Q: Which vaptan is contraindicated in liver failure during treatment of hyponatremia? 


 Answer: Conivaptan

Quinton Hemodialysis catheter insertion, use and care

Q: What could be the 4 life threatening side effects of Neupogen (Filgrastim)?


Answer:

1. Neupogen may bring sickle cell crisis after receiving it in patients with sickle cell disorders.

2. Spleen Rupture has been reported after the administration of Neupogen. Patients receiving Neupogen who report left upper abdominal pain should be evaluated for it.

3. ARDs (Acute respiratory distress syndrome) has been reported secondary to an influx of neutrophils to sites of inflammation in the lungs.

4. Alveolar Hemorrhage and Hemoptysis.

Q: What is Libman-Sacks endocarditis?



Answer: Libman-Sacks endocarditis is the most characteristic cardiac manifestation of systemic lupus erythematosus. The condition most commonly involves the mitral valve.

The vegetations are formed from strands of fibrin, neutrophils, lymphocytes, and histiocytes. It rarely produce significant valve dysfunction and rarely embolize.

No specific therapy is required for Libman-Sacks endocarditis. In clinical manifestations, standard treatment is required.

Q: Is Daptomycin dialyzable?


Answer: No

In renal failure patients on CRRT and HD - every 48 hour dosing is recommended.

On Chylothorax

Chylothorax is defined as triglycerides more than 113 mg/dl (1.24 mmol/L) in pleural cavity.

A number of therapeutic interventions have been used to reduce chyle production and promote resolution of a chylothorax. Initial management typically includes restriction or temporary cessation of enteral feedings. Enteral feedings high in medium-chain triglycerides (MCT), or parenteral nutrition may be used. Total parenteral nutrition typically results in resolution in 75 to 80% of cases by that time. In resistant cases, pleurodesis, ligation of the thoracic duct, or placement of drains and pleuroperitoneal shunts may be considered.

Octreotide has become another option for management of patients with chylothorax. Although the exact mechanism by which the drug exerts its effects has not been defined, it is believed that the multiple effects of octreotide on the gastrointestinal tract and the reduction in splanchnic blood flow reduce thoracic duct flow and decrease the triglyceride content of chyle.

Q: Why it is not a good idea to add Sorbitol while administrating Katexalate for Hyperkalemia ?



Answer:  Concern for Bowel Necrosis

In 2010, the FDA has already issued a warning of increased risk for GI Necrosis.

Q: 57 year old male severe diabetes and ESRD, 'coded' in cath lab. Patient is now in ICU after VA-ECMO (inserted by surgeon after cut down). Looking at previous record you found that patient is extremely vasculopath and putting dialysis catheter would be "next to impossible". Nephrology wrote orders to start CVVHD. What would be your option?



Answer: Doing CRRT via ECMO cannulation

If situation arise, CRRT can be performed simultaneouly via same cannulas.

One relatively unknown use of DDAVP (Desmopressin)
Desmopressin (DDAVP) can be use in treatment of sleep apnea. Patients prescribed DDAVP are found to have 4.5 times more likely to sleep without disruption than with placebo. FDA has banned the treatment of sleep apnea with desmopressin, particularly nasal sprays due to reported deaths, hyponatremia and seizures.
Desmopressin tablets are still use for sleep apnea. Side effects are as above along with severe vomiting, diarrhea, fever and flu like symptoms.

Q: What is Gray platelet syndrome? 


Answer: Gray platelet syndrome is a congenital bleeding disorder caused by a reduction or absence of alpha-granules in blood platelets. Not only, it causes thrombocytopenia but also releases of protein normally contained in these granules into the marrow, which in turn causes myelofibrosis. It poses a risk of increase bleed, which can be life threatening. 

Grey Platelet Syndrome is named for the greyish appearance of these platelets when viewed with a microscope.

