Q: 54 year old male with CKD-5 but not yet initiated on hemodialysis (HD) is admitted to ICU with volume overload. Patient informed you that he already has ArterioVenous Fistula (AVF) created in his upper arm a week ago in anticipation of HD. Your next step

A) Insert temporary HD catheter
B) Use AVF
C) Use AVF fistula only if thrill is palpable
D) Conservative management till AVF mature


Answer: A

By Anatomy, veins are usually thin-walled and relatively fragile.  Creation of AVF subjects vein to high pressure and high flow, and causes a series of changes characterized by dilation and thickening of the venous wall. It requires at least 2 weeks of time period for AVF to be stable/mature to access. Accessing AVF prior to maturation may cause life-threatening bleeding and complications. 


Reference: 

Pisoni RL, Young EW, Mapes DL, et al. Vascular access use and outcomes in the U.S., Europe, and Japan: results from the Dialysis Outcomes and Practice Patterns Study. Nephrol News Issues 2003; 17:38.

Q: Is obtaining organ donation from a death row prisoner in exchange of reduced sentence is ethical?  

 Answer: No 

It has been suggested to offer reduced sentence in exchange of organs to death row prisoners. But it raises many ethical questions. It may influence jurors, displace justice and manipulation of system by different parties involved. So far, the United Network for Organ Sharing (UNOS) and the Organ Procurement and Transplantation Network (OPTN) has not favored this approach.


Reference:

 https://optn.transplant.hrsa.gov/resources/ethics/the-ethics-of-organ-donation-from-condemned-prisoners/

Q: 44 year old male is admitted to ICU with fever, sepsis and get diagnosed with acute cholingitis. GI service has been called for emergent endoscopic retrograde cholangiopancreatography (ERCP). Which one request you will make to GI service while performing ERCP?


Answer: To send cultures obtained from bile (or stents) removed at  ERCP to help direct antibiotic therapy. E. coli is the most common bug followed by Klebsiella and Enterobacter species. 



Reference: 

1. Negm AA, Schott A, Vonberg RP, et al. Routine bile collection for microbiological analysis during cholangiography and its impact on the management of cholangitis. Gastrointest Endosc 2010; 72:284.

Q: After finishing the insertion of Central Venous Catheter (CVC), resistance was felt while injecting and checking back-flow of distal port. What should be your first concern?


Answer: Retained Guidewire

 Retained guidewire is a well know complication of CVC insertion. Even before the guidewire is suspected to be lost, resistance to injection and poor backflow from the distal (usually brown) port is the first sign of the retained wire inside the vessel. 

X-ray should be obtained promptly. 


Further reading:

Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth. 2002;88:144–6.

Q: 62 year old male had a witness embolic CVA in the hospital. Stroke team was promptly called and TPA was started while in radiology suite finishing CT scan protocol. What could be one hind side of giving thrombolytic therapy too early in CVA? 


Answer: Hyperacute thromboemboli is usually platelet-rich and this can make is resistant to thrombolysis. But this clinical pearl is only of academic importance and should not play any role in making the decision for thrombolytic therapy in CVA, as there is no way to known the exact composition of the thromboembolic material.


Reference: 

Fulgham JR, Ingall TJ, Stead LG, et al. Management of acute ischemic stroke. Mayo Clin Proc 2004; 79:1459.

A note on confusion between Myoclonus and seizure after Etomidate administration

Administration of etomidate  during intubation may cause myoclonus which may be read as seizure episode. Etomidate is unique in the sense that though it decreases cerebral blood flow, it preserves cerebral perfusion pressure. This myoclonus is benign. Most intubated patients go on sedation post-intubation and myoclonus do not recur. Vigilance is required to not to read this myoclonus as seizure and should not require million dollar workup unless clinically indicated. 

Q: Why purpura fulminans requires treatment with protein C concentrate instead of FFP though it contains Protein C?


Answer:  Half life of Protein C in FFP is very short, so it should not be used as a source of protein C. 


 References: 

 Smith OP, White B, Vaughan D, et al. Use of protein-C concentrate, heparin, and haemodiafiltration in meningococcus-induced purpura fulminans. Lancet 1997; 350:1590. 


Dreyfus M, Magny JF, Bridey F, et al. Treatment of homozygous protein C deficiency and neonatal purpura fulminans with a purified protein C concentrate. N Engl J Med 1991; 325:1565.

Q: What does NPO stand for?

Answer:  Nulla Per Os 

To be precise, NPO stands for Nulla Per Os which is a latin for Nothing by mouth.

