Parvovirus B19

 Q: 32 years old female is admitted to ICU with aplastic crisis with a recent history of intrauterine fetal demise. Subsequent workup leads to the diagnosis of Parvovirus B19. All of the following are considered among the five major syndromes of Parvovirus B19 EXCEPT?

A) Fifth disease (in children) 

B) Myocarditis 

C) Transient aplastic crisis 

D) Fetal infection 

E) Pure red blood cell aplasia 

Answer: B

Parvovirus B19 continues to be an important discussion in medicine as 50 percent of child-bearing age women worldwide lack measurable IgG to parvovirus B19. 

There are five established syndromes associated with parvovirus B19, which are

1. Fifth disease/erythema infectiosum in children 
2. Transient aplastic crisis, occurs usually in patients  with chronic hemolytic disorders 
3. Fetal infection manifesting as non-immune hydrops fetalis, intrauterine fetal death, miscarriage, or cardiomyopathy 
4. Pure red blood cell aplasia in immunocompromised hosts 
5. Arthropathy 

 Myocarditis manifesting as dilated cardiomyopathy or left heart failure has been reported but not established as a definite syndrome.

#Ob-Gyn

#hematology

#ID

References:

1. Rodis JF, Quinn DL, Gary GW Jr, et al. Management and outcomes of pregnancies complicated by human B19 parvovirus infection: a prospective study. Am J Obstet Gynecol 1990; 163:1168. 

2. Gratacós E, Torres PJ, Vidal J, et al. The incidence of human parvovirus B19 infection during pregnancy and its impact on perinatal outcome. J Infect Dis 1995; 171:1360.

3. Stewart GC, Lopez-Molina J, Gottumukkala RV, et al. Myocardial parvovirus B19 persistence: lack of association with clinicopathologic phenotype in adults with heart failure. Circ Heart Fail 2011; 4:71. 

4. Kühl U, Rohde M, Lassner D, et al. miRNA as activity markers in Parvo B19 associated heart disease. Herz 2012; 37:637.

5. Heegaard ED, Brown KE. Human parvovirus B19. Clin Microbiol Rev. 2002;15(3):485-505. doi:10.1128/CMR.15.3.485-505.2002

6. Servey JT, Reamy BV, Hodge J. Clinical presentations of parvovirus B19 infection. Am Fam Physician. 2007 Feb 1;75(3):373-6. PMID: 17304869.

Lidocaine use in NGT insertion

 Q: Which of the following facilitates the nasogastric tube (NGT) insertion? (select one)

A) topical lidocaine 

B) nebulized lidocaine

Answer: B

It may be surprising that concomitant use of nebulized lidocaine helps more than the topical use of lidocaine during NGT insertion. This is due to the fact that nebulized lidocaine suppresses the cough reflex during NGT insertion. 

In addition, to suppress the gag reflex it may help to ask the patient, if co-operative and alert, to sip water during the procedure. Sipping liquid not only helps to advance the tube with swallowing but also relieves NGT's irritation at the back of the oropharynx to some degree.

Topical lidocaine so far failed to show any benefit in the insertion of NGT in two studies 20 years apart (1) (2).

#procedures

References:

1. West HH. Topical anesthesia for nasogastric tube placement. Ann Emerg Med. 1982 Nov;11(11):645. 

2.  Uri O, Yosefov L, Haim A, Behrbalk E, Halpern P. Lidocaine gel as an anesthetic protocol for nasogastric tube insertion in the ED. Am J Emerg Med. 2011 May;29(4):386-90. 

3. Cullen L, Taylor D, Taylor S, Chu K. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug;44(2):131-7.

IVF in electricity burn

 Q: In patients with high voltage electrical injuries, a urine output target should be? (select one) 

A) decreased

B) increased

Answer: B

 One of the basic goals of patients with burns is to preserve the end-organs function. Few parameters which can be helpful are urine output,  central venous pressure (CVP), and/or Swan Ganz guided hemodynamic values. Urine output continued to be the cornerstone guide of these patients' fluid resuscitation. In any average patient, ideally, the target is 1 mL/kg/hour for adults. A clinician should adjust this target per each patient, particularly in light of the Total Body Surface Area (TBSA) of burn.

In patients with high voltage electrical injuries, higher urine output should be targeted/maintained as there is an increased risk of myoglobinuria and acute kidney injury (AKI).

#burns

#hemodynamics

#resuscitation

#nephrology

References:

Culnan DM, Farner K, Bitz GH, et al. Volume Resuscitation in Patients With High-Voltage Electrical Injuries. Ann Plast Surg 2018; 80:S113.

CINV

 Q: 32 years old female on active chemotherapy is recovering in ICU. Oncology service wants to restart her chemotherapy cycle with Cisplatin. Patient request anti-emetic prior to her chemotherapy agent. A chemotherapy agent can be anticipated for the risk of its emetic properties (risk of inducing vomiting)?

A) True

B) False

Answer: A

Fortunately, a chemotherapy agent can be fairly accurately predicted for its risk of causing chemotherapy-induced-nausea-vomiting (CINV). This helps a clinician to prescribe prophylaxis for chemotherapy. Broadly, they are divided into four categories. 