A note on Factor 7 (rVIIa) and thrombocytopenia

Factor 7 (rVIIa - Novoseven) is now significantly use as off label in uncontrolled bleeding. It may not be efective in the presence of severe thrombocytopenia and should be corrected prior to its administration. Although there are case reports of the successful use of rVIIa in severe thrombocytopenia, a low platelet count is likely to predict a poor or partial response to rVIIa therapy.

Its haemostatic effects are mediated by the thrombin it generates by both tissue factor (TF) dependent and independent mechanisms. The TF independent mechanism requires platelets for the direct activation of Factor X on their surface by rVIIa.

Q: Despite its logistic concerns, prone positioning in severe ARDS still keeps it role. What 3 things have shown to benefits patients in recent literature, when applying prone position in ARDS?


Answer:

1. Prone positioning offers benefits in the most hypoxemic (P/F less than 100-130) ARDS patients.

2. It is beneficial when applied early.

3. It is beneficial if given for long session (more than 12 hrs).

Q: 53 year old female post-operatively developed propofol induced dystonia. What could be a possible treatment beside stopping propofol?

Answer:  prone position!

See following case report and discussion at:

Novel management of propofol induced dystonia in the post anaesthesia care unit - Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists - Feb, 2007 Source Volume: 35 Source Issue: 1 URL link: http://www.biomedsearch.com/article/Novel-management-propofol-induced-dystonia/188796766.html

Q: What is the half life of Precedex (dexmedetomidine), when it is fully on board?


Answer: About 2 - 3 hours!

Q: What is "Whoosh test"? 


Answer: The whoosh test is done by rapidly injecting air down the NasoGastric tube while auscultating over the epigastrium. Gurgling indicates probability of NGT in the stomach, whilst its absence suggests NGT is elsewhere (lung, oesophagus, pharynx etc).

Tandem Heart

Q: Ischemic colitis remained a clinical diagnosis. Despite normal labs or no bloody stools, which one clinical sign should promptly lead to diagnosis of Ischemic colitis?

Answer: "pain out of proportion to physical findings", specifically excruciating abdominal pain despite limited focal tenderness. Labs and other clinical signs may lag behind.

Q: ID service advise you to consider Octreotide for a patient with Aids related diarrhea. What is the dosing?


Answer: 100 to 500 mcg SC tid


Though evidence is weak but Octrotide has been used in AIDS related refractory chronic diarrhea. Octreotide is a candidate drug for the treatment of these patients as it inhibits gastrointestinal motility and increase the transit time.

Q: 58 year old male with Renal failure, but not yet on dialysis, is admitted with ST elevation MI and taken to cath lab for PCI and stent placement. Patient is back in unit and has been written to be started on glycoprotein IIb/IIIa inhibitor. What would be your choice?


Answer: Reopro Eptifibatide gets renal elimination and in such patients Abciximab (Reopro) would be a better choice.

In case Integrilin has to be given, renal dosing should be provided.

Update on platelet inhibition assay (for Plavix monitoring) 

 The VerifyNow P2Y12 assay is used for monitoring platelet inhibition for patients on medications like clopidogrel (plavix). The company has modified the assay so that, from now on, the instrument will only report out in “P2Y12 Reaction Units” or PRU, % inhibition will no longer be reported. 

The normal reference range is 194-418 PRU. Based on a review of the literature, the optimal P2Y12 result for patients on clopidrogrel is approximately 240 – 180 PRU. 

•  above 240 PRU the patient is at increased risk of thrombosis, 
•  below 180 PRU the patient is at increased risk of bleeding.

Q: While working in ICU you over heard on hospital paging system "Code Silver". What does it mean?

Answer: A person with weapon in hospital!

Hospitals may use their own codes but few codes are universally and informally shared by all.

Animation of TIPS

Q: Why steroids remain mainstay of treatment in Neurocysticercosis?


Answer: Albendazole and Praziquantel are both effective in treatment of Neurocysticercosis. They are given under cover of steroids. Steroids are essentially needed as inflammatory reactions to the dying parasite could be life threatening with mental status changes and convulsions.

