Thursday, December 31, 2015

Q: Metabolic Alkalosis causes Hypocalcemia 

 A) True
B) False


Answer: 
True


Alkalosis causes an ionization of albumin, making in more negative. Due to higher negative charge on albumin, calcium binds to albumin with greater affinity, resulting in reduction of total free calcium. It may get clinically significant in severe or persistent alkalosis. 

The opposite is true for acidosis.

Wednesday, December 30, 2015

Q: While reviewing chest X-ray after floating Pulmonary Artery Catheter (PAC), you suspect possible knotting of catheter in right ventricle. Which one bedside trick may help in resolving knot before embarking on more invasive resolutions?


Answer: Inject about 20 mL of iced solution through the distal lumen 


If knotting of swan-ganz catheter(PAC) is suspected, many times injecting about 20 mL of cold sterile saline or iced solution through the distal lumen stiffens the catheter and help in resolving the knot. Interestingly, this trick was described almost 40 years ago, even before swan-ganz catheters later became popular in 1980s and 1990s. If this trick does not work, patient needs to go to cardiac catheter laboratory for placement of a wire under fluoroscopy. Alternatively, Interventional Radiology (IR) or vascular surgical service need to be consulted. In all ultimate failed cases, cardiothoracic surgery may require to perform open extraction of PAC.



 Reference: 

 Mond HG, Clark DW, Nesbitt SJ, Schlant RC. A technique for unknotting an intracardiac flow-directed balloon catheter. Chest 1975; 67:731.

Tuesday, December 29, 2015

Q:  Triad of 
  • thrombocytopenia, 
  • a left-shifted granulocytic series on smear, and 
  •  an immunoblast count exceeding 10 percent of the total lymphoid series
is diagnostic of which disease?


Answer:  Hantavirus cardiopulmonary syndrome (HCPS)

If HCPS is strongly suspected and if above triad is found in a patient, it calls for a prompt response, probably insertion of ECMO device. HCPS is unique in the sense that symptoms of noncardiogenic pulmonary edema and hemodynamic collapse happens abruptly. Interestingly, symptoms resolve as quickly as the onset. Usual time period of hemodynamic instability lasts between 24 to 48 hours and proper and preemptive hemodynamic support can be life saving in literal sense.


References:

Koster F, Foucar K, Hjelle B, et al. Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review. Am J Clin Pathol 2001; 116:665.  

Hallin GW, Simpson SQ, Crowell RE, et al. Cardiopulmonary manifestations of hantavirus pulmonary syndrome. Crit Care Med 1996; 24:252.

Crowley MR, Katz RW, Kessler R, et al. Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation. Crit Care Med 1998; 26:409.

Monday, December 28, 2015

Q: At what level of ventilator settings, surgically placed tracheostomy(ST) is preferred over bedside Percutaneous Dilational Tracheostomy(PDT)?


Answer:  Nothing beats an experienced operator irrespective of which technique is used. Though PDT is now considered as standard of care for tracheostomy but in few cases ST should be prefered over PDT. Three conditions deserve special attention. 

Firstly, coagulation abnormalities, since bleeding vessels are under direct vision in ST, and provides better control against any bleeding catastrophe. 

Secondly, high ventilator settings, particularly when FiO2 is at or above 70% or PEEP is at or above 10. 

Thirdly, obese patients with "no neck" or patients with previous surgery or mass in neck area.

In Trauma-ICU, added condition of unstable cervical spine need consideration of ST technique.




Sunday, December 27, 2015

Q: 78 year old male admitted 2 days ago with Transient Ischemic Attack(TIA) and community acquired pneumonia to ICU. Patient developed SVT(Supraventricular Tachycardia) with Heart Rate of 190 causing hypotension. All of the following can be part of management except?

A) IV fluid(IVF)
B) Carotid sinus massage
C) Oxygen to counter hypoxemia
D) Cardioversion
E) Adenosine 



Answer: B

According to guidelines from various societies carotid sinus massage should not be performed in patients with TIA or CVA (cerebrovascular accident) within last three months. Also, it should be avoided in patients on side of carotid artery stenosis or on patients with carotid artery bruit.


IVF is an integral part of management in hemodynamic instability with arrhythmia.


Hypoxemia can be a major trigger of SVT in patients with respiratory disease and oxygen should be administer to counter it.


Cardioversion and Adenosine are both viable options in management of SVT. 




 References:

1. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631

2. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006; 113:316.

Saturday, December 26, 2015

Q; What isidrabiotaparinux? 


Answer:  idrabiotaparinux can be called third generation long acting fondaparinux.

First generation Fondaparinux (arixtra) is the only clinically known low molecular weight Heparin which can be used in Heparin-Induced-Thrombocytopenia (HIT). But on flip side, it has no reversal in case of bleeding except supportive treatment via transfusions.

Second generation fondaparinux is called idraparinux but it quickly lost its charm (actually development)  as it was extremely long acting with dosing once a week without any reversal like parent fondaparinux.

Third generation fondaparinux is called idrabiotaparinux. It is in Phase 3 trials and have advantage of availability of reversal, though it remained once a week dosing. The reversal is via intravenous administration of avidin, which binds to the biotin molecule in the drug. Once a week dosing with availability of reversal may make it a good choice as outpatient treatment  of venous thromboembolism.


References:

1. Equinox Investigators. Efficacy and safety of once weekly subcutaneous idrabiotaparinux in the treatment of patients with symptomatic deep venous thrombosis. J Thromb Haemost 2011; 9:92.

2. Büller HR, Gallus AS, Pillion G, et al. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet 2012; 379:123.

3.  Paty I, Trellu M, Destors JM, et al. Reversibility of the anti-FXa activity of idrabiotaparinux (biotinylated idraparinux) by intravenous avidin infusion. J Thromb Haemost 2010; 8:722.

Thursday, December 24, 2015

Q: While performing subclavian central vein cannulation, you inadvertently puncture the subclavian artery. Beside applying pressure, which one other maneuver may help in preventive massive bleeding?


Answer:  Elevation of the ipsilateral arm

Ideally, like Internal Jugular vein(IJ) Subclavian vein(SC) should also be cannulated under ultrasound guidance. Special probes are available for subclavian vein visualization under ultrasound. In case, if during SC-CVC cannulation subclavian artery gets punctured, after withdrawing the needle, alongside applying pressure, elevating the ipsilateral arm overhead may help, as it compresses the vein.

Wednesday, December 23, 2015

Q: Presence of leukoaraiosis increases the risk of intracerebral hemorrhage after intravenous thrombolysis for acute ischemic stroke. What is leukoaraiosis?


