Đánh giá của Hội đồng chăm sóc phê bình gây mê 2020

Đánh giá của Hội đồng chăm sóc phê bình gây mê được rèn luyện như một khái niệm bắt nguồn từ việc chuẩn bị cho các bác sĩ chăm sóc quan trọng đồng nghiệp tham gia và thành công trong Kỳ thi cấp chứng chỉ chăm sóc quan trọng của Hội đồng gây mê Hoa Kỳ (ABACCCE) Mục tiêu này rất quan trọng vì nó nói lên mục đích của chúng tôi với tư cách là bác sĩ lâm sàng và nhà giáo dục trong việc chuẩn bị thế hệ bác sĩ gây mê hồi sức Trong thời gian của tôi với tư cách là giám đốc chương trình (bắt đầu hoạt động vào năm 2011), tôi nhận thấy có rất nhiều tài liệu phù hợp và phù hợp với các bác sĩ chuẩn bị cho cuộc kiểm tra - đặc biệt là chu phẫu và phạm vi rộng chẳng hạn như ABACCCE Tôi đã tự mình trải nghiệm điều này khi tôi là một sinh viên vừa tốt nghiệp Với tư cách là người biên tập cuốn sách này, chúng tôi đã tìm mọi cách trong khả năng của mình để ngăn những người khác khỏi trải nghiệm lo lắng do cơ hội thực hành tối thiểu cho một cuộc kiểm tra chăm sóc nghiêm trọng với các câu hỏi được viết bởi các tác giả có chung kiến ​​thức nền về gây mê Chúng tôi hy vọng rằng, sau khi đọc cuốn sách này, udience sẽ học được điều gì đó mới, có thể xác định điểm mạnh và điểm yếu của họ, và có được quan điểm về nội dung thực tế quan trọng đối với một bác sĩ lâm sàng thành công và lãnh đạo trong đơn vị chăm sóc đặc biệt. Các biên tập viên và tác giả đã nỗ lực rất nhiều để thực hiện Những câu hỏi đầy thách thức nhưng công bằng, cũng như thấu đáo nhưng đơn giản, cho người đọc Cuốn sách này được tạo ra với quan điểm và niềm đam mê của các nhà giáo dục trên khắp đất nước, những người hy vọng sẽ làm cho quá trình chuẩn bị lên bảng bớt căng thẳng và hiệu quả hơn Mỗi chương được viết bởi một tác giả tích cực cung cấp sự quan tâm trong phạm vi của chương Ngoài ra, các biên tập viên đã cố gắng làm cho định dạng và phong cách của các câu hỏi phù hợp với mức độ khó của đề thi Cuốn sách này sẽ không thể thực hiện được nếu không có sự chăm chỉ của người cố vấn của tôi, Dr. Popovich và cộng sự của tôi, Tiến sĩ Grewal; trong nỗ lực này, chúng tôi đã tạo ra một mối quan hệ đối tác lâu dài tập trung vào giáo dục, và họ cảm ơn tôi Sản phẩm kết quả là nỗ lực chung của cả nhóm chúng tôi, trong đó tôi tự hào là một thành viên. Xin cho phép tôi bày tỏ lòng biết ơn đến các thầy thuốc và những người cố vấn đã làm cho cuốn sách này trở nên khả thi: Tiến sĩ Howard Nearman, chủ tịch của tôi trong thời gian tôi cư trú, với tư cách là bác sĩ chuyên khoa gây mê hồi sức đã truyền cảm hứng cho tôi làm việc chăm chỉ nhất có thể để noi gương ông ấy như một bác sĩ nhân ái và nhà lãnh đạo hiệu quả; đồng giám đốc chương trình cư trú của tôi, Tiến sĩ Matthew Norcia (một bác sĩ chuyên khoa khác) và Tiến sĩ David Wallace, người đã rất khuyến khích tôi theo đuổi sự nghiệp chăm sóc quan trọng; Giám đốc chương trình của nghiên cứu sinh của tôi, Tiến sĩ Marc Popovich (đồng biên tập), người đã dạy tôi cách tự tin và thấu đáo với tư cách là một bác sĩ chuyên khoa và cung cấp cho tôi các kỹ năng để tạo và lãnh đạo một bộ phận chăm sóc quan trọng mới tại một cơ sở mới; bố mẹ tôi, những người luôn nhấn mạnh rằng tôi phải nỗ lực 100% cho mọi việc mà tôi làm; bệnh nhân của tôi, những người cho tôi đặc ân chăm sóc họ trong những giờ phút đen tối nhất và là người, cho đến ngày nay, dạy tôi điều gì đó mới trong kinh nghiệm học tập suốt đời của tôi; và cuối cùng, người vợ xinh đẹp và vô cùng ủng hộ của tôi và ba đứa con của chúng tôi, những người đã hy sinh đêm và cuối tuần cùng nhau để cho phép cuốn sách này thành hiện thực. George W Williams, MD, FASA, FCCM, FCCP ix 16 NUTR ITION George W Williams QU E STIONS 1 Một nam giới 42 tuổi, 70 kg được đưa vào phòng chăm sóc đặc biệt (ICU) với nhiễm trùng huyết sau phẫu thuật sau khi phẫu thuật cấp cứu vùng bụng Sau 8 ngày nhập viện ICU, anh ta vẫn dùng thuốc vận mạch liều thấp để duy trì. huyết áp bình thường (HA) Kết quả chụp cắt lớp vi tính (CT) hiển thị ở đây: có thể đảm bảo can thiệp Điều nào sau đây là hữu ích nhất Nghiên cứu tiếp theo để thực hiện? A Prealbumin B Cân bằng nitơ C Transferrin D Hấp thu paracetamol 3. Một bệnh nhân được chẩn đoán bị suy dinh dưỡng protein-calo