Monday, December 30, 2013

Complications of IVC filter

If video does not work, try link


Saturday, December 28, 2013

Q: What percentage of patients may develop HIT (Heparin Induced Thrombocytopenia) with Heparin treatment?

Answer:   About 5%

Its about 5.0 percent in patients exposed to heparin for more than four days but only 0.2 percent for those treated with unfractionated heparin for less than four days.

But to note, recently some studies have suggested incidence up to 15%!

1. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106:2710.

2. Smythe MA, Koerber JM, Mattson JC. The incidence of recognized heparin-induced thrombocytopenia in a large, tertiary care teaching hospital. Chest 2007; 131:1644.

3. Oliveira GB, Crespo EM, Becker RC, et al. Incidence and prognostic significance of thrombocytopenia in patients treated with prolonged heparin therapy. Arch Intern Med 2008; 168:94.

Friday, December 27, 2013

Q: To avoid falsely low Anti-XA assay for Heparin/LMWH anticoagulation effect, what is the most optimum time in lab to separate plasma from cellular components?

Answer: To avoid falsely low Anti-XA assay for Heparin/LMWH anticoagulation effect, Plasma must be separated from cellular components within 1 hour. Platelet factor 4, released by platelets, neutralizes the effect of heparin.


Weitz JI. Antithrombotic Drugs. In: Hoffman F, Benz EJ, Shattil SJ, eds. Hematology: Basic Principles and Practice. 5th ed. Philadelpha, PA: Churchill Livingstone; 2009: Chapter 137.

Thursday, December 26, 2013

Q: After how long PTT can be checked if Protamine is given for Heparin reversal?

Answer: About 5 - 15 minutes

It is recommended to check PTT in 6 hours again due to possibility of Heparin rebound phenomenon.

Wednesday, December 25, 2013

Tuesday, December 24, 2013

Q: What is shelf life of Plateletpheresis? 

Answer: 5 days 

Platelets are stored at room temperature with continuous gentle agitation for up to 5 days. So, Platelets are not suppose to be in cooler at bedside while awaiting transfusion. 

Apheresis platelets are collected from an individual donor during a 2-3 hour apheresis procedure and contain about 3 x 1011 platelets (equivalent of 6-8 units of platelet concentrate; a therapeutic dose for an adult).

Monday, December 23, 2013

Q: How much fluid is needed at least to produce clinical symptoms in Pleural effusion? 

Answer: About 300 ml

Usually patient can tolerate mild pleural effusion without having any clinical symptoms.



Sunday, December 22, 2013

Q: 32 year old female is admitted to ICU after cardio-pumonary collapse secondary to Hanta Virus infection. What is the treatment of Hanta Virus Cardio-Pumonary syndrome (HCPS)?

Answer: Supportive - Probable ECMO insertion

Though ribavirin has been suggested in HCPS but has not shown any survival benefit. Research literature is available on use of neutralizing antibodies (passive immunotherapy) for HCPS but so far has not been used much in clinical practice.

Supportive treatment till symptoms resolved.


Mertz GJ, Miedzinski L, Goade D, et al. Placebo-controlled, double-blind trial of intravenous ribavirin for the treatment of hantavirus cardiopulmonary syndrome in North America. Clin Infect Dis. Nov 1 2004;39(9):1307-13.

Bharadwaj M, Nofchissey R, Goade D, Koster F, Hjelle B. Humoral immune responses in the hantavirus cardiopulmonary syndrome. J Infect Dis. Jul 2000;182(1):43-8.

Saturday, December 21, 2013

Q: You are trying to float Pulmonary artery catheter (PAC) in a 64 year old patient with severe right ventricular (RV) enlargement. Despite various attempts, catheter continue to curl in RV. What one trick can help you to get PAC pass from RV into Pulmonary artery (PA)?

Answer: When Right side of the heart is dilated or have high pressures, it is hard to place air-filled balloon at proper position.