• Highly emetic – >90% risk of emesis 
• Moderately emetic – 30 to 90% risk of emesis
• Low emetogenicity – 10 to 30% risk of emesis 
• Minimally emetic – < 10% risk of emesis

Many centers follow proper CINV protocol in this regard. 

#oncology

References:

1. Roila F, Hesketh PJ, Herrstedt J, Antiemetic Subcommitte of the Multinational Association of Supportive Care in Cancer. Prevention of chemotherapy- and radiotherapy-induced emesis: results of the 2004 Perugia International Antiemetic Consensus Conference. Ann Oncol 2006; 17:20. 

2. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol 2016; 27:v119. 

3.  Hesketh PJ, Kris MG, Basch E, et al. Antiemetics: ASCO Guideline Update. J Clin Oncol 2020; 38:2782.

WBC evaluation

 Q: Neutrophilia associated with corticosteroids is usually accompanied by? (select one) 

 A) Monocytosis

B) Eosinophilia

Answer: A

Many times it may become difficult to determine the cause of leucocytosis in ICU particularly when steroids are on board. One of the key evaluations is to look at the other lineage of WBCs.

One of the examples is the presence of monocytosis. Reading it with other clinical scenarios may help tremendously. Neutrophilia with monocytosis can be present in many conditions such as varicella-zoster, bacterial endocarditis, malaria, typhoid fever, corticosteroids, and asplenia. Monocytosis has also been described as a biomarker for inflammatory bowel disease.

 Similarly, eosinophilia and/or basophilia with neutrophilia is common with allergy, helminths, and parasitic infections.

#Laboratory-medicine

#pharmacology

References:

Lynch DT, Hall J, Foucar K. How I investigate monocytosis. Int J Lab Hematol. 2018 Apr;40(2):107-114. doi: 10.1111/ijlh.12776. Epub 2018 Jan 18. PMID: 29345409.

2. Anderson A, Cherfane C, Click B, Ramos-Rivers C, Koutroubakis IE, Hashash JG, Babichenko D, Tang G, Dunn M, Barrie A, Proksell S, Dueker J, Johnston E, Schwartz M, Binion DG. Monocytosis Is a Biomarker of Severity in Inflammatory Bowel Disease: Analysis of a 6-Year Prospective Natural History Registry. Inflamm Bowel Dis. 2021 Mar 9:izab031. doi: 10.1093/ibd/izab031. Epub ahead of print. PMID: 33693659.

Carotid endarterectomy hyperperfusion syndrome

Q: What is carotid endarterectomy hyperperfusion syndrome? 

 Answer: Immediately after repair of carotid stenosis, a patient may experience headache, and in some cases seizures, intracerebral hemorrhage (ICH), and/or cerebral edema. If not treated it may lead to death. 

Status-post Carotid Endarterectomy (CEA), there is an increase in cerebral blood flow. This is due to impaired cerebral auto-regulation. Hyperperfusion syndrome should be closely watched in patients who have prior high-grade i.e., > 80% stenosis, or may have a recent stroke. 

Patient usually complains of headaches at the ipsilateral side of the surgery. Headache improves with the upright position and optimization of the blood pressure.

#surgical-critical-care

#neurology

References:

1. Bouri S, Thapar A, Shalhoub J, et al. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg 2011; 41:229. 

2. Pennekamp CW, Tromp SC, Ackerstaff RG, et al. Prediction of cerebral hyperperfusion after carotid endarterectomy with transcranial Doppler. Eur J Vasc Endovasc Surg 2012; 43:371.

3. W Tosh, M Patteril, Cerebral oximetry, BJA Education, Volume 16, Issue 12, December 2016, Pages 417–421, https://doi.org/10.1093/bjaed/mkw024

A System Biology Journey to DAMPen Acute Lung Inflammation

 

A System Biology Journey to DAMPen Acute Lung Inflammation - Sr. Skip Garcia

Link: https://watch.houstonmethodist.org/media/Critical+Care+Grand+Rounds_June+21_2021-+A+System+Biology+Journey+to+DAMPen+Acute+Lung+Inflammation/1_sopmilto

   

Gallstone ileus

 Q: Gallstone ileus is due to? (select one) 

A) mechanical bowel obstruction 

B) non-mechanical bowel obstruction

Answer: A

Gallstones can easily pass through the intestine except at few places such as ileum, the narrowest part of the intestine. It can also occur at the jejunum and stomach. In patients with prior pathology causing strictures such as inflammatory bowel disease, abdominal surgeries, or diverticulitis, it carries a high risk. 

It can also occur after endoscopic sphincterotomy where a large enough stone can cause obstruction. It frequently occurs concurrently with the Mirizzi syndrome (common hepatic duct obstruction due to extrinsic compression from impacted stone in cystic duct). The narrowing of the common hepatic duct can cause cholecystenteric fistula, creating a pathologic exit route for stones. Mirizzi syndrome was first described by Mirizzi more than 70 years ago. 

#surgical-critical-care

References:

1. Mirizzi PL. Syndrome del conducto hepatico. J Int Chir 1948; 8:731. 

2. Halabi WJ, Kang CY, Ketana N, et al. Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg 2014; 259:329. 

3. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292. 

4. Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World J Surg 2008; 32:2237. 