Answer: Leukoaraiosis is also known as white matter hyperintensities. Radiologically, they appear as decreased density on CT and increased signal intensity on T2/FLAIR sequences on MRI. Leukoaraiosis is a nonspecific finding by itself  but may be a manifestation of underlying diseased vessels and frequently seen in patients with hypertension, tobacco use, diabetes, ischemic heart disease etc. Various factors increase the risk of intracerebral hemorrhage after intravenous thrombolysis for acute ischemic stroke. Intensivists are usually the first line of caregivers beside neurologists to get call  for any complication after intravenous thrombolysis for acute ischemic stroke. These factors include presence of leukoaraiosis prior to thrombolysis, stroke severity, age, history of heart disease particularly atrial fibrillation, uncontrolled diabetes, chronic kidney disease (CKD), uncontrolled blood pressure after thrombolysis, thrombocytopenia, on antiplatelet or warfarin therapy etc.




References:

1. Neumann-Haefelin T, Hoelig S, Berkefeld J, et al. Leukoaraiosis is a risk factor for symptomatic intracerebral hemorrhage after thrombolysis for acute stroke. Stroke 2006; 37:2463. 

2. Palumbo V, Boulanger JM, Hill MD, et al. Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke. Neurology 2007; 68:1020

3. Curtze S, Haapaniemi E, Melkas S, et al. White Matter Lesions Double the Risk of Post-Thrombolytic Intracerebral Hemorrhage. Stroke 2015; 46:2149.

Tuesday, December 22, 2015

Q: For elevated intracranial pressure (ICP), few basic strategies at bedside play huge role in overall management and outcome. Name few?


Answer: 
  1. Keep head of the bed elevated at around 30 degrees
  2. Avoid excessive flexion or rotation of the neck 
  3. Avoid too restrictive taping around the neck 
  4. Minimize endotracheal suctioning (minimize Valsalva response)
All of the above maneuvers are targeted  to maximize venous outflow from the head and to keep ICP from rising.


 Reference: 

 Rosner MJ, Coley IB. Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 1986; 65:636.

Monday, December 21, 2015

Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome

Background: Studies in patients with acute coronary syndrome (ACS) undergoing invasive management showed conflicting conclusions regarding the effect of access site on outcomes.

Purpose: To summarize evidence from recent, high-quality trials that compared clinical outcomes occurring with radial versus femoral access in invasively managed adults with ACS.

 Data Sources: English-language publications in MEDLINE, EMBASE, and Cochrane databases between January 1990 and August 2015. Study Selection: Randomized trials of radial versus femoral access in invasively managed patients with ACS.

 Data Extraction: Two investigators independently extracted the study data and rated the risk of bias.

 Data Synthesis: Of 17 identified randomized trials, 4 were high-quality multicenter trials that involved a total of 17 133 patients. Pooled data from the 4 trials showed that radial access reduced death (relative risk [RR], 0.73 [95% CI, 0.59 to 0.90]; P = 0.003), major adverse cardiovascular events (RR, 0.86 [CI, 0.75 to 0.98]; P = 0.025), and major bleeding (RR, 0.57 [CI, 0.37 to 0.88]; P = 0.011). Radial procedures lasted slightly longer (standardized mean difference, 0.11 minutes) and had higher risk for access-site crossover (6.3% vs. 1.7%) than did femoral procedures.

 Limitation: Heterogeneity in outcomes definitions and potential treatment modifiers across studies, including operator experience in radial procedures and concurrent anticoagulant regimens.

Conclusion: Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS undergoing invasive management. 


Reference: 

Giuseppe Andò, MD, PhD; and Davide Capodanno, MD, PhD - A Call to Arms: Radial Artery Access for Percutaneous Coronary Intervention Ann Intern Med. 2015;163(12):932-940. - December 15, 2015

Sunday, December 20, 2015

Q:  What is the 'rule of thumb' for giving Digoxin immune Fab (digibind, DigiFab) in patients with digoxin ingestion resulting in toxicity?


Answer:  Each vial of DigiFab  contains 40 mg of Fab and it binds 0.5 mg digoxin. As a 'rule of thumb'

  • - in acute ingestion of unknown amount 10 vials are recommended, and if required 10 more vials can be administered.
  • - in patients on chronic digoxin therapy, where toxicity is suspected -  6 vials should be sufficient to resolve symptoms.
Resolution can be best monitored by EKG changes. Resolution may be visible in 30 minutes but it takes 2-4 hours before full effect takes place. 


DigiFab is usually given in IV preparation over 30 minutes, but IV push can be given in life-threatening situations though it may cause some febrile reactions, otherwise it is considered to be a safe medicine. It should be avoided in patients with allergy to sheep protein and papaya extracts.

Saturday, December 19, 2015

A note on gastric mucosal acidosis as a mechanical weaning parameter

 Gastric mucosal acidosis has been proposed and studied as an indicator of mechanical ventilator weaning success or failure. Assumption based on the idea that in respiratory distress blood supply get diverted from the splanchnic vascular bed to the respiratory muscles. It has also been proposed that gastric mucosal acidosis if accompanied by higher intraluminal gastric carbon dioxide (PgCO2) can provide a more better criteria of ventilator weaning success or failure. In clinical practice, it is not popular probably because it requires  a special nasogastric tube. Also, other clinical indices so far remained satisfactory for clinicians.



References: 

1. Mohsenifar Z, Hay A, Hay J, et al. Gastric intramural pH as a predictor of success or failure in weaning patients from mechanical ventilation. Ann Intern Med 1993; 119:794. 

2. Hurtado FJ, Berón M, Olivera W, et al. Gastric intramucosal pH and intraluminal PCO2 during weaning from mechanical ventilation. Crit Care Med 2001; 29:70.

Friday, December 18, 2015


Q: In patients with exacerbation of congestive heart failure(CHF) - what is the appropriate target for weight reduction with diuresis?


Answer:  An appropriate target  in  exacerbation of  CHF with diuresis is weight reduction of about 1.0 kg/day.

Thursday, December 17, 2015

Q: 58 year old male who underwent Left single lung transplant for idiopathic pulmonary fibrosis (IPF) about 2 days ago, developed shortness of breath(SOB) and found to have pneumothorax(PTX) on Right side. 'Pneumocath' resolved the PTX. What would be the further management?


Answer: 
Interestingly, after single lung transplantation, secondary spontaneous pneumothoraces have been reported on contralateral side. Important point to remember is that these secondary spontaneous pneumothoraces are prone to recur and requires further step beyond chest tube insertion. Obliteration of pleural space via any appropriate method like  talc pleurodesis should be strongly considered.


 References: 

1.  Spaggiari L, Rusca M, Carbognani P, et al. Contralateral spontaneous pneumothorax after single lung transplantation for fibrosis. Acta Biomed Ateneo Parmense 1993; 64:29. 


2. Waller DA, Conacher ID, Dark JH. Videothoracoscopic pleurectomy after contralateral single-lung transplantation. Ann Thorac Surg 1994; 57:1021.

Wednesday, December 16, 2015

Q: Uncontrollable laughing or crying may occur during  which kind of seizure?


