Q: During Tumor Lysis Syndrome, often diuretic is required along with IV hydration to keep urine out-put @ 80-100 cc/hr. What added advantage Furosemide provides beside diuresis in Tumor Lysis Syndome (TLS)?

Answer:  In TLS if diuretic is required; loop diuretics such as furosemide is preferred because they not only induce diuresis, but may also treat hyperkalemia, which is one of the life-threatening manifestation of TLS.

Q: In acute eosinophilic pneumonia (AEP), pleural fluid is  (choose one)?

A) Exudative

or

B) Transudative

Answer:  A

In AEP, the pleural fluid is exudative with an increased percentage of eosinophils.

Reference:

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

Q: What is the 'rule of thumb' equivalent conversion between Metoprolol and carvedilol ?

Answer:  metoprolol 50mg  = carvedilol 12.5mg

While making change to carvedilol, concern should be considered  about the possibility of symptoms related mainly to α blockade mediated vasodilation. Ideally, slowing the rate of titration or reducing the dose is preffered. It would be prudent not to add other vasodilators such as calcium antagonists, nitrates, or other antihypertensives or diuretics during the switch.

Q: Which of the following are the risk factor for contrast induced nephropathy (CIN) except?

A) CKD (chronic kidney disease)

B) Diabetes mellitus
C) Hypertension
D) Anemia
E) CAD (coronary artery disease)

Answer:  E

It is interesting to note that except for CKD, physicians are less aware of other risk factors which may lead to contrast induced nephropathy. It is associated with a significantly higher risk of in-hospital and 1-year mortality, even in patients who do not need dialysis! It is very less appreciated that patients with CKD in the setting of diabetes mellitus have a 4-fold increase in the risk of CIN compared with patients without diabetes mellitus or preexisting CKD.

Other risk factors include Age, Hypertension, Metabolic syndrome, Anemia, Multiple myeloma, Hypoalbuminemia, previous renal transplant, hypovolemia, CHF, hypotension, volume of contrast as well as viscosity, osmolarity, ionicity, and molecular structure of contrast.

Q:What is the risk of adding bicarbonate in IVF during treatment of Rhabdomyolysis?

Answer: The addition of bicarbonate to the IVF to make the urine more alkaline to prevent cast formation in the kidneys is no more recommended. Data fail to show any benefit above saline alone, and actually it can worsen hypocalcemia by enhancing calcium and phosphate deposition in the tissues.

References:

1. Huerta-Alardín AL; Varon J; Marik PE (2005). "Bench-to-bedside review: rhabdomyolysis – an overview for clinicians". Critical Care 9 (2): 158–69.

2.  Vanholder R; Sever MS; Erek E; Lameire N (1 August 2000). "Rhabdomyolysis". Journal of the American Society of Nephrology 11 (8): 1553–61.

Q:Using amiodarone and simvastatin may cause which life threatening complication?

Answer:  Rhabdomyolysis

Interaction between Amiodarone and simvastatin is dose dependent. Any dose of simvastatin exceeding 20 mg, if used along with Amiodarone, may cause rhabdomyolysis. 

Q: Depending on Lorazepam infusion rate, what could be one way of suspecting Propylene Glycol (PG) toxicity?

Answer:  Though formulations of lorazepam infusion containing PG vary based on product and manufacturer, but in general mixing 1 mg of lorazepam with 1 ml of diluent yields a final solution containing 0.4 ml (415 mg) of PG for each milliliter of infusion. Serum levels of 17.7 mg/dl are associated with increased serum lactate and elevated anion gap acidosis.

Q: Simultaneous use of which commonly used drugs during intubation may exacerbate etomidate-related adrenal insufficiency?

Answer:  Opioids and benzodiazepines.

Simultaneous use of etomidate with opioids and/or benzodiazepines has shown tendency to exacerbate etomidate-related adrenal insufficiency, at least in 2 studies.

References:

1. Daniell, Harry (2008). "Opioid and benzodiazepine contributions to etomidate-associated adrenal insufficiency". Intensive Care Medicine 34 (11): 2117–8.

2. Daniell, HW (2008). "Opioid contribution to decreased cortisol levels in critical care patients". Arch Surg 143 (12): 1147–1148.

