Q: All of the following are contraindications for use of neostigmine in acute colonic pseudo-obstruction (Ogilvie's syndrome) except ?

A) Severe coronary artery disease (CAD)
B) cecal diameter more than 12 cm
C) Seizure
D) Therapy with beta-blockers
E) Peritonitis


Answer: B

Neostigmine may induce bradycardia and hypotension and should be avoided in patients with compromised cardiac function or on therapy with B-Blocker with lower heart rate. Also it decreases the threshold for seizures. Other risk factors are restlessness, bronchoconstriction, nausea, vomiting, increase salivation, diarrhea and sweating.

Neostigmine is indicated in patients who fails conservative therapy and are risk for perforation with cecal diameter more than 12 cm.

Q: In clinical practice which approach is better for arterial catheter insertion (A-Line) - select one 

A) direct puncture 
or
B) guidewire approach?


Answer:  B

In clinical practice, guidewire approach is found to be more efficient than direct puncture (catheter over needle) in cannulation of arterial lines.  Guidewire approach takes less time to perform, require lesser number of catheters, and lesser number of attempts than the direct puncture approach.


References: 

1. Beards SC, Doedens L, Jackson A, Lipman J. A comparison of arterial lines and insertion techniques in critically ill patients. Anaesthesia 1994; 49:968. 

2. Mangar D, Thrush DN, Connell GR, Downs JB. Direct or modified Seldinger guide wire-directed technique for arterial catheter insertion. Anesth Analg 1993; 76:714.

Q: In acute Aortic Dissection at least which three vessels should always be examined for pulse deficits?


Answer: 

• Carotid
• Brachial
• Femoral 

Higher the number of pulse deficits in acute aortic dissesction, higher the chances of mortality within 24 hours of presentation. Pulse deficit in acute aortic dissection occurs either due to intimal flap or compression by hematoma. As expected, it is more common with aortic arch or thoracoabdominal aortic dissection.


Reference: 

Bossone E, Rampoldi V, Nienaber CA, et al. Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection. Am J Cardiol 2002; 89:851.

Q: Which one observation may help in differentiating plerual effusion from parenchymal lung disease?


Answer: Pleural effusion is more likely; if pulmonary vessels can be visualized through the opacity of pleural effusion but air bronchograms cannot be.

Q: All of the follow are risk factors for Transfusion Related Acute Lung Injury (TRALI) except?

A) Liver transplantation 
B) Alcohol abuse  
C) High peak airway pressure on  mechanical ventilator
D) High interleukin (IL)-8 levels 
E) Negative fluid balance


Answer:  E

Various risk factors have been identified via various studies for TRALI and it includes positive fluid balance. Other factors include liver transplantation, alcohol abuse, septic shock, high peak airway,  smoking, high interleukin (IL)-8 levels, emergency cardiac surgery, hematologic malignancy, massive transfusion and others.


References: 

1. Gajic O, Rana R, Winters JL, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med 2007; 176:886. 

2.  Toy P, Gajic O, Bacchetti P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood 2012; 119:1757.

Q: What does it mean by Fourth generation HIV test?


Answer:  Fourth-generation HIV test is a combination of HIV-1, HIV-2 antibodies and p24 antigen. Testing of p24 antigen has advantage of possible detection of HIV infection before antibodies are produced, closing the window in which test may come negative despite having infection. In many countries like UK they are recommended as a first-line assay. With this test you may not need to do western blot test.

Q: Why administration of rFVIIa without co-administration of Vitamin-K may be deceiving in treatment of warfarin induced intra-cranial-hemorrhage (ICH)?


 Answer: Administration of rFVIIa alone, without co-administration of Vitamin-K, will normalize the INR but will not replace other vitamin K-dependent clotting factors. It corrects only the warfarin-induced reduction in the level of factor VII. Normalization of INR  gives a false sense of security. Also, half life of rFVIIa is only 2-3 hours and Vitamin-K is required for sustained reversal of warfarin.

Q: 54 year old male is admitted to ICU with chills, fever and new onset of murmur. Patient is diagnosed with 'Streptococcus Bovis' endocardititis after 4 bottles reported positive for blood culture and vegetation on mitral valve found on Echo. What should be your next concern?


Answer: Colon cancer

About 7 percent of all infective endocarditis occurs due to 'Streptococcus Bovis', which has high association with colon cancer as well as underling inflammatory bowed disease (IBD). 54 is somewhate late for diagnosis of IBD and should raise high suspicion of colon cancer. Another bacteria which is highly associated with colon cancer is Clostridium septicum. 


