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2009 ICU pearls

More than 1000 pearls


1.Pulmonary Vein ablation
Almost all atrial fibrillation signals come from the four pulmonary veins. Pulmonary vein antrum
isolation (PVAI), also called pulmonary vein ablation, is a treatment for atrial fibrillation. A
special machine delivers energy through the catheters to the area of the atria that connects to
the pulmonary vein (ostia). This energy (ablation) produces a circular scar that blocks any
impulses firing from within the pulmonary vein, thereby “disconnecting” the pathway of the
abnormal rhythm and preventing atrial fibrillation. In some cases, pulmonary vein ablation also
may be performed in other parts of the heart such as the superior vena cava.

Anatomic Carto map of the left atrium showing lesion sets in circumferential pulmonary vein
ablation. (A) Circumferential lesions in the left atrium encircling individual pulmonary veins. (B)
Circumferential lesions were placed in the left atrium encircling ipsilateral pulmonary veins.
Additional linear lesions were placed to the posterior left atrium and the mitral isthmus.

LIPV, left inferior pulmonary vein;
LSPV, left superior pulmonary vein;
MA, mitral annulus;
RIPV, right inferior pulmonary vein;
RSPV, right superior pulmonary vein.


2.Vasopressin-Steroid Combo?
Is vasopressin-Steroid combo better for septic shock? and if vasopressin alone is bad?- see this
recent study.
Objective: Vasopressin and corticosteroids are often added to support cardiovascular
dysfunction in patients who have septic shock that is nonresponsive to fluid resuscitation and
norepinephrine infusion. However, it is unknown whether vasopressin treatment interacts with
corticosteroid treatment.
Design: Post hoc substudy of a multicenter randomized blinded controlled trial of vasopressin
vs. norepinephrine in septic shock. 779 patients who had septic shock and were ongoing
hypotension requiring at least 5 μg/min of norepinephrine infusion for 6 hours.
Interventions: Patients were randomized to blinded vasopressin (0.01-0.03 units/min) or
norepinephrine (5-15 μg/min) infusion added to open-label vasopressors. Corticosteroids were
given according to clinical judgment at any time in the 28-day postrandomization period.
Primary end point : 28-day mortality. We tested for
Secondary end points: Organ dysfunction, use of open-label vasopressors and vasopressin levels.

There was a statistically significant interaction between vasopressin infusion and
corticosteroid treatment (p = 0.008).

In patients who had septic shock and were also treated with corticosteroids, vasopressin,
compared to norepinephrine, was associated with significantly decreased mortality
(35.9% vs. 44.7%, respectively, p = 0.03).

In contrast, in patients who did not receive corticosteroids, vasopressin was associated
with increased mortality compared with norepinephrine (33.7% vs. 21.3%, respectively, p
= 0.06).

In patients who received vasopressin infusion, use of corticosteroids significantly
increased plasma vasopressin levels by 33% at 6 hours (p = 0.006) to 67% at 24 hours (p
= 0.025) compared with patients who did not receive corticosteroids.

Conclusions: There is a statistically significant interaction between vasopressin and
corticosteroids. The combination of low-dose vasopressin and corticosteroids was associated
with decreased mortality and organ dysfunction compared with norepinephrine and
Editors’ comment: Note - “In contrast, in patients who did not receive corticosteroids,
vasopressin was associated with increased mortality compared with norepinephrine”

Interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock - Critical Care
Medicine:Volume 37(3)March 2009pp 811-818

pediatric pearl
2.Transporting infants on prostaglandin E1
Transporting infants on prostaglandin E1 infusion (PGE1) is used in the palliation of ductaldependent congenital heart lesions and helps maintain the patency of the ductus arteriosus.
Prostaglandin E(1) adverse effects are noted in 38% of infants, including 18% with apnea. 14%
of infants required intubation for prostaglandin E(1)-related adverse effects.
To Intubate or Not to Intubate? Transporting Infants on Prostaglandin E1 - Pediatrics. 2009 Jan;123(1):e25-30

3.Scenario: 47 year old male admitted from cardiac cath. lab after insertion of pericardial
catheter with drainage bag. Patient is hemodynamically stable. Few hours later nurse reported
that blood in pericardial bag appears more ‘darker’ and ‘bloody’. Describe various methods to
rule out ventricular punture by pericardial catheter?
Answer: There could be various laboratory and non-laboratory methods to rule out ventricular
punture by pericardial catheter.
1. Though not always true but pure pericardial fluid usually does not clot.
2. Decholin test - Inject 3 ml of Sodium dehydrocholate (Decholin) in pericardial catheter. If
patient complains of bitter taste within few minutes - ventricular rupture is likely.
3. Fluorescein test - Inject Fluorescein in pericardial catheter and look for fluorescent ‘flush’
under ultraviolet light beneath the skin of the eyelid. If visible - ventricular rupture is likely.
4. Draw hematocrit from venous blood and compare with pericardial hematocrit. Same values of
hematocrit make ventricular rupture highly likely.
5. Draw ABG from venous blood and compare with pericardial ABG. PO2 is usually lower and
PCO2 is usually higher in pericardial fluid. Same values in ABGs make ventricular rupture likely.

4.Q: Why blood in pleural fluid does not clot?
Answer: Hemorrhage within the pleural space generally does not clot due to 3 reasons
1. mechanical defibrination (movement of lungs)
2. activation of fibrinolytic mechanisms
3. Also, platelets disappears within hours following hemorrhage


5.Q: What is your diagnosis.
Second degree (Wenckebach) AV block or Third degree AV block?

Answer: Third degree AV block.Though it appears that PR interval is progressively getting
bigger (like second degree wenckebach block) - but on close inspection - P waves and QRS
complexes are marching independently.

