Monday, June 14, 2021

Potassium and EKG changes

 Q: The progression of EKG changes correlate well with the serum potassium concentration?

A) Yes

B) No


Answer: B

There are several EKG changes that occur with hyperkalemia. In early phases, the most well-known is a tall peaked T wave. The less known fact is that it should be read with a shortened QT interval. This is followed by progressive lengthening of the PR interval along with QRS duration. The disappearance of P-wave is relatively a late sign. QRS continues to widen and become a sine wave. This quickly degenerates into asystole. 

Although above is the classic progress of EKG changes, hyperkalemia can be characterized by various other appearances on the EKG including bradycardia, idioventricular rhythms, V. Tach., V. Fib., pseudo-ST-elevations mimicking myocardial infarction, and pseudo-Brugada patterns. 

The most important thing to remember is that an EKG change in hyperkalemia is an urgency to treat, as they do not correlate well with the serum potassium level.

#cardiology


References:


1. Littmann L, Gibbs MA. Electrocardiographic manifestations of severe hyperkalemia. J Electrocardiol 2018; 51:814. 

2. Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol. 2008 Mar;3(2):324-30. doi: 10.2215/CJN.04611007. Epub 2008 Jan 30. PMID: 18235147; PMCID: PMC2390954.

3. Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963-971. doi:10.5811/westjem.2017.6.33033

Sunday, June 13, 2021

Acyclovir side effect

 Q: 44 years old male with End-Stage Renal Failure (ESRD) on chronic peritoneal dialysis is admitted to ICU with Herpes pneumonia and started on acyclovir. Patient progressively developed agitation, delirium and went into coma. Patients on peritoneal dialysis have higher risk of acyclovir toxicity?

A) True

B) False


Answer: A

When it comes to Acyclovir two considerations are very important. First, acyclovir itself can cause Acute Kidney Injury (AKI) by precipitating relatively insoluble acyclovir crystals in the renal tubules. This risk is high with intravenous (IV) route and can be eliminated by reducing the dose and prior high hydration with urine output around 75-100 cc/hr. This can be challenging in cardiac or renal patients, not on dialysis yet. 

When it comes to patients already on dialysis, peritoneal dialysis is not very effective in the removal of acyclovir. This is due to the fact that the drug is not highly bound to plasma protein. It quickly penetrates tissue and fluid including cerebrospinal fluid (CSF). A nephrologist and a pharmacist should be consulted to avoid this dreaded complication.


#pharmacology


References:

1. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy 2009; 29:562. 

2. Patel J, Hayes B, Bauler L, Mastenbrook J. Neurologic Acyclovir Toxicity in the Absence of Kidney Injury. J Emerg Med 2019; 57:e35. 

3. Gentry JL 3rd, Peterson C. Death Delusions and Myoclonus: Acyclovir Toxicity. Am J Med 2015; 128:692. 

4. Davenport A, Goel S, Mackenzie JC. Neurotoxicity of acyclovir in patients with end-stage renal failure treated with continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1992; 20:647. 

5. Stathoulopoulou F, Almond MK, Dhillon S, Raftery MJ. Clinical pharmacokinetics of oral acyclovir in patients on continuous ambulatory peritoneal dialysis. Nephron 1996; 74:337.

Saturday, June 12, 2021

GAP in IPF

 Q: 64 years old male who has never had access to any healthcare, admitted to ICU with severe hypoxemia. Subsequent workup led to diagnosis of idiopathic lung fibrosis (IPF). Pulmonology service starts to calculate the GAP model.  The GAP stands for? (select one)

A) Gene-Age-Physiology model 

B) Gender-Age-Physiology model

C) Graded-Age-Physiology model

D) Guided-Age-Physiology model

E) Goal-directed-Age-Physiology model


Answer: B

GAP is a validated clinical prediction model for patients with IPF to predict 1, 2, and 3-year mortality. The calculator takes into account - gender, age, predicted Forced Vital Capacity (FVC) and predicted diffusing capacity of the lungs for carbon monoxide (DLCO). Once combined with functional status, patient wishes, and other clinical conditions it helps to decide on the aggressiveness of treatment ranging from lung transplant to palliation.

The calculator is simple to use and can be viewed at  https://www.acponline.org/journals/annals/extras/gap/


# pulmonary

#transplantations


References:

1. Ley B, Ryerson CJ, Vittinghoff E, Ryu JH, Tomassetti S, Lee JS, Poletti V, Buccioli M, Elicker BM, Jones KD, King TE Jr, Collard HR. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med. 2012 May 15;156(10):684-91. doi: 10.7326/0003-4819-156-10-201205150-00004. PMID: 22586007.

2. Lee SH, Kim SY, Kim DS, Kim YW, Chung MP, Uh ST, Park CS, Jeong SH, Park YB, Lee HL, Shin JW, Lee EJ, Lee JH, Jegal Y, Lee HK, Kim YH, Song JW, Park SW, Park MS. Predicting survival of patients with idiopathic pulmonary fibrosis using GAP score: a nationwide cohort study. Respir Res. 2016 Oct 18;17(1):131. doi: 10.1186/s12931-016-0454-0. PMID: 27756398; PMCID: PMC5069824.

Friday, June 11, 2021

panniculitis

 Q: In acute pancreatitis - panniculitis are most commonly found at? (select one) 

A) Chest area 

B) Flank area 

C) Upper extremities 

D) Lower extremities 

E) Perineal area 


 Answer: D

Physical exam particularly cutaneous exam can be of profound help in acute pancreatitis. 

Panniculitis are actually subcutaneous nodular fat necrosis lesions which are tender to touch and appears as reddish nodules. They are commonly found in distal areas of lower extremities, though may be present at other places in the body. 

Two other significant cutaneous findings are Cullen's sign and Grey Turner sign. Cullen's sign is ecchymotic discoloration in the periumbilical region and Grey Turner sign is ecchymotic discoloration mostly along the flanks. These two signs are due to retroperitoneal bleed subsequent to pancreatic necrosis. 

Besides above, other cutaneous findings can also be of help such as xanthomas in hyperlipidemic pancreatitis.


#physical-exam

#GI


References:

1.  Dahl PR, Su WP, Cullimore KC, Dicken CH. Pancreatic panniculitis. J Am Acad Dermatol 1995; 33:413. 

2. Bennett RG, Petrozzi JW. Nodular subcutaneous fat necrosis. A manifestation of silent pancreatitis. Arch Dermatol 1975; 111:896.