Filling the balloon with 1 mL of sterile saline and placing the patient in a more upright position allows gravity to cause the PAC to pass into PA. Once the catheter is in position, aspirate the saline and replace it with air to ensure reproducible Wedge tracings.

Friday, December 20, 2013

Measuring "Wedge" with postive pressure ventilation

"Expiratory holding" approach in measuring end-expiratory pulmonary artery wedge pressure for mechanically ventilated patients.


To accurately measure the end-expiratory pulmonary artery wedge pressure (PAWP) with the "expiration holding" function on the ventilator and the "pulmonary artery wedge pressure review" software on the monitor.


Fifty prospective measurements were made on 12 patients undergoing pulmonary artery catheter and mechanical ventilation. All measurements were divided into <8 mmHg or ≥8 mmHg subgroups according to respiratory variability, and they were then subdivided into either an airway pressure display measurement group (AM group) or an expiration holding (EH) group for comparison.


In all measurements, the two groups showed similar levels of accuracy; however, for the time spent for measurement, the EH group was much faster than the airway pressure display measurement group (P<0.001). Additionally, the EH group was associated with lower medical costs.


The expiration holding approach measured the PAWP more accurately, more quickly, and with reduced costs in comparison to the airway pressure display approach.


Yang W,  Zhao X, Feng Q, An Y, Wei K,  Wang W, Li C, Cheng X - "Expiratory holding" approach in measuring end-expiratory pulmonary artery wedge pressure for mechanically ventilated patients. - Patient Prefer Adherence. -  2013 Oct 8;7:1041-5. doi: 10.2147/PPA.S52122.

Thursday, December 19, 2013

Q: What is Oxygenation Index?


The Oxygenation Index (OI) is defined as the reciprocal of PF times MAP (Mean Airway Pressure)

OI = (FiO2 × mean airway pressure)/PaO2.

It is proposed that OI is a better representative of oxygenation dysfunction as it takes in account mean airway pressure from ventilator. A lower oxygenation index is better. As the oxygenation of a person improves, they will be able to achieve a higher PaO2 at a lower FiO2

Tuesday, December 17, 2013

Q: 54 year old male with HIV admitted to ICU with Respiratory failure. Initial work up showed LDH level of 1200 IU/L. What is your probable diagnosis?

Answer: Histoplasmosis

An LDH level of more than 450 IU/L is 9.33 times more likely to be associated with a diagnosis of histoplasmosis than with PCP. An LDH level of 450 IU/L or greater had a sensitivity and specificity of 70% and 80%, respectively; a value of 600 IU/L or greater had sensitivity and specificity of 50% and 89%.

Thus, serum LDH levels of 600 IU/L or greater are suggestive of histoplasmosis rather than PCP in appropriate clinical settings. 

Butt AA, Michaels S, Greer D, Clark R, Kissinger P, Martin DH (July 2002). "Serum LDH level as a clue to the diagnosis of histoplasmosis". AIDS Read 12 (7): 317–21.

Monday, December 16, 2013

Q: In Hemolytic Anemia, does haptoglobin increase or decrease? (Choose one) 

Answer: Decrease 

Haptoglobin is the protein that in blood plasma, haptoglobin binds free hemoglobin released from erythrocytes with high affinity. The haptoglobin-hemoglobin complex will then be removed by the reticuloendothelial system, mostly in the spleen. 

In intravascular hemolysis, free hemoglobin will be released into circulation and hence haptoglobin will bind the hemoglobin. This causes a decline in haptoglobin levels.

