Q: Succinylcholine should be use with caution for intubation in all of the  following patients with except 

A) Neuromuscular diseases

B) Burns, 

C) Closed head injury,

 D) Drowning,

 E) Acute MI 

Answer: E

It is well known that Succinylcholine should be used with caution in some patients as a single injection of Succinylcholine can lead to massive release of potassium from skeletal muscles, like in patients with neuromuscular diseases (Guillain–Barré syndrome, myopathy, tetanus), burns, closed head injury, massive acidosis. Often forgotten and missed in this list is the near drowning patients.

Acute myocardial infarction (MI) is not a contra-indication to use of Succinylcholine.

Q: What one trick may be used in patient during intubation to avoid rapid hypoxemia during paralytic phase due to neuromuscular blocker use?  

Answer: Pre-oxygenation or de-nitogenation i.e. increasing oxygen reservoir in dead space and tissues via NRM is an integral part of preparation before intubation to avoid hypoxemia during paralytic phase of intubation. In ICU, patients may have very little reserve and may quickly deteriorate if airway cannot be establish within reasonable time. The oxygen reservoir can be supplemented by passive diffusion during the apneic period of Rapid Sequence Intubation (RSI) with the application of oxygen via nasal catheter.

Q: 57 year old male with ESRD is admitted to ICU with hyperkalemia in "7.5 range" causing EKG changes and arrhythmias. Emergent dialysis(HD) is called. Patient tolerated dialysis very well and now has stable hemodynamics. When should potassium level should be checked again?

A) Continuously during HD

B) Immediately after HD

C) 30 minutes after HD

D) After few hours of HD 

Answer: D

Hemodialysis (HD)  is the most effective treatment of hyperkalemia and will cause a fall in both intracellular and extracellular levels. Extreme caution should be exercise while following potassium level as the potassium levels tend to rebound after dialysis. Potassium level should never be checked immediately after dialysis. A potassium level drawn several hours after hemodialysis is reliable.

Q: What is the effect of Sodium bicarbonate and THAM on Na and K (Sodium and Potassium)? 

 Answer: 

Sodium bicarbonate decreases serum potassium,

THAM does not do anything to serum potassium 

Sodium bicarbonate increases serum sodium

THAM decreases serum sodium

Q: What is Terson syndrome?

Answer: Terson syndrome is a vitreous hemorrhage in association with subarachnoid hemorrhage, due to elevated intracranial pressure (ICP). 

(Basics) Q: How diarrhea is defined in ICU?   Answer:  Diarrhea  can be best defined in ICU as at least three or more liquid stools per day.

Q: What is the relapsing rate in Clostridium Difficile Colitis (CDI) ? 

Answer:  About 25% 

Clostridium difficile Colitis (CDI) remains a huge healthcare related issue. In patients with already diagnosed CDI, high vigilance is required, as relapses of CDI is up to 25%. Recently, it has been reported  that recurrence is seen in 15–35% of patients after an initial episode, with the rate rising to 35–65% after the first recurrence!

Reference: 
 Johnson S. - Recurrent Clostridium difficile infection: a review of risk factors, treatments, and outcomes. J. Infect. 58, 403–410 (2009)

Q: Which part of the bodies are more prone to be "Red" in "Red Man Syndrome" secondary to IV Vancomycin?

Answer:  Face, Neck and Upper Torso 

"Red man syndrome" is a potential side effect that may occur with vancomycin administration. It is not a true allergic reaction and is probably related to the release of histamine.

It can be avoided with slowing  (over 2 hours) and diluting the infusion and with previous history or concern for any risk, pre-treatment with a histamine-1 antagonist prior to any further dose may help.

Q: Why Albumin is used in Liver dialysis?

Answer:  

Liver dialysis is similar to hemodialysis and based on the same principles. Hemodialysis removes only water soluble toxins and does not remove toxins bound to albumin. Therefore, the removal of lipophilic, albumin-bound substances such as bilirubin, bile acids, metabolites of aromatic amino acids, medium-chain fatty acids and cytokines require albumin in liver dialysis. Liver dialysis is only a short term bridge to transplantation or liver recovery and, unlike renal dialysis cannot go for an extended period. Single Pass Albumin Dialysis (SPAD) is a simple method of albumin dialysis using standard renal replacement therapy machines without an additional perfusion pump system.