Answer:  Frontal lobe seizure

As frontal lobe deals with more advanced function of brain, its manifestations are complex. They are hard to diagnose, and often occurs during sleep. Similarly, they are often preceded by expressive fear.  In Frontal Lobe Epilepsy fear is expressed on the person's face, in contrast to Temporal Lobe Epilepsy where fear is more inside the patient. Clinically, they are highly associated with tumors or vascular malformations.




 References: 

1.  "Frontal lobe seizures: Symptoms". Diseases and Conditions. Mayoclinic.com. 2008-10-11.

2. Panayiotopoulos C (2005). "Symptomatic and Probably Symptomatic Focal Epilepsies: Topographical Symptomatology and Classification". The Epilepsies. Blandon Medical Publishing.

3. Kramer U, Riviello JJ, Carmant L, Black PM, Madsen J, Holmes GL (February 1997). "Clinical characteristics of complex partial seizures: a temporal versus a frontal lobe onset". Seizure 6 (1): 57–61.

Tuesday, December 15, 2015

Q: All of the following strategies can be applied for ventilator management if patient develops Broncho-pleural fistula (BPF) except? 

A) Minimize the ventilator-delivered breaths.
B) Minimize the tidal volume
C) Decrease the inspiratory flow rate 
D) Decrease chest tube suction 
E) Endeavors to expedite the extubation



Answer: C

If patient develop BPF, all measures should be implied to decrease the level of positive pressure deliver via ventilator like decreasing respiratory rates, tidal volumes, PEEP and ideally to extubate the patient. Chest tube suction is another form of pressure suction from other side. 

Choice C is wrong as decreasing the inspiratory flow rate will increase the Inspiratory to Expiratory ratio (I:E) ratio and thereby chances of auto-PEEP.

Choice A and B may cause permissive hypercapnia but it should be perfectly fine.



Monday, December 14, 2015

Q: Peripherally Inserted Central Venous Catheters, popularly known as PICCs are know to carry higher risk of upper extremities deep venous thrombosis (UE-DVT). All of the following are associated with higher risk of UE-DVT except

A) Right-sided insertion
B) Vancomycin infusion
C) TPN infusion
D) Basilic placement
E) Renal failure



 Answer: A

One recent study of 400 patients published from St. Elizabeth Health Center, Youngstown, OH showed that following factors are associated with increased risk of UE-DVTs

  •  trauma
  • renal failure
  • left-sided catheters
  •  basilic placement
  • TPN, and 
  • infusion with antibiotics, specifically vancomycin

Interestingly, prophylaxis with low molecular weight heparin, unfractionated heparin or use of warfarin did not prevent the development of venous thrombosis in patients with PICCs


Reference: 

Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012; 13:231.

Sunday, December 13, 2015




Q: What is spontaneous HIT?

 Answer: When Heparin Induced Thrombocytopenia (HIT) occurs without heparin exposure is called spontaneous HIT. Risk factors are preceding infectious or inflammatory events, or orthopedic surgery. Spontaneous HIT is defined as: "otherwise unexplained thrombocytopenia/thrombosis without proximate heparin exposure and with anti-PF4/heparin IgG antibodies that cause strong in vitro platelet activation even in the absence of heparin"


Reference: 

1. Warkentin TE, Basciano PA, Knopman J, Bernstein RA. Spontaneous heparin-induced thrombocytopenia syndrome: 2 new cases and a proposal for defining this disorder. Blood 2014; 123:3651.


2. Mallik A, Carlson KB, DeSancho MT. A patient with 'spontaneous' heparin-induced thrombocytopenia and thrombosis after undergoing knee replacement. Blood Coagul Fibrinolysis 2011; 22:73. 

3. Pongas G, Dasgupta SK, Thiagarajan P. Antiplatelet factor 4/heparin antibodies in patients with gram negative bacteremia. Thromb Res 2013; 132:217.

Saturday, December 12, 2015

Q: What is Lok Index?


Answer: Lok Index determines cirrhosis probability in hepatitis C by taking into account of 4 parameters
  • Platelets 
  • ALT 
  • AST 
  • INR
 Lok index less than 20 percent effectively rules out cirrhosis in hepatitis C. Manual calculation is difficult but online calculators are available via any search engine.



Reference:

 Lok AS, Ghany MG, Goodman ZD, et al. Predicting cirrhosis in patients with hepatitis C based on standard laboratory tests: results of the HALT-C cohort. Hepatology 2005; 42:282.

Friday, December 11, 2015

Q: What is the difference between dose of Naloxone given intra-nasally and via other routes?


Answer:  Naloxone can be administered via intravenous, intramuscular, subcutaneous or intranasal routes. Dose for all routes except for intranasal is 0.4 mg of the 0.4 mg/1 mL concentration. For intranasal route higher dose is required up to 2 mg of the 1 mg/1 mL concentration. Intranasal administration is recommended with a mucosal atomizer device to ensure proper spray on nasal mucosa.

Thursday, December 10, 2015



Q: What is the Principle of Double Effect (PDE) at End of Life care?


Answer: "an action having foreseen harmful effects practically inseparable from the good effect is justifiable".

In End of Life care administering medication to relieve pain is morally justifiable despite knowing the possible bad effect i.e death, though all endeavours should be exercised to minimize the risk of the bad effect and the benefit of good action outweighs the risk of bad effect.  


Reference: 

Quill TE. Principle of double effect and end-of-life pain management: additional myths and a limited role. J Palliat Med 1998; 1:333.

Wednesday, December 9, 2015




Q: Which hematologic condition is expected after insertion of Ventricular Assisted Device (VAD) post-operatively?


Answer:  Acquired von Willebrand disease (aVWD)

 High shear stress of pumps of VADs causes proteolysis of large VWF multimers, resulting in aVWD. It may cause life threatening bleeding. It is so common that all patients with continuous flow VADs should be assumed to have aVWD. Diagnosis can be documented by specific tests though not required. Treatment include desmopressin (DDAVP), VWF concentrates, recombinant factor VIIa, antifibrinolytic agents, and supportive treatment with transfusions.



Reference: 

 Heilmann C, Geisen U, Beyersdorf F, et al. Acquired Von Willebrand syndrome is an early-onset problem in ventricular assist device patients. Eur J Cardiothorac Surg 2011; 40:1328.

Tuesday, December 8, 2015

Q: 48 year old male with alcoholic cirrhosis is admitted to ICU with upper GI bleed. 2 large bore IVs are inserted. IV PPI and Octreotide drips are started. Blood products are arranged. Gastroenterology service is planning to do upper GI scope. Which one additional treatment may help in better visualization during endoscope?


Answer: intravenous erythromycin

Recommended dose is 3 mg/kg intravenously over half hour, an hour prior to endoscopy. A single dose of intravenous erythromycin given 20 to 120 minutes significantly improve visibility and successful single endoscopy. 


