Q: 23 year old male presented to ER with shortness of breath. Patient history is significant with mediastinal mass and had radiation and chemotherapy 2 months ago. Following is the CXR. What is your probable diagnosis?

Answer: Radiation Pneumonitis

Radiation Pneumonitis occurs at dose beyond 4500 rads and is likely to happen if dose  >6000 R for duration of 5-6 weeks. Concurrent or later chemotherapy increases the risk. It starts with  exudative phase, progress to organizing phase and to fibrotic phase.  It usually occurs 6 weeks up to 6 months after treatment. One diagnostic clue is its confinement to radiation portal. A straight line effect, which confines of the radiation port, is virtually diagnostic of radiation-induced lung injury. Exclusion of other possible causes of the findings, such as infection, thromboembolic disease, drug-induced pneumonitis etc. should be sought before final diagnosis. Further workup may require CT scan, ECHO and biopsy.

Steroids have been suggested as a treatment but may not be very helpful.

Q: 32 year old male is admitted to ICU after he was brought to ER from beach after his SCUBA diving. Patient was found to be hallucinating, short of breath and just don't look too well. Patient recovered after getting 100% oxygen and IVF in ER, which was continued in ICU. Patient wants to sign AMA as he has flight from Miami to Seattle in next 4 hours. What would be your suggestion?


Answer: Avoid Air travel.

Complications of SCUBA  include hypothermia, trauma, decompression sickness, and nitrogen narcosis. Decompression sickness occurs when a diver returns to the surface and gas tensions in the tissue exceeds the ambient pressure, leading to the liberation of free gas from the tissues in the form of bubbles. It may cause various nonspecific systemic symptoms and may be life-threatening with pneumothorax or involvement of CNS. Patient should avoid air travel for 12 hours after uneventful SCUBA diving and 48 hours or may be more in case of symptomatic air travel.



References:

1. Freiberger JJ, Denoble PJ, Pieper CF, et al. The relative risk of decompression sickness during and after air travel following diving. Aviat Space Environ Med 2002; 73:980.

Q: At what level of FiO2 oxygen toxicity may occur? (select one)

A) more than 40% for more than four days
B)  more than 60% for more than four days
C)  more than 80% for more than two days
D) 100% beyond 24 hours 
E) There is no well-defined threshold FiO2 or duration for oxygen toxicity



Answer: E

Objective of above question is to enhance the awareness of supplemental oxygen in ICU. Conventionally 60% of FiO2 is used as threshold for oxygen toxicity. But this is a huge misconception. There is no well-defined threshold or duration of supplemental oxygen below which oxygen toxicity may or may not occur. Any level of or duration of  supplemental oxygen therapy may cause various effects like absorptive atelectasis, worsening of  hypercapnia in COPD patients, airway injury as well as parenchymal lung injury. Underlying lung disease, overall functional and nutritional status, and previous exposure to high risk lung medicines particularly bleomycin exposure may cause oxygen toxicity at any level and at any duration. PaO2 between 60 and 70 mmHg and pulse-ox oxygen saturation around 92% should be sufficient and beyond this add relatively little to the oxygen content of the blood. Most importantly, along with optimum FiO2, optimal PEEP should be provided in ventilated patients.

Q: In acute Pancreatitis which IVF is preferred?


Answer: Lactated Ringer's (LR)

Though evidence is weak but at least one small study of 40 patients showed that fluid resuscitation with lactated Ringer's in acute pancreatitis may be more beneficial. Patients who received lactated Ringer's had significantly lower mean C-reactive protein (CRP) levels compared with patients who received normal saline (52 versus 104 mg/dL) and also a significantly less systemic inflammatory response syndrome (SIRS) after 24 hours (84 versus 0 percent). 


Reference:

Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:710.

Picture Diagnosis

Answer: Hepatic portal venous gas is a rare X-ray finding in extended bowel necrosis and predicts a very high mortality in patients who presents with clinical signs c/w bowel ischemia.

Q: 34 year old male admitted to ICU with viral entero-gastritis overnight for IV hydration due to 'soft blood pressure'. On call resident ordered ultrasound of abdomen, which accidentally diagnosed Autosomal dominant polycystic kidney disease (ADPKD). Patient is at high risk for which other diseases?