Q: Out of the following, which has shown promise in the treatment of  "Fat Embolism Syndrome" (FES)? 

 A) Aspirin

B) Prophylactic antibiotics

C) Plasma Exchange (PE)

D) Emergent Hemodialysis (HD)

E) Statins

Answer: A (Aspirin) 

The best and evidence based treatment to reduce the risk of "Fat Embolism Syndrome" after long bone fractures is early immobilization of fractures and preferably operative correction. Also limiting the elevation in intraosseous pressure during orthopaedic procedures, reduces the intravasation of intramedullary fat and other debris. Other maneuvers which can be used to limit intraosseous pressure, are use of cementless fixation of hip prostheses and unreamed intramedullary femoral shaft stabilization.

Corticosteroid have been suggested for long time but is controversial and has very weak evidences, but it remained in use as risk vs benefit ratio is low.

Interestingly, treatment of patients with FES with aspirin resulted in significant normalization of blood gases, coagulation proteins, and platelet numbers when compared with controls.

Heparin has also been suggested as its clear lipaemic serum by stimulating lipase activity , but heparin greatly increases the risk of bleeding in patients with bone fracture.

Statins, Antibiotics, PE and HD have no role in FES.

Q: 34 year old oncology patient on active chemotherapy cycles admitted to ICU with neutropenic fever and sepsis. Patient is started on broad spectrum antibiotics and "Sepsis protocol". Oncology service also added filgrastim. While a week later in ICU as patient was getting ready to get transfer out of ICU, c/o severe LUQ pain radiating to shoulder. What is your concern? 



Answer: Splenic rupture 

Granulocyte colony stimulating factors (G-CSF) are frequently used in patients s/p chemotherapy to avoid complications of neutropenia. One of the rare but catastrophic complication of G-CSF is splenic rupture. Cardiovascular and neurologic events, and splenic rupture are known side effects of high dose G-CSF therapy. Most of the reported cases are either healthy donors of stem cell transplant patients or patients undergoing peripheral blood stem cell mobilization for transplant (PBSCT). But it is also reported and should be watched for patients on active chemotherapy with neutropenia. Splenic rupture is thought to be due to extramedullary myelopoies leading to parenchymal congestion.

Q: You have been called to Oncology floor to manage patient who was admitted for routine chemotherapy. According to nurse, patient was just started on IV fluid and took his regular pre-chemo meds which include Dexametasone, Ranitidine, Diphenhydramine, Ondansetron and Rasburicase. It appears patient went into anaphylactic shock and required intubation and resuscitation. According to chart patient has tolerated all these meds over last one year without any problem. Which drug is the probable cause?

A) Dexametasone,

B) Ranitidine, 
C) Diphenhydramine
D) ondansetron 
E) Rasburicase


Answer: E (Rasburicase)

Rasburicase is commonly used to avoid tumor lysis syndrome. It is a unique drug in the sense that anaphylaxis is rare with first dose and is more common with repeated courses.

In general, allopurinol and intravenous hydration is the first line of management unless the patient is allergic to allopurinol, and requires Rasburicase. 



Reference:

Allen KC, Champlain AH, Cotliar JA, et al. Risk of Anaphylaxis with Repeated Courses of Rasburicase: A Research on Adverse Drug Events and Reports (RADAR) Project. Drug Saf 2015; 38:183.

Q: 54 year old male with ESRD on hemodialysis is admitted to ICU with shortness of breath. ER resident ordered CT scan of chest "just to be safe", which is reported negative for PE. Radiologist commented on some slices from abdomen about splenomegaly. Patient is clinically improving in ICU after session of dialysis. What would be your next step?