References: 

1. Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002; 123:17. 

2. Carbonell N, Pauwels A, Serfaty L, et al. Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Am J Gastroenterol 2006; 101:1211.

Monday, December 7, 2015



Q: All of the following can be prescribed to patient with sickle cell crisis as an adjuvant except?

A) Folic acid 

B) Vitamin D
C) Magnesium
D) Vitamin C
E) Iron



Answer: E

Iron overload is a major risk and a complication in patients with sickle cell disease (SCD). Most of these patients, by the time they reach adulthood, have enough blood transfusions to have iron overload. On the contrary, patients with SCD are usually candidates for iron chelation therapy.



Reference:

 P. B. Walter, P. Harmatz, and E. Vichinsky, “Iron metabolism and iron chelation in sickle cell disease,” Acta Haematologica, vol. 122, no. 2-3, pp. 174–183, 2009.

Sunday, December 6, 2015

Q: Tumor lysis syndrome (TLS) is an oncologic emergency. All of the following electrolyte derangements can occur in TLS except?

A) Hyperphosphatemia
B) Hypercalcemia
C) Hyperkalemia
D) Hyperuricemia
E) Xanthinuria


Answer: B

Hyperphosphatemia and consequently hypocalcemia are one of the hallmark of TLS. The phosphorus concentration in malignant cells are much higher than in normal cells. Its combination with calcium (calcium-phosphate) causes marked hypocalcemia. Actually it is calcium-phosphate precipitation in the renal tubules which leads to AKI (acute kidney injury) in TLS. If calcium phosphate product goes to more than or equal to 70 mg2/dL2, CRRT should be strongly considered. 

 With breakdown of cells, life threatening hyperkalemia and hyperuricemia may occur. Most patients with TLS receives allopurinol which causes xanthine precipitation in the tubules.

Saturday, December 5, 2015

Q:  34 year old male has been put on extracorporeal membrane oxygenation (ECMO) due to ARDS. What should be the target parameters on ventilator?



Answer: Whole idea behind insertion of ECMO in severe ARDS is to "rest the lung". Ideally, all barotrauma, volutrauma and oxygen toxicity should be minimized. Target parameters should be plateau airway pressures less than 20 cm H2O and minimal FiO2 as tolerated. Added benefit of reduce positive pressure ventilation is improved venous return and cardiac output.

Friday, December 4, 2015



Q: 57 year old male with End Stage Renal Disease (ESRD) is in ICU with septic shock and now on Continuous Renal Replacement Therapy (CRRT). Patient's catheter has frequent problem with clotting despite changing it twice to different sites and use of citrate solution. Patient previously has history of GI bleed per chart. What approach can be taken for use of heparin for CRRT in patients with possible risk of bleeding?



Answer:  One approach which was described 35 years ago but still applicable and has been used with success in such scenarios - is giving boluses of 500 units of heparin every 30 minutes to keep the activated clotting time more than 150 but less than 200 seconds. Heparin can be used in low dose with continuous infusion keeping tight parameter of ACT as per above. 



Reference: 

Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: regional versus low-dose heparin. Kidney Int 1979; 16:513.

Thursday, December 3, 2015



Question: 34 year old male with history of ulcerative colitis(UC) is admitted to ICU with dehydration secondary to diarrhea. Initial lab testing is consistent with electrolyte abnormality but marked elevation of alkaline phosphatase. What is your concern?


Answer:  Primary sclerosing cholangitis (PSC)

Patients with UC are at very high risk of developing PSC. Pathology is thought to be same i.e autoimmunity. To make things complicated, it increases the risks of cholangiocarcinoma as well as colorectal cancer. In synchrony with UC, treatment consists of immunosuppressants, chelators and steroids. Symptomatic relief can be provided with endoscopic dilation and stenting of strictures, but it does not reverse the disease progression. Liver transplantation is the last hope.

Wednesday, December 2, 2015

Q: 54 year male in ICU with multi system organ failure (MSOF) get diagnosed with deep venous thrombosis (DVT). Patient had severe gastrointestinal (GI) bleed 2 days ago when he almost died. He is not eligible for travel to go for any further imaging due to high ventilator requirement. What is your next option? (Best answer) 

A) Start low dose IV Heparin and titrate slowly up 
B) IVC filter at bedside 
C) Observation and repeat bedside duplex in 24 hours
D) Start low dose SQ anticoagulation 
E) catheter directed thrombolysis


Answer: B

Out of all of the above IVC filter at bedside under fluoroscopy is the best option. If fluoroscopy is not available bedside ultrasound can be used. 

A, D and E are not appropriate choices due to life-threatening GI bleed in last 48 hours.

C is not a good choice when bedside IVC filter is available.



 Reference: 

 Uppal B, Flinn WR, Benjamin ME. The bedside insertion of inferior vena cava filters using ultrasound guidance. Perspect Vasc Surg Endovasc Ther 2007; 19:78.

Tuesday, December 1, 2015

Q: Beside proper analgesia, what is the the other advantage of giving local anesthesia before inserting arterial catheter for invasive monitoring?


Answer: Beside relief of pain, major advantage of local analgesia during arterial catheter insertion is reduction of vasospasm.



Reference:

Guidelines for the measurement of respiratory function. Recommendations of the British Thoracic Society and the Association of Respiratory Technicians and Physiologists. Respir Med 1994; 88:165.

Monday, November 30, 2015

A note on amylase concentration in ascitic fluid 


In uncomplicated ascites due to cirrhosis or congestive heart failure, ascitic fluid/serum ratio (AF/S ratio) of amylase is about 0.4. As this ratio rises other disease processes should be ruled out like  pancreatitis or bowel perforation. In pancreatic ascites, the ascitic fluid amylase concentration is usually above 1000 int. unit/L, and the A-F/S ratio may rise up to 6.0.


 Reference: 

 Runyon BA. Amylase levels in ascitic fluid. J Clin Gastroenterol 1987; 9:172.

Sunday, November 29, 2015





Q: 42 year old male, a day after his return from france is admitted to ICU with c/o severe dehydration due to gastroenteritis. The patient get diagnosed with a history of mushroom poisoning and is discharged to home after resolution of symptoms with supportive treatment. Patient is now back in ER  with c/o severe burning, redness and swelling of bilateral extremities?


Answer:  Erythromelalgia 

Erythromelalgia is the triad of
  • severe burning pain in the extremities 
  • severe redness (erythema) of the extremities 
  • Edema of the extremities
Objective of above question is to highlight the point that:  Management, treatment, expectations and follow up in mushroom poisoning requires proper identification of specific mushroom type. Clinically it ranges from simple gastroenteritis to delayed liver toxicity. 