nặng và được đưa vào khoa cấp cứu (ED) để theo dõi hội chứng cho ăn. Một nội soi được thực hiện mà không có tổn thương ruột nào được ghi nhận, và dinh dưỡng được bắt đầu Loại nào sau đây cung cấp năng lượng NHIỀU NHẤT cho mỗi gam? A Lipid B Protein C Glucose D Arginine Bệnh nhân đang dung nạp thức ăn ống kcal / mL, được truyền với tốc độ 100 mL / giờ Bước tiếp theo nào sau đây là phù hợp nhất? 4. Một đường ống thông trung tâm (PICC) đưa vào ngoại vi được đặt cho một bệnh nhân bị huyết khối tĩnh mạch sâu và đái tháo đường týp cần dùng kháng sinh tiêm tĩnh mạch (IV) cho bệnh viêm tủy xương và nuôi dưỡng toàn bộ qua đường tĩnh mạch (TPN) Hai ngày sau khi đặt, bệnh nhân được lưu ý bị hạ thân nhiệt, hạ huyết áp và mê sảng Anh ấy được chuyển đến ICU để xử trí thêm Nguyên nhân nào sau đây có khả năng xảy ra nhất đối với biểu hiện của anh ấy? A Viêm tắc tĩnh mạch B Bệnh mạch máu ngoại vi C Hạ thân nhiệt D TPN A Giảm thức ăn có ống B Lặp lại CT trong 72 giờ C Đo nhiệt lượng gián tiếp D Buồng trứng và ký sinh trùng 2. Trong khi thực hiện đánh giá buổi sáng, u

https://t.me/Anesthesia_Books   A N E S T H E S IOL O G Y CR I T IC A L C A R E B OA R D   R E V I E W     A NESTHESIOLOGY CR ITICA L CAR E BOAR D R EV IEW EDITED BY George W Williams, MD, FASA, FCCM, FCCP ASSOCIATE PROFESSOR OF ANESTHESIOLOGY AND CRITICAL CARE MEDICINE VICE CHAIR FOR CRITICAL CARE MEDICINE PROGR AM DIRECTOR, ANESTHESIOLOGY CRITICAL CARE MEDICINE FELLOWSHIP M E D I C A L C O - ​D I R E C T O R , S U R G I C A L I N T E N S I V E C A R E   U N I T LY NDON B. JOHNSON GENER AL HOSPITAL HOUSTON, TX, USA C O -​E D I T O R S Navneet Kaur Grewal, MD ASSISTANT PROFESSOR OF ANESTHESIOLOGY AND CRITICAL CARE MEDICINE ASSISTANT PROGRAM DIRECTOR, ANESTHESIOLOGY CRITICAL CARE MEDICINE FELLOWSHIP PROGR AM DIRECTOR OF EDUCATION, MEDICAL/SURGICAL AND C A R DIOVA S C U L A R I N T E N SI V E C A R E U N I T S MEMORIAL HERMANN SOUTHWEST HOSPITAL HOUSTON, TX, USA Marc J Popovich, MD, FCCM HELMUT F CASCOR BI PROFESSOR A ND CH A IR, DEPA RTM ENT OF A NESTHESIOLOGY AND PERIOPER ATIVE MEDICINE CASE WESTERN RESERVE UNIVERSITY SCHOOL OF MEDICINE UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER CLEVELAND, OH, USA   Oxford University Press is a department of the University of Oxford It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America © Oxford University Press 2020 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer CIP data is on file at the Library of Congress ISBN 978–​0–​19–​090804–​1 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice Treatment for the conditions described in this material is highly dependent on the individual circumstances And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material The authors and the publisher not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/​or application of any of the contents of this material 1 3 5 7 9 8 6 4 2 Printed by Sheridan Books, Inc., United States of America   To God who makes all things possible To my beautiful wife and best friend, Erin To Eden, Emeri, and Gabriel, who bring immeasurable joy to our lives     CONTENTS Preface Contributors ix xi Central Nervous System Robert Brown Obstetric Critical Care Marc J Popovich Hematology and Oncology Talia K Ben-​Jacob, Danielle L Behrens, and Christopher P Potestio Gastroenterology Naveen Kukreja Trauma and Disaster Management Joshua Person and Lillian S. Kao Critical Care Review: Burns James M Cross, Tonya C George, and Todd F. Huzar Sedation, Pain Management, and Pharmacology Sophie Samuel and Jennifer Cortes Endocrinology Navneet Kaur Grewal and George W Williams Immunology and Infectious Diseases Joti Juneja Mucci 10 Statistics, Ethics, and Management George W Williams 11 Pulmonology Ted Lytle and Marc J Popovich 12 Cardiovascular I: Physiology and Management Linda W. Young 13 Cardiovascular II: Mechanical Support and Resuscitation John C. Klick 14 Renal Acid–​Base Olakunle Idowu 15 Procedures Navneet Kaur Grewal 16 Nutrition George W Williams 19 24 43 60 78 87 100 106 115 124 133 148 165 179 188 Index 197 vii     PR EFACE The Anesthesiology Critical Care Board Review was forged as a concept rooted in working