Friday, May 31, 2019

LVAD thrombosis

Q: 58 year old male with Left Ventricular Assist Device (LVAD) is admitted to ICU with syncope and shortness of breath (SOB). Cardiology team suspects sub-optimal anti-coagulation, and thrombosis is suspected. All of the following can be clinical or laboratory markers in this patient except?

A) reddish-brown urine
B) increase creatinine
C) elevated serum LDH
D) increased serum haptoglobin
E) increased free plasma hemoglobin

Answer: D

The risk of thrombosis in continuous LVADs is one of the most major concern and all of these patients require adequate anticoagulation. Obstruction of the pump can be potentially fatal. In such patient, interventions are required on an emergent basis. Some of the parameters to confirm pump thrombosis are presence of reddish-brown urine, worsening renal function,  elevated serum LDH, decrease serum haptoglobin and increase free plasma hemoglobin.




Starling RC, Moazami N, Silvestry SC, et al. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370:33.

Thursday, May 30, 2019

SCD crisis

Q: The gold standard for assessment of pain in a patient with acute exacerbation of vaso-occlusive crisis in sickle cell disease (SCD) is?

A) patient's report of his change in pain level
B) Clinician's assessment on physical exam
C) absence of hemolysis
D) stability of the hemoglobin level

Answer: A

The gold standard for assessment of pain in a patient with acute exacerbation of vaso-occlusive crisis in sickle cell disease (SCD) is patient's own description of his change in pain level. Patient's with SCD disease are found to be reliable in reporting either change in intensity or change of location of pain from their previous baseline. This precedes before any clinical or laboratory finding.




2. Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA 2014; 312:1033.

Wednesday, May 29, 2019


Q: 34 year old male recent immigrant from China is admitted via ED to ICU where he presented with massive epistaxis without any provocation. Emergent Ear-Nose-Throat service was obtained in ER to control the hemorrhage. What is the underlying concern?

Answer; Nasopharyngeal cancers

 Epistaxis can be either from anterior or posterior vessels. Anterior nosebleeds are the most common and usually benign. Posterior nose-bleeds can be potentially life-threatening, and be a sign of major clinical disease like carotid artery aneurysm or neoplasm.

Nasopharyngeal cancers are common in patients of Chinese origin and can result in massive bleeding.



1. Liu JK, Gottfried ON, Amini A, Couldwell WT. Aneurysms of the petrous internal carotid artery: anatomy, origins, and treatment. Neurosurg Focus 2004; 17:E13. 

2. Chen D, Concus AP, Halbach VV, Cheung SW. Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy. Laryngoscope 1998; 108:326. 

3. CHENG HER. Nasopharyngeal Cancer and the Southeast Asian Patient Am Fam Physician. 2001 May 1;63(9):1776-1783.

Tuesday, May 28, 2019

Oxygen effect

Q:Administration of supplemental Oxygen has an anxiolytic effect? (select one) 

A) True
B) False

Answer: A

The administration of supplemental oxygen is found to have an anxiolytic as well as an anti-dyspneic effect besides promoting sleep. This positive effect may also carry some negative effect. As patient feels more relaxed and get sleeping, progressive hypercarbia may ensue particularly in patients with underlying COPD via Haldane effect.



Malhotra A, Schwartz DR, Ayas N, et al. Treatment of oxygen-induced hypercapnia. Lancet 2001; 357:884. 

Orem J. The nature of the wakefulness stimulus for breathing. Prog Clin Biol Res 1990; 345:23.

Monday, May 27, 2019

Hyperemesis Gravidarum

Q: 28 years old female with 12 weeks of pregnancy is admitted to ICU with hypotension and severe hypovolemia secondary to hyperemesis gravidarum. Which of the following is considered as the first line of treatment in hyperemesis gravidarum? 

