Heart transplant in PPCM

Q: Patients who develop Peri-Partum Cardiomyopathy (PPCM) and receive heart transplant, have? (select one)

A) Better outcome
B) Worse outcome


Answer: B

Unfortunately, patients with PPCM do not fare well in comparison to other groups of cardiomyopathy. Data showed them to have worse long-term survival. They have a higher rate of rejection, poorer graft survival, and a higher need for retransplantation. Interestingly younger patients do worse. Some of the postulated reasons are higher allosensitization and higher pretransplant acuity.

#transplantation
#cardiology
#OB-Gyn



Reference:


Rasmusson K, Brunisholz K, Budge D, et al. Peripartum cardiomyopathy: post-transplant outcomes from the United Network for Organ Sharing Database. J Heart Lung Transplant 2012; 31:180.

ETOH ketoacidosis

Q: All of the following are the features of acute alcohol (ETOH) ketoacidosis except? 

A) history of chronic alcohol abuse
B) malnutrition
C) coma
D) nausea and vomiting
E) abdominal pain 


Answer:   C

In comparison to patients with diabetic ketoacidosis, particularly patients with nonketotic hyperosmolar hyperglycemia, patients with alcoholic ketoacidosis are usually more alert and lucid. In former conditions, there is a huge osmotic diuresis resulting in rising of effective plasma osmolality. This osmotic diuresis is not a feature of alcoholic ketoacidosis, preventing these patients from the neurologic manifestations of a marked rise in the effective plasma osmolality.

#toxicology
#acid-base
#acidosis



References:

1. Wrenn KD, Slovis CM, Minion GE, Rutkowski R. The syndrome of alcoholic ketoacidosis. Am J Med 1991; 91:119.

2.  Palmer JP. Alcoholic ketoacidosis: clinical and laboratory presentation, pathophysiology and treatment. Clin Endocrinol Metab 1983; 12:381.

3. Fulop M, Ben-Ezra J, Bock J. Alcoholic ketosis. Alcohol Clin Exp Res 1986; 10:610.

Fe supplement in IBD

Q: For all of the following reasons intravenous (IV) Iron (Fe) is a preferred route of administration in Inflammatory bowel disease (IBD) except? 

 A) Oral Fe is associated with increased disease activity 
B) Oral Fe is associated with increased abdominal pain 
 C) Oral Fe is poorly absorbed  
D) IV Fe has better response in iron-restricted erythropoiesis 
 E) IV Fe causes better termination of gut's microbial diversity


Answer: E


Iron deficiency and iron deficiency anemia is a part of IBD. Many patients in ICU with exacerbation of IBD may require iron treatment for severe debilitating anemia. IV Iron is preferred for various reasons. Not only the oral Fe is associated with intolerance and abdominal pain (choice B) but can also exacerbate the disease activity (choice A). Due to inflammation, it is poorly absorbed (choice C). IV Fe has shown to better overcome the iron-restricted erythropoiesis which occurs due to systemic response in IBD (choice D).

Actually, microbial diversity is required to terminate the flare-ups of IBD and IV Fe helps in preserving that (see reference#3).

#hematology
#gastroenterology


References:

1. Gomollón F, Gisbert JP. Intravenous iron in inflammatory bowel diseases. Curr Opin Gastroenterol 2013; 29:201. 

2.  Erichsen K, Ulvik RJ, Nysaeter G, et al. Oral ferrous fumarate or intravenous iron sucrose for patients with inflammatory bowel disease. Scand J Gastroenterol 2005; 40:1058. 

3. Lee T, Clavel T, Smirnov K, et al. Oral versus intravenous iron replacement therapy distinctly alters the gut microbiota and metabolome in patients with IBD. Gut 2017; 66:863.

ABG errors

Q: Leukocytosis (High WBC) may falsely   ______________ the PaO2 in arterial blood gas (ABG)? (select one)

A) Increases
B) Decreases


Answer; B

White Blood Cells (WBCs/leukocytes) consumes oxygen and may give falsely low PaO2 in ABG. This can be countered by putting ABG sample on ice and get analyzed within 15 minutes of a draw.

