Q; 48 year old male developed spontaneous hemoperitoneum 2 hours after uneventful procedure of Paracentesis?


Answer:

Spontaneous hemoperitoneum is a rare but life threatening complication after large volume Paracentesis (usually if beyond 4 litres). It is due to mesenteric variceal bleed.

Q; Succinylcholine is contraindicated (relatively) for intubation in which poisoining?


Answer: Organophosphate poisoining.

Organophosphate may potentiate effects of succinylcholine. Succinylcholine is relatively contraindicated in Organophosphate poisoining.

Q: What is the half life of Argatroban?


Answer: About 50 minutes

As Argatroban is metabolized in the liver, assuming patient has a normal liver function, its half life is about 50 minutes. It is monitored by PTT in same way as heparin drip.

In contrast, lepirudin, another direct thrombin inhibitor is primarily cleared by kidneys and should be either avoided or adjusted with renal insufficiency.

Fentanyl Cough

Fentanyl is probably the most commonly used opioid in ICUs. Fentanyl is associated with coughing in upto 30% of patients. Usually its benign but may become explosive causing discomfort and increased intracranial and intra-ocular pressures. The various mechanisms proposed to explain fentanyl induced cough are inhibition of central sympathetic outflow leading to vagal predominance, histamine release or deformation of the tracheobronchial wall stimulating the irritant receptors.

Treatment is aerosol inhalation of Salbutamol, beclomethasone or sodium chromoglycate if needed.

Q; Why Haldol (Haloperidol) should be use with caution in burn patients?


Answer: The burn patient may be more prone to extrapyramidal symptoms of Haldol because of increased sensitivity of skeletal muscle neuromuscular junctions to acetylcholine after thermal injury.

Q: Which one renal failure (crisis) is treated/managed by ACE inhibitor?


Answer: Scleroderma Renal Crisis!

Scleroderma Renal Crisis is one of the few rheumatological emergency where early diagnosis and treatment can make big difference in outcome. Wrong diagnosis may lead to wrong management pathway and eventually to very high mortality. SRC is heralded with hypertensive crisis associated with acute renal failure but the pearl is to avoid IV Labetolol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. calcium channel blockers may help. Renal dialysis is a last resort. It has been suggested that use of steroids is associated with onset of scleroderma renal crisis.

Seenario: 57 year old male with previous history of Right pneumonectomy requires central venous line. Which would be your site of choice?


Answer: Any except left internal jugular or left subclavian.

Patient already has Right pneumonectomy and if develops pneumothorax at left side, would be dead without any lungs - or without prompt action.

Levetiracetam (keppra) and Vitamin B6 - something to think of when writing Keppra!

Levetiracetam (keppra) has been reported to cause many behavioral and psychiatric disturbances including anxiety, irritability, depression etc. Recent literature (thoug mostly from pediatric population) suggests that the addition of pyridoxine (vitamin B6) may curtail some of the these symptoms.


Pyridoxine supplementation for the treatment of levetiracetam-induced behavior side effects in children: preliminary results - Epilepsy Behav. 2008 Oct;13(3):557-9. Epub 2008 Aug 3.

Behavioral effects of levetiracetam mitigated by pyridoxine. - J Child Adolesc Psychopharmacol. 2009 Apr;19(2):209-11

Q: What is Jacksonian seizure?


A: Jacksonian seizure is an unique type of simple partial seizures in which symptoms start in one part of the body, then spread to another - "epileptic march". Abnormal movements may occur in the hand or foot, then move up the limb as the electrical activity spreads in the brain. People are completely aware of what is occurring during the seizure.

Jacksonian seizures are extremely varied and may involve, for example, apparently purposeful movements such as turning the head, eye movements, smacking the lips, mouth movements, drooling, rhythmic muscle contractions in a part of the body, abnormal numbness, tingling, and a crawling sensation over the skin. These motor symptoms spread slowly from one part of the body to another.

(These seizures are named after an english neurologist, John Hughlings Jackson who described it in 1863)

Q: 72 year old male with history of myasthenia gravis is now admitted with GI bleed. You are writing orders and converting essential meds to IV form. What is the conversion from PO to IV of Pyridostigmine (Mastinon)?


Answer: Conversion is 1/30th of PO dose.

e.g: 90 mg would be equivalent to 3 mg IV. Inravenous form should be given preferably via slow infusion.

Q: 72 year old male after CABG (Cardiac bypass surgery) developed chylothorax confirmed after diagnostic thoracentesis. Nutritional changes were made. Due to various co-morbidities surgeon asked your advise on non-surgical approaches?


Answer: Administer Octreotide 100 mcg SQ every 8 hours for 5 days.

Octreotide has shown benefit in medical (non-surgical) treatment of chylothorax.

Dalokay Kilic, MD, Ekber Sahin, MD, Oner Gulcan, MD, Bulent Bolat, MD, Riza Turkoz, MD, Ahmet Hatipoglu, MD (2005). Octreotide for Treating Chylothorax after Cardiac Surgery Texas Heart Institute Journal 32 (3): 437–39

Q: Why we call it DobbHoff tube?