5. Despland M, Clavien PA, Mentha G, Rohner A. Gallstone ileus and bowel perforation after endoscopic sphincterotomy. Am J Gastroenterol 1992; 87:886. 

6. Basili G, Lorenzetti L, Celona G, et al. Gallstone ileus in patient with Crohn's disease: report of a clinical observation. Surg Endosc 2006; 20:703.

ophthalmologic emergency after radioiodine treatment for Grave's disease

 Q: 34 years old female is admitted to ICU from ED as an ophthalmologic emergency. Patient recently started on radioiodine treatment for her Grave's disease. What should be the next step of treatment?

 Answer: Add glucocorticoids

In patients with Graves' disease, the commencement of therapy with radioiodine aggravates the orbitopathy, popularly known as exophthalmos. It can be sight-threatening. The treatment is the addition of glucocorticoids. Most clinicians start glucocorticoids prophylactically if there is any risk of such deterioration. 

Radioiodine treatment is considered relatively contraindication in moderate to severe and/or sight-threatening exophthalmos. Interestingly, besides existing orbitopathy smoking is considered the greatest risk. Baseline high T3 level is also considered a risk for such deterioration. 

If started, steroids need to be continued and tapered over 6-8 weeks.

#endocrinology

#opthalmology

References:

1. Shiber S, Stiebel-Kalish H, Shimon I, et al. Glucocorticoid regimens for prevention of Graves' ophthalmopathy progression following radioiodine treatment: systematic review and meta-analysis. Thyroid 2014; 24:1515. 

2. Lai A, Sassi L, Compri E, et al. Lower dose prednisone prevents radioiodine-associated exacerbation of initially mild or absent graves' orbitopathy: a retrospective cohort study. J Clin Endocrinol Metab 2010; 95:1333. 

3. Vannucchi G, Covelli D, Campi I, et al. Prevention of Orbitopathy by Oral or Intravenous Steroid Prophylaxis in Short Duration Graves' Disease Patients Undergoing Radioiodine Ablation: A Prospective Randomized Control Trial Study. Thyroid 2019; 29:1828. 

4. Hautzel H, Pisar E, Yazdan-Doust N, et al. Qualitative and quantitative impact of protective glucocorticoid therapy on the effective 131I half-life in radioiodine therapy for Graves disease. J Nucl Med 2010; 51:1917.

HIV meds

 Q: What are the six steps of life cycle of human immunodeficiency virus (HIV), and what is its clinical significance? 

Answer: These are the six steps of HIV life cycle: 

1. Entry consisting of binding and fusion 
2. Reverse transcription 
3. Integration 
4. Replication consists of transcription and translation 
5. Assembly 
6. Budding and maturation 

Clinically it is significant to know as different HIV meds act at different steps 

• Entry – maraviroc, enfuvirtide, and fostemsavir 
• Reverse transcription – Nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) 
• Integration – Integrase strand transfer inhibitors (INSTIs) 
• Replication – None so far 
• Assembly – None so far 
• Budding and maturation – Protease inhibitors

#ID

#pharmacology

#HIV

References:

1. Bhatti AB, Usman M, Kandi V. Current Scenario of HIV/AIDS, Treatment Options, and Major Challenges with Compliance to Antiretroviral Therapy. Cureus. 2016;8(3):e515. Published 2016 Mar 1. doi:10.7759/cureus.515 

2. Kemnic TR, Gulick PG. HIV Antiretroviral Therapy. [Updated 2020 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513308/

CAPS

Q: All of the following are required for the criteria of "catastrophic antiphospholipid syndrome" (CAPS) EXCEPT? (select one) 

A) History of antiphospholipid syndrome (APS) and/or antiphospholipid antibodies (aPL) 

B) Two or more new organ thromboses within a month 

C) Biopsy confirmation of a microthrombus 

D) Exclusion of other causes of multiple organ thromboses or microthromboses

Answer: B

It is important to know that CAPS is a very rare phenomenon, occurring only in 0.8 percent of patients of APS. This is important as other causes may look alike CAPS such as Heparin-Induced Thrombocytopenia (HIT) may deceive a clinician and may lead to wrong management. There are four strict criteria to establish CAPS 

●History of APS and/or antiphospholipid antibodies (aPL) 

●Three or more new organ thromboses within a week 

●Biopsy confirmation of a microthrombus 

●Exclusion of other causes of multiple organ thromboses or microthromboses

If not all four criteria can be established, it can be label as "probable CAPS".

#rheumatology

References:

1. Asherson, RA, Cervera, R, de Groot, PG, et al. Lupus 2003; 12:530 

2. Nayer A, Ortega LM. Catastrophic antiphospholipid syndrome: a clinical review. J Nephropathol. 2014 Jan;3(1):9-17. doi: 10.12860/jnp.2014.03. Epub 2014 Jan 1. PMID: 24644537; PMCID: PMC3956908. 

3. Carmi O, Berla M, Shoenfeld Y, Levy Y. Diagnosis and management of catastrophic antiphospholipid syndrome. Expert Rev Hematol. 2017 Apr;10(4):365-374. doi: 10.1080/17474086.2017.1300522. Epub 2017 Mar 13. PMID: 28277850.

IABP hemodynamic effects

 Q: All of the following are the hemodynamic effects of Intra-Aortic-Balloon Pump (IABP) EXCEPT?

