Clinical Case Scenario
Recent advancements in the management of acute decompensated heart failure (ADHF) have focused on optimizing decongestion strategies through combination diuretic therapy. Clinical trials, such as ADVOR, CLOROTIC, and others, have evaluated novel interventions to enhance diuretic efficacy, overcome resistance, and improve patient outcomes.
Which of the following statements best reflects the evidence from these studies?
Author’s Name:
Nirmalyo Lodh
Field of Specialization: Anaesthesiology, Intensive Care Medicine, ECMO & Critical Care, Echocardiography
Qualifications / credentials: MBBS, MD, MRCP(UK) DM (Critical Care Medicine), EDIC, EDAIC, Severe Respiratory Failure & ECMO Fellowship (GSTT, London)
Current Designation: Senior Clinical Fellow in Critical Care & Advanced Echocardiography
Department: Critical Care Medicine
Institute: Guy’s & St Thomas NHS Foundation Trust, London
Email ID: nirmalyo1991@gmail.com, nirmalyo.lodh@gstt.nhs.uk
Field of Specialization: Anaesthesiology, Critical Care Medicine Qualifications / credentials: MBBS, MD, DNB, Postdoctoral fellowship (Critical care) DM (Critical Care Medicine), MNAMS Current Designation: Consultant & Program Director, Adult Critical Care Department: Critical Care Medicine Institute: King Hamad University Hospital, Bahrain Email ID: mohd.saif@khuh.org.bh, drsaif2k2@gmail.com
Clinical Case Scenario
The initiation of renal replacement therapy (RRT) in critically ill patients remains a topic of debate. The ELAIN, AKIKI, STARRT-AKI, and IDEAL ICU trials sought to identify the best timing for starting this therapy in patients wit acute kidney injury. The results of these studies have provided valuable insights, yet they highlight the complexity of managing acute kidney injury (AKI) in critical care settings.
Select the INCORRECT statement about the four trials mentioned above.
Clinical Case Scenario
Incorporating kinetic GFR (kGFR) into clinical practice offers a promising approach to enhancing the accuracy of kidney function assessment in acute settings.
Which of the following best describes the concept of kGFR?
Clinical Case Scenario
A 38-year-old female, gravida 7, para 3, living 3, abortus 3 (G7P3L3A3) at 28 weeks of gestation with a monochorionic, diamniotic twin pregnancy underwent emergency lower segment caesarean section (LSCS) for pre-eclampsia. She was also a known case of gestational diabetes mellitus (GDM). Although her intra-operative course was uneventful, on POD 4, she developed gradually progressive and persistent abdominal pain, distension, with tenderness on palpation. A new-onset fever was noted with urine output of 250 ml over the past 24 hours. Her lab investigations on POD 4 revealed elevated C-reactive protein (CRP, 180 mg/L), and urine analysis showed leukocytes 50-100 per high-power field and positive leukocyte esterase, suggestive of UTI. Renal function tests revealed a serum creatinine of 3.4 mg/dL and BUN of 133 mg/dL. Contrast-Enhanced CT (CECT) abdomen and pelvis revealed significant free fluid in the peritoneal cavity with evidence of intraperitoneal extravasation of contrast at the dome of the bladder (Figure 1). A pigtail catheter was inserted for ascitic fluid drainage. The normal bladder anatomy is shown in the figure below (Figure 2).
Figure 1: Intraperitoneal extravasation of contrast and a clear defect in the dome of the bladder (black arrow) (Image courtesy: www.radiopaedia.org)
Figure 2: Normal bladder anatomy
Which of the following statements is incorrect regarding this case?
Clinical Case Scenario
A 65-year-old male patient with a history of chronic kidney disease and hypertension was admitted to the ICU with severe metabolic acidosis. Despite standard medical therapy, his peripheral venous blood gas analysis shows pH: 7.23, base excess [BE]: -4 mEq/L, PaCO2: 32 mm Hg, and lactate: 6 mmol/L. The medical team decided to administer sodium bicarbonate to correct the acidosis.
Question: What is one of the main potential risks associated with the use of sodium bicarbonate therapy in ICU patients with severe metabolic acidosis and AKI?
