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Last date for submission of forms is 31st December 2009.

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MCQ 16

Birbeck bodies are seen in

a - Pulmonary Langerhans' cell histiocytosis

b - Lymphangitic carcinomatosis

c - Lipoid pneumonia

d - Hypersensitivity pneumonitis

Ans: a - Pulmonary Langerhans' cell histiocytosis

Causes of ALI/ ARDS

Causes of Acute Lung Injury and Acute Respiratory Distress Symdrome are:

DIRECT Causes:

• Pneumonia
• Aspiration
• Inhalational injuries
• Blunt pulmonary trauma
• Near drowning

INDIRECT Causes:

• Sepsis
• Severe traumatic shock
• Large volume blood transfusion (>15 units)
• Pancreatitis
• Reperfusion after cardiopulmonary bypass

Although more than 60 conditions have been associated with ARDS, the most frequent cause is sepsis, followed by pneumonia and aspiration.

MCQ 15:

Most common cause of ARDS?

a – Sepsis

b – Trauma

c – Pneumonia

d – Aspiration

Ans: Sepsis

Click here to read about Causes of ARDS

MCQ 14:

All increase oxygenation except:

a. FiO2

b. Minute volume

c. PEEP

d. None of the above

Ans: Minute volume

MCQ 13:

Patient having asynchrony on Assist Control Ventilation,

What will you not do?

a. Adjust the trigger sensitivity

b. Change the inspiratory:expiratory time

c. Change the tidal volume

d. Change the mode of ventilation

Ans: c. Change the Tidal Volume

Knaus Criteria for Multiple System Organ Failure

Multiple systems organ failure is said present when more than one of the system dysfunctions is detected by test values exceeding the threshold values.

1. Respiratory failure (presence of one or more):

- Respiratory frequency <5, >49 (>two years of age)
- Alveolar-arterial difference in O2 >350 mmHg or PaO2/ Fi02 <200 (without congenital cardiac lesion)
- Requires mechanical ventilatory support >24 h
- PaCO2 >50 mmHg and pHa <7.25

2. Circulatory failure (presence of one or more):

- Heart rate <50/mm or episode of ventricular tachycardia/fibrillation
- Mean systemic arterial pressure <50 mmHg and (or) systolic systemic arterial pressure <60 mmHg
- Cardiac Index <2 L/min per sq. meter of body surface (acute onset) and (or) pHa <7.25, PaCO2, <35 without respiratory failure

3. Renal failure (presence of one or more):

- Urine volume 9.3 mL/kg body weight per hour for 8h
- Serum creatinine >266 umol/L
- Urea nitrogen >1.00 g/L or urea >0.60 g/L

4. Hepatic failure (presence of both):

- Bilirubin >60 mg/L or a twofold increase in alkaline phosphatase in serum and
- Prothrombin time >4 s over upper limit of normal range or a twofold increase in aspartate aminotransferase in serum

5. Hematologic failure (presence of one or more):

- Leukocytes <1500/mL or >40000/mL
- Platelets <20000/mL or evidence of ongoing disseminated intravascular coagulation

6. Neurologic failure

- Glasgow Coma Scale <6 (without sedation)

7. Uncontrolled sepsis (presence of one or more):

- Positive blood culture despite antibiotic therapy
- Fever >39.5 °C (rectal temp) for >24 h or spikes on three successive days

MCQ 12:

All increase the chances of VAP ( ventilator associated pneumonia), except:

a – Prolonged ventilator support and reintubation

b – Enteral feeding

c – Prone ventilation

d – Intra-hospital transfer

Ans: c – Prone ventilation

 

Click here to read more about VAP

MCQ 11:

All the following drugs are dialysable except:

a – Salicylate

b – Sertaline

c - Ethylene Glycol

d - Methanol

(This question appeared both in 2008 and 2009 FNB Entrance)

Ans: b – Sertaline

Click here to read more about toxins removed by hemodialysis

Toxicology:

Toxins removable by Hemodialysis:
- Salicylates
- Lithium
- Methanol
- Ethylene Glycol
- Isopropanol

Toxins removable by Hemoperfusion
- Barbiturates
- Carbamazepine
- Theophylline
- Valproic Acid

MCQ 10:

Plasmapheresis is indicated in all, except

a – Hyperviscosity syndrome

b – Idiopathic thrombocytopenic Purpura (ITP)

c – Acute Inflammatory Demyelinating Polyneuropathy (AIDP)

d – Thrombotic Thrombocytopenic Purpura (TTP)

Ans: b – Idiopathic thrombocytopenic Purpura (ITP)

Click here to read more about 'Indications of Plasmapheresis'

Indications of Plasmapheresis:

1. Hyperviscosity syndromes (treatment of choice)

2. Myasthenic crisis

3. Hemolytic Uremic Syndrome / Thrombotic Thrombocytopenic Purpura

4. Guillain Barre Syndrome / Acute Inflammatory Demyelinating Polyneuropathy

5. Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome

6. Desensitization prior to transplantation by reducing the level of antidonor antibodies via plasmapheresis of blood has been useful in reducing the hazard of hyperacute rejection.