References: 

1.  Corredoira-Sánchez J, García-Garrote F, Rabuñal R, et al. Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study. Clin Infect Dis 2012; 55:491.

2.  Boleij A, van Gelder MM, Swinkels DW, Tjalsma H. Clinical Importance of Streptococcus gallolyticus infection among colorectal cancer patients: systematic review and meta-analysis. Clin Infect Dis 2011; 53:870. 

3.  Moshkowitz M, Arber N, Wajsman R, et al. Streptococcus bovis endocarditis as a presenting manifestation of idiopathic ulcerative colitis.

4.  Postgrad Med J 1992; 68:930. Boleij A, Schaeps RM, Tjalsma H. Association between Streptococcus bovis and colon cancer. J Clin Microbiol 2009; 47:516.

Q: How much ice cooled saline should kept available at bedside while performing bronchoscopy to control massive hemoptysis?


Answer: About one litre

If it is decided to use ice cooled saline lavage while trying to control massive hemoptysis - it is advisable to keep about twenty 50 mL syringes ready, as it may take anywhere from 300cc to 1000cc of ice cooled saline to see desirable effect via vasoconstriction.



 References: 

1.  Conlan AA, Hurwitz SS, Krige L, et al. Massive hemoptysis. Review of 123 cases. J Thorac Cardiovasc Surg 1983; 85:120. 

2. Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.

Q: Chagas disease effect: (Choose one) 

A) parasympathetic autonomic nervous system 
B) sympathetic autonomic nervous system


Answer:  A 

In chagas disease, selective incremental failure of the parasympathetic nervous system eventually leads to megaesophagus, megacolon and dilated cardiomyopathy. Cardiomyopathy is the usual cause of death in Chagas disease. Underlying mechanism of pathology occurs via inflammatory response, cellular lesions, and fibrosis. Intracellular amastigotes destroy the intramural neurons of the parasympathetic  autonomic nervous system in the GI tract and heart, leading to mega-intestine and dilated cardiomyopathy.

Q: What does blue Toe syndrome on clinical exam means?


Answer:  The blue toe with preserved pulses should raise the strong suspicion of embolic occlusion of the foot arteries, and should raise the alarm as it may be a herald symptom of more severe, future embolic events, which may threaten the whole limb. 



Reference:

Karmody AM, Powers SR, Monaco VJ, Leather RP. "Blue toe" syndrome. An indication for limb salvage surgery. Arch Surg 1976; 111:1263.

Q: In most cases, Janeway lesions in Infective Endocarditis signifies what?


Answer: Janeway lesions are more common and points towards acute infective endocarditis instead of  subacute Infective Endocarditis. They are usually  distal, flat, ecchymotic, and painless and are caused by septc emboli which deposit bacteria, forming microabscesses.

Q: What are the six-steps process to conflict resolution in clinical cases, where providers may believe that further care of the patient is futile?


Answer:

1. Inform the surrogate about the conflict resolution process, 
2. request review by a multidisciplinary hospital committee, 
3.  continue dialogue between the clinical team and surrogate, 
4.  inform surrogates of their right to seek legal intervention, 
5.  attempt to transfer the patient to a willing provider, and 
6.  implement a plan of care

Source: Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults - Article from Douglas B White, MD, MAS in UpToDate

{Objective of above question is to highlight the fourth point - where there is often a failure to inform surrogates of their right to seek legal intervention, for obvious reasons!}


Further Readings:

1. Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997; 25:887.

2. Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281:937.

Q: About what percentage of patients usually have Swallowing impairment post extubation?


Answer:  About 50%!

Data is not strong but interestingly almost half of the patients who remain intubed for more than 48 hours develop some degree of  swallowing impairment. Usually it resolves by itself and requires only aspiration precaution and fulfillment of nutritional needs. Severity of underlying disease and length of intubation determines the length, severity and duration of post-extubation dysphagia.


Reference: 

Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest 2010; 137:665.

Q: What is the role of Indomethacin in acute liver failure?


Answer:  It has been reported that increased Intra-Cranial Pressure (ICP) in fulminant  hepatic failure which stays refractory to all treatments may respond to a single intravenous dose of 25 mg  Indomethacin given over one minute. Proposed mechanism of action is cerebral vasoconstriction.


References: 

 1. Clemmesen JO, Hansen BA, Larsen FS. Indomethacin normalizes intracranial pressure in acute liver failure: a twenty-three-year-old woman treated with indomethacin. Hepatology 1997; 26:1423.