A) decrease in systolic pressure 

B) increase in diastolic pressure 

C) increase in heart rate 

D) decrease in the mean pulmonary capillary wedge pressure 

E) increase in cardiac output

Answer: C

All of the above are the desired effects of IABP except choice C. With improved hemodynamics, heart rate is expected to decrease by 20 percent. 

In the above question, it would be worth mentioning that choice B i.e., increase in diastolic pressure may augment by 30 percent. This desired effect raises coronary blood flow to the myocardial area perfused by a critically ischemic vessel.

#hemodynamics

References:

1. De Silva K, Lumley M, Kailey B, Alastruey J, Guilcher A, Asrress KN, Plein S, Marber M, Redwood S, Perera D. Coronary and microvascular physiology during intra-aortic balloon counterpulsation. JACC Cardiovasc Interv. 2014 Jun;7(6):631-40. doi: 10.1016/j.jcin.2013.11.023. Epub 2014 Apr 9. PMID: 24726295.

2. Takeuchi M, Nohtomi Y, Yoshitani H, Miyazaki C, Sakamoto K, Yoshikawa J. Enhanced coronary flow velocity during intra-aortic balloon pumping assessed by transthoracic Doppler echocardiography. J Am Coll Cardiol. 2004 Feb 4;43(3):368-76. doi: 10.1016/j.jacc.2003.08.047. PMID: 15013116.

Lemierre Syndrome

 Q: Healthy people are at higher risk of developing Lemierre syndrome?

A) True

B) False

Answer: A

Septic thrombophlebitis of the internal jugular vein is called Lemierre syndrome. Although rare, it tends to occur more in healthy teens and young adults, with a high incidence in males. It is caused by normal oropharyngeal flora. The most common pathogen is the anaerobic nonmotile, filamentous, non-spore-forming gram-negative bacillus, called Fusobacterium necrophorum. 

Lemierre syndrome is usually preceded 2-3 weeks prior by tonsilitis or infection of peritonsillar tissue. It is also reported after dental infection, mastoiditis, otitis media, sinusitis, or parotitis. It mostly occurs via local invasion. Some authors also suspect hematogenous spread via tonsillar vein or via the lymphatics. 

Empiric antibiotics should be started as soon as possible. Monotherapy with piperacillin-tazobactam or a carbapenem is possible. Ceftriaxone can also be used but metronidazole should be added to it. Penicillin-based antibiotics are generally avoided as resistance is high globally.

#ID

References:

1. Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis 2012; 12:808. 

2. Karkos PD, Asrani S, Karkos CD, Leong SC, Theochari EG, Alexopoulou TD, Assimakopoulos AD. Lemierre's syndrome: A systematic review. Laryngoscope. 2009 Aug;119(8):1552-9. doi: 10.1002/lary.20542. PMID: 19554637.

3. Gore MR. Lemierre Syndrome: A Meta-analysis. Int Arch Otorhinolaryngol. 2020 Jul;24(3):e379-e385. doi: 10.1055/s-0039-3402433. Epub 2020 Apr 24. PMID: 32754251; PMCID: PMC7394644.

NPE in SAH

 Q: What are the few predictors to expect neurogenic pulmonary edema (NPE) in patients admitted with subarachnoid hemorrhage (SAH)?

Answer: NPE can be a fatal complication after intracranial hemorrhage (ICH) particularly SAH. Intensivists should be expecting it if one or more of the following signs present in these patients: 

• hyperglycemia
• acidosis
• high lactate level
• EKG change
• heart rate variability
• elevated troponin, and 
• leukocytosis

#neurology

#neurosurgery

#surgical-critical-care

#pulmonary

References:

1. Hong-Sheng L, Qin SU, Xiao-Dong Z, et al. Identification and Treatment of the Early Form of Neurogenic Pulmonary Edema in Emergency Room. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2015; 37:343. 

2. Satoh E, Tagami T, Watanabe A, et al. Association between serum lactate levels and early neurogenic pulmonary edema after nontraumatic subarachnoid hemorrhage. J Nippon Med Sch 2014; 81:305. 

3. Chen WL, Huang CH, Chen JH, et al. ECG abnormalities predict neurogenic pulmonary edema in patients with subarachnoid hemorrhage. Am J Emerg Med 2016; 34:79. 

4. Chen WL, Chang SH, Chen JH, et al. Heart Rate Variability Predicts Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2016; 25:71. 

5. Nastasovic T, Milakovic B, Marinkovic JE, et al. Could cardiac biomarkers predict neurogenic pulmonary edema in aneurysmal subarachnoid hemorrhage? Acta Neurochir (Wien) 2017; 159:705.

Thrombocytosis

 Q: How a simple blood smear can help to make a differential diagnosis in thrombocytosis?

Answer: The size/shape of the platelets on the simple blood smear can quickly guide clinicians towards the cause of persistent thrombocytosis (a common condition encountered in ICU).

If platelets are seen equivalent to RBC sizes - it is probably due to a myeloproliferative neoplasm (PMN). In contrast, young platelets are a sign of a reactive process or a familial disorder. 

Again, platelets larger than RBCs, called giant platelets - and/or - conglomerates of platelets, bizarre shapes, megakaryocytic fragments, hypogranular platelet - are seen with PMN or familial disorders. This is unlikely in reactive thrombocytosis.

