Monday, May 22, 2017

On oral liposomal iron

 Effect of oral liposomal iron versus intravenous iron for treatment of iron deficiency anaemia in CKD patients: a randomized trial. 

 Pisani A, Riccio E, Sabbatini M, Andreucci M, Del Rio A, Visciano B.

Nephrol Dial Transplant. 2015 Apr;30(4):645-52. 

INTRODUCTION: Iron deficiency is a common cause of anaemia in non-dialysis chronic kidney disease (ND-CKD). Controversies exist about the optimal route of administration for iron therapy. Liposomal iron, a new generation oral iron with high gastrointestinal absorption and bioavailability and a low incidence of side effects, seems to be a promising new strategy of iron replacement. Therefore, we conducted a study to determine whether liposomal iron, compared with intravenous (IV) iron, improves anaemia in ND-CKD patients.

METHODS: In this randomized, open-label trial, 99 patients with CKD (stage 3-5, not on dialysis) and iron deficiency anaemia [haemoglobin (Hb) ≤12 g/dL, ferritin ≤100 ng/mL, transferrin saturation ≤25%] were assigned (2:1) to receive oral liposomal iron (30 mg/day, Group OS) or a total dose of 1000 mg of IV iron gluconate (125 mg infused weekly) (Group IV) for 3 months. The patients were followed-up for the treatment period and 1 month after drug withdrawal. The primary end point was to evaluate the effects of the two treatments on Hb levels; the iron status, compliance and adverse effects were also evaluated.

RESULTS: The short-term therapy with IV iron produced a more rapid Hb increase compared with liposomal iron, although the final increase in Hb was similar with either treatment; the difference between the groups was statistically significant at the first month and such difference disappeared at the end of treatment. After iron withdrawal, Hb concentrations remained stable in Group IV, while recovered to baseline in the OS group. The replenishment of iron stores was greater in the IV group. The incidence of adverse event was significantly lower in the oral group (P < 0.001), and the adherence was similar in the two groups.

CONCLUSIONS: Our study shows that oral liposomal iron is a safe and efficacious alternative to IV iron gluconate to correct anaemia in ND-CKD patients, although its effects on repletion of iron stores and on stability of Hb after drug discontinuation are lower. 

Sunday, May 21, 2017

Q: What is FeMg?

Answer:  Fractional excretion of magnesium

In refractory hypomagnesemia, it may require to find the route of continous loss of magnesium from the body. Two major routes of elimination of magnesium from the body are either gastrointestinal (GI) and renal. To distinguish magnesium loss between these two routes can be made by FeMg by formula

                           UMg  x  PCr
 FEMg    =    —————————   x    100 percent
                    (0.7  x  PMg)  x  UCr

U = Urine
P = Plasma
Cr = Creatinine

FEMg more than 2% indicates inappropriate renal wasting.


1. Topf, J.M. & Murray, P.T. (2003) Hypomagnesemia and hypermagnesemia. Reviews in Endocrine & Metabolic Disorders, 4, 195– 206.

2. Elisaf M, Panteli K, Theodorou J, Siamopoulos KC. Fractional excretion of magnesium in normal subjects and in patients with hypomagnesemia. Magnes Res 1997; 10:315.

Saturday, May 20, 2017

Q: All of the following electrolyte abnormalities occurs during Cardio-Pulmonary-Bypass (CPB) except

A) hypocalcemia
B) hyperkalemia, 
C) hypermagnesemia
D) hyperglycemia

Answer: C

Hypomagnesemia is frequently occurred during CPB due to two reasons

1. Diuresis 
2. Hemodilution with magnesium-free fluids during CPB

Therefore, it is a common practice to administer 2 grams of magnesium sulfate 2 g at the conclusion of CPB.


1.  England MR, Gordon G, Salem M, Chernow B. Magnesium administration and dysrhythmias after cardiac surgery. A placebo-controlled, double-blind, randomized trial. JAMA 1992; 268:2395. 