A) metoclopramide
B) prochlorperazine
C) promethazine
D) droperidol
E) dexamethasone 

Answer: C

Experts have tried to find the best approach for a wide range of nausea stimulators depending on neurotransmitters. Unfortunately, so far no specific neurotransmitter can be identified for pregnancy-related severe nausea. But promethazine is found to be most effective and considered as the first line of treatment in hyperemesis gravidarum. Serotonin antagonists and corticosteroids are considered as second-line agents. Interestingly, the use of ginger and vitamin B6 is also found to be effective.




Flake ZA, Scalley RD, Bailey AG. Practical selection of antiemetics. Am Fam Physician 2004; 69:1169.

Sunday, May 26, 2019

Hypercapnia effects

Q: Permissive hypercapnia tends to induce? (select one) 

A) Vasoconstriction 

B) vasodilation

Answer: B

Despite augmentation of sympathomimetic output permissive hypercapnia tends to induce systemic vasodilation, particularly in hypovolemic patients. To maintain adequate hemodynamic, permissive hypercapnia may require both beta blocker to counter tachycardia and adequate volume replacement to counter vasodilation.



1. Kavanagh BP, Laffey JG. Hypercapnia: permissive and therapeutic. Minerva Anestesiol 2006; 72:567. 

2. Nahurn, A, Marini, JJ. Alternatives to conventional mechanical ventilation in acute respiratory failure. Curr Pulmonol 1994; 15:157.

Saturday, May 25, 2019

Septic arthritis

Q: Septic Arthritis most commonly occurs via? (select one) 

 A) hematogenous seeding 
 B) direct inoculation 
 C) extension of infection

Answer: A

The cause of hematogenous seeding for septic arthritis is most common particularly if bacteremia occurs with Staphylococcus aureus which has a high propensity to adhere to the synovial tissues. The synovial membrane does not carry any limiting basement membrane and thus has a very high risk to acquire infection. This piece of knowledge becomes extremely important in patients with blood cultures positive for Staphylococcus aureus, though other organisms can also cause septic arthritis. Clinical exam in such instances is essential.

Direct inoculation via bites, trauma, post-surgery,  procedures like arthroscopy, and unsterile intra-articular injection is also common.

Extension of infections from osteomyelitis or diverticulitis may occur due to the dissection of infection into the adjacent joints. In ICU, line infections may extend into joints, particularly after subclavian and femoral line insertions.



1. Goldenberg DL. Septic arthritis and other infections of rheumatologic significance. Rheum Dis Clin North Am 1991; 17:149. 

2. Mader JT, Shirtliff M, Calhoun JH. The host and the skeletal infection: classification and pathogenesis of acute bacterial bone and joint sepsis. Baillieres Best Pract Res Clin Rheumatol 1999; 13:1. 

3. Balato G, Di Donato SL, Ascione T, et al. Knee Septic Arthritis after Arthroscopy: Incidence, Risk Factors, Functional Outcome, and Infection Eradication Rate. Joints 2017; 5:107. 

4. Aglas F, Gretler J, Rainer F, Krejs GJ. Sternoclavicular septic arthritis: a rare but serious complication of subclavian venous catheterization. Clin Rheumatol 1994; 13:507. 

5. Fromm SE, Toohey JS. Septic arthritis of the hip in an adult following repeated femoral venipuncture. Orthopedics 1996; 19:1047. 

6. Messieh M, Turner R, Bunch F, Camer S. Hip sepsis from retroperitoneal rupture of diverticular disease. Orthop Rev 1993; 22:597.

Friday, May 24, 2019

Sports hematology

Q: By default, athletes are supposed to have some degree of? (select one) 

 A) anemia 
 B) polycythemia

Answer: A

Contrary to popular belief, athletes are relatively prone to be anemic when compared with the same segment of general healthy non-athlete adults, unless they are abusing performance-enhancing agents. Some of the reasons behind this paradox is increased plasma volume in athletes causing dilutional anemia, exercise-induced inflammatory cytokines, and intravascular hemolysis, popularly known as "march" hemoglobinuria. Also, athletes are at higher risk of gastrointestinal bleeding and iron deficiency anemia.



