Tuesday, March 31, 2020

withdrawal of clonidine and BB

Q: Withdrawal of clonidine and beta-blockers may cause rebound symptoms. How they differ in manifestations?


Withdrawal of clonidine, which may occur with oral as well as transdermal patch can cause acute rebound hypertension (HTN). This rebound HTN is usually above the pretreatment level.

Although less appreciated but withdrawal of beta-blockers can be relatively more devastating. Not only it causes rebound HTN but also tends to produce more tachycardia,  angina, myocardial infarction, or even sudden death. This may occur in patients who may not have previous diagnosis of coronary symptoms.



1. Vanholder R, Carpentier J, Schurgers M, Clement DL. Rebound phenomenon during gradual withdrawal of clonidine. Br Med J 1977; 1:1138. 

2.  Metz S, Klein C, Morton N. Rebound hypertension after discontinuation of transdermal clonidine therapy. Am J Med 1987; 82:17. 

3. Psaty BM, Koepsell TD, Wagner EH, et al. The relative risk of incident coronary heart disease associated with recently stopping the use of beta-blockers. JAMA 1990; 263:1653. 

4.  Miller RR, Olson HG, Amsterdam EA, Mason DT. Propranolol-withdrawal rebound phenomenon. Exacerbation of coronary events after abrupt cessation of antianginal therapy. N Engl J Med 1975; 293:416.

Monday, March 30, 2020

L SC vein CVC advantage

Q: Access of which side of the subclavian (SC) vein is preferred when cardiac access is desired?

A) right
B) Left

Answer: B

Left subclavian vein is a better approach when cardiac access is desired as when temporary transvenous pacer or pulmonary artery catheter (Swan-Ganz) placement is to be done. Left SC is more easily directed into the superior vena cava and right heart.



1. Land RE. The relationship of the left subclavian vein to the clavicle: practical considerations pertinent to the percutaneous catheterization of the subclavian vein. J Thorac Cardiovasc Surg 1972; 63:564.

2. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994 Dec 29. 331 (26):1735-8.

Sunday, March 29, 2020

PO and IV furosemide

Q: Natriuresis from oral furosemide is lower than the intravenous (IV) furosemide?

A) True
B) False

Answer: B

Although oral furosemide is half potent than IV furosemide natriuresis effect is the same.

This is due to the reason that the plasma diuretic concentrations stay sustained above the diuretic threshold for a longer period of time with oral form, and causes the same level of natriuresis as the IV dose. 

To complicate the matter, there is a huge variability in the degree of bioavailability of oral furosemide between different patients with same kidney functions and even within the same patient at different times.




1. Kaojarern S, Day B, Brater DC. The time course of delivery of furosemide into urine: an independent determinant of overall response. Kidney Int 1982; 22:69. 

2. Ellison DH, Felker GM. Diuretic Treatment in Heart Failure. N Engl J Med 2017; 377:1964.

Saturday, March 28, 2020

​COVID Management in a nutshell

Disclaimer: As COVID management is changing due to its denovo nature, this is the best compilation we found so far. Use it at your best judgment.

Friday, March 27, 2020


Q: Ertapenem (invanz) has a _________ spectrum of activity than imipenem or meropenem? (select one)

A) narrower 
B) wider

Answer: A

Ertapenem is relatively a newer carbapenem. It has a narrower spectrum of activity than imipenem or meropenem. Clinically, it is mostly used for abdominal coverage as it is active against most Enterobacteriaceae and anaerobes. Added advantage is its longer half-life and can be administered once daily.




1. Collins VL, Marchaim D, Pogue JM, et al. Efficacy of ertapenem for treatment of bloodstream infections caused by extended-spectrum-β-lactamase-producing Enterobacteriaceae. Antimicrob Agents Chemother. 2012;56(4):2173-2177. 

2. Curran M, Simpson D, Perry C. Ertapenem: A Review of Its Use in the Management of Bacterial Infections. Drugs. 2003;63(17):1855-1878.

