Peritonitis

 Peritonitis is defined as an inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein. Depending on the underlying pathology, the resultant peritonitis may be infectious or sterile (ie, chemical or mechanical).

Peritoneal infections are classified as primary (ie, from hematogenous dissemination, usually in the setting of an immunocompromised state), secondary (ie, related to a pathologic process in a visceral organ, such as perforation or trauma, including iatrogenic trauma), or tertiary (ie, persistent or recurrent infection after adequate initial therapy). Primary peritonitis is most often spontaneous bacterial peritonitis (SBP) seen mostly in with chronic liver disease. Secondary peritonitis is by far the most common form of peritonitis encountered in clinical practice. Tertiary peritonitis often develops in the absence of the original visceral organ pathology.

Infections of the peritoneum are further divided into generalized (peritonitis) and localized (intra-abdominal abscess).

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Hypomagnesemia

Hypomagnesemia is common among hospitalized patients and frequently occurs with other electrolyte disorders, including hypokalemia and hypocalcemia. Magnesium depletion usually results from inadequate intake plus impairment of renal conservation or gastrointestinal absorption.

Drugs can cause hypomagnesemia. Examples include chronic (> 1 year) use of a proton pump inhibitor and concomitant use of diuretics. Amphotericin B can cause hypomagnesemia, hypokalemia, and acute kidney injury. The risk of each of these is increased with duration of therapy with amphotericin B and concomitant use of another nephrotoxic agent. Liposomal amphotericin B is less likely to cause either kidney injury or hypomagnesemia.

Trousseau sign is the precipitation of carpal spasm by reduction of the blood supply to the hand with a tourniquet or blood pressure cuff inflated to 20 mm Hg above systolic blood pressure applied to the forearm for 3 minutes.

Chvostek sign is an involuntary twitching of the facial muscles elicited by a light tapping of the facial nerve just anterior to the exterior auditory meatus.

Serum magnesium concentration < 1.8 mg/dL

Hypomagnesemia is diagnosed by measurement of serum magnesium concentration.

Severe hypomagnesemia usually results in concentrations of < 1.25 mg/dL.

Associated hypocalcemia and hypocalciuria are common.

Hypokalemia with increased urinary potassium excretion and metabolic alkalosis may be present.

Treatment with magnesium salts is indicated when magnesium deficiency is symptomatic or the magnesium concentration is persistently < 1.25 mg/dL. Patients with alcohol use disorder are treated empirically. In such patients, deficits approaching 12 to 24 mg/kg are possible.

When serum magnesium is ≤ 1.25 mg/dL but symptoms are less severe, magnesium sulfate may be given IV in 5% D/W at a rate of 1 g/hour as slow infusion for up to 10 hours. In less severe cases of hypomagnesemia, gradual repletion may be achieved by administration of smaller parenteral doses over 3 to 5 days until the serum magnesium concentration is normal. 

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Procalcitonin (PCT)

 

Procalcitonin (PCT) has developed into a promising new biomarker for early detection of (systemic) bacterial infections. PCT is a 116-amino acid residue that was first explained by Le Moullec et al. in 1984; however, its diagnostic significance was not recognized until 1993. In 1993, Assicot et al. demonstrated a positive correlation between high serum levels of PCT and patients with positive findings for bacterial infection and sepsis (eg, positive blood cultures). PCT assays with a specificity of 79%, is utilized to more accurately determine if a bacterial species is the cause of a patient’s systemic inflammatory reaction.

Procalcitonin serum levels have been shown to increase 6 to 12 hours following initial bacterial infections and increase steadily 2 to 4 hours following the onset of sepsis. The half-life of PCT is between 20 to 24 hours; therefore, when a proper host immune response and antibiotic therapy are in place, PCT levels decrease accordingly by 50% over 24 hours.

PCT serum levels can become elevated among patients during times of noninfectious conditions, such as with trauma, burns, carcinomas (medullary C-cell, small cell lung, & bronchial carcinoid), immunomodulator therapy that increase proinflammatory cytokines, cardiogenic shock, first 2 days of a neonate's life, during peritoneal dialysis treatment, and in cirrhotic patients (Child-Pugh Class C). Furthermore, PCT levels have found to be falsely elevated in patients suffering from various degrees of chronic kidney disease which can, in turn, alter baseline results making the determination of an underlying bacterial infection difficult to establish.

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Thoracolumbar Spine Fracture

 Thoracolumbar Spine Fracture

The most common mechanisms for thoracolumbar traumatic injuries include motor vehicle accidents, falls from height, recreational injuries, and work-related injuries. Most of them are high-velocity and high-energy injuries, which usually involve additional injuries.