A) Call surgery for splenectomy

B) No intervention
C) Work up to rule out lymphoma
D) Work up for underlying portal hypertension
E) Switch from hemodialysis to Peritoneal dialysis

Answer: B (No intervention) 

Splenomegaly in chronic hemodialysis is a normal and regular finding and does not require any intervention unless until it is clinically causing problem. Splenic enlargement is probably due either to red cell damage produced by haemodialysis or to an immunological reaction induced by component of haemodialysis.

Above MCQ also signifies the importance of avoiding unnecessary work up.

Q: 54 year old male is admitted to ICU with infective endocarditis. Blood cultures are growing Clostridium septicum, What is your next concern? 

Answer: Colon cancer 

Clostridium septicum is part of the natural flora of the bowel, and is associated with colonic malignancies. When they present as the causative agent in endocarditis, it is secondary to colon cancer proved otherwise and calls for a concomitant colonoscopy. Another bacteria causing endocarditis and found to be associated with colon malignancy is S. bovis.

Reference:

Chew SSB, Lubowski DZ (2001). "Clostridium septicum and malignancy". ANZ Journal of Surgery 71 (11): 647–649.

Q: How long does it take for fever to subside after stopping offending agent in "Drug Induced Fever"?

Answer: About 72 hours 

Fever does not subside instantly after stopping drug in suspected drug induced fever. It may take 48-96 hours, and may persist for weeks if other manifestations of hypersensitivity accompany the fever, such as a maculopapular rash. Other causes of persistent fever despite discontinuation of offending drug is slow elimination rate.

Q: Name at least one most commonly used drug in ICU which causes diarrhea in its elixir form

Answer: Acetaminophen 

Acetaminophen elixir is preferred in ICU as it is easy to administer liquid form via feeding tube. But it is very hyperosmolar ( > 3,000 mosm/kg H2O) and may be a cause of diarrhea in ICU. Similar is the case with Potassium and multi-vitamin elixir.

Q: What is the general overlap time between IV insulin and SQ insulin at resolution of DKA

Answer: About 60 minutes (few recommends upto 2 hours)

Patients with known diabetes may be given insulin at the dosage they were receiving before the onset of DKA. In patients with newly diagnosed diabetes, an initial insulin dose of 0.6 unit/kg/day is usually sufficient. Overlapping of subcutaneous insulin and intravenous insulin infusion for 1- or 2-h avoid recurrence of hyperglycemia or ketoacidosis.

Importantly, if patients are not able to eat, intravenous insulin should be continued while an infusion of 5% dextrose in half-normal saline is given at a rate of 100–200 mL/h.

Q: 54 year old male with PMH of HTN, DM, Steroid dependent COPD - is admitted to ICU with confusion, hypotension, severe vomiting and diarrhea, sudden penetrating pain in the legs, lower back and abdomen associated with Hypoglycemia, Hyponatremia, Hyperkalemia and Hypercalcemia. Your diagnosis?

A) Acute lumbar disc herniation

B) "Bleed in the head"

C) Addisonian Crisis

D) DKA (Diabetes Keto-acidosis)

Answer: Addisonian Crisis 

Adrenal crisis or Addisonian crisis is a potentially life-threatening situation requiring immediate emergent attention. Clinically it presents with constellation of symptoms caused by insufficient levels of cortisol. Suddenly stopping intake of steroids is one major cause of it.

Q: What does it mean by Quaternary care?

Answer:

Quaternary care is an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely available, including experimental medicine and uncommon diagnostic or surgical procedures.

Q: 46 year old female with history of gout is admitted to ICU with fever, hypotension and right swollen knee with pain. Knee is aspirated under sterile condition. You received call from lab that Lactate level in joint aspirate is 16 mmol/l. What does it mean?

Answer:  Likely diagnosis of septic arthritis instead of inflammatory process 

A lactate level in the synovial fluid of greater than 10 mmol/l makes the diagnosis very likely. synovial lactate is a useful adjunct test to synovial WBC, gram stain and other values in ruling in/out septic arthritis.

