Q: 58 year old male with IPF (interstitial Pulmonary fibrosis) became unstable and required intubation. "Swan" is floated with high pulmonary pressure. Nebulized Flolan (Epoprostenol) is initiated at room temperature. How frequent Nebulizer, infusion tubing and connections should be changed?

A) Once a day

B) Once a week

C) Every 8 hours

D) Every 72 hours

E) There is no need to change

Answer: C

Flolan for nebulized delivery must be reconstituted with glycine and is usually not compatible with any other solution. Glycine is sticky and viscous and also needs to be shielded from light. It is recommended to keep reconstituted solution cold with icepacks during administration (around 2-8 degrees C) as Flolan is stable for 8 hrs at room temp., and 24 hours if refrigerated. Nebulizer, infusion tubing and connections should be changed every 24 hrs (refrigerated) or every 8 hrs (unrefrigerated) as drug expires.

Q: Which modality/drug is no more recommended for Asystole per 2010 ACLS guidelines?

A) Epinephrine

B) Atropine

C) Transcutaneous Pacemaker

D) Transvenous Pacemaker

E) Vasopressin

Answer: B

In ACLS, Atropine is no more recommended during Asystole/PEA. Routine use of atropine during PEA or asystole has not shown any therapeutic benefit.

Oxygen dissociation curve

If video is not visible click below

Here

http://youtu.be/HYbvwMSzqdY

Bedside caution on Thrombolytic therapy for central venous catheter occlusion

Thrombolytic agents successfully clear central venous catheter occlusions in most cases. (1).

Good practice is, once catheter function is restored, aspirate 4-5 mL of blood to remove thrombolytic  from catheter.




Reference / further reading:

1. Jacquelyn L. Baskin and col. - Thrombolytic therapy for central venous catheter occlusion - Haematologica. 2012 May; 97(5): 641–650.

 Skinfold vs Pneumothorax

"Absence of lung markings is not sufficient to make diagnosis of pneumothorax as lung may fold on itself"!

Click here* to have very informative slide presentation on recognising pneumothorax on CXR (from learningradiology.com)



*link: http://www.learningradiology.com/medstudents/recognizingseries/pneumothoraxflashpage.htm

An interesting way to find "optimum PEEP"

(Abstract)

This study was conducted to evaluate the effectiveness and safety of a practical protocol for titrating positive end-expiratory pressure (PEEP) involving recruitment maneuver (RM) and decremental PEEP.

Seventeen consecutive patients with acute lung injury who underwent PEEP titration were included in the analysis. After baseline ventilation, RM (continuous positive airway pressure, 35 cm H2O for 45 sec) was performed and PEEP was increased to 20 cmH2O or the highest PEEP guaranteeing the minimal tidal volume of 5 mL/kg. Then PEEP was decreased every 20 min in 2 cmH2O decrements.

The "optimal" PEEP was defined as the lowest PEEP attainable without causing a significant drop (>10%) in PaO2. The "optimal PEEP" was 14.5 +/- 3.8 cmH2O. PaO2 /FI O2 ratio was 154.8 +/- 63.3 mmHg at baseline and improved to 290.0 +/- 96.4 mmHg at highest PEEP and 302.7 +/- 94.2 mmHg at "optimal PEEP", both significantly higher than baseline (p<0.05).

Static compliance was significantly higher at "optimal" PEEP (27.2 +/- 10.4 mL/ cmH2O) compared to highest PEEP (22.3 +/- 7.7 mL/cmH2O) (p<0.05).

Three patients experienced transient hypotension and one patient experienced atrial premature contractions. No patient had gross barotrauma.

PEEP titration protocol involving RM and PEEP decrement was effective in improving oxygenation and was generally well-tolerated.



Reference:

Suh GY and col. - A practical protocol for titrating "optimal" PEEP in acute lung injury: recruitment maneuver and PEEP decrement..

J Korean Med Sci. 2003 Jun;18(3):349-54.

Q: What dose of Versed (midazolam) is optimum for antegrade amnesia?

Answer: About 0.05 – 0.1 mg/kg.

Reference:

Bulach R: Double-blind randomized controlled trial to determine extent of amnesia with midazolam given immediately before general anaesthesia. BJA 2005;94:300-5

Q: What is 80-10-10 distribution in brain?

Answer:

80% - Parenchyma

10% - Blood

10% - CSF

On IV acetaminophen

 "Compared to oral acetaminophen, IV acetaminophen achieves a rapid elevation in plasma concentration and higher peak levels. The IV form achieves plasma levels rarely achieved by similar oral doses of acetaminophen and produces 75% higher central nervous system (CNS) bioavailability compared to the oral form. The analgesic effect peaks within one hour and lasts for four to six hours." 

 Read full article here 

Darrell Harrington, MD 
Chief, Division of General Internal Medicine 
Harbor-UCLA Medical Center, Los Angeles 

 Source: Today's Hospitalist

Ultrasound Guidance for Thoracentesis 
 

 

Q: The Model for End-Stage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. Formula for MELD score is

MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43

If patient is already on Dialysis - what value of Creatinine is automatically substituted?

Answer: 4

In interpreting the MELD Score in hospitalized patients, the 3 month mortality is:

• 40 or more — 71.3% mortality
• 30–39 — 52.6% mortality
• 20–29 — 19.6% mortality
• 10–19 — 6.0% mortality
• <9 — 1.9% mortality

Q:  Cardiac output is the volume of blood being pumped by the heart, (left or right ventricle), in the time interval of ......

? (choose one)

A) One minute

B) One second

C) each beat

D) one respiratory cycle

Answer:  A) Per minute

Cardiac output is the volume of blood pumped by the heart per minute (mL blood/min). 

Cardiac output is a function of heart rate and stroke volume. The heart rate is simply the number of heart beats per minute. The stroke volume is the volume of blood, in milliliters (mL), pumped out of the heart with each beat. 

Cardiac Output in mL/min = heart rate (beats/min) X stroke volume (mL/beat)

An average resting cardiac output would be 5.6 L/min for a human male and 4.9 L/min for a female.

Q: Why it is important to look at CXR for a patient presenting with symptoms consistent with Myasthenia Gravis?


Answer:  To Rule out Lambert-Eaton Myasthenic syndrome.

Lung cancer has strong association with this syndrome.

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.