Q: Hepatic encephalopathy tends to worse after all of the following except

A) GI bleed
B) Bout of sepsis
C) Use of Rifaximin
D) Dehydration
E) After procedure TIPSS (transjugular intrahepatic portosystemic shunt)




Answer: C

GI bleed unloads huge amount of protein in GI tract and tends to make hepatic encephalopathy. Electrolyte and Metabolic disturbances in sepsis, dehydration, hypoxia etc. tends to do the same. TIPSS is commonly performed in liver patients to treat portal hypertension. In 30% of patients, hepatic encephalopathy transiently get worse after TIPPS, as intestinally derived compounds requiring hepatic detoxification bypass the liver and remain in the systemic circulation.

Rifaximin is the treatment of hepatic encephalopathy.

Q: All of the following can be used in the diagnosis of haemochromatosis except

A) Serum ferritin
B) Liver biopsy
C) HFE (Human hemochromatosis protein)
D) MRI
E) Blood smear




Answer: E

 MRI is quickly emerging as a noninvasive alternative to accurately estimate iron deposition levels in major organs as liver, heart, joints, pituitary gland etc.

Other tests are well known for the diagnosis of haemochromatosis.

Preparation of blood smear does not help in the diagnosis of haemochromatosis.

Q: All of the following are contraindicated in tachyarrthymia of Wolff–Parkinson–White syndrome (WPW) except

A) Cardioversion,
B)  Adenosine, 
C) Diltiazem, 
D) Lopressor



Answer: A

AV node blockers should be avoided in atrial fibrillation and atrial flutter with WPW like adenosine, calcium channel blockers and beta blockers. They exacerbate the syndrome by blocking the heart's normal electrical pathway.

Happy July 4 - God bless America

Use of Intravenous Sodium Nitroprusside in Acute Schizophrenia

Interesting study

The treatment of schizophrenia remains a challenge, and the currently available antipsychotic drugs are slow acting and produce a number of adverse effects.

Objective  To examine the effectiveness and safety of a single intravenous administration of sodium nitroprusside (0.5 μg/kg/min for 4 hours) on the positive, negative, anxiety, and depressive symptoms in patients with schizophrenia.

Design  Single-center, randomized, double-blind, placebo-controlled trial performed from March 9, 2007, to March 12, 2009.

Participants  Twenty inpatients aged 19 to 40 years with a diagnosis of schizophrenia who were in the first 5 years of the disease who are taking antipsychotics.

Intervention  Sodium nitroprusside administration.

Main Outcome Measures  The 18-item Brief Psychiatric Rating Scale and the negative subscale of the Positive and Negative Syndrome Scale.

Results  After the infusion of sodium nitroprusside, a rapid (within 4 hours) improvement of symptoms was observed. The placebo and experimental groups had significant differences in the 18-item Brief Psychiatric Rating Scale total score and subscale scores, which persisted for 4 weeks after infusion.

Conclusions  The results clearly show a therapeutic effect of sodium nitroprusside. If this drug is approved for routine clinical use in patients with schizophrenia, this discovery will be an important advance in the pharmacologic treatment of this devastating disorder. 

Reference:

Jaime E. C. Hallak, MD, PhD; Joao Paulo Maia-de-Oliveira, MD; Joao Abrao, MD, PhD; Paulo R. Evora, MD, PhD; Antonio W. Zuardi, MD, PhD; Jose A. S. Crippa, MD, PhD; Paulo Belmonte-de-Abreu, MD; Glen B. Baker, PhD, DSc; Serdar M. Dursun, MD, PhD, FRCPC - Rapid Improvement of Acute Schizophrenia Symptoms After Intravenous Sodium Nitroprusside: A Randomized, Double-blind, Placebo-Controlled Trial  - JAMA Psychiatry. 2013;70(7):668-676

Q: Name few other antihypertensive drugs for use in Pregnancy-Induced-Hypertension (Gestational Hypertension) - if it is resistant to traditionally well known drugs used in such conditions like  Labetalol, Hydralazine and Methyldopa?

