Q: Linezolid causes lactic acidosis due to mitochondrial dysfunction. It requires at least 2 weeks of intake/infusion?  - True or False?


Answer: False

Previously it was thought that  linezolid driven lactic acidosis requires prolonged course of antibiotic treatment, but now reports suggest it can occur even at initiation of the antibiotic, particularly if patient may have underlying MELAS syndrome (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes).

Q: 65 year old male is now recovering in ICU after COPD exacerbation. Pulmonary rehabilitation is recommended by pulmonary service.  Out of the following, all are part of the pulmonary rehabilitation in severe COPD patients except? 

A) Lower and upper extremity exercises
B) High dose steroid with tapering
C) Breathing training 
D) Psychological support 
E) Education


Answer: B

Pulmonary rehabilitation along with medical management found to be very effective in patients with COPD who requires hospitalizations due to exacerbations. It consists of four components:

• conditioning, 
• breathing retraining, 
• education, and 
• psychological support 

The Goal of pulmonary rehabilitation is to potentially prevent exacerbations of COPD and use of steroids.



References:

Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188:e13. 

Q: How to differentiate between the Cardiac and hepatic (cirrhotic) source of Ascites?


Answer: Cardiac source of Ascites needs to fulfill 2 criteria

1. SAAG (Serum Ascites Albumin Gap) equal or more than 1.1 g/dL
2. Ascitic fluid Total Protein level equal or more than 2.5 g/dL

Cirrhosis from which cardiac source usually needs to be differentiated only satisfies first criteria. 

Q: How to rule out Osmotic Diarrhea in ICU?


Answer: The easiest way to rule out osmotic diarrhea is via calculating simple formula of Osmotic gap

290-2 x (stool Na + Stool K)

Gap more than 100 mOsm/kg, is probably an osmotic diarrhea. 
Gap less than 50mOsm/Kg rules out osmotic diarrhea. 
Gap between 50 and 100 mOsm/kg is equivocal

In ICU most usual causes of osmoticc diarrhea are medications (containing nonabsorbable sugar alcohols like Sorbitol) and tube feeds.


Further reading: -  Here -Mechanisms, prevention, and management of diarrhea in enteral nutrition -  Kevin Whelan and Ste´phane M. Schneider -  Current Opinion in Gastroenterology 2011, 27:152–159 

Q: Which meningitis may present with asymmetric flaccid paralysis during mosquito season in summer to early fall?


Answer: West Nile (WN)

WN virus infection may present as an acute asymmetric weakness of the limbs or flaccid paralysis. Paralysis results from an anterior horn cell process. To make diagnosis difficult, symptoms may occur with or without signs of meningitis or encephalitis.



References:

1. Sejvar JJ, Bode AV, Marfin AA, et al. West Nile virus-associated flaccid paralysis. Emerg Infect Dis 2005; 11:1021. 

2. Li J, Loeb JA, Shy ME, et al. Asymmetric flaccid paralysis: a neuromuscular presentation of West Nile virus infection. Ann Neurol 2003; 53:703. 

3. Jeha LE, Sila CA, Lederman RJ, et al. West Nile virus infection: a new acute paralytic illness. Neurology 2003; 61:55. 

Q: Aplastic crisis in Sickle-cell disease (SCD) is triggered by which virus? 


Answer:  Parvovirus B19

Parvovirus B19 has the ability to directly affects RBC precursors upto the point to complete cease its production for two to three days. Normal individual can tolerate this offence but patients with SCD due to their shortened red cell life go into aplastic crisis, marked by remarkable paleness pale appearance, tachycardia  and severe fatigue. Crisis is all hallmarked by reticulocytopenia followed by brisk reticulocytosis. Treatment is supportive and may require transfusion.

Q: All of the following are likely to cause Sterile pyuria except?

A) Gonorrhea
B) Acetaminophen intake
C) Genitourinary tuberculosis
D) Urosepsis
E) Kawasaki disease


Answer:  D 

Sterile pyuria is defined as a urine specimen which contains white blood cells but stays sterile by any standard culturing techniques. Any WBC count without positive culture in urine should be glanced again to rule out any other underlying disease. Urosepsis, on the other hand, is term broadly used to describe generalized sepsis and bacteremia due to positive bacteriuria. 

The objective of above question is to recall diseases which may cause sterile pyuria and may lie low for diagnosis.

Q: Acute Promyelocytic Leukemia (APL), is considered a medical emergency as it culminates into high early mortality. It is one of the malignancy where treatment should be started as soon as the diagnosis is suspected due to cytologic and clinical criteria, and definitive (cyto)genetic confirmation is not required. Reason for high mortality in APL is due to

A) Blast crisis 
B) DIC 
C) Liver failure 
D) CVA 
E) Sudden cardiac death 


Answer: B

APL is considered a medical emergency and treatment should get started without cytogenetic diagnosis if  cytologic and clinical criteria is satisfied. The First line of a drug is all-trans retinoic acid (ATRA). The Reason for a high rate of early mortality is usually due to hemorrhage from a characteristic coagulopathy. 