The T10-L2 thoracolumbar region is the most common area of injury to the spine from trauma due to the specific biomechanics of this segment of the spine. Injury to this area can result in a permanent neurological deficit from compression or direct injury to the nerve roots of the cauda equina or the conus medullaris and warrants immediate attention and assessment.

American Spinal Injury Association (ASIA) impairment scale:

A - Complete: No motor or sensory function is preserved below the neurological level

B - Incomplete: Sensory function preserved but no motor function is preserved below the neurological level including the S4–S5 segments

C - Incomplete: Motor function is preserved at the most caudal sacral segments for voluntary anal contraction. The motor function below the neurological level is preserved with less than half of key muscles that have a muscle grade ≥ 3

D - Incomplete: Motor function is preserved below the neurological level with at least half of key muscles that have a muscle grade ≥ 3

E - Normal: Motor and sensory function are normal

Compression fracture. While the front (anterior) of the vertebra breaks and loses height, the back (posterior) part of it does not. This type of fracture is usually stable (the bones have not moved out of place) and is rarely associated with neurologic problems. Compression fractures commonly occur in patients with osteoporosis.

Axial burst fracture.  In this type of fracture, the vertebra loses height on both the front and back sides. It is often caused by landing on the feet after falling from a significant height. An axial burst fracture can sometimes result in nerve compression. Some fractures are stable, while others are significantly unstable (the bones have moved out of place).

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Hematology Algorithms

Hematology Algorithms 

Anemia is described as a reduction in the proportion of the red blood cells. Most patients experience some symptoms related to anemia when the hemoglobin drops below 7.0 g/dL. RBC are produced in the bone marrow and released into circulation. Approximately 1% of RBC are removed from circulation per day. Imbalance in production to removal or destruction of RBC leads to anemia. 

The etiology of anemia depends on whether the anemia is hypo-proliferative (i.e., corrected reticulocyte count <2%) or hyperproliferative (i.e., corrected reticulocyte count >2%).  Hypo-proliferative anemias are further divided by the mean corpuscular volume into microcytic anemia (MCV<80 fl), normocytic anemia (MCV 80-100 fl) & macrocytic anemia (MCV>100 fl). 

Pancytopenia is a hematologic condition characterized by a decrease in all three peripheral blood cell lines. It is characterized by the hemoglobin of less than 12 g/dL in women and 13 g/dL in men, platelets of less than 150,000 per mcL, and leukocytes of less than 4000 per ml (or absolute neutrophil count of less than 1800 per ml). However, these thresholds largely dependent on age, sex, race as well as varying clinical scenarios. 

Leukopenia is primarily seen as neutropenia since neutrophils constitute the majority of the leukocytes. The etiology of pancytopenia can be broadly categorized as a central type that involves production disorders or a peripheral type that involves disorders of increased destruction. These causes could contribute to the pancytopenia independently or as a combination. 

Red cell distribution width (RDW) = (standard deviation of MCV/mean MCV) × 100. 

Normal range11.5–14.5% has suspicion of thalassemia trait & high often indicates IDA 

Mentzer index = (MCV/RBC count). 

< 13 may represent thalassemia trait & >13 often indicates IDA

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Coagulation cascade and Role of Anticoagulants.

 Normal coagulation pathway represents a balance between the pro coagulant pathway that is responsible for clot formation and the mechanisms that inhibit the same beyond the injury site. Imbalance of the coagulation system may occur in the perioperative period or during critical illness, which may be secondary to numerous factors leading to a tendency of either thrombosis or bleeding.

The plasma coagulation system in mammalian blood consists of a cascade of enzyme activation events in which serine proteases activate the proteins (proenzymes and procofactors) in the next step of the cascade via limited proteolysis. The ultimate outcome is the polymerization of fibrin and the activation of platelets, leading to a blood clot. This process is protective, as it prevents excessive blood loss following injury (normal hemostasis). Unfortunately, the blood clotting system can also lead to unwanted blood clots inside blood vessels (pathologic thrombosis), which is a leading cause of disability and death in the developed world. There are two main mechanisms for triggering the blood clotting, termed the tissue factor pathway and the contact pathway. Only one of these pathways (the tissue factor pathway) functions in normal hemostasis. Both pathways, however, contribute to thrombosis. 

The blood coagulation cascade culminates with the conversion of fibrinogen to fibrin, essentially transmitting the proteolytic injury signal into a fibrin clot capable of occluding the inciting tissue defect. Fibrinogen is the most abundant coagulation protein in plasma, consistent with its mechanical rather than signaling role.