Sunday, December 15, 2013

Q: What are the 3 parameters which can be followed to see the progression/resolution/remission in treatment of TTP (Thrombotic thrombocytopenic purpura)

Answer: Measurements of 

  • LDH, 
  • platelets, and 
  • schistocytes 

Saturday, December 14, 2013


Massive hemorrhage and resuscitation can result in refractory coagulopathy if not aggressively treated. The use of MTPs facilitate rapid availability of components in an increased ratio of plasma and platelets to RBCs. Increased ratios of plasma and platelets to RBCs and their timely administration are thought to improved outcome in trauma, decrease coagulopathy and transfusion requirements based on retrospective data. Large volumes of plasma are required to correct coagulopathy, so early administration is presumably more efficacious. The approach would be different when specific factor concentrates are used. Point of care viscoelastic assays may allow for goal directed therapy in coagulopathy of trauma and massive transfusion including the use of antifibrinolytics when appropriate (although localized fibrinolysis may not be seen on TEG/ROTEM). Single agent therapy such as rFVIIa may have a role in coagulopathic trauma patients but safety is still a concern. A restrictive transfusion strategy should be adopted once hemorrhage is controlled to minimize unnecessary exposure to blood.

MTP practice is still fraught with many unresolved issues such as use of fibrinogen and/or prothrombin complex concentrate and blunt vs penetrating trauma. Understanding the mechanism of hemorrhage is not universal and is different in the obstetrical population as it is in pediatric or cardiovascular patients. This may add to the limitation of universal adoption of a single ratio driven MTP. Well designed, prospective randomized trials are required to determine optimal transfusion ratios and timing of blood component administration.


Friday, December 13, 2013

Red blood cell transfusion: a clinical practice guideline from the AABB (American Association of Blood Banks)


The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).


The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).


The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).


The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

Red blood cell transfusion: a clinical practice guideline from the AABB.
Ann Intern Med. 2012 Jul 3;157(1):49-58. 

Thursday, December 12, 2013

Q: How female gender effects TRALI (Transfusion related acute lung injury)?

Plasma from female donors is associated with an increased risk of TRALI, while RBCs from female donors are not.

Middelburg RA, Van Stein D, Zupanska B, Uhrynowska M, Gajic O, Muñiz-Diaz E, Galvez NN, Silliman CC, Krusius T, Wallis JP, Vandenbroucke JP, Briët E, Van Der Bom JG. - Female donors and transfusion-related acute lung injury: A case-referent study from the International TRALI Unisex Research Group. Transfusion. 2010 Nov;50(11):2447-54.

Wednesday, December 11, 2013

Q: How Lactate Ringer's Solution helps in maintaining more stabilized PH in large volume resuscitation?
The Lactate Ringer's (LR) solution contains 28 mmol/L of Lactate. The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis.

Tuesday, December 10, 2013

Q: What is the rule of thumb for intravenous resuscitation in GI bleed?


Replace each milliliter of blood loss with 3 mL of crystalloid fluid.

Monday, December 9, 2013

Q: Assuming patient has normal renal function, what is a laboratory way to determine that GI bleed is likely to be upper?

If the ratio of blood urea nitrogen to creatinine is greater than 30 the source is more likely from the upper GI tract. 


Srygley FD, Gerardo CJ, Tran T, Fisher DA (March 2012). "Does this patient have a severe upper gastrointestinal bleed?". JAMA 307 (10): 1072–9

Sunday, December 8, 2013

Q: What is the advantage Fosinopril (Monopril) over other ACE-Inhibitors?

Answer:  Unlike other ACE inhibitors which are primarily excreted by the kidneys, fosinopril is eliminated from the body via both renal and hepatic routes. This makes fosinopril little more a drug of safer choice than other ACE inhibitors for heart failure patients with some kidney function impairment. Fosinopril is de-esterified by the liver or by gastrointestinal mucosa and is converted to its active form, fosinoprilat.

Saturday, December 7, 2013

Q: 52 year old male with established diagnosis of Hereditary angioedema is admitted to ICU for unrelated reason. Which one group of anti-hypertensives should be avoided?