#acid-base
#procedures


References:

1. Bageant, RA. Variations in arterial blood gas measurements due to sampling techniques. Respir Care 1975; 20:565. 

2. Harsten A, Berg B, Inerot S, Muth L. Importance of correct handling of samples for the results of blood gas analysis. Acta Anaesthesiol Scand 1988; 32:365. 

"Theo" toxicity

Q: All of the following may occur with Theophylline overdose except? 

A) cerebral vasoconstriction 
B) hyperkalemia 
C) hyperglycemia 
D) metabolic acidosis 
E) arrhythmias


Answr: B

Most of the Theophylline effect occurs via antagonism of adenosine receptors and indirect adrenergic activity (see below). This effect is used for its primary use as a bronchodilator. In the case of overdose, it causes arrhythmias (choice E), cerebral vasoconstriction (choice A) and seizure. One of the dilemmas occurs when cardiac arrhythmia results in hypotension and need for vasopressor arises. Theophylline itself increases the level of epinephrine, norepinephrine, and dopamine via catecholamine elevation. In such scenarios, vasopressin may be a relatively safer choice, though no guideline or recommendation is available for this particular clinical situation.

At higher doses, theophylline acts as a phosphodiesterase inhibitor and increases the levels of cyclic adenosine monophosphate which augments beta-adrenergic activity. It results in hypokalemia, hyperglycemia, metabolic acidosis, and beta-adrenergic mediated vasodilatation.

#toxicology
#hemodynamic


References:

1. Minton NA, Henry JA. Acute and chronic human toxicity of theophylline. Hum Exp Toxicol 1996; 15:471. 

2. Shannon M. Hypokalemia, hyperglycemia and plasma catecholamine activity after severe theophylline intoxication. J Toxicol Clin Toxicol 1994; 32:41.

Relative Index

Q: What is "Relative index" in cardiology biomarkers?  


Answer: Relative index is a ratio of CK-MB/total CK. The formula is 

Relative index = CK-MB/total CK x 100

Relative index helps in differentiating elevation of CK-MB between skeletal and cardiac origin. 

• Ratio < 3 is consistent with skeletal muscle source
• Ratio > 5 indicates cardiac source

#cardiology

#laboratory-science

Reference:

TP Singh, AK Nigam, AK Gupta, B Singh. Cardiac Biomarkers: When to Test? – Physician Perspective Journal, Indian Academy of Clinical Medicine z Vol. 12, No. 2, April-June, 2011

PEEP and PAOP

Q: If patient has a Pulmonary Artery Catheter (PAC) in place and excessive Positive End Expiratory Pressure (PEEP) is applied on ventilator, what is the rule of thumb to calculate correct Pulmonary Artery Occlusion Pressure (PAOP/wedge Pressure)? 



Answer: PEEP usually does not effect PAOP/wedge pressure clinically but once the requirement of PEEP starts going above 8-10, PAOP should be adjusted by subtracting 

•  one-half of the PEEP level from the PAOP, if lung compliance is normal, or 
•  one-quarter of the PEEP level if lung compliance is reduced 

For example, if a patient with acute respiratory distress syndrome (ARDS) (decreased lung compliance) with an applied PEEP of 12 cm H2O and has a wedge pressure of 14 mm Hg, the recalculated wedge pressure would be 10 mm Hg. 

#procedure
#hemodynamics
#cardiology
#pulmonary
#ventilators 



Reference:

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

AS and endocarditis prophylaxis

Q: All patients with critical Aortic Stenosis should receive endocarditis prophylaxis?

A) True
B) False


Answer: B

Unfortunately, very few cases of infective endocarditis (IE) can be prevented by antibiotic prophylaxis. New guidelines recommend antibiotic prophylaxis only for patients with underlying cardiac conditions associated with the highest risk. High-risk cardiac conditions are defined as prosthetic valves, congenital heart disease (CHD), history of infective endocarditis and heart transplant patients with valvular disease.

#cardiology
#infectiousdiseases


References:

1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.

2. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54.