7. Post-transfusion Purpura

8. Pemphigus Vulgaris

9. Familial chylomicronemia syndrome (during pregnancy)

10. POEMS (polyneuropathy, organomegaly, endocrinopathy, M-proteins, and skin changes) syndrome

MCQ 9:

All are true about APACHE II severity score in ICU, except:

a – Appropriate Physiological and Chronic Health Evaluation

b – Includes 12 physiological parameters

c – Assessed within the first 24 hours of ICU admission

d – Does not take into account the primary disease

Ans: a – Appropriate Physiological and Chronic Health Evaluation

Click here to read more about APACHE II scoring system

MCQ 8:

Patient is having ARDS with a Peak Inspiratory Pressure of 65 cm H2O; develops a pneumothorax, what will you do?

a – Increase the Fractional concentration of O2

b – Switch over to Pressure Control Ventilation

c – Decrease the tidal volume

d – Decrease the respiratory rate

Ans: Switch over to Pressure control ventilation

MCQ 7:

All are active against anaerobes except:

a – Metronidazole

b – Clindamycin

c – Meropenem

d – Levofloxacin

Ans : Levofloxacin

Diagnostic Criteria for ALI and ARDS

1. Acute Onset

2. Presence of a predisposing condition.

3. Bilateral infiltrates on frontal chest x-ray, consistent with pulmonary edema.

4. PaO2 / FiO2 < 200 mm Hg for ARDS, < 300 mm Hg for ALI, regardless of the level of positive end-expiratory pressure (PEEP).

5. Pulmonary artery occlusion pressure =18 mm Hg or no clinical evidence of left atrial hypertension.

Bernard GR, Artigas A, Brigham KL, et al. The American–European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am Rev Respir Crit Care Med 1994;149:818–824.

MCQ 6:

All can be given in Aortic Dissection except:

a – Analgesics

b – Sodium Nitroprusside

c – Labetalol

d – Sodium Nitroprusside + Labetalol

Ans B – Sodium Nitroprusside

This is the best answer by exclusion! All of above can be given!Sodium Nitroprusside should be used only in the presence of rate controlling agents.

Care should be taken to avoid direct acting vasodilators in the absence of negative chronotropic medications, as they may induce reflex tachycardia, increasing dP/dT with worsening dissection. (ref: Washington Manual of Critical Care)

MCQ 5:

All are markers of decreased tissue perfusion, except:

a – Lactate

b – Central venous oxygen saturation

c – Ammonia

d – None of above

Ans: C

Click here to know more about Central venous oxygen saturation

Metabolic Acidosis: Causes

Elevated anion gap:

• Methanol intoxication
• Uremia
• Diabetic ketoacidosis, alcoholic ketoacidosis, starvation ketoacidosis
• Paraldehyde toxicity
• Isoniazid
• Lactic acidosis
  • Type A:  tissue ischemia
  • Type B:  Altered cellular metabolism
• Ethanol or ethylene glycol intoxication
• Salicylate intoxication

Normal anion gap: will have increase in [Cl-]

• GI loss of HCO₃-
  • Diarrhea, ileostomy, proximal colostomy, ureteral diversion
• Renal loss of HCO₃-
  • proximal RTA
  • carbonic anhydrase inhibitor (acetazolamide)
• Renal tubular disease
  • ATN
  • Chronic renal disease
  • Distal RTA
  • Aldosterone inhibitors or absence
  • NaCl infusion, TPN, NH₄+ administration

MCQ 4:

Decrease in spO2 is seen in all except:

a – Meth-hemoglobinemia

b- Carboxy-hemoglobinemia

c – Sulfhemoglobinemia

d – Fetal hemoglobin

 

Ans: Carboxy-hemoglobinemia

 

The effect of HbCO may be discerned by examining its absorption spectrum. At 920 nm, HbCO has an extremely low absorbance and therefore does not contribute to total absorbance. At 660 nm,
however, HbCO has an absorbance very similar to that of HbO2 , and SpO2 will therefore be falsely high. (ref: Miller)

COHb is typically read by a two-diode oximeter as 90% oxyhemoglobin and 10% reduced hemoglobin, resulting in false elevations of SpO₂. In the emergency department setting or shortly after ICU admission, a gap between pulse oximetry and Po₂ or cooximetrically measured oxygen saturation may suggest elevated COHb levels, particularly in patients with smoke inhalation or potential carbon monoxide poisoning. (Ref: Irwin and Rippe)

MCQ 3:

A patient has a pulse oximeter saturation (spO2) of 85%, where as his saturation on ABG (saO2) is 93%, what is the likely cause???

