Q: While floating a Pulmonary Artery Catheter, as you  inflate balloon and enter right ventricle, nurse inform you that monitor is reading pressure 90/0. What is the problem?

Answer: Probably you are in left ventricle instead of right ventricle

Link: http://youtu.be/SvlK9XU7ThU

Q: What are the essential components of Decorticate and Decerebrate posturing

Answer:

Decorticate posturing:

• Elbows, wrists and fingers flexed
• Legs extended but rorated inwards

Decorticate posturing indicates damage to areas in cerebral hemispheres, the internal capsule, and the thalamus.

Decerebrate posturing:

• the head is arched back,
• the arms are extended by the sides (elbows extended),
• the legs are extended.

Decerebrate posturing indicates brain stem damage, specifically with lesions or compression in the midbrain and lesions in the cerebellum.

Progression from decorticate posturing to decerebrate posturing is often indicative of brain herniation.

Q: What is the recommended DVT prophylaxis in patients with no major risk undergoing spinal surgery?

Answer: For patients who have no major risk factors, antithrombotic prophylaxis following elective spine surgery is not recommended. 

Q: What are the added risk factors for pressure ulcer in ICU patients in addition to other hospitalized adult patients?

Answer:

1) Age

2) Length of ICU stay

3) Norepinephrine administration

4) Cardiovascular disease state

Please read following article and review on "Pressure Ulcer Management"

Cox J., - Predictors of pressure ulcers in adult critical care patients. - Am J Crit Care. 2011 Sep;20(5):364-75.

Link: http://www.aacn.org/wd/Cetests/media/a112005.pdf

Q: Ideally, how frequent lubricant should be applied in ICU patients, who have exposed cornea to prevent keratopathy/keratitis?

Answer: Some degree of keratopathy develops in about 60% of intubated and sedated patients. Incomplete lid closure increases the risk of corneal damage very high (70% vs. 30%). Fluid imbalance and positive pressure ventilation (Ventilator eye) may make it impossible to close eyelids completely. Lubricant should be applied ideally every two hours, particularly if any sort of cornea is exposed. Overall, literature lean more towards moist chamber application than lubricant application.

References:

1. Imanaka H, Taenaka N, Nakamura J, et al: Ocular surface disorders in the critically ill. Anesth Analg 1997; 85:343-346

2. McHugh J, Alexander P, Kalhoro A, et al: Screening for ocular surface disease in the intensive care unit. 2008;22:1465–1468

3. Mercieca F, Suresh P, Morton A, et al: Ocular surface disease in intensive care unit patients. Eye 1999; 13:231-236

4. Koroloff N, Boots R, Lipman J, et al: A randomized controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient. Intensive Care Med 2004; 6:1122-1126

5. Parkin B, Turner A, Moore E, et al: Bacterial keratitis in the critically ill. Br J Ophthalmol 1997; 12:1060-1063

6. Suresh P, Mercieca F, Morton A, et al: Eye care for the critically ill. Intensive Care Med 2000; 2:162-166

Q: What is Palla's sign in Pulmonary Embolism (PE)?

Answer: A chest x-ray shows a prominent right descending pulmonary artery, along with an area of focal oligemia (Westermark’s sign).

Q: 45 year old female with established diagnosis of pheochromocytoma and on maintenance dose of phenoxybenzamine - presented with septic shock. Which pressors may not work on her?

Answer: Epinephrine and Norepinephrine

Phenoxybenzamine forms a permanent covalent bond with adrenergic receptors. It remains permanently bound to the receptor, preventing adrenaline and noradrenaline from binding. This causes vasodilatation, due to its antagonistic effect at the alpha-1 adrenoceptor.

Q: What advantage plasma exchange provides in acute exacerbation of Wegner's Granulomatosis?

Answer: It does not improve mortality but may rescue renal failure

Reference:

1.Klemmer PJ, Chalermskulrat W, Reif MS, et al. Plasmapheresis therapy for diffuse alveolar hemorrhage in patients with small-vessel vasculitis. Am J Kidney Dis 2003;42:1149–1153.

2.Nguyen T, Martin MK, Indrikovs AJ. Plasmapheresis for diffuse alveolar hemorrhage in a patient with Wegener's granulomatosis: case report and review of the literature. J Clin Apher 2005;20:230–234.

Q: What is the recommendation for giving Haldol (Haloperidol) in patients over age 65? 

Answer: Haldol should be use with caution in elderly patients. Doses should be smaller in 0.25 - 0.5 mg range, and ideally should not exceed more than 2 mg over 24 hours period.

Q: What is the clinical utility of doing free plasma Hemoglobin? 

Answer: Plasma normally contains no free hemoglobin. Significant amounts of hemoglobin occur in plasma following hemolysis either from a transfusion reaction or any mechanical fragmentation of red blood cells.

Caution should be taken not to perform test on serum, as hemoglobin gets liberated from red blood cells during clotting. Moreover, elevated bilirubin levels interfere with the quantitation of the total plasma hemoglobin.

Reference:

Fairbanks VF, Ziesmer SC, O'Brien PC: Methods for measuring plasma hemoglobin in micromolar concentration compared. Clin Chem 1992;38:132-140

Q: You have been called to ER to evaluate a patient with severe headache. You ruled out SAH (Subarachnoid hemorrhage) with radiological imagings and you strongly suspect acute migraine. What one non-narcotic medicine may help you to treat severe acute migraine? 

Answer: Metoclopramide

A meta-analysis of 13 randomized controlled trials concluded that intravenous metoclopramide should be considered a primary agent in the treatment of migraine in emergency departments.

Reference:

Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369–1373

Q: "Worst headache of life" or "like being kicked in the head" is the classic presentation in SAH (Subarachnoid hemorrhage) . Many patients report neck stiffness too. What is the usual lag time reported between headache and neck stiffness, and strongly suggests SAH?

Answer: About 6 hours.

In classic SAH presentation, neck stiffness usually presents six hours after initial onset of SAH.

Reference:

Warrell, David A; Timothy M. Cox, et al. (2003). Oxford Textbook of Medicine, Fourth Edition, Volume 3. Oxford. pp. 1032–34

Q: Which patient population is at highest risk of developing HIT (Heparin Induced Thrombocytopenia)?

Answer: 

Female Gender receiving heparin after a recent surgical procedure, particularly cardiothoracic surgery.

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