Erythromelalgia is used in mushroom poisoning to identify 2 species 
  • Clitocybe acromelalga, found mostly in Japan and 
  • Clitocybe amoenolens found mostly in France
It is also described as a side effect of calcium channel blockers. It may occur as an isolated disease or as a manifestation of other diseases particularly bone marrow diseases.  Interestingly, nicotine is said to improve symptoms.



References:

1.  Nakajima N, Ueda M, Higashi N, Katayama Y. Erythromelalgia associated with Clitocybe acromelalga intoxication. Clin Toxicol (Phila) 2013; 51:451.


2. Saviuc PF, Danel VC, Moreau PA, Guez DR, Claustre AM, Carpentier PH, Mallaret MP, Ducluzeau R. "Erythromelalgia and mushroom poisoning". J. Toxicol Clin Toxicol 39 (4): 403–07 (2001)


3. Diaz, James H.  "Syndromic diagnosis and management of confirmed mushroom poisonings". Critical Care Medicine 33 (2): 427–36.(February 2005).

Saturday, November 28, 2015

A note on hyponatremia in patients with cirrhosis 


Mechanism of action: Patients with cirrhosis develops systemic vasodilation causing activation of endogenous vasoconstrictors including antidiuretic hormone (ADH). ADH in return causes the water retention and subsequently hyponatremia. 


Clinical significance: Hyponatremia in patients with cirrhosis is a significant predictor of death. Also, hyponatremia is found to be associated with an increased risk of the central pontine demyelination and neurologic dysfunction after liver transplantation.




 References: 

1.  Biggins SW, Rodriguez HJ, Bacchetti P, et al. Serum sodium predicts mortality in patients listed for liver transplantation. Hepatology 2005; 41:32. 

2. Ruf AE, Kremers WK, Chavez LL, et al. Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone. Liver Transpl 2005; 11:336. 

3. Kim WR, Biggins SW, Kremers WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med 2008; 359:1018.

Friday, November 27, 2015

Q: What is the most recommended way to measure core body temperature during therapeutic hypothermia (TH)?


Answer: Esophageal temperature measurement

As
  • bladder temperature depends on urine output
  • rectal measurement lags behind
  • axillary and tympanic measurements are out of body and misleading
esophageal temperature measurement is considered the most accurate method to follow core temperature during whole process of therapeutic hypothermia (TH).



Reference: 

 Erickson RS, Kirklin SK. Comparison of ear-based, bladder, oral, and axillary methods for core temperature measurement. Crit Care Med 1993; 21:1528.

Thursday, November 26, 2015

Q; Which food poisoning is common after Thanksgiving meal?



Answer: Salmonella Gastroenteritis 

It is usually self-limited and resolve within a week and only requires replacement of fluids and electrolytes. In "soft call" for antibiotics, three days course of  ciprofloxacin 500 mg orally twice daily should be sufficient. In severe cases, full course of intravenous third generation cephalosporin can be used.


The best prevention against Salmonella gastroenteritis from turkey, beside having proper handling and clean dressing, is to thaw slowly over 3-5 days in refrigerator - or - with cold water over half day. 
It is not a good idea to thaw turkey on the counter. On room temperature as frozen turkey gets thaw from the outside in and as the surface gets warm, bacteria multiply to dangerous levels. 

Happy safe Thanksgiving :)

Wednesday, November 25, 2015

Case: 52 year old male after thoracotomy for recurrent pleural effusion with previous history of mechanical MVR (Mechanical Valve Replacement) is in ICU POD # 3. Epidural was inserted at the time of surgery. Warfarin was initiated on POD # 1 on surgeon's recommendation. Today patient's international normalized ratio (INR) is 2.9. As you mention administration of Vitamin K to decrease INR for safe removal of epidural catheter, surgeon strongly advised you to avoid vitamin K as patient has very high risk of thrombosis. Your next action plan would be?


Answer: Remove Epidural

Ideally, INR should be less than 1.5 for epidural removal but if risk of reversing warfarin is higher than removal of epidural, it can be remove without any intervention such as reversal with Vitamin K up to INR of 3.0. Caution should be exercise to watch any other concomitant drug which may affect hemostasis and continuous neurologic monitoring after removal.



References: 

1. Horlocker TT, Wedel DJ, Rowlingon JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64. 

2. Wysokinski WE, McBane RD. Periprocedural bridging management of anticoagulation. Circulation 2012; 126:486.

Tuesday, November 24, 2015

Q: All of the following are the risk factors for hyperammonemia in recent lung transplant patients except?

A)  use of total parenteral nutrition (TPN),

B) Persistent abdominal complaints
C) Pre-transplant diagnosis of idiopathic pulmonary arterial hypertension
D) History of seizure


Answer: D
 (seizure is the result, not the risk for hyperammonemia in post lung transplant patients)

Severe hyperammonemia is an unfortunate, unexpected and hard to manage complication after lung transplant. The cause of  hyperammonemia is due to urea cycle abnormalities but exact mechanism is still not very clear. Any unexplained central symptoms including lethargy, delirium, seizure or coma in post-lung transplant patients should quickly prompt the diagnosis of  hyperammonemia as morbidity and mortality is very high, if left untreated. Diagnosis can be confirmed by presence of  Ureaplasma in blood, plasma or BAL via PCR.

Treatment is 4 folds

1. Prevention: of exogenous nitrogen sources in feeding, 
2. Removal: Hemodialysis in severe cases to clear ammonia 
3. Replacement: Administration of intravenous sodium benzoate and sodium phenylacetate to serve as alternatives to urea for the excretion of nitrogenous wastes
4. Killing: of Ureaplasma organisms via antibiotics as macrolides, fluoroquinolones, and tetracyclines



References: 

1. Lichtenstein GR, Yang YX, Nunes FA, et al. Fatal hyperammonemia after orthotopic lung transplantation. Ann Intern Med 2000; 132:283. 

2. Bharat A, Cunningham SA, Scott Budinger GR, et al. Disseminated Ureaplasma infection as a cause of fatal hyperammonemia in humans. Sci Transl Med 2015; 7:284re3. 

3. Rueda JF, Caldwell C, Brennan DC. Successful treatment of hyperammonemia after lung transplantation. Ann Intern Med 1998; 128:956. 

4. Anwar S, Gupta D, Ashraf MA, et al. Symptomatic hyperammonemia after lung transplantation: lessons learnt. Hemodial Int 2014; 18:185.

Monday, November 23, 2015

Q: Correction of which of the following electrolyte abnormality has direct association with improvement of hepatic encephalopathy?

A) Hyponatremia
B) Hypokalemia
C) Hypocalcemia
D) Hypomagnesemia
E) Hypophosphatemia 



Answer:  B

Almost 50 years ago it was determined that hypokalemia increases the renal ammonia production and so correction of hypokalemia has direct and significant effect on treatment of hepatic encephalopathy.



Reference:

Gabduzda GJ, Hall PW 3rd. Relation of potassium depletion to renal ammonium metabolism and hepatic coma. Medicine (Baltimore) 1966; 45:481.