Answer: ADPKD is characterized by cysts in the kidneys, which eventually lead to End Stage Renal Disease (ESRD) usually in fifth decade and usually is associated with cysts in other organs. Patients are at risk and should be educate and screened for 

• Cerebral aneurysms 
• Hepatic and pancreatic cysts 
• Valvular heart disease 
• Colon diverticulum 
• Abdominal wall and inguinal hernia 
• Seminal vesicle cysts 
• Cervicocephalic artery dissections, 
• Dolichoectasias 
• Central retinal vascular occlusions

A note on Urea Diuresis

Urea acts as an osmotic agent and causes polyuria. Causes of large amounts of urea that may produce urea diuresis is various and less appreciated in ICUs like.  

• Administration of high amounts of protein in enteral feed or parenteral nutrition, which eventually will catabolized to urea.
• Resolution from azotemia after AKI (Acute Kidney Injury)
• In Rhabdomyolysis or decub. ulcers where muscle protein catabolism results in the production of urea.
• In rare cases, urea at a dose of 30 g/day is used to treat SIADH  by increasing urinary solute excretion and enhance water excretion.

Q: In which conditions hydronephrosis may occur without urinary obstruction?

Answer:  

Conventional wisdom is that hydronephrosis occurs only with urinary obstruction but hydronephrosis may occur without urinary obstruction when patient is prone to a large diuresis, which may distend the intrarenal collecting system, like in congenital nephrogenic diabetes insipidus.

Q: 58 year old male admitted to ICU with acute Cholecystitis. CT scan of abdomen showed additional finding of infra-renal Abdominal Aortic Aneurysm with diameter of 5 cm. In asymptomatic patients, what is the usual cut-off point to consider surgical intervention in AAA? 

A) 4 cm

B) 4.5 cm

C) 5 cm

D) 5.5 cm

E)  6 cm

Answer: D

Though many factors effect the decision to consider surgical intervention in asymptomatic AAA like age, gender, rate of expansion and other associated co-morbidities but in general 2009 guidelines from the Society for Vascular Surgery recommends observation for asymptomatic AAA <5.5 cm in diameter. For female gender, a lower threshold of 5 cm is also recommended for elective repair of asymptomatic AAA as studies have shown higher rate of rupture in women compared with men for AAA of the same diameter.

Reference:

Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009; 50:880.

Q: All of the following are described as treatment of cholesterol emboli syndrome except? 

A) Thrombolytics
B) Aortic stent
C) statin
D) antiplatelets
E)  angiotensin-converting enzyme inhibitors


Answer: A

Though evidences are weak but literature has good description of possible relationship between use of thrombolytics and anticoagulants. It is postulated that thrombolysis and anticoagulation  may lead to plaque hemorrhage, plaque rupture, and subsequent cholesterol embolization syndrome.

Aortic stents and vascular bypasses provide more mechanical improvement. Statins may have some direct benefit by decreasing cholesterol level. Antiplatelets and angiotensin-converting enzyme inhibitors provide indirect benefits by protecting coronary vessels.

Paradoxity of PCP and HIV

Non-HIV-infected patients who get treated for Pneumocystis pneumonia (PCP) generally have worse outcome than in HIV-infected patients. Mortality from PCP in patients with HIV infection is about 10 to 20 percent compared with 35 to 50 percent in those without HIV. One possible explanation is that immuno-compromised patients are unable to mount sufficient inflammatory response.

Reference:

Sepkowitz KA. Opportunistic infections in patients with and patients without Acquired Immunodeficiency Syndrome. Clin Infect Dis 2002; 34:1098.

 Classification of Pulmonary Hypertension (PH)

The World Health Organization (WHO) classifies patients with PH into five groups based upon etiology - and may carry different management plan due to underlying cause of the PH.

Group 1  — Patients with group 1 pulmonary arterial hypertension (PAH). It was called idiopathic pulmonary arterial hypertension (IPAH) or primary pulmonary hypertension. It may be hereditary or due to diseases that localize to small pulmonary arterioles, such as connective tissue diseases, HIV, portal hypertension, congenital heart disease, schistosomiasis, and possible drug use.

Group 2  — Patients with group 2 have PH secondary to left heart disease including valvular heart disease. This requires underlying cardiac disease management.

