Q: What are the absolute and relative contraindications to Extracorporeal membrane oxygenation (ECMO) in Patients with ARDS?

Answer:

Absolute contraindications to ECMO include:

• Ongoing terminal disease that will not resolve or stabilize,
• contraindication to anticoagulation,
• intracranial hemorrhage,
• refusal to receive blood products

Relative contraindications to ECMO (due to historically poor survival rates): 

• Mechanical ventilatory support for more than 10 days and high pressure mechanical ventilatory support for more than 7 days

Extracorporeal membrane oxygenation (ECMO) in Patients with ARDS - Pauline K. Park M.D., James M. Blum M.D., Lena M. Napolitano, M.D., Gail Annich, M.D., Jonathan W. Haft, M.D., and Robert H. Bartlett, M.D. - University of Michigan Health System -http://www.thoracic.org/clinical/critical-care/refractory-ards/pages/ecmo.php

Q: How do you write the drip of soda bicarbonate in preventing contrast induced nephropathy ?


A: Use 154meq/L of sodium bicarbonate (3 amps) in 1 litre of D5W.

Give 3ml/kg/hr one hr prior to the exam.
Give 1ml/kg/hr during the exam and for 6 hours after the exam.

Happy Thanksgiving

Q: What is Diabetes innocence?

Answer: Diabetes innocence also known as renal glucosuria, is a condition in which the simple sugar glucose is excreted in the urine, despite normal or low blood glucose levels. This is due to improper functioning of the renal tubules. In most affected individuals, it is asymptomatic. Condition is thought to be inherited as an autosomal recessive trait.

Q: In Salicylate toxicity what is the target of Urine PH?


Answer: 8


Renal elimination of salicylate can be achieved by alkaline diuresis to increase urine pH, ideally to more than/= 8. Alkaline diuresis is indicated for patients with any symptoms of poisoning and should not be delayed until salicylate levels are determined. This intervention is safe and exponentially increases salicylate excretion. Because hypokalemia may interfere with alkaline diuresis, patients are given a solution consisting of 1 L of 5% D/W, with 3 (50-mEq) ampules of NaHCO3, and 40 mEq of KCl. Serum K should be monitored closely.

Fecal Bacteriotherapy for the Treatment of Recurrent Clostridium Difficile Infection in Adults

We found following thorough work on above topic on internet from  Julie L. Cramer as a Clinical Graduate Project Submitted to the Faculty of the School of Physician Assistant Studies, Pacific University, Hillsboro, OR for the Masters of Science Degree program.

Fecal Bacteriotherapy for the Treatment of Recurrent Clostridium Difficile Infection in Adults

The Impella cardiac device

On Takotsubo Cardiomyopathy

Females are seven to nine times more likely to suffer "broken heart syndrome," when sudden or prolonged stress like an emotional breakup or death causes overwhelming heart failure or heart attack-like symptoms, the first nationwide study of this finds. Usually patients recover with no lasting damage.....

Japanese doctors first recognized this syndrome around 1990 and named it Takotsubo cardiomyopathy; tako tsubo are octopus traps that resemble the unusual pot-like shape of the stricken heart.

It happens when a big shock, even a good one like winning the lottery, triggers a rush of adrenaline and other stress hormones that cause the heart's main pumping chamber (Left ventricle).

Dr. Abhishek Deshmukh of the University of Arkansas reported study results Wednesday at an American Heart Association conference in Florida. Using a federal database with about 1,000 hospitals, Dr. Deshmukh found 6,229 cases in 2007. Only 671 involved men. After adjusting for high blood pressure, smoking and other factors that can affect heart problems, women seemed 7.5 times more likely to suffer the syndrome than men. It was three times more common in women over 55 than in younger women. And women younger than 55 were 9.5 times more likely to suffer it than men of that age....

One theory is that hormones play a role. Another is that men have more adrenaline receptors on cells in their hearts than women do, "so maybe men are able to handle stress better" and the chemical surge it releases, Deshmukh said.

About 1 percent of such cases prove fatal, the new study shows. About 10 percent of victims will have a second episode sometime in their lives. And although heart attacks happen more in winter, broken heart syndrome is more common in summer.

Full report here

Previous related pearl here

Angioplasty without surgical backup


"Balloon angioplasty, has become so safe that surgical backup is no longer needed when treating low-risk, simple cases." Study leader Dr. Thomas Aversano of Johns Hopkins University presented results Monday at an American Heart Association conference in Florida.

The study was the first large experiment to see if doing it without surgical backup was safe. About 4,500 were given angioplasty at hospitals that had heart surgeons available, and 14,000 others had it at facilities without one. Hospitals without heart surgeons on duty had to complete special training to make sure experienced doctors were doing the angioplasty procedures. And patients were carefully selected to avoid especially troublesome types of blockages.