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Diverticula

 A gut diverticulum (singular) is an outpouching of the wall of the gut to form a sac. Diverticula (plural) may occur at any level from esophagus to colon. A true diverticulum includes all three layers of the gut; the lining mucosa, the muscularis, and the outer serosa. False diverticula are missing the muscularis and are therefore very thin walled. Colonic diverticula are typically false.

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Guidelines for the pacemaker insertion

 There are 3 types of artificial pacemakers:

• Implantable pulse generators with endocardial or myocardial electrodes
• External, miniaturized, patient portable, battery-powered, pulse generators with exteriorized electrodes for temporary transvenous endocardial or transthoracic myocardial pacing
• Console battery or AC-powered cardioverters or monitors with high-current external transcutaneous or low-current endocardial or myocardial circuits for temporary pacing in asynchronous or demand modes, with manual or triggered initiation of pacing

Following conditions are included in the ACC/AHA/HRS guidelines for the pacemaker insertion

• Sinus Node Dysfunction

1. Documented symptomatic sinus bradycardia including frequent sinus pauses which produce symptoms and symptomatic sinus bradycardia that results from required drug therapy for medical condition
2. Symptomatic chronotropic incompetence (failure to achieve 85% of age-predicted maximal heart rate during formal or informal stress test or inability to mount age appropriate heart rate during activities of daily living)

• Acquired Atrioventricular (AV) Block

1. Complete third-degree AV block with or without symptoms.
2. Symptomatic second degree AV block, Mobitz type I and II
3. Exercise-induced second or third degree AV block in the absence of myocardial infarction
4. Mobitz II with widened QRS complex

• Chronic Bifascicular Block

1. Advanced second-degree AV block or intermittent third-degree AV block
2. Alternating bundle-branch block
3. Type II second-degree AV block.

• After Acute Phase of Myocardial Infarction

1. Permanent ventricular pacing for persistent second degree AV block in the His-Purkinje system with alternating bundle branch block or third degree AV block within or below the His-Purkinje system after the ST-segment elevation MI (STEMI)
2. Permanent ventricular pacing for a transient advanced second or third-degree infranodal AV block and associated bundle branch block
3. Permanent ventricular pacing for persistent and symptomatic second or third degree AV block

• Neurocardiogenic Syncope and Hypersensitive Carotid Sinus Syndrome

1. Recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds

• Post Cardiac Transplantation

1. For persistent inappropriate or symptomatic bradycardia not expected to resolve and for other class I indications of permanent pacing.

• Hypertrophic Cardiomyopathy (HCM)

1. Patients with HCM having Sinus node dysfunction and AV block

• Pacing to Prevent Tachycardia

1. For sustained pause dependent VT, with or without QT prolongation

• Cardiac Resynchronization Therapy (CRT) in Patients with Severe Systolic Heart Failure

1. Patients with left ventricular ejection fraction (LVEF) of less than or equal to 35%, sinus rhythm, LBBB (left bundle branch block), New York Heart Association (NYHA) Class II, III or IV symptoms while on optimal medical therapy with a QRS duration of greater than or equal to 150 ms, CRT with or without ICD is indicated

• Congenital Heart Disease

1. For advanced second or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output; also for advanced second or third-degree AV block which is not expected to resolve or persists for 7 days or longer after cardiac surgery
2. For sinus node dysfunction with a correlation of symptoms during age inappropriate bradycardia
3. Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy or ventricular dysfunction
4. Congenital third-degree AV block in an infant with a ventricular rate of less than or equal to 55 bpm or with congenital heart disease with a ventricular rate of less than or equal to 70 bpm

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Sodium-glucose co-transporter 2 (SGLT2) inhibitors

 Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of glucose-lowering drugs. They work by blocking the low-affinity, high-capacity SGLT2 protein located in the proximal convoluted tubule of the nephron. The SGLT2 protein is responsible for the resorption of approximately 90% of filtered glucose while the remainder is reabsorbed by SGLT1 proteins found on the distal part of the proximal convoluted tubule. SGLT2 inhibition results in glycosuria (and natriuresis as the protein is a co-transporter), thereby lowering plasma glucose concentrations. This mechanism is unique compared with all other glucose-lowering agents as it does not interfere with endogenous insulin or incretin pathways.

In recent cardiovascular outcome trials, SGLT2 inhibitors are associated with 30%–35% lower risk of hospitalization for heart failure. Other glucose-lowering agents appear to be more potent than SGLT2 inhibitors, but fail to reduce cardiovascular risk, particularly with regard to heart failure outcomes. Moreover, although the glucose-lowering efficacy of SGLT2-inhibitor therapy declines at lower estimated glomerular filtration rates, its cardiovascular benefits are remarkably preserved, even in patients with renal impairment. This implies differing mechanisms of action in glycemic control and cardiovascular risk reduction. 