Sunday, November 22, 2015

A note on "very slow" correction of sodium in Hypernatremia


Classic teaching on treatment of Hypernatremia is to avoid rapid correction of sodium. Everybody gets it but unfortunately seldom it is mentioned that "very slow" correction of sodium in hypernatremia can be equally fatal. Ideal number for correction of sodium in hypernatremia is no more than 10 meq/L over 24 hours - but - equally it is important to avoid correction less than 6 meq/L over 24 hours.


Reference: 

Alshayeb HM, Showkat A, Babar F, et al. Severe hypernatremia correction rate and mortality in hospitalized patients. Am J Med Sci 2011; 341:356.

Saturday, November 21, 2015

Q:  48 year old female admitted to ICU with pulmonary embolism (PE) diagnosed via CTA in ER. While reviewing ER record, you noticed that patient pulse oximetry was 93% on arrival on room air. What does it signifies?


Answer:   One interesting study of 207 patients from North Carolina was published in 2003 in American Journal of Medicine which found that in patients with PE, pulse oximetry level less than 95% at the time of diagnosis is associated with higher risk of in-hospital complications like respiratory failure, obstructive shock or death.



Reference: 

Kline JA, Hernandez-Nino J, Newgard CD, et al. Use of pulse oximetry to predict in-hospital complications in normotensive patients with pulmonary embolism. Am J Med 2003; 115:203.

Friday, November 20, 2015

NURSE
Mnemonics to guide family communication in ICU

N = name the person while addressing
U = understanding their situation
R = respecting their values
S = supporting their emotions
E = exploring their concerns


Reference:

Selph RB, Shiang J, Engelberg R, et al. Empathy and life support decisions in intensive care units. J Gen Intern Med 2008; 23:1311.

Thursday, November 19, 2015

Q: Exclusively from hemodynamic perspective, which level of systemic vascular resistance (SVR) is acceptable to avoid organ damage from excessive vasoconstriction?


Answer: 1300 dynes x sec/cm5

During management of "shock", the appropriate mean arterial pressure (MAP) to protect organs is around 65 mmHg. Vasopressors are routinely used to achieve this MAP but simultaneously over use of vasoconstrictors may expose organs to ischemia. If pulmonary artery catheter is in place, keeping systemic vascular resistance (SVR) below 1300 dynes x sec/cm5 is usually safe.


Reference:

Redl-Wenzl EM, Armbruster C, Edelmann G, et al. The effects of norepinephrine on hemodynamics and renal function in severe septic shock states. Intensive Care Med 1993; 19:151.

Wednesday, November 18, 2015

Q: Cisatracurium is the most commonly used neuromuscular blockade in ICU. Which one common pitfall should be kept in mind while using this drug? 


Answer: Patients with profound sepsis may require higher dose as they may not only have a delayed response but also reduced response to described standard dosing regimens in textbooks.



Reference:

Liu X, Kruger PS, Weiss M, Roberts MS. The pharmacokinetics and pharmacodynamics of cisatracurium in critically ill patients with severe sepsis. Br J Clin Pharmacol 2012; 73:741.

Tuesday, November 17, 2015

Q; Which one simple trick while creating Z-track (in paracentesis) may help to avoid ascitic fluid leak post-procedure?


Answer: Creating Z-track with gauze pad 

 Creation of Z-track to perform paracentesis helps in avoiding ascitic fluid leak post-procedure. It is simple and easy to perform, but the biggest hurdle during creation of Z-track is to have proper traction due to wetness from cleansing solution. Using a gauze pad to pull on the skin for Z-track creation provides good traction - and consequently avoids lingering problem of ascitic fluid leak after paracentesis.

Monday, November 16, 2015

Q: What is the "rule of thumb" to avoid hypothermia in massive blood transfusion?


Answer: Blood warmer should be used  when more than three units of blood get transfused. 

As described, six units of pRBCs at 4ºC will reduce the body temperature of an average adult by 1ºC. 

Sunday, November 15, 2015

Q: What is the difference between 3 factor or 4 factor PCCs (prothrombin-complex concentrates)?


Answer:  PCCs (prothrombin-complex concentrates) are used in reversal of acute bleeding from warfarin, particularly in intracranial bleeds. They have advantage of be effective within minutes (usually 10 minutes).

Factors  II, IX, X and VII are four vitamin K-dependent factors.
  • Three factor PCCs contain coagulation factors II, IX, and X
  • Four factor PCCs contain coagulation factors II, IX, X and VII 
Though data is not very strong but there is a weak evidence that correction of INR is more reliable with four-factor PCC than with three-factor PCC.



References: 

1. Bershad EM, Suarez JI. Prothrombin complex concentrates for oral anticoagulant therapy-related intracranial hemorrhage: a review of the literature. Neurocrit Care 2010; 12:403. 

2. Voils SA, Baird B. Systematic review: 3-factor versus 4-factor prothrombin complex concentrate for warfarin reversal: does it matter? Thromb Res 2012; 130:833.

Saturday, November 14, 2015

Q: What is Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PM-NASAH)?


Answer:  Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PM-NASAH) is a subtype of subarachnoid hemorrhage (SAH) patients with pattern of 

  • localized blood on CT scan of head 
  • normal cerebral angiography, and 
  •  usually a benign clinical course 

It presents as severe headache and should be managed in a similar fashion till PM-NASAH is established. In most cases the etiology remains undetermined. 



Reference: 

 Flaherty ML, Haverbusch M, Kissela B, et al. Perimesencephalic subarachnoid hemorrhage: incidence, risk factors, and outcome. J Stroke Cerebrovasc Dis 2005; 14:267.

Friday, November 13, 2015

Q: All of the following can be a cause of Rhabdomyolysis except?

A) Status asthmaticus
B) Administration of neuro-muscular blockade (NMB)
C) High-dose Steroids
D) Capillary leak syndrome
E)  Loop Diuretics



Answer:  E

It is important to understand that rhabdomyolysis can be multi-factorial and various disease processes which "prime" muscles for hypoxia, weakness or breakdown such as overexertion in status asthmaticus, NMB and steroid administration, or capillary leak syndrome causing compartment syndrome type picture can cause rhabdomyolysis. Loop diuretics actually sometime get use as an adjuvant treatment in rhabdomyolysis.

Thursday, November 12, 2015

Q: Stress ulcer prophylaxis in ICU should be use with caution with proper indications. Blanket use of stress ulcer prophylaxis in all ICU patients may increase the risk of

A) Nosocomial pneumonia 
B) Clostridium difficile infection
C) Drug interactions
D) Thrombocytopenia 
E) All of the above


Answer: E

Objective of above question is to highlight proper use of stress ulcer prophylaxis in ICUs. With overuse of protocols and check-lists there is always a danger of overuse of stress ulcer prophylaxis. Major indications of stress ulcer prophylaxis are


  •  Coagulopathy, 
  •  Mechanical ventilation for  more than 48 hours
  • History of GI bleed in last 12 months
  • Traumatic brain injury
  •  traumatic spinal cord injury
  •  burn injury
  •  severe sepsis
  • high steroid treatment

Every patient should be prioritize on case to case basis instead of blanket order set.

