Q: Which lab is most reliable in following the effect of plasmapheresis in resolution of TTP (Thrombotic thrombocytopenic purpura)?


Ans: LDH

Declining LDH level is a pretty good indicator that plasma exchange is working to treat TTP.

Q: What is Fat Embolism Syndrome?


Ans: Fat embolism syndrome usually occur 1-3 days after a traumatic injury and are predominantly

• pulmonary - shortness of breath, hypoxemia,


• neurological - agitation, delirium, or coma,


• dermatological - petechial rash, and


• haematological - anaemia, low platelets

The syndrome manifests more frequently in fractures of the pelvis or long bones. The petechial rash is the pathognomonic hallmark of the syndrome.

Treatment is supportive.

Scenario: 25 year old patient presented to the emergency room with complaint of 2 days history of muscular weakness which is symmetric and descending and diplopia. He denies any fever or chills. He does give the history of having injury to the face. He works as marine driller. His symptoms are progressively getting worse. His vitals signs reveal no fever, and bradycardia with the heart rate of 48 and blood pressure of 120/80 mm hg. His Slow vital capacity was 1 liter (33% of predicted). He was admitted in intensive care unit.


Diagnosis: Botulism (110 cases in US per year with 3 percent being wound Botulism)

Differential diagnosis: Mysthenia Gravis, Lambert-Eaton syndrome, Guillain-Barre’s syndrome, poliolmyelitis, Ticks paralysis, heavy metal intoxication.

Botulism has an acute onset with bilateral cranial neuropathies and symmetric descending weakness. Key feature include:

•Patient is afebrile
•Symmetric neurological deficit
•Patient is responsive
•Normal or slow heart rate and normal blood pressure
•No sensory deficit
•Blurred vision

Treatment:

•Equine serum botulism antitoxin
•Penicillin G intravenously 3 grams every 4 hours

Q: "Hot as a hare, dry as a bone, red as a beet, mad as a hatter"

describes which toxicity?


Answer: Anticholinergic toxicity. Symptoms include

• Hyperthermia,


• Dry skin,


• Tachycardia,


• Delirium,


• Urinary retention


• Mydriasis

Anticholinergics include Atropine, ipratropium bromide, Glycopyrrolate etc

3 tips on reading Pulmonary Artery Occlusion Pressure (PAOP)/pulmonary wedge pressure (PWP) with EKG

PWP should be measured as

• mean of 'A' wave


• at end expiration


• after QRS complex of EKG

It is recommended to read wedge pressure from paper print out instead of directly from monitor

Q: Progesterone is also an “anticonvulsant.” True or false?

Answer: True

Catamenial epilepsy is defined as seizure exacerbation in women aligned with their menstrual cycle. It usually subsides in menopause and thought to be related to estrrogen.

Progesterone is the mainstay of the treatment.

Q: Glucagon bypass the beta-adrenergic receptor site and is a good alternative therapy for profound beta-blocker intoxications. Glucagon increases heart rate and myocardial contractility, and improves atrioventricular conduction. What is the dose of Glucagon in B-blocer overdose?

Answer: The doses of glucagon required to reverse severe beta-blockade are 50 micrograms/kg iv loading dose, followed by a continuous infusion of 1-15 mg/h, titrated to patient response.

Glucagon has shown similar benefit but to lesser extent in Calcium-channel blockers overdose.

Picture Diagnosis

Answer: LAD (left anterior descending coronary artery) aneurysm

Also notice stenosis of distal left main coronary artery along with large proximal LAD aneurysm.

Coronary aneurysms may be from trauma during cardiac catheterization, but it is the hallmark of Kawasaki disease.

Serum-ascites albumin gradient (SAAG)

A serum-ascites albumin gradient (SAAG) is a useful test for differential diagnosis of Ascites. Both should be drawn/measured at same time.

Q: What is the best way to follow on Amiodarone overdose?

Answer: Follow serial QT duration

Surprisingly, Overdose with amiodarone is usually benign as it is very poorly and variably absorbed. But all such patients should be admitted to ICU/CCU for close observation and serial EKGs.

On EKG, Amiodarone leads to a prolonged QT interval due to its blocking of repolarising of. potassium channel. The QT duration is the best indicator of the extent of potassium channel blockade.

The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia

Interesting study published this month (May 2011) in CCM Journal regarding selective digestive tract decontamination aims to eradicate Gram-negative bacteria in both the intestinal tract and respiratory tract. Patients selected were with ICU stay of more than 48 hrs that received selective digestive tract decontamination (n = 2,667), selective oropharyngeal decontamination (n = 2,166) or standard care (n = 1,945).

Results showed that respiratory tract decolonization was associated with a 33% and intestinal tract decolonization was associated with a 45% reduction in the occurrence of intensive care unit-acquired Gram-negative bacteremia.



The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia - Critical Care Medicine: May 2011 - Volume 39 - Issue 5 - pp 961-966

"MRSA Bundle"!

This week NEJM has published an interesting article from Veterans Affairs (VA) system where a “MRSA bundle” was implemented in 2007 in acute care VA hospitals nationwide.

