Monday, May 20, 2019

LA in ethylene glycol poisoning

Q: The major reason for lactic acidosis in ethylene glycol poisoning is? (select one) 

A) laboratory error 
B) Impaired mitochondrial function


Answer: A

It is true that patients with ethylene glycol poisoning have some portion of lactic acidosis from true tissue ischemia (Type A Lactic acidosis) but most reported high lactate in ethylene glycol poisoning is due to the fact that many counters/devices in the laboratory cannot distinguish lactate from glycolate, which is structurally similar to lactate and a metabolite of ethylene glycol.


#toxicology

#Laboratory-medicine
#acidosis


Reference:


Pernet P, Bénéteau-Burnat B, Vaubourdolle M, et al. False elevation of blood lactate reveals ethylene glycol poisoning. Am J Emerg Med 2009; 27:132.e1.

Sunday, May 19, 2019

ACE-I cough

Q: 53 year old male was admitted to ICU with hypertensive crisis. Patient is now improved and transitioning to oral anti-hypertensive. Patient develop refractory cough from Angiotensin Converting Enzyme inhibitors (ACE-I). All of the following are the treatment of ACE-I induced cough except?

A) theophylline
B) inhaled sodium cromoglycate
C) picotamide
D) withdrawal of the ACE inhibitor
E)  acetylsalicylic acid (ASA) / Aspirin


Answer: E

The most effective treatment of ACE-I induced cough is the withdrawal of drug but in case if it can not be done, there are few drugs which may help to curtail the intensity and frequency of cough like theophylline, inhaled sodium cromoglycate, and picotamide which is a thromboxane antagonist. This clinical pearl becomes important as cough from ACE-I may persists up to three months even if ACE-I is withdrawn. 

Aspirin is known to induce cough 5.

#pharmacology
#pulmonary


References:

1. Cazzola M, Matera MG, Liccardi G, et al. Theophylline in the inhibition of angiotensin-converting enzyme inhibitor-induced cough. Respiration 1993; 60:212. 


2. Hargreaves MR, Benson MK. Inhaled sodium cromoglycate in angiotensin-converting enzyme inhibitor cough. Lancet 1995; 345:13. 


3. Malini PL, Strocchi E, Zanardi M, et al. Thromboxane antagonism and cough induced by angiotensin-converting-enzyme inhibitor. Lancet 1997; 350:15. 


4. Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:169S. 


5. Cottin V, Cordier JF. Iatrogenic drug-induced bronchospasm, cough, and bronchiolitis. Etiologic and physiopathologic aspects - Rev Mal Respir. 1996;13(4):339-60.

Saturday, May 18, 2019

Achalasia

Q: All of the following have been described as medical treatments of Achalasia except?

A) nitrates
B)  sildenafil
C) terbutaline
D) theophylline 
E) Potassium chloride tablets


Answer: E

Achalasia is mostly a surgical disease or requires an invasive intervention like botox. Medical therapy is considered only as second-line therapy for patients who are not a candidate for invasive interventions.


Administrating short-acting nitrates 10 minutes prior to a meal helps in relaxing the smooth muscle of the Lower Esophageal Sphincter (LES) and improves the symptoms of achalasia (choice A)


5-phosphodiesterase inhibitors (choice B), anticholinergics, beta-adrenergic agonists (choice C), and theophylline (choice D) have been suggested as treatments of achalasia.


Potassium chloride tablets are usually very big in size and are known to directly damage the esophageal wall, and should be ideally avoided in achalasia.


#gastroenterology

#surgicalcriticalcare


References:


1. Wen ZH, Gardener E, Wang YP. Nitrates for achalasia. Cochrane Database Syst Rev 2004; :CD002299. 


2. Kahrilas PJ, Pandolfino JE. Treatments for achalasia in 2017: how to choose among them. Curr Opin Gastroenterol 2017; 33:270. 


3. Bassotti G, Annese V. Review article: pharmacological options in achalasia. Aliment Pharmacol Ther 1999; 13:1391.

Friday, May 17, 2019

Rapid acting insulin in DKA

Q: Use of rapid-acting insulin analog instead of regular insulin improves outcome in Diabetic Ketoacidosis (DKA)? (select one)

A) True
B) False


Answer: B

Rapid-acting insulins which include Aspart, Glulisine and Lyspro is used in insulin pumps as continuous subcutaneous insulin infusion. It was proposed that they may improve outcome in DKA if used intravenously instead of regular insulin, but clinical studies failed to show any benefit.


#endocrinology



Reference:


Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care 2009; 32:1164.

Thursday, May 16, 2019

SD-Plasma

Q: What is Solvent/detergent-treated plasma (SD-plasma)?


Answer:  Solvent/detergent-treated plasma (SD-plasma) is a processed plasma with solvents. Its main utility is to reduce the risk of transmission of enveloped viruses i.e. human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). 

When FFP is processed with solvent it not only dilutes and neutralizes the antibodies present in the plasma pool but also lowers the antibody against blood cells and plasma proteins.


#hematology


Reference:


Hellstern P. Fresh-frozen plasma, pathogen-reduced single-donor plasma or bio-pharmaceutical plasma? Transfus Apher Sci. 2008;39:69–74.

Wednesday, May 15, 2019

TPN

Q: The cutoff point to hold copper and manganese in total parenteral nutrition (TPN) in ICU patients with cholestasis is? 