3.  Zhanel GG, Johanson C, Embil JM, Noreddin A, Gin A, Vercaigne L, Hoban DJ. Ertapenem: review of a new carbapenem.- Expert Rev Anti Infect Ther. 2005 Feb;3(1):23-39.

Thursday, March 26, 2020

euphoria with non-narcotic

Q: which of the following drug is more prone to induce euphoria? 

A) Gabapentin 
B) Pregabalin 

Answer: B

As there is a high sense of use of non-narcotics in ICU, gabapentin and pregabalin has become front line drugs in multi-model pain managements. But both of these drugs come with its own side-effects. Pregabalin is a lipophilic gamma aminobutyric acid (GABA) analog to facilitate diffusion across the blood-brain barrier. It provides analgesia quicker than gabapentin. On the same note, it has become a drug of abuse as it provides a sense of euphoria. This particular side effect has made this drug classified as a controlled substance in the United States.




1. Gahr M, Franke B, Freudenmann RW, Kölle MA, Schönfeldt-Lecuona C. Concerns about pregabalin: Further experience with its potential of causing addictive behaviors. J Addict Med. 2013;7:147–9. 

2. Feng MR, Turluck D, Burleigh J, et al. Brain microdialysis and PK/PD correlation of pregabalin in rats. Eur J Drug Metab Pharmacokinet 2001; 26:123.

Wednesday, March 25, 2020

COVID-19 usual pattern of symptoms and diagnostis window

Learning objective: To pay attention to windows of false-negatives and PCR diagnostic window

Tuesday, March 24, 2020


Q: 48 year male with history of chronic back pain is admitted to ICU with opioid and other substance overdose/abuse. Patient is now recovering. Pain team recommend only Abuse deterrent formulations (ADFs) of opioids for patient. What is Abuse deterrent formulations (ADFs) of opioids? 

Answer:  Patients on chronic opioid prescription drugs sometimes chew the tablets or crush them to facilitate smoking, inhalation, or intravenous (IV) injection. Deterrent formulations, popularly known as ADFs, are designed to prevent these altered routes of administration, while retaining efficacy with oral administration. Although theoretically it makes a lot of sense but evidence seems lacking in its effect from prevention of abuse, or decreasing adverse effects. Also, they are not very cost-effective.



1. Maincent J, Zhang F. Recent advances in abuse-deterrent technologies for the delivery of opioids. Int J Pharm 2016; 510:57.
US Food and Drug Administration. 

2. Abuse-deterrent opioids—evaluation and labeling. Guidance for industry. 2015. https://www.fda.gov/downloads/Drugs/Guidances/UCM334743.pdf (Accessed on March 11, 2020).

Monday, March 23, 2020


Q: 32 year old male presented to ED after new year Friday night party with chest pain and hypertension. He admits using Cocaine. Initial labs showed hypokalemia of 2.9 mEq/L. What would be your concern? 

Answer: Clenbuterol 

 Clenbuterol is an adulterant frequently found in cocaine and heroin. Clenbuterol tends to cause a tetrad of 

  •  tachycardia 
  •  hyperglycemia
  •  palpitations, and 
  •  hypokalemia 
Also, it may cause nausea, hypo or hypertension, thyrotoxicosis, chest pain, venous hyperoxia but with lactic acidosis, central symptoms of agitation and anxiety. Treatment is supportive. 



 Centers for Disease Control and Prevention (CDC). Atypical reactions associated with heroin use--five states, January-April 2005. MMWR Morb Mortal Wkly Rep 2005; 54:793.

Sunday, March 22, 2020

hydroxychloroquine in symptomatic COVID-19 patients

Q: What is the recommended dose and treatment course of hydroxychloroquine in symptomatic COVID-19 patients?

Answer: 200 mg three times per day for 10 days

Both chloroquine and hydroxychloroquine inhibits SARS-CoV-2 at least in vitro. Hydroxychloroquine appears to have more potent antiviral activity than Chloroquine. In COVID-19, some data from China has shown reduced progression of disease and decreased duration of symptoms. The dose is 200 mg three times per day for 10 days. 