#hematology

#oncology 

References:

1. Greinacher A, Pecci A, Kunishima S, Althaus K, Nurden P, Balduini CL, Bakchoul T. Diagnosis of inherited platelet disorders on a blood smear: a tool to facilitate worldwide diagnosis of platelet disorders. J Thromb Haemost. 2017 Jul;15(7):1511-1521. doi: 10.1111/jth.13729. Epub 2017 Jun 4. PMID: 28457011.

2. Adewoyin AS, Nwogoh B. Peripheral blood film - a review. Ann Ib Postgrad Med. 2014;12(2):71-79.

3. Bleeker JS, Hogan WJ. Thrombocytosis: diagnostic evaluation, thrombotic risk stratification, and risk-based management strategies. Thrombosis. 2011;2011:536062. doi:10.1155/2011/536062

Direct and indirect bilirubinemia

 Q: Which of the following cause conjugated hyperbilirubinemia? (select one) 

A) Hemolysis 

B) Sepsis 

C) Impaired hepatic bilirubin uptake 

D) Dyserythropoiesis 

E) Total parenteral nutrition

Answer: E

Distinguishing hyperbilirubinemia between conjugated and unconjugated clears the path to diagnosis. Conjugated bilirubin is also called direct bilirubin, and unconjugated bilirubin indirect bilirubin. This can be remembered by knowing that most of the causes of indirect bilirubinemia are outside the liver and haven't got a chance to conjugate inside the liver.

The most common causes of unconjugated hyperbilirubinemia in ICU are hemolysis, dyserythropoiesis, and stress situations like sepsis. Conjugated hyperbilirubinemia is mostly seen in biliary obstruction, various forms of hepatitis, primary biliary cholangitis (PBC), drugs, toxins, and ischemia (shock liver). 

Total parenteral nutrition (TPN) is frequently used in ICU and usually causes conjugated hyperbilirubinemia.

#hepatology

References:

1. Mitra A, Ahn J. Liver Disease in Patients on Total Parenteral Nutrition. Clin Liver Dis. 2017 Nov;21(4):687-695. doi: 10.1016/j.cld.2017.06.00

2. Żalikowska-Gardocka M, Przybyłkowski A. Review of parenteral nutrition-associated liver disease. Clin Exp Hepatol. 2020;6(2):65-73. doi:10.5114/ceh.2019.955288. Epub 2017 Aug 19. PMID: 28987256.

3. Raman M, Allard JP. Parenteral nutrition related hepato-biliary disease in adults. Appl Physiol Nutr Metab. 2007 Aug;32(4):646-54. doi: 10.1139/H07-056. PMID: 17622278.

Potassium and EKG changes

 Q: The progression of EKG changes correlate well with the serum potassium concentration?

A) Yes

B) No

Answer: B

There are several EKG changes that occur with hyperkalemia. In early phases, the most well-known is a tall peaked T wave. The less known fact is that it should be read with a shortened QT interval. This is followed by progressive lengthening of the PR interval along with QRS duration. The disappearance of P-wave is relatively a late sign. QRS continues to widen and become a sine wave. This quickly degenerates into asystole. 

Although above is the classic progress of EKG changes, hyperkalemia can be characterized by various other appearances on the EKG including bradycardia, idioventricular rhythms, V. Tach., V. Fib., pseudo-ST-elevations mimicking myocardial infarction, and pseudo-Brugada patterns. 

The most important thing to remember is that an EKG change in hyperkalemia is an urgency to treat, as they do not correlate well with the serum potassium level.

#cardiology

References:

1. Littmann L, Gibbs MA. Electrocardiographic manifestations of severe hyperkalemia. J Electrocardiol 2018; 51:814. 

2. Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol. 2008 Mar;3(2):324-30. doi: 10.2215/CJN.04611007. Epub 2008 Jan 30. PMID: 18235147; PMCID: PMC2390954.

3. Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963-971. doi:10.5811/westjem.2017.6.33033

Acyclovir side effect

 Q: 44 years old male with End-Stage Renal Failure (ESRD) on chronic peritoneal dialysis is admitted to ICU with Herpes pneumonia and started on acyclovir. Patient progressively developed agitation, delirium and went into coma. Patients on peritoneal dialysis have higher risk of acyclovir toxicity?

A) True

B) False

Answer: A

When it comes to Acyclovir two considerations are very important. First, acyclovir itself can cause Acute Kidney Injury (AKI) by precipitating relatively insoluble acyclovir crystals in the renal tubules. This risk is high with intravenous (IV) route and can be eliminated by reducing the dose and prior high hydration with urine output around 75-100 cc/hr. This can be challenging in cardiac or renal patients, not on dialysis yet. 

When it comes to patients already on dialysis, peritoneal dialysis is not very effective in the removal of acyclovir. This is due to the fact that the drug is not highly bound to plasma protein. It quickly penetrates tissue and fluid including cerebrospinal fluid (CSF). A nephrologist and a pharmacist should be consulted to avoid this dreaded complication.

#pharmacology

References:

1. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy 2009; 29:562. 

2. Patel J, Hayes B, Bauler L, Mastenbrook J. Neurologic Acyclovir Toxicity in the Absence of Kidney Injury. J Emerg Med 2019; 57:e35. 

