Q; Why 4 coagulation factors combination is called FEIBA?


Answer: FEIBA stands for 'factor eight inhibitor bypassing agent'. It is a combination of Factors II, VII, IX and X. 

FEIBA is used in patients who have antibodies or deficiency of Factor VIII e.g. in haemophilic patients. FEIBA contains the proenzymes of the prothrombin complex factors, prothrombin, FVII, FIX and FX, but only very small amounts of their activation products, with the exception of FVIIa, which is contained in FEIBA in greater amounts. FEIBA controls bleeding by induction and facilitation of thrombin generation, (a process for which FV is crucial). 


Reference:

Turecek PL, Váradi K, Gritsch H, Schwarz HP - FEIBA: mode of action - Haemophilia. 2004 Sep;10 Suppl 2:3-9. 

Q: All of the following are orally active direct factor Xa inhibitors except

A) rivaroxaban (Xarelto),
B) apixaban (Eliquis),
C) edoxaban (Lixiana, Savaysa), 
D) betrixaban (Bevyxxa)
E) dabigatran (Pradaxa)


Answer: E

Dabigatran (Pradaxa) is the orally active Direct Thrombin Inhibitor (DTI), all others are orally active direct factor Xa inhibitors.

Reversal for Dabigatran is available. Also, it is dialysable.

Q: It is important to avoid hyperthermia after Cardio-Pulmonary Bypass (CPB). Out of following which organ failure has shown to be associated with hypethermia after CPB?

A) Liver
B) Kidney
C) Right heart
D) Pancreas
E) Adrenal


Answer: B

Hyperthermia (body temperature more than 37°C) after CPB has shown to be  associated with Acute Kidney Injury (AKI), worsened neurologic and neurocognitive outcomes and mediastinitis.


References:

1. Engelman R, Baker RA, Likosky DS, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management during Cardiopulmonary Bypass. J Extra Corpor Technol 2015; 47:145.

2. Grocott HP, Mackensen GB, Grigore AM, et al. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke 2002; 33:537.

3. Newland RF, Tully PJ, Baker RA. Hyperthermic perfusion during cardiopulmonary bypass and postoperative temperature are independent predictors of acute kidney injury following cardiac surgery. Perfusion 2013; 28:223.

4. Groom RC, Rassias AJ, Cormack JE, et al. Highest core temperature during cardiopulmonary bypass and rate of mediastinitis. Perfusion 2004; 19:119. Fallis WM. Monitoring bladder temperatures in the OR. AORN J 2002; 76:467.

Q: What is "Ketofol"?

Answer: "Ketofol" is a nickname of combination used for Ketamine and Propofol. There is a very weak evidence out there that this combination may work better for procedures. Ketamine is a dissociative anesthetic and provides sedation, analgesia, and amnesia, and exerts a sympathomimetic effect. Propofol is an ultra short-acting hypnotic agent, with an added advantage of antiemetic property.

Recommend mix is 1:1 ratio.



References:

1.  Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57(5):425-33.e2. 

3. Andolfatto G, Abu-Laban R, Zed P, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012;59(6):504-12.e1-2.

Q: In Thromboelastography (TEG) :: "G" stands for? 

 A) Reaction time 
 B) Clot formation time 
C) Maximal amplitude 
 D) Lysis at 30 min 
 E) Clot viscoelasticity


Answer: E

Objective of above question is to highlight an important entity in Thromboelastography (TEG). It is a value calculated from platelet and fibrin performance, and represents the CLOT STRENGTH or CLOT STABILITY. It is a log derivative of Maximal Amplitude (MA) and has the units of Kdynes/cm2.

"R" is the reaction time (the time it takes the coagulation cascade to generate thrombin and fibrin).
"K" is the clot firmness ( clot firmness).
"α" (alpha) is the angle (describes the kinetics of clot formation).
"MA" is the maximum amplitude (describes the maximum clot strength).
"Ly30" is the percent clot lysis 30 minutes (after the MA is reached).

