More Next Blog sherif_badrawy@yahoo.

com Dashboard Sign Out

icuroom.net Archive
Pearls on Intensive Care Medicine Practice

Monday, July 17, 2017 Moderator

A note on relationship between fever and ventilator weaning

.
There is not a huge literature on association between fever and ventilator weaning but weak
evidence is available which shows that once temperature goes above 100.4 F (38 C), it may
hamper with successful weaning. This may be due to the assumption that fever increases
minute ventilation and may increase the work of breathing. There is no real cutoff of
Subscribe To
temperature is described above which weaning should be avoided though.

Posts
References:
All Comments
1. Netzer G, Dowdy DW, Harrington T, et al. Fever is associated with delayed ventilator liberation in acute lung injury. Ann Am
Thorac Soc 2013; 10:608.

2. Amoateng-Adjepong Y, Jacob BK, Ahmad M, Manthous CA. The effect of sepsis on breathing pattern and weaning outcomes in
Follow by Email
patients recovering from respiratory failure. Chest 1997; 112:472.
Email address... Submit
Posted by ICU room Pearls at 1:00 AM No comments:

Labels: pulmonary
Blog Archive

2017 (192)
July (16)
Sunday, July 16, 2017
June (29)
May (30)
Q: 'Phlegmasia cerulea dolens' happens in
April (30)
A) Deep Venous Thrombosis (DVT) March (29)
B) Septic shock
C) Severe Vasoplegia February (28)
D) Cholesterol Emboli January (30)
E) Diabetic toe
2016 (359)
2015 (362)
Answer: A
2014 (360)
'Phlegmasia cerulea dolens' translates to 'painful blue edema' and is a hallmark of a severe
2013 (253)
form of DVT which results from extensive thrombotic occlusion of the major and the collateral
veins of an extremity. It is characterized by sudden severe pain, swelling, cyanosis and edema 2012 (188)
of the affected limb. It carries extremely high risk of massive pulmonary embolism (PE) even
2011 (55)
though anticoagulation is given. Therefore, invasive vascular intervention is needed. Beneath
this, underlying disease process like Heparin Induced Thrombocytopenia (HIT) or malignancy
is always a fear.

References:

1. Sarwar S, Narra S, Munir A. Phlegmasia cerulea dolens. Tex Heart Inst J 2009; 36:76.

2. Barham, Kalleen; Tina Shah (2007-01-18). "Images in Clinical Medicine: Phlegmasia Cerulea Dolens". The New England Journal
of Medicine. 356 (3): e3.

Posted by ICU room Pearls at 3:30 AM No comments:

Labels: hematology
Friday, July 14, 2017

Q: What is the best type of Cardiac MRI to evaluate severity of valvular regurgitation and
stenosis?

Answer: Flow velocity encoding or phase contrast Cardiac MRI

Flow velocity encoding Cardiac MRI directly measure blood flow and is useful for quantifying
the severity of valvular regurgitation and stenosis, intra-cardiac shunt size, and the severity of
arterial vascular stenosis.

Reference:

Beerbaum P, Krperich H, Barth P, et al. Noninvasive quantification of left-to-right shunt in pediatric patients: phase-contrast cine
magnetic resonance imaging compared with invasive oximetry. Circulation 2001; 103:2476.

Posted by ICU room Pearls at 3:00 AM No comments:

Labels: cardiology

Thursday, July 13, 2017

Q: What is Maastricht classification?

Answer: Non-heart beating donors (NHBDs) are grouped into 5 categories by the Maastricht
classification, and divided into controlled and uncontrolled

I - Brought in dead - uncontrolled

II - Unsuccessful resuscitation - uncontrolled

III - Awaiting cardiac arrest - controlled

IV - Cardiac arrest after brain-stem death - uncontrolled

V - Cardiac arrest in a hospital inpatient - uncontrolled

Categories helped in determining which organs should be procured e.g., only tissues such as
heart valves, skin and corneas can be taken from category I donors, but category III donors
may have major organs retrieved after cardiac arrest under more controlled and specialized
professionals.