Diagnosis?

Answer: Pulmonary Embolism

Though classic S1Q3T3 is found only in 20-30% of PE cases, but if found it is highly suggestive of PE.

Q: Fluoroquinolones are found to be most effective antibiotics in acute cholangitis (given no resistance and good local profile). Even it has been shown that monotherapy with ciprofloxacin may be as effective as triple therapy with ceftazidime, ampicillin, and metronidazole. What is the reason? 


Answer:  Fluoroquinolones are very effective in acute cholangitis as in comparison to other antibiotics, they have high rates of biliary excretion. In case of Fluoroquinolones allergy or resistance, monotherapy with a beta lactam antibiotics is also good. At the end initial goal is to cover antibiotics that cover colonic bacteria, and later de-escalate/modify depending on growth of cultures.


Reference:

1. Leung JW, Ling TK, Chan RC, et al. Antibiotics, biliary sepsis, and bile duct stones. Gastrointest Endosc 1994; 40:716. 

2. Sung JJ, Lyon DJ, Suen R, et al. Intravenous ciprofloxacin as treatment for patients with acute suppurative cholangitis: a randomized, controlled clinical trial. J Antimicrob Chemother 1995; 35:855.

Q: Which of the following is not part of MELD (Model For End-Stage Liver Disease) score? 

A) Bilirubin 
B) Creatinine 
C) Sodium 
D) INR
E) AST


Answer: E

The MELD is recently updated in January 2016 and now it includes serum sodium level. MELD score determines the highest priority to receive liver transplants in the US. If the patient has been dialyzed twice within last one week, then the value for serum creatinine used should be 4.0.

Q: During rescuing Balloon tamponade (Sengstaken-Blakemore tube) for esophageal variceal bleeding which balloon should be inflated first? (Select one) 

A) Esophageal
B) Gastric 


Answer: B

Balloon tamponade is usually used as a last minute rescue therapy in life and death situation in massive esophageal bleeding. It requires an experienced operator as it carries a high risk of esophageal rupture. After intubation, oral route is a preferred to insert tube. The gastric tube is inflated first with about 400-500 cc of air and pulled to apply tamponade and tension via pulley usually above the head of the bed. Only if bleeding does not stop after inflation of gastric port, the esophageal port should be inflated to about 30 to 40 mmHg. Overinflation of esophageal port may rupture esophagus.

Q: Patient informed you that he has a history of Pyrosis. What does that mean?


Answer:  Heartburn 

Pyrosis is the designated term for heartburn. It came from Greek word purōsis which is a derivative of word  puroun, meaning 'set on fire' ( pur = 'fire').

Q: What is the rule of thumb to calculate effect of PEEP on wedge pressure (Pulmonary Artery Occlusion Pressure - PAOP)?


Answer:  

If swan (pulmonary artery catheter)  is appropriately positioned in zone 3 of lung, ideally PEEP should not be a concern as  airway pressure does not get transmitted to the vasculature. But in real world, there is always some effect of higher PEEP on PAOP. In patients with high PEEP around 10, PAOP can be predicted by subtracting one-quarter of the PEEP - as most patients on higher PEEP usually have compromised compliance. If compliance appears to be normal on ventilator (unlikely in ICU), one-half of the PEEP should be subtracted.



Reference:

Teboul, JL, Besbes, M, Andrivet, P, et al. A bedside index assessing the reliability of pulmonary artery occlusion pressure measurements during mechanical ventilation with positive end-expiratory pressure. J Crit Care 1992; 7:22.

Q: In which of the following conditions, Pulmonary-Arterial-Diastolic-Pressure (PADP) is usually higher 6 or more than to Pulmonary Wedge Pressure (PWP or PAOP)?

A) Acute Cardiogenic shock
B) Cardiac Tamponade
C) Ventricular Septal Defect
D) Acute Right heart failure
E) Pulmonary Hypertension


Answer: E

PADP is usually either near equal or higher than PWP but if this difference exceeds more than 6, it may be calling to consider pulmonary hypertension.

Pearl: If PWP/PAOP is higher than PADP, it is an error.

Q: What are the 3 characteristics of WPW syndrome on EKG? 


 Answer: 

•  a short PR interval (0.12 seconds) - causing fusion beat 
• delta wave (from rapid ventricular activation via the accessory pathway) 
•  normal terminal portion of the QRS

Q: Out of the following, in which condition warfarin can be continued in pregnancy despite its teratogenic risks?