3. Gentry JL 3rd, Peterson C. Death Delusions and Myoclonus: Acyclovir Toxicity. Am J Med 2015; 128:692. 

4. Davenport A, Goel S, Mackenzie JC. Neurotoxicity of acyclovir in patients with end-stage renal failure treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 20:647. 

5. Stathoulopoulou F, Almond MK, Dhillon S, Raftery MJ. Clinical pharmacokinetics of oral acyclovir in patients on continuous ambulatory peritoneal dialysis. Nephron 1996; 74:337.

GAP in IPF

 Q: 64 years old male who has never had access to any healthcare, admitted to ICU with severe hypoxemia. Subsequent workup led to diagnosis of idiopathic lung fibrosis (IPF). Pulmonology service starts to calculate the GAP model.  The GAP stands for? (select one)

A) Gene-Age-Physiology model 

B) Gender-Age-Physiology model

C) Graded-Age-Physiology model

D) Guided-Age-Physiology model

E) Goal-directed-Age-Physiology model

Answer: B

GAP is a validated clinical prediction model for patients with IPF to predict 1, 2, and 3-year mortality. The calculator takes into account - gender, age, predicted Forced Vital Capacity (FVC) and predicted diffusing capacity of the lungs for carbon monoxide (DLCO). Once combined with functional status, patient wishes, and other clinical conditions it helps to decide on the aggressiveness of treatment ranging from lung transplant to palliation.

The calculator is simple to use and can be viewed at  https://www.acponline.org/journals/annals/extras/gap/

# pulmonary

#transplantations

References:

1. Ley B, Ryerson CJ, Vittinghoff E, Ryu JH, Tomassetti S, Lee JS, Poletti V, Buccioli M, Elicker BM, Jones KD, King TE Jr, Collard HR. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med. 2012 May 15;156(10):684-91. doi: 10.7326/0003-4819-156-10-201205150-00004. PMID: 22586007.

2. Lee SH, Kim SY, Kim DS, Kim YW, Chung MP, Uh ST, Park CS, Jeong SH, Park YB, Lee HL, Shin JW, Lee EJ, Lee JH, Jegal Y, Lee HK, Kim YH, Song JW, Park SW, Park MS. Predicting survival of patients with idiopathic pulmonary fibrosis using GAP score: a nationwide cohort study. Respir Res. 2016 Oct 18;17(1):131. doi: 10.1186/s12931-016-0454-0. PMID: 27756398; PMCID: PMC5069824.

panniculitis

 Q: In acute pancreatitis - panniculitis are most commonly found at? (select one) 

A) Chest area 

B) Flank area 

C) Upper extremities 

D) Lower extremities 

E) Perineal area 

 Answer: D

Physical exam particularly cutaneous exam can be of profound help in acute pancreatitis. 

Panniculitis are actually subcutaneous nodular fat necrosis lesions which are tender to touch and appears as reddish nodules. They are commonly found in distal areas of lower extremities, though may be present at other places in the body. 

Two other significant cutaneous findings are Cullen's sign and Grey Turner sign. Cullen's sign is ecchymotic discoloration in the periumbilical region and Grey Turner sign is ecchymotic discoloration mostly along the flanks. These two signs are due to retroperitoneal bleed subsequent to pancreatic necrosis. 

Besides above, other cutaneous findings can also be of help such as xanthomas in hyperlipidemic pancreatitis.

#physical-exam

#GI

References:

1.  Dahl PR, Su WP, Cullimore KC, Dicken CH. Pancreatic panniculitis. J Am Acad Dermatol 1995; 33:413. 

2. Bennett RG, Petrozzi JW. Nodular subcutaneous fat necrosis. A manifestation of silent pancreatitis. Arch Dermatol 1975; 111:896.

3. Mookadam F, Cikes M. Images in clinical medicine. Cullen's and Turner's signs. N Engl J Med 2005; 353:1386.

bell and the diaphragm of the stethoscope

Q:  The diaphragm of the stethoscope detects best? (select one) 

A) high-frequency sounds 

B) low-frequency sounds

Answer: A

The stethoscope has two heads: Bell and Diaphragm - 

• Bell is best to detect low-frequency sounds like third and fourth heart sounds 
• Diaphragm is best to detect high-frequency sounds like pericardial and pleural friction rubs

#physical-exam

References:

1. Murphy RL. In defense of the stethoscope. Respir Care. 2008 Mar;53(3):355-69. PMID: 18291053. 

2. David L, Dumitrascu DL. The bicentennial of the stethoscope: a reappraisal. Clujul Med. 2017;90(3):361-363. doi:10.15386/cjmed-821 

3. O'Neill D. Using a stethoscope in clinical practice in the acute sector. Prof Nurse. 2003 Mar;18(7):391-4. PMID: 12674046.

SBO grading

 Q: There are how many grades of Small Bowel Obstruction (SBO)? (select one)

A) Minimum, Moderate and Severe

B) 1, 11, and 111

C) 1, 11, 111, 1V, and V

Answer: C

The American Association for the Surgery of Trauma (AAST) has developed a grading system for SBO taking into consideration the radiological and operative criteria. It has been validated as reliable in subsequent studies. Higher grading predicts at least three things 

• Higher hospital Length of Stay (LOS) 
• Higher ICU LOS, and 
• Higher complications.

