Thursday, December 31, 2015

Q: Metabolic Alkalosis causes Hypocalcemia 

 A) True
B) False


Answer: 
True


Alkalosis causes an ionization of albumin, making in more negative. Due to higher negative charge on albumin, calcium binds to albumin with greater affinity, resulting in reduction of total free calcium. It may get clinically significant in severe or persistent alkalosis. 

The opposite is true for acidosis.

Wednesday, December 30, 2015

Q: While reviewing chest X-ray after floating Pulmonary Artery Catheter (PAC), you suspect possible knotting of catheter in right ventricle. Which one bedside trick may help in resolving knot before embarking on more invasive resolutions?


Answer: Inject about 20 mL of iced solution through the distal lumen 


If knotting of swan-ganz catheter(PAC) is suspected, many times injecting about 20 mL of cold sterile saline or iced solution through the distal lumen stiffens the catheter and help in resolving the knot. Interestingly, this trick was described almost 40 years ago, even before swan-ganz catheters later became popular in 1980s and 1990s. If this trick does not work, patient needs to go to cardiac catheter laboratory for placement of a wire under fluoroscopy. Alternatively, Interventional Radiology (IR) or vascular surgical service need to be consulted. In all ultimate failed cases, cardiothoracic surgery may require to perform open extraction of PAC.



 Reference: 

 Mond HG, Clark DW, Nesbitt SJ, Schlant RC. A technique for unknotting an intracardiac flow-directed balloon catheter. Chest 1975; 67:731.

Tuesday, December 29, 2015

Q:  Triad of 
  • thrombocytopenia, 
  • a left-shifted granulocytic series on smear, and 
  •  an immunoblast count exceeding 10 percent of the total lymphoid series
is diagnostic of which disease?


Answer:  Hantavirus cardiopulmonary syndrome (HCPS)

If HCPS is strongly suspected and if above triad is found in a patient, it calls for a prompt response, probably insertion of ECMO device. HCPS is unique in the sense that symptoms of noncardiogenic pulmonary edema and hemodynamic collapse happens abruptly. Interestingly, symptoms resolve as quickly as the onset. Usual time period of hemodynamic instability lasts between 24 to 48 hours and proper and preemptive hemodynamic support can be life saving in literal sense.


References:

Koster F, Foucar K, Hjelle B, et al. Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review. Am J Clin Pathol 2001; 116:665.  

Hallin GW, Simpson SQ, Crowell RE, et al. Cardiopulmonary manifestations of hantavirus pulmonary syndrome. Crit Care Med 1996; 24:252.

Crowley MR, Katz RW, Kessler R, et al. Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation. Crit Care Med 1998; 26:409.

Monday, December 28, 2015

Q: At what level of ventilator settings, surgically placed tracheostomy(ST) is preferred over bedside Percutaneous Dilational Tracheostomy(PDT)?


Answer:  Nothing beats an experienced operator irrespective of which technique is used. Though PDT is now considered as standard of care for tracheostomy but in few cases ST should be prefered over PDT. Three conditions deserve special attention. 

Firstly, coagulation abnormalities, since bleeding vessels are under direct vision in ST, and provides better control against any bleeding catastrophe. 

Secondly, high ventilator settings, particularly when FiO2 is at or above 70% or PEEP is at or above 10. 

Thirdly, obese patients with "no neck" or patients with previous surgery or mass in neck area.

In Trauma-ICU, added condition of unstable cervical spine need consideration of ST technique.




Sunday, December 27, 2015

Q: 78 year old male admitted 2 days ago with Transient Ischemic Attack(TIA) and community acquired pneumonia to ICU. Patient developed SVT(Supraventricular Tachycardia) with Heart Rate of 190 causing hypotension. All of the following can be part of management except?

A) IV fluid(IVF)
B) Carotid sinus massage
C) Oxygen to counter hypoxemia
D) Cardioversion
E) Adenosine 



Answer: B

According to guidelines from various societies carotid sinus massage should not be performed in patients with TIA or CVA (cerebrovascular accident) within last three months. Also, it should be avoided in patients on side of carotid artery stenosis or on patients with carotid artery bruit.


IVF is an integral part of management in hemodynamic instability with arrhythmia.


Hypoxemia can be a major trigger of SVT in patients with respiratory disease and oxygen should be administer to counter it.


Cardioversion and Adenosine are both viable options in management of SVT. 