Also, Albendazole when co administered with a steroid (to treat inflammation) results in increased absorption of albendazole.

Both Albendazole and Praziquantel are recommended to give with fatty meal.

Earplugs in ICU

"The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception."

Read interesting article recently published at ccforum.com

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients: Critical Care 2012, 16:R73

URL: http://ccforum.com/content/16/3/R73

Q: Inverted sleep-wake pattern (i.e sleeping by day and being awake at night), is the hallmark or at least sign of which encephelopathy?



Answer: Hepatic Encephelopathy

Mild to moderate hepatic encephalopathy is characterized by forgetfulness, confusion, irritability, inverted sleep-wake pattern, irritability, tremors etc.

Q: 52 year old male patient has been overdosed in ICU with Ambien (Zolpidem) due to medication error. What intervention may help to diagnose as well as reverse the effect of Ambien?


Answer: Flumazenil

Zolpidem's (ambien) hypnotic effects are similar to those of the benzodiazepine, though molecularly it is distinct from the classical benzodiazepine. But due to similarlity in their hypnotic effects, Flumazenil which is a benzodiazepine receptor antagonist, also reverses zolpidem's sedative/hypnotic effect.

Q: Which drug overdose may present as ST elevation MI?




Answer: Eszopiclone (lunesta)

Lunesta is unique in a sense that its overdose may presents as ST elevation MI with increase Troponin due to coronary vasospasm. It may lead to V. Fib. as well as cardiac arrest.



Lunesta overdose: ST-elevation coronary vasospasm, troponemia, and ventricular fibrillation arrest.- Am J Emerg Med. 2006 Oct;24(6):741-6.

Q: Which ACE Inhibitor is well known to cause taste disturbances?


Answer: Captopril

Taste disturbance, infrequent with most ACE inhibitors, is more prevalent in captopril and is attributed to its sulfhydryl moiety. Though captopril is not in much use in USA, it is still very much in use in developing countries due to its cost effectiveness.

Q: In Ascites, if patient requires both spironolactone and furosemide - what combination minimize the danger of hypokalemia?


Answer: Generally, patients with ascites respond well to spironolactone. For nonresponders, a loop diuretic may also be added.

The ratio of 100 mg : 40 mg reduces risks of hypokalemia.

Q: 23 year old male is admitted to ICU after severe Abdominal pain. CT scan reports foreign body obstruction. GI service performed upper and lower GI scope and advised surgical consult. Their diagnosis was Rapunzel syndrome?


Answer: The Rapunzel syndrome is a rare intestinal condition resulting from condition called trichophagia (eating hair).

Trichophagia is a severe form of condition called Trichotillomania (also known as "trichotillosis"). It is the compulsive urge to pull out one's own hair leading to noticeable hair loss. In trichophagia, people with trichotillomania may also ingest the hair that they pull; which can lead to a hair ball formation in GI tract called trichobezoar, and may cause GI obstruction.

Rapunzel syndrome, is an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed. Because the human gastrointestinal tract is unable to digest human hair, the trichobezoar may require surgical treatment.

The syndrome is named after the long-haired girl Rapunzel in the fairy tale.

Neurology


Q: What is Ribot's law of retrograde amnesia?



Answer: Ribot's Law of retrograde amnesia states that there is a time gradient in retrograde amnesia, so that recent memories are more likely to be lost than the more remote memories.

Some examples are, in which bilingual patients recovered different languages with differential progress. In some cases, aphasics recover or preferentially improve only the first-acquired language.

Please note, in Neurology, Ribot’s Law is not universally accepted.

Q: What are the 3 major causes of false or factitious or pseudo hyponatremia?


Answer:

1. Severe hypertriglyceridemia,
2. Massive elevation of immunoglobulins as in multiple myeloma,
3. Severe hyperglycemia.