necessary to use heparinized saline in pressure bag for arterial line
monitoring? Answer: No Previously, it was a standard to use heparinized saline to use
with pressure bag during arterial line monitoring. But recent guidelines suggest
NOT to use heaprinized saline. Simple saline is equally good for flushing blood and
medications through arterial lines, and it poses minimal risk of causing adverse
drug events like potential HIT (Heparin Induced
1. Eliminate the Use of Heparin Solution with Arterial Lines - ihi.org
recommendations, last update 04/23/2011 2. Whitta RK, Hall KF, Bennetts TM, Welman L, - Comparison of normal or
heparinised saline flushing on function of arterial lines., Crit Care Resusc. 2006 Sep;8(3):205-8.
D-lactate is a byproduct of bacterial metabolism and may
accumulate in patients with short-gut syndrome, and a common finding in patients
with a history of gastric bypass or small-bowel resection. Bacteria metabolized
glucose and carbohydrate to D-lactic acid, which is then systemically absorbed.
D-lactate is only slowly metabolized by human subjects, and accumulate in
patients with short guts. Usually it is clinically a benign
Treatment consists of
Restriction of simple sugars,
Bicarbonate administration if any clinical
Use of metronidazole has been described but it is controversial as
antibiotics can make the syndrome worse by permitting overgrowth of
Q;What are the 3 catheter based
interventions to perform mechanical thrombectomy in massive/submassive pulmonary
embolism? Answer: Broadly
there are 3 categories of percutaneous catheter intervention in pulmonary
Mechanical thrombectomy should be avoided beyond the main and lobar
pulmonary arterial branches. Direct
intra-arterial delivery of thrombolytics, may be helpful if mechanical
thrombectomy is ineffective.
*Rheolytic thrombectomy catheters use a high-velocity saline jet to fragment adjacent thrombus by creating a Venturi effect.
Fava M, Loyola S. Applications of percutaneous mechanical
thrombectomy in pulmonary embolism. Tech Vasc Interv Radiol. 2003; 6: 53–58.
Cho KJ, Dasika NL. Catheter technique for pulmonary embolectomy
or thrombofragmentation. Semin Vasc Surg. 2000; 13: 221–235.
Kucher N, Windecker S, Banz Y, Schmitz-Rode T, Mettler D,
Meier B, Hess OM. Percutaneous catheter thrombectomy device for acute pulmonary
embolism: in vitro and in vivo testing. Radiology. 2005; 236:
Q;Which test would be better in
predicting septic arthritis?
An elevated CRP (C-reactive protein) is helpful in determining the presence of a septic
joint. The ESR and CRP are almost always raised on admission, CRP
being more specific in diagnostics. Both elevated erythrocyte sedimentation rate (ESR) or
C-reactive protein (CRP) is useful in following response to
Reference:Usefulness of CRP and ESR in predicting septic
joints South Med J. 2010 Jun;103(6):522-6.
Tumor lysis syndrome cause
Hypocalcemia. Because of the hyperphosphatemia, calcium is precipitated to form calcium phosphate,
leading to hypocalcemia. Hypocalcemia may lead to tetany, seizures etc.
Patients about to receive chemotherapy for a
cancer with a high cell turnover rate, like lymphomas and leukemias, should
receive prophylactic allopurinol as
well as IV hydration to target urine output > 2.5 L/day. Rasburicase is an
alternative to allopurinol. Alkalization of the urine is controversial and has shown no
Which tumors are more prone to give
negative cytology in malignant pleural effusion?
Generally cytology is positive only in approximately 60 percent of malignant
pleural effusions, but following tumors are more prone to have
Other factors which effects the cytology of
malignant effusion are the tumor burden in the pleural space, amount of pleural
fluid submitted and the expertise of the cytologist.
Usually 10 mL of pleural fluid should be adequate
for cytologic processing.
1. Maskell NA, Butland RJ, Pleural
Diseases Group, Standards of Care Committee, British Thoracic Society. BTS
guidelines for the investigation of a unilateral pleural effusion in
adults. Thorax. 2003;58(suppl
2. Sallach SM, Sallach JA, Vasquez E,
Schultz L, Kvale P. Volume of pleural fluid required for diagnosis of pleural
Septic pulmonary emboli is embolization of intravascular
thrombus containing microorganisms into the lungs. Septic emboli can occur from
varying sources like tricuspid valve
endocarditis, infection elsewhere in the body with
associated septal defect, infected deep venous thrombosis, venous lines /
central venous catheters, pacemaker wires etc.