6.Q: Describe any other related IV use of Narcan (NALOXONE), beside its use as
an anti-dote for narcotic overdose?
Answer: To counter-act pruritus associated with epidural analgesia.
To neutralize pruritis caused by an opiate, without compromising analgesic effect - continuous
drip can be prepared with 4 mg of Narcan in 250 cc D5W or D5NS = 16 mcg/cc and can be given
at rate of 1 mcg/kg/h. It can be titrated upto 5 mcg/kg/h as tolerated.
Related Previous Pearl: Oral Narcan for opioid induced constipation !

7.Q; You received following CT scan report on a patient
”The peripheral opacities are present in the form of triangles, with the base of the triangle
along the pleural surface and the tip of the triangle toward the mediastinum”
What would be your diagnosis in patient with cough, fever, dyspnea, hemoptysis and hypoxia?

Answer: Bronchiolitis Obliterans Organizing Pneumonia (BOOP)
The chest computed tomographic scan shows findings similar to the chest radiograph in BOOP,

with bilateral areas of consolidation and ground glass opacities, usually with a peripheral location
(figure 2B). Not always but sometimes the peripheral opacities are in the form of triangles, with
the base of the triangle along the pleural surface and the tip of the triangle toward the
mediastinum (figure 2C).

Bronchiolitis obliterans with organizing pneumonia: outcome. - Thorax, 1995;50(suppl 1):S59-S64

8.Q; What’s your diagnosis?

Answer: Chest x-ray of a large bulla with infection in a patient with Bullous emphysema; showing
fluid level

9.Q: How supplemental oxygen helps in accelerating the resolution of a
Answer: oxygen may speed resolution of the pneumothorax by increasing the gradient for
nitrogen absorption. Resolution of pneumothorax has shown increase rate of absorption if
oxygen supplement is increased from a lower concentration via nasal cannula to a partial
rebreathing mask. Oxygen therapy results in a fourfold increase in the mean rate of absorption.
This fact is known since last 40 years and still applicable and easy to do 1. During inhalation of
room air the total gas pressure in blood from the distal end of a capillary is about 706 mm Hg,
whereas during inhalation of 100% oxygen it is about 146 mm Hg. This difference is mainly due
to a reduction in partial pressure of nitrogen from 573 mm Hg to a zero - and can be
accompanied by an increase in the partial pressure of oxygen in arterial blood from 100 to 640
mm Hg. oxygen utilization in the tissues ensures that the partial pressure of oxygen in end6|Page

capillary blood rises only slightly from 40 mm Hg to about 53 mm Hg.
Pneumothorax during needle lung biopsy can be prevented by breathing 100% oxygen 2.

1. Oxygen Therapy for Spontaneous Pneumothorax - Br Med J. 1971 October 9; 4(5779): 86–88.
2. Prevention of pneumothorax in needle lung biopsy by breathing 100% oxygen - Thorax. 1980 January; 35(1): 37–41.

10.Q: What is the classic Beck triad of pericardial tamponade?


muffled heart sounds,

jugular venous distension

11.Q: What position is recommended for intubation in pregnant patient ?
Answer: Ear to Sternal Notch Positioning

In pregnancy, a wedge made of blankets or towels may be placed under the right hip to displace
the uterus laterally and facilitate venous return to the heart or an assistant may displace the
uterus manually. Ear-to-sternal notch position is prefered in pregnant and morbidly obese
patients to improve alignment of the pharyngeal, oral, and laryngeal axes and maximize the
laryngoscopic view.
RELATED VIDEO: Rapid aiway management positioner (RAMP)
RELATED ARTICLE: Emergency Airway Management in the Pregnant Patient


12.Does N-terminal pro-brain natriuretic peptide (N-proBNP) and troponin I (TnI)
profile following mitral and/or aortic valve surgery in children correlate with
echocardiography measures and outcome criteria?
In a prospective cross-controlled study in twenty children with acquired valvular disease
requiring valvular surgery N-proBNP correlated with the Pediatric Heart Failure Index, left
ventricle shortening fraction, left atrium to aorta ratio, left ventricle mass index, end-systolic
wall stress, and with outcome measures such as inotropic score, duration of inotropic support,
and ICU length of stay. Preoperative N-proBNP was significantly more elevated in patients with
complicated outcome than in patients with uneventful postoperative course.
Conclusion: In pediatric valvular patients, perioperative N-proBNP is a promising risk
stratification predicting factor. It is correlated with evolutive echocardiographic measures,
need for inotropic support, and ICU length of stay.
BNP could be used as marker of heart failure in conjunction with other measures such as
echocardiographic finding and clinical severity of illness while explaining parents about short
term outcome after surgery such as length of intensive care, need for inotrope support etc.
Value of brain natriuretic peptide in the perioperative follow-up of children with valvular
disease.- Intensive Care Med. 2008 Jun;34(6):1109-13.

13.Case: How Fondaparinux (Arixtra) is different in Mechanism of action from heparins
(unfractionated and low molecular weights), which may give it advantage of not causing HIT
(Heparin induced Thrombocytopenia)?
Answer : Fondaparinux (ARIXTRA) is the synthetic Factor Xa inhibitor. While other
antithrombotics may inhibit multiple factors in the coagulation cascade, Fondaparinux
selectively inhibits only Factor Xa. Fondaparinux is not a heparin. Fondaparinux is the
pentasaccharide antithrombotic agent inhibiting only factor Xa.