Answer:

Hydralazine, Methyldopa and Labetalol are well known for their use in Gestational Hypertension. Administration of ACE inhibitors during the second and third trimesters are absolutely contraindicated as it can result in a number of fetal adverse effects, including growth retardation, renal failure, persistent patent ductus arteriosus, respiratory distress syndrome, fetal hypotensive syndrome, and prepartum death.

4 other drugs which may be used in patients who are unresponsive to Hydralazine, Methyldopa and Labetolol are

1. Diazoxide, but should be watched due to interference with glucose metabolism.

2. Intravenous isradipine, but data is not widely available on it.

3.  Sodium nitroprusside should be used only as a last resort - as it may have some adverse effects on the fetus.

4. Short-acting nifedipine (oral/sublingual) has been reported to be effective in the acute treatment of severe hypertension in pregnancy, but should be used with caution as short-acting nifedipine may be associated with maternal hypotension.

Q: Which of the following antihypertensive may be use in treatment of myelodysplastic syndrome (MDS)?

A) Lopressor

B) Clonidine

C) Lisinopril

D) Hydralazine

E) Methyldopa 

Answer:  D 

Hydralazine has also been used successfully as a treatment for myelodysplastic syndrome in its capacity as a DNA methyltransferase inhibitor along with magnesium valproate.

Reference:

Candelaria, M; Herrera, A; Labardini, J; González-Fierro, A; Trejo-Becerril, C; Taja-Chayeb, L; Pérez-Cárdenas, E; Cruz-Hernández, E; Arias-Bofill, D; Vidal, S; Cervera, E; Dueñas-Gonzalez, A (5 October 2010). "Hydralazine and magnesium valproate as epigenetic treatment for myelodysplastic syndrome. Preliminary results of a phase-II trial". Annals of Hematology 90 (4): 379–387

Q: All of the following decrease the effectiveness of Adenosine except?\

A) caffeine,

B) theophylline

C) chocolate

D) carbamazepine

Answer:  D 

In ICU,  Adenosine is a common drug used for termination of Supra Ventricular Tachycardia (SVT).  It is important to know the interactions of various drugs with Adenosine as it may require either higher or lower than standard "push" of Adenosine.

People with habit of drinking lot of coffee(caffeine) or tea(theophylline) or consuming large amount of chocolate(theobromine) may require higher than usual dose of Adenosine. In contrast, carbamazepine or dipyridamole may increase the effect of adenosine.

Q: What is the acceptable postvoid residual (PVR) volume?

A) none

B) less than 30 cc

C) 50 cc

D) 100 cc

E) less than 200 cc

Answer:  D

In ICU, a bladder scan is a preferred method instead of "straight cath" (an invasive “in and out”  urinary catheterization) to assess postvoid residual (PVR) volume, which shouldn't be higher than 100 mL.  Scan should be typically performed 10 minutes after a patient has last voided.

"Straight Cath." should be avoided as it is an invasive “in and out” urinary catheterization, which can be uncomfortable. Moreover, pose a direct risk of trauma and infection.

Q: What is ABCDE or bladder bundle  to decrease "Catheter Associated Urinary Tract Infections" (CAUTI)?

Answer:

“Bladder Bundle” is implemented by the Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality, called “ABCDE” approach

• Adherence to general infection control principles is important (e.g., hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education).
• Bladder ultrasound may avoid indwelling catheterization.
• Condom catheters or other alternatives to an indwelling catheter such as intermittent catheterization should be considered in appropriate patients.
• Do not use the indwelling catheter unless you must!
• Early removal of the catheter using a reminder or nurse-initiated removal protocol appears warranted.

Reference:

Saint S, Olmsted RN, Fakih MG, et al. Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 2009;35(9):449–55

Q: 42 year old male with out of hospital cardiac arrest, is now in ICU undergoing therapeutic hypothermia. When it would be appropriate to start enteral nutrition on him?

