Friday October 3, 2008


Case: 58 year male brought to ER with high fever along with mental status change. In ER patient had a witnessed seizure. Urine output is marginal. You received following lab values

Hb 7 gm/dl, Platelets: 14 /μL, Cr.: 2.6 mg/dl

Your next line of action along with treating rescuing airway and treating seizure is: (choose one)

A) Initiate Sepsis protocol
B) Perform Lumbar punture (to rule out meningitis)
C) Transfue platelets
D) Call for plasmapheresis
E) Initiate Dialysis



Answer: D

This patient most probably has thrombotic thrombocytopenic purpura (TTP). It has 5 basic criteria

• thrombocytopenia,
• Microangiopathic hemolytic anemia,
• CNS dysfunction,
• fever, and
• renal failure

The therapeutic effects of plasmapheresis in the critically ill patient with TTP are often dramatic: Severe neurologic manifestations may disappear, and laboratory abnormalities may diminish in a few hours. Platelet transfusions should be avoided because they have been accompanied by marked deterioration in either renal or neurologic status. The treatment of seizures in TTP is the same as for seizures with other complicated hematologic disorders.

Splenectomy is a reasonable treatment option for TTP patients refractory to standard TPE or who have experienced multiple and/or complicated relapses 2.


Review at emedicine.com: Thrombotic thrombocytopenic purpura (TTP)



Reference: Click to get abstrat

1. Thrombotic thrombocytopenic purpura: Treatment with plasmapheresis - American Journal of Hematology, Vol. 24 issue 4, Pages 329 - 339, Published Online: 11 Jul 2006

2. Role of splenectomy in patients with refractory or relapsed thrombotic thrombocytopenic purpura. Aqui NA, Stein SH, Konkle B, Abrams CS, Strobl FJ. Journal of Clinical Apheresis 2003;18:51-54.

Thursday October 2, 2008


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
Peres Nomogram

References: click to get abstract / article

1. Guidewire Dislodgment of Inferior Vena Cava Filters During Insertion of Central Venous Catheters, Vascular and Endovascular Surgery, Vol. 31, No. 5, 587-593 (1997)

2. Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 2000; 28: 138–42

3. Greenfield Inferior Vena Cava Filter Dislodged During Central Venous Catheter placement, Chest 1994;106;957-959

Wednesday October 1, 2008


Q: Propofol may lower the serum concentration of which essential element?

A: Zinc

Propofol treated patients have shown greater urinary losses of zinc and iron and to lower serum zinc concentrations. But the clinical significance of trace metal losses is unclear and requires further study.



Reference: click to get abstract

1. Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients - Intensive care medicine Supplement 2000, vol. 26, n4, pp. S413-S421 (30 ref.)