Q: How long should be waited before drawing lidocaine level, if started as an IV infusion for termination of arrhythmias?

Answer:  24 hours

Lidocaine is a class IB antiarrhythmic used to treat premature ventricular contractions (PVCs), ventricular tachycardia, and fibrillation. The therapeutic level for lidocaine is 1.5-5.0 mcg/mL, and Lidocaine toxicity can be seen at levels greater than 5 mcg/mL including seizures, cardiovascular depression, AV block, and hypotension. If administered as an infusion levels can be drawn at any time after the steady state is reached which is usually attained within 18-24 hours.

Q: Why it is important to avoid the syringe used to anesthetize the thoracentesis site, to collect pleural fluid?


Answer: 3 things which may significantly effect the PH and consequently diagnosis are

• air,
•  lidocaine, and
• heparin

The syringe used to anesthetize the thoracentesis site should not be used to collect pleural fluid because even a small volume of residual lidocaine will affect pH. 

Q: Name at least three acute conditions which may shows livedo reticularis in ICU?


Answer: List of diseases and drugs which may cause livedo reticularis is long but in ICU following 3 conditions may be commonly seen

• Cholesterol emboli status after cardiac catheterization
• Acute Pancreatitis 
• Antiphospholipid syndrome

On Post cardiac surgery vasodilatation (PCSV)

Post cardiac surgery vasodilatation (PCSV) is possibly related to a vasopressin deficiency that could relate to chronic stimulation of adeno-hypophysis. It is shown that patients who experienced PCSV had significantly

•  higher copeptin plasma concentration before cardiopulmonary bypass
• lower arginine vasopressin (AVP) concentrations at 8th postoperative hour (H8)

PCSV patients had

• preoperative hyponatremia
• decreased left ventricle ejection fraction, and
• experienced more complex surgery (alike redo)

The best predictive value for preoperative copeptin plasma concentration was 9.43 pmol/l with a sensitivity of 90% and a specificity of 77%.




Reference:

Pascal H Colson, Cedric Bernard, Joachim Struck, Nils G Morgenthaler, Bernard Albat and Gilles Guillon - Post cardiac surgery vasoplegia is associated with high preoperative copeptin plasma concentration - Critical Care 2011, 15:R255 

Doing daily weights is in ICU

Doing daily weights is in ICU is cumbersome and not always feasible to perform for various reasons. But it does have co-relation with outcomes.

Abstract

PURPOSE: Body weight fluctuates daily throughout a patient's stay in the intensive care unit (ICU) due to a variety of factors, including fluid balance, nutritional status, type of acute illness, and presence of comorbidities. This study investigated the association between change in body weight and clinical outcomes in critically ill patients during short-term hospitalization in the ICU.

METHODS: All patients admitted to the Gyeongsang National University hospital between January 2010 and December 2011 who met the inclusion criteria of age 18 or above and ICU hospitalization for at least 2 days were prospectively enrolled in this study. Body weight was measured at admission and daily thereafter using a bed scale. Univariate and multivariate linear and logistic regression analyses were performed to evaluate factors associated with mortality and the association between changes in body weight and clinical outcomes, including duration of mechanical ventilation (MV) use, length of ICU stay, and ICU mortality.

RESULTS: Of the 140 patients examined, 33 died during ICU hospitalization, yielding an ICU mortality rate of 23.6%. Non-survivors experienced higher rates of severe sepsis and septic shock and greater weight gain than survivors on days 2, 3, 4, 5, and 6 of ICU hospitalization (P < .05). Increase of body weight on days 2 through 7 on ICU admission was correlated with the longer stay of ICU, and increase on days 3 through 7 on ICU admission was correlated with the prolonged use of mechanical ventilation. Increase of body weight on days 3 through 5 on ICU admission was associated with ICU mortality.

CONCLUSIONS: Increase in body weight of critically ill patients may be correlated with duration of mechanical ventilation use and longer stay of ICU hospitalization and be associated with ICU mortality.



Reference:

You JW, Lee SJ, Kim YE, Cho YJ, Jeong YY, Kim HC, Lee JD, Kim JR, Hwang YS. - Association between weight change and clinical outcomes in critically ill patients. - J Crit Care. 2013 Dec;28(6):923-7.