Answer: Patients receiving therapeutic hypothermia can begin enteral nutrition during the rewarming process. One recent study showed that During period 1 (cooling), patients tolerated a median of 72% of administered feed. During period 2 (rewarming phase), a median of 95% of administered feed was tolerated. During period 3 (normothermia) a median of 100% of administered feed was tolerated. Absorption of enteral feed increased with increasing core temperature.

Reference:

Williams ML, Nolan JP - Is enteral feeding tolerated during therapeutic hypothermia? - Resuscitation. 2014 Nov;85(11):1469-72.

Paradox of Phosphate in Rhabdomyolysis

Severe hypophosphatemia cause depletion of ATP and consequently cause rhabdomyolysis and inability of muscle cells to maintain membrane integrity. However, a paradoxical consequence occurs; with muscle breakdown in rhabdomyolysis, the damaged cells release phosphate into the extracellular space, masking the laboratory level or even clinical effects of hypophosphatemia. Plasma levels of hypophosphatemia will be misleading during the peak CPK level of rhabdomyolysis and should be repeated once rhabdomyolysis starts to resolve.

Reference:

Knochel JP. Hypophosphatemia and rhabdomyolysis. Am J Med. 1992 May. 92(5):455-7

Q: Which electrolyte's deficiency is found to be associated with Posterior reversible encephalopathy syndrome (PRES)?

A) Sodium

B) Potassium
C) Magnesium
D) Phosphate
E) Calcium



Answer:  C

Posterior reversible encephalopathy syndrome (PRES), is characterized by headache, confusion, possible seizures and visual loss. It may occur in malignant hypertension and eclampsia. Also, frequently seen in transplant unit from Tacrolimus toxicity.  Diagnosis is made by MRI of the brain. Hypomagnesemia is found to be a contributing factor in PRES.

Q: What percentage of patients in ICU develops some sort of ocular surface disorders?

Answer:  60% 

Patients in ICU develops impaired ocular defence mechanisms as a result of use of sedatives, neuromuscular blockades, multiorgan failures, positive pressure ventilation and various other reasons. Unfortunately, it does not get emphasis enough in teaching of Critical Care Medicine at bedside, and required ophthalmology consults frequently go ignored. Moisture chambers are said to be significantly better method than lubrication at preventing exposure keratopathy in ICU.

References:

Grixti A, Sadri M, Edgar J, Datta AV. Common ocular surface disorders in patients in intensive care units. The Ocular Surface. 2012;10:26–42

Q: Ibutilide, despite its effective role in management of atrial fibrillation, remained less popular, due to fear of causing polymorphic ventricular tachycardia. What adjuvant treatment may decrease the chances of this side effect?

Answer:  Concurrent administration of high dose IV magnesium

Concurrent administration of high dose ( 4-5 grams) IV magnesium enhances the ability of ibutilide to successfully convert atrial fibrillation (or flutter), and attenuate the QT interval prolongation associated with ibutilide, and so lowers the rate of polymorphic ventricular tachycardia. 

References:

Tercius AJ, Kluger J, Coleman CI, White CM. Intravenous magnesium sulfate enhances the ability of intravenous ibutilide to successfully convert atrial fibrillation or flutter. Pacing Clin Electrophysiol 2007; 30:1331.

Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010; 106:673.

Q: 32 year old male who just returned from Bangladesh after 4 weeks trip has been admitted to ICU with active suicidal ideations. According to family, patient has no previous psychiatric history. Patient took all required vaccinations before departing and list of medications shows only mefloquine (larium) while abroad. All lab work is normal except for EKG which showed prolong QTc interval?

Answer: Mefloquine, a popular drug for prevention of Malaria as it requires to take only once a week while travelling carries a potential for serious neuropsychiatric side effects that may persist even after discontinuing administration of the drug. It may include anxiety, hallucinations, depression, unusual behavior, suicidal ideations, dizziness, loss of balance, tinnitus, headache, insomnia, vivid dreams, seizures etc. It is estimated that about 11-17% of travelers are incapacitated to some degree. It may also cause prolong QTc interval.