Some reports suggest that it is associated with a higher rate of undetectable SARS-CoV-2 RNA on nasopharyngeal specimens by day 6 compared with no specific treatment (70 % vs 12.5%). Also, addition of azithromycin in combination with hydroxychloroquine appeared to have additional benefit, although the basis for this benefit is not clear.




1. Yao X, Ye F, Zhang M, et al. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis 2020. 

 2. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends 2020; 14:72. 

 3. Colson P, Rolain JM, Lagier JC, et al. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19. Int J Antimicrob Agents 2020; :105932. 

 4. Cortegiani A, Ingoglia G, Ippolito M, et al. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 2020. 

 5. Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐randomized clinical trial. International Journal of Antimicrobial Agents – 

Saturday, March 21, 2020

rigors from conventional amphotericin B

Q: Q: Which drug can be used to overcome rigors caused by conventional amphotericin B administration?

Answer:  Meperidine 

Although, an old trick but Meperidine has still been used off-label with success for shivering in post-operative patients. Usually, an intravenous (IV) dose of 12.5 mg is sufficient. 

Similarly, it can be used to overcome shivering which is common with the conventional form of amphotericin B. It requires a little higher dose in this instance i.e. IV 25 to 50 mg. Ideally, the dose should not be repeated. It takes about 10-12 minutes to show action after administration. It is still an off-label use.



Burks LC, Aisner J, Fortner CL, Wiernik PH. Meperidine for the treatment of shaking chills and fever. Arch Intern Med. 1980;140(4):483-484. 

Friday, March 20, 2020

Erythromycin in UGI bleed

Q: What's the optimum time to administer erythromycin in patients who may require endoscopy in acute upper gastrointestinal (UGI) bleed? 

Answer: Anywhere 30 to 90 minutes prior to endoscopy

Erythromycin is a prokinetic which promotes gastric emptying as it is an agonist of motilin receptors. It improves gastric emptying and so the visualization at endoscopy. Not only it excludes the need of second scope but there is weak evidence that it may even shortens the hospital stay.

It should be given as an intravenous (IV) over 20-30 minutes with the recommended dose of 3 mg/kg.  90 minutes prior to scope is ideal but as acute UGI can be a time-constrained situation, 30 minutes prior to endoscope is also acceptable. 



1. Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002; 123:17. 

2.  Coffin B, Pocard M, Panis Y, et al. Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Gastrointest Endosc 2002; 56:174. 

3.  Altraif I, Handoo FA, Aljumah A, et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest Endosc 2011; 73:245. 

4.  Carbonell N, Pauwels A, Serfaty L, et al. Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Am J Gastroenterol 2006; 101:1211. 

5. Rahman R, Nguyen DL, Sohail U, et al. Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review. Ann Gastroenterol 2016; 29:312.

Thursday, March 19, 2020

hypoalbuminemia in right heart failure patient

Q: What's the exact etiology for hypoalbuminemia in the right heart failure patient?

Answer: The objective of this question is to clarify the precise mechanism of hypoalbuminemia in patients with right heart failure. This occurs due to malnutrition and protein-losing gastroenteropathy secondary to intestinal lymphatic pressure. This gets complicated by low cardiac output. 

Clinically this is a significant entity as the degree of hypoalbuminemia does not correlate with the degree of histologic liver damage, but is an independent predictor of death in patients with acute or chronic heart failure.

This also explains why the most common LFT abnormality in these patients has elevated serum bilirubin, although elevated serum aminotransferase levels can be seen too.




Samsky MD, Patel CB, DeWald TA, et al. Cardiohepatic interactions in heart failure: an overview and clinical implications. J Am Coll Cardiol 2013; 61:2397.