2. Booth JV, Phillips-Bute B, McCants CB, et al. Low serum magnesium level predicts major adverse cardiac events after coronary artery bypass graft surgery. Am Heart J 2003; 145:1108.

Friday, May 19, 2017

Q: All of the following drugs can be used as a rescue therapy in refractory delirium tremens (DT) except?

A) phenobarbital 
B) Propofol 
C) dexmedetomidine 
D) haloperidol 
E)) higher dose of lorazepam

Answer:  D

Once patient requires more than 10 mg of lorazepam, suspicion for refractory DT should be raised. Lorazepam dose can be further escalated  up to 40 mg in first four hours of treatment (as far as hemodynamics remain stable). All other choices in this question i.e A, B and C are appropriate choices.

Phenobarbital has the advantage of working in synergy with benzodiazepines 1.

Dexmedetomidine is now frequently used as it may help in avoiding mechanical intubation, though evidence-based used is still weak 2.

Propofol is another excellent choice though it surely buys mechanical ventilation 3.

Haloperidol should never be used used or to least with maximum caution as  it lower the seizure, interfere with heat dissipation and cause QT prolongation.


1. Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med 2013; 44:592. 

2. Tolonen J, Rossinen J, Alho H, Harjola VP. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med 2013; 20:425. 

3. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000; 28:1781. 

Thursday, May 18, 2017

Q: After lung volume reduction surgery in COPD patients, they should be left intubated till air leak on chest tubes resolved. 

A) Yes 
B) No

Answer:  No

Ideally, after lung volume reduction surgery in COPD patients, patients should be extubated in OR to avoid positive pressure ventilation, given other clinical scenarios are stable. If needed, reintubation can be salvaged with transient use of Non-invasive positive pressure ventilation (NIPPV).


 Boasquevisque CH, Yildirim E, Waddel TK, Keshavjee S. Surgical techniques: lung transplant and lung volume reduction. Proc Am Thorac Soc 2009; 6:66.

Wednesday, May 17, 2017

Q: How it could be determined to administer drug before or after plasmapheresis? 

 Answer: Plasmaphresis is frequently performed in ICU for various immunologic, infectious, drug overdose and metabolic diseases. If it is a lipophillic drug, it should be administer after plasmaphresis, as they are highly protein-bound, and have a small volume of distribution.


Kale-Pradham PB, Woo MH. A review of the effects of plasmapheresis on drug clearance. Pharmacotherapy. 1997;17:684-695

Tuesday, May 16, 2017

Q: If hyperbaric oxygen is used as an adjuvant to treat deep tissue infection, what is the target tissue oxygen tension?

Answer: Above 300 mmHg

Hyperbaric Oxygen, popularly known as HBO is now increasingly used in tertiary care centers as an adjuvant treatment in deep tissue infections such as gas gangrene, necrotizing fasciitis, and Fournier's gangrene. It requires 2-3 sessions daily of HBO with target to keep tissue oxygen tension above 300 mmHg to inhibit clostridial spore and exotoxin production.


Roth RN, Weiss LD. Hyperbaric oxygen and wound healing. Clin Dermatol 1994; 12:141.

Monday, May 15, 2017

Q: 54 year old female is in ICU with end stage metastatic ovarian cancer. Patient is made DNR/DNI by the family. Patient has painful ascites and palliative large volume paracentesis is planned. Should albumin be given for large volume malignant related paracentesis?

A) Yes
B) No

Answer: No

Large volume paracentesis for malignancy-related ascites usually does not cause hemodynamic issues, so forth albumin infusion is not needed alike other causes of ascites. 


Halpin TF, McCann TO. Dynamics of body fluids following the rapid removal of large volumes of ascites. Am J Obstet Gynecol 1971; 110:103.

Sunday, May 14, 2017

Q: Which of the following electrolyte abnormality may increase the risk of post-operative ileus

A) Hypokalemia
B) Hyperkalemia

Answer: A

Post-operatively hypokalemia worsens ileus. 

Though newer evidences have questioned this conventional teaching, but so far it is important  to continue to consider hypokalemia as one of the causes of post-operative ileus. 