 A) total bilirubin of 2 
 B) total bilirubin of 3 
C) total bilirubin of 4 
D) total bilirubin of 5 
E) It depends on liver transaminases


Answer: A

A large number of patients in ICU receive TPN, but 'one size does not fit all'. It is frequently required to alter the prescription of TPN depending on underlying clinical situations and labs. Copper and manganese get excreted via bile. They should be held off in patients where suspicion of cholestasis arises. Total bilirubin (TB) of 2 mg/dl is considered a cut off for this purpose.


#nutrition

#hepatology


Reference:


Jin J, Mulesa L, Carrilero Rouillet M. Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician. Nutrients. 2017;9(5):440. Published 2017 Apr 28. doi:10.3390/nu9050440

Tuesday, May 14, 2019

PTX and CXR

Q: A pneumothorax (PTX) can be best identified on which position of chest X-ray? (select one) 

A) upright 
B) supine 
C) lateral decubitus



Answer: C

In a lateral decubitus view, most pleural air accumulates in the non-dependent lateral location. This is the most sensitive way of demonstrating PTX as even 5 mL of pleural air can be visible.


The second most sensitive is an upright position as it requires only 50 mL of air to demonstrate the PTX, and the least sensitive is the supine position which requires 500 mL of air to demonstrate PTX.

#pulmonary
#radiology


Reference: 

 1. Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193.



Monday, May 13, 2019

succussion splash

Q: How succussion splash (SS) can be demonstrated during the physical exam of a patient? 


Answer: Succussion splash can be elicited by placing the stethoscope over body area suspected of gas and fluid retention and rocking the patient back and forth vigorously. 

Demonstration of abdominal succussion splash is well known in Gastric Outlet Obstruction. It is due to the presence of gas and fluid in an obstructed stomach and indicates retained gastric contents for more than three hours after a meal. In abdominal SS, a patient is rocked by holding both hips. 

A less well-known and interesting demonstration of succession splash can be done in patients with achalasia or even hydropneumothorax. This is called thoracic succussion splash: a new symptom and sign of achalasia. A patient may himself described such sound with activities like jogging or bending. It can be heard both over the anterior and the posterior chest when the patient is rocked vigorously back and forth. 

#gastroenterology
#surgicalcriticalcare



 References: 

1. Valle JD. Chapter 293. Peptic Ulcer Disease and Related Disorders. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. 

2.  Sullivan SN. Thoracic succussion splash: a new symptom and sign of achalasia. . J Clin Gastroenterol. 1990 Dec;12(6):670-1.

Sunday, May 12, 2019

CIM

Q: Critical Illness Myopathy (CIM) affects more? (select one)

 A) proximal muscles
 B) distal muscles


Answer: A

CIM is very common and still an under-recognized disease in ICU. After few days in ICU, it may become the most common cause of failure to wean from mechanical ventilation. The most common presenting symptom is flaccid quadriparesis which affects proximal more than distal muscles. Facial muscle weakness is also common but usually, go undiagnosed. The best differential diagnosis is due to the fact that this facial weakness mostly spares extraocular muscle.


#criticalillness




References:


1. Lacomis D, Giuliani MJ, Van Cott A, Kramer DJ. Acute myopathy of intensive care: clinical, electromyographic, and pathological aspects. Ann Neurol 1996; 40:645. 


2. Latronico N, Peli E, Botteri M. Critical illness myopathy and neuropathy. Curr Opin Crit Care 2005; 11:126. 


3. Deconinck N, Van Parijs V, Beckers-Bleukx G, Van den Bergh P. Critical illness myopathy unrelated to corticosteroids or neuromuscular blocking agents. Neuromuscul Disord 1998; 8:186.


4. Lacomis D, Zochodne DW, Bird SJ. Critical illness myopathy. Muscle Nerve 2000; 23:1785.

Saturday, May 11, 2019

Protected PCI

Q: What is the Protected percutaneous coronary intervention (PCI) procedure?



Answer: Protected PCI is a PCI performed under the cover of extra support from a heart device mostly left ventricular assist device (LVAD) such as impella. In patients who are suspected to have a high degree of coronary blockages, or may have a high risk of hemodynamic collapse, may benefit from protected PCI. Patients with underlying ischemic cardiomyopathy with low ejection fraction, severe diabetes, old age, history of peripheral vascular disease, or prior bypass surgery should be considered for protected PCI.

#cardiology

#hemodynamic


References:


1. Pesarini G, Gratta A, Dolci G, Lunardi M, Ribichini FL. Impella-protected PCI: the clinical results achieved so far. Minerva Cardioangiol. 2018 Oct;66(5):612-618. 

2.  O'Neill, W. W.; N. S. Kleiman; J. Moses; J. P. S. Henriques; S. Dixon; J. Massaro; I. Palacios; B. Maini; S. Mulukutla; V. Dzavik; J. Popma; P. S. Douglas; M. Ohman (2012). "A Prospective, Randomized Clinical Trial of Hemodynamic Support With Impella 2.5 Versus Intra-Aortic Balloon Pump in Patients Undergoing High-Risk Percutaneous Coronary Intervention: The PROTECT II Study". Circulation. 126 (14): 1717–1727.

Friday, May 10, 2019

PICS

Q: In post-intensive care syndrome (PICS), which one is the higher predictor of post ICU cognitive dysfunction? (select one)

A) degree and duration of delirium

B) degree and duration of sedating medications



Answer: A

Although an answer may be easy to guess, the objective of this question is to enhance three aspects of ICU care. One is to put emphasis on PICS, still an under-recognized condition. Second, long term effects of delirium in ICU, and third most important point to emphasize, is to put a little break on the notion of avoiding all sedation in ICU! Being an intensivist is more of an art than science. An ICU physician, being a healer needs to draw a fine line between patient's comfort and oversedation. Many times sedation is required to avoid not only short term but long term sequelae of critical care illnesses.