Wednesday, November 11, 2015

Q: Positive elucidation of HEPATOJUGULAR REFLUX is roughly equivalent to what level of pulmonary wedge pressure?


Answer: About 15 mm Hg or higher

HEPATOJUGULAR REFLUX, also called abdominojugular test, is a one lost simple bedside maneuver. The hepatojugular reflux is assessed by applying sustained pressure for 15 seconds over the upper abdomen as patient breathes normally. Usual Jugular Venous Pressure (JVP) is about 1 to 3 cm increase, but with right ventricle (RV) failure, it exceeds above 3 cm. This is due to increase preload secondary to increase venous return with manually induced intraabdominal pressure. A raised diaphragm may also plays a part. Interestingly, in left ventricular failure, a positive hepatojugular reflux has been demonstrated to be equivalent of about 15 mm Hg or higher of pulmonary capillary wedge pressure in patients. Elucidation of hepatojugular reflex in left ventricular failure is hard to explain but hypothesis is impaired right ventricular compliance with left heart failure.




Reference: 

 Ewy GA. The abdominojugular test: technique and hemodynamic correlates. Ann Intern Med 1988; 109:456.



Tuesday, November 10, 2015

Q: How you define neutropenic fever assuming absolute neutrophil count (ANC) is less than 500 cells/microL?


Answer: Fever in neutropenic patients is defined as a single oral temperature of  101.0°F (38.3°C) or a temperature of 100.4°F(38.0°C) sustained for more than 1 hour. 



Reference:

Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56.

Monday, November 9, 2015

Q: Osler's nodes are hallmark of infective endocarditis (IE). But they can be found with which ICU related procedure?


Answer: Infected arterial lines

This is true that Osler's nodes are considered as one of the hallmark of IE but they can be seen in other conditions such as Systemic Lupus Erythematosus(SLE), Marantic endocarditis and Disseminated gonococcal infection. In ICU if  arterial catheters get infected, Osler's node may be seen distal to them. They have been found mostly associated with infected radial lines.



Reference: 

Infectious Diseases in Critical Care Medicine By Burke A. Cunha - 1998 - Page 453

Sunday, November 8, 2015

Q; 53 year old male with newly diagnosed lung cancer and has been found to have recurrent pleural effusion is scheduled to have talc pleurodesis. Patient has following list of medications. Which one of the following should be preferably discontinued for a successful pleurodesis 

A) Vancomycin 
B) Cefepime 
C) Hydrocortisone 
D) Lopressor 
E) Albuterol 



Answer: C

Understandably, any drug which has anti-inflammatory effect will decrease the effect of pleurodesis. Steroids, NSAIDs or any anti-anti-inflammatory drug should be taken off list, if absolutely not needed, few days prior to procedure.



Reference: 

 Xie C, Teixeira LR, McGovern JP, Light RW. Systemic corticosteroids decrease the effectiveness of talc pleurodesis. Am J Respir Crit Care Med 1998; 157:1441.

Saturday, November 7, 2015

A note on Hepatic anticoagulation


Though it is true that hepatic patients are more prone to bleed but there are other reasons for it like thrombocytopenia, dysfunctional platelets or blood flow variations. It would be a mistake to read increase prothrombin time (PT) or international normalized ratio (INR) as a sign of anticoagulation in patients with liver insufficiency. Hepatic patients with increase INR are not auto-anticoagulated. In most cases due to slow and chronic nature of the liver diseases body achieves a so called "rebalanced" hemostasis. Thromboelastography (TEG) or thromboelastometry (ROTEM) are said to be more reliable as they reflect dynamic changes in clot formation and lysis.


Reference:

Northup PG, Caldwell SH. Coagulation in liver disease: a guide for the clinician. Clin Gastroenterol Hepatol 2013; 11:1064.

Friday, November 6, 2015

Q: Massive blood transfusion may cause clinically symptomatic hypocalcemia due to added citrate in pRBC. What is the 'rule of thumb' for calcium replacement during massive blood transfusion?



Answer: 1:3 

One calcium gluconate ampule per three pRBC bags

To be precise, 10 mL of  calcium gluconate be given per 250 mL of blood OR  5 mL of calcium chloride should be given per 250 mL of blood.  Some authorities prefer calcium chloride over calcium gluconate.

The risk of citrate toxicity (causing hypocalcemia)  increases with liver insufficiency or in "shock liver", which is very common in such circumstances. 



Reference: 

British Committee for Standards in Haematology, Stainsby D, MacLennan S, et al. Guidelines on the management of massive blood loss. Br J Haematol 2006; 135:634.

Thursday, November 5, 2015

Q: How many breaths should be allowed after intubation before accepting "change of color" on  end-tidal carbon dioxide (EtCO2) as a proper placement of Endotracheal tube (ETT)?


Answer: 5 or more

GI tract (esophagus) may emit detectable amounts of CO2 during the first few positive pressure breaths. 5 or more exhalations with a consistent "color change" (usually purple to yellow) should be allowed before declaring proper placement of Endotracheal tube (ETT). To note, this is not applicable to patients who are getting intubated during full cardiac arrest, as due to absence of spontaneous circulation there will be no gas exchange and no detectable EtCO2.

Wednesday, November 4, 2015

Q: Usually which of the following is the first EKG sign in hyperkalemia?

A) A tall peaked T wave with shortened QT interval 
B) Progressive lengthening of the PR interval 
C) Progressive lengthening of the  QRS duration
C) Sine wave
D) Ventricular standstill



Answer: A

A tall peaked T wave with shortened QT interval is the earliest sign. It is followed by progressive lengthening of the PR interval and QRS duration. As hyperkalemia worsen, P wave progressively disappear, the QRS widens towards a sine wave. Eventually, ventricular standstill with a flat line is the final thing!

MOST IMPORTANT THING TO REMEMBER - The progression and severity of ECG changes in hyperkalemia do not correlate with the serum potassium concentration, and there is no table to co-relate.

Tuesday, November 3, 2015

Q: 52 year old male with history of hypertension and Chronic Kidney Disease with last known Glomerular Filtration Rate(GFR) 25mL/min (but not on hemodialysis) presented with acute chest pain radiating to back with high suspicion of Aortic dissection. ER resident obtained Gadolinium based magnetic resonance imaging(MRI/MRA) for better images. Now you are worried about Nephrogenic Systemic Fibrosis. What would be your next step?



Answer: Perform Hemodialysis (HD)

Hemodialysis immediately after gadolinium removes most of the contrast agent, followed by second session next day.



