Sunday, July 31, 2011

 Sapien heart valve gets FDA approval

"A newer incarnation of the Sapien transcatheter heart valve may lower the risk of major vascular complications compared with the first-generation device.

Although the overall short-term performance was similar between patients on both the Sapien THV and the newer Sapien XT, patients with the XT had significantly fewer major vascular events (11.1% versus 33.3%, P=0.004), according to Antonio Colombo, MD, of San Raffaele Scientific Institute in Milan, and colleagues.

They reported their findings in the July issue of the Journal of the American College of Cardiology: Cardiovascular Interventions.

An FDA panel recommended approval of the first-generation valve earlier this week. FDA advisory committee panelist Ralph Brindis, MD, of Kaiser Permanente in Oakland, Calif., said the second-generation device is being evaluated in the PARTNER II trial and will likely be submitted for approval upon completion of that study".

Read full report here (from

Friday, July 29, 2011

A note on Factor 7 (rVIIa) and thrombocytopenia

Factor 7 (rVIIa - Novoseven) is now significantly use as off label in uncontrolled bleeding. It may not be efective in the presence of severe thrombocytopenia and should be corrected prior to its administration. Although there are case reports of the successful use of rVIIa in severe thrombocytopenia, a low platelet count is likely to predict a poor or partial response to rVIIa therapy.

Its haemostatic effects are mediated by the thrombin it generates by both tissue factor (TF) dependent and independent mechanisms. The TF independent mechanism requires platelets for the direct activation of Factor X on their surface by rVIIa.

Thursday, July 28, 2011

Q; Whats the first and major concern in person who may have clonidine overdose/toxicity?

A: Repiratory depression/Apnea and need of endotracheal intubation.

CNS toxicity in clonidine overdose is similar to that seen in opiates - which is many time missed by caregiver. Central effect of clonidine includes CNS lethargy or coma, miosis and respiratory depression or apnea. Other CNS signs and symptoms include Hypotonia or hyporeflexia, Seizures, Ataxia, dysarthria, Weakness and Hallucinations.

Wednesday, July 27, 2011

Q: 30 year old pregnant female admitted with Hyperemesis Gravidarum(HG). patient is hypotensive, dehydrated and hypoglycemic. Before writing IVF orders what would be your concern and which additional order you will consider?

Answer: Wernicke's Encephalopathy (WE)

There is a high risk of WE in HG after 3-4 weeks of persistent vomiting. Thiamine should be given prior to glucose and dextrose infusion.

Tuesday, July 26, 2011

Q: While performing LP (Lumbar puncture) you encountered Green color CSF fluid. What may be the cause of it?

Answer: Hyperbilirubinemia. Purulent CSF may also sometime appears Green. It should be read with other values in CSF.

The cerebrospinal fluid (CSF) is produced from arterial blood by the choroid plexuses of the lateral and fourth ventricles by a combined process of diffusion, pinocytosis and active transfer. The total volume of CSF in the adult is about 140 ml. The volume of the ventricles is about 25 ml. CSF is absorbed across the arachnoid villi into the venous circulation.The rate of absorption correlates with the CSF pressure.

Monday, July 25, 2011

Q; Which poisoning presents with garlic odor?

A: Organophosphate poisoning

Sunday, July 24, 2011

EKG changes in adrenal crisis

Q: 37 year old female admitted to ICU with hypotension, hyponatremia, hyperkalemia, metabolic acidosis, and hypoglycemia. Hypotensive shock is refractory to fluid resuscitation. You highly suspect adrenal crisis. You order all required workup. What changes you expect to see in EKG with adrenal crisis?

Answer: Adrenal crisis may cause T wave changes from peaked T waves secondary to hyperkalemia to deep negative T waves. More importantly it causes prolongation of the QT interval which should be considered serious as it may degenerate into ventricular arrhythmias.

