Antiseptics and skin washes should not be used.
• Free bleeding of puncture wounds should be encouraged gently but wounds should not be sucked.

Guidelines state that "feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they are visibly bloody."

• The sooner after exposure that Anti Retroviral Therapy is started the better. Guidelines recommends starting prophylaxis up to a week after exposure.
• Recommendation is to treat for a duration of 4 weeks.
• Recommended regimen is emtricitabine + tenofovir + raltegravir. 
• HIV testing at 6, 12, and 24 weeks

Reference:

"Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recomme

Q: Which of the following can be used as a treatment in Torsade de Pointes except

A)Overdrive intravenous pacing

B) Cardioversion

C) Phenytoin

D) Lidocaine

E) Isoproterenol

F) Amiodarone 

Answer: F

Best treatment of Torsades De Pointes is removal of an offending cause like hypokalemia, hypomagnesemia, drugs causing prolong QTc prolongation.

IV Magnesium is the drug of choice, as bolus of  1-2 g IV over 30-60 seconds, followed by a continuous infusion. Supplemental potassium may help. Phenytoin, Lidocaine, Mexiletine and Isoproterenol has been suggested.

QT interval shortens with a faster heart rate, so overdrive pacing can be effective  at a rate of 90-110 bpm until the QT interval is normalized. Overdrive pacing may be necessary at a rate of up to 140 bpm to control the rhythm.Conversion with combination of phenytoin and overdrive pacing as been described frequently.

Amiodarone which is the mainstay of treatment in ACLS usually is ineffective. Objective of the above question is to highlight the importance of the identification of the proper rhythm. Torsade is extremely common in ICU mostly due to either electrolyte disturbance of multiple offending drugs.

Q: At what level of decreased Glomerular filtration rate (GFR), insulin resistance (IR) may occur? 

Answer:  around 50 or less

Clinical relevance: IR is common (but may go unnoticed due to its sub-clinical manifestations) in patients with mild-to-moderate CKD (Chronic Kidney Disease). Consequently, IR is an independent predictor of cardiovascular mortality in ESRD, therefore, IR may be an important therapeutic target for reduction of cardiovascular mortality in patients with CKD.

Treatment: Thiazolidinediones (TZDs) are a class of oral diabetic medications that increase insulin sensitivity in peripheral tissue. Also, proper nutritional supplementation, prevention of dyslipidemia, vitamin D deficiency and anemia  improves insulin sensitivity among the CKD population.

References:

S. Kobayashi, K. Maesato, H. Moriya, T. Ohtake, and T. Ikeda, “Insulin resistance in patients with chronic kidney disease,” American Journal of Kidney Diseases, vol. 45, no. 2, pp. 275–280, 2005.

K. Shinohara, T. Shoji, M. Emoto et al., “Insulin resistance as an independent predictor of cardiovascular mortality in patients with end-stage renal disease,” Journal of the American Society of Nephrology, vol. 13, no. 7, pp. 1894–1900, 2002.

S. M. Brunelli, R. Thadhani, T. A. Ikizler, and H. I. Feldman, “Thiazolidinedione use is associated with better survival in hemodialysis patients with non-insulin dependent diabetes,” Kidney International, vol. 75, no. 9, pp. 961–968, 2009.

Q: 22 year old male just came out of OR to ICU after uncomplicated peri-operative course of kidney transplant. Patient is extubated and vitals are stable. Patient has good urine output. Patient has been started on protocol of anti-rejection medicines. After 30 minutes patient developed high grade fever, chills and hypotension. Clinical picture appears like septic shock. What could be other differential diagnosis? 

Answer: cytokine release syndrome

Solid organ transplants require immediate post-op infusion of Anti-Thymocyte-Globulin (ATG) infusion. ATG infusion may induce cytokine release syndrome and may causes high grade fevers, chills and rigors during administration. Cytokine infusion syndrome can be controlled/avoided with pre-medication with methylprednisolone, diphenhydramine 25–50 mg, and acetaminophen 650 mg - and by slowing the infusion rate of ATG. Cytokine release syndrome is a common immediate complication particularly after the infusion of first dose of ATG.

The pathogenesis is that the antibodies bind to the T cell receptor, activating the T cells before they are destroyed. The cytokines released by the activated T cells produce a type of systemic inflammatory response (SIRS) manifested by hypotension, fever and rigors.

Severe cases are called cytokine storms.

.

On restraints, delirium and open visting hours in ICU

One of the trick which has been suggested and has been used successfully by nursing staff, but still under utilized is getting family online /phone/ even cam (if privacy insured) with patient.

"Parikh recalled a night during his residency rotation where instead of restraining a patient, the medical team in the ICU reoriented the patient by reminding him where he was and the time of day, offered him medication to treat his anxiety, and called his wife and put her on the telephone to provide a familiar voice. "The patient eventually calmed down without the need for restraints or other aggressive interventions, and the next morning his mental status improved," he wrote. "I hope that stories like his can become the standard, not the exception, in the ICU."