3. Mookadam F, Cikes M. Images in clinical medicine. Cullen's and Turner's signs. N Engl J Med 2005; 353:1386.

Thursday, June 10, 2021

bell and the diaphragm of the stethoscope

Q:  The diaphragm of the stethoscope detects best? (select one) 

A) high-frequency sounds 

B) low-frequency sounds


Answer: A

The stethoscope has two heads: Bell and Diaphragm - 

  • Bell is best to detect low-frequency sounds like third and fourth heart sounds 
  • Diaphragm is best to detect high-frequency sounds like pericardial and pleural friction rubs

#physical-exam


References:

1. Murphy RL. In defense of the stethoscope. Respir Care. 2008 Mar;53(3):355-69. PMID: 18291053. 

2. David L, Dumitrascu DL. The bicentennial of the stethoscope: a reappraisal. Clujul Med. 2017;90(3):361-363. doi:10.15386/cjmed-821 

3. O'Neill D. Using a stethoscope in clinical practice in the acute sector. Prof Nurse. 2003 Mar;18(7):391-4. PMID: 12674046.

Wednesday, June 9, 2021

SBO grading

 Q: There are how many grades of Small Bowel Obstruction (SBO)? (select one)

A) Minimum, Moderate and Severe

B) 1, 11, and 111

C) 1, 11, 111, 1V, and V


Answer: C

The American Association for the Surgery of Trauma (AAST) has developed a grading system for SBO taking into consideration the radiological and operative criteria. It has been validated as reliable in subsequent studies. Higher grading predicts at least three things 

  • Higher hospital Length of Stay (LOS) 
  • Higher ICU LOS, and 
  • Higher complications.



#surgical-critical-care


Reference:

1. Hernandez MC, Haddad NN, Cullinane DC, Yeh DD, Wydo S, Inaba K, Duane TM, Pakula A, Skinner R, Rodriguez CJ, Dunn J, Sams VG, Zielinski MD, Choudhry A, Turay D, Yune JM, Watras J, Widom KA, Cull J, Toschlog EA, Graybill JC; EAST SBO Workgroup. The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2018 Feb;84(2):372-378. doi: 10.1097/TA.0000000000001736. PMID: 29117026.

Tuesday, June 8, 2021

strategies to decrease steroids side effects

 Q: Locally acting glucocorticoids have a lesser risk of superimposed infections than systemic glucocorticoids? 

 A) True 

B) False 


Answer: A

There are various strategies to reduce the risk of superimposed infections. Some of the strategies which can be considered are:

1. Applying glucocorticoids directly to the area/system which is targeted such as a nebulizer or inhaler for respiratory disease, or an oral steroid with high, first-pass metabolism like budesonide for intestinal inflammation. 

2. Alternate-day dosing if clinically appropriate. Prednisone effect may last up to 36 hours, and dexamethasone effect may last up to 72 hours.

3. Early mobilization and physical therapy to counter myopathy. 

#pharmacology


References:

1. Fauci AS, Dale DC, Balow JE. Glucocorticosteroid therapy: mechanisms of action and clinical considerations. Ann Intern Med 1976; 84:304.

Monday, June 7, 2021

NCT

 Q: Number connection test (NCT), also known as Reitan Test is used to evaluate which pathology? 

 Answer: Hepatic encephalopathy

NCT (Reitan Test) is a timed connect-the-numbers test. With no underlying hepatic encephalopathy, patients finish the test in seconds less than or equal to their age in years. If a patient is 40 years of age, he should finish the test in less than or in 40 seconds. Another rule of thumb described is that any healthy person should be able to finish in 30 seconds. 

Test was invented to administered in two-four parts but subsequent experience found that only one part is as effective as complete test.

Details can be found at:

 https://anthc.org/wp-content/uploads/2017/05/Numbers-Connection-Test.pdf


#hepatology


References:

1. Conn HO. Trailmaking and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Am J Dig Dis 1977; 22:541. 

2. Amodio P, Del Piccolo F, Marchetti P, et al. Clinical features and survivial of cirrhotic patients with subclinical cognitive alterations detected by the number connection test and computerized psychometric tests. Hepatology 1999; 29:1662.

3. Weissenborn K, Rückert N, Hecker H, Manns MP. The number connection tests A and B: interindividual variability and use for the assessment of early hepatic encephalopathy. J Hepatol 1998; 28:646.

Sunday, June 6, 2021

Lugol's solution - routes of administration

 Q: 22 years old female is admitted to ICU with thyroid storm. Iodine solution is planned to be administered. Patient is having severe nausea and may not tolerate oral intake. Can it be given intravenously?

A) Yes

B) No


Answer: A

In a thyroid storm, iodine should be planned to be administered an hour after the first dose of thionamide. Iodine is mostly available as a potassium iodide-iodine solution, popularly known as Lugol's solution. The standard dose is 10 drops. If a patient cannot tolerate oral intake it can be added to intravenous fluid (IVF). Moreover, iodine may cause esophageal or duodenal mucosal damage leading to bleeding and should be diluted in a beverage or given with food. 

The iodine solution can also be administrated rectally.


#endocrinology


References:

1. Benua RS, Becker DV, Hurley JR. Thyroid storm. In: Current Therapy in Endocrinology and Metabolism, Bardin CW (Ed), Mosby, St. Louis 1994. p.75.

2. Yeung SC, Go R, Balasubramanyam A. Rectal administration of iodide and propylthiouracil in the treatment of thyroid storm. Thyroid 1995; 5:403.

Saturday, June 5, 2021

HBO in CO

 Q: What are the indications for hyperbaric oxygen in carbon mono-oxide (CO) poisoning?

Answer: There are two major interventions required in the acute management of CO poisoning.

  1. Removal of the source
  2. Oxygen

Hyperbaric oxygen if available should be considered in the following situations:

  • CO level >25% 
  • CO level >20% in pregnant patients 
  • Loss of consciousness 
  • PH less than 7.1 by arterial blood gas (ABG) 
  • End-organ ischemia evident by EKG changes, chest pain, encephalopathy, and others
#toxicology



References:

1. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998; 339:1603. 

2. Hampson NB, Dunford RG, Kramer CC, Norkool DM. Selection criteria utilized for hyperbaric oxygen treatment of carbon monoxide poisoning. J Emerg Med 1995; 13:227. 

3. Huang CC, Ho CH, Chen YC, et al. Hyperbaric Oxygen Therapy Is Associated With Lower Short- and Long-Term Mortality in Patients With Carbon Monoxide Poisoning. Chest 2017; 152:943.

4. Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy. Intensive Care Med 1991; 17:289.

Friday, June 4, 2021

Dapto in MRSA CNS infections

 Q: Daptomycin is a good alternative to vancomycin if required to use in MRSA meningitis?

A) True

B) False


Answer: B

Daptomycin has no role in Central Nervous System (CNS) infections. It has very poor penetration into the cerebrospinal fluid (CSF). This is due to two reasons. First, it has a high molecular mass, and second, it is highly protein-bound. Unlike other drugs, meningeal inflammation does not increase its CSF penetration. 