Possible diagnosis:

a – Carboxyhemoglobin

b – Methhemoglobin

c – Fetal hemoglobin

d – sulfhemoglobin

Ans: b – Methhemoglobinemia.

Because methemoglobin absorbs more light at 660 nm than at 990 nm, it affects pulse oximetry readings when methemoglobin levels exceed 6%. Moreover, higher levels of methemoglobin tend to bias the reading toward 85% to 90%. (Ref: Irwin and Rippe.)

In the presence of high HbMet concentrations, the measured SpO2 approaches 85%, independently of the actual arterial oxygenation. (Ref: Miller)

Recommended daily protein intake:

Normal / unstressed 0.75 g/kg/day

Critical illness/ injury 1.0 – 1.5 g/kg/day

Acute renal failure (undialyzed) 0.8 – 1.0 g/kg/day

Acute renal failure (dialyzed) 1.2 – 1.4 g/kg/day

Peritoneal dialysis 1.3 – 1.5 g/kg/day

Burns and Sepsis 1.5 – 2.0 g/kg/day

CVVHD 1.7 – 2.5 g/kg/day

Generally, the optimal protein intake in critically ill patients is given at twice the recommended daily amount (approximately 0.8 g per kg per day) of normal adults, at approximately 1.5 g per kg per day. With renal impairment, at least 1 g per kg should be provided and greater amounts given if tolerated or dialysis is initiated. In patients with liver failure at least 1 g per kg of standard protein should be provided and up to 1.5 g per kg if tolerated. This is done recognizing the overall impairments in protein utilization that accompanies metabolic stress, as well as the heightened needs during catabolism.

Ref: The Washington Manual of Critical Care; Irwin and Rippe’s Intensive Care Medicine

MCQ 2:

Non Caloric Protein requirement in an critically ill patient:

a – 0.8 g/kg/day

b – 1.0 g/kg/day

c – 1.5 g/kg/day

d – 2.0 g/kg/day 

 

Answer: 1.5 g/kg/day

Read here about recommended daily protein intake

Well’s Criteria for Pulmonary Embolus

VARIABLES	POINTS
Symptoms/signs of DVT ( minimum of leg swelling and pain with palpation of the deep veins	3.0
Alternative diagnosis deemed less likely than PE	3.0
Heart rate >100 beats/min	1.5
Immobilization/surgery in previous 4 wk	1.5
Previous VTE	1.5
Hemoptysis	1.0
Recent or current malignancy	1.0

Clinical Probability:

Low Probability <2.0

Intermediate Probability 2.0 -6.0

High Probability >6.0

Well’s Criteria for Deep Venous Thrombosis

VARIABLES	POINTS
Cancer (receiving treatment, treated in the past six months, or palliative care	1
Paralysis, paresis, or recent plaster immobilization of the lower extremities	1
Recently bedridden for three days or more, or major surgery within the previous 12 weeks requiring general or regional anesthesia	1
Localized tenderness along the distribution of the deep venous system	1
Entire leg swollen	1
Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tibial tuberosity)	1
Pitting edema confined to the symptomatic leg	1
Collateral superficial veins (non-varicose)	1
Previously documented DVT	1
Alternative diagnosis at least as likely as DVT	Minus 2

</= 1 points: Clinical probability of DVT unlikely
> 1 points: Clinical probability of DVT likely

Risk Factors for Venous Thrombo Embolism

Surgery                                                                                                Trauma (major or lower extremity)                         Immobility, paresis                                                  Malignancy                                                                                             Cancer therapy (hormonal, chemotherapy, or radiotherapy)
Previous VTE
Increasing age
Pregnancy and the postpartum period
Estrogen-containing oral contraception or hormone replacement therapy
Selective estrogen receptor modulators
Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Myeloproliferative disorders
Paroxysmal nocturnal hemoglobinuria
Obesity
Smoking
Varicose veins
Central venous catheterization
Inherited or acquired thrombophilia

MCQ 1:

Following increase the chances of Pulmonary Embolism during surgery except:

a – Chronic Renal Failure

b – Use of Oral contraceptive Pills

c – Lupus

d – Adenocarcinoma

 

Ans: Chronic Renal Failure

Click here to read more about risk factors for venous thromboembolism

Click here to read Well's criteria for deep venous thrombosis

Click here to read Well's criteria for pulmonary embolus