1. Dufaux B, Hoederath A, Streitberger I, et al. Serum ferritin, transferrin, haptoglobin, and iron in middle- and long-distance runners, elite rowers, and professional racing cyclists. Int J Sports Med 1981; 2:43. 

2. Shaskey DJ, Green GA. Sports haematology. Sports Med 2000; 29:27. 

3.  Rudzki SJ, Hazard H, Collinson D. Gastrointestinal blood loss in triathletes: it's etiology and relationship to sports anaemia. Aust J Sci Med Sport 1995; 27:3. 

4. Selby GB, Eichner ER. Endurance swimming, intravascular hemolysis, anemia, and iron depletion. New perspective on athlete's anemia. Am J Med 1986; 81:791. 

5. Sawka MN, Convertino VA, Eichner ER, et al. Blood volume: importance and adaptations to exercise training, environmental stresses, and trauma/sickness. Med Sci Sports Exerc 2000; 32:332.

6. Peeling P, Dawson B, Goodman C, et al. Athletic induced iron deficiency: new insights into the role of inflammation, cytokines and hormones. Eur J Appl Physiol 2008; 103:381.

Thursday, May 23, 2019

anticoagulation in pregnancy

Q: 28 year old female with 20 weeks pregnancy is admitted to ICU with pulmonary embolism. Patient developed Heparin Induced Thrombocytopenia (HIT) with heparin infusion and was switched to bivalirudin. Patient can be transitioned to which of the following with relative safety?

A) Subcutaneous (SQ) full dose enoxaparin
B) Warfarin
C) Dabigatran 
D) Apixaban 
E) Subcutaneous (SQ) fondaparinux

Answer: E

Objective of the above question is to highlight the point that fast getting popular direct oral anticoagulants (DOACs) i.e. dabigatran, apixaban, edoxaban, or rivaroxaban are not safe in pregnancy or breastfeeding.  (Choices C and D)

Warfarin is well known to be avoided in pregnancy. (Choice B)

Once the suspicion or diagnosis of HIT is made, any kind of heparin should be avoided like enoxaprin. (Choice A)

Fondaparinux is a synthesized version of the active pentasaccharide subunit of heparin, with the property of no interaction with platelet factor 4, and can be used safely in pregnancy and HIT. (Choice E)



1. Wijesiriwardana A, Lees DA, Lush C. Fondaparinux as anticoagulant in a pregnant woman with heparin allergy. Blood Coagul Fibrinolysis 2006; 17:147–149. 

2.  Lameijer H, Aalberts JJJ, van Veldhuisen DJ, Meijer K, Pieper PG. Efficacy and safety of direct oral anticoagulants during pregnancy; a systematic literature review. Thromb Res. 2018 Sep;169:123-127.

Wednesday, May 22, 2019

Status Epilepticus

Q: Convulsive status epilepticus is defined as a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms that lead to abnormally prolonged seizures. The temporal threshold for this duration is?

A) 5 minutes
B) 10 minutes
C) 20 minutes
D) 30 minutes
E) no time period is specified

Answer: A

The definition suggested by The International League Against Epilepsy (ILAE) for status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms that lead to abnormally prolonged seizures. The temporal threshold of duration

  • for convulsive status epilepticus is 5 minutes, and 
  • for non-convulsive status epilepticus is 10 minute



1. Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia 2015; 56:1515.

Tuesday, May 21, 2019

Ribavirin and pregnancy

Q: 43 year old male with a recent history of hematopoietic cell transplant is getting transferred out of ICU. He was treated with oral ribavirin while in ICU for his respiratory tract infection. What advise you will give to him and his wife?

Answer: Inhaled and oral Ribavirin has shown some efficacy in patients with hematopoietic cell transplant who develop respiratory infections with respiratory syncytial virus (RSV).

Ribavirin is teratogenic and has a long half life. In childbearing age female patients, a negative pregnancy test is mandatory before prescribing ribavirin. It is also recommended to avoid Ribavirin in male patients whose partners are pregnant. And, if a man receives oral ribavirin, his female partner should avoid pregnancy for at least six months after the completion of the treatment.