In this regards, read the following article - a hot debate in Critical Care community - regarding open ICU hours for family:

Practice Alert: family-visitation-adult-icu **

* RAVI PARIKH - Rethinking Hospital Restraints - http://www.theatlantic.com/health/archive/2014/08/rethinking-hospital-restraints/375647/

** http://www.aacn.org/WD/practice/docs/practicealerts/family-visitation-adult-icu-practicealert.pdf

Q: 62 year old male was admitted to ICU for urosepsis. Patient is recovering from sepsis. Patient c/o pain on his right great toe in the morning and resident diagnosed it with acute gout. Clinical exam shows painful and inflamed joint. Laboratory confirmed hyperurecemia. Patient  has never been treated previously for gout and is not taking any medicine on chronic basis. what would be your next step?



Answer: Rule out septic arthritis

Patient with recent sepsis should be ruled out for septic arthritis particularly in view of no previous history, Hyperurecemia may be an accidental finding. Septic arthritis may clinically looks like gout or pseudogout on exam. If un-treated septic arthritis may become life threatening. Gold standard to distinguish between septic arthritis and crystal-induced arthritis is via examination of joint fluid.

Q: Tumor Lysis Syndrome can do all of the following except:

A) Hyperkalemia

B) Hyperphosphatemia

C) Hypercalcemia

D) Hyperuricemia


Answer: C

Tumor Lysis syndrome causes hypocalcemia instead of hypercalcemia

Cairo and Bishop defined a classification system for tumor lysis syndrome dividing it into categories

Laboratory tumor lysis syndrome: 
(abnormality in 2 or more of the following, occurring within three days before or seven days after chemotherapy).

• uric acid > 8 mg/dL or 25% increase
• potassium > 6 meq/L or 25% increase
• phosphate > 4.5 mg/dL or 25% increase
• calcium < 7 mg/dL or 25% decrease

Clinical tumor lysis syndrome: 
(laboratory tumor lysis syndrome plus one or more of the following)

• increased serum creatinine (1.5 times upper limit of normal)
• cardiac arrhythmia or sudden death
• seizure

Reference:

Cairo MS, Bishop M (October 2004). "Tumour lysis syndrome: new therapeutic strategies and classification". Br. J. Haematol. 127 (1): 3–11.

Interesting story on foley catheter related urethral trauma

"When I was a resident, a fellow was sick of being called about a demented old man pulling his catheter and occasionally pulling it out. He was so frustrated he tucked the real catheter between his legs and taped it to the back of his leg, he then taped 7-8 dummy foleys that the patient could reach and intermittently pull on to keep himself busy!"

Source:  http://forums.studentdoctor.net/

Q: What is considered as an endpoint success in Barbiturate coma therapy (BCT)  from ICP (intra cranial pressure) control perspective in neurotrauma patients?

Answer: ICP < 20 mmHg for at least 48 hours, at a minimum

Patients, whose ICPs are successfully controlled by pentobarbital, had at least five times greater chance of survival. 

References:

Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD. High dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg. 1988;69:15–23.

Etienne D, Jacques B, Arlette V, Florence L, Jean LV. Barbiturate coma for intracranial hypertension: clinical observations. J Crit Care. 2002;17:58–62.

Horsley JS. The intracranial pressure during barbital narcosis. Lancet. 1937;1:141–143.

Michael WL, Scott AD, Mary ES, Roger RB, Dan RT. The efficacy of barbiturate coma in the management of uncontrolled intracranial hypertension following neurosurgical trauma. J Neurotrauma. 1994;11:325–331.

Q: What anti-seizure medicine may cause hyperammonemic encephalopathy, despite normal liver function, normal doses and normal serum levels?

Answer: Valproic acid (VPA)

The use of valproic acid (VPA) (Depakote) frequently causes hyperammonemia. Usually it is clinically not significant but in some people, hyperammonemia may be clinically evident as encephalopathy, which may become life threatening. Valproic acid-induced hyperammonemic encephalopathy may occur in people with normal liver function, with normal doses and normal serum levels.

Reference:

Wadzinski J, Franks R, Roane D, Bayard M. - Valproate-associated hyperammonemic encephalopathy. - .J Am Board Fam Med. 2007 Sep-Oct;20(5):499-502.

Q: What is the heterotopic heart transplant?

Answer: Mostly heart transplant is orthotopic means the patient's own heart is removed and new heart is transplanted.

In heterotopic heart transplant, surgeon may decide to leave the patient's own heart along with new heart (yes! double heart).  The chambers and blood vessels of both hearts can be connected. It may be perform when native heart has a chance to recover, there is a high likelihood of rejection, if the donor heart is sensed to be weak or the patient has underlying severe pulmonary hypertension.

Q: Beside steroids which drug may cause hyperglycemia in post-transplant patients?