#PICS
#delirium


Reference:

Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306.

Thursday, May 9, 2019

Posaconazole

Q: 54 year old diabetic male is admitted to ICU with mucormycosis. Patient becomes stable after few days of intravenous antifungal therapy, a plan was made to switch to oral posaconazole. Bioavailability for posaconazole is better with? (select one) 

A) posaconazole delayed-release tablets 
B) oral suspension of posaconazole


Answer: A

The oral suspension of posaconazole is usually not highly bioavailable and requires fatty foods for absorption. Enteral feeding of infected patients in ICU stay variable and so bioavailability of oral suspensions cannot be relied upon.


#pharmacology

#infectiousdiseases


References: 


1.  Spanakis EK, Aperis G, Mylonakis E. New agents for the treatment of fungal infections: clinical efficacy and gaps in coverage. Clin Infect Dis 2006; 43:1060. 

2.  Noxafil (posaconazole) injection for intravenous use, delayed-release tablets for oral use, oral suspension, prescribing information. https://www.merck.com/product/usa/pi_circulars/n/noxafil/noxafil_pi.pdf 

Wednesday, May 8, 2019

Ports on NGT

Q: The large bore (16 F ) nasogastric tube (NGT), popularly known as Salem Sump tube has two lumens at the outside. The larger lumen is usually connected to the intermittent wall suction. What is the function of the open port on the side (pigtail), usually blue in color?


Answer:  Most commonly used NGTs in ICU has two lumens. The larger lumen is usually connected to the intermittent wall suction for draining gastric contents, irrigation, and delivery of medications or feeding. The smaller lumen (called sump port) which is usually of blue color and hangs out as a side port vents to atmosphere. This equalizes the pressure in the stomach once the stomach is empty. This serves the purpose of preventing the distal holes of NGT from adhering to the stomach wall. Also, this port should never be clamped while suction is being applied. 

#procedures


Reference:


1. Bard Medical Sump Naso-Gastric Tube 

http://m.bardmedical.com/media/751612/nasogastric-sump-tubes.pdf 

 2. Bong CL, Macachor JD, Hwang NC. Insertion of the nasogastric tube made easy. Anesthesiology. 2004 Jul;101(1):266. 

3. Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract. 2012 Dec;27(6):738-48. 

 4. Tucker A, Lewis J. Procedures in practice. Passing a nasogastric tube. Br Med J. 1980 Oct 25;281(6248):1128-9.

Tuesday, May 7, 2019

RHF in heart transplant

Q: What is the best way to anticipate Right Heart Failure (RHF) in post heart transplant patients?



Answer: If a patient has 

  • elevated pulmonary artery systolic pressure >50 mmHg, 
  • elevated PVR >3 Wood units (320 dynes-sec-cm-5) or 
  • elevated transpulmonary gradient of >15 mmHg, 

is at high risk for RHF after a transplanted heart. 

Two considerations are of utmost importance:

1. If a patient has an irreversible severe pulmonary hypertension, combined heart-lung transplantation should be considered.


2. If a patient is on chronically administered pulmonary vasodilator therapy, it should be continued during the pre-bypass period, and such therapies will likely be necessary to achieve separation from cardiopulmonary bypass (CPB) after a heart transplant.


#transplantation
#cardiology
#pulmonary



References:


1. De Santo LS, Romano G, Maiello C, et al. Pulmonary artery hypertension in heart transplant recipients: how much is too much? Eur J Cardiothorac Surg 2012; 42:864. 

2. Vakil K, Duval S, Sharma A, et al. Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis. Int J Cardiol 2014; 176:595.

Monday, May 6, 2019

Post CABG A fib

Q: Which group of patients have a lower rate of atrial fibrillation post coronary artery bypass grafting (CABG) surgery?

A) Off-pump CABG
B) On-pump CABG


Answer: A

Although evidence is weak literature leans towards off-pump CABG for a lesser risk of post-op Atrial fibrillation.


#surgicalcriticalcare
#cardiology


References:

1. Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 2004; 77:1567.

2. Almassi GH, Pecsi SA, Collins JF, et al. Predictors and impact of postoperative atrial fibrillation on patients' outcomes: a report from the Randomized On Versus Off Bypass trial. J Thorac Cardiovasc Surg 2012; 143:93.

3.  Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002; 359:1194. ff-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 2004; 77:1567. 

Sunday, May 5, 2019

Extravasation of pressors

Q; In case of extravasation of intravenous pressor in ICU, all of the following can be used as an antidote except?

A) Phentolamine (injection locally)

B) Nitroglycerin (topical)
C) Terbutaline (inject locally)
D) Clonidine (topical)


Answer: D

 Extravasation of all intravenous infusions is an inherent risk. In the case of extravasation of VASOpressors following sequential steps should be taken before giving an antidote


1. Immediately stop the infusion 
2. Disconnect the infusion but leave cannula or needle in place 
3. Gently aspirate the extravasated solution 
4. Do NOT flush the line 
5. Remove the needle or cannula (now)
6. Elevate the extremity. 


Phentolamine is the first choice in vasopressor extravasation. Depending on the area of extravasation, 5 to 10 mg of phentolamine should be diluted in 10 to 20 mL NS and administer by injecting locally at the extravasation site as soon as possible. It can be applied up to 12 hours of the accident. 

 Alternatively, Nitroglycerin topical 2% ointment in a 1-inch strip can be applied to the site of ischemia and can be continued every 8 hours until the situation seems resolved.

Another option is to dilute 1 mg of terbutaline in 10 mL NS and inject locally at the extravasation site. 