Rebetol (ribivarin) 

Monday, May 20, 2019

LA in ethylene glycol poisoning

Q: The major reason for lactic acidosis in ethylene glycol poisoning is? (select one) 

A) laboratory error 
B) Impaired mitochondrial function

Answer: A

It is true that patients with ethylene glycol poisoning have some portion of lactic acidosis from true tissue ischemia (Type A Lactic acidosis) but most reported high lactate in ethylene glycol poisoning is due to the fact that many counters/devices in the laboratory cannot distinguish lactate from glycolate, which is structurally similar to lactate and a metabolite of ethylene glycol.




Pernet P, Bénéteau-Burnat B, Vaubourdolle M, et al. False elevation of blood lactate reveals ethylene glycol poisoning. Am J Emerg Med 2009; 27:132.e1.

Sunday, May 19, 2019

ACE-I cough

Q: 53 year old male was admitted to ICU with hypertensive crisis. Patient is now improved and transitioning to oral anti-hypertensive. Patient develop refractory cough from Angiotensin Converting Enzyme inhibitors (ACE-I). All of the following are the treatment of ACE-I induced cough except?

A) theophylline
B) inhaled sodium cromoglycate
C) picotamide
D) withdrawal of the ACE inhibitor
E)  acetylsalicylic acid (ASA) / Aspirin

Answer: E

The most effective treatment of ACE-I induced cough is the withdrawal of drug but in case if it can not be done, there are few drugs which may help to curtail the intensity and frequency of cough like theophylline, inhaled sodium cromoglycate, and picotamide which is a thromboxane antagonist. This clinical pearl becomes important as cough from ACE-I may persists up to three months even if ACE-I is withdrawn. 

Aspirin is known to induce cough 5.



1. Cazzola M, Matera MG, Liccardi G, et al. Theophylline in the inhibition of angiotensin-converting enzyme inhibitor-induced cough. Respiration 1993; 60:212. 

2. Hargreaves MR, Benson MK. Inhaled sodium cromoglycate in angiotensin-converting enzyme inhibitor cough. Lancet 1995; 345:13. 

3. Malini PL, Strocchi E, Zanardi M, et al. Thromboxane antagonism and cough induced by angiotensin-converting-enzyme inhibitor. Lancet 1997; 350:15. 

4. Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:169S. 

5. Cottin V, Cordier JF. Iatrogenic drug-induced bronchospasm, cough, and bronchiolitis. Etiologic and physiopathologic aspects - Rev Mal Respir. 1996;13(4):339-60.

Saturday, May 18, 2019


Q: All of the following have been described as medical treatments of Achalasia except?

A) nitrates
B)  sildenafil
C) terbutaline
D) theophylline 
E) Potassium chloride tablets

Answer: E

Achalasia is mostly a surgical disease or requires an invasive intervention like botox. Medical therapy is considered only as second-line therapy for patients who are not a candidate for invasive interventions.

Administrating short-acting nitrates 10 minutes prior to a meal helps in relaxing the smooth muscle of the Lower Esophageal Sphincter (LES) and improves the symptoms of achalasia (choice A)

5-phosphodiesterase inhibitors (choice B), anticholinergics, beta-adrenergic agonists (choice C), and theophylline (choice D) have been suggested as treatments of achalasia.

Potassium chloride tablets are usually very big in size and are known to directly damage the esophageal wall, and should be ideally avoided in achalasia.




1. Wen ZH, Gardener E, Wang YP. Nitrates for achalasia. Cochrane Database Syst Rev 2004; :CD002299. 

2. Kahrilas PJ, Pandolfino JE. Treatments for achalasia in 2017: how to choose among them. Curr Opin Gastroenterol 2017; 33:270. 