Also, it is not a good choice in pneumonia as it gets inactivated by alveolar surfactants. It has its the best value in skin and soft tissue infections with Methicillin-resistant Staphylococcus aureus (MRSA).

#ID


References:

1. Piva S, Di Paolo A, Galeotti L, et al. Daptomycin Plasma and CSF Levels in Patients with Healthcare-Associated Meningitis. Neurocrit Care 2019; 31:116. 

2. Kullar R, Chin JN, Edwards DJ, et al. Pharmacokinetics of single-dose daptomycin in patients with suspected or confirmed neurological infections. Antimicrob Agents Chemother 2011; 55:3505. 

3. Silverman JA, Mortin LI, Vanpraagh AD, et al. Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact. J Infect Dis 2005; 191:2149.

Thursday, June 3, 2021

HH

 Case: 33 years old male with no past medical history is admitted to ICU with Diabetes Ketoacidosis (DKA). On examination, he is found to have skin hyperpigmentation and pedal edema. Labs were remarkable for severe transaminitis. Patient reports overuse of elements and vitamins. The presumptive diagnosis of  Hereditary Hemochromatosis (HH) is made on the basis of family history and further lab testing. Out of the following which diagnostic test should be ordered next? (select one)

A) Echocardiogram

B) Liver biopsy


Answer: A

Hereditary Hemochromatosis (HH) is the most common genetic disorder in the world. This is due to the mutations in the HH gene known as HFEThis leads to increased intestinal iron absorption and total-body iron overload. In recent years over ingestion of over-the-counter vitamins became a concern for more symptomatic presentations for these patients.

A liver biopsy is not required for the diagnosis of HH. Estimation by MRI for iron stores can be done in the majority of the patients. Echocardiography should be done as cardiac iron overload may lead to dilated cardiomyopathy, as evident in our patient with pedal edema.

DKA can be a presenting symptom due to pancreatic infiltration.

#endocrinology

#hepatology

#cardiology

#metabolism


References:

1. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 31-1994. A 25-year-old man with the recent onset of diabetes mellitus and congestive heart failure. N Engl J Med 1994; 331:460. 

2. Raju K, Venkataramappa SM. Primary Hemochromatosis Presenting as Type 2 Diabetes Mellitus: A Case Report with Review of Literature. Int J Appl Basic Med Res. 2018;8(1):57-60. doi:10.4103/ijabmr.IJABMR_402_16 

3. Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS; American Association for the Study of Liver Diseases. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology. 2011 Jul;54(1):328-43. doi: 10.1002/hep.24330. PMID: 21452290; PMCID: PMC3149125.

Wednesday, June 2, 2021

Erythromycin site of action as a motility agent

 Q: Erythromycin is frequently used in ICU as a motility agent. Which part of the stomach it works upon? (select one)

A) cardia

B) fundus

C) body

D) pyloric antrum

E) pyloric canal


Answer: B

Erythromycin is frequently used as a motility agent in ICU as it is a motilin agonist. It works mostly in the stomach as a gastric emptying agent by inducing high-amplitude gastric propulsive contractions. It works mostly at the fundus region which helps in suppressing the fundus' accommodative response after the enteral feed. The lowest starting dose should be used i.e., 40 mg prior to a meal or three times a day to avoid tachyphylaxis which may occur quickly with 250 mg dose three times a day. 

Some institutions follow a proper algorithm for gastroparesis.

#GI


References:

1. Keshavarzian A, Isaac RM. Erythromycin accelerates gastric emptying of indigestible solids and transpyloric migration of the tip of an enteral feeding tube in fasting and fed states. Am J Gastroenterol 1993; 88:193. 

2. Camilleri M. Clinical practice. Diabetic gastroparesis. N Engl J Med 2007; 356:820.

Tuesday, June 1, 2021

Quinolones side effects

 Q: Name at least five side effects of fluoroquinolone that should be kept in mind for ICU/hospitalized patients? 

Answer:

1. prolong QTc interval which may become fatal with electrolyte abnormalities and concomitant use of other drugs causing QTc prolongation

2. increased risk of aortic aneurysm and dissection - this risk may persist for about eight weeks after use. It should be avoided in elderly patients with such a history or with severe vascular diseases such as Marfan syndrome

3. malregulation of glucose level causing hyper and/or hypoglycemia

4. increased risk of CNS effects including seizures, increased intracranial pressure (pseudotumor cerebri), lightheadedness, and tremors

5. increased risk of peripheral neuropathy - we included this side effect here as this can be irreversible

6. increased risk of psychiatric issues such as toxic psychosis, hallucinations, paranoia, agitation, restlessness, delirium, insomnia, anxiety, memory impairment, confusion, depression, and suicidal thoughts

7. increased risk of tendinopathy in patients on chronic steroid, renal insufficiency or solid organ transplant recipients


#pharmacology


References:

1. Stahlmann R, Lode H. Toxicity of quinolones. Drugs. 1999;58 Suppl 2:37-42. doi: 10.2165/00003495-199958002-00007. PMID: 10553703.

2. Friedrich LV and Dougherty R, “Fatal Hypoglycemia Associated With Levofloxacin,” Pharmacotherapy, 2004, 24(12):1807-12.

3. Khaliq Y and Zhanel GG. Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature. Clin Infect Dis. 2003;36(11):1404-1410

4. Lawrence KR, Adra M, Keir C. Hypoglycemia-Induced Anoxic Brain Injury Possibly Associated With Levofloxacin. J Infect. 2006;52(6):e177-e180.

5. Lee CC, Lee MG, Hsieh R, et al. Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 2018;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067

Monday, May 31, 2021

Calcium in tyhroid storm

 Q: Which is more common in thyroid storm?

A) Hypercalcemia 

B) Hypocalcemia


Answer: A

There is only one specific laboratory marker in thyroid storm i.e., low TSH and high free T4 and/or T3. All other laboratory findings are non-specific but help in making the diagnosis. One of such non-specific but important laboratory findings is hypercalcemia though mostly at a milder level. This is due to increased bone resorption and hemoconcentration. 

Other associated findings can be hyperglycemia and abnormal LFT. Interestingly, CBC can have either leukocytosis or leukopenia.

#endocrine


Reference:

Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 2006; 35:663.

Sunday, May 30, 2021

simethicone add in the bowel preparation

 Q: 58 years old male is admitted to ICU with lower gastrointestinal bleed (LGIB). Consulting service requests to add simethicone to the bowel preparation. What is the advantage of adding simethicone to bowel preparation? 