Tuesday, March 17, 2020

Ultrasound Findings in COVID-19

Ultrasound Findings in COVID-19 

  • Thick B Lines 
  • Subpleural consolidations 
  • Rare Pleural Effusions

Monday, March 16, 2020

recurrent C. difficile

Q: How the recurrent C. difficile infection (CDI) is defined?

Answer: Recurrent C. difficile infection is defined by resolution of CDI symptoms while on appropriate therapy, followed by the reappearance of symptoms within two to eight weeks after treatment has been stopped.

Looking closely, it has four aspects. 

1. is less likely to be a re-infection. Usually, it is a relapse of the previous infection.

2. There should be a resolution of CDI symptoms while on appropriate therapy previously 
3. Time-period to define recurrent C. difficile infection is within two to eight weeks 
4. This time-period should be counted after the treatment has been stopped

Clinically, this is important as it distinguishes between relapsing, re-infecting and refractory CDI infections. And, all three may require different clinical approaches.



1. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1.

Kamboj M, Khosa P, Kaltsas A, et al. Relapse versus reinfection: surveillance of Clostridium difficile infection. Clin Infect Dis 2011; 53:1003.

Sunday, March 15, 2020

Vitamin K and Vascular calcification

Vitamin K and Vascular calcification connection

Less well known and less discussed topic is the connection between deficiency of Vitamin K and vascular calcification, particularly coronary vessels. An active form of Matrix Gla protein plays a role in vascular calcification. It requires vitamin K for carboxylation for its activity. Vitamin K deficiency can lead to increased vascular calcification because of a lack of matrix Gla protein activity. Although data is weak but points towards deficiency of Vitamin K and increased calcification of coronary vessels.



1. Beulens JW, Bots ML, Atsma F, et al. High dietary menaquinone intake is associated with reduced coronary calcification. Atherosclerosis 2009; 203:489. 

2. Shea MK, O'Donnell CJ, Hoffmann U, et al. Vitamin K supplementation and progression of coronary artery calcium in older men and women. Am J Clin Nutr 2009; 89:1799.

Saturday, March 14, 2020

AA gradient adjustment

Q: A-a gradient should be ideally adjusted for? 

A) age 
B) gender 

Answer: A

The formula for A-a gradient is 

 A-a gradient = 2.5 + 0.21 x age in years 

Where: 0.21 is the room air - and should be substituted with the level of oxygen patient is breathing. 



Sarkar M, Niranjan N, Banyal PK. Mechanisms of hypoxemia [published correction appears in Lung India. 2017 Mar-Apr;34(2):220]. Lung India. 2017;34(1):47–60. doi:10.4103/0970-2113.197116

Friday, March 13, 2020

Opioid toxicology

Q: All of the following are the risk factors for misuse and increase morbidity and mortality for nonmedical use of sedatives or tranquilizers except

A) White race 
B) Male sex 
C) Uninsured 
D) Unemployed 
E) Cigarette use

Answer: B

In the United States, overdose deaths involving benzodiazepines have increased many folds in last few years. It has been called a crisis. This is particularly concerning in combination with alcohol or opioids. A massive cohort of 92,000 adults has been examined and various risk factors have been identified. It includes

 ●White race 

 ●Female sex 
 ●Panic symptoms 
 ●Other psychiatric symptoms 
 ●Alcohol abuse or dependence 
 ●Cigarette use 
 ●Illicit drug use 
 ●History of IV drug use



Becker WC, Fiellin DA, Desai RA. Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug Alcohol Depend 2007; 90:280.

Thursday, March 12, 2020

HIV meds conversion

Q: Which of the following HIV drugs can be crushed?

A) Tenofovir 

B)  Ritonavir  

Answer: A

The objective of above question is to highlight the pearl that "all HIV drugs are not created equal". This becomes more important as many HIV patients cannot swallow pills due to underlying candidal esophagitis. 

When it comes to HIV meds, conversion from tablet to liquid form may not be equal. Similarly, some can be crushed and some can not be. 

Pharmacy should be consulted prior to making any change in patients' medication profile.




