Q: Name 3 unusual complications of Propofol beside propofol infusion syndrome?


Answer:

• Dystonia and myoclonic movements
• Euphoria (also sexual hallucinations)
• Priapism

Editors' note: Following is a very important video to watch as ultrasound based diagnosis of pneumothorax is becoming more and more a standard. It will be available in our video section.

Q: 42 year old male with well known history of cirrhosis is admitted with shortness of breath. Clinical exam showed ascites and CXR showed hydrothorax. Paracentesis is performed in ER with some relief. Chest tube is planned by ER resident. Why it would be a bad idea to insert - particularly a large bore chest tube in a patient with hydrothorax?



Answer: Insertion of chest tube in hydrothorax is a bad idea as it usually results in uncontrollable fluid loss and has a high mortality secondary to hypovolemic shock. Therapeutic thoracocentesis with albumin replacement may provide temporary relief but may refill again. Thoracocentesis combined with pleurodesy, LeVeen or Denver shunt or surgical repair are other options. Management of underlying cause is warranted like placement of TIPS.

Q: 21 year old female is admitted with severe headache. There is no past medical history except she is recently started on Minocycline for the treatment of her acne. What is your suspicion?



Answer: Pseudotumor cerebri (PTC) or idiopathic intracranial hypertension

Tetracycline, Doxycycline and Minocycline are known to cause PTC.The mechanism by which they induce pseudotumor cerebri is not known.

Minocycline may cause persistently elevated intracranial pressure, and may require medical and surgical treatment beyond discontinuation of the medication. It is not a benign condition and and aggressive interventions are needed to prevent severe morbidity like vision loss.



References:

• A. M. Chiu, W. L. Chuenkongkaew, W. T. Cornblath, et al., “Minocycline treatment and pseudotumor cerebri syndrome,” American Journal of Ophthalmology, vol. 126, no. 1, pp. 116–121, 1998.
• K. Mochizuki, T. Takahashi, M. Kano, K. Terajima, and N. Hori, “Pseudotumor cerebri induced by minocycline therapy for acne vulgaris,” Japanese Journal of Ophthalmology, vol. 46, no. 6, pp. 668–672, 2002.
• D. I. Friedman, L. K. Gordon, R. A. Egan, et al., “Doxycycline and intracranial hypertension,” Neurology, vol. 62, no. 12, pp. 2297–2299, 2004.
• A. Kesler, Y. Goldhammer, A. Hadayer, and P. Pianka, “The outcome of pseudotumor cerebri induced by tetracycline therapy,” Acta Neurologica Scandinavica, vol. 110, no. 6, pp. 408–411, 2004.

Q: 21 year old male is admitted from ER with acute respiratory failure. Patient is intubated. CXR shows bilateral ARDS. You started antibiotics. There is no significant past medical history.Brother told you patient just started smoking. You decide to perform bronchoscopy. What is your suspicion?



Answer: Acute eosinophillic pneumonia

Increasing body of evidence suggest close association between new onset or even change in smoking habit and acute eosinophillic pneumonia. Suspicion should be high in yound patients presenting with acute respiratory distress. Early diagnosis is crucial as patients with AEP respond rapidly to high doses of systemic corticosteroids.



Uchiyama H, Suda T, Nakamura Y, et al. Alterations in smoking habits are associated with acute eosinophilic pneumonia. Chest. May 2008;133(5):1174-80

Q: What does it mean by Cryptic Shock?



Answer:The term "cryptic shock" is used for patients with deceptively normal hemodynamic parameters, yet have high morbidity and mortality because of global ischemia with increased lactate blood level. It is also called "normotensive shock". Even "hypertensive shock" is described as in cardiogenic shock but with marked sympathetic system activation or during a hypertensive crisis due to pheochromocytoma with evidence of tissue hypoxia (high lactate blood level).

Q: Pre-oxygenation (or denitrogenation) is an important step during intubation. What length of time is good to perform pre-oxygenation to avoid rapid hypoxemia during intubation?



Answer: About 3 minutes


Nitrogen constitutes about 79% of air. Goal of pre-oxygenation is to replace nitrogen at the alveolar level causing nitrogen washout and creating an oxygen reservoir in the functional residual capacity of the lungs. Most of denitrogenation occurs in 2 minutes. Good preoxygenation of about 3 minutes may provide up to 8 minutes of apnea time in otherwise healthy adults but the desaturation rate is more rapid in sicker patients because of their higher metabolic rate and underlying pulmonary disease such as ARDS.

Various methods to provide good preoxygenation includes high-flow oxygen via a nonrebreather face mask (spontaneously breathing patient) or by using Ambu bag. 8 deep breaths over 60 seconds by using full vital capacity should provide good pre-oxygenation. Also BiPap mask is a good way of performing good denitrogenation. Patients on non-invasive mask ventilation should be left on it till intubation procedure is set to perform.

Q: Why Daptomycin is a bad choice for use in Pneumonia?


Answer: Daptomycin is a bad choice in the treatment of respiratory tract infections because surfactant in lungs binds daptomycin, leaving free drug concentrations in pulmonary secretions to very minimal. This is the only known organ-specific inhibition of an antibiotic.


Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact. - J Infect Dis. 2005 Jun 15;191(12):2149-52.