3. Bassotti G, Annese V. Review article: pharmacological options in achalasia. Aliment Pharmacol Ther 1999; 13:1391.

Friday, May 17, 2019

Rapid acting insulin in DKA

Q: Use of rapid-acting insulin analog instead of regular insulin improves outcome in Diabetic Ketoacidosis (DKA)? (select one)

A) True
B) False

Answer: B

Rapid-acting insulins which include Aspart, Glulisine and Lyspro is used in insulin pumps as continuous subcutaneous insulin infusion. It was proposed that they may improve outcome in DKA if used intravenously instead of regular insulin, but clinical studies failed to show any benefit.



Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care 2009; 32:1164.

Thursday, May 16, 2019


Q: What is Solvent/detergent-treated plasma (SD-plasma)?

Answer:  Solvent/detergent-treated plasma (SD-plasma) is a processed plasma with solvents. Its main utility is to reduce the risk of transmission of enveloped viruses i.e. human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). 

When FFP is processed with solvent it not only dilutes and neutralizes the antibodies present in the plasma pool but also lowers the antibody against blood cells and plasma proteins.



Hellstern P. Fresh-frozen plasma, pathogen-reduced single-donor plasma or bio-pharmaceutical plasma? Transfus Apher Sci. 2008;39:69–74.

Wednesday, May 15, 2019


Q: The cutoff point to hold copper and manganese in total parenteral nutrition (TPN) in ICU patients with cholestasis is? 

 A) total bilirubin of 2 
 B) total bilirubin of 3 
C) total bilirubin of 4 
D) total bilirubin of 5 
E) It depends on liver transaminases

Answer: A

A large number of patients in ICU receive TPN, but 'one size does not fit all'. It is frequently required to alter the prescription of TPN depending on underlying clinical situations and labs. Copper and manganese get excreted via bile. They should be held off in patients where suspicion of cholestasis arises. Total bilirubin (TB) of 2 mg/dl is considered a cut off for this purpose.




Jin J, Mulesa L, Carrilero Rouillet M. Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician. Nutrients. 2017;9(5):440. Published 2017 Apr 28. doi:10.3390/nu9050440

Tuesday, May 14, 2019


Q: A pneumothorax (PTX) can be best identified on which position of chest X-ray? (select one) 

A) upright 
B) supine 
C) lateral decubitus

Answer: C

In a lateral decubitus view, most pleural air accumulates in the non-dependent lateral location. This is the most sensitive way of demonstrating PTX as even 5 mL of pleural air can be visible.

The second most sensitive is an upright position as it requires only 50 mL of air to demonstrate the PTX, and the least sensitive is the supine position which requires 500 mL of air to demonstrate PTX.



 1. Carr JJ, Reed JC, Choplin RH, et al. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193.

Monday, May 13, 2019

succussion splash

Q: How succussion splash (SS) can be demonstrated during the physical exam of a patient? 

Answer: Succussion splash can be elicited by placing the stethoscope over body area suspected of gas and fluid retention and rocking the patient back and forth vigorously. 

Demonstration of abdominal succussion splash is well known in Gastric Outlet Obstruction. It is due to the presence of gas and fluid in an obstructed stomach and indicates retained gastric contents for more than three hours after a meal. In abdominal SS, a patient is rocked by holding both hips. 

A less well-known and interesting demonstration of succession splash can be done in patients with achalasia or even hydropneumothorax. This is called thoracic succussion splash: a new symptom and sign of achalasia. A patient may himself described such sound with activities like jogging or bending. It can be heard both over the anterior and the posterior chest when the patient is rocked vigorously back and forth. 



1. Valle JD. Chapter 293. Peptic Ulcer Disease and Related Disorders. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. 

2.  Sullivan SN. Thoracic succussion splash: a new symptom and sign of achalasia. . J Clin Gastroenterol. 1990 Dec;12(6):670-1.

Sunday, May 12, 2019


Q: Critical Illness Myopathy (CIM) affects more? (select one)

 A) proximal muscles
 B) distal muscles

Answer: A

CIM is very common and still an under-recognized disease in ICU. After few days in ICU, it may become the most common cause of failure to wean from mechanical ventilation. The most common presenting symptom is flaccid quadriparesis which affects proximal more than distal muscles. Facial muscle weakness is also common but usually, go undiagnosed. The best differential diagnosis is due to the fact that this facial weakness mostly spares extraocular muscle.