to prepare critical care fellow physicians to take and be successful on the American Board of Anesthesiology Critical Care Certification Examination (ABACCCE) This goal is important because it speaks to our purpose as clinicians and educators in preparing the next generation of anesthesiologist intensivists In my time as a program director (which functionally started in 2011), I found there to be a paucity of materials suited for and tailored to physicians preparing for the examination—​in particular, a perioperative and wide-​ranging examination such as the ABACCCE I experienced this myself when I was a recent fellow graduate As editors of this book, we sought to everything in our power to prevent others from an anxiety-​laden experience resulting from minimal opportunities to practice for a critical care examination with questions written by authors that shared a background in anesthesiology It is our hope that, after reading this book, our audience would have learned something new, been able to identify their strengths and weaknesses, and gain a perspective of factual content that is important for a successful clinician and leader in the intensive care unit The editors and authors put a great deal of effort toward making the questions challenging yet fair, as well as thorough yet straightforward, for the reader This book was created with the perspective and passion of educators from across the country who hope to make the process of board preparation less stressful and more productive Each chapter has been written by an author who actively provides care within the domain of the chapter Additionally, the editors have endeavored to make the format and style of the questions consistent with an examination’s level of difficulty This book would not have been possible without the hard work of my mentor Dr. Popovich and my partner Dr. Grewal; in this effort, we have generated a lasting partnership focused on education, and they have my thanks The resulting product is a collective effort of our team, of which I am proud to be a member Please allow me to express my gratitude to the physicians and mentors that made this book possible:  Dr.  Howard Nearman, my chairman during my residency who as an anesthesiologist intensivist inspired me to work as hard as I  could to be emulate his example as a compassionate physician and effective leader; my residency program co-​ directors Dr.  Matthew Norcia (another intensivist) and Dr. David Wallace, who strongly encouraged me to pursue a career in critical care; the program director of my fellowship, Dr. Marc Popovich (co-​editor), who taught me how to be confident and thorough as an intensivist and provided me with the skills to create and lead a new critical care division at a new institution; my parents, who always insisted that I give 100% effort to everything that I do; my patients, who give me the privilege of caring for them in their darkest hours and who, to this day, teach me something new in my experience of lifelong learning; and finally, my beautiful and incredibly supportive wife and our three children, who sacrificed nights and weekends together to allow this book to come to fruition George W Williams, MD, FASA, FCCM, FCCP ix   16 NUTR ITION George W Williams QU E STIONS 1. A 42-​year-​old 70-​kg male is admitted to the intensive care unit (ICU) with postoperative sepsis after emergent abdominal surgery Following 8  days of admission to the ICU, he remains on low-​dose vasopressors to maintain a normal blood pressure (BP) The computed tomography (CT) scan shown here is obtained: intervention may be warranted Which of the following is the MOST useful next study to perform? A Prealbumin B Nitrogen balance C Transferrin D Paracetamol absorption 3.  