2. Tofteng F, Larsen FS. The effect of indomethacin on intracranial pressure, cerebral perfusion and extracellular lactate and glutamate concentrations in patients with fulminant hepatic failure. J Cereb Blood Flow Metab 2004; 24:798.

Q: Out of  the following which antibiotic is found to be associated with eosinophilic pneumonia?

A) Linezolid
B) Daptomycin
C) Vancomycin
D) Erythromycin
E) Metronidazole



Answer:  B

 Daptomycin has been clearly shown to be associated with eosinophilic pneumonia, which can be life-threatening. To note, Daptomycin binds to pulmonary surfactant, and it is presumed that it accumulates in alveolar spaces and subsequently causes injury and the inflammation.



Reference: 

 Hayes D Jr, Anstead MI, Kuhn RJ. Eosinophilic pneumonia induced by daptomycin. J Infect 2007;54:e211-e213

Q: 48-year-old male after Orthotopic Heart Transplant (OHT) developed severe Disseminated intravascular coagulation (DIC). What should be most underlying worry?


Answer: Acute organ rejection

Though Disseminated intravascular coagulation (DIC) is a well-known phenomenon underlying various diseases in ICU and requires treatment of the underlying issue, but severe DIC immediately  after solid organ  transplantation should raise high suspicion of acute rejection and should alert physicians to take extra effort to salvage the transplant besides bleeding which is commonly fatal if not controlled.

Q: All of the following are the hallmark of Thrombotic thrombocytopenic purpura (TTP) except?

A) Increased lactate dehydrogenase (LDH)
B) Microangiopathic hemolytic anemia (MAHA) 
C) Increased haptoglobin level
D) Massively increased INR 
E)  Elevated bilirubin


Answer:  D

Interestingly and to make differential diagnosis easy, coagulation profile is almost always normal in TTP, unless until some other underlying disease like sepsis may cause DIC (Disseminated Intravascular Coagulation).

Q: What does it mean by purge solution in Impella ® cardiac device?


Answer:  Purge refers to the solution which flows through the Impella® Catheter in the opposite direction of the patient’s blood being drawn into the catheter during device support. The purge solution creates a pressure barrier that prevents blood from entering the Impella ® motor. The recommended solution is the dextrose and its concentration determines the viscosity and flow rate of the purge fluid. Makers of the Impella device recommend solutions from D-5 to D-20. Higher concentration of dextrose i.e. D-20 provides higher barrier pressure but on the down side requires replacement of Impella® purge cassette daily. On the other hand, purge solution of 5% dextrose provides lesser barrier but the purge cassette can be used for 5 days. As a standard practice, heparin is added in the purge solution for anticoagulation.

Q: 22-year-old male with a known history of Ulcerative Colitis presents with abdominal pain and diarrhea. All of the following medications should be avoided except? 

A) Anticholinergic
B) Antidiarrheal
C) NSAIDs
D) Rifaximin
D) Narcotics


 Answer:  D

All medications which can predispose to toxic megacolon during acute exacerbation of Ulcerative Colitis should be avoided. Rifaximin has recently been studied and found to be of benefit in treatment and maintenance of Ulcerative Colitis.



 References: 

1. Guslandi M, Petrone MC, Testoni PA. Rifaximin for active ulcerative colitis. Inflamm Bowel Dis. 2006;12:335. 

2. Gionchetti P, Rizzello F, Ferrieri A, Venturi A, Brignola C, Ferretti M, Peruzzo S, Miglioli M, Campieri M. Rifaximin in patients with moderate or severe ulcerative colitis refractory to steroid-treatment: a double-blind, placebo-controlled trial. Dig Dis Sci. 1999;44:1220–1221.

Q: Why intravenous diuretics are preferred over oral diuretics till patient resolves clinical significant edema or anasarca?


Answer: Patients with high degree of edema may also have mucosal edema and consequently decrease intestinal perfusion as well as reduced intestinal motility. Once edema is reduce enough, IV diuretic can be changed to PO form.


Reference: 

Krämer BK, Schweda F, Riegger GA. Diuretic treatment and diuretic resistance in heart failure. Am J Med 1999; 106:90.

Q: How HIT Expert Probability (HEP) Score differs from 4 T's score in the management of Heparin Induced Thrombocytopenia (HIT)?