1. . Lowman RM. The potassium depletion states and postoperative ileus. The role of the potassium ion. Radiology 1971;98:691-4.

Saturday, May 13, 2017

Q: Ultrasound-based elastography can be used to evaluate

A) liver fibrosis
B) Acute Kidney Injury
C) Non-Ischemic Cardiomyopathy
D) Splenic infarction
E) Response to thrombolytic therapy

Answer: A

 Principle behind ultrasound-based elastography is simple. As expected, fibrotic tissue differs from normal healthy tissue in a way that they respond to excitation. Ultrasound-based elastography can be used as an alternative to liver biopsy for the assessment of hepatic fibrosis. Not only liver biopsy carries bleeding risk due to its invasive nature but also provides only a small portion of the liver parenchyma.

In experienced hands, ultrasound-based elastography can also be used to predict complications of cirrhosis such as development of varices and hepatocellular carcinoma. Also, it can differentiate between benign and malignant lesions and can diagnose focal nodular hyperplasia.

To further refine, this technique is divided accordingly into transient elastography, point-shear wave elastography (SWE), two-dimensional (2D)-SWE, and strain elastography. 


1.  Parkes J, Guha IN, Roderick P, et al. Enhanced Liver Fibrosis (ELF) test accurately identifies liver fibrosis in patients with chronic hepatitis C. J Viral Hepat 2011; 18:23.

2. Guibal A, Boularan C, Bruce M, et al. Evaluation of shearwave elastography for the characterisation of focal liver lesions on ultrasound. Eur Radiol 2013; 23:1138.

3. Brunel T, Guibal A, Boularan C, et al. Focal nodular hyperplasia and hepatocellular adenoma: The value of shear wave elastography for differential diagnosis. Eur J Radiol 2015; 84:2059.

4. Lu Q, Ling W, Lu C, et al. Hepatocellular carcinoma: stiffness value and ratio to discriminate malignant from benign focal liver lesions. Radiology 2015; 275:880.

5. Nahon P, Kettaneh A, Tengher-Barna I, et al. Assessment of liver fibrosis using transient elastography in patients with alcoholic liver disease. J Hepatol 2008; 49:1062.

Friday, May 12, 2017

A note on Ultrasound Enhanced Thrombolysis in CVA 

Though literature is still young but it shows that ultrasound energy may have a biologic effect that may facilitates the activity of intravenous tPA in ischemic stroke. It is provided via high-frequency transcranial Doppler (TCD). This combination can be further enhanced by the administration of microbubbles (air or gas) which is used as ultrasound contrast agents. While applying this technique, it should be kept in mind that there is some evidence that combination of ultrasound and tPA in ischemic stroke may increase the risk cerebral hemorrhage.


 1. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004; 351:2170.

2. Ricci S, Dinia L, Del Sette M, et al. Sonothrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2012; :CD008348. 

3. Nacu A, Kvistad CE, Naess H, et al. NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study): Randomized Controlled Contrast-Enhanced Sonothrombolysis in an Unselected Acute Ischemic Stroke Population. Stroke 2017; 48:335. 

4. Dinia L, Rubiera M, Ribo M, et al. Reperfusion after stroke sonothrombolysis with microbubbles may predict intracranial bleeding. Neurology 2009; 73:775. Tsivgoulis G, Alexandrov A. Ultrasound-enhanced thrombolysis: from bedside to bench. Stroke 2008; 39:1404.

Thursday, May 11, 2017

Q: Reexpansion pulmonary edema (RPE) may arises after rapid re-expansion of a lung that has been collapsed, for at least how many days?

Answer: Three

Re-expansion pulmonary edema (RPE) is a well known but potentially life-threatening complication of chest tube insertion that usually arises after rapid pulmonary re-expansion that has been down or collapsed, for usually about three days - either due to air (pneumo) or fluid (pleural / hemo / hydro thorax).

Wednesday, May 10, 2017

Q: Which of the following may be use as an antidote in Tacrolimus toxicity?