A) Atrial fibrillation
B) Deep Vein Thrombosis (DVT)
C) Pulmonary Embolism (PE)
D) Mechanical valve
E) It is absolutely contraindicated in pregnancy


Answer: D

 Management of anticoagulation in patients with pregnancy is extremely difficult as LMW Heparin or unfractionated Heparin may fail to provide optimum anticoagulation. It requires extensive discussion between mother and a physician, and all options and risks should be conveyed to the mother. Despite its risks of teratogenicity, warfarin is a drug of choice up to week 37 in high-risk patients with mechanical valves. Full discussion of management of anticoagulation of mechanical valves in pregnant patient is out of the scope here, but it requires extensive planning.

Q:  What is the minimal rate of bleeding needed to have diagnostic value angiography in  GI bleed?


Answer:  0.5 ml/min

 For severe gastrointestinal bleed, which remains undiagnosed by upper or lower GI scope, angiography is a great tool to pinpoint bleeding vessel, but if the minimal rate of bleeding is less than 0.5 mL/minute, it may not provide good diagnostic value angiography in GI bleed.

What is heparin rebound? Exploring the parallel meanings that have existed for over 45 years 

"Two different meanings of heparin rebound phenomenon have existed for at least 45 years. Because precision is one of the fundamental rules in medicine, it may be wise to try to diminish the possible harm caused by imprecise use of the term. In addition to speed of onset and duration of a rebound effect, and the attendant morbidity and mortality risks, it is essential to know two other characteristics: which drug's withdrawal is causing rebound, and what patho-physiologic processes ensue as a result. Thus, one way to avoid confusion about rebound phenomenon is to avoid using only the name of the drug with the word "rebound" (eg, pro-pranolol rebound). It is preferable to identify the process by stating "rebound following withdrawal of" and then insert the name of the drug (eg, hypertension rebound following the withdrawal of propranolol). For a thrombotic tendency or complication of heparin discontinuation, "thrombotic rebound following heparin withdrawal" would be more accurate. As for heparin rebound in patients after cardiopulmonary bypass surgery, the term might be renamed "rebound heparin activity."

Read full article here  (Goran P. Koracevic, MD, PhD)

Weblink: http://www.hcplive.com/journals/cardiology-review-online/2008/may2008/may-2008-koracevic

A note on permeability aspect of ARDS

ARDS many times as a misnomer called 'permeability pulmonary edema' because this is the most striking, important and pathological feature of Acute Respiratory Distress Syndrome (ARDS). At the cellular level, the damage of alveolar-capillary membrane causes the leak of protein. One way to differentiate between cardiogenic and non-cardiogenic edema is the concentration of protein in the interstitium (established more than 35 years ago). In ARDS protein exceeds 60 percent of the plasma value, and in cardiogenic pulmonary edema, it is less than 45 percent.


Reference: 

 Fein A, Grossman RF, Jones JG, et al. The value of edema fluid protein measurement in patients with pulmonary edema. Am J Med 1979; 67:32.

Q: In Adaptive Support Ventilation (ASV) operator has to set (select one)

A) Respiratory rate
B) Minute volume
C) Tidal volume
D) Pressure support
E) inspiratory/expiratory time ratio


Answer: B

In Adaptive Support Ventilation (ASV®), operator sets minute volume and ventilator automatically determines an optimal tidal volume / respiratory rate combination. It takes into consideration patient's work of breathing (patient’s respiratory mechanics) - breath to breath -and adjust inspiratory pressure, respiratory rate, and inspiratory/expiratory time ratio. Operator can set limit, if wishes, to maximum tidal volume by setting a maximum inspiratory pressure. In patient's who are now ready to wean, ASV adjusts pressure support - breath to breath -, which determines and help to recover patient's inspiratory strength - and assist in weaning.

A note on Locked-in Syndrome 

There is a generalized misconception that all locked-in patients prefer to die instead of stay in dreadful locked-in state. On the contrary, one study of 13 survivors from an initial cohort of 29 patients showed following results

• satisfaction with life was expressed by 7 patients, 
• occasional depression was reported for 5 patients, 
• euthanasia was never considered by 7, 
• euthanasia was considered but refused by 6, and 
• a wish to die was expressed by 1 patient, 
• None had  DNR directives

Reference: 

 Doble JE, Haig AJ, Anderson C, Katz R. Impairment, activity, participation, life satisfaction, and survival in persons with locked-in syndrome for over a decade: follow-up on a previously reported cohort. J Head Trauma Rehabil 2003; 18:435.

Q: 44-year-old asthmatic patient is admitted to ICU with frequent seizure episodes. There is a high suspicion of theophylline overdose Which of the commonly used anticonvulsants should not be used?

Answer: Phenytoin and fosphenytoin

Studies have shown phenytoin and/or fosphenytoin may make seizures worse  caused by  theophylline. Similarly, is true for seizures from Cocaine.


Reference:

Paloucek FP, Rodvold KA. Evaluation of theophylline overdoses and toxicities. Ann Emerg Med 1988; 17:135.