Group 3  — Patients with group 3  have PH secondary to diseases causing hypoxemia, such as COPD, ILD, sleep-disorders and others. Supplemental oxygen may be a mainstay of treatment.

Group 4  — Patients with group 4 PH have  due to thromboembolic occlusion of the proximal or distal pulmonary vasculature. In this group anticoagulation is primary medical therapy, at least in earlier stage.

Group 5 — Group 5 PH includes with multi-factorial mechanisms like hematologic disorders (eg, myeloproliferative disorders and chronic hemolytic anemia), systemic disorders (eg, sarcoidosis), metabolic disorders (eg, glycogen storage disease), and others.

Q: 34 year old male with history of HIV on anti-retroviral therapy is admitted to ICU with shortness of breath. There is a concern for right heart failure on ECHO. Pulmonary artery catheter is floated. Patient is found to have moderate to severe pulmonary hypertension. Decision is made to add sildenafil in treatment plan. What precaution should be taken?  

Answer: Patients with HIV are usually on protease inhibitors for their maintenance therapy. Protease inhibitors inhibit the metabolism of sildenafil, increasing the chances of side effects many folds. Recommendation for patients on protease inhibitors to use sildenafil is no more than 25 mg every 48 hours.

Q: 65 year old male on warfarin for atrial fibrillation, presented to ER with severe upper GI bleed. GI service would be available to perform upper scope in 2 hours. All of the following are part of this severe acute upper non-variceal GI bleed except?

A) pRBC

B) FFP

C) IV Proton pump inhibitor

D) Erythromycin

E) Octrotide

Answer: E

A, B and C are obvious choices. Objective of this question is 2 folds.

Firstly, to limelight role of prokinetics in patients with acute upper GI bleeding. Prokinetic agent improves gastric visualization at the time of endoscopy by clearing the stomach of clots, and food. In severe upper GI bleed erythromycin with dose of 3 mg/kg IV over 30 minutes, an hour prior to endoscopy may help. Studies have found it to be a very safe strategy.

Secondly, to emphasize that Octreotide is not recommended for routine use in patients with acute nonvariceal upper GI bleeding, though it is used as a precaution when endoscopy is not quickly available or not possible for other reasons.

Q: 28 year male start having fever, chills, hypotension 10 minutes after start of pRBC transfusion, You suspect "transfusion reaction". You stopped transfusion and advised nurse not to discard bag and tubing and start IVF. Blood bank is notified. Which IVFs should be avoided in such situation?

Answer: LR and any dextrose contain solutions

Lactate Ringer contains calcium and may precipitate clotting of any blood remaining in the intravenous line. Dextrose-containing solutions should be avoided as dextrose may hemolyze any of the remaining red cells in the line. Normal saline is preferred with 100 to 200 cc/hour (watch for volume overload situation for CHF patients) to target a urine output above 100 cc/hour.

Q: Risk of TRALI (Transfusion Related Acute Lung Injury) can be decreased by avoiding FFP donors from? (select one)

A) Male donors

B) Never pregnant female donors

C) Multiparous female donors

D) Any person older than 60

E) Any person with previous history of receiving transfusion

Answer: C

Incidence of TRALI can be decreased by avoiding donations from multiparous women as they are most likely to contain anti-leukocyte antibodies. It is recommended to transfuse plasma products predominantly from male donors, female donors with no prior pregnancy, or from donors who test negative for HLA-antibodies.

Q: What is the "1:1:1 approach" in trauma patients who may require massive transfusion?

Answer:  Studies have shown that patients who have sustained severe trauma and may require massive transfusion do better if they receive a 1:1:1 ratio of FFP to platelets to RBCs at the outset of resuscitation. Patients with 1:1:1 transfusion strategy are more likely to have adequate hemostasis and fewer exsanguination deaths at 24 hours.

References:

1. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007; 63:805.

2. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447.

3. Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009; 66:41.

4. Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients. Transfusion 2010; 50:493.

5. de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusion 2011; 51:1925.

Q: 54 year old male is scheduled for Coronary Artery Bypass (CABG). On review of medical record from previous admissions you noticed possible occurrence of  HIT (Heparin Induced Thrombocytopenia) 2 years ago after his unstable angina episode. You ordered Heparin antibodies STAT and are reported negative. What is your recommendation to surgeon?