Clinical Case Scenario
A 60-year-old male with a history of hypertension and diabetes mellitus is admitted to the hospital with a three-day history of vomiting, decreased oral intake, and reduced urine output. On initial assessment, he appears lethargic, with dry mucous membranes, poor skin turgor, and cool extremities. His blood pressure is 85/60 mmHg, heart rate is 110 bpm, and respiratory rate is 22 breaths per minute. The patient’s laboratory results reveal elevated serum creatinine (2.8 mg/dL, baseline 1.0 mg/dL), elevated blood urea nitrogen (BUN) of 45 mg/dL, and electrolyte imbalances.
The clinical team is concerned about acute kidney injury (AKI) in the context of hypovolemia and discusses the importance of accurate volume status assessment to guide resuscitation and prevent further kidney damage. Appropriate fluid resuscitation is considered to optimize renal perfusion.
Question: Which of the following methods is most appropriate for assessing intravascular volume status in this patient with AKI?
Clinical Case Scenario
A 45-year-old male undergoing treatment for diffuse large B-cell lymphoma at a day care center develops oliguria 24 hours post-chemotherapy. Despite aggressive hydration, rasburicase, and allopurinol, the patient remains oliguric. Laboratory results reveal a serum potassium of 7.2 mEq/L, serum phosphate of 8.5 mg/dL, serum calcium of 6.0 mg/dL, serum uric acid of 20 mg/dL, and a creatinine level of 4.5 mg/dL. A critical care referral is made after the patient exhibits stridor and generalized muscle cramps. The 12-lead ECG shows a QTc interval of 550 msec.
What is the next best step in management?
Clinical Case Scenario
A 22-year-old male with Burkitt lymphoma arrives at oncology day care with acute abdominal pain, nausea, vomiting, and confusion shortly after starting R-CODOX-M (rituximab, cyclophosphamide, vincristine, doxorubicin, and methotrexate). His vitals are BP 90/67 mmHg, HR 121/min, SpO2 95% on room air, and respiratory rate 25/min. Venous blood gas analysis shows: pH 7.23, PCO2 26 mmoL/L, HCO3 17 mmoL/L, Lactate 2.24 mmoL/L.
Laboratory tests reveal the following:
Despite initial aggressive intravenous fluid resuscitation and treatment with rasburicase, the patient’s urine output has dropped significantly, and he is now anuric.
Which of the following is the most likely complication this patient is experiencing?
“I discovered, that the saline solution which I had used had not been prepared with distilled water, but with pipe water supplied by the New River Water Company. As this water contains minute traces of various inorganic substances, I at once tested the action of saline solution made with distilled water and I found that I did not get the effects described in the paper referred to. It is obvious therefore, that the effects I had obtained are due to some of the inorganic constituents of the pipe water”
These were the words of Sydney Ringer, a British clinician and physiologist, is recognised for formulating the ‘Ringer’s solution,’ which facilitated the maintenance of isolated frog heart contractions, ultimately contributing to the creation of an isotonic solution utilised in medical research.
Which particular inorganic compound referred to here had the most profound impact in maintaining the frog heart contractions?
Clinical Case Scenario
A 45-year-old female is admitted to the Intensive Care Unit (ICU) with confusion, fever, and petechial rash. She has a history of fatigue, easy bruising, and intermittent abdominal pain over the past two weeks. On physical examination, she is febrile (38.5°C), hypotensive (BP: 95/60 mmHg), and tachycardic (HR: 120 bpm). She has scattered petechiae on her extremities and mild scleral icterus. Initial laboratory findings reveal severe thrombocytopenia (platelet count: 12,000/µL), microangiopathic hemolytic anemia (hemoglobin: 7.5 g/dL with schistocytes seen on blood smear), elevated lactate dehydrogenase (LDH), and normal coagulation parameters. Renal function tests show acute kidney injury (creatinine: 3.2 mg/dL), and a urine dipstick is positive for hemoglobin without red blood cells on microscopy.
The clinical presentation and lab findings strongly suggest a diagnosis of thrombotic thrombocytopenic purpura (TTP). The patient is immediately started on plasma exchange therapy along with corticosteroids. Due to significant renal impairment, continuous renal replacement therapy (CRRT) is initiated concurrently to manage fluid overload and electrolyte imbalances. The ICU team discusses the therapeutic goals and complications associated with TTP and the rationale for the chosen interventions.