Clonidine is an alpha-2 adrenergic agonist and has no role in the treatment.


#toxicology



References:


1.  Plum, M., & Moukhachen, O. (2017). Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. P & T : a peer-reviewed journal for formulary management, 42(9), 581-592. 


2. Reynolds PM, Maclaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632

Saturday, May 4, 2019

Vitamin C and Folate in vasodilation

Q: What is the theoretical basis of using Vitamin C and Folate in vasodilatation? 


Answer:  In experimental models, Vitamin C and folate are found to prevent the degradation of Nitric Oxide (NO). Although most of the work is done in the background of the effect of hypercholesterolemia on vasomotor action, they have shown this effect as an independent factor without any change in lipid metabolism. Vitamin C and folate improve the endothelial function and the vasomotor response. 5-methyltetrahydrofolate is the active form of folic acid and found to be particularly useful in this mechanism. 

#hemodynmaics
#sepsis



References:


Ting HH, Timimi FK, Haley EA, et al. Vitamin C improves endothelium-dependent vasodilation in forearm resistance vessels of humans with hypercholesterolemia. Circulation 1997; 95:2617. 


Verhaar MC, Wever RM, Kastelein JJ, et al. 5-methyltetrahydrofolate, the active form of folic acid, restores endothelial function in familial hypercholesterolemia. Circulation 1998; 97:237. 


Verhaar MC, Wever RM, Kastelein JJ, et al. Effects of oral folic acid supplementation on endothelial function in familial hypercholesterolemia. A randomized placebo-controlled trial. Circulation 1999; 100:335. 


Friday, May 3, 2019

Activated Charcoal and ETOH poisoning

Q: Administration of activated charcoal (AC) should be administrated if a patient presents early with any type of alcohol poisoning? (select one) 

A) True
B) False


Answer: B

Common alcohols poisonings in ICU i.e.,

  • Acetone
  • Ethanol 
  • Ethylene glycol 
  • Isopropanol Methanol
do not get adsorb to AC - and are not recommended in acute alcohol poisonings.

Other stuff where AC is not helpful is metals like Arsenic, Lead, Mercury, Iron, Zinc and Cadmium. Also, inorganic ions like Lithium, Sodium, Calcium, Potassium, Magnesium, Fluoride and Iodide do not get adsorb to AC.

#toxicology



References:


1. Minocha A, Herold DA, Barth JT, et al. Activated charcoal in oral ethanol absorption: lack of effect in humans. J Toxicol Clin Toxicol 1986; 24:225.


2. Chyka PA, Seger D, Krenzelok EP, et al. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43:61. 


3. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1999; 37:731.

Thursday, May 2, 2019

CDI

Q: Metronidazole and vancomycin, which are the mainstay of treatment of C. difficile infection (CDI) can itself cause the C. difficile infection? (select one)

A) True
B) False


Answer: A

Any antibiotic can cause CDI, including metronidazole and vancomycin. The most notorious antibiotics to cause CDI include quinolones, clindamycin, penicillins, and cephalosporins. Risk get enhanced in proportion when multiple antibiotics are used. Also, the risk of CDI is proportional to the duration of antibiotic use.


#infectiousdiseases

#pharmacology


References: 

1.  Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. N Engl J Med 1994; 330:257.

2. Stevens V, Dumyati G, Fine LS, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011; 53:42.

Wednesday, May 1, 2019

Treatment of native and prosthetic valve Candida endocarditis

Q: Treatment of native and prosthetic valve candida endocarditis requires both (combine) antifungal medical therapy and surgical valve replacement? (select one)

A) True
B) False


Answer: A

It is true that there is some evidence to support only antifungal medical therapy for the treatment of native and prosthetic valve candida endocarditis but the latest guidelines from the Infectious Diseases Society of America (IDSA) and the American Heart Association (AHA) recommends a combined medical and surgical treatment for the treatment of native as well as prosthetic valve candida endocarditis.

#infectiousdiseases

#cardiology


References:


1. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.


2. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.

Tuesday, April 30, 2019

WE

Q: Wernicke Encephalopathy (WE) is more common in? (select one)

A) Male
B) Female


Answer: B

The paradox of Wernicke encephalopathy (WE)  is that the cases of WE in men outnumbered those in women, but women are more susceptible to acquire WE than men. This is not a true paradox 
after adjusting for alcohol dependence, which is higher in men.

#neurology



Reference:

1. Victor, M, Adams, RA, Collins, GH. The Wernicke-Korsakoff syndrome and related disorders due to alcoholism and malnutrition. FA Davis, Philadelphia 1989.


2.  Harper C. The incidence of Wernicke's encephalopathy in Australia--a neuropathological study of 131 cases. J Neurol Neurosurg Psychiatry 1983; 46:593.

Monday, April 29, 2019

thiamine def

Q: Hemodialysis or peritoneal dialysis causes the loss of? (select one)

A) Water soluble vitamins
B) Fat soluble vitamins


Answer: A

Although it may be easy to guess the answer as dialysis serves the purpose of euvolemia, the objective of the above question is to pinpoint the loss of a very important vitamin, Thiamine. There is a misconception that thiamine is only deficient in chronic alcoholism patients. Thiamine is water-soluble and can be deficient in many other situations like anorexia nervosa, hyperemesis of pregnancy, total parental nutrition (TPN) and starvation.


#nephrology

#vitamins


Reference:


Hung SC, Hung SH, Tarng DC, et al. Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients. Am J Kidney Dis 2001; 38:941. 

Sunday, April 28, 2019

Gallavardin phenomenon

Q: What is Gallavardin phenomenon?