Answer: 

Patient with a history of HIT who requires cardiopulmonary bypass can safely be anticoagulated with heparin, provided 2 conditions

•  HIT antibodies are absent and
• the heparin exposure is limited to the operative procedure only

Bivalirudin has also been recommended for patients with risk of HIT who are undergoing CABG but its use remained low due to concern of high bleeding during bypass.

Q: 54 year old male with ESRD (End Stage Renal Disease) on hemodialysis (HD) - who developed HIT (Heparin Induced Thrombocytopenia) while in ICU and on bivalirudin now - need placement of new dialysis catheter. What caution should be taken while holding bivalirudin before procedure?

Answer: 

Bivalirudin is cleared from plasma by a combination of both renal mechanism and proteolytic cleavage. Half-life of bivalirudin with normal renal function is 25 minutes but in patients with ERSD who are HD dependent may go up to 3.5 hours. So caution should be taken while performing procedures.

Q: In abdominal compartment syndrome (ACS), intra-abdominal pressure (IAP) should be measure at? (select one)

A) End-Inspiration

B) End- expiration
C) continuous respiration
D) Mean of end-inspiration and end-expiration values


Answer: B

IAP is usually measured indirectly by using intra-vesicular pressure as measured through a bladder catheter.

IAP should be measured in millimeters of mercury at end-expiration; the patient should be supine and refrain from spontaneous muscle contractions. The midaxillary line is used as the zero reference level for IAP measurement.

Q: What generally defines constipation in ICU?


Answer: Constipation in ICU is generally defined as ‘failure of the bowel to open for three consecutive days’. Some papers have used four days cut off time too, but in general no bowel movement beyond three days is defined as constipation. Sounds very simple, but constipation carries enormous domino effect in ICU, and should be address with due attention. Constipation can cause abdominal distension, vomiting, restlessness, gut obstruction, intra-abdominal hypertension and possible perforation. Cases have been reported of its association with pulmonary embolism. And, its association with increase LOS and failure to wean from ventilator is well documented.

Q: Define Status Epilepticus?

Answer: Traditionally, status epilepticus is defined as a constant seizure lasting for more than 30-minutes. But over years, it has been redefined in various ways and, in nut shell, new definition defines Status epilepticus as any epileptic seizure of greater than five minutes or more than one seizure within a five-minute period without the person returning to normal between them.



Reference:

Al-Mufti, F; Claassen, J (Oct 2014). "Neurocritical Care: Status Epilepticus Review.". Critical Care Clinics 30 (4): 751–764.

Q: All of the following are contra-indicated for liver transplantation (OLT) except?

A) severe infections/sepsis
B) ongoing ETOH or drug use
C) non-compliance
D) end stage COPD
E) hepatocellular carcinoma



Answer: E

Hepatocellular carcinoma (HCC) is not a contraindication for OLT. Actually, it has shown improved survival with OLT in early HCC. 2 popular criteria used are Milan and UCSF. 

Q: Name at least five conditions seen in ICU - beside rapid correction of hyponatremia - which may cause Central pontine myelinolysis (CPM)?

Answer: Firstly, Central pontine myelinolysis (CPM) is a misnomer as it may occur outside the pons. Secondly, it is a demyelination process - and so the better term would be "osmotic demyelination syndrome". Thirdly, other disease processes seen in ICU, beside rapid correction of hyponatremia may also cause osmotic demyelination syndrome like

• in post liver transplant patients
• in patients with severe alcoholism or any disease process causing Wernicke encephalopathy due to malnutrition or electrolyte imbalance
• in patients with severe burns
• in AIDS patients
• in post hematopoietic stem cell transplantation patients

Q: What one pitfall should be avoided while treating psychogenic polydipsia by  just fluid restriction?

Answer: Physicians easily tend to fall into a false comfort zone, once it is determined that hyponatremia is secondary only due to psychogenic polydipsia, and just fluid restriction will slowly correct hyponatremia without any further complication. But, even severe hyponatremia can correct rapidly with just fluid restriction, despite that hyponatremia is associated with absent ADH secretion. Correction of hyponatremia too rapidly may cause central pontine myelinolysis (CPM) with permanent neurologic deficits. In all cases, very close monitoring of Sodium level should be maintained irrespective of the cause of hyponatremia.