Answer: Visualization during colonoscopy can be restricted due to the high gas bubbles burden. Simethicone is used during the procedure to reduce gas bubbles. Simethicone use in the midst of the procedure carries an inherent risk of contamination. This persists despite proper procedures followed for disinfection and reprocessing methods. This objective can be achieved by adding simethicone to the bowel preparation before the procedure./span>

#procedures


References:

1. Barakat MT, Huang RJ, Banerjee S. Simethicone is retained in endoscopes despite reprocessing: impact of its use on working channel fluid retention and adenosine triphosphate bioluminescence values (with video). Gastrointest Endosc 2019; 89:115. 

2. Moraveji S, Casner N, Bashashati M, et al. The role of oral simethicone on the adenoma detection rate and other quality indicators of screening colonoscopy: a randomized, controlled, observer-blinded clinical trial. Gastrointest Endosc 2019; 90:141.

Saturday, May 29, 2021

Griffiths' point

 Q: What is Griffiths' point? 

Answer: The two most high-risk areas in intestinal ischemia are splenic flexure and rectosigmoid junction. 

Griffiths' point is the area for splenic flexure which is the cause of concern. It is defined as the site of communication of the ascending left colic artery (LCA) with the marginal artery (MA) of Drummond, and anastomotic bridging between the right and left terminal branches of the ascending LCA at the splenic flexure of the colon. 

Similarly, the area for concern for rectosigmoid junction is called Sudeck's point, where the descending branch of the LCA makes an anastomosis with the superior branches of the rectal artery, also known as hemorrhoidal artery.  

#surgical-critical-care


References:

1. Meyers MA. Griffiths' point: critical anastomosis at the splenic flexure. Significance in ischemia of the colon. AJR Am J Roentgenol 1976; 126:77.

2. van Tonder JJ, Boon JM, Becker JH, van Schoor AN. Anatomical considerations on Sudeck's critical point and its relevance to colorectal surgery. Clin Anat 2007; 20:424.




Friday, May 28, 2021

ETOH and acetaminophen toxicity

Q: Ingestion of alcohol and acetaminophen together increases the risk of acute acetaminophen toxicity by many folds?

A) True

B) False


Answer: B

It may be of surprise but acute alcohol ingestion may be protective against acute acetaminophen toxicity. This is due to the fact that alcohol is a substrate of the CYP2E1 enzyme. It may lower the risk by almost two-third. Alcohol competes with acetaminophen for CYP2E1 and decreases the amount of NAPQI produced. 

CYP2E1 is a member of the cytochrome P450 mixed-function oxidase system, and NAPQI is N-acetyl-p-benzoquinone imine, a toxic byproduct produced during acetaminophen metabolism.

#toxicology


References:

1. Thummel KE, Slattery JT, Nelson SD. Mechanism by which ethanol diminishes the hepatotoxicity of acetaminophen. J Pharmacol Exp Ther 1988; 245:129. 

2. Slattery JT, Nelson SD, Thummel KE. The complex interaction between ethanol and acetaminophen. Clin Pharmacol Ther 1996; 60:241. 

3. Waring WS, Stephen AF, Malkowska AM, Robinson OD. Acute ethanol coingestion confers a lower risk of hepatotoxicity after deliberate acetaminophen overdose. Acad Emerg Med 2008; 15:54.

Thursday, May 27, 2021

components of delirium

 Q: What are the five components to define delirium?

Answer: Over the last two decades delirium has been identified as one of the most influential factors in short and long-term outcomes of hospitalized patients. By definition it should have five components:

  • acute
  • potentially reversible 
  • impairment of consciousness 
  • impairment of cognitive function 
  • fluctuates in severity

It is of vital importance to understand the statement that "Delirium is an organic mental syndrome." It is defined as: "an acute and potentially reversible impairment of consciousness and cognitive function that fluctuates in severity."

#neurology


Reference:

Hansen-Flaschen J. Improving patient tolerance of mechanical ventilation. Challenges ahead. Crit Care Clin 1994; 10:659.

Wednesday, May 26, 2021

ESR for age

 Q: What's the formula to correct Erythrocyte Sedimentation Rate (ESR) for age?

Answer: Non-specific or benign elevation in ESR can occur in the following situations: 

  • age 
  • female gender 
  • anemia 
  • kidney disease 
  • obesity 
  •  Labs high temperature (common in hot climate) 

Age and female sex are the most common causes in the population for an isolated non-specific elevated ESR. The ballpark (not very specific) formulae to correct the upper limit of the reference range of ESR are 

Men = (age in years)/2 

Female = (age in years + 10)/2

#lab-science


References:

1. Miller A, Green M, Robinson D. Simple rule for calculating normal erythrocyte sedimentation rate. Br Med J (Clin Res Ed) 1983; 286:266. 

2. Arik N, Bedir A, Günaydin M, et al. Do erythrocyte sedimentation rate and C-reactive protein levels have diagnostic usefulness in patients with renal failure? Nephron 2000; 86:224. 

3. Leff RD, Akre SP. Obesity and the erythrocyte sedimentation rate. Ann Intern Med 1986; 105:143.

Tuesday, May 25, 2021

Treatment in serotonin Syndrome

 Q: All of the following should be avoided as a treatment in serotonin syndrome EXCEPT? (select one) 

A) Chlorpromazine 

B) Benzodiazepine 

C) Propranolol 

D) Bromocriptine 

E) Dantrolene


Answer: B

Except for sedation (benzodiazepine), discontinuation of an offending drug, and supportive treatment, none of the treatments has shown any benefit in serotonin syndrome. Although cyproheptadine is widely used, it has a very weak evidence of direct benefit. Due to its low-risk, it is ok to use as benefit outweighs the risk.

Chlorpromazine can worsen hyperthermia of serotonin syndrome (choice A).

Propranolol with its long duration of action may mask tachycardia and misguide clinicians (choice C). 

Bromocriptine is also found to make serotonin syndrome worse (choice D). 

Dantrolene is the treatment for malignant hyperthermia and has no role in serotonin syndrome (choice E).

#neurology


References:

1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112. 

2. Nisijima K, Shioda K, Yoshino T, et al. Diazepam and chlormethiazole attenuate the development of hyperthermia in an animal model of the serotonin syndrome. Neurochem Int 2003; 43:155. 

3. Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med 1998; 16:615.

Monday, May 24, 2021

Remdesivir in organ failures

 Q: Remdesivir should be given to patients with caution in? (select one)

A) Liver insufficiency

B) Kidney insufficiency

C) Both liver and kidney insufficiencies

D) Irrespectively all COVID 19 patients should get it


Answer: C

Remdesivir has become one of the mainstays of the treatment in COVID-19. Remdesivir's contraindication in liver insufficiency is well-known. The objective of this question is to highlight its effect with renal insufficiency. Remdesivir itself is not harmful to the kidney. Actually, the vehicle in which it is prepared i.e., cyclodextrin can accumulate in renal insufficiency and may become toxic for the body. So far there is no established quantification. At this point, it is recommended to be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min per 1.73 m2. Said that a decision should be made clinically per individual patient. 