Answer: 95 years ago Dr. Gallavardin reported that murmur of aortic valve stenosis may change its quality and becomes musical at the apex. This can be confused as a murmur of mitral regurgitation. Both murmurs can be differentiated by the fact that the apical murmur of the Gallavardin phenomenon does not radiate to left axilla.

#cardiology

#physical-exam


References:


1. Bedford DE (July 1958). "Louis Gallavardin". Br Heart J. 20 (3): 299–301

Saturday, April 27, 2019

FFP in ACE-I induced angio-edema

Q: Fresh Frozen Plasma (FFP) is used to treat Angiotensin-converting enzyme (ACE) inhibitors induced angioedema because it contains? (Select One) 

A) Angiotensin-converting enzyme (ACE)
 B) bradykinin


Answer: A

Fresh frozen plasma contains a subsequent amount of the enzyme ACE, which degrades bradykinin and helps in resolution of angioedema. This is a common knowledge that ACE-I induced angioedema is bradykinin-mediated but very few people understand the actual reason behind using FFP in this condition. It is an effective treatment and may be very valuable during refractory or resistant ACE-I induced angioedema. 


#hematology

#allergy-immunology


References:


1. Karim MY, Masood A. Fresh-frozen plasma as a treatment for life-threatening ACE-inhibitor angioedema. J Allergy Clin Immunol 2002; 109:370. 

2. Warrier MR, Copilevitz CA, Dykewicz MS, Slavin RG. Fresh frozen plasma in the treatment of resistant angiotensin-converting enzyme inhibitor angioedema. Ann Allergy Asthma Immunol 2004; 92:573. 

3. Hassen GW, Kalantari H, Parraga M, et al. Fresh frozen plasma for progressive and refractory angiotensin-converting enzyme inhibitor-induced angioedema. J Emerg Med 2013; 44:764.

Friday, April 26, 2019

RCA in ALF


Q: Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) should be used with caution at least in which one condition?



Answer: Acute liver failure

RCA should be used with high caution whenever there is a suspicion of decrease clearance of citrate. One such commonly encountered situation in ICU is an acute liver failure when transaminases go into thousands. In ICU this is most commonly seen in shock liver. Inability of liver to metabolize citrate results in severe acidosis and a decrease in ionized calcium.


#nephrology

#hepatology


References:


1. Apsner R, Schwarzenhofer M, Derfler K, et al. Impairment of citrate metabolism in acute hepatic failure. Wien Klin Wochenschr 1997; 109:123. 

2. Kramer L, Bauer E, Joukhadar C, et al. Citrate pharmacokinetics and metabolism in cirrhotic and noncirrhotic critically ill patients. Crit Care Med 2003; 31:2450. 


Thursday, April 25, 2019

hypertensive autonomic storm in deceased organ donor

Q: During the management of the deceased organ donor, a hypertensive autonomic storm may become a hurdle due to massive sympathetic discharge following brain death. Which drug can best counteract this effect?


Answer: Esmolol

Usual sequelae following brain death is an initial hypertensive crisis followed by hypotension. This hypertensive crisis and tachycardia are frequently referred to as an autonomic storm. This happens due to massive sympathetic discharge after brain death. Esmolol, a beta-adrenergic antagonist, being a short-acting agent is best to counteract this effect.


#transplantation

#cardiology


References


1. Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med 2015; 43:1291. 


2. Audibert G, Charpentier C, Seguin-Devaux C, et al. Improvement of donor myocardial function after treatment of autonomic storm during brain death. Transplantation 2006; 82:1031. 

3. Ferrera R, Hadour G, Tamion F, et al. Brain death provokes very acute alteration in myocardial morphology detected by echocardiography: preventive effect of beta-blockers. Transpl Int 2011; 24:300.

Wednesday, April 24, 2019

Methyldopa

Q: Anti-hypertensive drug methyldopa is prone to cause? (select one)

A) Sinus Tachycardia
B) Sinus Bradycardia


Answer: B

Being sympatholytic drug methyldopa tends to cause sinus bradycardia. Clinically this may become significant if other sympatholytic drugs i.e beta blockers or clonidine are used concomitantly. Moreover, methyldopa can cause directly sinus node dysfunction resulting in sinus bradycardia.

#pharmacology
#cardiology
#hemodynamic


References:

1. van Zwieten PA, Thoolen MJ, Timmermans PB. The hypotensive activity and side effects of methyldopa, clonidine, and guanfacine. Hypertension. 1984 Sep-Oct;6(5 Pt 2):II28-33. 

2. Jesse C. Davis, MD; James A. Reiffel, MD; J. Thomas Bigger Jr, MD Sinus Node Dysfunction Caused by Methyldopa and Digoxin JAMA. 1981;245(12):1241-1243.

Tuesday, April 23, 2019

neostigmine in colonic pseudo-obstruction

Q: 67 year old male is admitted to ICU with acute colonic pseudo-obstruction and cecal diameter >11 cm. There was no resolution of symptoms with all conservative treatment. Decision was made to use Neostigmine. Which one trick may help to reduce the side effect of bradycardia and bronchoconstriction?


Answer:  Coadministration of glycopyrrolate

 Neostigmine  can be used to relieve acute colonic pseudo-obstruction when conservative treatments remain ineffective. The usual dose is 2 mg IV given over 5 minutes. Being an acetylcholinesterase inhibitor, neostigmine carries the risk of causing bradycardia and bronchoconstriction. Coadministration of glycopyrrolate, which is an anticholinergic agent and may have some activity on the muscarinic receptors of the colon, may help to reduce these side effects.