Answer: 

In HEP score, points are subtracted or added depending on bleeding or presence of devices or other causes of Thrombocytopenia. It is an excellent measuring score but may be cumbersome. A HEP score cut-off of 2 would lead to 100% sensitivity and 60% specificity while a cut-off of 5 would maximize sensitivity/specificity at 86% and 88%, respectively,

Clinical Feature	Presentation	Score
Magnitude of fall in platelet count (measured from peak to nadir since heparin exposure)	< 30%	-1
	30-50%	+1
	>50%	+3
Timing of fall in platelet count	For patients in whom typical onset HIT is suspected:
	Fall begins < 4 days after heparin exposure	-2
	Fall begins 4 days after heparin exposure	+2
	Fall begins 5-10 days after heparin exposure	+3
	Fall begins 11-14 days after heparin exposure	+2
	Fall begins > 14 days after heparin exposure	-1
	For patients with previous heparin exposure in the last 100 days in whom rapid onset HIT is suspected:
	Fall begins < 48 hours after heparin exposure	+2
	Fall begins > 48 hours after heparin exposure	-1
Nadir platelet count	≤ 20 × 109 L−1	-2
	> 20 × 109 L−1	+2
Thrombosis (select no more than one)	For patients in whom typical onset HIT is suspected:
	New VTE or ATE > 4 days after heparin exposure	+3
	Progression of pre-existing VTE/ATE while receiving heparin	+2
	For patients in whom rapid onset HIT is suspected:
	New VTE or ATE after heparin exposure	+3
	Progression of pre-existing VTE /ATE while receiving heparin	+2
Skin necrosis	Skin necrosis at subcutaneous heparin injection sites	+3
Acute systemic reaction	Acute systemic reaction after intravenous heparin bolus	+2
Bleeding	Presence of bleeding, petechiae, or extensive bruising	-1
Other causes of thrombocytopenia (select all that apply)	Presence of a chronic thrombocytopenic disorder	-1
	Newly initiation non-heparin med known to cause thrombocytopenia	-2
	Severe infection	-2
	Severe DIC (fibrinogen < 100 mg/dL and D-dimer > 5 mcg/ml)	-2
	Indwelling intra-arterial device (IABP, VAD, ECMO)	-2
	Cardiopulmonary bypass within previous 96 hrs	-1
	No other apparent cause	+3
VTE=venous thromboembolism; ATE=arterial thromboembolism; DIC=disseminated intravascular coagulation

References: 

1. Cuker A, Arepally G, Crowther MA, et al. The HIT Expert Probability (HEP) Score: a novel pre-test probability model for heparin-induced thrombocytopenia based on broad expert opinion. J Thromb Haemost 2010; 8:2642. 

2. Joseph L, Gomes MP, Al Solaiman F, et al. External validation of the HIT Expert Probability (HEP) score. Thromb Haemost 2015; 113:633.

Q: 58 year old male is admitted to ICU overnight with exacerbation of COPD. Patient required intubation. Patient CXR next morning showed pneumothorax with progressively worsening desaturation. Immediately chest tube is inserted but didn't bring any relief and patient remained hypoxic. CXR showed no resolution of CXR. Malposition of chest tube, either intrafissural or intraparenchymal is suspected as there is no air leak. What should be the next step?

A) Remove chest tube immediately and repeat CXR
B) Call Thoracic surgery
C) Increase PEEP on ventilator for desaturation
D) Extubate and reintubate patient
E) Increase suction on chest tube from -20 to -40


Answer: B

About 25% of chest tubes may be malpositioned on blind insertion. Objective of above question is to emphasize that in such scenarios inserted chest tube should not be removed as it may cause further harm by worsening pneumothorax. Thoracic surgery should be called to insert new chest tube and once it is working, old chest tube can be removed with caution. Ideally, CT scan of chest should be performed before removal of previous chest tube given patient is clinically stable.

C) is wrong as increased PEEP may harm by causing further increase in pneumothorax.

D) is crazy! No! you never do that!

E) can be tried under close watch but it may not solve the original problem.


Reference: 

 Lim KE, Tai SC, Chan CY, et al. Diagnosis of malpositioned chest tubes after emergency tube thoracostomy: is computed tomography more accurate than chest radiograph? Clin Imaging 2005; 29:401.

Q: Which of the following disease may require prophylaxes for both thromboembolism and infective endocarditis?

A) Deep Venous Thrombosis
B) Obstructive hypertrophic cardiomyopathy 
C) Acute saddle Pulmonary Embolism
D) Mitral prolapse
E) Sickle Cell disease



Answer:  B

Out of all the diseases, obstructive hypertrophic cardiomyopathy may require both prophylaxes. As patients with obstructive hypertrophic cardiomyopathy are prone to develop atrial fibrillation, prophylactic anticoagulation is recommended. Though official guidelines don't recommend antibiotic prophylaxis in these patients against infective endocarditis, data suggests and favor practice of antibiotic prophylaxis in such patients before dental or any invasive procedure.