The bundle consisted of

1. universal nasal surveillance for MRSA,

2.contact precautions for patients colonized or infected with MRSA,

3. hand hygiene, and

4. a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients.

Method implemented was: each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care–associated transmissions of and infections with MRSA.

Results showed that the rates of health care–associated MRSA infections in ICUs declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P value less than 0.001 for trend). During this same period, the rates of health care–associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P value less than 0.001 for trend).

It was concluded that a program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care–associated transmissions of and infections with MRSA in a large health care system.

Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections- N Engl J Med 2011; 364:1419-1430, April 14, 2011

Q: In massive hemoptysis - For massive right-sided pulmonary bleeding, the left mainstem bronchus intubation over bronchoscope is preferred but the unilateral intubation of the right lung with massive left-sided bleeds is not recommended. What is the reason?

Answer: For massive right-sided pulmonary bleeding, the left mainstem bronchus is intubated over the bronchoscope. Unilateral intubation of the right lung with massive left-sided bleeds is not recommended due to the risk of right upper lobe occlusion. Alternative in this case is to use a double lumen endotracheal tube to isolate the unaffected lung.

Giving Doctors Orders

"When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

...................................................."

Read full article by Maureen Dowd in NYT here

On "Beer Potomania" (Beer induced hyponatremia)

Severe hyponatremia associated with intake of large quantities of beer or after episode of binge beer drinking is called beer potomania. Patients usually present with mental status change deteriorating into seizure or coma.

Pathophysiology:Hypoosmolality of the beer associated with poor nutrition leads to the inability to excrete sufficient amounts of free water.

Clinical significance: This hyponatremia doesn't respond well to restriction of free water but treatment with isotonic saline results in the rapid clearance of the accumulated excess free water and clinical improvement.

Q: What is the advantage of adding Sildenafil with inhaled NO in treatment of pulmonary hypertension?

Answer: Sildenafil not only decreases pulmonary pressures but also prevents rebound pulmonary vasoconstriction on withdrawal of inhaled NO.

Mehta S. Sildenafil for pulmonary arterial hypertension: exciting, but protection required. Chest. 2003 Apr; 123(4): 989-92.

Q: 48 year old male s/p single lung transplant ten days ago developed tremors all over the body associated with confusion. What could be the likely cause?

Answer: Prograf toxicity

Prograf (FK 506,Tacrolimus) is a commonly used medicine in transplant patients and its level should be monitored closely. Dosage should be adjusted based on the trough levels of medication. Normal trough level is 5-15 ng/ml.

Prograf toxicity may cause blurred vision, liver and renal failure, tremors, hyperkalemia, hypomagnesemia, and neurological problems such as seizure, encephalopathy, cerebral edema, confusion etc.

Q: What is Bickerstaff's brainstem encephalitis (BBE)?

Answer: Bickerstaff's brainstem encephalitis (BBE), is a variant of Guillain–Barré syndrome. It is characterized by acute onset of

• ophthalmoplegia,


• ataxia,


• disturbance of consciousness,


• hyperreflexia or Babinski's sign

The course of the disease can be monophasic or remitting-relapsing but despite severe initial presentation usually it has a good prognosis. MRI plays a critical role in the diagnosis of BBE, characterized by large, irregular hyperintense lesions located mainly in the brainstem, especially in the pons, midbrain and medulla.

Q: 32 year old diabetic female is admitted with fever, chills, abdominal pain, nausea, vomiting, left flank pain with crepitation over left flank and urinary symptoms. What's your concern?

Answer: Emphysematous pyelonephritis

Emphysematous pyelonephritis is a necrotizing acute nephritis with extension of the infection through the renal capsule. This leads to the presence of gas within the kidney and in the perinephric space.

The mortality rate is 60% - 80% despite medical treatment and usually require surgical intervention with nephrectomy.

Q: Hypotension secondary to Milrinone therapy can be managed more efficiently with which pressor?

A) Norepinehrine

B) Dopamine

C) Vasopressin

D) Phenylephrine

E) Epinephrine

Answer: Vasopressin

Certainly any pressor can be use for hypotension but literature point towards vasopressin as better choice of pressor in milrinone induced hypotension. Low-dose vasopressin decreased the PVR/SVR ratio that was increased by milrinone. Considering the importance of maintaining systemic perfusion pressure as well as reducing right heart afterload, milrinone–vasopressin may provide better hemodynamics than milrinone–norephinephrine during the management of right heart failure.

Comparative hemodynamic effects of vasopressin and norepinephrine after milrinone-induced hypotension in off-pump coronary artery bypass surgical patients - Eur J Cardiothorac Surg 2006;29:952-956

Case: 47 year old male of Indian sub-continent origin admitted to ICU with status epilepticus. Patient has recently been started on TB prophylaxis medicine at his new work place. What is your probable diagnosis and what would be the treatment?

Answer: Isoniazid (INH) induced seizures.

Isoniazid (INH) induced seizures is unique in the sense that it is usually refractory to standard anticonvulsant therapy. Even dose as low as as 1.5 g can be neurologically toxic.