1. Lacomis D, Giuliani MJ, Van Cott A, Kramer DJ. Acute myopathy of intensive care: clinical, electromyographic, and pathological aspects. Ann Neurol 1996; 40:645. 

2. Latronico N, Peli E, Botteri M. Critical illness myopathy and neuropathy. Curr Opin Crit Care 2005; 11:126. 

3. Deconinck N, Van Parijs V, Beckers-Bleukx G, Van den Bergh P. Critical illness myopathy unrelated to corticosteroids or neuromuscular blocking agents. Neuromuscul Disord 1998; 8:186.

4. Lacomis D, Zochodne DW, Bird SJ. Critical illness myopathy. Muscle Nerve 2000; 23:1785.

Saturday, May 11, 2019

Protected PCI

Q: What is the Protected percutaneous coronary intervention (PCI) procedure?

Answer: Protected PCI is a PCI performed under the cover of extra support from a heart device mostly left ventricular assist device (LVAD) such as impella. In patients who are suspected to have a high degree of coronary blockages, or may have a high risk of hemodynamic collapse, may benefit from protected PCI. Patients with underlying ischemic cardiomyopathy with low ejection fraction, severe diabetes, old age, history of peripheral vascular disease, or prior bypass surgery should be considered for protected PCI.




1. Pesarini G, Gratta A, Dolci G, Lunardi M, Ribichini FL. Impella-protected PCI: the clinical results achieved so far. Minerva Cardioangiol. 2018 Oct;66(5):612-618. 

2.  O'Neill, W. W.; N. S. Kleiman; J. Moses; J. P. S. Henriques; S. Dixon; J. Massaro; I. Palacios; B. Maini; S. Mulukutla; V. Dzavik; J. Popma; P. S. Douglas; M. Ohman (2012). "A Prospective, Randomized Clinical Trial of Hemodynamic Support With Impella 2.5 Versus Intra-Aortic Balloon Pump in Patients Undergoing High-Risk Percutaneous Coronary Intervention: The PROTECT II Study". Circulation. 126 (14): 1717–1727.

Friday, May 10, 2019


Q: In post-intensive care syndrome (PICS), which one is the higher predictor of post ICU cognitive dysfunction? (select one)

A) degree and duration of delirium

B) degree and duration of sedating medications

Answer: A

Although an answer may be easy to guess, the objective of this question is to enhance three aspects of ICU care. One is to put emphasis on PICS, still an under-recognized condition. Second, long term effects of delirium in ICU, and third most important point to emphasize, is to put a little break on the notion of avoiding all sedation in ICU! Being an intensivist is more of an art than science. An ICU physician, being a healer needs to draw a fine line between patient's comfort and oversedation. Many times sedation is required to avoid not only short term but long term sequelae of critical care illnesses.



Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306.

Thursday, May 9, 2019


Q: 54 year old diabetic male is admitted to ICU with mucormycosis. Patient becomes stable after few days of intravenous antifungal therapy, a plan was made to switch to oral posaconazole. Bioavailability for posaconazole is better with? (select one) 

A) posaconazole delayed-release tablets 
B) oral suspension of posaconazole

Answer: A

The oral suspension of posaconazole is usually not highly bioavailable and requires fatty foods for absorption. Enteral feeding of infected patients in ICU stay variable and so bioavailability of oral suspensions cannot be relied upon.




1.  Spanakis EK, Aperis G, Mylonakis E. New agents for the treatment of fungal infections: clinical efficacy and gaps in coverage. Clin Infect Dis 2006; 43:1060. 

2.  Noxafil (posaconazole) injection for intravenous use, delayed-release tablets for oral use, oral suspension, prescribing information. 

Wednesday, May 8, 2019

Ports on NGT

Q: The large bore (16 F ) nasogastric tube (NGT), popularly known as Salem Sump tube has two lumens at the outside. The larger lumen is usually connected to the intermittent wall suction. What is the function of the open port on the side (pigtail), usually blue in color?