A)  Eslicarbazepine acetate (Aptiom)
B)  Gabapentin (Neurontin)
C)  Phenytoin (Dilantin)
D)  Levetiracetam (Keppra)
E) Divalproex (Depakote) 

Answer: C

 Tacrolimus is metabolized by the CYP3A enzymes, which are found in the liver and intestinal wall. Unfortunately, hemodialysis or plasma exchange are ineffective in Tacrolimus toxicity. It has been suggested that CYP3A4 inducers phenytoin and phenobarbital can used to increase the clearance and of the tacrolimus. They also have the additional benefit of seizure prevention, another well documented effect of tacrolimus overdose. 


1. Z. Karasu, A. Gurakar, J. Carlson et al., “Acute tacrolimus overdose and treatment with phenytoin in liver transplant recipients,” Journal of Oklahoma State Medical Association, vol. 94, no. 4, pp. 121–123, 2001.

2. Wada, M. Takada, T. Ueda et al., “Drug interactions between tacrolimus and phenytoin in Japanese heart transplant recipients: 2 case reports,” International Journal of Clinical Pharmacology and Therapeutics, vol. 45, no. 9, pp. 524–528, 2007

Tuesday, May 9, 2017

Q: What percentage of patients after Left Ventricular Assist Device (LVAD) may developed Aortic Regurgitation?

Answer:  In about 25 percent

Those patients who develop clinically significant aortic regurgitation may require surgery. One non-surgical fix is to keep the pump speed set to maintain intermittent AV opening under. This should be performed by experienced cardiologist under echocardiographic monitoring. This is probably due to the fusion of aortic valve leaflets. 


1. Pak SW, Uriel N, Takayama H, et al. Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices. J Heart Lung Transplant 2010; 29:1172. 

2. Cowger J, Pagani FD, Haft JW, et al. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail 2010; 3:668. 

3. Hatano M, Kinugawa K, Shiga T, et al. Less frequent opening of the aortic valve and a continuous flow pump are risk factors for postoperative onset of aortic insufficiency in patients with a left ventricular assist device. Circ J 2011; 75:1147. 

Monday, May 8, 2017

Q; 74 year old male is admitted to ICU with  widely metastasize cancer of unknown origin. Patient stays "full code" as per his wishes. Oncology service has planned full body radiation therapy (RT). Patient previously had an immense issue with nausea and vomiting (NV) with chemotherapy. Patient should be given

A) Prophylactic treatment for NV with Steroids and Ondansetron
B) Prophylactic treatment for NV with Steroids only
C) Prophylactic treatment for NV with  Ondansetron only
D) Prophylactic treatment is not needed for Radiation therapy

Answer: A

Like chemotherapy, RT also induces NV (RINV) depending on patient's characteristic and amount of radiation. RT is classified into four categories

High – Total body irradiation
Moderate – upper abdominal irradiation as well as craniospinal radition
Low – region specific like cranium, head and neck, thorax or pelvic region
Minimal – Breast and extremities

Except for minimal risk, all patients may benefit from some sort of prophylactic treatment oin RINV. Patients with high and +/- moderated risks should be treated with dual coverage


1. Basch E, Prestrud AA, Hesketh PJ, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29:4189.

2. Ruhlmann CH, Jahn F, Jordan K, et al. 2016 updated MASCC/ESMO consensus recommendations: prevention of radiotherapy-induced nausea and vomiting. Support Care Cancer 2017; 25:309.

3. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol 2016; 27:v119.

Sunday, May 7, 2017

Picture Diagnosis

Q: 22 year old male is admitted to ICU with severe abdominal pain and anemia. While in ICU, patient was diagnosed with intestinal obstruction due to intussusception. Patient's family history is undetermined. Looking at his lips, what is the most probable diagnosis?

Answer: Peutz-Jeghers syndrome (PJS)

 PJS has a specific characteristic muco-cutaneous ppigmenation. Black to brown spots with less than 1 mm size presented mostly on lower lips and perioral area. Diagnosis can be confirmed with genetic testing.