Answer:  ACE-Inhibitors
Hereditary angioedema is an autosomal dominantly inherited blood disorder that causes episodic attacks of swelling that may affect the face, extremities, genitals, gastrointestinal tract and upper airways. Hereditary angioedema  is caused by a deficiency of the C1 esterase inhibitor, a protein of the complement system.

Treatment with ACE inhibitors is contraindicated, as it can lead to bradykinin accumulation, which can precipitate disease episodes.

Friday, December 6, 2013

the EDEN randomized trial

Initial trophic vs full enteral feeding in patients with acute lung injury:

the EDEN randomized trial.


The amount of enteral nutrition patients with acute lung injury need is unknown.


To determine if initial lower-volume trophic enteral feeding would increase ventilator-free days and decrease gastrointestinal intolerances compared with initial full enteral feeding.


The EDEN study, a randomized, open-label, multicenter trial conducted from January 2, 2008, through April 12, 2011. Participants were 1000 adults within 48 hours of developing acute lung injury requiring mechanical ventilation whose physicians intended to start enteral nutrition at 44 hospitals in the National Heart, Lung, and Blood Institute ARDS Clinical Trials Network.


Participants were randomized to receive either trophic or full enteral feeding for the first 6 days. After day 6, the care of all patients who were still receiving mechanical ventilation was managed according to the full feeding protocol.


Ventilator-free days to study day 28.


Baseline characteristics were similar between the trophic-feeding (n = 508) and full-feeding (n = 492) groups. The full-feeding group received more enteral calories for the first 6 days, about 1300 kcal/d compared with 400 kcal/d (P < .001). Initial trophic feeding did not increase the number of ventilator-free days (14.9 [95% CI, 13.9 to 15.8] vs 15.0 [95% CI, 14.1 to 15.9]; difference, -0.1 [95% CI, -1.4 to 1.2]; P = .89) or reduce 60-day mortality (23.2% [95% CI, 19.6% to 26.9%] vs 22.2% [95% CI, 18.5% to 25.8%]; difference, 1.0% [95% CI, -4.1% to 6.3%]; P = .77) compared with full feeding. There were no differences in infectious complications between the groups. Despite receiving more prokinetic agents, the full-feeding group experienced more vomiting (2.2% vs 1.7% of patient feeding days; P = .05), elevated gastric residual volumes (4.9% vs 2.2% of feeding days; P < .001), and constipation (3.1% vs 2.1% of feeding days; P = .003). Mean plasma glucose values and average hourly insulin administration were both higher in the full-feeding group over the first 6 days.


In patients with acute lung injury, compared with full enteral feeding, a strategy of initial trophic enteral feeding for up to 6 days did not improve ventilator-free days, 60-day mortality, or infectious complications but was associated with less gastrointestinal intolerance.


Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. -
JAMA. 2012 Feb 22;307(8):795-803. - National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials NetworkRice TWWheeler APThompson BT,Steingrub JHite RDMoss MMorris ADong NRock P.

Thursday, December 5, 2013

Q: What are the less well know risk factors for C.Diff. Colitis in ICU beside previous antibiotics usage, age and severity of illness?
  1. Antacid therapy
  2. Stool softeners
  3. Nasogastric or oro-gastric tubes
  4. Enteral feeds
  5. Cathartics


1. Poutanen SM, Simor AE: Clostridium difficile–associated diarrhea in adults. CMAJ 2004;171:51-58

2. Thielman NM, Wilson KH: Antibiotic-associated colitis -  Mandell GL, Bennett JE, Dolin R (eds): Principles and Practice of Infectious Diseases, 6th ed, vol 1. Philadelphia: Elsevier, 2005, pp 1249-1262.