If a clinician decides to use Remdesivir in a patient on continuous renal replacement therapy (CRRT), hemodialysis (HD), or extracorporeal membrane oxygenation (ECMO), no dose adjustment is required. In fact, it may require a higher dose due to its potential of removal or sequestration. A pharmacist should be consulted. Moreover, Remdesivir should not be prescribed with hydroxychloroquine or chloroquine. It may cause a fatal drug interaction.

#pharmacology

#COVID-19

#nephrology


References:

1. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/214787Orig1s000lbl.pdf (Accessed on May 23, 2021). 

2. Chaijamorn W, Rungkitwattanakul D, Nuchtavorn N, et al. Antiviral Dosing Modification for Coronavirus Disease 2019-Infected Patients Receiving Extracorporeal Therapy. Crit Care Explor. 2020;2(10):e0242. Published 2020 Oct 1. doi:10.1097/CCE.0000000000000242

3. Adamsick ML, Gandhi RG, Bidell MR, et al. Remdesivir in Patients with Acute or Chronic Kidney Disease and COVID-19. J Am Soc Nephrol 2020; 31:1384. 

4. Thakare S, Gandhi C, Modi T, et al. Safety of Remdesivir in Patients With Acute Kidney Injury or CKD. Kidney Int Rep 2021; 6:206.

Sunday, May 23, 2021

culture-negative endocarditis and Bartonella

 Q: Describe a few associated risk factors in culture-negative endocarditis where Bartonella should be covered with antibiotics?

Answer:  Bartonella is considered a significant cause of culture-negative endocarditis. Interestingly more than two-third of cases involved are in men. Other risk factors are

  • homelessness
  • alcoholism
  • infestation with body lice 
  • contact with cats
  • valvular heart disease 
  • history of HIV
Clinical significance: Clinical suspicion to cover Bartonella is important in culture-negative endocarditis. It takes time for the blood culture for Bartonella to turn positive. Also, it requires a special stain and PCR to establish the diagnosis. Antibiotic coverage requires doxycycline, aminoglycoside, and +/- ceftriaxone. 

#ID
#cardiology


References:

1. Spach DH, Callis KP, Paauw DS, et al. Endocarditis caused by Rochalimaea quintana in a patient infected with human immunodeficiency virus. J Clin Microbiol 1993; 31:692.

2. Raoult D, Fournier PE, Vandenesch F, et al. Outcome and treatment of Bartonella endocarditis. Arch Intern Med 2003; 163:226.

3. Ghidey FY, Igbinosa O, Mills K, et al. Case series of Bartonella quintana blood culture-negative endocarditis in Washington, DC. JMM Case Rep 2016; 3:e005049. 

4. Fournier PE, Lelievre H, Eykyn SJ, et al. Epidemiologic and clinical characteristics of Bartonella quintana and Bartonella henselae endocarditis: a study of 48 patients. Medicine (Baltimore) 2001; 80:245.

Saturday, May 22, 2021

Fondaparinux and HIT

Q: Fondaparinux like other low molecular weight heparins (LMWH) may cause heparin-induced thrombocytopenia (HIT)? 

A) True 
B) False


Answer: B

Fondaparinux is one of the unique low molecular weight heparins which does not cause HIT. It is an indirect inhibitor of factor Xa, but does not inhibit thrombin and does not interact with platelets or platelet factor 4 (PF-4). Also, Fondaparinux is 100 percent bioavailable after SQ administration. 

Despite these advantages, Fondaparinux never gets much popular in US hospitals due to various reasons. It has a very pretty long half-life of 15-17 hours, and in case of bleeding, there is no specific antidote. It takes three to five half-lives which translates to two to four days till all bleeding risks subside. Also, it gets eliminated via kidney, and renal insufficiency is widely common in ICU patients.

#pharmacology
#hematology


References:

1. Linkins LA, Hu G, Warkentin TE. Systematic review of fondaparinux for heparin-induced thrombocytopenia: When there are no randomized controlled trials. Res Pract Thromb Haemost. 2018 Aug 9;2(4):678-683. doi: 10.1002/rth2.12145. PMID: 30349886; PMCID: PMC6178656. 

2. Warkentin TE, Cook RJ, Marder VJ, et al. Anti-platelet factor 4/heparin antibodies in orthopedic surgery patients receiving antithrombotic prophylaxis with fondaparinux or enoxaparin. Blood 2005; 106:3791. 

3. Warkentin TE. Fondaparinux: does it cause HIT? Can it treat HIT? Expert Rev Hematol. 2010 Oct;3(5):567-81. doi: 10.1586/ehm.10.54. PMID: 21083474.

Friday, May 21, 2021

corticosteroids in CNS toxoplasmosis

 Q: What is the caveat of using corticosteroids during the management of CNS toxoplasmosis?

Answer: It is not absolutely necessary to add corticosteroids in the management of toxoplasmosis. It should be used judiciously if there is a mass effect in the brain, edema or midline shift. 

Corticosteroids can deceive the actual underlying progress of the patients' response by rapidly improving only the symptoms. It reduces the ring enhancement and surrounding edema, but may also lead to secondary opportunistic infections, which can be detrimental in these immunocompromised patients.

#ID


References:

1. Sonneville R, Schmidt M, Messika J, Ait Hssain A, da Silva D, Klein IF, Bouadma L, Wolff M, Mourvillier B. Neurologic outcomes and adjunctive steroids in HIV patients with severe cerebral toxoplasmosis. Neurology. 2012 Oct 23;79(17):1762-6. doi: 10.1212/WNL.0b013e3182704040. Epub 2012 Oct 10. PMID: 23054235. 

2. Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care. 2019;18:2325958219867315. doi:10.1177/2325958219867315

Thursday, May 20, 2021

lithium toxicity

 Q: EKG changes in lithium toxicity can be fatal? 

A) True

B) False


Answer: B

Despite EKG changes, cardiac events are rare in acute or chronic lithium toxicity. It is actually neurological symptoms that are more worrisome. Common EKG findings are bradycardia with flattened T waves and prolonged QTc intervals. 

Acute lithium toxicity causes nausea, vomiting, and diarrhea. Hydration in this phase is of clinical importance as dehydration can exacerbate lithium toxicity and lead to acute kidney failure. 

Neurologic findings imply a late phase of toxicity. It may cause confusion, agitation, tremors, fasciculations, myoclonic jerks, and seizures. Hemodialysis is indicated.