References:

1. Saitoh T, Hayasaka K, Tanaka Y, et al. Dialyzability of gadodiamide in hemodialysis patients. Radiat Med 2006; 24:445. 

2. Okada S, Katagiri K, Kumazaki T, Yokoyama H. Safety of gadolinium contrast agent in hemodialysis patients. Acta Radiol 2001; 42:339.

Monday, November 2, 2015

Q: While inserting central venous catheter (CVC), after successful obtainment of vein and free passage of wire, how big of a cut/nick should be given in skin to pass dilator to create track in subcutaneous tissues?



Answer: About 3 mm

Most post-procedure oozing at CVC  site occurs due to large scalpel cut given between passing wire and passing dilator. 3 mm cut is usually enough to pass dilator and insert CVC catheter without having post-procedure oozing.

Sunday, November 1, 2015

Q: 47 year old female is brought to ER with shortness of breath. She was always in good health but developed acute shortness of breath as she heard news of her son's death. Patient was sent for emergent CT scan with pulmonary embolism protocol which was reported negative but radiologist mentioned apical ballooning appearance of the left ventricle. Consistent with history your presumed diagnosis is "takotsubo" cardiomyopathy. As patient arrived to ICU what should be your first maneuver at bedside as you attempt to keep hemodynamics stable?



Answer: ECHOCARDIOGRAM


Echocardiogram should be performed as soon as possible in "takotsubo" cardiomyopathy not only to establish diagnosis but to rule out left ventricular outflow tract (LVOT) obstruction. Up to one fourth of patients in stress or "takotsubo" cardiomyopathy may develop LVOT due to apical ballooning of ventricle. Management entirely differs depending on presence or absence of LVOT in stress cardiomyopathy, popularly known as "takotsubo" cardiomyopathy.

Inotrope should be avoided in LVOT form of stress cardiomyopathy but may be useful in non-LVOT form of stress cardiomyopathy with frequent echo monitoring (as inotrope may convert non-LVOT to LVOT stress cardiomyopathy). 

 LVOT type stress cardiomyopathy may require fluid resuscitation in contrast to non-LVOT type which is treated more in usual fashion with heart failure treatment.



 References: 

 1. Villareal RP, Achari A, Wilansky S, Wilson JM. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc 2001; 76:79.


2. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929.


3. De Backer O, Debonnaire P, Gevaert S, et al. Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience. BMC Cardiovasc Disord 2014; 14:147. 


4. De Backer O, Debonnaire P, Muyldermans L, Missault L. Tako-tsubo cardiomyopathy with left ventricular outflow tract (LVOT) obstruction: case report and review of the literature. Acta Clin Belg 2011; 66:298.

Saturday, October 31, 2015

Q: In  acute decompensated pulmonary embolism (PE), how long does it take to see improvement of right ventricular (RV) function after receiving thrombolytic therapy?


Answer: About 12 hours

Patients who receives successful thrombolytic therapy usually finds improved RV function within 12 hours. In contrast, as expected patients treated only with anticoagulation may take up to one week to see improved RV function.




References:

1. Konstantinides S, Tiede N, Geibel A, et al. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998; 82:966. 

2. Sharma GV, Burleson VA, Sasahara AA. Effect of thrombolytic therapy on pulmonary-capillary blood volume in patients with pulmonary embolism. N Engl J Med 1980; 303:842. 

3. Come PC. Echocardiographic evaluation of pulmonary embolism and its response to therapeutic interventions. Chest 1992; 101:151S.

Friday, October 30, 2015

Q: The overall incidence of Pulmonary Embolism (PE) is higher in (choose one)

A) Male or  B) Female


Answer: Male

Contrary to popular belief - overall incidence of Pulmonary Embolism (PE) is higher in males. 

Clinical significance: During PE evaluation, same level of suspicion should be exercise for male patients as for female patients.



References:

1. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998; 158:585. 

2. Naess IA, Christiansen SC, Romundstad P, et al. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 2007; 5:692. 

3. Tagalakis V, Patenaude V, Kahn SR, Suissa S. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort. Am J Med 2013; 126:832.e13.

Thursday, October 29, 2015

Q: Which valve abnormality is common after insertion of continuous Left Ventricular Assist Device (LVAD)? 


Answer:  Aortic regurgitation 

 New aortic regurgitation may occur in about one fourth of patients who receives LVAD.  It may become clinically symptomatic requiring surgical fix. Temporary fix is to increase the speed of LVAD up to the point where aortic valve opening is observed under echocardiogram. This is recommended under the assumption that most aortic regurgitation after LVAD occurs in patients whose aortic valve stays closed. But permanent treatment is via surgery. Prophylactic stitch procedure at the time of LVAD insertion has also been proposed to avoid aortic regurgitation later.



References:

1.  Pak SW, Uriel N, Takayama H, et al. Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices. J Heart Lung Transplant 2010; 29:1172.

2. Cowger J, Pagani FD, Haft JW, et al. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail 2010; 3:668.

Wednesday, October 28, 2015

Q: Which one of the following should be avoided in patients who are at high risk of cardiogenic shock (pre-shock state) secondary to acute myocardial infarction?

A) aspirin
B) beta-blocker
C) heparin
D) intra-aortic balloon pump 
E) GP IIb/IIIa inhibitors



Answer:  B

Though beta-blockers are mainstay of treatment in coronary artery disease they can be detrimental in acute phase after acute MI, in patients who are in pre-shock state (impending cardiogenic shock). This may be due to the fact that beta-blockers have negative inotropic effect. According to COMMIT trial randomization to early beta blockade in patients who have not developed shock yet, there was a 30 percent higher occurrence of cardiogenic shock in patients 
  • Above age 70
  •  systolic blood pressure (BP) less than 120 mm Hg 
  •  heart rate greater than 110 beats per minute
  •  those with Killip Class over 1
All other choices are in fact indicated in acute MI management.



Reference: 

Chen ZM, et al. "Early intravenous then oral metoprolol in 45 852 patients with acute myocardial infarction: randomised placebo-controlled trial". The Lancet. 2005. 366(9497):1622-1632.

Tuesday, October 27, 2015

Q: 58 year old male with end stage renal disease (ESRD) developed  acute gout. All of the following can be used except

A) Glucocorticoids

B) NSAIDs 
C) Colchicine
D) Proton pump inhibitors (PPIs)
E) Acetaminophen 



Answer: C

Colchicine should be avoided in ESRD patients even if they are on hemodialysis as colchicine does not get removed by hemodialysis. Patients may develop toxicity fairly quickly. Glucocorticoids in any form i.e  intraarticular, oral or parenteral is the first line of treatment in these patients, which is in contrast to non-renal patients. Once patient is on hemodialysis NSAIDs should be ok to use in mild to moderate attacks. PPIs and acetaminophen have no contraindications in gout.