References: 

1.  Pasquale G Di, Andreoli A, Lusa AM, et al. Cerebral embolic risk in hypertrophic cardiomyopathy. In: Advances in Cardiomyopathies, Baroldi G, Camerini F, Goodwin JF (Eds), Springer-Verlag, 1990. p.90. 

2. Spirito P, Rapezzi C, Bellone P, et al. Infective endocarditis in hypertrophic cardiomyopathy: prevalence, incidence, and indications for antibiotic prophylaxis. Circulation 1999; 99:2132.

A note on exacerbation of seafood allergy due to antacids 

Patients with allergy to seafood should take caution while taking antacids/antiulcer therapy. Antacids increase the gastric PH and consequently may impair the digestion of food proteins. Evidence is weak but pathophysiology suggests that antacids may increase risk of allergy to ingested seafood.




References: 

1. Untersmayr E, Schöll I, Swoboda I, et al. Antacid medication inhibits digestion of dietary proteins and causes food allergy: a fish allergy model in BALB/c mice. J Allergy Clin Immunol 2003; 112:616. 

2. Untersmayr E, Vestergaard H, Malling HJ, et al. Incomplete digestion of codfish represents a risk factor for anaphylaxis in patients with allergy. J Allergy Clin Immunol 2007; 119:711.

Q: What is the one advantage of ultrafiltration in further regular management of refractory congestive heart failure?


Answer:  Extracorporeal ultrafiltration may restore responsiveness to loop diuretics in standard management of congestive heart failure (CHF). In other words, may get rid of refractoriness of CHF.


 Reference: 

 Libetta C, Sepe V, Zucchi M, et al. Intermittent haemodiafiltration in refractory congestive heart failure: BNP and balance of inflammatory cytokines. Nephrol Dial Transplant 2007; 22:2013.

Q: What is one off label use of  Ondansetron (Zofran) in Surgical ICUs beside management of  post-operative nausea and vomiting (PONV)?


Answer:  Post-op shivering

Zofran has been reported as effective as Demerol for post-op shivering  as a single intravenous dose 2 minutes before anesthesia. It can reduce shivering from 50 to 13.3% along with its good safety profile.



References:  

1. Generali JA, Cada DJ (August 2009). "Ondansetron: postanesthetic shivering" - Hospital Pharmacy 44 (8): 670–1.1. 

2. Kelsaka E, Baris S, karakoya D, Sarihasan B. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med. 2006;31:40–5.

3. Powell RM, Buggy DJ. Ondansetron given before induction of anesthesia reduces shivering after general anesthesia. Anesth Analg. 2000;90:1423–7.

Q: 68 year old male with previous history of hypertension controlled at home with Lopressor - admitted to ICU with community acquired pneumonia. While receiving first dose of intravenous antibiotics, patient became flushed and hypotensive. Anaphylaxis from antibiotic is suspected. "Epi" is administrated. Patient's response to epinephrine seems not optimum. Knowing patient was on chronic beta-blocker therapy at home, you decided to administer Glucagon. Which caution should be exercise?


Answer: Avoiding quick IV push

Patients on chronic beta-blocker therapy are likely to be resistant to epinephrine. Glucagon has an unique property of been inotropic and chronotropic effects that are not mediated through beta-receptors. Quick IV push, which are common to practice in such situations, should be avoided as rapid administration can induce vomiting and aspiration pneumonia. It should administered slowly over five minutes.



Reference: 

Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J 2005; 22:272.

Q: Encephalopathy resembling very much like Wernicke's encephalopathy is common after which transplant?


Answer:  Pancreatic transplant

Pancreatic transplant patients may develop encephalopathy which is very much alike Wernicke's encephalopathy. It is usually transient and reversible, and also known as pancreatic encephalopathy. Hallmark feature of this encephalopathy is autonomic findings.


 Reference: 

 Patchell RA. Neurological complications of organ transplantation. Ann Neurol 1994; 36:688.

Q: Ketamine has all of the properties except 

A) dissociative anesthetic
B)  increase mean arterial pressure (MAP)
C) increase intracranial pressure (ICP)
D) cause reemergence phenomenon
E) Bronchoconstriction



Answer:  E

One of the reason Ketamine is still advocated by many in Rapid Sequence Intubation (RSI) because it has many good properties like dissociative anesthetic with good amnestic and sedative effects. It has good Hemodynamic profile and a bronchodilator. It should be use with caution in neuro patients.