1. Nyberg CR, Patterson BY, Williams MM. When patients cannot take pills: Antiretroviral drug formulations for managing adult HIV infection topics. Top Antivir Med 2011; 19:126. 

2. Swindells S, Flexner C, Fletcher CV, Jacobson JM. The critical need for alternative antiretroviral formulations and obstacles to their development. J Infect Dis 2011; 204:669.

Wednesday, March 11, 2020

Inadvertent cannulation of the right gonadal vein can occur while inserting IVC filter

Q: Inadvertent cannulation of the right gonadal vein can occur while inserting inferior vena cava (IVC) filter? (select one)  

A) when access is from above (e.g., jugular vein)
B) when access is from below (e.g., femoral vein)

Answer: A

The left gonadal vein drains into the left renal vein but the right gonadal vein drains directly into IVC.

Clinically this is important as inadvertent cannulation of the right gonadal vein with access from an internal jugular vein can appear similar to that of the IVC. If the operator is not aware of the slight change in the trajectory of the wire, IVC filter can get deployed in the right gonadal vein.



1. Sharma S, Mukund A, Agarwal S, Srivastava DN. Case of a misplaced IVC filter: a lesson to learn. Cardiovasc Intervent Radiol. 2010 Aug;33(4):880-2. doi: 10.1007/s00270-010-9825-y.

2. Ding PX, Han XW, Liu C, Ren KW. Inferior vena cava filter misplacement in the right ovarian vein and successful removal by loop-snare technique in a patient with inferior vena cava agenesis. J Vasc Surg Cases Innov Tech. 2018;4(4):324–326. Published 2018 Dec 10. doi:10.1016/j.jvscit.2017.12.006

Tuesday, March 10, 2020

ASA toxicity

Q: The diagnosis of aspirin (ASA) toxicity should be correlated well with the timing of aspirin ingestion? (select one)

A) True
B) False

Answer: B

In normal circumstances, non-enteric coated ASA gets rapidly absorbed in the stomach, and peak concentration is reached within an hour. But in case of its overdose peak levels can be delayed for six hours or even longer. This is due to the phenomenon of pylorospasm. Also, bezoar formation may occur. Moreover, in case of overdose hepatic detoxification becomes saturated, and elimination becomes dependent upon relatively slower renal excretion and half-life may get extended up to 30 hours.



1. Rivera W, Kleinschmidt KC, Velez LI, et al. Delayed salicylate toxicity at 35 hours without early manifestations following a single salicylate ingestion. Ann Pharmacother 2004; 38:1186. 

2. Garella S. Extracorporeal techniques in the treatment of exogenous intoxications. Kidney Int 1988; 33:735.

Monday, March 9, 2020

Types of VSDs

Q: What is Gerbode defect, a variant of Ventricular Septal Defects (VSDs)?

Answer: Most of the books/articles/experts describe four types of VSDs. The objective of this question is to highlight a technically 5th type or a variant of VSD.

Type 1:  Infundibular VSD:  This is due to the deficiency in the septum above and anterior to the crista supraventricularis, beneath the aortic and pulmonary valves. Due to location it has given names as supracristal, subarterial, subpulmonary, conal, or doubly-committed VSD. As it is very close to aortic valve, clinically it is more prone to cause progressive aortic regurgitation. 

Type 2: Membranous VSD: This is the most common type of VSD and is due to deficiency of the membranous septum. When muscular septum gets involved it is called peri or paramembranous VSD. 

Type 3: Atrioventricular or canal VSD: This is due to the deficiency of the inlet septum located beneath both mitral and tricuspid valves. 

Type 4: Muscular defects: These are bordered only by muscle within the trabecular septum. 

Gerbode defect: This is not counted as Type 5  but technically considered as a VSD. This is due to deficiency of the membranous septum separating the left ventricle (LV) from the right atrium. This is the least common type but when present causes LV-to-right atrial shunt.