#gastroenterology

#surgicalcriticalcare
#pharmacology


Reference:


Korsten MA, Rosman AS, Ng A, et al. Infusion of neostigmine-glycopyrrolate for bowel evacuation in persons with spinal cord injury. Am J Gastroenterol 2005; 100:1560.

Monday, April 22, 2019

End of life eye care

Q: What is the reason for the inability to close the eyes of terminally ill patients who are chronically sick?


Answer: Cachexia 

 The objective of the above question is to emphasize the importance of the passionate care of terminally ill patients. Cachexia causes the loss of retroorbital fat pad, and the orbit falls too posterior in its socket. This leads to constant exposure of conjunctiva even when the patient is sleeping or sedated. Damage can be prevented with the use of ophthalmic lubricants or artificial tears.


#endofcare

#opthalmology


Further readings: 


1. Bailey FA, Burgio KL, Woodby LL, et al. Improving processes of hospital care during the last hours of life. Arch Intern Med 2005; 165:1722. 


2. Plonk WM Jr, Arnold RM. Terminal care: the last weeks of life. J Palliat Med 2005; 8:1042.

3. Pantilat SZ. End-of-life care for the hospitalized patient. Med Clin North Am 2002; 86:749.

Sunday, April 21, 2019

Eclampsia

Q: All of the followings are the antecedent signs & symptoms of Eclampsia except?

A) Hypertension 
B) Headache 
C) Visual disturbances 
D) Ankle clonus
E) Left upper quadrant pain 


Answer: E

About 3/4th of the patients with eclampsia have some antecedent signs and symptoms developing in the hours prior to the initial seizure. Hypertension is the most common sign followed by a headache. Although visual disturbances have been classically described only a quarter of the women developed this. Ankle clonus is also reported.


It's a right upper quadrant or epigastric pain which is common, proposed to be due to stretching of the liver capsule.


#Ob-Gyn

#neurology


References:


1. Berhan Y, Berhan A. Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res 2015; 41:831. 


2. Chuan FS, Charles BG, Boyle RK, Rasiah RL. Population pharmacokinetics of magnesium in preeclampsia. Am J Obstet Gynecol 2001; 185:593.

Saturday, April 20, 2019

Delta P on ECMO

Q: What does Delta P on ECMO's every day monitoring signifies?



Answer: The difference between the pressures on pre and post membrane outlets provides the transmembrane pressure gradient. An increase in the trans-membrane pressure gradient indicates clot formation within the oxygenator. The trans-membrane pressure gradient should stay less than 50 mm Hg. If high, it requires proper anti-coagulation or may be the replacement of oxygenator.


#ECMO



References:  


1. Adult Extra Corporeal membrane Oxygenation (ECMO); Policy & Guideline. RPAH 2010 

2. Extra Corporeal Membrane Oxygenation (ECMO) in the Intensive Care Unit. St Vincent’s Hospital Sydney ICU 2010 3. Marasco, S.F., Lukas, G., McDonald, M., McMillan, J., & Ihle, B. (2008).

3.Review of ECMO (Extra Corporeal Membrane Oxygenation) support in critically ill adult patients. Heart, Lung and Circulation, 17S: S41-S47.

Friday, April 19, 2019

HBV in pregnancy

Q: Acute Hepatitis B Virus (HBV) has the highest rate of transmission? (select one)

A) early in the pregnancy
B) near the time of delivery


Answer: B

This piece of maternal hepatology is extremely important to know as an active intervention is required if HBV occurs near the time of delivery.

Transmission to the fetus may be as low as 10 percent in the early part of the pregnancy but may go up to 60 percent at the time of delivery. Hepatitis panel should be followed closely. If hepatitis B surface antigen (HBsAg) stays positive or has detectable serum HBV DNA near the delivery, baby should receive hepatitis B immune globulin and the 1st dose of the hepatitis B vaccine within 12 hours of birth. Ideally, a hepatologist should be consulted.

#hepatology
#OB-Gyn


References:

1. Sookoian S. Liver disease during pregnancy: acute viral hepatitis. Ann Hepatol 2006; 5:231. 

 2. Jonas MM. Hepatitis B and pregnancy: an underestimated issue. Liver Int 2009; 29 Suppl 1:133.

Thursday, April 18, 2019

PG toxicity

Q: Continuous intravenous (IV) lorazepam is frequently used in ICU. Propylene glycol (PG) is the carrier to administer IV lorazepam drip. Prolong use of IV lorazepam may cause propylene glycol toxicity. Which one test could predict and correlate directly with PG toxicity?


Answer:  Osmolal gap 

 Propylene glycol toxicity may occur with prolong administration of lorazepam or diazepam. It can cause significant skin and soft tissue necrosis in case of extravasation, arrhythmia, hemodynamic instability, lactic acidosis, seizure, coma, and eventually multi-system organ failure (MSOF). Propylene glycol causes hyperosmolarity and an anion gap metabolic acidosis. In case of any suspicion, osmolal gap correlates with PG concentrations and can be a reliable surrogate marker of PG toxicity. Treatment is to discontinue the infusion and, if life-threatening, emergent hemodialysis should be instituted. 

#toxicology


References:

1. Wilson KC, Reardon C, Theodore AC, Farber HW. Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study. Chest 2005; 128:1674. 

2. Barnes BJ, Gerst C, Smith JR, et al. Osmol gap as a surrogate marker for serum propylene glycol concentrations in patients receiving lorazepam for sedation. Pharmacotherapy 2006; 26:23. 