Answer:  Most commonly used NGTs in ICU has two lumens. The larger lumen is usually connected to the intermittent wall suction for draining gastric contents, irrigation, and delivery of medications or feeding. The smaller lumen (called sump port) which is usually of blue color and hangs out as a side port vents to atmosphere. This equalizes the pressure in the stomach once the stomach is empty. This serves the purpose of preventing the distal holes of NGT from adhering to the stomach wall. Also, this port should never be clamped while suction is being applied. 



1. Bard Medical Sump Naso-Gastric Tube 

 2. Bong CL, Macachor JD, Hwang NC. Insertion of the nasogastric tube made easy. Anesthesiology. 2004 Jul;101(1):266. 

3. Stayner JL, Bhatnagar A, McGinn AN, Fang JC. Feeding tube placement: errors and complications. Nutr Clin Pract. 2012 Dec;27(6):738-48. 

 4. Tucker A, Lewis J. Procedures in practice. Passing a nasogastric tube. Br Med J. 1980 Oct 25;281(6248):1128-9.

Tuesday, May 7, 2019

RHF in heart transplant

Q: What is the best way to anticipate Right Heart Failure (RHF) in post heart transplant patients?

Answer: If a patient has 

  • elevated pulmonary artery systolic pressure >50 mmHg, 
  • elevated PVR >3 Wood units (320 dynes-sec-cm-5) or 
  • elevated transpulmonary gradient of >15 mmHg, 

is at high risk for RHF after a transplanted heart. 

Two considerations are of utmost importance:

1. If a patient has an irreversible severe pulmonary hypertension, combined heart-lung transplantation should be considered.

2. If a patient is on chronically administered pulmonary vasodilator therapy, it should be continued during the pre-bypass period, and such therapies will likely be necessary to achieve separation from cardiopulmonary bypass (CPB) after a heart transplant.



1. De Santo LS, Romano G, Maiello C, et al. Pulmonary artery hypertension in heart transplant recipients: how much is too much? Eur J Cardiothorac Surg 2012; 42:864. 

2. Vakil K, Duval S, Sharma A, et al. Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis. Int J Cardiol 2014; 176:595.

Monday, May 6, 2019

Post CABG A fib

Q: Which group of patients have a lower rate of atrial fibrillation post coronary artery bypass grafting (CABG) surgery?

A) Off-pump CABG
B) On-pump CABG

Answer: A

Although evidence is weak literature leans towards off-pump CABG for a lesser risk of post-op Atrial fibrillation.



1. Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 2004; 77:1567.

2. Almassi GH, Pecsi SA, Collins JF, et al. Predictors and impact of postoperative atrial fibrillation on patients' outcomes: a report from the Randomized On Versus Off Bypass trial. J Thorac Cardiovasc Surg 2012; 143:93.

3.  Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002; 359:1194. ff-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass grafting? Ann Thorac Surg 2004; 77:1567. 

Sunday, May 5, 2019

Extravasation of pressors

Q; In case of extravasation of intravenous pressor in ICU, all of the following can be used as an antidote except?

A) Phentolamine (injection locally)

B) Nitroglycerin (topical)
C) Terbutaline (inject locally)
D) Clonidine (topical)

Answer: D

 Extravasation of all intravenous infusions is an inherent risk. In the case of extravasation of VASOpressors following sequential steps should be taken before giving an antidote

1. Immediately stop the infusion 
2. Disconnect the infusion but leave cannula or needle in place 
3. Gently aspirate the extravasated solution 
4. Do NOT flush the line 
5. Remove the needle or cannula (now)
6. Elevate the extremity. 

Phentolamine is the first choice in vasopressor extravasation. Depending on the area of extravasation, 5 to 10 mg of phentolamine should be diluted in 10 to 20 mL NS and administer by injecting locally at the extravasation site as soon as possible. It can be applied up to 12 hours of the accident. 