References:                             

AlKadi, HO (2007). "Antimalarial drug toxicity: a review". Chemotherapy 53 (6): 385–91.

Schlagenhauf, P. (1999). "Mefloquine for malaria chemoprophylaxis 1992-1998". Travel Med 6 (2): 122–123.

Jacquerioz, FA; Croft, AM (2009-10-07). Jacquerioz, Frederique A, ed. "Drugs for preventing malaria in travellers". Cochrane database of systematic reviews (Online) (4): CD006491

Q: 22  year old male is admitted to Texas Medical Center with high spiking fever and symptoms consistent with Malaria. Patient has a recent history of travel to his hometown in Midwestern USA. After blood smear preparation, patient has been diagnosed with babesiosis instead of malaria, and has been started on a combination treatment of atovaquone and azithromycin.  Patient continue to deteriorate. Diagnosis has been confirmed meanwhile with PCR. What is the next line of treatment?

Answer:   Exchange transfusion

There are 2 combination treatments used in babesiosis

• atovaquone and azithromycin
• clindamycin and quinine

But in severe and life-threatening cases, exchange transfusion (ET) is indicated. Babesiosis is generally a subclinical infection in most normal hosts, but it can be life threatening in asplenic patients, older, or immunocompromised individuals progressing to coma, renal failure, or ARDS. ET is recommended to reduce the level of parasitized RBCs, to remove cytokines, and to improve the rheologic properties of the blood.

Q: What is the trauma triad of death?

Answer: The trauma triad of death is the combination 

• hypothermia,
• acidosis and
• coagulopathy

This combination is commonly seen in patients who have sustained severe traumatic injuries and if presents results in a significant rise in the mortality rate. The three conditions share a complex relationship; each factor can compound the others, resulting in high mortality if the cycle continues uninterrupted.

Q: Beside listening with stethoscope at abdomen and obtaining CXR after insertion of Naso-Gastric tube (NG-tube), what could be another quick bedside method to confirm proper NG-tube placement in stomach?

Answer:   Aspirate some fluid from the NG tube with a syringe. Test this fluid with pH paper to determine the acidity of the fluid. If the pH is 4 or below then the tube is most likely in the stomach. pH paper is different from blue litmus paper and is called universal pH paper or strip. It is advised to avoid blue litmus paper.

Since no pulmonary aspirates have been reported below pH of 5.99, a pH value of 5.5 or below will exclude 100 per cent of pulmonary placements.

Q: 29 year old female is admitted to ICU after severe uro-sepsis. Patient remained in ICU for a week and now recovering - but still on TPN as she was unable to tolerate enteral feed. Due to abnormal liver enzyme, resident ordered ultrasound of Right Upper Quadrant. Radiology called you with report that: Patient is displaying "champagne sign"? 



Answer: One of the ultrasonographic features suggestive of acalculous cholecystitis include emphysematous cholecystitis with gas bubbles arising in the fundus of the gallbladder, known as "champagne sign". It is considered as a specific sign for acalculous cholecystitis.

Q: 52 year old male is admitted to ICU after severe Organophosphate poisoning, requiring frequent Atropine IV pushes, followed by IV infusion. What is the best parameter to determine the titration of Atropine?

Answer: Secretions

Organophosphate poisoning results from exposure to insecticides/pesticides or nerve agents. Also, it is frequently used in suicides. The effects of organophosphate poisoning on muscarinic receptors are Salivation, Lacrimation, Urination, Defecation, increase Gastrointestinal motility, Emesis, Miosis(mnemonics are SLUDGEM or MUDDLES).

