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.
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).
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. Read "DIAGNOSIS OF PLEURAL EFFUSION: A SYSTEMATIC APPROACH" - AMERICAN JOURNAL OF CRITICAL CARE, March 2011, Volume 20, No. 2 HERE Link:http://www.aacn.org/wd/cetests/media/a112002.pdf
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
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
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.
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.
"Expiratory holding" approach in measuring end-expiratory
pulmonary artery wedge pressure for mechanically ventilated
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
expiration holding approach measured the PAWP more accurately, more quickly, and
with reduced costs in comparison to the airway pressure display
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:
The Oxygenation Index (OI) is defined as the
reciprocal of PF times MAP (Mean Airway Pressure)
(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
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
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.
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.
SUMMARY of MASSIVE TRANSFUSION PROTOCOL (MTP) for HEMORRHAGIC SHOCK - ASA COMMITTEE on BLOOD MANAGEMENT
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.
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.
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.
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.
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
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.
Initial trophic vs full enteral feeding in patients with acute lung
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.
SETTING, AND PARTICIPANTS:
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
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.
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
Network, Rice TW, Wheeler AP, Thompson BT,Steingrub
J, Hite RD, Moss M, Morris A, Dong N, Rock P.
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.
Q: Out of following
which one may be use as an adjuvant treatment in Thyrotoxic Periodic Paralysis
A) Calcium Channel
B) Non selective Beta Blockers
Answer: B (Non
selective Beta Blockers -propranolol)
In Thyrotoxic Periodic Paralysis (TTP),
propranolol, a nonselective beta-blocker, has shown to prevent the intracellular
shift of potassium and phosphate by blunting the hyperadrenergic stimulation of
Na+/ K+–ATPase. Studies have shown tha propranolol given alone (orally or iv)
normalizes serum potassium levels on an average of 2 hours. It is recommended to
use with main treatment if blood pressure can
1. Shayne P, Hart A. Thyrotoxic periodic
paralysis terminated with intravenous propranolol. Ann Emerg Med.
2. Birkhahn RH, Gaeta TJ, Melniker L.
Thyrotoxic periodic paralysis and intravenous propranolol in the emergency
setting. J Emerg Med. 2000;18(2):199–202.
3. Lin SH, Lin YF. Propanolol rapidly
reverses paralysis, hypokalemia, and hypophosphatemia in thyrotoxic periodic
paralysis. Am J Kidney Dis. 2001;37(3):620–623.
4. Huang TY, Lin SH. Thyrotoxic hypokalemic
periodic paralysis reversed by propranolol without rebound hyperkalemia. Ann
Emerg Med. 2001;37(4):415–416.
5. Yeung RT, Tse TF. Thyrotoxic periodic
paralysis: effect of propranolol. Am J Med. 1974;57(4):584–590.
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.
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.
Q: What is the optimum time of administrating Nimodipine in Subarachnoid Hemorrhage (SAH)?
Answer: In subarachnoid hemorrhage (SAH), nimodipine's is use primarily in the prevention of cerebral vasospasm. It should be started within 4 days of a subarachnoid hemorrhage (SAH) and should be continued for 21 days. Nimodipine is a calcium channel blocker and has selectivity for cerebral vasculature.
Q: What are the best places to
obtain TCD (Trans Cranial Doppler)?
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.
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
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
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
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
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.