Q: What is HEART score?

Answer: Heart score is an attempt to objectively quantify the risk of Myocardial Infarction on presentation depending on five factors.

H = History
E = EKG
A = Age
R = Risk factors
T = Troponin

Low risk = 0-3
Intermediate risk = 4-6
High risk = 7-10

Q: Smoking decreases the risk of recurrence in Crohn's Disease (CD)?

A) True
B) False


Answer: False 

There are four types of recurrences in Crohn's Disease

• Histological
• Clinical, 
• Endoscopic, and 
• Surgical 

Smoking increases the recurrence rate of all types of CD. Post-operative advice against smoking is essential in CD.


References:

1. Ryan WR, Allan RN, Yamamoto T, Keighley MR. Crohn's disease patients who quit smoking have a reduced risk of reoperation for recurrence. Am J Surg 2004; 187:219.

2. Reese GE, Nanidis T, Borysiewicz C, et al. The effect of smoking after surgery for Crohn's disease: a meta-analysis of observational studies. Int J Colorectal Dis 2008; 23:1213.

Q: How you can differentiate acute Sub-Dural-Hematoma (SDH) from subacute or chronic SDHs on CT scan of head?


Answer: 

On CT scan of head, acute SDH appears as a high-density crescentic collection across the hemispheric convexity. 

In contrast, subacute and chronic SDH appears as isodense or hypodense crescent-shaped lesions  that deform the surface of the brain.

Q: Which of the following can be used in the treatment of severe diarrhea in immunocompromised host secondary to Cryptosporidium except

A) Nitazoxanide
B) Paromomycin
C) Azithromycin 
D) Clarithromycin 


Answer: D

Debilitating diarrhea secondary to Cryptosporidium   is a significant problem in immunocompromised hosts. Though supportive treatment, reduction of immunosuppression or restoration of the immune system are the mainstay of treatment. But, in life-threatening diarrhea usually nitazoxanide or paromomycin in combination with  azithromycin can be used. Interestingly, azithromycin though effective as a treatment but is not effective as a prophylaxis. On the other hand, clarithromycin or rifabutin may be protective, but not useful as a treatment.



References:

1.  Legrand F, Grenouillet F, Larosa F, et al. Diagnosis and treatment of digestive cryptosporidiosis in allogeneic haematopoietic stem cell transplant recipients: a prospective single centre study. Bone Marrow Transplant 2011; 46:858. 

2.  Palmieri F, Cicalini S, Froio N, et al. Pulmonary cryptosporidiosis in an AIDS patient: successful treatment with paromomycin plus azithromycin. Int J STD AIDS 2005; 16:515. 

3. Rossignol JF. Nitazoxanide in the treatment of acquired immune deficiency syndrome-related cryptosporidiosis: results of the United States compassionate use program in 365 patients. Aliment Pharmacol Ther 2006; 24:887. 

4. Holmberg SD, Moorman AC, Von Bargen JC, et al. Possible effectiveness of clarithromycin and rifabutin for cryptosporidiosis chemoprophylaxis in HIV disease. HIV Outpatient Study (HOPS) Investigators. JAMA 1998; 279:384.

Q: 28 year old male with previous history of ulcerative colitis is admitted to ICU with exacerbation of his disease upto fulminant level. Radiological workup showed colonic dilatation of 5.5 cm. Beside regular management with IVF, NPO, naso-gastric tube decompression, antibiotics, steroids and surgical evaluation - which one simple non-pharmacological maneuver at bedside may help?


 Answer: Intermittent rolling maneuvers every couple of hours or the knee-elbow position may help to redistribute gas in the colon and may help in promoting decompression.



References:

1. Present DH, Wolfson D, Gelernt IM, et al. Medical decompression of toxic megacolon by "rolling". A new technique of decompression with favorable long-term follow-up. J Clin Gastroenterol 1988; 10:485. 