Friday, July 22, 2011

Nomogram for Enoxaparin Treatment

Anti Factor Xa level: less than 0.35 u/ml
Hold Next Dose?: No
Dose Change?: increase by 25%
Repeat Anti Factor Xa level?: 4 hours post next dose

Anti Factor Xa level: 0.35 to 0.69 u/ml
Hold Next Dose?: No

Dose Change?: increase by 15%
Repeat Anti Factor Xa level?: 4 hours post next dose

Anti Factor Xa level: 0.7 to 1.1 u/ml
Hold Next Dose?: No
Dose Change?: 0
Repeat Anti Factor Xa level?: 1 x per week at 4 hours post dose

Anti Factor Xa level: 1.1 to 1.5 u/ml
Hold Next Dose?: No
Dose Change?: decrease by 20%
Repeat Anti Factor Xa level?: 4 hours post next dose

Anti Factor Xa level: 1.6 to 2.0 u/ml
Hold next dose?: No
Dose Change?: decrease by 30%
Repeat Anti Factor Xa level?: 4 hours post next dose

Anti Factor Xa level: more than 2.0 u/ml
For these patients, all further doses should be held, and the anti factor Xa level measured q 12 hours until the anti factor Xa level is less than 0.5 u/ml. Enoxaparin can then be restarted at a dose 40% less than was originally prescribed.

The above nomogram assumes that there is no bleeding.

Thursday, July 21, 2011

Q: What is "wedged blood PO2" and what is the clinical implication?

Answer: "Wedged blood Po2" is the level of PO2 while Pulmonary artery catheter baloon is inflated (wedging).

Wedge blood Po2 should be atleast 20 mm Hg higher than arterial PO2 (ABG) to confirm that you are measuring Pulmonary artery occlusion pressure at right level/spot.

Paul L. Marino - The little ICU book of facts and Formulas, 2009 - Page 119

Wednesday, July 20, 2011

Case: You inserted central line. While you were on your way to check CXR to confirm line placement, nurse request you to check KUB also to confirm enteral feeding tube placement (DHT). Interestingly, KUB shot this morning had IVC filter which is no more present there ?

Answer: Guide wire during central line procedure probably travelled into inferior vena cava and dislodged IVC filter !!!

Related previous pearls:

Guide wire length

Tuesday, July 19, 2011

Calcium in Dig toxicity

Case: 74 year old male has been found to have arrhythmia with runs of wide complex ventricular tachycardia. Patient so far remained hemodynamically stable. You request crash cart near bed, applied pads to chest and send STAT labs and start reviewing patient's chart. You noticed 4 days ago digoxin level was 1.9 and since then his serum creatinine is steadily rising from 1.6 to 2.8. You suspected "Dig. toxicity" and called lab to run STAT dig. level. Indeed Dig. level is back with 3.4 and accompanying labs showed K+ level of 6.9. You ordered "Digi-bind" (Digoxin Immune Fab). Pharmacy informed you, "it will take time before Digi-bind gets to ICU". Interim you started treating hyperkalemia with IV insulin, D-50, IV bicarb., IV calcium and albuterol neb. treatments. Where did you go wrong ?

Answer: Calcium has shown to make digoxin toxicity worse. It may be more wise to avoid calcium in management of hyperkalemia from digoxin toxicity. Some literature has shown the similar membrane stabalizing effect from magnesium and may be used instead of calcium.

Caution should be taken not to go very aggressive in treating hyperkalemia, or atleast potassium should be followed very closely if DigiFab is planned. With administration of DigiFab (Digibind), potassium shifts back into the cell and life threatening hypokalemia may develop rapidly. Digoxin causes a shift of potassium from inside to outside of the cell and may cause severe hyperkalemia but overall there is a whole body deficit of potassium. With administration of Digi-bind, actual hypokalemia may manifest which could be equally life threatening.

Monday, July 18, 2011

Scenario: 52 year old male is back from cardiac angioplasty with abciximab (ReoPro) infusion. Pre-cath labs were normal. CBC was send per protocol after 4 hours of abciximab infusion and lab call with critical platelet level of 62. Abciximab was stopped and hematology consulted. Hematology made a trip to lab and advised to restart abciximab !!


Pseudothrombocytopenia is a common phenomenon with patients on abciximab (ReoPro). It is a benign condition and is not a real thrombocytopenia as platelets actually clump in collecting tubes containg EDTA. It is an important diagnosis to make as it may subject patient to unwanted treatments. Diagnosis can be made by reviewing peripheral blood film or drawing blood in citrated or heparinized tube. It is not clear why abciximab cause more EDTA-induced platelet clumping.