Reference:

Carpenter, CR; Schuur, JD; Everett, WW; Pines, JM (August 2011). "Evidence-based diagnostics: adult septic arthritis.". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 18 (8): 781–96

Q: Which one other test beside Glomerular Filtration Rate (GFR) and Serum Creatinine (SCr) , can be used in early stage to detect 'Contrast Induced Nephropathy'?

Answer:  Serum cystatin C 

Cystatin C is a protein that is produced throughout in the body by all cells. It contains a nucleus. It is filtered from the blood by the kidneys, and broken down at a constant rate. It is has been found to be an accurate marker of GFR.

Compared with SCr, cystatin C changes much earlier after contrast administration and is not subject to confounding factors, such age, sex, and muscle mass, that influence SCr values independent of the underlying GFR.

Cystatin C is increasingly being used as a marker of renal function in cardiac surgical patients.

Reference:

Droppa M, Desch S, Blase P, et al. Impact of N-acetylcysteine on contrast-induced nephropathy defined by cystatin C in patients with ST-elevation myocardial infarction undergoing primary angioplasty. Clin Res Cardiol. Jun 28 2011

Q: All of the following have shown to decrease post cardiac surgery atrial fibrillation?

A) Statins

B) Corticosteroids

C) Magnesium

D) N-acetylcysteine

E) All of the above

Answer:  E 

Post cardiac surgery Atrial Fibrillation is associated with a higher incidence of heart failure, stroke, prolonged hospital stay, and increased costs. Beside using B-blockers, Amiodarone and Atrial pacing, many other treatments have been studied and found to have effect on it.

Q: What is the characteristic of Hypertension in Cushing's triad?

Answer: Widening of pulse pressure

Cushing's triad is defined as having:

• Irregular respirations
• Bradycardia
• Hypertension

It is caused by increased pressure inside the skull and indicates ischemia to the brain. In response to rising intracranial pressure (ICP), respiratory rate increases, rather than depth of ventilation. It causes reflexive hypertension with widening of pulse pressure and bradycardia instead of tachycardia.

Q: Rapid correction of Sodium particularly in chronic hyponatremia can be dangerous as it may cause osmotic demyelination commonly known as Central Pontine Myelinolysis (CPM), which is typically irreversible. What are the main risk factors for development of CPM?

Answer: 

• Associated hypokalemia,
• female gender,
• history of alcoholism,
• history of liver transplant  

Reference:  Murase T, Sugimura Y, Takefuji S, et al. Mechanisms and therapy of osmotic demyelination. Am J Med. Jul 2006;119(7 Suppl 1):S69-73.

Q: Lorazepam is one of the most common drug for sedation in ICU. Vehicle to transport this drug in IV infusion is Propylene Glycol. With high dose and prolong infusion of Lorazepam, Propylene Glycol toxicity is a huge concern. What 2 tests may help in ruling out Propylene Glycol toxicity if suspected?

Answer:

• Osmolal gap
• Hyperlactatemia

Risk for Propylene Glycol Toxicity is high in patients with renal insufficiency particularly in patients with a creatinine clearance of 30 ml/minute or below. 

Reference:

Reynolds HN, Teiken P, Regan ME, et al. Hyperlactatemia, increased osmolar gap, and renal dysfunction during contin-uous lorazepam infusion. Crit Care Med 2000;28:1631-4.

Q: Beside dipyridamole (Persantine), name at least one drug in which dose of  adenosine should be decreased?

Answer: Diazepam (Valium)

Though experimental but due to potential chance of drug interaction, adenosine should be given with caution in patients receiving Diazepam. 

Reference:

A.S. CLANACHAN and R.J. MARSHALL - POTENTIATION OF THE EFFECTS OF ADENOSINE ON ISOLATED CARDIAC AND SMOOTH MUSCLE BY DIAZEPAM - Volume 71, Issue 2, pages 459–466, February 1980, Br. J. Pharmac. (1980), 71, 459-466

Q: What is the 'Atropine test' during determination of Brain Death Evaluation?