Post Cardiac Surgery Pleural Effusion

Q: Pleural effusion is common at which side in early post coronary artery bypass grafting (CABG) surgery? (select one)  

A) Right 
B) Left


Answer:  B

Early pleural effusions after CABG surgery are usually benign and mostly occur on left side. These are also seen commonly after a heart transplant. In contrast, cardiac valve surgeries are less intent to produce pleural effusions. If the effusion is symptomatic, large and on the right side, it may be a sign of some other underlying disease process (see interesting reference #4 below in this regard).

#pulmonary
#surgicalcriticalcare


References:

1. Vargas FS, Cukier A, Hueb W, et al. Relationship between pleural effusion and pericardial involvement after myocardial revascularization. Chest 1994; 105:1748.

2. Ulubay G, Küpeli E, Er Dedekargınoğlu B, et al. Postoperative Pleural Effusions After Orthotopic Heart Transplant: Cause, Clinical Manifestations, and Course. Exp Clin Transplant 2016; 14:125. 

3. Light RW, Rogers JT, Cheng D, Rodriguez RM. Large pleural effusions occurring after coronary artery bypass grafting. Cardiovascular Surgery Associates, PC. Ann Intern Med 1999; 130:891. 

4. Kunizawa A, Fujioka M, Mink S, Keller E. Central venous catheter-induced delayed hydrothorax via progressive erosion of central venous wall. Minerva Anestesiol 2010; 76:868. 

hung up reflexes

Q: Woltman sign, also known as "hung-up" deep tendon reflexes on clinical examination is a sign of? (select one) 

A) Hypothyroidism 
B) Hyperthyroidism 


Answer: A 

"hung-up" deep tendon reflexes on clinical examination are due to delayed muscle relaxation - and is a frequent finding in myopathy secondary to hypothyroidism. It is more evident in severe hypothyroidism and is considered a classic sign of this disease. 

(Reference has a video demonstration included. Click on the link)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492977/


#physicalexam
#endocrine
#musculoskeletal


Reference: 

Cyriac S, d'Souza SC, Lunawat D, Shivananda P, Swaminathan M. A classic sign of hypothyroidism: a video demonstration. CMAJ. 2008;179(4):387. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492977/

Peliosis hepatis in chronic kidney disease

Q: Peliosis hepatis in chronic kidney disease patients get treated by kidney transplantation?  

A) True 
B) False 


 Answer: B 

Peliosis hepatis, first described about 70 years ago, is one dreaded disease which has many etiologies but unfortunately no specific treatment. Moreover, it goes undiagnosed without any symptom for an extended period. Although mostly limited to the liver, it may occur in other organs such as spleen or lungs. By definition, it a proliferation of the sinusoidal hepatic capillaries that results in cystic blood-filled cavities throughout the liver. It may occur due to drugs (steroids are the most common), underlying immune disorders or infections particularly with tuberculosis.

For reasons not clearly understood, in renal patients peliosis hepatis either gets acquired or gets worse after transplant. Probable etiologies are immunosuppressant drugs or development of opportunistic infections after transplantation.

#transplantation
#hepatology
#nephrology 


References:

1. ZAK FG. Peliosis hepatis. Am J Pathol 1950; 26:1. 

2. Izumi S, Nishiuchi M, Kameda Y, et al. Laparoscopic study of peliosis hepatis and nodular transformation of the liver before and after renal transplantation: natural history and aetiology in follow-up cases. J Hepatol 1994; 20:129.

 3. Cavalcanti R, Pol S, Carnot F, et al. Impact and evolution of peliosis hepatis in renal transplant recipients. Transplantation 1994; 58:315. 

4. Ahsan N, Rao KV. Hepatobiliary diseases after kidney transplantation unrelated to classic hepatitis virus. Semin Dial 2002; 15:358.

solitary hypoalbuminemia and non-cardiogenic edema

Q: Solitary hypoalbuminemia can cause non-cardiogenic edema? 