* EDTA (Ethylenediaminetetraacetic acid) is a commonly used anticoagulant in sampling tubes for blood counts.

Sunday, July 17, 2011

Euthyroid Sick Syndrome

Word of wisdom is not to check thyroid function test in ICUs as it takes only few hours for patient to ‘abnormalize’ thyroid function test under stress but if clinically indicated send full "Thyroid Function Test” including TSH, Total T3, Total T4, Free T4 and rT3 (reverse T3). There is no absolute trend but general rule of thumb is as patient get sicker and sicker “all fall but reverse rise” i.e rT3 (reverse T3) will be elevated.

Saturday, July 16, 2011

Warfarin risk score

Anemia (3 points),

Severe renal disease–defined as glomerular filtration rate  less than 30 ml/min or on dialysis (3 points),

Age  more than/= 75 years (2 points),

Prior bleeding (1 point), and

Hypertension (1 point)

Cumulative point score was associated with major hemorrhage rates ranging from 0.4% (at 0 points) to 17.3% (at 10 points).

Three categories of risk
low risk 0-3 points;
intermediate risk 4 points;
high risk 5-10 points


Thursday, July 14, 2011

A july post - 'Post fellowship shock syndrome'

Post fellowship shock syndrome is a kind of culture shock for young graduates when they transit from big tertiary care academic centers to regular community based medical practice. Transit from high tech., literature oriented, academic based and superior nursing quality to business oriented, "thats how we do things here" practice, no house staff support, no billing and business experience and wide spectrum of nursing quality - put unprepared young graduates into mental and cultural shock and may leave them frustrated with present situation. And sometime in changing jobs they find themselves jumping from firepan to fire. It is important to prepare graduating residents and fellows for business and billing practice of medicine.

(Post fellowship shock syndrome is a term invented by editors of this website)

Wednesday, July 13, 2011

Q: 28 year old male is recently started on Isoniazide (INH) after he was tested postive for PPD during routine employment exam. He is now admitted with seizure. What is the treatment

Answer: IV Pyridoxine (Vitamin B6)

Five grams of IV pyridoxine given over 5-10 minutes is sufficient to abolish the neurologic effects of isoniazid in most cases. Repeat dosing may be required for persistent seizure activity. Patients usually do not respond to most of the antiepileptics.

Tuesday, July 12, 2011

Tegaderm CHG Dressing with Cavilon No Sting Barrier Film
Tegaderm CHG is a transparent dressing integrated with CHG (chlorhexidine gluconate) that serves as a barrier to organisms, including those most commonly associated with CLBSI. It comes with No Sting Barrier Film, which is a fast-drying, non-sticky, alcohol-free liquid barrier film that forms a breathable, transparent coating on the skin. No Sting protects damaged or intact skin from body fluids, adhesive trauma, friction, and incontinence. The No Sting Barrier Film application prior to Tegaderm increases the adhesiveness of the dressing, and the likelihood that the dressing will remain intact for 7 days.

Similar product: biopatch

Monday, July 11, 2011

Systolic Anterior Motion(SAM) following Mitral Valve Prolapse Repair

Sunday, July 10, 2011

Q: Beside diuresis describe 2 more effects of furosemide (Lasix)?

Lasix is a diuretic which acts on the loop of henle and inhibits reabsorption of both sodium and chloride ions. Beside this basic function of diuresis

1. Lasix also causes peripheral vasodilation (mostly venodilatation) and an increase in systemic venous capacitance. Obviously this helps with the CHF patients.

2. Lasix reduces ICP and can be use in conjunction with Mannitol. By interfering with the Na transport which in turn slows the production of CSF fluid from the choroid plexi.

Saturday, July 9, 2011

Multaq - Thumbs down?