14.Hydroflouric acid exposure
Case: 23 year male while working in the refinery while disconnecting the hose was exposed to
hydrofluoric acid. Patient had inhalation of hydrofluoric acid. Patient had no past medical
history. Which of the following should be done first?
a. Albuterol nebulizer with 2.5 mg albuterol
b. Albuterol nebulizer with 10mg albuterol
c. Calcium gluconate nebulizer treatment
d. 10% mucomyst treatment
Answer : C
Calcium gluconate should be used after hydrofluoric acid exposure, and if there are any skin
lesions it should be applied there too. Patient should be observed for 24-48 for development of
pulmonary edema. Ionized calcium should be monitored very closely, and should be supplemented
with intravenous calcium gluconate if low.

15.Q: In Hypothermia induced Ventricular fibrillation which cardiac medicine is
preferred and which one may harm the patient?
Answer: Bretylium (5 mg/kg initially) is recommended for any hypothermic patient manifesting
significant new frank dysrhythmia. However, bretylium has a worldwide shortage and may not be

available. Relying on Amiodarone or Lidocaine are the next choices.
Procainamide may induce more ventricular fibrillation and should be avoided.
Defibrillation should also be performed simultaneously. Defibrillate at 2 J/kg (or the biphasic
equivalent) if patient remains in ventricular fibrillation or ventricular tachycardia. Success rates
of defibrillation are low if the core temperature is less than 32°C and should be performed with
rise in body temperature. Actually, because many arrhythmias convert spontaneously upon
rewarming, aggressive therapy of minor arrhythmias is not warranted. Transient ventricular
arrhythmias should be ignored. This also is true of bradycardia or atrial arrhythmias.
The cornerstone of treatment is rewarming the patient.

16.Case: 68 year old male presented to ER with left sided weakness and CVA (stroke) is
suspected. Patient has chronic history of atrial fibrillation and is on coumadin 4 mg every day
and record shows previously consistent therapeutic INR of 2.6 but today patient’s INR is 1.4.
According to wife, patient is very compliant with his medicines, rather he is very health
conscious and lately start doing more healthy diet consist of frequent green tea, fish oil,
ginseng, canola oil etc.
Answer: Green Tea carries a huge amount of Vitamin K. It is also present in clinically significant
amount in other healthy diets and herbals like fish oil, ginseng, canola oil etc.
Related Web site: http:/ www.warfarindosing.org/
Its a free Web site to help doctors begin warfarin therapy by estimating the therapeutic dose in patients new to

17.Case: 48 year old male presented to ER with Shortness of Breath. CXR showed massive left
sided pleural effusion. ER physician inserted chest tube but to surprise white milky fluid get
drained from chest. You made diagnosis of “Nontraumatic” Chylothorax. What are the 5 major
causes of “Nontraumatic” Chylothorax?
1. Lymphoma
2. cirrhosis,
3. tuberculosis,
4. sarcoidosis,
5. amyloidosis

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Lymphoma is the most common cause of “Nontraumatic” Chylothorax, representing about 60% of
all cases, with non-Hodgkin lymphoma more likely than Hodgkin lymphoma to cause a chylothorax.
Trauma is the second leading cause of chylothorax (25%) including iatrogenic injury to the
thoracic duct with thoracic procedures.
Pseudochylothorax: Chylothorax must be distinguished from pseudochylothorax, or cholesterol
pleurisy, which results from accumulation of cholesterol crystals in a chronic existing effusion.
The most common cause of pseudochylothorax is chronic rheumatoid pleurisy, followed by
tuberculosis and poorly treated empyema.

18.Q: Which electrolytes you need to watch closely while patient receives proton
pump inhibitor?
Answer: Magnesium (and potassium secondary to low magnesium)
Mechanism is not very clear. Absorption of dietary magnesium occurs in the ileum and colon via
carrier mediated transport and simple diffusion. Low gastric pH is thought to be important for
the absorption of minerals. Waves of acidity entering the small intestine from the stomach may
help to keep mineral salts in solution until they can be absorbed. Omeprazole induced
hypochlorhydria could therefore theoretically cause mineral deficiency, although there is no
clear evidence proven yet.

1. Omeprazole and refractory hypomagnesaemia - BMJ 2008;337:a425
2. Epstein M, McGrath S, Law F. Proton-pump inhibitors and hypomagnesemic hypoparathyroidism. N Engl J

19.Case: A 62 year old male with past medical history of diabetes mellitus, hyperlipidemia,
atrial fibrillation, hypertension, and mild renal insufficiency - presented to ER with severe
weakness, anuria and renal failure. Patient report extremely dark urine for few days prior to
presentation. Patient was discharged 5 weeks ago from hospital with Aspirin, Coumadin,
Lopressor, Amiodarone and simvastatin . Laboratory workup in ED showed creatine kinase (CK) in
80,000 U/L range. BUN 65 mg/dL, creatinine 4.6 mg/dL. Liver function test (LFT) are also
moderately elevated. What could be the reason of of this life threatening Rhabdomyolysis?
Answer: Simvastatin-Amiodarone Interaction
Simvastatin is metabolized primarily by CYP3A4, and amiodarone is a recognized inhibitor of
this enzyme. This drug interaction may cause severe life threatening Rhabdomyolysis. The risk
is higher in patients, particularly with simvastatin doses greater than 20 mg daily.

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20.IABP in severe septic shock - Bench to bedside?
Background: Fluid refractory septic shock can develop into a hypodynamic cardiovascular state
in both children and adults. Despite management of these patients with empirical inotropic
therapy (with or without a vasodilator), mortality remains high. The effect of cardiovascular
support using intra-aortic balloon counterpulsation was investigated in a hypodynamic,
mechanically ventilated canine sepsis model in which cardiovascular and pulmonary support were
titrated based on treatment protocols.
Methods: Each week, three animals (n = 33, 10-12 kg) were administered intrabronchial
Staphylococcus aureus challenge and then randomized to receive

intra-aortic balloon counterpulsation for 68 hrs or

no intra-aortic balloon counterpulsation (control)

Bacterial doses were increased over the study (4-8 x 109 cfu/kg) to assess the effects of
intra-aortic balloon counterpulsation during sepsis with increasing risk of death.