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Know the colors.

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Hypermagnesemia

 Hypermagnesemia occurs primarily in patients with acute or chronic kidney disease. In these individuals, some conditions, including proton pump inhibitors, malnourishment, and alcoholism, can increase the risk of hypermagnesemia. Hypothyroidism and especially cortico-adrenal insufficiency, are other recognized causes.

Hyperparathyroidism and alterations in calcium metabolism involving hypercalcemia and/or hypo-calciuria can lead to hypermagnesemia through an increased calcium-induced magnesium absorption in the tubule. Patients with familial hypocalciuric hypercalcemia (FHH), a rare autosomal dominant condition, can manifest hypermagnesemia.

Lithium-based psychotropic drugs can also lead to hypermagnesemia by reducing excretion. Patients with milk-alkali syndrome due to the ingestion of large amounts of calcium and absorbable alkali are more susceptible to develop hypermagnesemia. Magnesium levels can increase in hemolysis patients. Red blood cells contain three times as much magnesium as compared to plasma. The rupture of these cells pours magnesium into the plasma. However, symptomatic hypermagnesemia occurs only in the case of aggressive hemolysis. Tumor lysis syndrome, rhabdomyolysis, and acidosis (e.g., decompensated diabetes with ketoacidosis) can also induce hypermagnesemia through extracellular shifts.

Summary:

• Mild hypermagnesemia (less than 7 mg/dL) - Asymptomatic or pauci-symptomatic: weakness, nausea, dizziness, and confusion
• Moderate hypermagnesemia (7 to 12 mg/dL) - Decreased reflexes, worsening of the confusional state and sleepiness, bladder paralysis, flushing, headache, and constipation. A slight reduction in blood pressure, bradycardia, and blurred vision caused by diminished accommodation and convergence are usually present.
• Severe hypermagnesemia (greater than 12 mg/dL) - Muscle flaccid paralysis, decreased breathing rate, more evident hypotension and bradycardia, prolongation of the P-R interval, atrioventricular block, and lethargy are common. Coma and cardiorespiratory arrest can occur for higher values (over 15 mg/dL).

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Calcium metabolism and management

Ionized calcium is the physiologically active form. Ionized calcium acts as an intracellular 2nd messenger; it is involved in skeletal muscle contraction, excitation-contraction coupling in cardiac and smooth muscle, and activation of protein kinases and enzyme phosphorylation. Calcium is also involved in the action of other intracellular messengers, such as cAMP (cyclic adenosine monophosphate) and inositol 1,4,5-triphosphate, and thus mediates the cellular response to numerous hormones, including epinephrine, glucagon, vasopressin (antidiuretic hormone), secretin, and cholecystokinin.

Despite its important intracellular roles, about 99% of body calcium is in bone, mainly as hydroxyapatite crystals. About 1% of bone calcium is freely exchangeable with the extracellular fluid and, therefore, is available for buffering changes in calcium balance.

Normal total serum calcium concentration ranges from 8.8 to 10.4 mg/dL. About 40% of the total blood calcium is bound to plasma proteins, primarily albumin. The remaining 60% includes ionized calcium plus calcium complexed with phosphate and citrate. Total calcium (ie, protein-bound, complexed, and ionized calcium) is usually what is determined by clinical laboratory measurement.

However, ideally, ionized (or free) calcium should be estimated or measured because it is the physiologically active form of calcium in plasma and because its blood level does not always correlate with total serum calcium.

Ionized calcium is generally assumed to be about 50% of the total serum calcium.

Ionized calcium can be estimated, based on total serum calcium and serum albumin levels. Direct determination of ionized calcium, because of its technical difficulty, is usually restricted to patients in whom significant alteration of protein binding of serum calcium is suspected.

Normal ionized serum calcium concentration range varies somewhat between laboratories, but is typically 4.7 to 5.2 mg/dL.

 The regulation of both calcium and phosphate balance is greatly influenced by concentrations of circulating PTH, vitamin D, and, to a lesser extent, calcitonin. Calcium and phosphate concentrations are also linked by their ability to chemically react to form calcium phosphate. The product of concentrations of calcium and phosphate (in mg/dL) is estimated to be < 60 mg2/dL2 (< 4.8 mmol2/L2) normally; when the product exceeds 70 mg2/dL2 (5.6 mmol2/L2), precipitation of calcium phosphate crystals in soft tissue is much more likely. Calcification of vascular tissue accelerates arteriosclerotic vascular disease and may occur when the calcium and phosphate product is even lower (> 55 mg2/dL2 [4.4 mmol2/L2]), especially in patients with chronic kidney disease.

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