 References:

1. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631

2. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 2006; 113:316.

Saturday, December 26, 2015

Q; What isidrabiotaparinux? 


Answer:  idrabiotaparinux can be called third generation long acting fondaparinux.

First generation Fondaparinux (arixtra) is the only clinically known low molecular weight Heparin which can be used in Heparin-Induced-Thrombocytopenia (HIT). But on flip side, it has no reversal in case of bleeding except supportive treatment via transfusions.

Second generation fondaparinux is called idraparinux but it quickly lost its charm (actually development)  as it was extremely long acting with dosing once a week without any reversal like parent fondaparinux.

Third generation fondaparinux is called idrabiotaparinux. It is in Phase 3 trials and have advantage of availability of reversal, though it remained once a week dosing. The reversal is via intravenous administration of avidin, which binds to the biotin molecule in the drug. Once a week dosing with availability of reversal may make it a good choice as outpatient treatment  of venous thromboembolism.


References:

1. Equinox Investigators. Efficacy and safety of once weekly subcutaneous idrabiotaparinux in the treatment of patients with symptomatic deep venous thrombosis. J Thromb Haemost 2011; 9:92.

2. Büller HR, Gallus AS, Pillion G, et al. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet 2012; 379:123.

3.  Paty I, Trellu M, Destors JM, et al. Reversibility of the anti-FXa activity of idrabiotaparinux (biotinylated idraparinux) by intravenous avidin infusion. J Thromb Haemost 2010; 8:722.

Thursday, December 24, 2015

Q: While performing subclavian central vein cannulation, you inadvertently puncture the subclavian artery. Beside applying pressure, which one other maneuver may help in preventive massive bleeding?


Answer:  Elevation of the ipsilateral arm

Ideally, like Internal Jugular vein(IJ) Subclavian vein(SC) should also be cannulated under ultrasound guidance. Special probes are available for subclavian vein visualization under ultrasound. In case, if during SC-CVC cannulation subclavian artery gets punctured, after withdrawing the needle, alongside applying pressure, elevating the ipsilateral arm overhead may help, as it compresses the vein.

Wednesday, December 23, 2015

Q: Presence of leukoaraiosis increases the risk of intracerebral hemorrhage after intravenous thrombolysis for acute ischemic stroke. What is leukoaraiosis?


Answer: Leukoaraiosis is also known as white matter hyperintensities. Radiologically, they appear as decreased density on CT and increased signal intensity on T2/FLAIR sequences on MRI. Leukoaraiosis is a nonspecific finding by itself  but may be a manifestation of underlying diseased vessels and frequently seen in patients with hypertension, tobacco use, diabetes, ischemic heart disease etc. Various factors increase the risk of intracerebral hemorrhage after intravenous thrombolysis for acute ischemic stroke. Intensivists are usually the first line of caregivers beside neurologists to get call  for any complication after intravenous thrombolysis for acute ischemic stroke. These factors include presence of leukoaraiosis prior to thrombolysis, stroke severity, age, history of heart disease particularly atrial fibrillation, uncontrolled diabetes, chronic kidney disease (CKD), uncontrolled blood pressure after thrombolysis, thrombocytopenia, on antiplatelet or warfarin therapy etc.




References:

1. Neumann-Haefelin T, Hoelig S, Berkefeld J, et al. Leukoaraiosis is a risk factor for symptomatic intracerebral hemorrhage after thrombolysis for acute stroke. Stroke 2006; 37:2463. 

2. Palumbo V, Boulanger JM, Hill MD, et al. Leukoaraiosis and intracerebral hemorrhage after thrombolysis in acute stroke. Neurology 2007; 68:1020

3. Curtze S, Haapaniemi E, Melkas S, et al. White Matter Lesions Double the Risk of Post-Thrombolytic Intracerebral Hemorrhage. Stroke 2015; 46:2149.

Tuesday, December 22, 2015

Q: For elevated intracranial pressure (ICP), few basic strategies at bedside play huge role in overall management and outcome. Name few?


Answer: 
  1. Keep head of the bed elevated at around 30 degrees
  2. Avoid excessive flexion or rotation of the neck 
  3. Avoid too restrictive taping around the neck 
  4. Minimize endotracheal suctioning (minimize Valsalva response)
All of the above maneuvers are targeted  to maximize venous outflow from the head and to keep ICP from rising.


