Q: Patient's platelet count suddenly dropped from 283 k/uL to 25 k/uL. Patient is clinically stable and you expect pseudothrombocytopenia. What would be your instruction to nursing staff while repeating lab?

Answer: Send second blood sample with 'blue top'

Most pseudothrombocytopenia has been reported in association with the use of ethylenediaminetetraacetic acid (EDTA) as an anticoagulant. A second sample run with a different anticoagulant such as citrate (blue top tube) usually helps to rule out the error.

Q: In Dengue virus shock syndrome, what should triggers the blood transfusion?

Answer:

In contrast to other clinical situations, Blood transfusion should be initiated early in hemodynamically unstable patients suffering from Dengue virus shock syndrome,                           in the face of a decreasing hematocrit, rather than following hemoglobin concentration.

WHO (2009). Dengue Guidelines for Diagnosis, Treatment, Prevention and Control: Geneva: World Health Organization. 

Q: 52 year old male while on trip to Arizona encountered Scorpion sting and probable Envenomation. Patient is intubated in field and transferred to ED. Anascorp (only commercially available anti venom for scorpion bite) has been administered. Which factors should keep you on high alert for anaphylactic reaction from Scorpion anti venom administration?

Answer:

Anascorp® is made from equine (horse) plasma. Patients with known allergies to horse protein are particularly at risk for an anaphylactic reaction. Patients who have had previous therapy with Anascorp® or another equine antivenom/antitoxin may have become sensitized to equine proteins and be at risk for a severe hypersensitivity reaction.

GET SMASHED

The mnemonic GETSMASHED is used for common causes of Pancreatitis:

G - Gall stones

E - Ethanol

T- Trauma

S - Steroids

M - Mumps

A - Autoimmune

S - Scorpion sting

H - Hyperlipidaemia, Hypothermia, Hyperparathyroidism

E - ERCP

D - Drugs

Q: What is the advantage of intraduodenal feeding beside less chances of aspiration pneumonia?

Answer: Intraduodenal feeding causes

• a stronger GI response than intragastric feeding
• stimulates gallbladder contractions,
• accelerates small bowel transit time, and
• increases cholecystokinin and pancreatic polypeptide release

(In contrast, jejunal feeding does not stimulate pancreatic secretion, as is seen in intragastric or intraduodenal feeding)

 

Reference:

1. Ledeboer M, Masclee AA, Biemond I, Lamers CB. Effect of intragastric or intraduodenal administration of a polymeric diet on gallbladder motility, small-bowel transit time, and hormone release. Am J Gastroenterol. 1998;93:2089–2096

2. Ragins H, Levenson SM, Signer R, Stamford W, Seifter E. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man. Am J Surg. 1973;126:606–614

Q: What is the dose of Methylene blue (MB) in Vasoplegic Syndrome?

Answer: A single dose of IV MB, 2 mg/kg over 20-min infusion. Continuous MB infusion could be an option for patients not responding to a single dose of MB.

Reference:

Leyh RG, Kofidis T, Strüber M, Fischer S, Knobloch K, Wachsmann B, Hagl C,Simon AR, Haverich A. Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2003;125:1426-1431

A note on Magnesium level and Hemolysis

Magnesium concentrates in erythrocytes almost three times more than in serum. Hemolysis can increase plasma magnesium. Hypermagnesemia is expected only in massive hemolysis. The serum Mg is expected to rise by 0.1 mEq/L for every 250 mL of erythrocytes that lyse completely, so hypermagnesemia is expected only with massive hemolysis.

Q: What is the most important clinical relevance of TTKG (The trans-tubular potassium gradient)?

Answer: TTKG is calculated by following formula

TTKG = urine K+ X serum osmolality/serum K+ X urine osmolality

• A TTKG of greater than 8 indicates that aldosterone is present and that the collecting duct is responsive to it.
• A TTKG of less than 5 in the presence of hyperkalemia indicates aldosterone deficiency or resistance.

Q: What is the typical increase in potassium level after usual dose administration of  succinylcholine? 

Answer:  A typical increase of potassium ion serum concentration on administration of succinylcholine is 0.5 mmol per litre

Q: What is the dose of Ketamine in RSI (Rapid Sequence Intubation)?

Answer: Ketamine is given intravenously - 1 to 2 mg/kg. In patients with severe shock, half or even one fourth of dose has been advocated by some.

It has a time to effect of 45 to 60 seconds, and a duration of action of 10 to 20 minutes.

Ketamine has all good properties for use in "awake intubation" or in "possible difficult intubation".  It preserves respiratory drive, has a quick onset of action, good hemodynamic profile and has an analgesic properties. 