Q: Platelets are stored at (Select best)

A) room temperature
B) 4 degree centigrade
C) Ice cold deep freezer
D) At warmer temperature than room temperature


Answer: A 

Platelets are stored at room temperature. This is to prevent clustering of von Willebrand factor receptors on the platelet surface due to cold temperature. This decreases the shelf life of platelets to only 5 days as after that chances of bacterial growth is high.



Reference: 

Murphy S, Gardner FH. Effect of storage temperature on maintenance of platelet viability--deleterious effect of refrigerated storage. N Engl J Med 1969; 280:1094.

Q: Delivery of fetus should be carried out in acute fatty liver of pregnancy (select one) 

A) Anytime after 30 weeks of gestation
B) Only after 32 weeks of gestation
C) Should be carried out irrespective of gestational age

D) Anytime but only via vaginal delivery

E)  Should not be delivered till full term

Answer: C

Acute fatty liver of pregnancy happens in the third trimester. Prompt delivery of the fetus should be the goal but after stabilization of mother. Depending on clinical situation C-section may be required but need close monitoring and treatment of coagulopathy.

Q: What is the best time to initiate prone positioning in ARDS to get maximum benefit?

A) First 36 hours
B) Between 48 and 72 hours
C) When all rescue therapy fails in first week
D) One FiO2 is down to 80%
E) Once PEEP is down to at least 14


Answer: A

As per latest literature, we have learned that prone positioning  is most efficacious if initiated early. If patient get relatively stabilized and if it is evident from clinical picture that respiratory failure is severe, it would not be bad to keep low threshold to initiate prone positioning. Lung recruitment is most effective in early phase of ARDS. 


References: 

1. Mancebo J, Fernández R, Blanch L, et al. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 2006; 173:1233 

2.  Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159

Q: Lethal spontaneous gas gangrene is caused by 

 A) Clostridium perfringens 
B) Clostridium septicum 
C) Clostridium botulinum 
 D) Clostridium difficile 
 E) Clostridium tetani


Answer: B

Clostridium contains about 100 species but  only handful are known to cause disease in humans. C. perfringens, botulinum, difficile and tetani are well known. Less described is Clostridium septicum which has unique property to cause spontaneous gas gangrene without any trauma! Source is usually GI tract and is well known to be associated with colorectal cancer. It can quickly spread via its well known necrotic and lethal toxin called alpha toxin, if for any reason gut lining becomes necrotic or inflamed. Its other toxins are beta, gamma and delta toxins.


 References: 

1. Turnbull, TL; Cline, KS (1985). "Spontaneous clostridial myonecrosis". The Journal of Emergency Medicine. 3: 353–360

2. Liechti, ME; Schob, O; Kacl, GM; Caduff, B (2003). "Clostridium septicum aortitis in a patient with colon carcinoma". Eur J Clin Microbiol Infect Dis. 22: 632–634. 

3. Ballard J, Bryant A, Stevens D and Tweten RK (1992). Purification and characterization of the lethal toxin (alpha-toxin) of clostridium septicum. Infection and Immunity. 60(3): 784-790

Q: What is the best prevention against development of femoral pseudoaneurysm after inadvertent femoral artery puncture or presumed hematoma formation after line removal? 


  Answer: To continue to compress site for 5 more minutes, after bleeding noticed to be stop. 

 Most femoral pseudoaneurysms formed within seventy two hours after removal of the arterial line or puncture. It has been shown that just spending extra five minutes to compress the site, even after bleeding seems to be stopped reduces the incidence of pseudoaneurysm formation.



References:

1. El-Jack SS, Ruygrok PN, Webster MW, et al. Effectiveness of manual pressure hemostasis following transfemoral coronary angiography in patients on therapeutic warfarin anticoagulation. 

2. Am J Cardiol 2006; 97:485. 1. Katzenschlager R, Ugurluoglu A, Ahmadi A, et al. Incidence of pseudoaneurysm after diagnostic and therapeutic angiography. Radiology 1995; 195:463.

Q; 72 year old male with chronic A. fib., on coumadin - admitted with fall and subdural hematoma. Patient was intubated in ER for the protection of airway. Neurosurgery service decided to follow the patient closely at this point. Ideally, at what interval CT scan of the head should be repeated?


Answer: Within 6-8 hours

Due to the danger of  rapid hematoma expansion, particularly in patients with clinical compromise, a quick follow up CT head should be performed.