 Reference: 

 Rosner MJ, Coley IB. Cerebral perfusion pressure, intracranial pressure, and head elevation. J Neurosurg 1986; 65:636.

Monday, December 21, 2015

Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome

Background: Studies in patients with acute coronary syndrome (ACS) undergoing invasive management showed conflicting conclusions regarding the effect of access site on outcomes.

Purpose: To summarize evidence from recent, high-quality trials that compared clinical outcomes occurring with radial versus femoral access in invasively managed adults with ACS.

 Data Sources: English-language publications in MEDLINE, EMBASE, and Cochrane databases between January 1990 and August 2015. Study Selection: Randomized trials of radial versus femoral access in invasively managed patients with ACS.

 Data Extraction: Two investigators independently extracted the study data and rated the risk of bias.

 Data Synthesis: Of 17 identified randomized trials, 4 were high-quality multicenter trials that involved a total of 17 133 patients. Pooled data from the 4 trials showed that radial access reduced death (relative risk [RR], 0.73 [95% CI, 0.59 to 0.90]; P = 0.003), major adverse cardiovascular events (RR, 0.86 [CI, 0.75 to 0.98]; P = 0.025), and major bleeding (RR, 0.57 [CI, 0.37 to 0.88]; P = 0.011). Radial procedures lasted slightly longer (standardized mean difference, 0.11 minutes) and had higher risk for access-site crossover (6.3% vs. 1.7%) than did femoral procedures.

 Limitation: Heterogeneity in outcomes definitions and potential treatment modifiers across studies, including operator experience in radial procedures and concurrent anticoagulant regimens.

Conclusion: Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS undergoing invasive management. 


Reference: 

Giuseppe Andò, MD, PhD; and Davide Capodanno, MD, PhD - A Call to Arms: Radial Artery Access for Percutaneous Coronary Intervention Ann Intern Med. 2015;163(12):932-940. - December 15, 2015

Sunday, December 20, 2015

Q:  What is the 'rule of thumb' for giving Digoxin immune Fab (digibind, DigiFab) in patients with digoxin ingestion resulting in toxicity?


Answer:  Each vial of DigiFab  contains 40 mg of Fab and it binds 0.5 mg digoxin. As a 'rule of thumb'

  • - in acute ingestion of unknown amount 10 vials are recommended, and if required 10 more vials can be administered.
  • - in patients on chronic digoxin therapy, where toxicity is suspected -  6 vials should be sufficient to resolve symptoms.
Resolution can be best monitored by EKG changes. Resolution may be visible in 30 minutes but it takes 2-4 hours before full effect takes place. 


DigiFab is usually given in IV preparation over 30 minutes, but IV push can be given in life-threatening situations though it may cause some febrile reactions, otherwise it is considered to be a safe medicine. It should be avoided in patients with allergy to sheep protein and papaya extracts.

Saturday, December 19, 2015

A note on gastric mucosal acidosis as a mechanical weaning parameter

 Gastric mucosal acidosis has been proposed and studied as an indicator of mechanical ventilator weaning success or failure. Assumption based on the idea that in respiratory distress blood supply get diverted from the splanchnic vascular bed to the respiratory muscles. It has also been proposed that gastric mucosal acidosis if accompanied by higher intraluminal gastric carbon dioxide (PgCO2) can provide a more better criteria of ventilator weaning success or failure. In clinical practice, it is not popular probably because it requires  a special nasogastric tube. Also, other clinical indices so far remained satisfactory for clinicians.



References: 

1. Mohsenifar Z, Hay A, Hay J, et al. Gastric intramural pH as a predictor of success or failure in weaning patients from mechanical ventilation. Ann Intern Med 1993; 119:794. 

2. Hurtado FJ, Berón M, Olivera W, et al. Gastric intramucosal pH and intraluminal PCO2 during weaning from mechanical ventilation. Crit Care Med 2001; 29:70.

Friday, December 18, 2015


Q: In patients with exacerbation of congestive heart failure(CHF) - what is the appropriate target for weight reduction with diuresis?


Answer:  An appropriate target  in  exacerbation of  CHF with diuresis is weight reduction of about 1.0 kg/day.

Thursday, December 17, 2015

Q: 58 year old male who underwent Left single lung transplant for idiopathic pulmonary fibrosis (IPF) about 2 days ago, developed shortness of breath(SOB) and found to have pneumothorax(PTX) on Right side. 'Pneumocath' resolved the PTX. What would be the further management?