1. Tidake A, Gangurde P, Mahajan A. Gerbode Defect-A Rare Defect of Atrioventricular Septum and Tricuspid Valve. J Clin Diagn Res. 2015;9(9):OD06–OD8. doi:10.7860/JCDR/2015/14259.6531

2. Saker E, Bahri GN, Montalbano MJ, et al. Gerbode defect: A comprehensive review of its history, anatomy, embryology, pathophysiology, diagnosis, and treatment. J Saudi Heart Assoc. 2017;29(4):283–292. doi:10.1016/j.jsha.2017.01.006

Sunday, March 8, 2020


Q: The Confusion Assessment Method (CAM) to identify delirium is a better tool than Mini-Mental State Examination? 

A) True 
B) False

Answer: A

Developed almost 30 years ago and though it seems simple The Confusion Assessment Method (CAM) is extremely useful to identify patients who have delirium. It is found to be most accurate among all instruments available. Mini-Mental State Examination is found to be the least accurate.  CAM is found to have a sensitivity of 94 to 100 percent and a specificity of 90 to 95 percent.

For ICUs a variant of CAM is developed call CAM-ICU. 



1. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113:941. 

2. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA 2010; 304:779. 

3. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286:2703. 

4. Luetz A, Heymann A, Radtke FM, et al. Different assessment tools for intensive care unit delirium: which score to use? Crit Care Med 2010; 38:409. 

5. Mitasova A, Kostalova M, Bednarik J, et al. Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2012; 40:484.

Saturday, March 7, 2020

oxygen & sleep in ICU

Q: Low level of supplemental oxygen in ICU may promote sleep?

A) True
B) False

Answer:  A

Oxygen is known to have anxiolytic and anti-dyspneic effects. This leads some experts to believe that a low level of supplemental oxygen may be beneficial in ICU to promote sleep, particularly sleep-deprived patients. Human sleep is sustained via a drive to breathe in reticular activating system and metabolic control mechanisms. Supplemental oxygen may cause loss of the drive to breathe associated with reticular activating system.

Though in few patients it may also cause clinically significant hypercarbia.



1. Robert L Owens Supplemental Oxygen Needs During Sleep. Who Benefits? Respiratory Care January 2013, 58 (1) 32-47; DOI: https://doi.org/10.4187/respcare.01988

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

Friday, March 6, 2020

Opioid disposal

Q: 32 year old male is getting directly discharged from ICU to home. Patient has been prescribed oral narcotics for postop pain. FDA recommends to educate patients on safe opioid disposal. Per FDA guidelines, opioid drugs can be disposed of by flushing down the sink or toilet?

A) True
B) False

Answer: A

It may sound inappropriate but so far FDA still approves of disposing of most opioid drugs by flushing down the sink or toilet (list is available in the reference). Other recommended methods are taking excess opioids to US Drug Enforcement Agency (DEA) authorized take back locations, which are usually pharmacies or police stations. Also, opioids can be combined with an unpalatable substance and placed in a sealed container in household trash.



https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#Flush_List. (last accessed March 5, 2020)

Thursday, March 5, 2020


Q: How much time does it take for platelets to recover after the discontinuation of a drug in Drug-Induced Thrombocytopenia (DITP)?

Answer: one week

Many times it is hard to know the reason behind thrombocytopenia in ICU. One of the major causes of thrombocytopenia in ICU is Drug-Induced. It is extremely important to confirm the recovery of platelet count after the discontinuation of the drug to confirm the diagnosis of DITP. The platelet count usually starts to increase within a day or two days after the discontinuation of the drug. Full recovery usually occurs within a week. 

 Few exceptions are patients who are in severe liver or renal insufficiency. Also, some drugs take more than usual expected time in recovery particularly alemtuzumab, eptifibatide, and gold salts.




1. George JN, Raskob GE, Shah SR, et al. Drug-induced thrombocytopenia: a systematic review of published case reports. Ann Intern Med 1998; 129:886. 

2. Pedersen-Bjergaard U, Andersen M, Hansen PB. Drug-induced thrombocytopenia: clinical data on 309 cases and the effect of corticosteroid therapy. Eur J Clin Pharmacol 1997; 52:183. 