Answer: Tacrolimus

Hyperglycemia can occur in 33 to 47% of patients receiving tacrolimus. About 11 to 20% of patients develop Insulin-dependent diabetes post-transplant. In many patients it is reversible. It is found to be more common in blacks and in patients receiving high-dose steroids.

Q: 54 year old male is admitted to ICU after ischemic CVA causing dense right sided hemiplegia. Patient is scheduled to get MRI. While talking to wife, she informed you that patient had a recent work up for GI bleed as out-patient and capsule endoscopy was performed. What is your concern?

Answer: Bowel injury 

Device retention after capsule endoscopy may happen in patients with crohn's disease, neoplastic lesions, stenosis, and adhesions. The feared complication of MRI with capsule retention is migration of the capsule causing bowel perforation. It would be safe to document the passage of an endoscopic capsule before MRI by performing KUB.  Some centers recommend 30 days time period between capsule endoscopy and MRI.

Reference:

Berry PA, Srirajaskanthan R, Anderson SH. An urgent call to the magnetic resonance scanner: potential dangers of capsule endoscopy. Clin Gastroenterol Hepatol. 2010;8(5):A26

Q: 27 year old female is in ICU after acetaminophen toxicity. Patient was promptly started on N-acetylcysteine (NAC) in ER. Patient after 10 hours of N-acetylcysteine (NAC) infusion is clinically stable. Patient acetaminophen level is markedly down. What would be your next step?

A) Continue N-acetylcysteine (NAC)

B) stop  N-acetylcysteine (NAC) to avoid fluid overload

C)  check Amylase and Lipase

D) Check ABG and LFT and if normal - discharge patient home

Answer: A

The entire NAC protocol, should be completed even if patient clinically stabalizes or the acetaminophen plasma levels decreases. There is no reason to check amylase lipase if clinical signs are normal. Also, it may help to keep eye on ABG and LFT but patient should be kept in hospital till completely clear, as extended release forms of drug may bounce back the level.

Q: You were surprised with black colored pleural effusion on thoracentesis. What are your differential diagnosis?

Answer:

• infection with Aspergillus niger
• infection with Rizopus oryzae,
• malignant melanoma,
• non-small cell lung cancer 
• ruptured pancreatic pseudocyst,
• charcoal-containing empyema

Reference:

Saraya T, Light RW, Takizawa H, Goto H. Black pleural effusion. Am J Med. Jul 2013;126(7):641.e1-6.

RiaSTAP

In patients with fibrinogen deficiency, now along with cryopreciptate Fibrinogen Concentrate (Human) - Trade name RiaSTEp is available. RiaSTAP is not indicated for dysfibrinogenemia, but is indicated for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia. It may be use in acute post-op bleeding due to hypofibrinogenemia. Dose should be individually calculated for each patient based on

•  the target plasma fibrinogen level
• actual measured plasma fibrinogen level and
• body weight

formula is 

[Target level (mg/dL) - measured level (mg/dL)] /
 1.7 (mg/dL per mg/kg body weight)

When baseline fibrinogen level is not known, the recommended dose is 70 mg per kg of body weight.

Reference:

RiaSTEP package http://www.fda.gov/downloads/Biolog...ionatedPlasmaProducts/ucm094006.pdf

Q: Steroids are widely used in ICUs. How early it can cause psychosis?

Answer: 3 to 4 days

Steroid-induced psychosis may emerge within 3 to 4 days (to a median of 11 days) after a patient starts corticosteroid therapy. Unfortunately, even after steroids are discontinued, symptoms may persists up to 4 weeks. Meanwhile, different anti-psychotics may be used including haloperidol, olanzapine, risperidone, quetiapine, lithium, carbamazepine and others. Resistant cases may require electroconvulsive therapy. 

References:

1. Sirois F. Steroid psychosis: a review. Gen Hosp Psychiatry 2003;25:27-33.

2. Patten SB, Neutel CI. Corticosteroid-induced adverse psychiatric effects: incidence, diagnosis and management. Drug Saf 2000;22:111-22.

3.  Wada K, Yamada N, Suzuki K, et al. Recurrent cases of corticosteroid-induced mood disorder: a clinical characteristics and treatment. J Clin Psychiatry 2000;61:261-7.

4.  Brown ES, Chamberlain W, Dhanani N, et al. An open-label trial of olanzapine for corticosteroid-induced mood symptoms. J Affect Disord 2004;83:277-81.

5.  Wada K, Yamada N, Yamauchi Y, Kuroda S. Carbamazepine treatment of corticosteroid-induced mood disorder. J Affect Disord 2001;65:315-7.

6.  Siddiqui Z, Ramaswamy S, Petty F. Quetiapine therapy for corticosteroid-induced mania. Can J Psychiatry 2005;50:77-8.

7. DeSilva CC, Nurse MC, Vokey K. Steroid-induced psychosis treated with risperidone. Can J Psychiatry 2002;47:388-9.