Q: Name at least one condition which may give false positive "Dig. level", even if patient is not taking Digoxin?

Answer: Uremia

Endogenous digoxin-like substances may produce positive test results in patients not taking digoxin in uremia.

Q: In Oxygen-Hemoglobin dissociation curve, Left shift means high O2 affinity for Hb and Right shift means low O2 affinity for Hb. Which factors may cause Right shift in O2-Hb curve?

Answer: The causes of shift to right can be remembered using the mnemonic, 

"CADET, face Right!"

• CO2,
• Acidosis,
• 2,3-DPG,
• Exercise and
• Temperature

Burch-Wartofsky thyroid storm score

Q: What are the other advantages beside protection against atelectasis and hypoxemia of applying routine PEEP (at 5 to 8 cm H2O) to ventilator settings?

Answer: Application of routine  PEEP at 5 to 8 cm H2O PEEP is usually applied during routine ventilator settings to mitigates end-expiratory alveolar collapse. It not only protects against atelecatsis and hypoxemia, but also reduces the incidence of ventilator-associated pneumonia and lung injury, by decreasing the leakage of posterior pharyngeal secretions into the lower airway.

References:

1. Manzano F, Fernández-Mondéjar E, Colmenero M, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med 2008; 36:2225.

2. Lucangelo U, Zin WA, Antonaglia V, et al. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med 2008; 36:409.

Q: 46 year old male is in ICU intubated secondary to pneumonia and ARDS, requiring high "Bilevel" settings. Suddenly ventilator starts having high peak pressure alarm. What should be your next step?

Answer:

In event of sudden high peak pressure, hemodynamics are the first priority. If patient's hemodynamics are unstable, patient should be removed from the ventilator and bagged manually, and cause should be identified particularly auto-PEEP or tension pneumothorax - in patients with high PEEP settings. If hemodynamic improves with bagging auto-PEEP may be the likely cause. If it does not improve, tension pneumothorax should be high on list.

If patient's hemodynamics allow, a plateau pressure (Pplat) should be determined. In stable patient plateau pressure can be determined by getting an inspiratory pause on the ventilator.

If the difference between Ppeak and Pplat  is higher than about 5 cm/H20, probable causes are related to elevated airway resistance as bronchospasm, endotracheal tube obstruction or ventilator circuit obstruction.

If the difference between Ppeak and Pplat  is lower than about 5 cm/H20 cause is likely secondary to acute decrease of lung compliance as pneumothorax, pulmonary edema,  worsening ARDS, and auto-PEEP.

Q: What does suffixes p, T and D means after CKD (Chronic Kidney Disease)?

Answer:   

• The addition of p to a stage (e.g. CKD-4p) means that there is significant proteinuria
• The addition of T to a stage (e.g. CKD-2T) indicates that the patient has a renal transplant
• The addition of D to stage 5 CKD (e.g. CKD-5D) indicates that the patient is on dialysis

Q: What would be the likely change in nutrition formula if patient goes to only nocturnal feeding?

A) Calorie-dense formula

B) Formula with high water content

C) Using renal formula

D) Double the dose of standard formula

Answer:     A 

Calorically dense formulas are most practical for use in patients requiring nocturnal and/or bolus feeding. Most calorie dense formulae are concentrated in water content, and carried 2 cal/ml. Also, there is no need to switch to renal formula as they are specifically designed in contents only for renally impaired patients.

Q: Which drugs beside glucocorticoids may increase the risk of Propofol infusion syndrome (PRIS) in ICU ?

Answer: Catecholamines

Many triggering and predisposing factors for PRIS have been identified, but to all of them the priming factor is critical illness, particularly neurologic injury, trauma, sepsis or pancreatitis - beside age, cumulative dose of propofol, infusion of catecholamines, corticosteroids and interestingly inadequate delivery of carbohydrates.

Reference:

Vasile B, Rasulo F Candiani A, et al. The pathophysiology of  propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 2003;29:1417-25.

Q: 24 year old female diagnosed with HELLP syndrome, continue to get worse clinically despite delivery of baby and all conventional treatment. What is your next option?