A) True
B) False


Answer: B

It is true that pure hypoalbuminemia causes the peripheral edema due to the lowering of the transcapillary oncotic pressure gradient, but pulmonary capillaries have a greater baseline permeability to albumin. Because of this high permeability, a fall in the plasma albumin concentration is accompanied by a parallel decline in the pulmonary interstitial oncotic pressure, and the net effect is little or no change in the transcapillary oncotic pressure gradient.

#pulmonology
#cardiology


Reference: 

Taylor AE. Capillary fluid filtration. Starling forces and lymph flow. Circ Res 1981; 49:557.

CIN

Q: Which of the following has a higher risk of contrast-induced nephropathy (CIN)? (select one)

A) interventional coronary angiography
B) CT scan with intravenous (IV) contrast


Answer: A

The objective of above question is to emphasize the point that contrary to popular belief the risk of CIN from CT scan with IV contrast is relatively low even in patients with a lower degree of renal insufficiency.

Interventional coronary angiography is a way bigger risk for CIN due to its emergent nature, not allowing any time for any preventive measure, the patient is usually dehydrated and has hemodynamic instability.

#cardiology
#nephrology
#procedure


References:

1. Jurado-Román A, Hernández-Hernández F, García-Tejada J, et al. Role of hydration in contrast-induced nephropathy in patients who underwent primary percutaneous coronary intervention. Am J Cardiol 2015; 115:1174. 

2. Weisbord SD, Mor MK, Resnick AL, et al. Incidence and outcomes of contrast-induced AKI following computed tomography. Clin J Am Soc Nephrol 2008; 3:1274. 

3. McDonald RJ, McDonald JS, Carter RE, et al. Intravenous contrast material exposure is not an independent risk factor for dialysis or mortality. Radiology 2014; 273:714.

Skin fold in ICU mimicking PTX

Q: What is the most common cause of skin fold mimicking pneumothorax (PTX) in an ICU patient?

Answer:  In ICU most of the bedside chest X-rays are obtained by sliding radiographic plate (cassette) from the side under the patient's back. Skin folds should be suspected in obese patients with no reason to suspect PTX. Few clues to distinguish skin fold from PTX on chest X-ray are:

Skin Folds

• tends to extend beyond the rib cage
• tends to gradually increase in opacity 
• abrupt drop–off at the edge of the fold
• blood vessels extend beyond the fold (can be seen with magnifying/zooming-in the x-ray)

#pulmonary

Reference:

Stark, P, Eber, C. Pneumothorax or skin fold? Clin Intensive Care 1993; 4:45.

Cardiac cachexia

Q: All of the following are part of cardiac cachexia criteria except?

A) 10% edema-free body weight loss in the previous 12 months
B) Hb < 12 g/dL
C) serum albumin < 3.2 g/dL
D) a body mass index < 20 kg/m2
E) increased inflammatory markers


Answer: A

Cardiac cachexia is now a designated term. Cardiac failure leads to changes in all major organ physiology including nutritional status of the patient. It is now defined as "at least 5% edema-free body weight loss in the previous 12 months."

All other choices are accepted standard in the criteria of general cachexia.


#cardiology

#nutrition

References:

1. Christensen HM, Kistorp C, Schou M, Keller N, Zerahn B, Frystyk J, et al. Prevalence of cachexia in chronic heart failure and characteristics of body composition and metabolic status. Endocrine. 2013;43(3):626–634. 

2. Trullas JC, Formiga F, Montero M, Carrera-Izquierdo M, Grau-Amorós J, Chivite-Guillén D, RICA Investigators et al. Impact of weight loss on mortality in chronic heart failure: findings from the RICA Registry. Int J Cardiol. 2013;168(1):306–311

Difficult gender for intubation

Q: Which gender, in general, tends to present with more difficult airway? (select one)

A) Male
B) Female


Answer: A

The few well-known risk factors for difficult intubation are described by a mnemonic ROMAN

 R: Radiation or Restriction (Restriction includes neck immobility and intrinsic lung pathologies)
 O: Obstruction or Obesity or Obstructive Sleep Apnea
M: Mask Seal or (poor) Mallampati score or Male gender
A: Age (> 55)
N: No teeth – Edentulousness leads to difficult intubation

#procedures


References:

1. Walls R, Murphy M. Chapter 7: Identification of the Difficult Airway. Manual of Emergency Airway Management. Third Edition. Lippincott Williams & Wilkins 

2. Tulay Sahin Yildiz. Mine Solak. Kamil Toker. The incidence and risk factors of difficult mask ventilationJournal of Anesthesia February 2005, Volume 19, Issue 1, pp 7–11

Acute abdomen in CPAD patients

Q; 53 year old male on chronic continuous ambulatory peritoneal dialysis (CAPD) is admitted to ICU with acute abdominal pain. All of the following tests are important except?