Six weeks after angioplasties were done, success rates, complications and deaths did not differ between the two groups of patients. Emergency surgery was needed in only 30 cases - patients were transferred to hospitals with that capacity if the one treating them lacked it.


Full report here

Q: Abdomen can hold upto how much  of Ascitic fluid?


Answer: 25 Litre

Abdomen can hold 25 Litre of Ascitic fluid but care should be taken to avoid large volume paracentesis

Ultrasound Guidance for Paracentesis

Q: Which finding in CBC is highly suggestive of Adrenal crisis? (Select one)


A) Neutrophilia
B) Eosinophilia
C) Thrombocytopenia
D) Neutropenia
E) Polycythemia


Ans: Eosinophilia


Hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia may be present along with anemia and lymphocytosis, but eosinophilia with above serum chemistry findings is highly suggestive of Adrenal Crisis.

Q: 32 year old male preparing for London 2012 summer olympics in "Competitive Weightlifting" - complained of severe chest pain during training session which was radiating to back. What could be your first concern?



Answer: Aortic Dissection

There are increasing evidence that weight lifting related acute aortic dissection is a real phenomenon. Routine  screening echocardiography is recommended in such sports competition. Person with known aortic dilatation should be advised against weight lifting.


Weight lifting and aortic dissection: more evidence for a connection - Cardiology. 2007;107(2):103-6.

Q: What is the disadvantage of using steroids in Acute Pericarditis?


Answer: Steroids increases the chance of recurrent pericarditis. Colchicine is a very effective treatment. If Aspirin and NSAIDs are not sufficient, colchicine should be added to the regimen.

Corticosteroids for Recurrent PericarditisHigh Versus Low Doses: A Nonrandomized Observation - Circulation. 2008; 118: 667-671 Published oline before print July 21, 2008

Q: Which vitamin deficiency may cause life threatening lactic acidosis?



Answer: Thiamine (Vitamin B1) deficiency

Thiamine is part of the pyruvate-dehydrogenase (PDH) complex. Its deficiency inhibits pyruvate entry into mitochondria.

Clinical implication: It is important to add Thiamine on patients requring long term parentral nutrition (TPN)


Reference: Click to get references

1. Thiamine deficiency as a cause of life threatening lactic acidosis in total parenteral nutrition - Klin Wochenschr. 1991;69 Suppl 26:193-5.

2. Metabolic acidosis and thiamine deficiency - Mayo clinic Proceedings, March 1999 vol. 74 no. 3 259-263

3. Severe Lactic Acidosis Related to Acute Thiamine Deficiency - Journal of Parenteral and Enteral Nutrition, Vol. 15, No. 1, 105-109 (1991)

A note on Megace (Megestrol) and Adrenal insufficiency

Megestrol can induce alterations of the pituitary-adrenal axis in some patients. It is important to consider a diagnosis of adrenal insufficiency in patients with symptoms of fatigue, hypotension, and asthenia who have been treated with megestrol. Patients who require more than 12 weeks of treatment should have their morning free cortisol levels checked at 12 weeks and biweekly thereafter.

Megestrol acetate in cachexia and anorexia - Int J Nanomedicine. 2006 December; 1(4): 411–416. Published online 2006 December

Q: Fomepizole and ethanol are both use as treatment in Ethylene Glycol toxicity. What other medicines should be considered as adjuvant therapy in Ethylene Glycol toxicity?

Answer: Pyridoxine and Thiamine Pyridoxine (Vitamin B6) and Thiamine are cofactors in ethylene glycol metabolism and may be administered parenterally. On side note, while preparing antidotes early treatment with sodium bicarbonate should be initiated essential to correct acidosis. It may require upto 500-1000 mmol of bicarbonate within the first hours, especially if antidotal therapy is delayed.

Q: Caspofungin may cause which electrolyte abnormality?

Answer: Hypokalemia

Beside increase liver enzymes, other rare but life threatening side effects reported so far includes severe thrombophlebitis (require a greater dilution and infusion over an extended period) and severe hypokalemia, with serum potassium levels as low as 1.7 mg/dl.

Experience with Caspofungin in the Treatment of Persistent Fungemia in Neonates - Journal of Perinatology (2005) 25, 770–777; published online 13 October 2005

Holiday Heart Syndome

Holiday Heart Syndome was originally defined as "arrhythmias of the heart, sometimes apparent after a vacation or weekend away from work, following excessive alcohol consumption; usually transient". Same has been reported with recreational use of marijuana. The most common rhythm disorder is atrial fibrillation, which usually converts to normal sinus rhythm within 24 hours. It occurs in patients without structural heart disease and its clinical course is usually benign. Even modest alcohol intake may trigger paroxysmal atrial fibrillation.

Most patients with no evidence of structural heart disease can be discharged without further treatment once arrhythmia has stabilized with advise against the excessive use of alcohol. Patients with sustained tachyarrhythmia require treatment if the ventricular rate is excessive. Patients with structural heart disease needs further workup