#toxicology


References:

1. Demers RG, Heninger GR. Electrocardiographic T-wave changes during lithium carbonate treatment. JAMA 1971; 218:381. 

2. Offerman SR, Alsop JA, Lee J, Holmes JF. Hospitalized lithium overdose cases reported to the California Poison Control System. Clin Toxicol (Phila) 2010; 48:443. 

3. Adityanjee, Munshi KR, Thampy A. The syndrome of irreversible lithium-effectuated neurotoxicity. Clin Neuropharmacol 2005; 28:38. 

4. Rose SR, Klein-Schwartz W, Oderda GM, et al. Lithium intoxication with acute renal failure and death. Drug Intell Clin Pharm 1988; 22:691.

Wednesday, May 19, 2021

Carbamazepine overdose

 Q: Which of the following drug has no role in the management of Carbamazepine acute toxicity?

A) sodium bicarbonate 

B) diazepam 

C) propofol 

D) phenytoin 

 E) activated charcoal


Answer: D

The major concern in Carbamazepine overdose is QRS interval prolongation leading to fatal arrhythmias. The treatment is sodium bicarbonate to keep QRS interval below 110 milliseconds (choice A).

Seizure secondary to carbamazepine is best treated with benzodiazepines and if frequent boluses of benzodiazepines are required, the patient should be intubated and started on continuous infusion of propofol (Choices B and C).

Phenytoin has no role in Carbamazepine-induced seizure (choice D).

Like any other acute pharmacological toxic ingestion activated charcoal should be utilized for gastrointestinal decontamination (choice E).

#toxicology


References:

1. Spiller HA, Krenzelok EP, Cookson E. Carbamazepine overdose: a prospective study of serum levels and toxicity. J Toxicol Clin Toxicol. 1990;28(4):445-58. doi: 10.3109/15563659009038587. PMID: 2269999. 

2. Al Khalili Y, Sekhon S, Jain S. Carbamazepine Toxicity. 2021 Feb 15. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29939629.

Tuesday, May 18, 2021

vasospasm SAH

 Q: Which group of patients is more prone to have vasospasm after subarachnoid hemorrhage (SAH)? (select one)

A) less than 50 years of age

B) more than 50 years of age


Answer: A

The risk and the severity of vasospasm after SAH depends on the following factors 
  • severity of bleed 
  • proximity to the major intracerebral blood vessels
  • higher grade on Fisher and Claassen scales
  • age less than 50 years (due to higher capacity of vascular tone & elasticity)
  • hyperglycemia 
  • higher Glasgow coma scale score
Vasospasm follows SAH around day 3 and usually peaks at days 7 or 8. This lag is due to spasmogenic substances produced by the lysis of subarachnoid blood.

#neurology
#Neurosurgery


Reference:

Charpentier C, Audibert G, Guillemin F, et al. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke 1999; 30:1402.

Monday, May 17, 2021

Rx postpartum thyroiditis

 Q: 32 years old female is admitted to ICU with urosepsis. She is also found to be in postpartum thyroiditis. Which should be the first line of treatment besides management for urosepsis? 

A) propranolol

B) methimazole

C) propylthiouracil

D) radiation


Answer: A

Direct anti-thyroid management including methimazole, propylthiouracil, and radiation has no value in postpartum thyroiditis, also known as destructive thyroiditis. The synthesis of T4 and T3 is actually decreased in contrast to other hyperthyroid states. Condition is usually self-limiting and requires only symptomatic treatment. 

Propranolol is highly plasma protein-bound. This gives the advantage of minimal concentration in breast milk, and is a choice of beta-blocker in postpartum females. 

#endocrinology

#Ob-Gyn

#pharmacology


References:

1. Stagnaro-Green A. Postpartum thyroiditis. Best Pract Res Clin Endocrinol Metab. 2004 Jun;18(2):303-16. doi: 10.1016/j.beem.2004.03.008. PMID: 15157842. 

2. Beardmore KS, Morris JM, Gallery ED. Excretion of antihypertensive medication into human breast milk: a systematic review. Hypertens Pregnancy 2002; 21:85.

Sunday, May 16, 2021

Abdominal exam

  Q: During abdominal exam which step is preferred to be performed first? (select one)

A) Percussion 

 B) Palpation


Answer: A

Although there is no hard and fast rule in this regard, experts recommend starting an abdominal exam with gentle percussion. Palpation, particularly over the most tender area, may quickly lead to abdominal muscle guarding making further examination difficult on an unwilling patient. 

Gentle percussion will allow identifying mass or organomegaly with dullness, distended bowel with tympany, and ascites with shifting dullness. 

 If palpation is carried out first, it should be started from the quadrant with the least complaint to avoid abdominal rigidness.


#physical-exam

#GI


Reference:

Reuben A. Examination of the abdomen. Clin Liver Dis (Hoboken). 2016;7(6):143-150. Published 2016 Jun 28. doi:10.1002/cld.556

Saturday, May 15, 2021

polyarticular gout

 Q: 42 years old male is admitted to ICU with possible polyarticular septic arthritis. Subsequent workup turned it out to be gout instead of sepsis. Initial gout presentation can be polyarticular in which conditions?

Answer: In primary gout, the initial presentation is mostly uniarticular but polyarticular gout can happen in few conditions where hyperuricemia occurs. The two most prominent clinical situations are:

1. Myeloproliferative disorder or lymphoproliferative disorder. This was first described more than five decades ago.

2. Patients on immunosuppressant drugs such as cyclosporine or tacrolimus. Cyclosporine is more common than tacrolimus to cause polyarticular gout, and in few cases switching cyclosporine to tacrolimus may help. 

Another feature of polyarticular gout flare is its sequential or migratory nature. It may also occur in a cluster form i.e., involving adjacent joints, tendons, and bursas.


#rheumatology


References:

1. Yü TF. Secondary gout associated with myeloproliferative diseases. Arthritis Rheum 1965; 8:765.

2. Stamp L, Searle M, O'Donnell J, Chapman P. Gout in solid organ transplantation: a challenging clinical problem. Drugs. 2005;65(18):2593-611. doi: 10.2165/00003495-200565180-00004. PMID: 16392875.

Friday, May 14, 2021

vitamin k

 Q: Vitamin K absorption requires which organ to be properly functional? (select one)

A) Pancreas

B) Kidney

 

Answer: A

Once oral Vitamin K is taken its absorption requires three properly working functions:

  • pancreatic 
  • biliary 
  • fat absorption
Vitamin K is protein-bound as it reaches the intestine. Pancreatic enzymes in the small intestine through proteolytic action cleave vitamin K from protein. Once liberated, vitamin K solubilizes into mixed micelles by bile salts. These mixed micelles get absorbed into enterocytes, where they are incorporated into chylomicrons, facilitating absorption into the intestinal lymphatics and portal circulation.