A  patient is diagnosed with severe protein-​calorie malnutrition and admitted from the emergency department (ED) in order to monitor for refeeding syndrome A  colonoscopy is performed with no noted intestinal lesions, and nutrition is initiated Which of the following provides the MOST energy per gram? A Lipids B Protein C Glucose D Arginine The patient is tolerating kcal/​mL tube feeds, which have been infusing at 100 mL/​hour Which of the following is the MOST appropriate next step? 4. A peripherally inserted central catheter (PICC) line is placed in a patient with deep vein thrombosis and type diabetes mellitus who requires intravenous (IV) antibiotics for osteomyelitis and total parenteral nutrition (TPN) Two days after placement, the patient is noted to be hypothermic, hypotensive, and delirious He is transferred to the ICU for further management Which of the following is the MOST likely cause of his presentation? A Thrombophlebitis B Peripheral vascular disease C Hypothermia D TPN A Decrease tube feeds B Repeat CT in 72 hours C Indirect calorimetry D Stool ova and parasites 2.  While performing your morning assessments, the unit dietitian informs you that a patient who was admitted to the hospital 3  days ago is receiving g/​ kg per day of protein intake You determine that the patient’s wounds are healing slowly and that further 5. A 28-​year-​old male is admitted following a motor vehicle collision He has persistently altered mental status without obvious signs of trauma His family states that he was once treated for cocaine abuse Toxicology does not reveal illicit substances or alcohol intoxication The 18   Figure Q6.1 level of which of the following is MOST likely to be deficient in this patient? A Thiamine B Vitamin  E C Selenium D Linoleic  acid 6. A patient from the general medical floor is transferred to your ICU for workup of protracted diarrhea Clostridium difficile polymerase chain reaction (PCR) has been sent, and results are pending; labs reveal a white blood cell (WBC) count of 13.5 × 109 Although vital signs are within normal limits, the patient complains of weakness The electrocardiogram (ECG) is shown here Which of the following is the MOST appropriate to administer? A Packed red blood cells B Potassium C D5 water D Antibiotics 7. An 81-​year-​old male who on postoperative day after a transurethral resection of the prostate presents with fever, elevated WBC count, abdominal distention, and altered mental status A  kidney-​ureter-​bladder radiograph (KUB) is obtained and is shown here: He is noted to be producing cloudy nonconcentrated urine Which of the following would be the MOST appropriate next step? A TPN B IV fluid bolus C Antibiotics D Endoscopy 16  N u t r i t i o n   •   18   8.  A  70-​kg, 175-​cm female with past medical history significant for dyslipidemia is in the ICU following an ST-​elevation myocardial infarction She is intubated, sedated with midazolam, and fed with kcal/​mL tube feeds at a rate of 70 mL/​hour Additionally, she is afebrile and on scheduled acetaminophen for pain and a multivitamin elixir The nurse reports diarrhea and that the stool “does not smell like C Diff.” Her KUB is shown here: A Reduce tube feeds B Hemodialysis C Replete potassium D Administer hypertonic saline 10.  A  100-​kg patient on postoperative day after an emergent colectomy is now status post tracheostomy insertion, and all abdominal drains have been removed The patient is currently not on tube feeds, is receiving 50 mcg/​kg per minute of propofol, 100 mcg/​hour of fentanyl, and routine gastrointestinal prophylaxis and thromboprophylaxis You are called to the bedside while she us undergoing indirect calorimetry assessment, with results on the screen shown here (image courtesy of George Williams) After considering the patient’s resting energy expenditure (REE) as her clinical status, which rate BEST approximates the patient’s tube feed requirement? A 700 kcal/​day B 1400 kcal/​day C 2100 kcal/​day D 2800 kcal/​day Which of the following is the MOST appropriate to resolve the patient’s diarrhea? A Oral cimetidine B Oral vancomycin C Discontinuation of oral medications D Reduction of tube feeds 9. A 96 -​year-​old female with a past medical history significant for Brugada syndrome is found unconscious in her home by her family after she did not respond to phone calls for 4  days After interrogation, her pacemaker indicates frequent premature ventricular contractions with no shocks delivered Laboratory findings include: Sodium: 130  mEq/​L Potassium: 2.7  mEq/​L Chloride: 110  mEq/​L Bicarbonate: 31  mEq/​L Urea: 62  mg/​dL Creatinine: 2.1  mg/​dL 11. A patient is transferred from the f loor with altered mental status and marginally responsive to stimulus The hospitalist service reports that the patient has a history of polysubstance abuse You decide to place a feeding tube Which of the following is the BEST indication for placement of a postpyloric feeding tube? A Reduced aspiration risk B Ease of placement C More physiological digestion D Acute pancreatitis 12.  