Results: Compared with lower bacterial doses (4-7 x 109 colony-forming units/kg),
control animals challenged with the highest dose (8 x 109 colony-forming units/kg) had a
greater risk of death (mortality rate 86% vs. 17%), with worse lung injury ([A - a]o2),
and renal dysfunction (creatinine). These sicker animals required higher norepinephrine
infusion rates to maintain blood pressure (and higher Fio2) and positive end-expiratory
pressure levels to maintain oxygenation.

In animals receiving the highest bacterial dose, intra-aortic balloon counterpulsation
improved survival time (23.4 +/- 10 hrs longer) and lowered norepinephrine requirements
(0.43 +/- 0.17 [mu]g/kg/min) and systemic vascular resistance index (1.44 +/- 0.57
dynes/s/cm5/kg) compared with controls.

Despite these beneficial effects, intra-aortic balloon counterpulsation was associated
with an increase in blood urea nitrogen and creatinine

In animals receiving lower doses of bacteria, intra-aortic balloon counterpulsation had no
significant effects on survival or renal function

Conclusions: In a canine model of severe septic shock with a low cardiac index, intra-aortic
balloon counterpulsation prolongs survival time and lowers vasopressor requirements.

Reference:effects of intra-aortic balloon counterpulsation in a model of septic shock - Critical Care Medicine.
37(1):7-18, January 2009.

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13.Baseline Cortisol in Severe Community-Acquired Pneumonia
The aim of the study was to investigate the predictive value of adrenal response in patients with
severe CAP admitted to the ICU.
Methods: 72 patients with severe CAP admitted to the ICU were evaluated. Following were
measured in first 24 hours

Baseline and postcorticotropin cortisol levels

C-reactive protein (CRP),


clinical variables,

sequential organ failure assessment (SOFA) score

APACHE (acute physiology and chronic health evaluation) II, and

CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age ≥ 65 years) score

The major outcome measure was hospital mortality.
Results:Baseline cortisol levels were 18.1 μg/dL and the difference between baseline and
postcorticotropin cortisol after 250 μg of corticotropin was 19 μg/dL

Baseline cortisol levels presented positive correlations with scores of disease severity,
including CURB-65, APACHE II, and SOFA

Cortisol levels in nonsurvivors were higher than in survivors.

CIRCI (critical illness-related corticosteroid insufficiency) was diagnosed in 29 patients

In univariate analysis, baseline cortisol, CURB-65, and APACHE II were predictors of

The discriminative ability of baseline cortisol for in-hospital mortality was better than
APACHE II, CURB-65, SOFA, d-dimer, or CRP.

Conclusion: Baseline cortisol levels are better predictors of severity and outcome in severe CAP
than postcorticotropin cortisol or routinely measured laboratory parameters or scores as

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14.Q: What are the usual clues on chest X-ray to suggest subpulmonic effusions?
Answer: Following few suggests subpulmonic effusions.

Apparent elevation of the hemidiaphragm,

lateral displacement of the dome of the diaphragm,

increased distance between the apparent left hemidiaphragm and the gastric air bubble

Lateral decubitus films more reliably detect smaller pleural effusions. Failure of an effusion to
layer on lateral decubitus films indicates loculated pleural fluid or some other etiology causing
the increased pleural density.

The film on the left at first glance doesn’t appear to show fluid in the pleural space. The right
hemidiaphragm is elevated, and if one looks carefully there is blunting of the right constphrenic sulcus. Is there fluid in the pleural space? With the patient imaged with their right side
down (B), fluid flows by gravity out from under the diaphragm and layers along the chest wall.

15.Is Xigris safe with anticoagulation of CVVHD?
Drotrecogin alfa is use for the treatment of severe sepsis with multiple organ failure. Patients
with severe sepsis on renal replacement therapy (RRT), who typically receive additional
anticoagulation to prevent circuit clotting, may be at higher risk of bleeding. The aim of this
study was to analyse the filter survival time (FST), and to quantify the requirement of packed
red cells (PRC) and blood products during xigris infusion.
Methods: This was a single-centre, retrospective observational study conducted in an adult
intensive care unit (ICU). Thirty-five patients with severe sepsis who had received both RRT
and Drotrecogin alfa were identified.
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The proportion of filter changes due to filter clotting was similar during Drotrecogin alfa
infusion and with conventional anticoagulation Drotrecogin alfa infusion. There was no
difference in the Filter survival time(FST) and filter parameters during Drotrecogin alfa
in the presence or absence of additional anticoagulation with heparin or epoprostenol.

A similar proportion of patients required red cell transfusion, although a greater
proportion of patients received platelet and fresh frozen plasma (FFP) during
Drotrecogin alfa infusion compared to the Drotrecogin alfa period with no difference
between medical and surgical patients.

Conclusions: Additional anticoagulation during Drotrecogin alfa infusion does not appear to
improve Filter Survival Time (FST). The use of Drotrecogin alfa in patients with severe sepsis
requiring RRT is safe and is not associated with an increased need for PRC transfusion or major
bleeding events.