Answer: DobbHoff feeding tube was invented in 1976 by 2 surgeons Dr. Robert Dobbie and Dr. Hoffmeister - and so named after them.

Q: What's the easy way to estimate the distance from the right subclavian vein to the junction of the superior vena cava and right atrium?


Answer: For R- SC vein: (Height in cm)/10 – 2 cm

For R- IJ vein: (Height in cm)/10
For L-IJ vein: (Height in cm)/10 + 4 cm

Q: What is the conversion of Bumex to Lasix?

Answer: 1 mg of Bumex is equal to 40 mg of Lasix in potency.

Q: What is "Round belly sign" on CT scan in patients with suspicion of intra abdominal compartment syndrome (IACS)?

Answer: Round-belly sign will be termed positive for IACS if abdominal distention has an increased ratio of anteroposterior-to-transverse abdominal diameter of more tham 0.80 with 100% sensitivity and 94% specificity. Using a value of 0.82 increased the specificity to 99%.

Reference:

Pickhardt PJ, Shimony JS, Heiken JP, Buchman TG, Fisher AJ. The abdominal compartment syndrome: CT findings. AJR 1999;173:575 -579

On wider use of clonidine

Case: 49 year old female is admitted to ICU with mental status change. She was intubated in ER. Relatively she has no past medical history except recently started on Clonidine for relief of menopausal symptoms!


Comment: Recently clonidine has found many off-label uses including neuropathic pain, opioid detoxification, sleep hyperhidrosis, insomnia, relief of menopausal symptoms, ADHD and others.

Clonidine toxicity may have many central and cardiac effects like bradycardia, AV nodal block, Wenckebach, tachycardia, hypotension, transient hypertension, hypothermia, CNS depression, hyporeflexia, seizures, respiratory depression etc.

Treatment is mostly supportive but 2 antidotes which may help includes Narcan (Naloxone) and Yohimbine.

Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes


Background: Clopidogrel and aspirin are widely used for patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). However, evidence-based guidelines for dosing have not been established for either agent.


Methods: We randomly assigned, in a 2-by-2 factorial design, 25,086 patients with an acute coronary syndrome who were referred for an invasive strategy to either

• double-dose clopidogrel (a 600-mg loading dose on day 1, followed by 150 mg daily for 6 days and 75 mg daily thereafter) or
• standard-dose clopidogrel (a 300-mg loading dose and 75 mg daily thereafter) and either higher-dose aspirin (300 to 325 mg daily) or lower-dose aspirin (75 to 100 mg daily)
  

The primary outcome was cardiovascular death, myocardial infarction, or stroke at 30 days.


Results:

• The primary outcome occurred in 4.2% of patients assigned to double-dose clopidogrel as compared with 4.4% assigned to standard-dose clopidogrel
  Major bleeding occurred in 2.5% of patients in the double-dose group and in 2.0% in the standard-dose group
• Double-dose clopidogrel was associated with a significant reduction in the secondary outcome of stent thrombosis among the 17,263 patients who underwent PCI
• There was no significant difference between higher-dose and lower-dose aspirin with respect to the primary outcome or major bleeding
  

Conclusions: In patients with an acute coronary syndrome who were referred for an invasive strategy, there was no significant difference between a 7-day, double-dose clopidogrel regimen and the standard-dose regimen, or between higher-dose aspirin and lower-dose aspirin, with respect to the primary outcome of cardiovascular death, myocardial infarction, or stroke.

Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes - N Engl J Med 2010; 363:930-942 September 2, 2010

ECMO getting momentum!

Early ECMO-assisted primary PCI improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock

Objectives: This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention.

Methods: Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2).

Results:

• The incidence of profound shock (defined as systolic blood pressure remaining less than/=75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups

Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room.

• The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups

• Total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1
  
• The hospital survival time was remarkably longer in patients in group 2 than in patients in group 1

Conclusion: Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock - Critical Care Medicine. 38(9):1810-1817, September 2010.

Q: Which finding in CBC is highly suggestive of Adrenal crisis? (Select one)

A) Neutrophilia
B) Eosinophilia
C) Thrombocytopenia
D) Neutropenia
E) Polycythemia


Ans: Eosinophilia

Hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia may be present along with anemia and lymphocytosis, but eosinophilia with above serum chemistry findings is highly suggestive of Adrenal Crisis.

Q: Do you need radiological work up after femoral line placement?

Answer: Sometimes! (see below - retained guide wire after femoral line)

Neostigmine drip and Critical illness induced intestinal Pseudo-obstruction

IV Neostigmine has been used successfully in acute colonic pseudo-obstruction with quick colonic decompression after a bolus infusion. But it carries significant risk of adverse effects of cholinesterase inhibitors include bronchospasm, salivation, vomiting, life threatening bradycardia and hypotension. Atropine should be at bedside during the administration of neostigmine.

To counter act this life threatening bradycardia a slow infusion may be use which may carry a lower risk of bradycardia. This could also be extremely useful in patients with critical illness-related intestinal ileus unresponsive to other standard measures. The recommended dose of neostigmine for continuous infusion is 0.4-0.8 mg/h over 24 hours.