Wednesday, April 17, 2019

AP in pregnancy

Q: 24 year female at 34 weeks of pregnancy is admitted to ICU with exacerbation of asthma which is getting better. Routine labs showed three times higher than normal value of Serum alkaline phosphatase (AP). All other lab values are in normal range. What should be your next step?

A) STAT ultrasound of the liver
B) Emergent delivery of the baby
C) Check for HELLP syndrome
D) No intervention at this time
E) Check Hepatitis panel


Answer: D

Pregnancy may affect liver function test, particularly serum alkaline phosphatase. Total serum AP goes up to 3-4 times higher than normal, particularly in the third trimester. This is due to placental alkaline phosphatase. The best approach is to look at serum gamma-glutamyl transpeptidase (GGTP) level, which usually gets lower in pregnancy. This may help to confirm placental source of AP. In the absence of no other findings, there is no reason to go behind a million dollar workup.

Ultrasound of liver can be considered but there is no need for STAT order (choice A)

Patient's clinical situation is improving. Until and unless there is no harm anticipated to baby, there is no need to rush for delivery (choice B)

With normal platelet count and other LFTs in normal range, it is unlikely to be HELLP syndrome (choice C).

With no abnormality in AST, ALT, and bilirubin, hepatitis is very unlikely (choice E)


#Ob-gyn
#hepatology


Reference:

Bacq Y, Zarka O, Bréchot JF, et al. Liver function tests in normal pregnancy: a prospective study of 103 pregnant women and 103 matched controls. Hepatology 1996; 23:1030.

Tuesday, April 16, 2019

Secondary PPH

Q: Secondary postpartum hemorrhage (PPH) is defined as any significant uterine bleeding occurring after?

A) 24 hours postpartum
B) 48 hours postpartum
C) 72 hours postpartum
D) one week postpartum
E) it is not defined by time


Answer: A

Primary and secondary PPH is defined by the cutoff of a time period and is also limited by a time period. i.e., Secondary PPH is generally defined as any significant uterine bleeding between 24 hours and 12 weeks postpartum. This cutoff is set as management may become different for primary and secondary PPH.

#ob-gyn
#surgicalcriticalcare


References:

1. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017; 130:e168. 

2. Dossou M, Debost-Legrand A, Déchelotte P, et al. Severe secondary postpartum hemorrhage: a historical cohort. Birth 2015; 42:149.

Monday, April 15, 2019

Left Main Equivalent Disease

Q: What is Left main equivalent disease? 


Answer:  Although left main coronary artery disease (LMCAD) is a well-known disease, and a subject of frequent discussions, unfortunately, less attention gets paid to Left main equivalent disease, which is equally dreaded in morbidity and mortality.  Left main equivalent disease is defined as a combination of severe i.e. > 70 % stenosis of proximal left anterior descending (LAD) coronary artery and proximal left circumflex disease. It signifies a poor prognosis. Coronary artery bypass graft surgery (CABG) is associated with improved survival.

#cardiology
#surgicalcriticalcare


References:

1. Chaitman BR, Davis K, Fisher LD, et al. A life table and Cox regression analysis of patients with combined proximal left anterior descending and proximal left circumflex coronary artery disease: non-left main equivalent lesions (CASS). Circulation 1983; 68:1163. 

2. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation 1995; 91:2335.

Sunday, April 14, 2019

IVF in acute pancreatitis

Q: Which of the following intravenous fluid (IVF) preferred in acute pancreatitis?

A) Normal Saline (NS)
B) Lactate Ringer's (LR)


Answer: B

The three pillars of management of acute pancreatitis are
  • fluid resuscitation 
  • pain control
  • nutritional support 
IVF take precedence over everything as it has clearly shown that early and proper (considering renal failure and congestive heart failure) IVF resuscitation decreases analgesic requirement, increases enteral tolerance and decreases morbidity and mortality.

Although evidence is not very strong it favors LR as a preferred agent if there is no renal insuff., hypercalcemia or hyperkalemia. LR has shown to lower mean C-reactive protein (CRP) level and reduction in systemic inflammatory response syndrome (SIRS).

#gastroenterelogy
#resuscitation
#hemodynamic


References:

1. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13:e1. 

 2. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:710. 

3. Trikudanathan G, Navaneethan U, Vege SS. Current controversies in fluid resuscitation in acute pancreatitis: a systematic review. Pancreas 2012; 41:827. 

4. Gardner TB, Vege SS, Chari ST, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009; 9:770.

Saturday, April 13, 2019

IV contrast in sickle cell

Q: Intravenous iodinated contrast can induce sickle crisis in patients with sickle cell disease? (select one)

A) True
B) False


Answer:  B

It has been speculated in the past that IV iodinated contrast is not safe for sickle cell patients but this fear is proved to be unfounded. This was postulated that IV iodinated contrast contrast because of their high osmolality may cause osmotic shrinkage of red blood cells, and may precipitate a sickle cell crisis. Studies have shown that clinically this is not significant and risk is equivalent to general population if renal function is normal.

#radiology
#allergy


References:

1. Morcos SK. Review article: Acute serious and fatal reactions to contrast media: our current understanding. Br J Radiol 2005; 78:686. 

2. Kimberly L. et.al. Safety of Iodinated Intravenous Contrast Medium Administration in Sickle Cell Disease - The American Journal of Medicine Volume 125, Issue 1, January 2012, Pages 100.e11-100.e16

Friday, April 12, 2019

HBO any myopia

Q: Myopia from hyperbaric oxygen (HBO) is? (select one) 

 A) Reversible 
B) Irreversible


Answer: A

Modality of hyperbaric oxygen is frequently used as an adjuvant therapy in different variety of patients and it is not uncommon for an ICU physician to encounter it. But it comes with it's  own price. Some of the common complications are middle ear barotrauma, sinus barotrauma, myopia, pulmonary barotrauma, seizure and decompression sickness. 