What is the primary goal of plasma exchange therapy in the management of TTP?
Clinical Case Scenario
A 35-year-old male patient with severe hepatic encephalopathy due to liver failure presents with confusion, lethargy, and asterixis. Laboratory tests show significantly elevated ammonia levels (210 µmol/L) and impaired kidney functions (urea 55 mmol/L and creatinine 210 µmol/L). Lactate and bicarbonate levels in blood gas are at 10 mmol/L and 14 mmol/L respectively. Despite maximal medical therapy, including lactulose and rifaximin, the patient’s condition worsens. Continuous Renal Replacement Therapy (CRRT) is initiated.
What is the primary rationale for using CRRT in this patient, and what key technical considerations should be noted?
Clinical Case Scenario
A 48-year-old man presents with cough and fever, and a nasopharyngeal swab confirms influenza A. He begins treatment with oseltamivir but returns to the ED within 24 hours with high-grade fever, multifocal lung opacities on chest x-ray, and respiratory failure necessitating intubation and ICU admission. Blood cultures and bronchoalveolar lavage (BAL) reveal methicillin-resistant Staphylococcus aureus (MRSA). After receiving a 2-liter crystalloid bolus and appropriate antibiotics, he develops progressive hypotension. A central venous catheter (CVC) is inserted via the right internal jugular vein. His vital signs show mean arterial pressure (MAP) at 45 mm Hg, central venous pressure (CVP) at 11 mm Hg, central venous oxygen saturation (ScVO2) at 89%, arterial lactate at 10.2 mmol/L, and urine output of 10 cc/hr over the last 4 hours.
Which of the following statements is correct about the next step in management?
Clinical Case Scenario
After undergoing a 12-hour liver transplant surgery, a 56-year-old man received 15 units of RBCs, 8 units of FFP, 4 units of platelets, and 500 mL of albumin. He was transferred to the intensive care unit in a stable condition but developed signs of septic shock four hours later. Broad-spectrum antibiotics were initiated.
What is the most likely source of sepsis in this patient?
Clinical Case Scenario 1
A 72-year-old man is hospitalized for respiratory failure caused by pneumonia acquired in the community. Blood cultures confirm pneumococcal infection. He receives appropriate antibiotics but requires intubation due to worsening hypotension despite IV fluids. Norepinephrine and vasopressin are initiated to manage the worsening hypotension. Over the next 72 hours, his creatinine levels elevate from 1.0 to 4.6 mg/dl, and his urine output decreases to 0–5 mL/hr. A family conference is scheduled to discuss the potential need for continuous renal replacement therapy (CRRT).
Which of the following statements is the most accurate?
Clinical Case Scenario 1
A 58-year-old woman with a history of hypertension arrived at the Emergency Department with symptoms including fever, nausea, vomiting, and confusion. Her vital signs were as follows; temperature: 39.3°C, heart rate: 98/min, blood pressure: 132/64 mm Hg, respiratory rate: 26/min, and oxygen saturation (SaO2): 92% on room air. During the physical examination, she exhibited renal angle tenderness. Laboratory tests revealed a white blood cell count of 22,000/mm³, serum creatinine of 2.3 mg/dL (baseline 0.7 mg/dL), and more than 50 white blood cells per high power field on urine microscopy. A non-contrast CT scan of the abdomen and pelvis showed right perinephric stranding without stones or hydronephrosis. Blood and urine cultures were taken, ceftriaxone was administered, and she was admitted to the ICU.
Which of the following statements about this patient’s acute kidney injury (AKI) is most accurate?
Question 2
Which of the following statements regarding acute graft-versus-host disease (GVHD) after renal transplantation is TRUE?
Question 1
Which of the following statements is incorrect regarding the physiological process depicted in the figure?
Clinical Case Scenario 2
A 52-year-old male with septic shock and multiple organ failure is undergoing continuous renal replacement therapy (CRRT) in the ICU. The team decides to use citrate anticoagulation to manage his therapy.
What is the primary advantage of using citrate anticoagulation in CRRT?