2. Panos MZ, Wood MJ, Asquith P. Toxic megacolon: the knee-elbow position relieves bowel distension. Gut 1993; 34:1726.

Q; Which laboratory triad is highly suspicious and virtually diagnostic of Hantavirus?


Answer: 

• Thrombocytopenia
• a left-shifted granulocytic series
• an immunoblast abundance that exceeds 10 percent of the total lymphoid series

In cases, where suspicion of Hantavirus is high due to history of exposure, above triad is virtually diagnostic. Moreover, it carries an extremely significant herald of probable life-threatening Hantavirus Cardiopulmonary Syndrome. It warrants transfer to a tertiary care center where Extracorporeal Membrane Oxygenation (ECMO) is available.


References:

1. Koster F, Foucar K, Hjelle B, et al. Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review. Am J Clin Pathol 2001; 116:665. 

2. Moolenaar RL, Dalton C, Lipman HB, et al. Clinical features that differentiate hantavirus pulmonary syndrome from three other acute respiratory illnesses. Clin Infect Dis 1995; 21:643.

Q: All of the following are the Predictive scoring systems in the intensive care unit except? 

A) Acute Physiologic and Chronic Health Evaluation (APACHE) 
B) Simplified Acute Physiologic Score (SAPS) 
C) Mortality Prediction Model (MPM0)
D) Sepsis-related (or Sequential) Organ Failure Assessment (SOFA)
E) CURB 65


Answer:  E

One important and often misunderstood point to know regarding predictive scoring systems in ICU is that they are measures of disease severity that are used to predict outcomes (or mortality) of patient populations. They are not a great tool to predict outcomes in a single patient.

First four (choices A,B,C and D) are well validated  ICU predictive scoring systems.

CURB 65 is a  validated scoring to predict mortality in community-acquired pneumonia.


Recommended reading:

Scoring systems in the intensive care unit: A compendium-Rapsang AG, Shyam DC. Scoring systems in the intensive care unit: A compendium. Indian Journal of Critical Care Medicine :. 2014;18(4):220-228.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033855/

Q: Which of the following is usually not a dominant feature in amebiasis?

A) bloody stool
B) fecal leukocytes
C) Abdominal pain
D) Fever
E) Liver abscess


Answer: B

Amebiasis destroy leukocytes. In suspected cases, depending on clinical history,  the presence of bloody diarrhea in the absence of fecal leukocytes is suggestive of amebiasis. Though, this is not always true but guide towards the probable cause. Fecal leukocytes (and presence of their density) signifies an invasive pathogen, and usually very true for Salmonella or Shigella. 

Few or no leukocytes but many erythrocytes suggests amebiasis. 



Reference:

Pickering LK, DuPont HL, Olarte J, et al: Fecal leukocytes in enteric infections. Am J Clin Pathol 1977;68:562-565

Q: 44 year old male, recently migrated from a developing country is admitted to ICU with 'sepsis kind of picture', hypotension, fever, cough and low grade fever. CXR showed cavitary lesion at right upper lobe. Interferon-gamma release assays (IGRAs) is ordered by an on-call resident, which is reported negative now. Negative IGRAs rule out the active tuberculosis (TB). 

A) True
B) False


Answer: False

IGRAs is still a controversial test and has raised many eyebrows of experts as it has 'issues' with reproducibility in  labs, and require many perfect technical parameters. IGRAs can be a good diagnostic tools for latent tuberculosis infection (LTBI). But, it cannot distinguish between latent infection and active tuberculosis (TB).

A positive IGRA result may not necessarily indicate active TB, and a negative IGRA result may not rule out active TB.


References:

1. Menzies D, Pai M, Comstock G. Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research. Ann Intern Med 2007; 146:340.