References: 

Oertel M, Kelly DF, McArthur D, et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg 2002; 96:109. 

Servadei F, Nasi MT, Cremonini AM, et al. Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: a prospective study of 65 patients. J Trauma 1998; 44:868.

Q: 62 year old male with CHF is admitted to ICU with "V. Tach. storm". All measures to control his arrhythmia failed and cardiology service decided to do "Percutaneous Stellate Ganglion Block" (PSGB). At what level of spine it is usually done? 

A) C-2
B) C-5
C) T-1
D) T-8
E)  Trans-sternal


Answer: C

 Left "Percutaneous Stellate Ganglion Block" (PSGB) can be used as a last resort to suppress "V. Tach and V. Fib" in patients who are refractory to all measures including ablation. It is performed usually at the junction between the T1 vertebral body and the transverse process under fluoroscopy and digital subtraction angiography.



Reference: 

JUSTIN HAYASE, M.D., JIGAR PATEL, D.O.,SANJIV M. NARAYAN, M.D., Ph.D., F.A.C.C., F.H.R.S., DAVID E. KRUMMEN, M.D., F.A.C.C., F.H.R.S. - Percutaneous Stellate Ganglion Block Suppressing VT and VF in a Patient Refractory to VT Ablation - J Cardiovasc Electrophysiol. 2013 Aug; 24(8): 10.1111/jce.12138

Q: Beside acute myocardial infarction, in which one condition serial followup of troponin may be of  help?


Answer: It has been suggested to follow troponin levels as a method for detecting cardiotoxicity after high-dose cardio-toxic chemotherapy, and predicting future cardiomyopathy in such patients.


Reference:

Cardinale D, Sandri MT, Martinoni A, et al. Left ventricular dysfunction predicted by early troponin I release after high-dose chemotherapy. J Am Coll Cardiol 2000; 36:517.

Q; What one precaution should be taken while testing for capillary refill time?

 Answer:

Ideally Capillary Refill Time should be performed by holding a hand higher than heart-level. 

It is usually done by pressing the soft pad of a fingernail until it turns white, then taking note of the time needed for the color to normalize with release of pressure. It takes about three seconds.

Q: What is Mirizzi's syndrome?


Answer: Mirizzi's syndrome is a  complication where a gallstone gets impacted in the cystic duct or neck of the gallbladder resulting in compression of the common bile duct or common hepatic duct, causing obstructive jaundice. 

Clinical significance: Found to be associated or increased risk of gallbladder carcinoma

Q:   Due to history of pulmonary hypertension, 36 year old female is admitted to ICU for observation. Patient is on Epoprostenol via PICC line. During transport PICC line fell out by 6 cm. 'Pulmonary HTN' team requested to change or insert a new PICC line. What precaution is extremely important to take?


Answer:  Epoprostenol has a very short half-life of  about 2-3 mins. Moreover, it is unstable at room temperature. Extreme caution should be taken while changing or priming catheter as any change in dose, incidental bolus or interruption of the infusion can cause severe rebound pulmonary hypertension, which may become fatal.

Q: 44 year old female is transferred from Oncology floor with mental status change and found to be in Tumor Lysis Syndrome (TLS). What is the indication for hemo-dialysis (HD)? (select one)

A) Calcium-phosphate product more than or equal to70 mg2/dL
B) Calcium level of 11 mg/dL
C) Vitamin D level of 22 ng/mL
D) Parathyroid level of 110 pg/mL
E) Unavailability of bisphosphanate 



Answer: A

Tumor Lysis Syndrome is potentially an avoidable situation and may become fatal without adequate preparation in advance in tumors known to cause TLS. Hydration, Furosemide, electrolyte and uric acid management are the cornerstone of TLS. 

HD becomes an indication in severe oliguria/anuria, persistent hyperkalemia, Calcium-phosphate product more or equal to70 mg2/dL2 and calcium level above 18 mg/dL.

Q: How cardiac drug Ivabradine works?


Answer: Ivabradine (Corlanor), approved by FDA in 2015 works in heart by acting at "Funny Channel" (yes! it is the name). It is indicated for angina and CHF, when patient either fail or cannot tolerate beta-blockers.  It is popularly known as "cardiotonic", as it is reported to decrease rate of hospitalizations related to CHF. Its major side effect is "luminous phenomena" (sensations of enhanced brightness around visual field). Also, it need to be use with caution due to its various drug interactions. 