"A randomized trial of dronedarone (Multaq) in patients with permanent atrial fibrillation -- an unapproved indication for the antiarrhythmic drug -- has been stopped early because of increased cardiovascular events among patients receiving the product, its manufacturer said. Dronedarone, sold by sanofi-aventis, is currently approved to treat atrial flutter and paroxysmal or persistent -- but not permanent -- afib. The phase IIIb trial, called PALLAS, had enrolled 3,148 patients with permanent afib, with 70% showing symptoms for more than two years, according to a company statement. The same proportion also had heart failure at NYHA Class I to III at baseline."

Read full report here (From

Friday, July 8, 2011

The Effect of Catheter to Vein Ratio on Blood Flow Rates in a Simulated Model of PICC

Important work published this month in chest1 regarding catheter-related thrombosis. It is presumed that the presence of a catheter within the lumen of a vein will decrease flow and potentially create stasis and thrombosis.

Researchers used fluid mechanics to calculate relative flow rates as a function of the ratio of the catheter to vein diameters simulating the size of upper extremity veins and commonly used peripherally inserted central catheters (PICCs).

Results demonstrate that fluid flow is dramatically decreased, PICCs, in particular, may substantially decrease venous flow rates by as much as 93%.

The Effect of Catheter to Vein Ratio on Blood Flow Rates in a Simulated Model of Peripherally Inserted Central Venous Catheters- CHEST July 2011 vol. 140 no. 1 48-53

Thursday, July 7, 2011

Wednesday, July 6, 2011

Q: What does this single or double mark near cuff of ETT means if present?

Answer: ETT should be placed in a way that the vocal cords should be at the black mark (single mark) or keep the vocal cords between the two marks. These marking systems only provide a rough estimate and correct ET tube position depth should always be confirmed by other means

Tuesday, July 5, 2011

Biopatch application at CVC site

Application of BIOPATCH (ETHICON, Inc.), releases chlorhexidine gluconate (CHG), a broad-spectrum antimicrobial and antifungal agent at CVC insertion site and one application is good for up to 7 days. It is clinically proven in reducing Catheter-Related Blood Stream Infections (CRBSI ). It provides 360ยบ protection around insertion site even in the presence of organic matter including blood, sera, and proteins.

Monday, July 4, 2011

100 great things about America

"Though our affection for America is a year-round phenomenon, summer seems to make the heart and mind grow even fonder. Holidays contribute to this: Memorial Day ushers in the season, followed soon after by our Uncle Sam's favorite, July Fourth. Getting out into the great outdoors also kindles nation-love, as only a visit to national parks like Yellowstone or the Great Smoky Mountains can do. So, too, does the food of summer: grilled hot dogs and hamburgers, corn on the cob, and blueberry pie on a brimming picnic table. So we think it only fitting to present to you our second annual list of 100 Great Things About America right as we head into the summer solstice." ......Fortune/CNNMoney Magazine

Click here  to see 100 great things about this great nation on earth

Sunday, July 3, 2011

Dental workup and 2 'curious cases of SQ Emphysema'

1. In 1900, the first recorded case of spontaneous subcutaneous emphysema was reported in a bugler for the Royal Marines who had had a tooth extracted: playing the instrument had forced air through the hole where the tooth had been and into the tissues of his face.

2. A case of spontaneous subcutaneous emphysema was reported in a submariner for the US Navy who had had a root canal in the past; the increased pressure in the submarine forced air through it and into his face.

Parker GS, Mosborg DA, Foley RW, Stiernberg CM. "Spontaneous cervical and mediastinal emphysema". Laryngoscope 100 (9): 938–940 (September 1990).

Saturday, July 2, 2011

Q: Out of all Quinolones which is reported worse to cause CNS symptoms?

Answer: Moxifloxacin

Moxifloxacin is reported as worst among all quinolones for causing CNS toxicity which includes tremor, confusion, anxiety, insomnia, agitation, psychosis or even seizure.

Galatti L, Giustini SE, Sessa A, et al. - "Neuropsychiatric reactions to drugs: an analysis of spontaneous reports from general practitioners in Italy" , Pharmacological Research, Volume 51, Issue 3, March 2005, Pages 211-216

Friday, July 1, 2011

Q: Name at least 3 Antibiotics which should be use with caution in patients with active seizure?


1. Fluoroquinolones
2. Primaxin (Imipenem and Cilastatin)
3. Zyvox