Akimaru K, Katoh S, Ishiguro S, Miyake K, Shimanuki K, Tajiri T. Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case. Surg Today 2006;36(11):997-1002

Saturday, May 6, 2017

Q: How the proximal left anterior descending (LAD) coronary artery disease get define?

A)  proximal to and including the first major septal branch off left anterior descending coronary artery
B) proximal to and before the first major septal branch off left anterior descending coronary artery
C) First 3 cm 
D) It is an approximation on visual of artery

Answer: A

Definition of proximal left anterior descending (LAD) coronary artery disease includes the first major septal branch off left anterior descending coronary artery.

Friday, May 5, 2017

Q: Which of the following can have a predictive value in acute myocardial infarction (AMI)?

A) Glucose 
B) Sodium
C) Potassium
D) Calcium
E) Creatinine

Answer: A

In patients who don't have diabetes, and  have glucose concentrations between 110 and 143 mg/dL at presentation with AMI have a 3.9-fold higher risk of death in comparison to patients with lower glucose concentrations. Moreover, glucose values between 144 and 180 mg/dL  have a three-fold higher risk of  some degree of cardiogenic shock.

Diabetic patients with glucose concentrations more or equal to 180 to 196 mg/dL  have a higher risk of death compared with diabetic patients having normal or lower glucose level.


1. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355:773. 

2. Malmberg K, Norhammar A, Wedel H, Rydén L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99:2626. 

3. Goyal A, Mehta SR, Díaz R, et al. Differential clinical outcomes associated with hypoglycemia and hyperglycemia in acute myocardial infarction. Circulation 2009; 120:2429.

Thursday, May 4, 2017

Q; 34 year old man with recent Lyme disease is getting transferred to ICU for trans-venous pacemaker. EKG shows only 1st degree heart block. What could be the reason?

Answer:  Patients with lyme disease and first degree AV block with a PR interval more than or equal to 300 msec, should be watched in controlled environment and should be considered for a temporary pacemaker. Treatment with antibiotics should be pursued. Actually, improvement in PR interval could be a guide to a response to antibiotics in lyme disease carditis.


Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.

Wednesday, May 3, 2017

Q; Which of the following anti-seizure medicine has been reported to cause sinus node dysfunction and heart blocks?

A) Carbamazepine 
B) Tegretol 
C) Diazepam 
D) Lacosamide 
E) Levetiracetam

Answer: D

Lacosamide, due to its action enhances the slow inactivation of voltage-dependent sodium channels. This results in cardiac conduction disturbances, mostly atrial fibrillation and atrioventricular block.


1. Degiorgio CM. (2010) Atrial flutter/atrial fibrillation associated with lacosamide for partial seizures. Epilepsy Behav 18:322–324. 

2. Krause LU, Brodowski KO, Kellinghaus C. (2011) Atrioventricular block following lacosamide intoxication. Epilepsy Behav 20:725–727. 

3. Nizam A, Mylavarapu K, Thomas D, Briskin K, Wu B, Saluja D, Wong S. (2011) Lacosamide-induced second-degree atrioventricular block in a patient with partial epilepsy. Epilepsia 52:e153–e155. 

Tuesday, May 2, 2017

Q: What is the pathophsyiology behind Superior mesenteric artery syndrome? 

Answer: Superior mesenteric artery syndrome (first reported around little less than 100 years ago) can cause proximal small bowel obstruction. Loss of the intervening mesenteric fat pad causes narrowing of the space between the superior mesenteric artery and aorta. It leads to compression of the third portion of the duodenum. It's popular nick name is Cast syndrome, and also known as chronic duodenal ileus.


1. Wilkie DP. Chronic duodenal ileus. Br J Surg 1921; 9:204. Cohen LB, Field SP, Sachar DB. 

2. The superior mesenteric artery syndrome. The disease that isn't, or is it? J Clin Gastroenterol 1985; 7:113. 

3. Ylinen P, Kinnunen J, Höckerstedt K. Superior mesenteric artery syndrome. A follow-up study of 16 operated patients. J Clin Gastroenterol 1989; 11:386.