 Alternatively, Nitroglycerin topical 2% ointment in a 1-inch strip can be applied to the site of ischemia and can be continued every 8 hours until the situation seems resolved.

Another option is to dilute 1 mg of terbutaline in 10 mL NS and inject locally at the extravasation site. 

Clonidine is an alpha-2 adrenergic agonist and has no role in the treatment.



1.  Plum, M., & Moukhachen, O. (2017). Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. P & T : a peer-reviewed journal for formulary management, 42(9), 581-592. 

2. Reynolds PM, Maclaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632

Saturday, May 4, 2019

Vitamin C and Folate in vasodilation

Q: What is the theoretical basis of using Vitamin C and Folate in vasodilatation? 

Answer:  In experimental models, Vitamin C and folate are found to prevent the degradation of Nitric Oxide (NO). Although most of the work is done in the background of the effect of hypercholesterolemia on vasomotor action, they have shown this effect as an independent factor without any change in lipid metabolism. Vitamin C and folate improve the endothelial function and the vasomotor response. 5-methyltetrahydrofolate is the active form of folic acid and found to be particularly useful in this mechanism. 



Ting HH, Timimi FK, Haley EA, et al. Vitamin C improves endothelium-dependent vasodilation in forearm resistance vessels of humans with hypercholesterolemia. Circulation 1997; 95:2617. 

Verhaar MC, Wever RM, Kastelein JJ, et al. 5-methyltetrahydrofolate, the active form of folic acid, restores endothelial function in familial hypercholesterolemia. Circulation 1998; 97:237. 

Verhaar MC, Wever RM, Kastelein JJ, et al. Effects of oral folic acid supplementation on endothelial function in familial hypercholesterolemia. A randomized placebo-controlled trial. Circulation 1999; 100:335. 

Friday, May 3, 2019

Activated Charcoal and ETOH poisoning

Q: Administration of activated charcoal (AC) should be administrated if a patient presents early with any type of alcohol poisoning? (select one) 

A) True
B) False

Answer: B

Common alcohols poisonings in ICU i.e.,

  • Acetone
  • Ethanol 
  • Ethylene glycol 
  • Isopropanol Methanol
do not get adsorb to AC - and are not recommended in acute alcohol poisonings.

Other stuff where AC is not helpful is metals like Arsenic, Lead, Mercury, Iron, Zinc and Cadmium. Also, inorganic ions like Lithium, Sodium, Calcium, Potassium, Magnesium, Fluoride and Iodide do not get adsorb to AC.



1. Minocha A, Herold DA, Barth JT, et al. Activated charcoal in oral ethanol absorption: lack of effect in humans. J Toxicol Clin Toxicol 1986; 24:225.

2. Chyka PA, Seger D, Krenzelok EP, et al. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43:61. 

3. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1999; 37:731.

Thursday, May 2, 2019


Q: Metronidazole and vancomycin, which are the mainstay of treatment of C. difficile infection (CDI) can itself cause the C. difficile infection? (select one)

A) True
B) False

Answer: A

Any antibiotic can cause CDI, including metronidazole and vancomycin. The most notorious antibiotics to cause CDI include quinolones, clindamycin, penicillins, and cephalosporins. Risk get enhanced in proportion when multiple antibiotics are used. Also, the risk of CDI is proportional to the duration of antibiotic use.




1.  Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. N Engl J Med 1994; 330:257.

2. Stevens V, Dumyati G, Fine LS, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011; 53:42.

Wednesday, May 1, 2019

Treatment of native and prosthetic valve Candida endocarditis

Q: Treatment of native and prosthetic valve candida endocarditis requires both (combine) antifungal medical therapy and surgical valve replacement? (select one)

A) True
B) False

Answer: A

It is true that there is some evidence to support only antifungal medical therapy for the treatment of native and prosthetic valve candida endocarditis but the latest guidelines from the Infectious Diseases Society of America (IDSA) and the American Heart Association (AHA) recommends a combined medical and surgical treatment for the treatment of native as well as prosthetic valve candida endocarditis.




1. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.

2. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.