CT chest, "vessel
sign" is interesting to watch with peripheral
nodules with clearly identifiable feeding vessels. May be visible are -
subpleural nodular lesions or wedge-shaped densities with or without necrosis
caused by septic infarcts.
Q: Which lung
cancer is more prone to produce Syndrome of Inappropriate Antidiuretic Hormone
(SIADH)? Answer: Small cell
lung cancer SIADH is
associated with a number of malignancies but most notably with small-cell
lung cancer. SIADH
can also occur following head injury, following neck dissection and manipulation
of the nervous system, few drugs like morphine, NSAIDs etc and in a number of
other pulmonary processes like pneumonia, abscess, and tuberculosis. It can also
occur with endocrine diseases like hypothyroidism and glucocorticoid
Q: What is
clinical importance of Mayo-Robson point?
A point just above and to the right of the
umbilicus is called Mayo-Robson's point. At this point the tail of pancreas is
projected on the abdominal wall. Here tenderness on pressure exists in diseases
of the pancreas and it is a one clinical sign in acute
Answer: At least 16 gauge and ideally 12-14
As contrary to popular
belief and practice central line is not a large bore or resuscitation
Rapid infusion of volume is based on basic physics of Hagen-Poiseuille
equation. As per Hagen-Poiseuille equation just 2 fold increase in radius
increase flow by 16 fold but 2 fold increase in length decrease flow by 50%.
Technically regularly available central lines (TLC or PICC line)
is not ideal for IVF bolus due to longer length and smaller radius. 2 Large bore
(say 16 gauge) peripheral IVs or one large bore central short IV (cordis) are
real placements for aggressive resuscitation (due to bigger radius and shorter
Point is: Central line or two 18 G
peripherals should not be labeled as large bore IVs.
Q: 17 year old
male is admitted with bloody diarrhea and vomiting. Patient visited petting zoo
3 days ago with his friend. Now patient is hypotensive, no urine out put and
altered mental status. Probable diagnosis?
Hemolytic Uremic syndrome (HUS) should be high on list with
bloody diarrhea after visit to petting zoo. Other risk factors include
contamination viahamburger or
contact to infected person.
The GI symptoms usually starts after 4-6 days. Diarrhea
typically become hemorrhagic and may quickly set into septic shock.
usually not required, actually discouraged. Minor cases can be treated with
supportive treatment but in cases like above plasma exchange (plasmapheresis combined
with fresh-frozen plasma replacement) is currently the treatment of
Q:Ideally, mature Arterio-Venous
Fistula (AVF) for hemodialysis should have which basic
mature AVF should have the following characteristics to be safely punctured:
discernible vein margins,
greater than 600 mL/min,
diameter at least 0.6 cm and
should be located no more than 0.6 cm deep
Y. C. Kim, J. Y. Won, S. Y.
Choi, H. K. Ko, K. H. Lee, Y. do Lee, B. C. Kang, S. J. Kim, 2009 Percutaneous
treatment of central venous stenosis in hemodialysis patients: long-term
outcomes. Cardiovasc Intervent Radiol 32 2 271 278
Q: 54 year old
male who is POD # 22 heart transplant is found to have symptomatic bradycardia
with heart rate of 24. Resident administered 3 mg of Atropine without any
effect. Your explanation?
Atropine is ineffective and should be avoided in heart transplant
patients. The vagus nerve is not retransplanted after transplant and so
Atropine would be useless in symptomatic bradycardia.
The transplanted heart is able to function in its new host through
the capacity of its intact, intrinsic nervous system.The heart's nervous system
contains around 40,000 neurons, called sensory neurites, which detect
circulating hormones and neurochemicals and sense heart rate and pressure
information. Hormonal, chemical, rate and pressure information is translated
into neurological impulses by the heart's nervous system and sent from the heart
to the medulla in brain through several afferent pathways. The signals have a
regulatory role over many of the autonomic nervous system signals that flow out
of the brain to the heart, blood vessels and other glands and
Murphy D A, Thompson G W, et al (2000), The heart reinnervates after
transplantation. Annals of Thoracic Surgery; 69(6):
Q:36 year old female is in ICU with septic shock and diagnosed with strongyloidiasis. She also has severe GI ileus and was made NPO . She is on ivermectin. What is your option to administer her essential treatment?