Answer: 
Interestingly, after single lung transplantation, secondary spontaneous pneumothoraces have been reported on contralateral side. Important point to remember is that these secondary spontaneous pneumothoraces are prone to recur and requires further step beyond chest tube insertion. Obliteration of pleural space via any appropriate method like  talc pleurodesis should be strongly considered.


 References: 

1.  Spaggiari L, Rusca M, Carbognani P, et al. Contralateral spontaneous pneumothorax after single lung transplantation for fibrosis. Acta Biomed Ateneo Parmense 1993; 64:29. 


2. Waller DA, Conacher ID, Dark JH. Videothoracoscopic pleurectomy after contralateral single-lung transplantation. Ann Thorac Surg 1994; 57:1021.

Wednesday, December 16, 2015

Q: Uncontrollable laughing or crying may occur during  which kind of seizure?


Answer:  Frontal lobe seizure

As frontal lobe deals with more advanced function of brain, its manifestations are complex. They are hard to diagnose, and often occurs during sleep. Similarly, they are often preceded by expressive fear.  In Frontal Lobe Epilepsy fear is expressed on the person's face, in contrast to Temporal Lobe Epilepsy where fear is more inside the patient. Clinically, they are highly associated with tumors or vascular malformations.




 References: 

1.  "Frontal lobe seizures: Symptoms". Diseases and Conditions. Mayoclinic.com. 2008-10-11.

2. Panayiotopoulos C (2005). "Symptomatic and Probably Symptomatic Focal Epilepsies: Topographical Symptomatology and Classification". The Epilepsies. Blandon Medical Publishing.

3. Kramer U, Riviello JJ, Carmant L, Black PM, Madsen J, Holmes GL (February 1997). "Clinical characteristics of complex partial seizures: a temporal versus a frontal lobe onset". Seizure 6 (1): 57–61.

Tuesday, December 15, 2015

Q: All of the following strategies can be applied for ventilator management if patient develops Broncho-pleural fistula (BPF) except? 

A) Minimize the ventilator-delivered breaths.
B) Minimize the tidal volume
C) Decrease the inspiratory flow rate 
D) Decrease chest tube suction 
E) Endeavors to expedite the extubation



Answer: C

If patient develop BPF, all measures should be implied to decrease the level of positive pressure deliver via ventilator like decreasing respiratory rates, tidal volumes, PEEP and ideally to extubate the patient. Chest tube suction is another form of pressure suction from other side. 

Choice C is wrong as decreasing the inspiratory flow rate will increase the Inspiratory to Expiratory ratio (I:E) ratio and thereby chances of auto-PEEP.

Choice A and B may cause permissive hypercapnia but it should be perfectly fine.



Monday, December 14, 2015

Q: Peripherally Inserted Central Venous Catheters, popularly known as PICCs are know to carry higher risk of upper extremities deep venous thrombosis (UE-DVT). All of the following are associated with higher risk of UE-DVT except

A) Right-sided insertion
B) Vancomycin infusion
C) TPN infusion
D) Basilic placement
E) Renal failure



 Answer: A

One recent study of 400 patients published from St. Elizabeth Health Center, Youngstown, OH showed that following factors are associated with increased risk of UE-DVTs

  •  trauma
  • renal failure
  • left-sided catheters
  •  basilic placement
  • TPN, and 
  • infusion with antibiotics, specifically vancomycin

Interestingly, prophylaxis with low molecular weight heparin, unfractionated heparin or use of warfarin did not prevent the development of venous thrombosis in patients with PICCs


Reference: 

Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012; 13:231.

Sunday, December 13, 2015




Q: What is spontaneous HIT?

 Answer: When Heparin Induced Thrombocytopenia (HIT) occurs without heparin exposure is called spontaneous HIT. Risk factors are preceding infectious or inflammatory events, or orthopedic surgery. Spontaneous HIT is defined as: "otherwise unexplained thrombocytopenia/thrombosis without proximate heparin exposure and with anti-PF4/heparin IgG antibodies that cause strong in vitro platelet activation even in the absence of heparin"


Reference: 

1. Warkentin TE, Basciano PA, Knopman J, Bernstein RA. Spontaneous heparin-induced thrombocytopenia syndrome: 2 new cases and a proposal for defining this disorder. Blood 2014; 123:3651.


