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.