Answer: Rectal or SC administration of Ivermectin Ivermectin is the drug of choice for strongyloidiasis. It is usually given as PO with empty stomach but if PO route is note feasible, it can be given rectally or even as SC administration. Fusco DN, Downs JA, Satlin MJ, Pahuja M, Ramos L, Barie PS, et al. Non-oral treatment with ivermectin for disseminated strongyloidiasis. Am J Trop Med Hyg. Oct 2010;83(4):879-83
Botulinum toxin is destroyed by proper
thorough cooking but the spore itself is not killed by the temperatures at
normal boiling. Spores may grow again when conditions are right. All
commercially canned goods are required to undergo a "botulinum cook" in a
pressure cooker at 121 °C(250 °F) for 3 minutes, which most likely will kill
important thing to remember besides history taking is - paralysis is usually in
descending fashion, starting from cranial nerves downward towards arms and legs.
It also may effect respiratory muscles. Initial symptoms are double vision,
drooping of both eyelids, loss of facial expression, swallowing and speech
problems. The weakness then spreads - starting in the shoulders and proceeding
to the forearms - and again - from the thighs down to the
Q: 28 year old male, who just returned from Bangladesh 2 days ago presented to ED with vomiting, painless but profuse "rice water" type diarrhea - almost 20 liter/day! which smells like fish. On examination patient skin seems turning a bluish-gray hue. Your concern?
The hallmark of cholera is profuse, painless diarrhea and vomiting of clear fluid. Clinical symptoms starts from few hours upto five days after ingestion of the bacteria. The diarrhea is clasically described as "rice water" with fishy odor. Patient may produce 10 to 20 litres of diarrhea a day. Cholera has been nicknamed the "blue death" due to a patient's skin turning a bluish-gray hue from massive dehydration.
Doxycycline is the first line of agent for treatment, followed by cotrimoxazole, erythromycin, tetracycline, chloramphenicol,andfurazolidone. Fluoroquinolones, such asnorfloxacin, also may be used.
Captopril though not much in use in USA is a well known and frequently used ACE inhibitor in many developing countries, due to its availability in generic form and cost effectiveness.
Taste disturbances which is infrequent with most ACE inhibitors, are more prevalent in captopril. This is attributed to its sulfhydryl moiety. Altered taste sensation may include loss of taste perception, persistent salt taste or persistent metallic taste.
Fenoldopam is an antihypertensive
agent, which acts as a selective D1 receptor partial
Fenoldopam's concomitant use with a beta-blocker
should be avoided if possible. Unexpected hypotension can result from
beta-blocker inhibition of sympathetic-mediated reflex tachycardia in response
Cocaine overdose causes tachyarrhythmias and life-threatening hypertensive crisis. Moreover, Cocaine is very pyrogenic due to increased muscular activity and inhibited heat loss due to severe vasoconstriction.
Treatment of Cocaine overdose consists of administering a benzodiazepine, physical cooling, acetaminophen, non-beta-blocker treatment for hypertension and other supportive treatments.
Though not officially approved, dexmedetomidine and rimcazole have been found to be useful for treating cocaine overdose.
Rimcazole is an antagonist of the sigma receptor as well as is a dopamine reuptake inhibitor. Sigma receptors are thought to be involved in the psychosis that can be induced by some drugs such as PCP and cocaine. Rimcazole was originally researched as a potential antipsychotic but found to reduce the effects of cocaine.
1. Katz JL, Libby TA, Kopajtic T, Husbands SM, Newman AH. Behavioral effects of rimcazole analogues alone and in combination with cocaine. European Journal of Pharmacology. 2003 May 9;468(2):109-19.
2. Matsumoto RR, Hewett KL, Pouw B, Bowen WD, Husbands SM, Cao JJ, Hauck Newman A. Rimcazole analogs attenuate the convulsive effects of cocaine: correlation with binding to sigma receptors rather than dopamine transporters. Neuropharmacology. 2001 Dec;41(7):878-86.