A  patient has failed trials of enteric feeding for 8  days following a complex nephrectomy due to renal cell carcinoma The team dietitian suggests initiating TPN with lipids Which of the following is NOT a risk of TPN administration? A Inflammation B Acalculous cholecystitis C Hyperkalemia D Hypercapnia Following initiation of tube feeds, the patient appears clinically weaker and remains lethargic Which of the following is the MOST appropriate next step in management? 13.  Four days after a small bowel resection, a patient with a body mass index of 16 kg/​m2 has gastric output of 1200 mL/​shift, abdominal distention, and no bowel movements During the morning assessment, the 19 0  •  A n e s t h e s i o l o g y C r i t i c a l Ca r e B oa r d  Re v i e w   Time VCO2 VO2 RQ REE REE_Covar FIO2 Vt BTPS 7:46 241 304 0.79 2110 10 38.39 449 7:49 241 304 0.79 2110 10 38.39 449 7:53 239 300 0.79 2086 10 38.39 446 7:56 241 304 0.79 2110 10 38.39 449 VCO2 VCO2 FIO2 REE 400 400 40 2500 360 360 36 2250 320 320 32 2000 280 280 28 1750 240 240 24 1500 200 200 20 1250 160 160 16 1000 120 120 12 750 80 80 500 40 40 250 0 Time (Mid of 7) Figure Q10.1 patient apparently has had flatus but no other examination changes There is no central line present, and the family is concerned about the patient’s nutritional status Which of the following is the MOST appropriate next step? A Insert duodenal feeding tube B Initiate  TPN C Indirect calorimetry D Resume gastric feeding 14.  A  patient with a large left lower extremity wound is scheduled for daily plastic surgery procedures over the next two weeks Although he is conscious and communicating, he cannot swallow and has a duodenal feeding tube placed in order to provide nutrition while not in the operating room Which of the following would be the MOST effective means of gastric ulcer prophylaxis? A Administer tube feeds B Antacids C Sucralfate D Cimetidine 15.  A  56-​year-​old female becomes acutely hypotensive and is requiring vasopressors She is intubated because of hypoxia that was refractory to high-​flow nasal cannula oxygen Blood cultures are negative, but bronchial alveolar lavage cultures reveal 10,000 CFU of methicillin-​resistant Staphylococcus aureus Which of the following would be the MOST appropriate nutritional approach to this patient’s care? A Arginine supplementation B Underfeeding C Early  TPN D Trace elements 16  N u t r i t i o n   •   191   to metabolism) and the feces (~4–​6 g/​day), measuring the urinary urea nitrogen (UUN) and adding to g can pro1 ANSWER: C vide the total amount of nitrogen lost Therefore, nitrogen balance = protein administered (g)/​6.25 –​[UUN + ~4 g] This patient is receiving 35 kcal/​kg per day at his current Prealbumin can be used to measure overall nutrirate, which can be reasonably calculated in the testing envi- tion status because it has a relatively short half-​life (2  days) ronment While the range of caloric demand for a critically compared with transferrin (7 days) While these tests may be ill patient is 25 to 35 kcal/​kg per day, this requirement tends useful, they not provide an immediate assessment of the to change as the admission progresses After 7 days, most patient’s hospital nutrition status Paracetamol absorption is a patients enter a recovery phase, which results in a 35-​to 50-​ method of determining absorption in the small intestine and kcal/​kg per day caloric requirement While the amount of is not affected by absorption in the stomach This effectively calories that the patient is currently receiving is within this makes paracetamol a measure of the gastric emptying rate range, it is prudent and most