Filter survival time and blood products requirement in patients with severe sepsis receiving drotrecogin alfa
(activated) and requiring renal replacement therapy Critical Care 2008, 12:R163 (18 December 2008)

16.Sleepy residents: Are they sleepy in ICU
Recent study by Reddy and Surani * help to explore it further. The purpose of this study was to
provide an objective assessment of daytime sleepiness in medical residents working in the
medical ICUs. Sleep times for 2 days/nights prior to call and on the day/night of on-call were
assessed by actigraphy and sleep diaries. On-call and post-call measurements of residents’
sleepiness were measured both objectively, by means of a modified MSLT (2 nap sessions), as
well as subjectively, by Stanford Sleepiness Scale.
Results: Showed that despite an average sleep time of 7.15 h on nights leading to the call, Mean
Sleep Latency (MSL) on the on-call day was 9 +/– 4.4 min compared to the MSL on the post call
day of 4.8 +/–4.1 min. On the post-call day 14 residents (70%) had MSL values less than 5 min
suggesting severe sleepiness as compared to 6 (30%) on the on-call day.
Conclusion: Results demonstrate that residents working in the ICU despite reductions in work
hours demonstrate severe degree of sleepiness post-call.
Editorial comment: IOM recently came up with the suggestion to decrease the continuous
straight work hour to 16 hrs, and if to go for 30 hrs then between 10 pm and 8 am, the resident
should be given a break of 5 uninterrupted hours free of any duty or call.

Reddy R, Guntupalli K, Surani S, Alapat P, Subramanian S. Sleepiness in Medical intensive care unit residents. Chest
online first Nov 18. Chest, doi:10.1378/chest.08-0821

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17.Scenario: 48 year old male, hemodialysis dependent, admitted with gastro-intestinal bleed.
Last dialysis was 3 days ago. Patient received 4 units of pRBC and now hemodynamically stable.
Nurse calls you as she felt that rhythm looks different on monitor. Patient is asymptomatic.
Walking towards patient’s bed what would be your top diagnosis ?
Answer: Hyperkalemia
Transfusion-associated hyperkalemia is a potential life threatening condition in patients with
renal failure who have not been dialysed recently or with already elevated/borderline potassium
level and should be followed closely.

18.If there is bleeding with LMWH?
If protamine is given within 4 hours of the enoxaparin (Low Molecular Weight Heparins LMWH), then a neutralizing dose is: 1 mg of protamine per 1 mg of enoxaparin. The IV protamine
should be administered slowly atleast over 10 minutes as rapid infusion may cause anaphylactoid
type reaction. May repeat half of earlier dose of protamine after 6 hours with postulation that
half life of enoxaparin is longer than protamine.
LMWH, dalteparin (Fragmin) appears to be more responsive to protamine reversal.2 bonus
pearls1. Protamine does not help in reversing bleeding from Fondaparinux (Arixtra). Only
supportive treatment should be given with mean half-life of fondaparinux of 17-21 hours in
mind.2. Fresh frozen plasma is ineffective in reversal of LMWH to achieve hemostasis and
should not be use in these situations.

1. Accidental overdosage following administration of Lovenox - rxlist.com
2. Incomplete Reversal of Enoxaparin Toxicity by Protamine: Implications of Renal Insufficiency, Obesity, and Low
Molecular Weight Heparin Sulfate Content - Obesity Surgery, Volume 14, Number 5, 1 May 2004, pp. 695-698(4)

19.Hydroflouric acid exposure
Case: 23 year male while working in the refinery while disconnecting the hose was exposed to
hydrofluoric acid. Patient had inhalation of hydrofluoric acid. Patient had no past medical
history. Which of the following should be done first?
a. Albuterol nebulizer with 2.5 mg albuterol
b. Albuterol nebulizer with 10mg albuterol
c. Calcium gluconate nebulizer treatment
d. 10% mucomyst treatment

Answer : C
Calcium gluconate should be used after hydrofluoric acid exposure, and if there are any skin
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lesions it should be applied there too. Patient should be observed for 24-48 for development of
pulmonary edema. Ionized calcium should be monitored very closely, and should be supplemented
with intravenous calcium gluconate if low.

20.Glutamine (GlutaSolve)
Emerging literature in Critical Care nutrition shows that Glutamine supplement improves survival
from Multi Organ Failure. Low plasma glutamine has been shown to be an independent predictive
factor for a poor outcome. Glutamine is linked to improved immune function and fewer
Glutamine is a dietary non-essential amino acid, however during situations of extreme stress a
deficiency develops. Ideally, it needs 20-40 gram glutamine per day to restore plasma glutamine
levels to normal.
A major demand for glutamine via glutamate is for the production of the major cellular antioxidant glutathione. Low intramuscular glutathione levels are correlated with low glutamine and
glutamate levels in the critically ill patients. Glutamine has been shown protective to intestinal
cells. Patients with severe burns, who were nevertheless fed enterally, showed a significant
reduction in septicemia.
Delivery of 30g/day of glutamine jejunally in multiple-trauma patients led to a significant
reduction in pneumonia, bacteraemia, and severe sepsis.
Practically, Glutamine (GlutaSolve) can be given via enteral route 1 packet (15 gram) twice a day
after mixing in 100 cc of water.
Contraindications are acute renal failure without dialysis and moderate to severe hepatic
Glutamine in the critically ill , Richard D Griffiths, Professor of Medicine (Intensive Care), University of Liverpool,
UK. , lecture in Paris, June 9-10, 2005 - pdf file

21.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 - see CXR below.