The reemergence phenomenon (disturbing dreams) as patient emerges from ketamine-induced anesthesia, limits use of the drug for procedural sedation. Rreemergence phenomena can be decrease with concomitant use of a benzodiazepine

Q: What is the rule of thumb of dosing Argatroban in patients with significant liver dysfunction? 

Answer: Decrease dose by 75%

The dose should be adjusted by aPTT with a target of 1.5-3 times the baseline.

Q: Combination of Argatroban and Warfarin can give falsely very high INR. What would be the best method to know that INR would be in therapeutic range if Argatroban is discontinued? 

Answer: Measurement of chromogenic factor X level

The combination of argatroban and warfarin may raise the INR falsely to value higher than even beyond 5.0. Measuring chromogenic factor X level may help in smooth transition.  Once level of chromogenic factor X is below 40-45%, it typically indicates that the INR will be therapeutic (2-3) when the argatroban is discontinued.

Reference:

Hursting MJ, Lewis BE, Macfarlane DE. (2005). "Transitioning from argatroban to warfarin therapy in patients with heparin-induced thrombocytopenia.". Clin Appl Thromb Hemost 11 (3): 279–87.

Bedside Tracheostomy safe in community hospitals

"Bedside percutaneous tracheotomy can be done in critically ill patients with a low risk of morbidity in the community hospital setting. Among 41 intensive care unit (ICU) patients who underwent the procedure, there was a 2% complication rate and no procedure-related deaths, reported by Dr. Peter Abdelmessieh, from Lenox Hill Hospital in New York City, and colleagues, in a poster presentation at the recent annual meeting of the Society of Critical Care Medicine (SCCM)." 

 See full report here

Q: What is the advise for nursing staff taking care of patient on Ribavarin inhalation therapy?

Answer: 

Pregnant nursing staff or staff planning or anticipating pregnancy should not take care of patient on Ribavarin inhalation therapy. It has shown to cause fetal abnormalities.

Ribavirin is widely distributed in all tissues including brain, CSF and RBC . The volume of distribution of ribavirin is large and the length of time the drug is trapped varies greatly from tissue to tissue. RBCs store ribavirin for the lifetime of the cells, releasing it into the body's systems when old cells are degraded in the spleen.

Q: Why Thiazide diuretics are contraindicated in acute treatment of hypercalcemia?

Answer:  Thiazide diuretics increases the reabsorption of calcium.

 In acute treatment of hypercalcemia, a loop diuretic like furosemide is preferred to co-use with hydration as it increases the calcium excretion.

Q: 72 year old male received Morphine on medical floor and is now apneic. Pt. is DNR and DNI. As you call for Naloxone for reversal, you realized, only IV available is now not working and nursing staff has hard time finding new IV. What would be your next step?

Answer: Administer Naloxone IM or SC while bagging the patient.

If intravenous route is not available, Naloxone can be given via SC or IM route. It can also be administrated via intranasal or via ET route.

Q: Why flumazenil should be use with caution in patients with Cocaine overdose

Answer: Use of flumazenil in the cocaine-intoxicated patient may induce seizures.

It is common for patients to present with simultaneous overdose/abuse of benzodiazepine and cocaine. Administration of flumazenil to patients with benzodiazepine use may become life threatening . Cocaine is a gamma-aminobutyric acid (GABA) antagonist that may be potentiated by flumazenil. 

Q: What is the typical finding to look for in Broncho-Alveolar Lavage (BAL) in AEP (Acute Eosinophilic Pneumonia)? 


Answer: In AEP, in most patients, eosinophils will exceed 20% of cells in Broncho-Alveolar Lavage (BAL) fluid and average 37 to 54%. 



 References:

 Pope-Harman AL, Davis WB, Allen ED, Christoforidis AJ, Allen JN. Acute eosinophilic pneumonia. A summary of 15 cases and review of the literature. Medicine (Baltimore) 1996; 75 (6) 334–342

 Philit F, Etienne-Mastroïanni B, Parrot A, Guérin C, Robert D, Cordier JF. Idiopathic acute eosinophilic pneumonia: a study of 22 patients. Am J Respir Crit Care Med 2002; 166 (9) 1235–1239

Healthcare Personnel Attire in Non-Operating-Room Settings

"BBE Approach"

Bare below the elbows” (BBE): "This article defines BBE as Health Care Professional (HCP’s) wearing of short sleeves, no wristwatch, no jewelry, and no ties during clinical practice. Facilities may consider adoption of a BBE approach to inpatient care as an infection prevention adjunct, although the optimal choice of alternate attire, such as scrub uniforms or other short-sleeved personal attire, remains undefined"

Read full guidelines at  http://www.jstor.org/stable/10.1086/675066

Healthcare Personnel Attire in Non-Operating-Room Settings - infection Control and Hospital Epidemioogy, Vol. 35, No. 2, February 2014

Q: What is the effect of Losartan (Cozaar) and probably other Angiotensin II receptor antagonists (ARBs) on sexual function in patients?