appropriate to measure indi- While this may be useful in certain clinical situations, a test rect calorimetry so as to avoid overfeeding and its related of gastric emptying is not related to overall nutritional status complications Similarly, reducing tube feeds would likely Keyword: Nitrogen balance, other be counterproductive because more clinical data regarding the patient’s actual metabolism are needed Overfeeding of fats or glucose can stress the patient physiologically and compound insulin resistance Additionally, ANSWER: A when substrate excess is administered, metabolically induced increased oxidative processes and reactive oxygen The energy provided by a nutrient type is equal to the molecules are promoted The CT scan demonstrates free heat produced by the nutrient following oxidation; this is abdominal fluid, a clinical finding consistent with the abnormally expressed as kcal/​g Lipids provide the highest dominal sepsis that the patient presents with here As such, amount of energy per gram (9.1 kcal/​g), followed by protein repeating the CT scan would likely serve no clinical benefit (4 kcal/​g) and glucose (3.7 kcal/​g) When the metabolic oxWhile the patient is critically ill, a stool ova and parasites idation of all provided nutrients are added together, this can would not be most appropriate be used to determine the REE The REE should be used to Keywords:  Metabolic assessment (basal and stress energy determine the amount of nutrition to provide to a patient requirements); Indirect calorimetry owing to the tremendous changes in metabolism that can be seen during critical illness Arginine is a precursor to nitric oxide and is used to R E F E R E NC E S help rebuild muscle because it is a substrate in that process; it is particularly prone to depletion following trauma The Cynober L, Moore FA Nutrition and critical care In Nitenberg G, exact amount of arginine needed to meet metabolic needs ed Nutritional support in sepsis and multiple organ failure Nestlé is not known, although it is an additive in several types of Nutrition Workshop Series Clinical and Performance Program, volume Basel:  Nestec Ltd Vevey/​ S Karger AG; 2003, pp nutrition formulas A NSW E RS 223–​244 Griffiths RD Too much of a good thing: the curse of overfeeding Crit Care 2007;11(6):176 Rattanachaiwong S, Singer P Should we calculate or measure energy expenditure? Practical aspects in the ICU Nutrition 2018;55–​56:71–​75 ANSWER: B Nitrogen balance is an important tool to determine adequacy of nutrition Nitrogen balance can be effectively calculated by determining the amount of protein administered (in this case given in the question stem), and the amount of protein lost Of note, 16% of the weight of protein given is actually nitrogen; therefore, the total amount of protein administered can be divided by 6.25 to obtain the nitrogen administered With regard to losses, because protein is primarily lost in the urine (~67% of all protein relating Keywords:  Metabolic assessment (basal and stress energy requirements); Nitrogen balance, other R E F E R E NC E S Cynober L, Moore FA Nutrition and critical care In Nitenberg G, ed Nutritional support in sepsis and multiple organ failure Nestlé Nutrition Workshop Series Clinical and Performance Program, volume Basel:  Nestec Ltd Vevey/​ S Karger AG; 2003, pp 223–​244 Marino P The ICU book Philadelphia:  Wolters Kluwer Health/​ Lippincott Williams & Wilkins; 2014, pp 847–​848 ANSWER: D This patient is presenting with clinical signs of sepsis and is on TPN It is surmised that the possible immunosuppressive 19 2  •  A n e s t h e s i o l o g y C r i t i c a l Ca r e B oa r d  Re v i e w   effect of lipids in the septic patient occurs because long-​ chain fatty acids reduce the functionality of the reticuloendothelial system, neutrophils, and the relative presence of helper and suppressor T cells While oxidization of fatty acids is not shown to be impaired, sepsis appears to reduce the metabolism of fatty acids, leading to higher lipid concentrations in the blood and further exacerbating the potential for worsening of the sepsis While peripheral vascular disease is possible given