Wednesday, December 4, 2013

5 Steps of Hand Washing

Very Basic but very important 

  1. Wet hands with water
  2. Apply hand wash (soap)
  3. Lather and wash for AT LEAST 15 seconds
  4. Rinse both sides of hands with water
  5. Dry hands and shut off faucet with towel

Tuesday, December 3, 2013

THAM vs Sodium Bicarbonate in Metabolic acodosis

  • Sodium bicarbonate and THAM have a similar alkalinizing effect in patients with mild metabolic acidosis.
  • Effect of sodium bicarbonate is longer lasting.
  • Sodium bicarbonate decrease serum potassium, but THAM does not.
  • THAM tends to decrease serum sodium  (THAM may be the alkalinizing agent of choice in patients with hypernatremia)
  • Sodium bicarbonate increases PaCO2 and THAM decreases PaCO2.

Monday, December 2, 2013

Q: Which one other chemical is added in IV preparation of Primaxin which may effect acid base balance?

Answer:  Sodium Bicarbonate 

IV Primaxin is actually a combination of imipenem, cilastatin sodium and sodium bicarbonate which is added as a buffer.

Likelihood of having any clinical effect is low though.

Saturday, November 30, 2013

Q: Why commonly use medicine in 'transplant ICUs' may cause acute attack of Gout?

Answer: Tacrolimus (Prograf)

Cyclosporin was one main culprit in transplant patients to cause hyperuricemia and Gout but it has been reported with Tacrolimus too.

Friday, November 29, 2013

Q: Why steroids are not favored as treatment choice in acute pericarditis?

Answer: They increase the chance of recurrent pericarditis.


1. Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation. 2010;121:916–928.

2. Farand P, Belley-Côté ÉP. Give a bigger place for colchicine and a smaller place for corticosteroids in the algorithm for the treatment of acute and recurring pericarditis. MedActuel. 2010;10:1–5.

Thursday, November 28, 2013

Q: What is the basic objective of administrating D-5 dextrose solution peri and post operatively?

Answer: Administering a 5% dextrose solution peri and postoperatively usually provides a good balance between starvation reactions and hyperglycemia caused by sympathetic activation.

Tuesday, November 26, 2013

On Acute Hypernatremia

Interesting case report

Survival of acute hypernatremia due to massive soy sauce ingestion

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.


Carlberg DJ, Borek HA, Syverud SA, Holstege CP. - Survival of acute hypernatremia due to massive soy sauce ingestion. - J Emerg Med. 2013 Aug;45(2):228-31. , Epub 2013 Jun 2.

Monday, November 25, 2013

Q: Why initiation of warfarin is always recommended with Heparin/LMW Heparins, particularly at higher doses?

Answer: Warfarinization (start of warfarin) initially and temporarily may promote clot formation. This is due to the fact that the level of protein C and protein S are also dependent on vitamin K activity. Warfarin causes drop in protein C levels in first 36 hours. Also, reduced levels of protein S lead to a reduction in activity of protein C, for which it is the co-factor. This leads to a prothrombotic state. Thus, when warfarin is loaded at greater than 5 mg per day, it is advisable  to co-administer heparin.
Wittkowsky AK (2005). "Why warfarin and heparin need to overlap when treating acute venous thromboembolism". Dis Mon 51 (2–3): 112–5.

Saturday, November 23, 2013

Q: What are the best places to obtain TCD (Trans Cranial Doppler)?

Answer: The bones of the skull block the transmission of ultrasound, so areas  with thinner walls, called insonation windows get used for procedure. For Most preffered  areas are the temporal region above the cheekbone/zygomatic arch, through the eyes, below the jaw, and from the back of the head.

Thursday, November 21, 2013


The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.

Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.


A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.


Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.


Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.


Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
Marik PE, Flemmer M Harrison W: The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. - Crit Care Med. 2012 Aug;40(8):2479-85.

Wednesday, November 20, 2013

Monday, November 18, 2013

MACOCHA score to determine difficult intubation


Factors related to patient
Mallampati score III or IV
Obstructive apnea syndrome
Reduced mobility of cervical spine
Limited mouth opening <3 cm
Factors related to pathology
Severe hypoxemia (<80%)
Factor related to operator

Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9