Clinical Case Scenario 1
A 54-year-old male (weight 85 kg, height 175 cm) with a medical history of Type 2 diabetes mellitus, essential hypertension, chronic kidney disease (Stage 5), ischaemic heart disease, and heart failure with reduced ejection fraction (HFrEF) was admitted to the ICU with septic shock secondary to pneumonia. Currently he is on broad-spectrum antibiotics, vasopressors, and mechanical ventilation. His hemodynamic parameters and lab investigations are as follows:
Hemodynamics:
Blood Pressure: 90/50 mmHg (on norepinephrine at 0.1 mcg/kg/min)
Heart Rate: 110 bpm
Central Venous Pressure (CVP): 12 mmHg
Cardiac Output: 4 L/min
Urine output of 20 to 25 ml/hr
Labs:
Haemoglobin: 9.5 g/dL
WBC: 15,000 /µL
Platelets: 120,000 /µL
Serum creatinine: 6.5 mg/dL
Blood Urea Nitrogen (BUN): 70 mg/dL
Potassium: 5.8 mEq/L
Arterial Blood Gas (ABG): pH 7.25, PaCO2 30 mmHg, PaO2 75 mmHg, HCO3- 16 mEq/L
He was initiated on intermittent hemodialysis (IHD) for acute kidney injury and severe metabolic acidosis.
Initial settings: Blood flow rate 300 mL/min, Dialysate flow rate 500 mL/min, Ultrafiltration goal 2 litres over 4 hours.
1 hour into dialysis, his blood pressure dropped to 80/45 mmHg, and heart rate 120 bpm. His norepinephrine infusion rate increased to 0.2 mcg/kg/min; 500 mL of normal saline bolus was administered.
A review of the dialysis solution composition shows the following:
Base: bicarbonate 25 mM
Sodium: 130 mM
Potassium: 3.5 mM
Calcium: 1.5 mM (3.0 mEq/L)
Magnesium: 0.375 mM (0.75 mEq/L)
Dextrose: 5.5 mM (100 mg/dL)
Phosphate: none
Dialysis solution temperature: 33°C
At this point, to improve the hemodynamic tolerance of the ongoing intermittent hemodialysis session, the following changes are recommended, except:
Question 1
A 65-year-old, female (Weight: 70 kg, Height: 160 cm), with a previous medical history of end-stage renal disease (ESRD) on hemodialysis, essential hypertension, diabetes mellitus type 2, peripheral vascular disease admitted to the ICU with acute pulmonary oedema secondary to fluid overload. On day one, she presented with shortness of breath, orthopnoea, and bilateral lower extremity oedema.
Her vitals are as follows- Blood Pressure: 170/95 mmHg; Heart Rate: 100 bpm; Respiratory Rate: 28 breaths/min; Oxygen Saturation: 88% on room air, which improved to 95% on 5 L/min nasal cannula.
Her laboratory investigations are:
Hemoglobin: 10.5 g/dL
WBC: 11,000 /µL
Platelets: 140,000 /µL
Serum Creatinine: 8.2 mg/dL
Blood Urea Nitrogen (BUN): 90 mg/dL
Potassium: 6.2 mEq/L
BNP: 1500 pg/mL
Arterial Blood Gas (ABG) values are as follows– pH 7.30, PaCO2 : 50 mmHg, PaO2 : 65 mmHg, HCO3 : 24 mEq/L
A Chest X-ray showed bilateral pulmonary infiltrates consistent with pulmonary edema.
Emergency hemodialysis was planned, and a dialysis catheter insertion was scheduled as the patient does not have a functioning arteriovenous fistula.
Which of the following factors has the greatest impact on the flow rate of a dialysis catheter and which site should be selected (considering all available sites)?
Clinical Case Scenario 2
A 67-year-old woman with chronic heart failure presents with worsening dyspnea and significant peripheral edema. She is diagnosed with cardiorenal syndrome, and her renal function has declined considerably.
Which statement best reflects the management of cardiorenal syndrome (CRS)?
Question 1
A 60-year-old male patient with a history of diabetes mellitus and chronic kidney disease is admitted to the ICU with acute kidney injury (AKI). He also has a recent history of severe diarrhea. His arterial blood gas analysis is as follows:
pH:7.25,
HCO3: 17 mEq/L,
Na: 142 mEq/L
K: 3.3 mmoL/L
Cl: 112 mEq/L
Albumin: 3.0 mg/dL
Random blood sugar: 5 mmoL/L
Lactate: 2.3 mmoL/L
Which of the following is the most likely cause of his metabolic disorder?