References:

1. Kootstra, G.; Daemen, J.H.; Oomen, A.P. (1995), "Categories of non-heart-beating donors.", Transplantation proceedings, 27 (5):
28934

Posted by ICU room Pearls at 2:00 AM No comments:

Labels: end of life care

Wednesday, July 12, 2017

Q: A very narrow pulse pressure on the arterial line suggests all of the following except

A) aortic regurgitation
B) cardiac tamponade
C) severe cardiogenic shock
D) massive pulmonary embolism
E) tension pneumothorax

Answer: A

Aortic regurgitation causes widened pulse pressure, not a narrow pulse pressure, as in
diastole, the arterial pressure drops to fill the left ventricle though the regurgitating aortic
valve.

Posted by ICU room Pearls at 6:01 AM No comments:

Labels: hemodynamics

Tuesday, July 11, 2017

Q: While inserting radial arterial line, it should be placed as near as possible to radius styloid
process

A) True
B) False

Answer: B (False)

To target appropriate placement of radial arterial line, the best superficial anatomical marker is
over the radial pulse at the proximal flexor crease of the wrist. The insertion should be at least
1 cm proximal to the radius styloid process to avoid puncturing the retinaculum flexorum and
the small superficial branch of the radial artery.
Posted by ICU room Pearls at 12:30 AM No comments:

Labels: procedures

Monday, July 10, 2017

Q: Why hemodialysis (HD) is more effective than fomepizole in methanol toxicity?

Answer: Early HD may be more effective in methanol toxicity since endogenous clearance of
methanol in those treated with fomepizole is slow.

References:

1. Gonda A, Gault H, Churchill D, Hollomby D. Hemodialysis for methanol intoxication. Am J Med 1978; 64:749.

2. Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of methanol poisoning. N Engl J Med 2001; 344:424.

Posted by ICU room Pearls at 5:54 AM No comments:

Labels: toxicology

Sunday, July 9, 2017

Q: Fasting produces (choose one)

A) Hyperkalemia
B) Hypokalemia

Answer: A

Fasting can increase potassium movement out of the cells due probably due to reduced
insulin secretion. It's clinical implication is in patients who are in renal insufficiency or on
medicines which can induce hyperkalemia and left NPO in ICU.

References:

1. Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. J Am Soc Nephrol 1995; 6:1134.

2. Allon M, Takeshian A, Shanklin N. Effect of insulin-plus-glucose infusion with or without epinephrine on fasting hyperkalemia. Kidney Int 1993;
43:212.

Posted by ICU room Pearls at 1:00 AM No comments:

Labels: electrolytes and acid base

Saturday, July 8, 2017

Q: What is the preferred route of epinephrine in anaphylaxis?

A) Intra-Venous (IV)
B) Intra-Muscular (IM)
C) Subcutaneous (SC)
D) Oral
E) Nasal
Answer: B

IM route is the preferred, both over SC and IV routes. Obviously, over SC, it provides a quicker
increase in the plasma and tissue concentrations. IM route is also preferred over IV bolus as IV
bolus of "Epi" carries an inherent risk of cardiovascular complications.

References:

1. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin
Immunol 2001; 108:871.

2. Campbell RL, Bellolio MF, Knutson BD, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and
overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol
Pract 2015; 3:76.

Posted by ICU room Pearls at 1:00 AM No comments:

Labels: Miscellaneous

Friday, July 7, 2017

Q: All of the following cab be used to establish tuberculous pericarditis except?

A) acid-fast smear/culture
B) adenosine deaminase concentration
C) pericardial biopsy
D) right scalene lymph node biopsy (if lymphadenopathy)
E) transudative pericardial fluid

Answer: E

Tuberculous pericardial effusion is usually exudative and consist of high protein and
increased leukocyte count, with a predominance of lymphocytes and monocytes. Essentially,
Light's criteria for exudative pleural effusions can be equally applied for tuberculous
pericardial effusion.

Reference:

Reuter H, Burgess L, van Vuuren W, Doubell A. Diagnosing tuberculous pericarditis. QJM 2006; 99:827.

Posted by ICU room Pearls at 1:00 AM No comments:

Labels: infectious diseases

Thursday, July 6, 2017

Q: What is anticipatory emesis?

Answer: Anticipatory emesis is a conditioned response mostly in cancer patients who

previously had chemotherapy associated significant nausea and vomiting.

For review and further references:

Anticipatory Nausea and Vomiting - Joseph A. Roscoe, Ph.D., and Et al - Support Care
Cancer. 2011 Oct; 19(10): 15331538.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136579/
Posted by ICU room Pearls at 12:30 AM No comments:

Labels: Gastroenterology, Miscellaneous, oncology, psychiatry

Wednesday, July 5, 2017

Q: What is the first line of treatment in severe life-threatening babesiosis?

