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.

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).

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.

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.

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 :)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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. 

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.