#GI
#vitamins
#hematology


Reference:

1. Food and Nutrition Board of the Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2000). National Academies Press, Washington DC, 2000. p. 162-196 http://books.nap.edu/openbook.php?isbn=0309072794 (Accessed on April 29, 2021)

Thursday, May 13, 2021

AA and cardiac temponade

 Q: Why the perforation of proximal ascending aorta can cause cardiac tamponade? 

Answer: This is due to the anatomic location of the aortic root and first 10 cm of the ascending aorta, which lies within the pericardium. 

This is a surgical emergency. Without an appropriate workup, proceeding to pericadiocentesis just on the basis of echocardiography is not a prudent thing to do. Sole pericardiocentesis should be avoided as it may instantly lead to death due to increase tear of the aorta. Clinical presentation and other radiological findings should be carried out if time permits otherwise emergent call to OR is needed.

#surgical-critical-care

#cardiology


Reference:

1. Guo R, Feng YM, Wan D. Hemorrhagic cardiac tamponade complicated by acute type A aortic dissection: A case report with critical care ultrasound findings. Medicine (Baltimore). 2017;96(49):e8773. doi:10.1097/MD.0000000000008773 

2. Ryu, D.W., Lee, M.K. Cardiac tamponade associated with delayed ascending aortic perforation after blunt chest trauma: a case report. BMC Surg 17, 70 (2017). https://doi.org/10.1186/s12893-017-0266-2

Wednesday, May 12, 2021

PPI and magnesium

 Q: Use of proton pump inhibitor (PPI) in ICU may cause? (select one) 

A) hypomagnesemia 

B) hypermagnesemia


Answer: A

There are many reasons for hypomagnesemia in ICU. These include diarrhea, history of alcohol use, PPI use, and diuretics. Hypomagnesemia may lead to unexplained hypocalcemia or refractory hypokalemia. This may also cause cardiac arrhythmias and neuromuscular disturbances.

#electrolytes

#pharmacology


Reference:

1. Florentin M, Elisaf MS. Proton pump inhibitor-induced hypomagnesemia: A new challenge. World J Nephrol. 2012;1(6):151-154. doi:10.5527/wjn.v1.i6.151

2. Semb S, Helgstrand F, Hjørne F, Bytzer P. Persistent severe hypomagnesemia caused by proton pump inhibitor resolved after laparoscopic fundoplication. World J Gastroenterol. 2017;23(37):6907-6910. doi:10.3748/wjg.v23.i37.6907

Tuesday, May 11, 2021

Glucagon adjuvant treatment

 Q: 52 years old female admitted to ICU with an intentional overdose of metoprolol. IV glucagon has been planned as an antidote. Which one adjuvant treatment may be helpful to counter the side effect of glucagon?

Answer: antiemetic 

Despite weak evidence,  glucagon is frequently getting used in beta-blockers overdose. Glucagon should be given as a slow bolus followed by a continuous infusion. Glucagon activates adenylate cyclase causing an increase in adenosine 3'-5'-cyclic monophosphate (cAMP). Elevations in cAMP increase the intracellular calcium which augments contractility. 

Glucagon is known to induce vomiting. It may be helpful to add an antiemetic like ondansetron.

#toxicology


References:

1. Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol 2003; 41:595. 

2. Boyd R, Ghosh A. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta blocker overdose. Emerg Med J 2003; 20:266.

3. Ranganath L, Schaper F, Gama R, Morgan L. Mechanism of glucagon-induced nausea. Clin Endocrinol (Oxf). 1999 Aug;51(2):260-1. doi: 10.1046/j.1365-2265.1999.00845.x. PMID: 10469001.

Monday, May 10, 2021

ASA and ACE-I angioedema

 Q: Aspirin is a good adjuvant treatment for Angiotensin-Converting Enzyme Inhibitor (ACE-I) induced angioedema?

A) True

B) False


Answer: B

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) are risk factors to increase the likelihood of angioedema in patients taking ACE-I. Other risk factors include: 

  • Age over 65 years 
  • Female gender 
  • Tobacco history
  • History of seasonal allergies 
  • Previous episodes of angioedema
#allergy-immunology
#pharmacology


References:

1. Kostis JB, Kim HJ, Rusnak J, et al. Incidence and characteristics of angioedema associated with enalapril. Arch Intern Med 2005; 165:1637.

2. Banerji A, Clark S, Blanda M, et al. Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol 2008; 100:327. 

3.Hoover T, Lippmann M, Grouzmann E, et al. Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors. Clin Exp Allergy 2010; 40:50.

Sunday, May 9, 2021

Ascites and SBP

 Q:  The removal of ascitic fluid helps in decreasing the odds of spontaneous bacterial peritonitis (SBP)? 

A) True

B) False


Answer: A

Removal of ascitic fluid turns ascitic fluid opsonins more concentrated. This decreases the odds of SBP. 

A less tense abdomen also protects against the development of cellulitis and abdominal wall hernia. There is also less risk of developing hydrothorax by decreasing the chances of diaphragmatic rupture. Another less known effect is reduced expenditure of energy to heat the ascitic fluid. 

 Above said, despite all these benefits, there is no solid evidence that it improves underlying mortality.


#hepatology

#ID


References:

1. Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology 1986; 6:396. 

2. Runyon BA, Antillon MR, McHutchison JG. Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis. J Hepatol 1992; 14:249. 

3. Dolz C, Raurich JM, Ibáñez J, et al. Ascites increases the resting energy expenditure in liver cirrhosis. Gastroenterology 1991; 100:738.

Saturday, May 8, 2021

palmar erythema

 Q: The palmar erythema in cirrhosis is more prominent on? (select one) 

A) thenar eminence 

B) hypothenar eminence


Answer: B

The objective of this question is to enhance the importance of astute physical exams at the bedside. The presence of palmar erythema helps to confirm the diagnosis. Cirrhosis is one of the diseases which presents a wide range of physical findings. Few dermatological signs in cirrhosis are popularly known as 'stigmata of cirrhosis', and include spider angioma, palmar erythema, and abdominal wall collaterals. The palmar erythema is usually blotchy and patchy. It is more prominent on the hypothenar eminence. This palmar erythema spares the center of the palm. These findings are relatively easily identifiable on fair skin patients. 

Palmar erythema can be present in other diseases besides cirrhosis including Wilson's disease, neoplasms, and diabetes. Pregnant patients may also develop it transiently. 

#physical-exam

#hepatology


References:

 1. Serrao R, Zirwas M, English JC. Palmar erythema. Am J Clin Dermatol. 2007;8(6):347-56. doi: 10.2165/00128071-200708060-00004. PMID: 18039017.