A) Computed tomography (CT) scan of  abdomen and pelvis 
B) Peritoneal fluid spun hematocrit 
C) Peritoneal fluid cell count and differential 
D) Peritoneal fluid lipase 
E) Peripheral blood complete blood count (CBC)


Answer: D

Peritoneal fluid amylase (not lipase) of > 50 units/L in acute abdomen with patients having peritoneal dialysis catheter is a red flag for serious underlying damage. Second important test to look for is peritoneal fluid spun hematocrit. A level above 2 percent suggests significant intraperitoneal pathology.

 All other tests are expected to be on board in such scenarios.

#surgicalcriticalcare
#nephrology


References:

Lew SQ. Hemoperitoneum: bloody peritoneal dialysate in ESRD patients receiving peritoneal dialysis. Perit Dial Int 2007; 27:226.

Greenberg A, Bernardini J, Piraino BM, et al. Hemoperitoneum complicating chronic peritoneal dialysis: single-center experience and literature review. Am J Kidney Dis 1992; 19:252. 

HIT Variants - Rx

Q; Q; Which intervention/drug can help when conventional treatments fail in cases with "Heparin Induced Thrombocytopenia (HIT) variants"?

 
Answer: Intravenous immune globulin (IVIG)

HIT variants is an umbrella term used for delayed onset, refractory or spontaneous HIT. These are severe and can be lethal clinical conditions, as patients continue to have all signs and symptoms of HIT even when heparin has been long withdrawn, other treatment modalities have been tried or even where there is no heparin exposure. These patients tend to have "HIT-like antibodies". IVIG is found to be effective in blocking further platelet activation in such situations. The recommended dose is 1 g/kg/day for two doses or 0.4 g/kg daily for five days. Please note anticoagulation with a non-heparin agent should be continued to reduce the risk of thrombosis.

#hematology


References:

1. Padmanabhan A, Jones CG, Pechauer SM, et al. IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia. Chest 2017; 152:478. 

2. Ibrahim IF, Rice L. Intravenous Immunoglobulin for Heparin-Induced Thrombocytopenia. Chest 2017; 152:906. 

3. Azimov MB, Slater ED. Persistent Heparin-Induced Thrombocytopenia Treated With IVIg. Chest 2017; 152:679.

Blood gas, swan and cardiac arrest

Q; During cardiac arrest, which blood gas is more reliable?

A) Femoral artery (Arterial Blood Gas)
B) Pulmonary artery (Venous Blood Gas)


Answer:  B

During massive shock state arterial blood gas (ABG) does not accurately reflect the acid-base status as well as oxygenation at tissue levels. During such situation - given pulmonary artery catheter (PAC) is present - PH from PAC is the true indicator of the level of shock. In such scenarios, PH from ABG can be falsely high and can be very misleading. Unfortunately, PAC is not always present.

#hemodynanmic
#acid-base


References: 

1. Weil MH, Rackow EC, Trevino R, et al. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. N Engl J Med 1986; 315:153. 

2. Adrogué HJ, Rashad MN, Gorin AB, et al. Assessing acid-base status in circulatory failure. Differences between arterial and central venous blood. N Engl J Med 1989; 320:1312.

tPA in cardiac arrest due to PE

Q: How the tPA should be given to a patient who is in cardiac arrest due to massive pulmonary embolism (PE)?


Answer:  During cardiac arrest, due to PE it is not practical to wait for standard two hours infusion. tPA is available as a 50 mg vial and an entire vial should be given as an IV bolus over two minutes. Another dose should be repeated after 15 minutes if a patient remains in cardiac arrest.