Monday, May 1, 2017

Q; In which conditions an apical lordotic view of chest x-ray can be useful? 

 Answer: In regular chest x-ray, apices of lungs are covered by the clavicles. Idea behind obtaining an apical lordotic view of chest x-ray is to visualize the lung apices better, like in pancoast tumor or apical tuberculosis. In this era of CT scans, it may be only of academic interest but is expected of physicians to be aware of its utility.

Sunday, April 30, 2017

Q; How long does the antiseptic effect of Chlorhexidine last after it is applied during procedure prep?

Answer: About 6 hours

In comparison to other antiseptic preps during procedures, Chlorhexidine provides added advantage of its prolonged residual antiseptic effect.

Saturday, April 29, 2017

Question: Psychiatry service asked your help in management of a patient, who is transferred to ICU for Electroconvulsive Therapy (ECT). Which of the following drug may require reversal before initiating (ECT)? 

 A) lithium 
B) any antidepressant
C) any antipsychotic
D) any antihypertensive
E)  benzodiazepine

Answer: E

Most of the patient's prior drugs are safe during administration of ECT therapy, though lithium dose has been advocated to be decreased or on lower edge of therapeutic level 1.  

Benzodiazepines are usually discontinued before ECT therapy, but in those patients who still require them on board, should be transiently reversed just 2-3 minutes prior of ECT therapy with flumazenil. Benzodiazepines may decrease the intensity of the therapeutic ECT seizure.


1.  Dolenc TJ, Rasmussen KG. The safety of electroconvulsive therapy and lithium in combination: a case series and review of the literature. J ECT 2005; 21:165. 

2. Greenberg RM, Pettinati HM. Benzodiazepines and Electroconvulsive Therapy. Convuls Ther 1993; 9:262. 

3. Krystal AD, Watts BV, Weiner RD, et al. The use of flumazenil in the anxious and benzodiazepine-dependent ECT patient. J ECT 1998; 14:5.

Friday, April 28, 2017

Q: How mitral valve orifice area can be guessed depending on clinical symptoms?


  • The normal mitral valve orifice has a cross-sectional area of about 4.0 cm2.
  • Usually patients are asymptomatic till orifice area is reduced to 2 cm2. 
  • Mild symptoms may be present between 2 cm2 and 1.5 cm2.
  • Most patients become symptomatic when mitral valve area is decreased to 1.5 cm2 (moderate/on exertion)
  • If a patient symptoms are apparent, it can be easily guessed that mitral orifice area is at 1.0 cm2 or less. (even with mild exertion)
Combining with heart sounds auscultation, astute physician can predict valve area just on examination.

Thursday, April 27, 2017

Q: 64 year old female admitted in ICU is going for PET scan. Service requested you to keep patient NPO four hours prior to procedure and low carbohydrate diet 24 hours prior to procedure if feasible?

Answer: Hyperglycemia can interfere with PET scan. High serum glucose level competes with the fluorodeoxyglucose (FDG) for the same cell surface receptor and decreases intracellular FDG.


Torizuka T, Clavo AC, Wahl RL. Effect of hyperglycemia on in vitro tumor uptake of tritiated FDG, thymidine, L-methionine and L-leucine. J Nucl Med 1997; 38:382.

Wednesday, April 26, 2017

Q: Once adequate response is obtained from intravenous antibiotic, the choice of oral antibiotic in septic bursitis is? 

 Answer: In Septic bursitis, usual IV antibiotic is either Vancomycin or Cefazolin. Oral conversion to Clindamycin is most appropriate to cover MRSA ( methicillin-resistant S. aureus). Other oral antibiotics which may be used are dicloxacillin, doxycycline, or trimethoprim-sulfamethoxazole.

Tuesday, April 25, 2017

Q: After how many failed attempts of intubations, chances of complications and death rise exponentially?