2. Kakehashi R, Watanabe S, Ikoma J, Suzuki S. [Clinical symptoms of patients with liver cirrhosis]. Nihon Rinsho. 1994 Jan;52(1):40-4. Japanese. PMID: 8114308.

Friday, May 7, 2021

VITT

 Q: Patients developing severe thrombosis after the COVID-19 vaccine should be treated with heparin?

A) True

B) False


Answer: B

Vaccine-induced thrombotic thrombocytopenia (VITT) has been reported after the COVID-19 vaccine, particularly after adenovirus-based COVID-19 vaccines. This condition should be treated as Heparin-Induced Thrombocytopenia (HIT). Although there is no exposure to heparin clinical behavior is the same. Moreover, there are reports that patients deteriorate after receiving heparin in VITT. In these patients, it would be prudent to do anticoagulation only with non-heparin agents. In severe cases, intravenous immune globulin (IVIG) should be considered early in the case. 

Another important aspect is to follow the fibrinogen level. if it is below 100, consideration should be given to transfuse via blood product or synthetic version of fibrinogen. Alike all HIT patients, platelet transfusions should be avoided unless the bleeding is life-threatening. A hematologist should be on board to guide these unfortunate complex patients.


#COVID-19

#hematology


References:

1. Greinacher A, Thiele T, Warkentin TE, et al. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med 2021. 

2. https://www.hematology.org/covid-19/vaccine-induced-immune-thrombotic-thrombocytopenia (Accessed on May 6, 2021). 

3. https://b-s-h.org.uk/media/19530/guidance-version-13-on-mngmt-of-thrombosis-with-thrombocytopenia-occurring-after-c-19-vaccine_20210407.pdf (Accessed on May 6, 2021).

Thursday, May 6, 2021

Insulin resistance in COVID

 Q: Insulin resistance in COVID-19 is found to correlate with inflammatory markers? 

A) True 

B) False 


Answer:

One of the relatively less described subjects in hospitalized COVID-19 patients is cytokine-induced severe insulin resistance. This becomes even more important with the addition of dexamethasone in the treatment of the COVID-19. Moreover, the risk of hypoglycemia also becomes high as COVID-19 improves or nutritional status changes during hospitalization. This requires very close monitoring. Fortunately, insulin resistance is found to correlate with inflammatory markers of COVID-19, particularly IL-6. 

Or vice versa, insulin resistance itself can be a sign of poor outcome in COVID-19.


#COVID-19

endocrinology


References:

1. Wu L, Girgis CM, Cheung NW. COVID-19 and diabetes: Insulin requirements parallel illness severity in critically unwell patients. Clin Endocrinol (Oxf) 2020; 93:390.

2. Ren H, Yang Y, Wang F, et al. Association of the insulin resistance marker TyG index with the severity and mortality of COVID-19. Cardiovasc Diabetol 2020; 19:58.

Wednesday, May 5, 2021

Tramadol

 Q: Tramadol is frequently used in ICUs. It can cause respiratory depression?

A) Yes

B) No


Answer: A

Tramadol is a part of various post-operative protocols as an analgesic. Providers should be aware that it comes with some inherent risks like respiratory depression. It is available as intravenous injection, immediate-release, and extended-release tablets. In ICUs, its administration may concurrently occur with benzodiazepines or other CNS depressants. This can be potentially fatal in a non-intubated patient. Tramadol also increases the risk of seizures.

Staff should be instructed that tramadol tablet or capsule particularly extended-release should not be split, break, chew, crush, or dissolve. 

 #pharmacology 

#surgical-critical-care


 Reference: 

 1. Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2020 Aug 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/

2. Stamer UM, Stüber F, Muders T, Musshoff F. Respiratory depression with tramadol in a patient with renal impairment and CYP2D6 gene duplication. Anesth Analg. 2008 Sep;107(3):926-9. doi: 10.1213/ane.0b013e31817b796e. PMID: 18713907.

3. Minkowitz H, Leiman D, Lu L, et al. IV Tramadol - A New Treatment Option for Management of Post-Operative Pain in the US: An Open-Label, Single-Arm, Safety Trial Including Various Types of Surgery. J Pain Res. 2020;13:1155-1162. Published 2020 May 22. doi:10.2147/JPR.S251175

Tuesday, May 4, 2021

sch in pregnancy

 Q: Succinylcholine should be given to a pregnant patient depending on total body weight? 

A) True 

B) False 


Answer:

Dose of succinylcholine is given based on total body weight. Interestingly, this is true for pregnant patients too. This is due to the fact that overestimation of the dose of succinylcholine causes the same level of paralysis. One of the caveat is that duration of action of succinylcholine is longer in pregnant women. Serum cholinesterase activity is 30% less in pregnant females and immediate postpartum females. 

Recommended dose in these patients is 1.0 mg/kg.

#ob-gyn

#pharmacology

#procedures


References:

1. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483. 

2. Patanwala AE, Sakles JC. Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department. Emerg Med J 2017; 34:739. 

3. Gyasi HK, Mohy O, Abu-Gyamphi, Naquib M. Plasma cholinesterase level in Pregnancy-effect of enzyme activity on the duration of action of succinylcholine. Middle East J Anesthesiol 1986;8:379-85. 

4. Leighton BL, Cheek TG, Gross JB, Apfelbaum JL, Shantz BB, Gutsche BB, et al. Succinylcholine pharmacodynamics in peripartum females Anesthesiology 1986;64:202-5 

5. Rasheed MA, Palaria U, Bhadani UK, Quadir A. Determination of optimal dose of succinylcholine to facilitate endotracheal intubation in pregnant females undergoing elective cesarean section. J Obstet Anaesth Crit Care 2012;2:86-91

Monday, May 3, 2021

Yersinia enterocolitica and blood disorder

 Q; 19 years old adolescent male with some kind of blood disorder (not known to his roommate) is brought to ICU from a college dorm with sepsis-like symptoms. Subsequent workup led to the diagnosis of yersiniosis. Patients with which blood disorder are more prone to have yersiniosis?  

Answer: Thalassemia

Yersinia is ferrophilic (iron-loving). Thalassemia patients frequently develop iron overload due to frequent blood transfusions. Said that patients with thalassemia can develop severe yersiniosis without very high iron load. The reason for this phenomenon is not understood. 

Other risk factors are undercooked/raw pork products, un-sanitized water, cirrhosis, hemochromatosis, aplastic anemia, thalassemia, malignancy, diabetes, malnutrition, and gastrointestinal illnesses.

#ID
#hematology


Reference:

Adamkiewicz TV, Berkovitch M, Krishnan C, et al. Infection due to Yersinia enterocolitica in a series of patients with beta-thalassemia: incidence and predisposing factors. Clin Infect Dis 1998; 27:1362.