#surgical-critical-care

Reference:

1. Hernandez MC, Haddad NN, Cullinane DC, Yeh DD, Wydo S, Inaba K, Duane TM, Pakula A, Skinner R, Rodriguez CJ, Dunn J, Sams VG, Zielinski MD, Choudhry A, Turay D, Yune JM, Watras J, Widom KA, Cull J, Toschlog EA, Graybill JC; EAST SBO Workgroup. The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2018 Feb;84(2):372-378. doi: 10.1097/TA.0000000000001736. PMID: 29117026.

strategies to decrease steroids side effects

 Q: Locally acting glucocorticoids have a lesser risk of superimposed infections than systemic glucocorticoids? 

 A) True 

B) False 

Answer: A

There are various strategies to reduce the risk of superimposed infections. Some of the strategies which can be considered are:

1. Applying glucocorticoids directly to the area/system which is targeted such as a nebulizer or inhaler for respiratory disease, or an oral steroid with high, first-pass metabolism like budesonide for intestinal inflammation. 

2. Alternate-day dosing if clinically appropriate. Prednisone effect may last up to 36 hours, and dexamethasone effect may last up to 72 hours.

3. Early mobilization and physical therapy to counter myopathy. 

#pharmacology

References:

1. Fauci AS, Dale DC, Balow JE. Glucocorticosteroid therapy: mechanisms of action and clinical considerations. Ann Intern Med 1976; 84:304.

NCT

 Q: Number connection test (NCT), also known as Reitan Test is used to evaluate which pathology? 

 Answer: Hepatic encephalopathy

NCT (Reitan Test) is a timed connect-the-numbers test. With no underlying hepatic encephalopathy, patients finish the test in seconds less than or equal to their age in years. If a patient is 40 years of age, he should finish the test in less than or in 40 seconds. Another rule of thumb described is that any healthy person should be able to finish in 30 seconds. 

Test was invented to administered in two-four parts but subsequent experience found that only one part is as effective as complete test.

Details can be found at:

 https://anthc.org/wp-content/uploads/2017/05/Numbers-Connection-Test.pdf

#hepatology

References:

1. Conn HO. Trailmaking and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Am J Dig Dis 1977; 22:541. 

2. Amodio P, Del Piccolo F, Marchetti P, et al. Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 1999; 29:1662.

3. Weissenborn K, Rückert N, Hecker H, Manns MP. The number connection tests A and B: interindividual variability and use for the assessment of early hepatic encephalopathy. J Hepatol 1998; 28:646.

Lugol's solution - routes of administration

 Q: 22 years old female is admitted to ICU with thyroid storm. Iodine solution is planned to be administered. Patient is having severe nausea and may not tolerate oral intake. Can it be given intravenously?

A) Yes

B) No

Answer: A

In a thyroid storm, iodine should be planned to be administered an hour after the first dose of thionamide. Iodine is mostly available as a potassium iodide-iodine solution, popularly known as Lugol's solution. The standard dose is 10 drops. If a patient cannot tolerate oral intake it can be added to intravenous fluid (IVF). Moreover, iodine may cause esophageal or duodenal mucosal damage leading to bleeding and should be diluted in a beverage or given with food. 

The iodine solution can also be administrated rectally.

#endocrinology

References:

1. Benua RS, Becker DV, Hurley JR. Thyroid storm. In: Current Therapy in Endocrinology and Metabolism, Bardin CW (Ed), Mosby, St. Louis 1994. p.75.

2. Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid 1995; 5:403.

HBO in CO

 Q: What are the indications for hyperbaric oxygen in carbon mono-oxide (CO) poisoning?

Answer: There are two major interventions required in the acute management of CO poisoning.

1. Removal of the source
2. Oxygen

Hyperbaric oxygen if available should be considered in the following situations:

• CO level >25% 
• CO level >20% in pregnant patients 
• Loss of consciousness 
• PH less than 7.1 by arterial blood gas (ABG) 
• End-organ ischemia evident by EKG changes, chest pain, encephalopathy, and others

#toxicology

References:

1. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998; 339:1603. 

2. Hampson NB, Dunford RG, Kramer CC, Norkool DM. Selection criteria utilized for hyperbaric oxygen treatment of carbon monoxide poisoning. J Emerg Med 1995; 13:227. 

3. Huang CC, Ho CH, Chen YC, et al. Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. Chest 2017; 152:943.

4. Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy. Intensive Care Med 1991; 17:289.

Dapto in MRSA CNS infections

 Q: Daptomycin is a good alternative to vancomycin if required to use in MRSA meningitis?

A) True

B) False

Answer: B

Daptomycin has no role in Central Nervous System (CNS) infections. It has very poor penetration into the cerebrospinal fluid (CSF). This is due to two reasons. First, it has a high molecular mass, and second, it is highly protein-bound. Unlike other drugs, meningeal inflammation does not increase its CSF penetration. 

Also, it is not a good choice in pneumonia as it gets inactivated by alveolar surfactants. It has its the best value in skin and soft tissue infections with Methicillin-resistant Staphylococcus aureus (MRSA).