Answer: Plasmapheresis

Plasma exchange therapy can be very helpful in patients with post-partum hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome who are refractory to treatment.  Rapid improvement of the platelet, AST, ALT and LDH levels is expected.

Q: Name at least three drugs (intravenous infusions) which may decrease the ionized calcium and may require close monitoring?

Answer:

• Heparin
• Epinephrine
• Norepinephrine

Q: What could be the treatment of heparin induced hyperkalemia secondary to aldosterone suppression?

Answer:  fludrocortisone

The mechanism of heparin induced hypoaldosterone inhibition is thought to be suppression of aldosterone synthesis through a reduction in the number and affinity of angiotensin II receptors in the adrenal zona glomerulosa. This process dampens the stimulation by the renin–angiotensin system of retention of sodium and excretion of potassium. The maximum antagonism of aldosterone effects by heparin occurs after 4–6 days of therapy and may occur at any dosage.

Hypoaldosterone state induced by heparin is antagonized by fludrocortisone. Short-term use of fludrocortisone is a good option in hyperkalemic patients until the need for heparin therapy elapses.

Reference:

Sherman DS, Kass CL, Fish DN. Fludrocortisone for the treatment of heparin-induced hyperkalemia. Ann Pharmacother. 2000;34(5):606–610

Our website is very thankful to Dr. Richard Savel for sharing this video with us.

Link: https://www.youtube.com/watch?v=kmtJiAga_8Q&feature=youtu.be

Q: Which of the following is first to resolve during treatment of TTP while on Plasma Exchange Therapy? 

A) Thrombocytopenia
B) High LDH level
C) Neurologic symptoms
D)  Kidney dysfunction



Answer: C

 In patients who respond to plasma exchange for TTP treatment, the mean time to

•  normal neurologic function is 3 days, 
• a normal LDH is 5 days, 
• a normal platelet count is 10 days, and 
• normal renal function is 15 days

.

Q: Why Intravenous acyclovir should be given with adequate hydration and slow rate? 


Answer: To avoid Acyclovir crystalline nephropathy

Intravenous acyclovir may cause reversible nephrotoxicity due to precipitation of acyclovir crystals in the kidney. Risk factors for Acyclovir crystalline nephropathy are rapid infusion, dehydration and preexisting renal dysfunction. 

Q: Which one side effect of Glucagon should be kept in mind if it is used for hypoglycemia?


Answer: Rebound fatal hypoglycemia

Glucagon depletes glycogen stores, and can cause a fatal rebound hypoglycemia. Glucagon is a very effective and quick antidote in hypoglycemia when regular glucose have low likelihood of effectiveness as in patients who are on regular Beta-Blockers. Glucagon rapidly counters the metabolic effects of insulin in the liver, causing glycogenolysis and release of glucose into the blood, raising the glucose  level by 30–100 mg/dL within minutes in mostly all types of diabetic hypoglycemia. 

Q: What is the basis of maggot debridement therapy (MDT) in necrotic tissue therapy?


Answer: Maggots derive nutrients through a process known as "extracorporeal digestion" by secreting a broad spectrum of proteolytic enzymes. In maggot therapy, large numbers of small maggots consume necrotic tissue far more precisely than is possible in a normal surgical operation, and actually can debride a wound in just a day or two. Size (length and girth) of maggot can be monitored as they ingest necrotic tissues.

Febrile Neutropenia

The Multinational Association for Supportive Care in Cancer (MASCC) risk index can be used to identify low-risk patients (score cut off at 21 points) for serious complications of febrile neutropenia. Per 2010 guidelines from Infectious Diseases Society of America

• Cefepime, carbapenems or piperacillin/tazobactam are recommended for high-risk patients and 
• Co-amoxiclav and ciprofloxacin are recommended for low-risk patients. 

Patients who do not strictly fulfill the criteria of low-risk patients should be admitted to the hospital and treated as high-risk patients.

Q: Why Murphy eye is considered to be an essential part in endotracheal tube (ETT)?

Answer: The Murphy eye, which is actually a side hole between the cuff and the tip of the ETT, was introduced in 1941 by FJ Murphy to avoid complete ETT obstruction by mucus plugs. Other advantages include facilitation of retrograde intubation and to keep the right upper lobe ventilated in case ETT slide down into the right main bronchus.