INH induced seizure requires administration of a specific antidote, pyridoxine (B-6), with dose of 5 gram in IV form. Dose can be repeated 2 to 3 times if needed.

Q: What is Atropine test?

Answer: Atropine test is a simple pharmacological test based on the absence of cranial parasympathetic nervous influence on the heart in brain dead patients and may be a useful adjunct to testing brain stem function. A tachycardic response would demonstrate an intact cranial parasympathetic outflow. 2-3 mg of Atropine IV is then given. If there is less than 10 % or no increase in heart rate, this supports the diagnosis of brain death. Additional confirmatory tests are however required.

Anchoring Chest tube sutures (Rashid Method) - 4 steps

A simple technique for anchoring chest tubes - M.A. Rashid, T. Wikström, P. Örtenwall, Eur Respir J 1998; 12: 958–959

Q: Your Diagnosis?

Answer: Bilateral Pneumothoraces Bilateral pneumothoraces can be very deceiving as there is no deviation of trachea, and percussion and breath sounds seems equal on both sides. Clinically these patients are usually haemodynamically compromised and on CXR you may see the characteristic 'disappearing heart' with bilateral tension pneumothoraces.

Q: 78 year old DNR patient is in Atrial fibrillation with RVR (Rapid Ventricular Rate) causing borderline hypotension. Patient did not respond to Digoxin and Amiodarone. Patient is on chronic coumadin therapy with INR of 2.8. Echo ruled out any thrombus. Patient refuses any sort of cardioversion but oked any drug treatment. Cardiologist on consult informed you that he will be using ibutalide this afternoon to see if that works. To minimize the associated ventricular arrhythmia what could be your preventive strategy?

Answer: Administer Magnesium before ibutalide use

The risk of developing torsade de pointes with ibutilide is about 4% but it can reduced with intravenous infusion of high-dose magnesium sulfate and having potassium level around 4.5 range.

Reference: 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: 673–6

Q: Lorazepam(Ativan) and Diazepam(Valium) both have been used as first line treatment of Status Epilepticus. What advantage Lorazepam have over Diazepam?

Answer: Lorazepam and diazepam both have been used as a first line drugs in the management of Status Epilepticus. Though diazepam acts slightly faster than lorazepam its effective duration of action may be only 5-10 min - and may require repeated doses or quick followup with administration of phenytoin (or fosphenytoin). On the other hand once effective dose(s) of lorazepam is given, the effective duration of action of lorazepam is 8-10 hours, and so is more recommended for initial treatment of status epilepticus.

Q: Is Amniotic fluid embolism (AFE) a anaphylactoid reaction?

Answer: Yes

Amniotic fluid embolism (AFE) is a misnomer as clinical picture is more or less like acute collapse from pulmonary embolism but in fact it is an allergic type reaction. Amniotic fluid embolism (AFE) is a rare obstetric emergency in which amniotic fluid, fetal cells, hair, or other debris enters the mother's blood stream and triggers an allergic reaction - which results in cardiorespiratory collapse. Another hallmark of the disease is severe coagulopathy.

Diagnosis: In a patient who is suspected of having AFE, a sample should be obtained by aspiration of the distal port of a pulmonary artery catheter. If sample contains fetal squamous cells it is highly suggestive of AFE syndrome - but does not completely rule in or rule out other causes too.

Treatment: Immediate delivery of baby. Support coagulopathy and hemodynamics as per standard.

Q: What is Hamman's syndrome?

Answer: Hamman's syndrome is a clinical condition and frequently requires ICU admission for observation. It is a spontaneous pneumomediastinum with subcutaneous emphysema. It occurs mostly in young females peripartum or postpartum. It is named after the physician (Louis Hamman 1877–1946), who described it.

Hamman's syndrome usually occurs in the second stage of labor but can be delayed to the postpartum phase. An association with prolonged labor has been proposed (increase intrathoracic pressure) with rupture of alveoli.

Treatment is supportive and course is usually benign.

Dudley DK, Patten DE. Intrapartum pneumomediastinum associated with subcutaneous emphysema. CMAJ 1988;139:641-2

Q: Patient developed lower GI bleed in ICU. GI service after scope diagnosed anal fissure and prescribed Cardizem. Is this a mistake?

Answer: No

Cardizem (Diltiazem) is frequently used in the treatment of anal fissures - either via oral route or can be applied topically!

It has a very good short term success rates and provide temporary relief till surgical intervention is done, if required. Local application of it relaxes the sphincter muscle, and allows the healing to proceed.

Q: Enteral feeding is always preferred over parenteral feeding (TPN) in ICUs - as enteral feeding also prevents a very dangerous ICU entity - acalculous cholycystitis. What is the mechanism?

Answer: There are 2 synergistic components to this pathophysiology.

1. Bile Stasis: Absence of oral/enteral feeding results in a decrease or absence of cholecystokinin-induced gallbladder contraction.

2. Increase Bile Viscosity: Increased bile viscosity due to fever and dehydration causes acalculous cholycystitis.