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22.Q: Why IV Amiodarone cause hypotension?
A: Hypotension from IV amiodarone (particularly bolus) is not due to amiodarone itself but due
to its solubilized vehicle called polysorbate 80.
Polysorbate 80 itself can decreases heart rate by depressing AV nodal conduction and has
property of increasing atrial and ventricular myocardial refractory period but can cause
hypotension due to histamine releasing effect.Polysorbate 80 is also blamed for Acute
amiodarone-induced hepatitis but literature is scant on it.
1. Pharmacology and Toxicology of a New Aqueous Formulation of Intravenous Amiodarone (Amio-Aqueous) Compared
with Cordarone IV. - American Journal of Therapeutics. 12(1):9-16, January/February 2005.
2. Effects of amiodarone with and without polysorbate 80 on myocardial oxygen consumption and coronary blood flow
during treadmill exercise in the dog - J Cardiovasc Pharmacol. 1991 Jul;18(1):11-6.
3. Histamine-releasing properties of Polysorbate 80 in vitro and in vivo: correlation with its hypotensive action in the
dog - Agents Actions, 1985 Sep;16(6):470-7.
4. I.V. Amiodarone: What Do We Really Know About It? Cardiac Electrophysiology Review, Volume 2, Number 1 /
March, 1998
5. Early acute hepatitis with parenteral amiodarone: a toxic effect of the vehicle? - Gut, Vol 34, 565-566, 1993

23.Bedside trick
In scenarios where patient remains sleepy and delays extubation, it may be of help to try Ritalin
10 mg every 8 hours.Ritalin (methylphenidate), is a mild central nervous system stimulant and
helps in stimulating patient from prolong sedation.

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24.Acute kidney injury in ICU patients:
a comparison between the RIFLE and the Acute Kidney Injury Network classifications
AKIN=Acute Kidney Injury Network (AKIN) criteria
RIFLE=Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease criteria
This study evaluated the incidence of acute kidney injury and compared the ability of the
maximum RIFLE and of the maximum AKIN within intensive care unit hospitalization in
predicting inhospital mortality of critically ill patients.
Methods: Patients were retrospectively evaluated. Chronic kidney disease patients undergoing
dialysis or renal transplant patients were excluded from the analysis.
Results: In total, 662 patients (mean age, 58.6 ± 19.2 years; 392 males) were evaluated.

AKIN criteria allowed the identification of more patients as having acute kidney injury
(50.4% versus 43.8%,) and classified more patients with Stage 1 (risk in RIFLE) (21.1%
versus 14.7%), but no differences were observed for Stage 2 (injury in RIFLE) (10.1%
versus 11%) and for Stage 3 (failure in RIFLE) (19.2% versus 18.1%).

Mortality was significantly higher for acute kidney injury defined by any of the RIFLE
criteria (41.3% versus 11%) or of the AKIN criteria (39.8% versus 8.5%).

There were no statistical differences in mortality by the acute kidney injury
definition/classification criteria.

Conclusions: Although AKIN criteria could improve the sensitivity of the acute kidney injury
diagnosis, it does not seem to improve on the ability of the RIFLE criteria in predicting
inhospital mortality of critically ill patients.
Above pearl is contributed by: Tony Halat, MD - Clinical Instructor in Medicine, Department of Medicine, The
Methodist Hospital, Weill Medical College, Cornell University
Reference: Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the Acute Kidney
Injury Network classifications- Critical Care 2008, 12:R110

25.RIFLE Criteria for Acute Renal Dysfunction
RiskIncreased creatinine x 1.5 or GFR decrease more than 25%
UO less than 0.5ml/kg/h x 6 hr
InjuryIncreased creatinine x2 or GFR decrease more than 50%
UO less than 0.5ml/kg/h x 12 hr
Failure Increase creatinine x3 or GFR decrease more than 75%
UO less than 0.3ml/kg/h x 24 hr or Anuria x 12 hrs
LossPersistent ARF = complete loss of kidney function more than 4 weeks
ESKD End Stage Kidney Disease (> 3 months)
GFR; Glomerular Filtration Rate
ARF; Acute Renal Failure
ESKD; End Stage Kidney Disease
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Above pearl is contributed by: Tony Halat, MD, Clinical Instructor in Medicine, Department of Medicine, The
Methodist Hospital Weill Medical College, Cornell University

26.Q: Why Etomidate may not be a good choice in neurological and neuro-surgical
patients ?
A: It may decrease the seizure threshold.
Etomidate has fall out of favor in medical ICUs for intubation due to its transient effect of
causing adrenal insufficiency, which makes it undesirable in septic patients. But another less
known side effect is its ability to decrease the threshold for seizure.Despite its effect on
above 2 groups of patients, it is still a very valuable drug to use during intubation (atleast in
other patients) due to its quality of having minimal effect on hemodynamic changes, faster
effect (15 sec) and quick recovery (3-7 mins). Adrenocortical suppression after single dose is
transient which last for 12-36 hours.
See nice review article: Should We Use Etomidate as an Induction Agent for Endotracheal Intubation in Patients
WithSeptic Shock? - A Critical Appraisal from Dr. William L. Jackson, Critical Care Medicine Service, Department of
Surgery, Walter Reed Army Medical Center, Washington, DC. (Chest. 2005;127:1031-1038.)

27.Q: Is there a difference in metabolism between Cleviprex (clevidipine butyrate)
and other dihydropyridine Calcium Channel blocker?
IV Clevidipine butyrate(cleviprex) is rapidly metabolized by hydrolysis of the ester linkage,
primarily by esterases in the blood and extravascular tissues. In contrast, earlier generation of
dihydropyridine calcium channel blockers, such as nicardipine or nifedipine are metabolized by
liver or kidney. It can be titrated depending on the response of the individual patient to achieve
the desired blood pressure reduction.
The elimination of clevidipine butyrate is unlikely to be affected by hepatic or renal
dysfunction. Therefore, no dosing adjustment is necessary in patients with renal or hepatic
dysfunction. Unlike nicardipine, the clevidipine does not accumulate in the body, and its
clearance is therefore independent of body weight.

28.Citrate in CRRT
Q; Why we use citrate (when heparin is not used) to avoid filter clotting inCRRT /
CVVHD (continuous renal replacement therapy) ?
A: Citrate combines with calcium and cause extracorporeal chelation of calcium and blocks
calcium dependent steps of clotting cascade.When extracorporeal blood mix with venous blood,
the ionized calcium level get resotred and systemic anticoagulation get avoided. Also citrate get
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metabolized via liver and chelated calcium get release back in circulation which prevents
hypocalcemia (though frequent checks required particularly in liver insuff.).