 Most of these side effects are reversible including myopia.


#hyberbaric
#ophthalmology 


Reference:


Camporesi EM, Bosco G. Mechanisms of action of hyperbaric oxygen therapy. Undersea Hyperb Med 2014; 41:247.

Thursday, April 11, 2019

citrate

Q: During continuous renal replacement therapy (CRRT) what's the best way to assesses that the excessive citrate is given and regional citrate anticoagulation (RCA) may need to be stopped?


Answer: A ratio of total calcium to ionized calcium >2.5

Other ways to suspect excessive citrate during CRRT were worsening metabolic acidosis, increasing anion gap, decreasing ionized calcium or higher requirement of calcium infusion rates.


#nephrology



References:


1. Meier-Kriesche HU, Gitomer J, Finkel K, DuBose T. Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate anticoagulation. Crit Care Med 2001; 29:748. 


2. Bakker AJ, Boerma EC, Keidel H, et al. Detection of citrate overdose in critically ill patients on citrate-anticoagulated venovenous haemofiltration: use of ionised and total/ionised calcium. Clin Chem Lab Med 2006; 44:962.

Wednesday, April 10, 2019

vasoreactive test in PH

Q: All of the following can be used for vasoreactivity test in pulmonary hypertension except? 

 A) inhaled nitric oxide 
B) epoprostenol 
C) adenosine 
D) inhaled iloprost 
 E) sildenafil


Answer: E

Many times vasoreactive test in pulmonary hypertension is carried out in ICU setting as it requires close hemodynamic monitoring and right heart catheterization. Vasoreactivity test helps in determining the right agent for treatment. Drugs commonly used for vasoreactivity testing include inhaled nitric oxide, epoprostenol, adenosine, and inhaled iloprost. Sildenafil is not appropriate for this purpose.

#pulmonary
#procedure


Reference:

Badesch DB, Abman SH, Ahearn GS, et al. Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004; 126:35S.

Tuesday, April 9, 2019

Procalcitonin in VAP

Q: Procalcitonin has it's utility in Ventilator-Associated Pneumonia (VAP) for?  (select one)

A) Initiation of antibiotics 
B) Discontinuation of antibiotics


Answer: 

Unlike the utility of procalcitonin in making a decision for antibiotics initiation in suspected community-acquired pneumonia (CAP), it has practically no role in the initiation of antibiotics in VAP.1 But it certainly helps in determining when to stop antibiotics 2, as well as to act as a prognostic marker. 3, 4

#ventilators
#pulmonary
#infectiousdiseases


References:

1. Luyt CE, Combes A, Reynaud C, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008; 34:1434.


2. Stolz D, Smyrnios N, Eggimann P, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009; 34:1364.

3. Luyt CE, Guérin V, Combes A, et al. Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 2005; 171:48.

4. Hillas G, Vassilakopoulos T, Plantza P, et al. C-reactive protein and procalcitonin as predictors of survival and septic shock in ventilator-associated pneumonia. Eur Respir J 2010; 35:805.

Monday, April 8, 2019

tPA and clot location

Q: During reperfusion therapy for acute ischemic stroke (CVA) which clots are more resistant to thrombolysis? (select one) 

 A)  proximal in the cerebrovascular arterial tree 
 B) distal in the cerebrovascular arterial tree


Answer: 

In acute CVA proximal sites of occlusion in the cerebrovascular arterial tree are more resistant to thrombolysis i.e. a clot in an internal carotid artery (ICA) is expected to be more resistant than middle cerebral artery (MCA). This is due to the fact that clots more proximal in CV arterial-tree tend to be bigger in size. Moreover, they may be promoting adjacent thrombosis, resulting in a very long thrombus. Another contributing factor is the relative lack of fibrin in large vessels in situ thromboses in comparison to cardiac origin fibrin-rich embolic thromboses.



#neurology

#cardiology


References: 


1.  Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 2002; 33:2066. 

2. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007; 38:948. 

3. Molina CA, Montaner J, Arenillas JF, et al. Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke 2004; 35:486.

Sunday, April 7, 2019

pleural N-terminal pro-BNP in CHF

Q; What is the utility of measuring pleural N-terminal pro-BNP?


Answer: Excessive diuresis in congestive heart failure (CHF) may make pleural effusion looks exudative. Pleural fluid NT-proBNP has a high degree of correlation in CHF and may have a utility in such situations. 5

#pulmonary
#cardiology



References:

1. Porcel JM. Utilization of B-type natriuretic peptide and NT-proBNP in the diagnosis of pleural effusions due to heart failure. Curr Opin Pulm Med 2011; 17:215. 

2. Kolditz M, Halank M, Schiemanck CS, et al. High diagnostic accuracy of NT-proBNP for cardiac origin of pleural effusions. Eur Respir J 2006; 28:144. 

3. Tomcsányi J, Nagy E, Somlói M, et al. NT-brain natriuretic peptide levels in pleural fluid distinguish between pleural transudates and exudates. Eur J Heart Fail 2004; 6:753. 

4. Porcel JM, Martínez-Alonso M, Cao G, et al. Biomarkers of heart failure in pleural fluid. Chest 2009; 136:671. 

5. Porcel JM, Chorda J, Cao G, et al. Comparing serum and pleural fluid pro-brain natriuretic peptide (NT-proBNP) levels with pleural-to-serum albumin gradient for the identification of cardiac effusions misclassified by Light's criteria. Respirology 2007; 12:654.