#ID

References:

1. Piva S, Di Paolo A, Galeotti L, et al. Daptomycin Plasma and CSF Levels in Patients with Healthcare-Associated Meningitis. Neurocrit Care 2019; 31:116. 

2. Kullar R, Chin JN, Edwards DJ, et al. Pharmacokinetics of single-dose daptomycin in patients with suspected or confirmed neurological infections. Antimicrob Agents Chemother 2011; 55:3505. 

3. Silverman JA, Mortin LI, Vanpraagh AD, et al. Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact. J Infect Dis 2005; 191:2149.

HH

 Case: 33 years old male with no past medical history is admitted to ICU with Diabetes Ketoacidosis (DKA). On examination, he is found to have skin hyperpigmentation and pedal edema. Labs were remarkable for severe transaminitis. Patient reports overuse of elements and vitamins. The presumptive diagnosis of  Hereditary Hemochromatosis (HH) is made on the basis of family history and further lab testing. Out of the following which diagnostic test should be ordered next? (select one)

A) Echocardiogram

B) Liver biopsy

Answer: A

Hereditary Hemochromatosis (HH) is the most common genetic disorder in the world. This is due to the mutations in the HH gene known as HFE. This leads to increased intestinal iron absorption and total-body iron overload. In recent years over ingestion of over-the-counter vitamins became a concern for more symptomatic presentations for these patients.

A liver biopsy is not required for the diagnosis of HH. Estimation by MRI for iron stores can be done in the majority of the patients. Echocardiography should be done as cardiac iron overload may lead to dilated cardiomyopathy, as evident in our patient with pedal edema.

DKA can be a presenting symptom due to pancreatic infiltration.

#endocrinology

#hepatology

#cardiology

#metabolism

References:

1. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 31-1994. A 25-year-old man with the recent onset of diabetes mellitus and congestive heart failure. N Engl J Med 1994; 331:460. 

2. Raju K, Venkataramappa SM. Primary Hemochromatosis Presenting as Type 2 Diabetes Mellitus: A Case Report with Review of Literature. Int J Appl Basic Med Res. 2018;8(1):57-60. doi:10.4103/ijabmr.IJABMR_402_16 

3. Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS; American Association for the Study of Liver Diseases. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology. 2011 Jul;54(1):328-43. doi: 10.1002/hep.24330. PMID: 21452290; PMCID: PMC3149125.

Erythromycin site of action as a motility agent

 Q: Erythromycin is frequently used in ICU as a motility agent. Which part of the stomach it works upon? (select one)

A) cardia

B) fundus

C) body

D) pyloric antrum

E) pyloric canal

Answer: B

Erythromycin is frequently used as a motility agent in ICU as it is a motilin agonist. It works mostly in the stomach as a gastric emptying agent by inducing high-amplitude gastric propulsive contractions. It works mostly at the fundus region which helps in suppressing the fundus' accommodative response after the enteral feed. The lowest starting dose should be used i.e., 40 mg prior to a meal or three times a day to avoid tachyphylaxis which may occur quickly with 250 mg dose three times a day. 

Some institutions follow a proper algorithm for gastroparesis.

#GI

References:

1. Keshavarzian A, Isaac RM. Erythromycin accelerates gastric emptying of indigestible solids and transpyloric migration of the tip of an enteral feeding tube in fasting and fed states. Am J Gastroenterol 1993; 88:193. 

2. Camilleri M. Clinical practice. Diabetic gastroparesis. N Engl J Med 2007; 356:820.

Quinolones side effects

 Q: Name at least five side effects of fluoroquinolone that should be kept in mind for ICU/hospitalized patients? 

Answer:

1. prolong QTc interval which may become fatal with electrolyte abnormalities and concomitant use of other drugs causing QTc prolongation

2. increased risk of aortic aneurysm and dissection - this risk may persist for about eight weeks after use. It should be avoided in elderly patients with such a history or with severe vascular diseases such as Marfan syndrome

3. malregulation of glucose level causing hyper and/or hypoglycemia

4. increased risk of CNS effects including seizures, increased intracranial pressure (pseudotumor cerebri), lightheadedness, and tremors

5. increased risk of peripheral neuropathy - we included this side effect here as this can be irreversible

6. increased risk of psychiatric issues such as toxic psychosis, hallucinations, paranoia, agitation, restlessness, delirium, insomnia, anxiety, memory impairment, confusion, depression, and suicidal thoughts

7. increased risk of tendinopathy in patients on chronic steroid, renal insufficiency or solid organ transplant recipients

#pharmacology

References:

1. Stahlmann R, Lode H. Toxicity of quinolones. Drugs. 1999;58 Suppl 2:37-42. doi: 10.2165/00003495-199958002-00007. PMID: 10553703.

2. Friedrich LV and Dougherty R, “Fatal Hypoglycemia Associated With Levofloxacin,” Pharmacotherapy, 2004, 24(12):1807-12.

3. Khaliq Y and Zhanel GG. Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature. Clin Infect Dis. 2003;36(11):1404-1410

4. Lawrence KR, Adra M, Keir C. Hypoglycemia-Induced Anoxic Brain Injury Possibly Associated With Levofloxacin. J Infect. 2006;52(6):e177-e180.

5. Lee CC, Lee MG, Hsieh R, et al. Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 2018;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067