Related: Very nice review article: Acute Renal Failure in ICU
(reference: nephrologyrounds.org, december 2006, volume 4, issue 10) - pdf file

29.Probiotics for oral decontamination
Chlorhexidine (CHX) is commonly used to decontaminate the oral cavity to prevent ventilator
associated Pneumonia (VAP). CHX has several side effects including discoloration of teeth,
burning taste, local irritation. Bacteria can develop resistance to CHX specially MRSA.
Recently Klarin et all studied the role of Probiotic bacteria Lactobacillus plantarum 299 (Lp299)
and found to be equally effective to prevent colonization of pathogens in mechanically ventilated
patients 1.
Related previous pearl: C-difficile and probiotic drink
Reference: Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of
intubated patients: a randomised controlled open pilot study - Critical Care 2008, 12:R136

30.Characteristics of IV Antihypertensive agents
The following medicines are described for five effects
1. Therapy class
2. Onset of Action
3. Duration of action
4. Preload
5. Afterload
Nicardipine is Dihydropyridine Calcium Channel Blocker with onset in 5-10 minute and duration
of action 2-4 hours. It has No effect on Preload but decrease afterload.
Clevipidine Nicardipine is Dihydropyridine Calcium Channel Blocker with onset in 1 minute and
duration of action 10 minutes. It has No effect on Preload but decrease afterload.
Esmolol is Dihydropyridine Beta Blocker with onset in 6-10 minutes and dutation of action 20
minutes. It has No effect on Preload or afterload.
Fenoldopam is Dihydropyridine Dopamine-D1 like receptor agonist with onset in 10-15 minutes
and duration of action 10-15 minutes. It has No effect on Preload but decrease afterload.
Hydralazine is Arterial Vasodilator with onset in 10 minutes and duration of action 2-6 hours. It
has No effect on Preload but decrease afterload.
Labetolol is Selective alpha and non-selective beta adrenergic receptor blocker with onset in 521 | P a g e

10 minutes and duration of action 2-6 hours. It has No effect on Preload but decrease
Nitroglycerine is Nitrovasodilator with onset in 2-5 minutes and duration of action 10-20
minutes. It has No effect on Preload and minimal effect on afterload.
Sodium nitroprusside is Nitrovasodilator with onset in few seconds and duration of action 1-2
minutes. It has decrease Preload and afterload.

31.Low tidal volume and PEEP as per ARDS NET trial not good enough?
Study by Daniel Talmor recently published in NEJM addresses this issue. They used esophageal
pressure monitoring to guide the changes made on mechanical ventilation.
Method: They randomly assigned patients with acute lung injury or ARDS to undergo mechanical
ventilation with PEEP adjusted according to measurements of esophageal pressure (the
esophageal-pressure–guided group) or according to the Acute Respiratory Distress Syndrome
Network standard-of-care recommendations (the control group).The primary end point was
improvement in oxygenation. The secondary end points included respiratory-system compliance
and patient outcomes.
Results: The study was stopped early as it met its termination criteria after enrolling 61
patients. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen
at 72 hours was 88 mm Hg higher in the esophageal-pressure–guided group than in the control
group (95% confidence interval, 78.1 to 98.3; P=0.002). This effect was persistent over the
entire follow-up time (at 24, 48, and 72 hours; P=0.001 by repeated-measures analysis of
variance).Respiratory system compliance was also better (p-0.01)
Conclusion: As compared with the standard therapy in ARDS, the management of mechanical
ventilation by using esophageal pressure to estimate the transpulmonary pressure significantly
improves oxygenation and compliance.
Editorial Comment: Agree with author’s conclusion that further study is needed before it is
recommended as guideline.
Reference:Talmor D, Garge T, Malhotra A, et al. Mechanical Ventilation Guided by esophageal Pressure in Acute Lung
Injury. NEJM 2008; 359: 2095-2014

32.Q: Which phase of respiration on CXR is better to detect pneumothorax (like
after inserting central venous catheter)- inspiration or expiration ?
A: Expiration
Inspiration or expiration doesn’t effect the volume of air in pleural space and pneumothorax can
be detected better in expiration with less air volume in lung parenchyma, visually magnifying the
air in pleural area.

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33.Short note on short acting opioids
Sufentanyl, Fentanyl, Alfentanyl and Remifentanyl have gained popularity as preferred
analgesics for critically ill patients. These are not associated with hemodynamic changes and can
be given to patient with morphine intolerance or allergies. Fentanyl is about 100 times more
potent that morphine. The onset of actions is rapid and duration is short. The usual intermittent
doses do not need to be adjusted for renal or hepatic failure, however these drugs are
metabolized by liver and continuous infusion and large doses can accumulate specially in patients
with liver failure. The metabolites are largely inactive.
Remifentanyl is ultrashort acting opiate.
Please see review article:The place for short-acting opioids: special emphasis on remifentanil
Reference: Critical Care 2008, 12(Suppl 3):S5
Reference: Agents for sedation and analgesia in the intensive care unit - Ann Fr Anesth Reanim. 2008 Jul-Aug;27(78):560-6. Epub 2008 Jul 1

34.Platelet transfusion
Q: How long does it take for transfused platelet to show apparent effect?
A; About one hour.Each unit of platelet transfusion is expected to increase platelet count by 5 10,000 / uL, and platelet transfusion is usually given as 6 or 10 units together.