A) IV Vancomycin
B) PO Doxycycline plus IV Penicillin
C) Oral quinine plus intravenous clindamycin
D) IV or oral linezolid
E) Supportive treatment

Answer: C

Three regimens have been described for the treatment of severe (life-threatening) babesiosis

1. Oral quinine plus intravenous clindamycin

2. Atovaquone plus azithromycin
3. Atovaquone plus azithromycin plus clindamycin

Infectious Diseases Society of America (IDSA) guidelines, recommend oral quinine plus
intravenous clindamycin as a first line of therapy.

References:

1. Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, Treatment, and Prevention of Lyme Disease, Human Granulocytic
Anaplasmosis, and Babesiosis: A Review. JAMA 2016; 315:1767

2. Wittner M, Rowin KS, Tanowitz HB, et al. Successful chemotherapy of transfusion babesiosis. Ann Intern Med 1982; 96:601.

Posted by ICU room Pearls at 3:30 AM No comments:

Labels: infectious diseases

Tuesday, July 4, 2017

Happy Birthday My Great Nation

Posted by ICU room Pearls at 12:30 AM No comments:

Monday, July 3, 2017

Q: For pregnant women with acute pericarditis, after what age of gestation Nonsteroidal anti-
inflammatory drugs (NSAIDs) should be avoided and glucocorticoids should be considered?

Answer: 20 weeks

NSAIDs can be used for pregnant women with acute pericarditis who are less than 20 weeks of
gestation. But beyond that NSAIDs should be avoided and glucocorticoids should be
considered as a first line of therapy. After gestational week 20, NSAIDs may cause constriction
of the ductus arteriosus and impair fetal renal function.

Reference:

Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task
Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The
European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.

Posted by ICU room Pearls at 1:00 AM No comments:

Labels: cardiology

Sunday, July 2, 2017

Q: During the acute phase of ischemic stroke (in the first 24 hours) - given there is no risk for
aspiration, hemodynamic instability or of increased intracranial pressure - the head of the bed
should be kept

A) 0 - 15 degree
B) 30 - 45 degrees
C) 90 degrees
D) reverse trendelenburg
E) it does not matter

Answer: A

During the acute phase of ischemic stroke (in the first 24 hours) - given there is no risk for
aspiration, hemodynamic instability or of increased intracranial pressure - the head of the bed
should be kept 0 - 15 degrees. This is best on the hypothesis that cerebral perfusion is
maximal when patients are in the horizontal position, as well as to reduce the effect of stenotic
vessels and to maximize the collateral flow. But, it should be done after considering all clinical
risks particularly aspiration and increased intracranial pressure. Early mobilization and rehab.
should be the goal once acute phase is over. Actually, early mobilization during acute phase
(first 24 hours) may be harmful.

References:

1. Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of body position on intracranial pressure and cerebral perfusion in
patients with large hemispheric stroke. Stroke 2002; 33:497.

2. Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV. Heads down: flat positioning improves blood flow velocity in
acute ischemic stroke. Neurology 2005; 64:1354.

3. AVERT Trial Collaboration group, Bernhardt J, Langhorne P, et al. Efficacy and safety of very early mobilisation within 24 h of
stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386:46.

Posted by ICU room Pearls at 4:38 PM No comments:

Labels: neurology

Saturday, July 1, 2017

Q: What could be the hemodynamic pitfall of placing Dorsalis Pedis Arterial line?

Answer: Potentially dangerous hypotension being missed!

Due to distal systolic pulse amplification, the systolic peak is steeper the further down the
arterial vasculature tree blood travels - called reflected waves phenomenon. This may give
false sense of adequate blood pressure.
Reference:

Parry T, Hirsch N, Fauvel N. - Comparison of direct blood pressure measurement at the radial and dorsalis pedis arteries during
surgery in the horizontal and reverse Trendelenburg positions. - Anaesthesia. 1995 Jun;50(6):553-5.

Posted by ICU room Pearls at 6:20 AM No comments:

Labels: hemodynamics, procedures

Newer Posts Home Older Posts

Subscribe to: Posts (Atom)

Awesome Inc. theme. Powered by Blogger.