Established antidote is Atropine with dose around 3-5 milligrams every ten minutes. If symptoms continue, Atropine infusion can be started with 0.5-2.4 mg/kg/hr - till symptoms subsides. Longest reported infusion in literature is 5 weeks !!!Control of hyper-secretions served as the best monitoring parameter for titration of the drip rate.

Paradoxity of relationship

between

Thymoma and Myasthenia Gravis (MG)

Younger patients with generalized MG without thymoma benefit, paradoxically, from thymectomy. However, resection is usually performed for those with a thymoma in hope, but it is less likely to improve the MG symptoms.

Q: One of the advantage dronedarone (Multaq) has over amiodarone, is reduced toxicity due to absence of  the iodine moieties, which reduces iodine based toxicity paricularly in lungs and thyroid. What other advantage dronedarone has over Amiodarone?

Answer: Dronedarone is a benzofuran derivative related to amiodarone. Amiodarone though very popular but is well known for its toxicity due its high iodine content. In dronedarone, the iodine moieties are not present, reducing toxic effects. Another advantage, Dronedarone has a  methylsulfonamide group is added to reduce its lipophilicity,  and thus also reduces neurotoxic effects. 

Reference: 

Zimetbaum, PJ (2009). "Dronedarone for atrial fibrillation--an odyssey". The New England Journal of Medicine 360 (18): 1811–3.

Q: Which antibiotic can be used to counter cholestatic pruritus?

Answer: Rifampicin

Rifampicin can be used in the treatment of cholestatic pruritus. Actual mechanism of action is not very clear though.  First line therapy is generally cholestyramine, a bile acid sequestrant. But if needed Rifampicin can be used for patient's comfort.

Reference:

Hofmann, AF (2002). "Rifampicin and treatment of cholestatic pruritus". Gut 2002;50:436–9 51 (5): 756–757.

Q: What is double diaphragm sign on CXR?

Answer: Occasionally, a posterior subpulmonary pneumothorax will result in visualization of the more superior anterior diaphragmatic surface and the inferior posterior diaphragmatic surface, resulting in the double-diaphragm sign. Note CVC and chest tube on Right side.

Q: 52 year old female is admitted to ICU post-op. Patient has been given Ondansetron (Zofran) for severe nausea. Patient start complaing of loss of vision described as "puff of white steam sort of thing". What would be your next step?

A) Observe

B) Emergent opthalmology consult

C) Keep patient in supine position

D) Keep patient sitting at 90 degrees

E) Apply patch to eye with vision loss

Answer: A

Blurred vision or temporary loss of vision after administration of Zofran is a well known side effect. It is in most cases temporary and does not require any intervention. If symptoms re-occurs with every administration, other anti-emetic should be considered.

Q: All of the following are treatment of 'Tardive Dyskinesia' (TD) except?

A) Ondansetron 

B) Donepezil

C) Clonazepam

D) Vitamin B6

E) Quetiapine

Answer: E

All atypical antipsychotics like risperidone, olanzapine, clozapine, quetiapine, aripiprazole and ziprasidone carries risk for causing TD. Though Quetiapine and clozapine are considered the lowest risk agents for precipitating TD, but still they should be used with caution.

Q: How Erythromicin works as a motility agent?

Answer: Erythromycin, the macrolide antibiotic, daily divided dose of 1-2g daily is one of the drug of choice as a gastrokinetic agent in ICUs.  Erythromycin acts as a motilin agonist through its interaction with motilin receptors found in the stomach and upper GI tract. Erythromycin accelerates gastric emptying by increasing the frequency and amplitude of stomach and duodenal contractions.

Reference:

Stevens JE, Jones KL et al. Pathophysiology and pharmacotherapy of gastroparesis: current and future. perspectives. Expert Opin Pharmacother 2013; 14 (9): 1171-86

Q: 54 year old male admitted to ICU for aspiration pneumonia after ETOH intoxication. Patient has been kept on Precedex (Dexmetomidine) for 10 days to counter Delirium-Tremens. Patient is successufully extubated now. All drip get discontinued. Patient went into acute psychosis with tachycardia and hypertension. Your diagnosis.