Q: Why Cisatracurium should be use with caution in patients with history of severe epilepsy?


Answer: One of the metabolite of Cisatracurium after Hofmann elimination is laudanosine, which is  a modest CNS stimulant with epileptogenic activity and can readily crosses the blood–brain barrier.  It is not a clinical danger but in patients with severe history of epilepsy, it may help to keep this in mind.

Q: Night shift nurse informed you that patient has an episode of "Delirium" last night but it is resolved now. On your exam this AM, patient appears grossly intact. Should you be still worried?


Answer:  Yes

It is often under-appreciated that in ICU, delirium tends to fluctuate and any reported incident should be taken seriously. To concern to Critical Care physicians, it has been shown that even if delirium resolves, it may be followed for long time by a "loss of memory and reasoning power", end up meeting criteria for delirium for a very long time.  Disturbingly, findings shows that in ICU cohorts, 10% of patients still have delirium at the time of hospital discharge.



References:

1. Cole, MG; Ciampi, A; Belzile, E; Zhong, L (January 2009). "Persistent delirium in older hospital patients: a systematic review of frequency and prognosis.". Age and ageing 38 (1): 19–26.


2. Jackson, JC; Mitchell, N; Hopkins, RO (July 2009). "Cognitive functioning, mental health, and quality of life in ICU survivors: an overview.". Critical Care Clinics 25 (3): 615–28.

Q: What is the recommendation for core temperature before performing Apnea test in Brain Death Determination?


Answer: > 36 C (97 F)

Interestingly, most patients require a warming blanket to raise the body temperature and maintain a normal or near-normal temperature (>36°C). To avoid delaying an increase in PaCO2, normal or near-normal core temperature is preferred during the apnea test.

Q: Of the following which can be used as treatment of calcium channel blockers toxicity?

A)  Intravenous calcium
B)  Atropine
C) Hyperinsulinemia-euglycemia therapy 
D) lipid emulsion therapy
E) All of the above

Answer: E

Mild toxicity of Calcium channel blockers usually resolved with supportive treatment with IVF and transient support with pressors. In case of acute overdose, activated charcoal, gastric lavage, and polyethylene glycol may be used to decontaminate the gut.

In case of severe toxicity, Intravenous calcium can be used. Atropine as well as temporary intravenous pacemaker may be required for un-resolving bradycardia/blocks.

Hyperinsulinemia-euglycemia therapy has been advocated for treatment. Increased insulin mobilizes glucose from peripheral tissues to serve as an alternative fuel source for the heart. Treatment with lipid emulsion therapy has been described too with same mechanism of action.

Q: What is the antidote in the treatment of hydrofluoric acid burns?

Answer: Calcium

Hydrofluoric (HF) acid, is used mainly in glass etching, metal cleaning, electronics manufacturing and found in home rust removers. Hydrofluoric acid burns are unique in the sense that dilute solutions deeply penetrate before dissociating. Burns may leave the overlying skin intact, and pain may be severe with little surface abnormality.

Beside protecting "ABC", treatment of hydrofluoric acid burns is neutralization of the acid by use of calcium gluconate or specific agent such as Hexafluorine. Calcium gluconate gel or Hexafluorine should be applied liberally to the affected area. IV calcium may also be used if needed.

Q: All of the following can be used as a rescue treatment in life-threatening Amniotic Fluid Embolism (AFE) except?

A) blood products including Factor 7
B) pressors
C) pulmonary artery catheterization
D) Hemodialysis with plasmapheresis
E) extracorporeal membrane oxygenation (ECMO)


Answer: C

Management for AFE is supportive with IVF, pressors, blood products as needed to counter DIC bleeding. ECMO can be use as a rescue therapy. Hemodialysis with plasmapheresis has been reported with some success.

Pulmonary Artery Catheter may help in diagnosing AFE by collecting fetal squamous cell via distal port but itself is not a therapy of AFE.

Q: 24 year old obese male is admitted to ICU with suspected herpes encephalitis. What mistake should be avoided while dosing Acyclovir in obese patients?





Answer:  It should be dosed according to ideal body weight and not actual body weight.