#hemodynamic
#cardiology
#pulmonary


Reference: 

Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S501.

blood volume loss and hemodynamic

Q: Supine hypotension in an acute gastrointestinal bleed (GIB) indicates at least what percentage of total body blood loss?


Answer: 40 percent

Assessment of hemodynamic provides a good clue of total blood loss. 

• Only resting tachycardia is probably due to less than 15 percent of blood volume loss
• Orthostatic hypotension is consistent with at least 15 percent of blood volume loss
• Supine hypotension is consistent with at least 40 percent of blood volume loss

#gastroenterology
#hemodynamic


Reference:

1. Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am 2008; 92:491.

Grading of cardiac murmurs

Q: There are how many grades to classify the intensity of heart murmur?

Answer: Six 

There are six grades to classify the intensity of a cardiac murmur. The actual term is "Levine Grading scale". Another objective of this question is to highlight that - technically - the perfect way to auscultate cardiac murmurs is to compare the intensity of a murmur with first [S1] and second [S2] heart sounds 

• Grade I: faintest murmur that can be heard only with difficulty; and murmur is usually softer than S1 and S2 sounds 
• Grade II: faint murmur, which has the same intensity as S1 and S2 sounds 
• Grade III: murmur auscultated relatively easy but not palpable as a thrill, and it is louder than the S1 and S2 sounds 
• Grade IV: murmur auscultated relatively easy and palpable as a thrill, and it is louder than the S1 and S2 sounds 
• Grade V: very loud with a thrill and can be heard with the slightest touch (only with the rim) of the stethoscope 
• Grade VI: loudest and can be heard without a stethoscope

#physicalexam

#cardiology

Reference: 

Silverman ME, Wooley CF. Samuel A. Levine and the history of grading systolic murmurs. Am J Cardiol. 2008 Oct 15;102(8):1107-10.

bleeding with direct oral anticoagulants (DOACs)

Q: If bleeding occurs with direct oral anticoagulants (DOACs), oral activated charcoal can be administrated if the last dose is within last two hours? (select one)

A) Yes
B) No



Answer: A

In case of bleeding with DOACs,, there is a Grade 2C recommendation to administer oral activated charcoal if the last anticoagulant dose is within the previous two hours for dabigatran and edoxaban, six hours for apixaban, and eight hours for rivaroxaban.

#hematology
#pharmacology
#toxicology


References:

1. Siegal DM, Garcia DA, Crowther MA. How I treat target-specific oral anticoagulant-associated bleeding. Blood 2014; 123:1152. 

2. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017; 70:3042. 

3. Kaatz S, Kouides PA, Garcia DA, et al. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol 2012; 87 Suppl 1:S141.

"Vitamin C, thiamine, and hydrocortisone combo"

Q: What is the logic behind adding thiamine into "Vitamin C, thiamine, and hydrocortisone combo" adjuvant treatment in sepsis?



Answer: Paul Marik recently demonstrated the benefit of using a combination of high dose vitamin C, thiamine, and stress dose hydrocortisone in patients with sepsis. High dose vitamin C may cause renal oxalate crystallization. Thiamine (vitamin B1) prevents this crystallization. 

The combination doses suggested are 

• IV vitamin C - 1.5 g q 6 hours for four days or until ICU discharge
• IV thiamine - 200 mg q 12 hours for four days or until ICU discharge 
• IV hydrocortisone - 50 mg q 6 hours for seven days or until ICU discharge

#sepsis

#pharmacology

Reference: 

Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151:1229.

anti-coagulation in AF - compared to warfarin

Q: Which of the following is found to be superior in preventing stroke or systemic embolism, lowers overall mortality and less major bleeding in comparison to warfarin, in a patient with atrial fibrillation? 

A) Dabigatran 
B) Rivaroxaban 
C) Apixaban 
D) Edoxaban
E) Asipirin


Answer: C

Out of all of the above, in a large trial of 18,000 patients (the ARISTOTLE trial), Apixaban was found to be superior in preventing stroke or systemic embolism, less major bleeding, and lowers overall mortality, when compared to dose adjusted warfarin.