Clinical Case Scenario 2
A 45-year-old male presents to the emergency department with confusion and oliguria for one day. He has a history of discoloration of his eyes for the last five days. Laboratory tests reveal:
AST 320 U/L, ALT 410 U/L, GGT 229 U/L, INR > 1.5, Serum creatinine of 300 µmol/L.
Positive ANA (1:320), Positive Smooth Muscle Antibody (1:40), Elevated IgG levels.
Abdominal Ultrasound: Enlarged liver with mild hepatic inflammation, no evidence of cirrhosis or Budd-Chiari syndrome.
Other Tests: Negative viral hepatitis panel, normal ceruloplasmin, elevated ferritin. His GCS deteriorated from 13 to 7, for which the trachea was intubated and the patient was transferred to ICU. Inj Methylprednisolone 125 mg IV OD was started. Despite initial supportive measures, his condition continues to deteriorate.
Which of the following extracorporeal therapies is most appropriate to manage this patient’s condition?
Question 1
Shortly after a new Medical Renal Unit (MRU) opened, this outbreak led to 40 cases soon including deaths among patients and staff. The outbreak prompted the establishment of an advisory group led by Lord Rosenheim, which gave a series of recommendations and crucial containment measures. Despite precautions, the outbreak’s severity, had a lasting impact on infection control practices in medical settings. This outbreak in the 19th century was the subject of Colin Douglas’s popular outrageous novel “The Houseman’s Tale”, and it continues to influence the way physicians think about the risks of infection.
Choose the combination of place, year, causative organism and primary mode of outbreak transmission that is being referred to here.
Clinical Case Scenario 2
A 45-year-old male with severe respiratory distress syndrome is initiated on ECMO. During his stay in the ICU, he develops signs of acute kidney injury (AKI). The medical team is considering the best approach for renal replacement therapy (RRT) due to his hemodynamic instability.
Question: In this patient with AKI on ECMO, which of the following statements is correct?
Clinical Case Scenario 1
A 64-year-old man is admitted to the hospital with a cough, fever, and low oxygen levels. He quickly progresses to respiratory distress, necessitating endotracheal intubation. A chest x-ray reveals widespread bilateral lung opacities. An arterial blood gas shows a PaO2 of 70 mm Hg on 100% FiO2. Bedside echocardiography confirms normal left ventricular (LV) systolic function. A nasopharyngeal swab tests positive for influenza A.
Clinical Case Scenario 2
A 75-year-old man with diabetes mellitus, hypertension, and peripheral vascular disease underwent infra-renal endovascular repair (EVAR) of an 8-cm abdominal aortic aneurysm. Administration of iodinated contrast was used during the procedure. On day 3 following the procedure, serum creatinine rose from a preoperative value of 112 µmol/L to 150 µmol/L. Doppler ultrasound of renal vessels showed no abnormality. Bedside volume assessment using ultrasound was suggestive of euvolemia. A diagnosis of contrast-induced nephropathy (CIN) was suggested.
Clinical Case Scenario 1
An elderly woman, aged 76 and weighing 75 kg, is hospitalized to the Intensive Care Unit (ICU) with urosepsis. She experiences stage 3 Acute Kidney Injury (AKI). The urine output is 15-30 millilitres per hour. The creatinine level is 3.6 milligrams per deciliter (318.3 micromoles per litre). The urea level is 26 millimoles per litre. The potassium level is 5.2. The base excess is -7. Her current dosage of Noradrenaline support is 0.4 micrograms per kilogram per minute. The patient is currently on mechanical ventilation with a fraction of inspired oxygen (FiO2) of 0.6 and positive end-expiratory pressure (PEEP) of 10. The cumulative fluid balance is a positive 6 litres on the third day of the patient’s stay in the intensive care unit. Below are the important vital parameters. What is the optimal management strategy?
Clinical Case Scenario 2
Which antibiotic requires dose adjustment in a patient with creatinine clearance of 20 mL/minute/1.73 m2?