Answers: 2

In contrast to previously accepted 3 attempts, recently published data showed that after two failed attempts to insert End-Tracheal Tube (ETT), risk of complications and death go high.


 Buis ML, Maissan IM, Hoeks SE, et al. Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic review. Resuscitation 2016; 99:63.

Monday, April 24, 2017

Q: What is the dose of lipid emulsion in lidocaine toxicity?

 Answer: Lipid emulsion is suggested for lidocaine or local anesthetic toxicity particularly with cardiac arrhythmia or asystole.  It is a 1.5-mL/kg bolus of 20% lipid emulsion solution, followed by a 0.25-mL/kg per minute infusion for 30 to 60 minutes. The bolus can be repeated 1 to 2 times for continued symptoms.

Modus operandi is via "lipid sink". As lidocaine is lipid-soluble, it may reduce the overall plasma concentration. Another mechanism suggested is fostering of cardiac metabolism by augmenting the fatty acid supply, promoting aerobic metabolism and reducing acidosis,


1. Mazoit JX, Le Guen R, Beloeil H, Benhamou D. Binding of long-lasting local anesthetics to lipid emulsions. Anesthesiology. 2009;110(2): 380-386. 

2. Weinberg GL. Lipid infusion therapy: translation to clinical practice. Anesth Analg. 2008 May. 106(5):1340-2

Sunday, April 23, 2017

Question: What is Anton's syndrome? 


It's full nomenclature is Anton–Babinski syndrome. It is also called visual anosognosia. It is actually a type of stroke but may confuse staff as a delirium. Anatomically damage is in the occipital lobe, and patients are "cortically blind". Interestingly, patients affirm, that they are capable of seeing, despite clear examination proving blindness. They employ confabulation to fill in the missing sensory input. It is considered as one of the most complexed and poorly understood disease and probably due the fact that damage to the visual cortex results in the inability to communicate with the speech-language areas of the brain. Visual imagery is received but cannot be interpreted; the speech centers of the brain confabulate a response!!!

It is described after CVA, head injury and patients with JC virus.


1. Riddoch G. Dissociation of visual perceptions due to occipital injuries, with especial reference to appreciation of movement. Brain. 1917;40:15–57

2. Misra M, Rath S, Mohanty AB. Anton syndrome and cortical blindness due to bilateral occipital infarction. Indian J Ophthalmol. 1989;37:196.

3. McDaniel KD, McDaniel LD. Anton's syndrome in a patient with posttraumatic optic neuropathy and bifrontal contusions. Arch Neurol. 1991;48:101–105

Saturday, April 22, 2017

Q; Antimicrobial irrigation of the urinary bladder is an effective way of suppressing Urinary Tract Infections (UTI) in chronically catheterized bed bound patients, getting frequent ICU admissions for Urosepsis?

A) True
B) False

Answer: B

Antimicrobial irrigation of the bladder does not treat, prevent or supress urinary tract infection. On the contrary, it has shown to increase the risk of urosepsis as well as increase the antibiotic resistance. This practice should be abandoned, if in use. 


Schneeberger PM, Vreede RW, Bogdanowicz JF, van Dijk WC. A randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter. J Hosp Infect 1992; 21:223.

Friday, April 21, 2017

Q: Can steroids be used as an added medicine during 'code' (ACLS) ?  (select one)

A) Yes
B) No

Answer:   A

Actually, some of the studies have been showing role of steroids particularly for In-Hospital-Cardiac-Arrest (IHCA) patients. Though vasopressin is no more a part of ACLS, it has been suggested to give as a "Epi-Vasopressin-Steroid" combo!


1. Mentzelopoulos S, Zakynthinos S, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med. 2009;169:15-24. PMID: 19139319. 

2. Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013;310(3):270-9. 

3. Varvarousi G, Stefaniotou A, Varavaroussis D, et al. Glucocorticoids as an emergency pharmacologic agent for cardiopulmonary resuscitation. Cardiovasc Drugs Ther. 2014;28:477-88. PMCID: PMC4163188..