Answer: "Atropine test" during Brain Death evaluation is the failure of the heart rate to increase after 1- 2 mg of IV atropine intravenously. But remember, this excludes people with previous heart transplant.

The atropine test assesses bulbar parasympathetic activity on heart activity in brain-dead patients. 2 mg atropine is given under continuous monitoring for 10 minutes. Test is considered negative if heart rate is not augmented by 5 beats perminute or more than 3% compared with basal heart rate. 



References:

Ouaknine GE, Mercier C. Value of the atropine test in the confirmation of brain death- Union Med Can. 1985;114:76–80.

Huttemann E, Schelenz C, Sakka SG, et al. Atropine test and circulatory arrest in the fossa posterior assessed by transcranial Doppler. Intensive Care Med. 2000;26:422–5.  

Cardan C, Roth A, Biro J. The atropine test in the assessment of brain death. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir. 1983;32:393–7

Q: Patient coded in ICU and didn't survive the full ACLS  protocol. How long should you wait before officially declaring patient dead?



Answer: 5 to 10 minutes.

Often after failed ACLS, patient may recover circulation by himself/herself, which has been well described in literature and known as Lazarus syndrome or autoresuscitation. Many theories have been proposed in this regard including rebound potassium or epinephrine in circulation. Another popular theory is the relaxation of pressure in chest after resuscitation efforts have ended which allows the heart to expand, triggering the heart's electrical impulses and restarts the heartbeat.


References:

Ben-David M.D., Bruce; et al. (2001). "Survival After Failed Intraoperative Resuscitation: A Case of "Lazarus Syndrome". Anesthesia & Analgesia 92 (3): 690–692.

Walker, A.; H. McClelland; J. Brenchley (2001). "The Lazarus phenomenon following recreational drug use". Emerg Med J 18 (1): 74–75.

Pearls on use of Capnography in Code Blue

• When a person doing CPR tires, the patient's end-tidal CO2 falls. Its time to change  the guard, so a fresh rescuer takes over.
• When a patient experiences return of spontaneous circulation (ROSC), the first sign is often a sudden rise in the ETCO2 as the rush of circulation washes untransported CO2 from the tissues.
• A sudden drop in ETCO2 indicates that the patient has lost pulses and CPR may need to be initiated.

Q: Risk of Propofol infusion syndrome is high when used with following drugs in ICU?

A) Steroids

B) Epinephrine

C) Nor-Epinephrine

D) Dopamine

E) All of the above

Answer: E

Patients are more prone to develop propofol infusion syndrome if used after a prolonged infusion in combination with catecholamines and/or corticosteroids.

Vasile B, Rasulo F, Candiani A, Latronico N (2003). "The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome". Intensive Care Medicine 29 (9): 1417–25.

Propofol-Warfarin

Interaction usually get ignored in ICU

Intravenous lipids are often required for parenteral nutrition (PN) support in critically ill patients and are administered with continuous sedation if patients are receiving propofol, which contains soybean oil 10% as an emulsified preparation. High-dose propofol infusion was associated with reversal of enteral and intravenous warfarin anticoagulation in a 39-year-old woman with severe Crohn's disease. Despite increasing the daily dose of warfarin to 30 mg, anticoagulation was not achieved until propofol was discontinued. Reversal of anticoagulation recurred when PN support was supplemented with Liposyn II 20%. Lipid emulsions may interfere pharmacodynamically with warfarin activity by enhancing the production of clotting factors, facilitating platelet aggregation, or supplying vitamin K. They also may facilitate warfarin binding to albumin. Until further information regarding the mechanism of interference is elucidated, heparin therapy should be considered for initial anticoagulation in patients with intestinal absorptive deficiencies who receive high-dose lipid emulsions and require reliable anticoagulation. If warfarin is given, the international normalized ratio should be monitored daily to ensure adequate anticoagulation.

Warfarin resistance associated with intravenous lipid administration: discussion of propofol and review of the literature. - MacLaren R, Wachsman BA, Swift DK, Kuhl DA. - Pharmacotherapy. 1997 Nov-Dec;17(6):1331-7.