Dabigatran, Rivaroxaban and Edoxaban when compared to warfarin were all found to be non-superior/inferior in their respective trials.

Aspirin is not an anticoagulation suggested for atrial fibrillation.

#cardiology
#pharmacology


References:

1. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139. 

2. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365:883. 

3. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365:981. 

4. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369:2093.

dexmedetomidine

Q: All of the following regarding dexmedetomidine is correct except?

A) Preserve muscle tone
B) Preserve respiration
C) Can be given intranasally
D) a weak analgesic
E) Fail to provide any amnesia


Answer: E

Dexmedetomidine is a sedative frequently used in ICU as an infusion and has many favorable characteristics like it preserves muscle tone and respiration (choices A and B). It also provides a little degree of analgesia (choice D). 

It is relatively a less known fact, though used frequently in pediatric population, it can be given intra-nasally effectively in a dose of  2 to 3 mcg/kg (choice C).

Dexmedetomidine provides amnesia (choice E) but should not rely on it as amnestic effect is very unpredictable.


#sedation
#pharmacology


References:

1. Yu Q, Liu Y, Sun M, Zhang J, Zhao Y, Liu F, Li S, Tu S. Median effective dose of intranasal dexmedetomidine sedation for transthoracic echocardiography in pediatric patients with noncyanotic congenital heart disease: An up-and-down sequential allocation trial.  Paediatr Anaesth. 2017 Nov; 27(11):1108-1114. 

2. Wu X, Hang LH, Wang H, Shao DH, Xu YG, Cui W, Chen Z.  Intranasally Administered Adjunctive Dexmedetomidine Reduces Perioperative Anesthetic Requirements in General Anesthesia. Yonsei Med J. 2016 Jul;57(4):998-1005. 

Extravasation of pressors in ICU

Q; All of the pressors in ICU may respond to local area antidote treatment with phentolamine in case of extravasation except?

A) Phenylephrine
B) Norepinephrine
C) Epinephrine
D) Vasopressin
E) Dopamine


Answer: D

Local extravasation of pressors may cause ischemia in the area and can have a morbid long term effect.

Norepinephrine, epinephrine, and dopamine have affinities for both the alpha and beta receptors. Phenylephrine is a pure alpha1 agonist. They all need treatment in case of extravasation. Vasopressin exerts vasoconstriction via V1 receptors and may not respond to treatment with phentolamine, an antidote for such scenarios.

#toxicology


Reference:

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. 

TRALI risk factors

Q: All of the following are risk factors for Transfusion-related acute lung injury (TRALI) except? 

A) Liver transplantation surgery 
B) High peak airway pressure on mechanical ventilator 
C) Negative fluid balance 
D) Emergent cardiac surgery 
E) Hematologic malignancy


Answer: C

The list of risk factor for TRALI is very long and growing day by day as with more recognition of this syndrome. Some risk factors are very well known such as high interleukin (IL)-8 levels, massive transfusion, sepsis, mechanical ventilation, and a high Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Others are less well known as described in the choices A, B, D and E. Other less well-known factors for TRALI are a positive fluid balance (choice C), transfusion of platelet or plasma, recipient female gender, smoking, history of alcohol abuse, intravenous immune globulin preparations, female donor, and increased parity.

#hematology
#pulmonary


References:

1. Vlaar AP, Binnekade JM, Prins D, et al. Risk factors and outcome of transfusion-related acute lung injury in the critically ill: a nested case-control study. Crit Care Med 2010; 38:771. 

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

3. Vlaar AP, Hofstra JJ, Determann RM, et al. The incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: a prospective nested case-control study. Blood 2011; 117:4218. 

4. Gajic O, Rana R, Mendez JL, et al. Acute lung injury after blood transfusion in mechanically ventilated patients. Transfusion 2004; 44:1468. 

5. Rizk A, Gorson KC, Kenney L, Weinstein R. Transfusion-related acute lung injury after the infusion of IVIG. Transfusion 2001; 41:264. 