Answer: It improves markedly!

At least two studies have shown that ARBs improve sexual dysfuntion in hypertensive patients markedly.

In one study, 10 weeks of treatment with losartan, 88% of hypertensive males with sexual dysfunction reported improvement in at least one area of sexuality, with overall improvement in sexual satisfaction from 7.3% to 58.5%.

In another study comparing carvedilol (a Beta-Blocker), Valsartan also found to improve sexual function.

References:

1. Llisterri, JL; Lozano Vidal, JV; Aznar Vicente, J; Argaya Roca, M; Pol Bravo, C; Sanchez Zamorano, MA; Ferrario, CM (2001). "Sexual dysfunction in hypertensive patients treated with losartan". The American journal of the medical sciences 321(5): 336–41

2. Fogari, R; Zoppi, A; Poletti, L; Marasi, G; Mugellini, A; Corradi, L (2001). "Sexual activity in hypertensive men treated with valsartan or carvedilol: A crossover study". American journal of hypertension 14 (1): 27–31

Q: What was the major outcome/teaching point from ONTARGET study?

Answer: It is well know that ACE inhibitor drugs slows the progression of diabetic nephropathy. The major outcome of ONTARGET study was that, angiotensin receptor blockers (ARBs), have a similar benefit. However, combination therapy worsen renal outcomes, such as increasing serum creatinine and causing a greater decline in estimated glomerular filtration rate (eGFR).

Reference:

1. The ONTARGET Investigators; Yusuf, S; Teo, KK; Pogue, J; Dyal, L; Copland, I; Schumacher, H et al. (2008). "Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events". New England Journal of Medicine 358 (15): 1547–59.

Q: What is the average normal level of Carbon Mono-Oxide in near properly adjusted gas stoves in average USA household?

Answer: 5 to 15 ppm

0.1 ppm	Natural atmosphere level
0.5 to 5 ppm	Average level in homes
5 to 15 ppm	Near properly adjusted gas stoves in homes

Concentration	Symptoms
35 ppm	Headache and dizziness within six to eight hours of constant exposure
100 ppm	Slight headache in two to three hours
200 ppm	Slight headache within two to three hours; loss of judgment
400 ppm	Frontal headache within one to two hours
800 ppm	Dizziness, nausea, and convulsions within 45 min; insensible within 2 hours
1,600 ppm	Headache, tachycardia, dizziness, and nausea within 20 min; death in less than 2 hours
3,200 ppm	Headache, dizziness and nausea in five to ten minutes. Death within 30 minutes.
6,400 ppm	Headache and dizziness in one to two minutes. Convulsions, respiratory arrest, and death in less than 20 minutes.
12,800 ppm	Unconsciousness after 2–3 breaths. Death in less than three minutes.

References:

1. United States Environmental Protection Agency. Retrieved 2008-12-16.

2. Goldstein M (December 2008). "Carbon monoxide poisoning". Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association 34 (6): 538–542.

3.Struttmann T, Scheerer A, Prince TS, Goldstein LA (Nov 1998). "Unintentional carbon monoxide poisoning from an unlikely source". The Journal of the American Board of Family Practice 11 (6): 481–484

Q: Which one regularly use sedative in ICU can be a very good choice and getting evaluated for end of life comfort?


Answer:  Dexmedetomidine

Recently there is an interest in using dexmedetomidine in treating cancer patients at the end of life who are suffering from intractable pain, agitation or delirium.



References:

Jackson KC, Wang Z, Wohlt P, Fine PG (2006). "Dexmedetomidine a novel analgesic with palliative medicine potential". J Pain and Palliative Care Pharmacotherapy 20 (2): 23–7

Q: Name 5 drugs which can be use for post-operative shivering?


Answer: 

There is no pharmacological treatment  "Gold standard"  identified for post-operative shivering. Following drugs have been used with various success, meperidine been most responsive.

1. Meperidine
2. Tramadol
3. Magnesium
4. Clonidine
5. Dexmedetomidine



References:

1. Kranke P, Eberhart LH, Roewer N, Tramer MR. Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2002;949(2):453-460.

2. Kranke P, Eberhart LH, Roewer N, Tramer MR. Single-dose parenteral pharmacological interventions for the prevention of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2004; 99(3):718-727.

3. Schwarzkopf KRG, Hoff H, Hartmann M, Fritz HG. A comparison between meperidine, clonidine, and urapidil in the treatment of postanesthetic shivering. Anesth Analg. 2001;92(1):257-260.