Q: What is the average expansion rate of Abdominal Aortic Aneurysm(AAA)? 


Answer:  0.5 cm/year

On average AAA expand with the rate of half centimeter/year.

Clinical significance: AAA is a clinical condition which goes unnoticed many times until rupture occur or get diagnosed during other clinical processes. And, if AAA is already diagnosed follow up should be undertaken very closely. Value of aortic diameter and rate of expansion largely influence the decision of surgical intervention. Prior imaging studies carries significant importance. If average yearly rate of expansion is more than 0.5 cm per year, surgical consult is required. There are various other factors involved in this process like smoking, hypertension etc. Many authorities have define  rapid expansion as aneurysms that increase in size more than or equal to 5 mm over a six-month time-period, or more than or equal to 10 mm over a year.

Q: 42 year old male is admitted to ICU with acute on chronic liver failure. Which one test will effectively rule out liver failure secondary to hemochromatosis?

A) Ferritin level
B) Transferrin level
C) Total Bilirubin level
D) Chromium level
E) Serum ETOH  level


Answer: B

Transferrin level less than 45% effectively rule out liver insufficiency secondary to hemochromatosis. Ferritin level (a close call) is usually used later for a follow-up or to complete the comprehensive workup along with gene testing. A transferrin saturation more than 60 percent in males or more than 50 percent in females rule in hemochromatosis in most of the cases.

Other choices (C, D and E) does not rule out hemochromatosis.



Reference:

 Edwards CQ, Kushner JP. Screening for hemochromatosis. N Engl J Med 1993; 328:1616.

Angioedema after tPA: what neurointensivists should know

BACKGROUND: Angioedema is an underappreciated and potentially life-threatening complication of intravenous (IV) recombinant tissue plasminogen activator (rt-PA). Patients taking angiotensin converting enzyme (ACE) inhibitors are at increased risk of this rare complication.

Case report: A 74 year-old woman taking lisinopril for hypertension was treated with IV rt-PA for right hemispheric acute ischemic stroke. Shortly after completion of the rt-PA infusion, she developed asymmetric angioedema involving the tongue and left lower lip. No emergent airway intervention was needed. Following treatment with epinephrine, antihistamines, and corticosteroids, the edema resolved within 24 h. The patient made an excellent recovery from the ischemic stroke.

CONCLUSIONS: Orolingual angioedema can complicate rt-PA treatment of acute stroke and is often ipsilateral to the side of hemiparesis. Neurointensivists should be aware of this possibility, which is increased in patients taking ACE inhibitors. Epinephrine can be given safely in this scenario. Identification of high risk features may help guide decisions regarding early definitive airway management.


 Reference:

Fugate JE1, Kalimullah EA, Wijdicks EF. - Angioedema after tPA: what neurointensivists should know. - Neurocrit Care. 2012 Jun;16(3):440-3.

Q: Which of the following drugs is usually used to enhance the diagnostic value of the Dobutamine Stress Echocardiography (DSE) in evaluation of hibernating/viable myocardium?

A) Lopressor
B) Atropine
C) Hydralazine
D) Epinephrine
E) Vasopressin


Answer:  B

Two drugs which may be given with dobutamine to enhance the diagnostic value of DES are Atropine and Nitroglycerine.



Reference:

Poldermans D, Rambaldi R, Bax JJ, et al. Safety and utility of atropine addition during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction. Eur Heart J 1998; 19:1712.

Q: Dexamethasone is recommended for the treatment of HELLP syndrome - True or False?


Answer: False

Dexamethasone has been used traditionally in HELPP syndrome, but major large studies failed to show any benefits. Dexamethasone does not reduce the duration of hospitalization, the rate of blood products transfusion, any organ failure, time of recovery of coagulation or liver profiles, time of postpartum recovery, or any clinical parameter. Also,  Dexamethasone is not recommended by the ACOG task force.


 References: 

1.  Fonseca JE, Méndez F, Cataño C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005; 193:1591. 

2. Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev 2010; :CD008148.

Q: All of the following are predictors of failed extubation except?

A) Weak cough strength 
B) Glasgow Coma Score less than 8
C) Suctioning every four hours 
D) Reduced cuff leak
E) Presence of NG tube


Answer: C

The Objective of above question is to signify the importance of increase secretions in predictors of failed extubation. If the patient requires suctioning every two to three hours, extubation should be delayed and cause for increase secretions should be sought and corrected. As a guideline, if sputum volume is more than 2.5 mL/hr, it should be a concern. Other predictors of probable fail extubation are weak cough strength, Glasgow Coma Score less than 8, reduced cuff leak, presence of OG/NG tube, prolonged intubation or traumatic intubation, the larger size of ETT and few other clinical scenarios.


Reference:

Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004; 30:1334.