2. Metcalfe JZ, Everett CK, Steingart KR, et al. Interferon-γ release assays for active pulmonary tuberculosis diagnosis in adults in low- and middle-income countries: systematic review and meta-analysis. J Infect Dis 2011; 204 Suppl 4:S1120.

3. Mazurek GH, Jereb J, Vernon A, et al. Updated guidelines for using Interferon Gamma Release Assays to detect Mycobacterium tuberculosis infection - United States, 2010. 

4. MMWR Recomm Rep 2010; 59:1. 2. Sester M, Sotgiu G, Lange C, et al. Interferon-γ release assays for the diagnosis of active tuberculosis: a systematic review and meta-analysis. Eur Respir J 2011; 37:100.

Q: All of the following are symptoms of lung abscess(es) except

A) fever
B) shaking chills
C) sour-tasting sputum
D) night sweats
E) weight loss


Answer: B

As lung abscess(es) develop over the period of time, rigors (shaking chills) is usually absent as a clinical symptom.


Reference:

Clinical conferences at the Johns Hopkins Hospital: lung abscess. Johns Hopkins Med J 1982; 150:141.

Case Report

~ Editors' pick

High-dose hydroxocobalamin for vasoplegic syndrome causing false blood leak alarm on Hemodialysis

"Blood leak alarms are important safety features in a hemodialysis machine to protect patients from loss of blood through a rupture in the dialyzer membrane (true alarms). A false blood leak alarm can be triggered by air bubbles or detector malfunction (such as deposits of grease or scale). Hydroxocobalamin is an injectable form of vitamin B12 approved by the US Food and Drug Administration for the treatment of confirmed or suspected cyanide toxicity. Due to observations of an increase in arterial pressure after high-dose hydroxocobalamin infusion for the treatment of acute cyanide poisoning, it has recently been reported as an off-label rescue treatment for post–cardiopulmonary bypass vasoplegic syndrome. We report an 83-year-old man who received hydroxocobalamin following cardiac surgery for treatment of vasoplegic syndrome. The patient developed severe acute kidney injury with volume overload. Hydroxocobalamin interference with the blood leak detector compromised his dialysis treatment. We describe the use of continuous renal replacement therapy to overcome the hydroxocobalamin-related interference with hemodialysis. As the utility of hydroxocobalamin potentially expands, physicians must be aware of its inadvertent effect on renal replacement therapy."

Read full case-report  here

https://academic.oup.com/ckj/article/10/3/357/3071885/High-dose-hydroxocobalamin-for-vasoplegic-syndrome

Reference: High-dose hydroxocobalamin for vasoplegic syndrome causing false blood leak alarm Wisit Cheungpasitporn John Hui Kianoush B. Kashani Erica D. Wittwer Robert C. Albright, Jr John J. Dillon Clinical Kidney Journal, Volume 10, Issue 3, 1 June 2017, Pages 357–362

Q: Abrupt decreases in the respiratory compliance on ventilator includes all of the following

A) pneumothorax, 
B) severe atelectasis,  
C) pulmonary edema, 
D) abdominal distension
E) all of the above


Answer: E

Abrupt decrease of lung compliance can be of various reasons but should bring into mind all of the above correlating with clinical situation.

Q: All of the following are used in the treatment of decubitus ulcer? 

A) Negative pressure wound therapy (WoundVac) 
B) Hyperbaric oxygen therapy 
C) Ultrasound 
 D) Electrical stimulation 
E) All of the above


Answer:  E

​Objective of the above question is to highlight electrical stimulation as a treatment for decubitus ulcer, as other three are well known. If applied twice a day, it assumed to promote the migration and proliferation of fibroblasts.


References: 

1. Griffin JW, Tooms RE, Mendius RA, et al. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther 1991; 71:433. 

2. Feedar JA, Kloth LC, Gentzkow GD. Chronic dermal ulcer healing enhanced with monophasic pulsed electrical stimulation. Phys Ther 1991; 71:639. 

3. Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen 1999; 7:495.

Q: Which of the following cause frequent clotting (access failure) in Continuous Renal Replacement Therapy (CRRT)? 

A) high venous pressures 
B) length and inner diameter of the catheter 
C) CRRT via side holes of catheter 
D) curvy route (like subclavian access) 
E) high abdominal or thoracic pressure 
F) very negative thoracic pressures
G) All of the above 



 Answer: G

Objective of above question is to highlight various reasons which may cause issue with patency of catheter. Some of them are well know, and some of them are under appreciated.


References:

1. Unger JK, Haltern C, Portz B, Dohmen B, Gressner A, Rossaint R. Relation of haemofilter type to venous catheter resistance is crucial for filtration performance and haemocompatibility in CVVH – an in vitro study. Nephrol Dial Transplant. 2006;21:2191–2201. 

2. Jean G, Chazot C, Vanel T, Charra B, Terrat JC, Calemard E, Laurent G. Central venous catheters for haemodialysis: looking for optimal blood flow. Nephrol Dial Transplant. 1997;12:1689–1691. 

3. Mandolfo S, Borlandelli S, Ravani P, Imbasciati E. How to improve dialysis adequacy in patients with vascular access problems. J Vasc Access. 2006;7:53–59. 

Q: A patient with venous air embolization is recommended to be immediately placed into the left lateral decubitus position. In which position, a patient with an arterial air embolism should be placed?


Answer: Supine

Head down positions have the potential to exacerbate the cerebral edema that is typically induced by cerebral air embolism.


Reference:

Moon RE, de Lisle Dear G, Stolp BW. Treatment of decompression illness and latrogenic gas embolism. Respir Care Clin N Am 1999; 5:93.

Pulse Index on LVAD

Q: What does Pulsatility Index signifies on Left Ventricular Assist Device (LVAD) screen?


Answer: It is an index of patient's hemodynamics and LVAD flow, or in other words it reflects the heart’s contractility and stretch, as well as the patient’s volume status. For example, if patient's volume status is low pulsatility index will fall and vice versa. It is also defined as cardiac output provided by the patient vs pump.

High PI = more ventricular filling and higher pulsatility by a patient
Low PI = less ventricular filling and lower pulsatility by a patient

Clinical significance: Significant changes in pulsatility index indicates that an event may have occurred, like an obstruction of the inflow cannula, hypovolemia, arrhythmia, increased pulmonary artery pressure or right heart failure.

Bleomycin Induced Pulmonary Fibrosis

Q: 24 year old male is admitted in ICU.  Oncology service made decision to start bleomycin  for his underlying cancer. Which organ insufficiency may increase the risk of bleomycin induced pulmonary fibrosis?

A) previous lung insufficiency
B) renal insufficiency
C) liver insufficiency
D) cardiomyopathy
E) pancreatic insufficiency


Answer:  B

Total cumulative dose is mainly responsible for its lung toxicity and as  most of the bleomycin  is eliminated via kidney, renal insufficiency increases the risk of pulmonary fibrosis. Another risk factor is  rapid  infusion of the drug.



References:

1. Kawai K, Hinotsu S, Tomobe M, Akaza H. Serum creatinine level during chemotherapy for testicular cancer as a possible predictor of bleomycin-induced pulmonary toxicity. Jpn J Clin Oncol 1998; 28:546. 

2. Sleijfer S, van der Mark TW, Schraffordt Koops H, Mulder NH. Enhanced effects of bleomycin on pulmonary function disturbances in patients with decreased renal function due to cisplatin. Eur J Cancer 1996; 32A:550.

3. Carlson RW, Sikic BI. Continuous infusion or bolus injection in cancer chemotherapy. Ann Intern Med 1983; 99:823. 

4. Cooper KR, Hong WK. Prospective study of the pulmonary toxicity of continuously infused bleomycin. Cancer Treat Rep 1981; 65:419.