35.Case: 68 year old patient admitted with CHF. Now with diuresis patient is stabalized and
clinically stable to transfer to floor. Patient last CVP noted was 12. Patient bed is raised to
perform portable chest x-ray. With elevation of bed, will CVP (choose one)
1. Fall
2. Rise
3. No change
Answer: Will rise
CVP transducer and intravascular volume at “zero” point acts as a balance set of fluids. If
transducer goes down below zero point (like with elevation of bed) CVP will rise.

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36.Bedside trick - suspecting tracheal aspiration
One quick method of suspecting tracheal aspiration or at least ruling out tracheal aspiration is
checking glucose concentration by regular bedside glucose meters. A glucose concentration of
more than 20 mg/dl of bloodless tracheal aspirate doesn’t confirm but at least enhance the
suspicion of tracheal aspiration .Though literature is full of conflicting data for this method but
still it is a very quick, effective and easy way of suspecting or ruling out tracheal aspiration.

1. Clinical implications of the glucose test strip method for early detection of pulmonary aspiration in nasogastric
tube- fed patients - Taehan Kanho Hakhoe Chi. 2004 Dec;34(7):1215-23
2. Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of
enteral feedings in intubated adults - Chest, Vol 103, 117-121
3. Glucose content of tracheal aspirates: Implications for the detection of tube feeding aspiration. Crit Care Med
1994; 22:1557-1562
4. Glucose Content of Tracheal Aspirates - Letter to the Editor - Critical Care Medicine: Volume 23(8) August 1995
pp 1451-1452 .

37.Corticosteroids for the Prevention of Atrial Fibrillation After Cardiac Surgery
Atrial fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery. An
exaggerated inflammatory response has been proposed to be one etiological factor. Study was
done to test whether intravenous corticosteroid administration after cardiac surgery prevents
AF after cardiac surgery. A double-blind, randomized multicenter trial in 3 university hospitals
in Finland of 241 consecutive patients without prior AF or flutter and scheduled to undergo
first on-pump coronary artery bypass graft (CABG) surgery, aortic valve replacement, or
combined CABG surgery and aortic valve replacement.
Intervention: Patients were randomized to receive either 100-mg hydrocortisone or matching
placebo as follows: the first dose in the evening of the operative day, then 1 dose every 8 hours
during the next 3 days. In addition, all patients received oral metoprolol (50-150 mg/d) titrated
to heart rate.
Main Outcome Measure: Occurrence of AF during the first 84 hours after cardiac surgery.
Results The incidence of postoperative AF was significantly lower in the hydrocortisone group
(36/120 [30%]) than in the placebo group (58/121 [48%] Compared with placebo, patients
receiving hydrocortisone did not have higher rates of superficial or deep wound infections, or
other major complications.
Conclusion: Intravenous hydrocortisone reduced the incidence of AF after cardiac surgery.

Reference: Corticosteroids for the Prevention of Atrial Fibrillation After Cardiac Surgery JAMA. 2007;297:15621567.

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38.Do we need 8 or 15 days of antibiotics for Ventilator Associated Pneumonia
Chastre and his colleague look at the difference between 8 or 15 days of antibiotics use.
Decreasing the duration of antibiotics can help to decrease the resistance.
DESIGN, SETTING, AND PARTICIPANTS: Prospective, randomized, double-blind (until day
8) clinical trial conducted in 51 French ICUs.A total of 401 patients diagnosed as having
developed VAP by quantitative culture results of bronchoscopic specimens and who had received
initial appropriate empirical antimicrobial therapy were enrolled between May 1999 and June
INTERVENTION: A total of 197 patients were randomly assigned to receive 8 days and 204 to
receive 15 days of therapy with an antibiotic regimen selected by the treating physician.
MAIN OUTCOME MEASURES: Primary outcome measures-death from any cause,
microbiologically documented pulmonary infection recurrence, and antibiotic-free days-were
assessed 28 days after VAP onset and analyzed on an intent-to-treat basis.
RESULTS: Compared with patients treated for 15 days, those treated for 8 days had neither
excess mortality (18.8% vs. 17.2%) nor more recurrent infections (28.9% vs. 26.0%) .The
number of mechanical ventilation-free days, the number of organ failure-free days, the length
of ICU stay, and mortality rates on day 60 for the 2 groups did not differ.Although patients
with VAP caused by nonfermenting gram-negative bacilli, including Pseudomonas aeruginosa, did
not have more unfavorable outcomes when antimicrobial therapy lasted only 8 days, they did
have a higher pulmonary infection-recurrence rate compared with those receiving 15 days of
treatment (40.6% vs. 25.4%).
CONCLUSIONS: Among patients who had received appropriate initial empirical therapy, with
the possible exception of those developing nonfermenting gram-negative bacillus infections,
comparable clinical effectiveness against VAP was obtained with the 8- and 15-day treatment
regimens. The 8-day group had less antibiotic use.

Reference: Chastre J, Wolf M, Fago JY et al. Comparision of 8 vs 15 days of antibiotic therapy for ventilator
associated pneumonia in adults. JAMA 2003; 290: 2588-2598.

39.Do anti-Pseudomonal agents increase the Pseudomonas aeruginosa colonization?
Jose Martinez published a paper in Intensive Care Medicine to clarify the issues.
Setting: Prospective study in two medical ICU.
Measurements: Surveillance cultures from nares, pharynx, rectum and respiratory secretions.
Acquisition of resistance was defined as the isolation, after 48 hrs of ICU stay, of an isolate
resistant to a given antibiotics.
Results: Forty-four (13%) patients acquired 52 strains of P. aeruginosa.
Administration of piperacillin-tazobactam for more than/= 3 days and use of amikacin for more
than/= 3 days were positively associated with acquisition of P. aeruginosa, whereas use of
quinolones and antipseudomonal cephalosporins was protective.Exposure to quinolones and
cephalosporins was not associated with the acquisition of resistance, whereas it was linked with
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