Reference: 

Swedberg K, Komajda M, Böhm M, Borer JS, Ford I, Dubost-Brama A, Lerebours G, Tavazzi L; on behalf of the SHIFT Investigators (2010). "Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study". The Lancet. 376 (9744): 875–885.

Q: In patients who receive thrombolytic therapy for CVA, Aspirin can be started (select one)

A) After TPA dose
B) After 24 hours
C) After one week
D) Once Repeat CT scan shows no bleed
D) After ruling out microbleeds in MRI


Answer:  B

Aspirin/ASA (antiplatelet agents) should be held for first 24 hours after thrombolytic therapy in CVA.

ARTIS trial was stopped early due to higher symptomatic intracranial bleed in the intravenous aspirin group, and at 3 months, the favorable outcome was similar for both the aspirin and the no aspirin groups. 

Repeat CT scan and MRI may be sought after TPA in CVA patients, but they are not required to start ASA after 24 hours.


Reference: 

Zinkstok SM, Roos YB, ARTIS investigators. Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial. Lancet 2012; 380:731.

Q: Which infectious cause is prone to give acquired protein C deficiency?


Answer:  Meningococcemia causing purpura fulminans 

Other (mostly non-infectious) causes of acquired protein C deficiency are

• Acute thrombosis
• Warfarin therapy 
• Liver disease 
• Vitamin K deficiency 
• DIC

Reference:

Lorenzo Alberio, Bernhard Lämmle, and Charles T. Esmon - Protein C Replacement in Severe Meningococcemia: Rationale and Clinical Experience - Clin Infect Dis. (2001) 32 (9): 1338-1346.

Q: 44 year old male is in ICU with severe ARDS. Earlier, high PEEP caused pneumothorax and patient required the anterior chest tube. Air leak is still evident on chest tube. Patient is very unstable for transfer to ECMO equipped institution. As a rescue, you decided to try prone positioning. Is chest tube with air leak is an absolute contraindication to prone positioning?


Answer: No - it is a relative contraindication.

Following are the absolute contraindications for prone positioning

• Severe shock or severe hemodynamic instability (MAP less than 65)
• Signs of active bleeding
• Multiple trauma
• Spinal instability
• Pregnancy
• High intracranial pressure 
• Recent tracheostomy within last 2 weeks
• Sternotomy within last 2 weeks

If secured safely, chest tubes/pacemakers/catheters are not contraindicated for prone positioning.

Q: 58 year old male with PMH of Diabetes, HTN and renal insufficiency is transferred from floor  to ICU with sepsis. On examination, you find various unsuccessful attempts of inserting femoral central line. Subsequent workup diagnosed him with polymicrobial hip septic arthritis. What could be the causes of polymicrobial septic arthritis?


Answer: Septic arthritis is mostly monomicrobial and if joint aspiration proved it to be polymicrobial than there should be worry of few life-threatening conditions

1. Penetrating trauma
2. Direct extension (mostly after ruptured colonic diverticular disease)
3. Polymicrobial bacteremia

Most interesting in polymicrobial septic arthritis are case reports after (multiple) femoral venipunctures.


References:

1. Fromm SE, Toohey JS. Septic arthritis of the hip in an adult following repeated femoral venipuncture. Orthopedics 1996; 19:1047. 

Q: One definition of chylothorax is pleural fluid's triglyceride level greater than 110 mg/dL.  What is the other definition of chylothorax, if triglycerides concentration does not reach at 110 mg/dL but clinically chylothorax seems highly suspected?


Answer:   Presence of chylomicrons

In about 20 percent of chylothorax, triglyceride in pleural fluid may not reach the cutoff number of 110 mg/dL. In such scenarios presence of chylomicrons in the pleural fluid is enough to label it as chylothorax. Major differential diagnosis of chylothorax is with cholesterol effusions, which may be diagnostic with the presence of cholesterol crystals. Chylomicrons are not present in cholesterol pleural effusions and are diagnostic of chylothorax even if triglycerides is not at 110 mg/dL.

Q: 32 year old female is admitted to ICU with hypotension and possible sepsis. Patient's past medical history is unremarkable except that she started working 6 weeks ago at the spa to do pedicures. Knowing her history, out of the following which one would be your concern? 

A) Mycobacterium kansasii 
B) Mycobacterium marinum 
C) Mycobacterium avium-intra-cellulare (MAI) 
D) Mycobacterium tuberculosis 
E) Mycobacterium fortuitum 


Answer: E

The objective of above question is to address risk factors and knowledge of unusual infectious bugs may encounter in ICU. With the explosion of spas and salons in urban settings, ICU physicians are expected to know about Mycobacterium fortuitum as a risk. Also reported in similar setting is Mycobacterium mageritense.