3. Rousan TA, Aldoss IT, Cowley BD Jr, et al. Recurrent acute thrombocytopenia in the hospitalized patient: sepsis, DIC, HIT, or antibiotic-induced thrombocytopenia. Am J Hematol 2010; 85:71.

Wednesday, March 4, 2020


Q: In diffuse Alveolar Hemorrhage (DAH), What's the maximum dose of glucocorticoids that can be used? 

Answer: 2000 mg

In patients with DAH due to capillaritis, including systemic vasculitis, anti-glomerular basement membrane [GBM] syndrome, or rheumatic disease), despite no strong evidence a mega-dose of steroid has been a standard of care. Dose anywhere from 500 to 2000 mg daily in divided doses can be used. A high steroid dose is usually given as a course of 5 days and is recommended to a transition to oral agents, followed by tapering to a targeted maintenance dose.

As the role and dose of steroid in DAH are not established, some experts even suggested low dose steroid, to avoid the outfall from medium or high dose steroids 3.



1. Jennings CA, King TE Jr, Tuder R, et al. Diffuse alveolar hemorrhage with underlying isolated, pauciimmune pulmonary capillaritis. Am J Respir Crit Care Med 1997; 155:1101. 

2. Schwarz MI, Brown KK. Small vessel vasculitis of the lung. Thorax 2000; 55:502.

3.  NK Rathi et al. Low-, medium- and high-dose steroids with or without aminocaproic acid in adult hematopoietic SCT patients with diffuse alveolar hemorrhage. Bone Marrow Transplantation (2015) 50, 420–426

Tuesday, March 3, 2020

Medications in Alcohol usage disorder

Q: Which of the following drug can be used in alcohol use disorder while patient is still actively drinking?

A) naltrexone 
B) acamprosate

Answer: A

Naltrexone and acamprosate are the two drugs commonly used in patients with alcohol use disorder. Naltrexone has an advantage that it can be initiated while patient is still drinking. Also, Naltrexone due to its dosage frequency has more compliance. Naltrexone can be taken as a pill per day or as a monthly injection. While acamprosate requires a patient to take two pills three times a day. 

In severe liver disease, acamprosate is preferred and in severe renal insufficiency, naltrexone is preferred. Naltrexone is also preferred in patients who have a concurrent issue with opioid drug usage.




1. Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev 2010; :CD004332. 

2. Rösner S, Leucht S, Lehert P, Soyka M. Acamprosate supports abstinence, naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes. J Psychopharmacol 2008; 22:11.

Monday, March 2, 2020

AKI - definitation

Q: How the Acute Kidney Injury (AKI) is "defined" by Kidney Disease: Improving Global Outcomes (KDIGO)?


 The proposed definition from KDIGO includes
  • an increase in serum creatinine by ≥0.3 mg/dL  within 48 hours, or
  • an increase to ≥1.5 times the presumed baseline value that is known or presumed to have occurred within the prior seven days, or
  • a decrease in urine volume to  < 0.5 mL/kg/hour over six hours 
Reference section include all 3 major guidelines to define AKI including
  1.  Kidney Disease: Improving Global Outcomes (KDIGO) 
  2.  Acute Dialysis Quality Initiative (ADQI) - RIFLE criteria
  3. Acute Kidney Injury Network (AKIN) criteria



1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:1.

2. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8:B204. 

3. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007; 11:R31. 

Sunday, March 1, 2020

Extubation failure

Q: Inability to complete which four commands found to be associated with increased risk of extubation failure?

Answer: At least one study showed that failure to complete all of the following commands is associated with the extubation failure. Although study was small with only 88 patients, and needs reproducibility in a bigger trial.
  • open eyes, 
  • follow object with eyes, 
  • grasp hand, and 
  • stick out tongue
Patients who failed to complete all of the four commands were more than four times as likely to fail as those who completed all the four commands.



Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 2004; 30:1334.