2. Mallik A, Carlson KB, DeSancho MT. A patient with 'spontaneous' heparin-induced thrombocytopenia and thrombosis after undergoing knee replacement. Blood Coagul Fibrinolysis 2011; 22:73. 

3. Pongas G, Dasgupta SK, Thiagarajan P. Antiplatelet factor 4/heparin antibodies in patients with gram negative bacteremia. Thromb Res 2013; 132:217.

Saturday, December 12, 2015

Q: What is Lok Index?


Answer: Lok Index determines cirrhosis probability in hepatitis C by taking into account of 4 parameters
  • Platelets 
  • ALT 
  • AST 
  • INR
 Lok index less than 20 percent effectively rules out cirrhosis in hepatitis C. Manual calculation is difficult but online calculators are available via any search engine.



Reference:

 Lok AS, Ghany MG, Goodman ZD, et al. Predicting cirrhosis in patients with hepatitis C based on standard laboratory tests: results of the HALT-C cohort. Hepatology 2005; 42:282.

Friday, December 11, 2015

Q: What is the difference between dose of Naloxone given intra-nasally and via other routes?


Answer:  Naloxone can be administered via intravenous, intramuscular, subcutaneous or intranasal routes. Dose for all routes except for intranasal is 0.4 mg of the 0.4 mg/1 mL concentration. For intranasal route higher dose is required up to 2 mg of the 1 mg/1 mL concentration. Intranasal administration is recommended with a mucosal atomizer device to ensure proper spray on nasal mucosa.

Thursday, December 10, 2015



Q: What is the Principle of Double Effect (PDE) at End of Life care?


Answer: "an action having foreseen harmful effects practically inseparable from the good effect is justifiable".

In End of Life care administering medication to relieve pain is morally justifiable despite knowing the possible bad effect i.e death, though all endeavours should be exercised to minimize the risk of the bad effect and the benefit of good action outweighs the risk of bad effect.  


Reference: 

Quill TE. Principle of double effect and end-of-life pain management: additional myths and a limited role. J Palliat Med 1998; 1:333.

Wednesday, December 9, 2015




Q: Which hematologic condition is expected after insertion of Ventricular Assisted Device (VAD) post-operatively?


Answer:  Acquired von Willebrand disease (aVWD)

 High shear stress of pumps of VADs causes proteolysis of large VWF multimers, resulting in aVWD. It may cause life threatening bleeding. It is so common that all patients with continuous flow VADs should be assumed to have aVWD. Diagnosis can be documented by specific tests though not required. Treatment include desmopressin (DDAVP), VWF concentrates, recombinant factor VIIa, antifibrinolytic agents, and supportive treatment with transfusions.



Reference: 

 Heilmann C, Geisen U, Beyersdorf F, et al. Acquired Von Willebrand syndrome is an early-onset problem in ventricular assist device patients. Eur J Cardiothorac Surg 2011; 40:1328.

Tuesday, December 8, 2015

Q: 48 year old male with alcoholic cirrhosis is admitted to ICU with upper GI bleed. 2 large bore IVs are inserted. IV PPI and Octreotide drips are started. Blood products are arranged. Gastroenterology service is planning to do upper GI scope. Which one additional treatment may help in better visualization during endoscope?


Answer: intravenous erythromycin

Recommended dose is 3 mg/kg intravenously over half hour, an hour prior to endoscopy. A single dose of intravenous erythromycin given 20 to 120 minutes significantly improve visibility and successful single endoscopy. 


References: 

1. Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002; 123:17. 

2. Carbonell N, Pauwels A, Serfaty L, et al. Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Am J Gastroenterol 2006; 101:1211.

Monday, December 7, 2015



Q: All of the following can be prescribed to patient with sickle cell crisis as an adjuvant except?

A) Folic acid 

B) Vitamin D
C) Magnesium
D) Vitamin C
E) Iron



Answer: E

Iron overload is a major risk and a complication in patients with sickle cell disease (SCD). Most of these patients, by the time they reach adulthood, have enough blood transfusions to have iron overload. On the contrary, patients with SCD are usually candidates for iron chelation therapy.



Reference:

 P. B. Walter, P. Harmatz, and E. Vichinsky, “Iron metabolism and iron chelation in sickle cell disease,” Acta Haematologica, vol. 122, no. 2-3, pp. 174–183, 2009.

Sunday, December 6, 2015

Q: Tumor lysis syndrome (TLS) is an oncologic emergency. All of the following electrolyte derangements can occur in TLS except?