References: 

1. Sniezek PJ, Graham BS, Busch HB, et al. Rapidly growing mycobacterial infections after pedicures. Arch Dermatol 2003;139:629-34. 

2. Winthrop KL, Albridge K, South D, et al. The clinical management and outcome of nail salon-acquired Mycobacterium fortuitum skin infection. Clin Infect Dis 2004;38:38-44.

3. Winthrop KL, Abrams M, Yakrus M, et al. An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med 2002;346:1366-71. 

4. Gira AK, Reisenauer AH, Hammock L, et al. Furunculosis due to Mycobacterium mageritense associated with footbaths at a nail salon. J Clin Microbiol 2004;42:1813-7

5. Vugia DJ, Jang Y, Zizek C, Ely J, Winthrop KL, Desmond E. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis 2005;11:616-8. 

Q: 32 year old female is admitted to ICU with acute exacerbation of Multiple Sclerosis (MS). She is responding well to steroid treatment. Out of the following, which Vitamin is recommended as an adjuvant treatment in MS and should be added to her profile?

A) Vitamin A
B) Vitamin B12
C) Vitamin C
D) Vitamin D
E) Viamin E


Answer: D

Multiple studies have shown the direct beneficial effect of Vitamin D on preventing acute flares of MS. Though still, the exact mechanism is not clear but the answer may lie in the old wisdom of protective sunlight effect on MS. Use of Vitamin D in MS is now considered as a standard of treatment.



References:

1.  van der Mei IA, Ponsonby AL, Dwyer T, et al. Past exposure to sun, skin phenotype, and risk of multiple sclerosis: case-control study. BMJ 2003; 327:316. 

2. Salzer J, Hallmans G, Nyström M, et al. Vitamin D as a protective factor in multiple sclerosis. Neurology 2012; 79:2140. 

3. Mowry EM, Waubant E, McCulloch CE, et al. Vitamin D status predicts new brain magnetic resonance imaging activity in multiple sclerosis. Ann Neurol 2012; 72:234. 

4. Ascherio A, Munger KL, White R, et al. Vitamin D as an early predictor of multiple sclerosis activity and progression. JAMA Neurol 2014; 71:306.

Q: 52 year old male is transferred from neurology floor to ICU for intubation and emergent plasmapheresis due to exacerbation of myasthenia gravis. On exam, you found following skin findings. With given history, your diagnosis and concern?

Answer:  Pemphigus Vulgaris

Pemphigus Vulgaris is an autoimmune disorder found to be associated with myasthenia gravis and thymoma. It requires high dose corticosteroids treatment, otherwise can be fatal. First described 90 years ago1  but is still a valid association and should be investigated and treated aggressively.


References:

1. Senear-Usher, -F.E. and Usher, B. An unusual type of pemphigus combining features of lupusery the matosus. Arch. Derm: Syph., 1926; 13 761.

2. Winkler DT, Strnad P, Meier ML, Roten S, Went P, Lyrer P, Steck AJ: Myasthenia gravis, paraneoplastic pemphigus and thymoma. A rare triad. J Neurol. 2007, 254 (11): 1601-1603.

3. Meyer S, Kroiss M, Landthaler M, Vogt T: Thymoma, myasthenia gravis, eruptions of pemphigus vulgaris and a favourable course of relapsing melanoma: an immunological puzzle. Br J Dermatol. 2006, 155 (3): 638-640. 

Q: Out of following organisms which one is prone to produce adrenal insufficiency?

A) Coccidioidomycosis 
B) Histoplasmosis 
C) Aspergillosis 
D) Babesiosis 
E) Legionellosis


Answer: B

Review of literature shows many case reports with disseminated histoplasmosis affecting adrenal glands. Mostly it is reported as unilateral involvement but bilateral involvement has been reported too. Diagnosis is usually made by fine needle aspiration cytology. 


Reference: 

1. Rana C, Krishnani N, Kumari N. - Bilateral adrenal histoplasmosis in immunocompetent patients. - Diagn Cytopathol. 2011 Apr;39(4):294-6. 

2. Kumar M, Singh S, Govil S. Adrenal Histoplasmosis: Clinical presentation and imaging features in 9 cases. Abdominal Imaging, 2003, Sept-Oct.; 28(5); 703 - 708.