Scenario: 64 year old female developed C.Diff. Colitis in ICU. 2 days later urine color changed to dark brown and progressively became black! What is your diagnosis? - Choose one

A) Worsening C. Diff. Colitis despite treatment
B) Developing Rhabdomyolysis
C) Benign side effect of Metronidazole treatment - continue Metronidazole
D) Life threatening side effect of Metronidazole treatment - stop Metronidazole



Answer: C

Darken urine - dark brown to black - is a benign side effect of Metronidazole (Flagyl). It is due to water-soluble pigments formed during metabolism. No intervention is needed.

Q: While at bedside you noticed Dopamine drip is yellow in color. What does it mean?

Answer: Bag should be changed.

Any dark color discoloration of solutions containing dopamine indicates decomposition of the drug. Solutions that are darker than slightly yellow should not be used. Dopamine is sensitive to and should be protected from light.

Q: Give one non-infectious condition which can be treated by IV penicillin G?

Hint: It is use as an antidote.

Answer: A phalloides mushroom intoxication

There is no definitive antidote available for a phalloides mushroom intoxication, but high-dose continuous intravenous penicillin G has been reported to help but the exact mechanism is unknown.

Another useful treatment is said to be intravenous silibinin.

As with other toxin gastric decontamination with either activated carbon or gastric lavage should be done. Also like in other hepatic conditions associated with toxin ingestions N-acetylcysteine should also be used. Liver transplant team should be involved too.

Q: 52 year old alcoholic male who is frequent flyer at your ED presents again with symptoms of Wernicke encephalopathy. Despite quick repletion of Thiamine upto 300 mg IV - symptoms persist. What could be the missing point?



Answer: Hypomagmesemia

Patients with Wernicke encephalopathy may not response to parenteral thiamine in the presence of low magnesium level. Once magnesium is repleted thiamine will have effect, the blood transketolase activity will return to normal and clinical symptoms will resolve.

Please request pharmacy to provide fresh Thiamine solution, since old solutions quickly get inactive.

Merci Clot Retrieval Animation in CVA

(2 videos)

Learn about the Merci Retrieval System

Gadolinium, MRIs, Renal failure and Nephrogenic systemic fibrosis

Nephrogenic systemic fibrosis (NSF) is a rare but a serious disease that involves fibrosis of skin, joints, eyes, and internal organs. It is found to be associated with exposure to gadolinium for MRIs in patients with severe kidney failure. It can happen anywhere from few hours to months after exposure.

NSF is a clinical and histopathological diagnosis. Most patients with NSF require quick diagnosis and aggressive hemodialysis. Gadolinium-containing contrast is now considered relatively contraindicated in patients with an estimated GFR under 60 and especially under 30 ml/mn.

Not all but 4 of the 7 gadolinium contrast agents have been implicated in NSF.

End of Life Care!

Background: Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation.

Methods: We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients’ charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes.

Results: The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women.

The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours).

Using Cox regression, the independent predictors of a shorter time to death were

• nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35)
• number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19),
• vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and
• surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56).

Predictors of longer time to death were

• older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and
• female sex (HR, 0.86; 95% CI, 0.77-0.97).

Conclusions: Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.

Predictors of Time to Death After Terminal Withdrawal of Mechanical Ventilation in the ICU - CHEST August 2010 vol. 138 no. 2 289-297

19% of PFOs in ARDS!

Objective: Right-to-left shunting across a patent foramen ovale may occur in acute respiratory distress syndrome as a result of pulmonary hypertension and positive-pressure mechanical ventilation. The shunt may worsen the hypoxemia. The objective of our study was to determine the prevalence, clinical implications, and prognosis of patent foramen ovale shunting during acute respiratory distress syndrome.

Design: Prospective study of 203 consecutive patients with acute respiratory distress syndrome.

Interventions: Patent foramen ovale shunting was detected by using transesophageal echocardiography with modified gelatin contrast. Moderate-to-large shunting was defined as right-to-left passage of at least 10 bubbles through a valve-like structure within three cardiac cycles after complete opacification of the right atrium. In 85 patients without and 31 with shunting, the influence of the positive end-expiratory pressure level on shunting was studied.

Measurements and Results:

• The prevalence of moderate-to-large patent foramen ovale shunting was 19.2% (39 patients).
  
• Compared to those in the group without shunting, the patients in group with shunting had larger right ventricle dimensions, higher pulmonary artery systolic pressure, and a higher prevalence of cor pulmonale.
  
• Compared to patients without shunting, patients with shunting had a poorer Pao₂/Fio₂ ratio response to positive end-expiratory pressure, more often required prone positioning and nitric oxide as adjunctive interventions, and had fewer ventilator-free and intensive care unit-free days within the first 28 days.

Conclusions: Moderate-to-large patent foramen ovale shunting occurred in 19.2% of patients with acute respiratory distress syndrome, in keeping with findings from autopsy studies. Patent foramen ovale was associated with a poor oxygenation response to positive end-expiratory pressure, greater use of adjunctive interventions, and a longer intensive care unit stay.

Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome -Critical Care Medicine: September 2010 - Volume 38 - Issue 9 - pp 1786-1792