A) Hyperphosphatemia
B) Hypercalcemia
C) Hyperkalemia
D) Hyperuricemia
E) Xanthinuria


Answer: B

Hyperphosphatemia and consequently hypocalcemia are one of the hallmark of TLS. The phosphorus concentration in malignant cells are much higher than in normal cells. Its combination with calcium (calcium-phosphate) causes marked hypocalcemia. Actually it is calcium-phosphate precipitation in the renal tubules which leads to AKI (acute kidney injury) in TLS. If calcium phosphate product goes to more than or equal to 70 mg2/dL2, CRRT should be strongly considered. 

 With breakdown of cells, life threatening hyperkalemia and hyperuricemia may occur. Most patients with TLS receives allopurinol which causes xanthine precipitation in the tubules.

Saturday, December 5, 2015

Q:  34 year old male has been put on extracorporeal membrane oxygenation (ECMO) due to ARDS. What should be the target parameters on ventilator?



Answer: Whole idea behind insertion of ECMO in severe ARDS is to "rest the lung". Ideally, all barotrauma, volutrauma and oxygen toxicity should be minimized. Target parameters should be plateau airway pressures less than 20 cm H2O and minimal FiO2 as tolerated. Added benefit of reduce positive pressure ventilation is improved venous return and cardiac output.

Friday, December 4, 2015



Q: 57 year old male with End Stage Renal Disease (ESRD) is in ICU with septic shock and now on Continuous Renal Replacement Therapy (CRRT). Patient's catheter has frequent problem with clotting despite changing it twice to different sites and use of citrate solution. Patient previously has history of GI bleed per chart. What approach can be taken for use of heparin for CRRT in patients with possible risk of bleeding?



Answer:  One approach which was described 35 years ago but still applicable and has been used with success in such scenarios - is giving boluses of 500 units of heparin every 30 minutes to keep the activated clotting time more than 150 but less than 200 seconds. Heparin can be used in low dose with continuous infusion keeping tight parameter of ACT as per above. 



Reference: 

Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: regional versus low-dose heparin. Kidney Int 1979; 16:513.

Thursday, December 3, 2015



Question: 34 year old male with history of ulcerative colitis(UC) is admitted to ICU with dehydration secondary to diarrhea. Initial lab testing is consistent with electrolyte abnormality but marked elevation of alkaline phosphatase. What is your concern?


Answer:  Primary sclerosing cholangitis (PSC)

Patients with UC are at very high risk of developing PSC. Pathology is thought to be same i.e autoimmunity. To make things complicated, it increases the risks of cholangiocarcinoma as well as colorectal cancer. In synchrony with UC, treatment consists of immunosuppressants, chelators and steroids. Symptomatic relief can be provided with endoscopic dilation and stenting of strictures, but it does not reverse the disease progression. Liver transplantation is the last hope.

Wednesday, December 2, 2015

Q: 54 year male in ICU with multi system organ failure (MSOF) get diagnosed with deep venous thrombosis (DVT). Patient had severe gastrointestinal (GI) bleed 2 days ago when he almost died. He is not eligible for travel to go for any further imaging due to high ventilator requirement. What is your next option? (Best answer) 

A) Start low dose IV Heparin and titrate slowly up 
B) IVC filter at bedside 
C) Observation and repeat bedside duplex in 24 hours
D) Start low dose SQ anticoagulation 
E) catheter directed thrombolysis


Answer: B

Out of all of the above IVC filter at bedside under fluoroscopy is the best option. If fluoroscopy is not available bedside ultrasound can be used. 

A, D and E are not appropriate choices due to life-threatening GI bleed in last 48 hours.

C is not a good choice when bedside IVC filter is available.



 Reference: 

 Uppal B, Flinn WR, Benjamin ME. The bedside insertion of inferior vena cava filters using ultrasound guidance. Perspect Vasc Surg Endovasc Ther 2007; 19:78.

Tuesday, December 1, 2015

Q: Beside proper analgesia, what is the the other advantage of giving local anesthesia before inserting arterial catheter for invasive monitoring?


Answer: Beside relief of pain, major advantage of local analgesia during arterial catheter insertion is reduction of vasospasm.



Reference:

Guidelines for the measurement of respiratory function. Recommendations of the British Thoracic Society and the Association of Respiratory Technicians and Physiologists. Respir Med 1994; 88:165.