Q: Is Amiodarone dialyzable?


Answer: No

Amiodarone's excretion is primarily hepatic and biliary with almost no elimination via the renal route. Also, it is not dialyzable. It has elimination half-life average of 58 days, and 36 days for its active metabolite, desethylamiodarone (DEA). Accumulation of amiodarone and DEA occurs in adipose tissue and highly perfused organs i.e. liver, lungs. 

Q: Which drug is said to be responsible for various effects on van Gogh's paintings particularly Starry Night?

Answer: Digoxin

Digoxin may cause disturbance of color vision (mostly yellow and green) called xanthopsia. It is said that Vincent van Gogh's "Yellow Period" was influenced by concurrent digitalis therapy. Digoxin may cause a "halo" around each point of light which is evident in van Gogh's Starry Night. 

Q: Why non-selective B-Blockers are preferred in portal hypertension instead of selective B-Blockers?

Answer:

The non-selective β-blockers (like propranolol, timolol or nadolol etc) are preferred because they decrease both cardiac output by β1 blockade and splanchnic blood flow by blocking vasodilating β2 receptors at splanchnic vasculature.

Reference:

Talwalkar JA, Kamath PS (2004). "An evidence-based medicine approach to beta-blocker therapy in patients with cirrhosis". Am J Med 116 (11): 759–766

Q: DKA (Diabetic Ketoacidosis) may present or along with upper GI bleed. What is the usual cause of it?

Answer: Erosion of esophagus

Upper gastrointestinal hemorrhage complicates 9% of diabetic ketoacidosis hospitalizations. The most common lesion is erosive esophagitis. Hemorrhage correlates with glucose level, admission to the ICU, duration of diabetes and the presence of diabetic complications.

Reference:

Faigel DO, Metz DC .- Prevalence, etiology, and prognostic significance of upper gastrointestinal hemorrhage in diabetic ketoacidosis. - Dig Dis Sci. 1996 Jan;41(1):1-8.

Q: In which condition almost quarter (25%) of patients may have falsely positive elevated lipase level?

 

Answer: DKA (Diabetic Keto-acidosis)

In DKA nonspecific elevations of amylase and lipase occurs up to 25% of cases.

• Amylase elevation is correlated with pH and serum osmolality,
• Lipase elevation is correlated with serum osmolality alone.

Diagnosis of Acute Pancreatits based soley on elevated amylase or lipase, even>3 times normal, is  said to be not justifiable.



Reference:

Yadav D, Nair S, Norkus EP, Pitchumoni CS - Nonspecific hyperamylasemia and hyperlipasemia in diabetic ketoacidosis: incidence and correlation with biochemical abnormalities.- Am J Gastroenterol. 2000;95(11):3123.

Q: What is the ratio of Lipase to Amylase in acute pancreatitis from alcohol?

Answer: 2.5:1

If lipase level is about 2.5 to 3 times that of amylase, it is a strong indication of Alcoholic pancreatitis.

Reference:

Gumaste V, Dave P, Weissman D, Messer J (1991) - "Lipase/amylase ratio. A new index that distinguishes acute episodes of alcoholic from nonalcoholic acute pancreatitis". Gastroenterology 101 (5): 1361–6.

Q: In which condition Pantoprazole (protonix) dose is IV 80 mg  q 12 hours?

Answer: Zollinger-Ellison Syndrome

The dosage of IV Pantoprazole in patients with hypersecretory conditions associated with Zollinger-Ellison Syndrome or other neoplastic conditions is about 80 mg q12 hours. The frequency of dosing can be adjusted to individual patient needs based on acid output measurements. In some patients, 80 mg q8 hours may be needed to maintain acid output below 10 mEq/h.

Q: What is the risk of acid suppression medication in developing C. Diff. Colitis? 

Answer: 

Acid suppression medications increases the risk of C. Diff. Colitis.

H2-receptor antagonists increased the risk 1.5-fold,

and

Proton pump inhibitors by 1.7 with once-daily use and 2.4 with more than once-daily use

Reference: 

1. Howell, MD; Novack, V; Grgurich, P; Soulliard, D; Novack, L; Pencina, M; Talmor, D (May 2010). "Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection". Archives of Internal Medicine 170 (9): 784–90.

2. Deshpande, A; Pant, C; Pasupuleti, V; Rolston, DD; Jain, A; Deshpande, N; Thota, P; Sferra, TJ et al. (March 2012). "Association between proton pump inhibitor therapy and Clostridium difficile infection in a meta-analysis". Clinical Gastroenterology and Hepatology 10 (3): 225–33.