6. Gajic O, Yilmaz M, Iscimen R, et al. Transfusion from male-only versus female donors in critically ill recipients of high plasma volume components. Crit Care Med 2007; 35:1645.

Diuretic as anti-seizure

Q: Which diuretic has shown some promise in suppressing temporal lobe epilepsy?



Answer:  Bumetanide 

Bumetanide has been used in neonatal refractory seizures with success. It is an inhibitor of Na-K-Cl cotransporter (NKCC). The human body has Two isoforms of NKCC

• NKCC1 is expressed in the brain, and 
• NKCC2 is expressed in the kidney 

It has shown the potential of use in patients with temporal lobe epilepsy. 


#neurology
#pharmacology



References:

1. S. Eftekhari, J. Mehvari Habibabadi, M. Najafi Ziarani, et al. Bumetanide reduces seizure frequency in patients with temporal lobe epilepsy Epilepsia, 54 (2013), pp. e9-12

2. Bumetanide enhances phenobarbital efficacy in a neonatal seizure model Ann Neurol, 63 (2008), pp. 222-235 

3.  K.T. Kahle, K.J. Staley The bumetanide-sensitive Na-K-2Cl cotransporter NKCC1 as a potential target of a novel mechanism-based treatment strategy for neonatal seizures Neurosurg Focus, 25 (2008), Article E22

Pseudothrombocytopenia

Q: Which of the following drug can cause pseudothrombocytopenia? 

A) glycoprotein IIb/IIIa inhibitors 
B) Heparin
C) Acetaminophen 
D) Piperacillin 
E) Vancomycin 


Answer:  A

The objective of the above question is to highlight the main causes of pseudothrombocytopenia.

The usual anticoagulant used in phlebotomy tubes is ethylenediaminetetraacetic acid (EDTA). Many times in vitro platelet clumping may occur by ethylenediaminetetraacetic acid (EDTA)-dependent agglutinins. In such suspected scenarios, a blood sample should be sent in different anticoagulants based tubes after consulting laboratory personnel.

The most difficult situation is the use of glycoprotein IIb/IIIa inhibitors after acute coronary events. Although it is true that glycoprotein IIb/IIIa inhibitors can itself cause true thrombocytopenia but by default, any thrombocytopenia without any clinical finding with the use of glycoprotein IIb/IIIa inhibitors be read as pseudothrombocytopenia, as it may cause in vitro clumping of platelets.

Other major causes of pseudothrombocytopenia are insufficiently anticoagulated specimen and large size platelets (giant platelets) read as white blood cells by an automated counter.

#hematology
#cardiology
#pharmacology
#laboratory-medicine


Reference:

Bizzaro, Nicola Pathology - PSEUDOTHROMBOCYTOPENIA - Journal of the RCPA: 2009 - Volume 41 - Issue - p 34

LVOT

Q: All of the following are good choices for medical therapy in Left Ventricular Outflow Obstruction (LVOT)/Hypertrophic cardiomyopathy (HCM) except? 

A) beta blocker 
B) verapamil 
C) disopyramide 
D) nifedipine 
E) diltiazem 


 Answer:  D

Objective of above question is to highlight the drugs which should be avoided in LVOT/HCM. Two major classes of drugs which should ideally be avoided or at least be used with caution are

●Vasodilators
●Diuretics

Vasodilators which includes dihydropyridine calcium channel blockers (eg, nifedipine, amlodipine), nitroglycerin, angiotensin converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs), can cause fatal hemodynmic collapse by producing a fall in peripheral vascular resistance which may increase LVOT obstruction and ventricular filling pressures. Diuretics reduce the preload and so ventricular filling, worsening the LVOT symptoms.

#cardiology
#hemodynamics


References:

1. Veselka J, Anavekar NS, Charron P. Hypertrophic obstructive cardiomyopathy. Lancet 2017; 389:1253. 

2. Rothman RD, Baggish AL, O'Callaghan C, et al. Management strategy in 249 consecutive patients with obstructive hypertrophic cardiomyopathy referred to a dedicated program. Am J Cardiol 2012; 110:1169.