A) Unmasking of underlying Delirium Tremens

B) New ICU Psychosis

C) CVA

D) dexmedetomidine withdrawal syndrome

E) New onset sepsis

Answer:   D

Dexmedetomidine is an α(2)-adrenoreceptor agonist which is used in the ICU for various reasons due to its sedative, analgesic and anxiolytic properties. Lately, it has shown good profile for ETOH and drug withdrawal syndromes. Withdrawal of Dexmedetomidine after prolong infusion may produce a withdrawal syndrome of sympathetic over-activity, characterized by tachycardia, hypertension and agitation.

In such instances oral longer acting clonidine could be use to bridge the withdrawal. We utilized the principle of managing acute drug withdrawal with longer acting medications.

A is wrong as 14 days is a long time for re-emergence of DTs.

B is possible but unlikely as patient was getting better.

C is wrong as patient symptoms are not c/w CVA

E is wrong as there are no other signs of sepsis

References:

Kukoyi A, Coker S, Lewis L, Nierenberg D. - Two cases of acute dexmedetomidine withdrawal syndrome following prolonged infusion in the intensive care unit: Report of cases and review of the literature. - Hum Exp Toxicol. 2013 Jan;32(1):107-10.

Jamie L. Miller, PharmD, Christine Allen, MD, and Peter N. Johnson, PharmD - Neurologic Withdrawal Symptoms Following Abrupt Discontinuation of a Prolonged Dexmedetomidine Infusion in a Child - J Pediatr Pharmacol Ther. 2010 Jan-Mar; 15(1): 38–42.

Q: 62 year old male patient admitted last night with CVA was send from ICU to radiology department for MRI. Nursing staff appropriately filled out the pre-MRI form. While patient was getting transferred from bed to MRI table, MRI staff decided to hold MRI after noticing a patch on patient's skin?

Answer:  

Transdermal drug patches are generally composed of 3 layers:

• a liner that is discarded before application,
• the drug itself, and
• the backing furthest from the skin.

Some transdermal systems have a metallic component, which allows controlled absorption of the medication through the skin. Aluminum is commonly used and is an excellent conductor of heat. When patients undergo a magnetic resonance imaging (MRI) scan, a patient wearing a patch containing aluminum, the overheated metal may cause excessive heating, and may cause local burns.

To be on safe side, it is important to re-confirm the drug patch, if it contains aluminum layer, or best to remove it.

Q: Oxygen should be given to all suspected coronary syndrome patients, even if their saturation is normal.

True or False?

Answer: False

Traditionally, high flow oxygen with recommendation of  4 L/min was recommended for everyone with suspected coronary syndromes but recent data shows that routine use  of oxygen in all coronary syndrome may lead to increased mortality and infarct size. Therefore, oxygen is recommended only if oxygen saturation is low or patient is in respiratory distress.

References:

1. Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M, Beasley R (March 2009). "Routine use of oxygen in the treatment of myocardial infarction: systematic review". Heart 95 (3): 198–202.

2. Cabello JB, Burls A, Emparanza JI, Bayliss S, Quinn T (2013). Cabello, Juan B, ed. "Oxygen therapy for acute myocardial infarction". Cochrane Database Syst Rev 8: CD00716

3. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, Caso P, Dudek D, Gielen S, Huber K, Ohman M, Petrie MC, Sonntag F, Uva MS, Storey RF, Wijns W, Zahger D. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054.

4. Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, Van't Hof A, Widimsky P, Zahger D. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J. Advance Access published August 24, 2012, doi:10.1093/eurheartj/ehs215.

Q: In the treatment of acute exacerbations of asthma  delivery of beta-agonist via Metered Dose Inhaler(MDI)-spacer is better than nebulizer. How many MDI inhalations are equivalent to one nebulizer treatment?

Answer: Four to six carefully administered inhalations from an MDI with spacer have generally been found to equal one nebulizer treatment.