the presence of diabetes, the stem does not provide any information making this selection more likely Although hypothermia may result in metabolic dysfunction, this presentation is more likely the result of overwhelming sepsis and not the cause of infection or immunosuppression Deep vein thrombosis may result in fever, but it is not characteristically associated with fever and hypotension R E F E R E NC E S Alhazzani W, Jacobi J, Sindi A et  al The effect of selenium therapy on mortality in patients with sepsis syndrome: a systematic review and meta-​analysis of randomized controlled trials Crit Care Med 2013;41(6):1555–​1564 Marino P The ICU book Philadelphia:  Wolters Kluwer Health/​ Lippincott Williams & Wilkins; 2014, pp 851–​853 ANSWER: B The patient presents following protracted diarrhea with likely associated volume loss and hypokalemia The ECG shown demonstrates T-​wave inversion with mild tachycardia, which would be consistent with both hypokalemia and hypovolemia While muscle weakness may be seen in hypokaKeyword: Nutritional support (enteral, parenteral) lemia, most patients not have symptoms Approximately 50% of patients present with ECG changes None of the provided answers would result in fluid resuscitation approR E F E R E NC E S priate for this presentation because only 7% of D5 water administered would remain intravascular after administraMarino P The ICU book Philadelphia:  Wolters Kluwer Health/​ tion, and it could also lead to hypovolemic hyponatremia Lippincott Williams & Wilkins; 2014, pp 847–​848 Vincent J, Abraham E, Moore F et  al Textbook of critical care, 6th in this case There is no indication of anemia based on the edition Philadelphia: Elsevier Saunders; 2011, p. 724 clinical data provided Because being afebrile is implied (normal vital signs), with a marginally elevated WBC count, the need for antibiotics is questionable and therefore not the BEST answer based on the information provided ANSWER: A Keywords: Diarrhea, nausea, vomiting Thiamine (vitamin B1) is key in carbohydrate metabolism because it functions as a coenzyme for pyruvate dehydrogenase (which allows pyruvate to enter mitochondria) Because of this, thiamine deficiency affects the brain, which is sensitive to disruptions in availability of adenosine triphosphate Overall, it is likely that vitamin requirements are higher for septic patients than for normal patients because reports of deficiency have been written in the absence of supplementation Vitamin E is helpful in reducing reperfusion injury following aortic cross-​clamping, and serum levels may be useful to monitor if deficiency is suspected; it does not appear to be pertinent in this presentation Selenium deficiency has been shown to be associated with sepsis, and supplementation of selenium may be helpful in reducing mortality in sepsis, although no effect on length of stay or pneumonia was found As such, more data are needed to confirm the role of selenium in sepsis Linoleic acid is the only fatty acid that must be ingested or provided in the diet A scaly rash, susceptibility to infection, and cardiac dysfunction are seen with this deficiency Linoleic acid is provided automatically in most nutritional regimens, and safflower oil should be the additive in order to provide this essential item Keyword: Nutritional deficiencies R E F E R E NC E Marino P The ICU book Philadelphia:  Wolters Kluwer Health/​ Lippincott Williams & Wilkins; 2014, p. 677 ANSWER: C The KUB and presentation described are consistent with an ileus While less common, urinary tract infections may lead to an ileus or a small bowel obstruction picture Although an ileus may prevent administration of tube feeds, TPN should not be given immediately because it is associated with disruption of gut mucosa and infectious complications IV fluids may be helpful and commonly needed in the setting of ileus, but a bolus does not appear to be needed under these circumstances because the patient is urinating well IV fluids are certainly useful while providing bowel rest for patients with an ileus (e.g., Ogilvie syndrome or pseudo-​obstruction) Endoscopy may eventually be part of the patient’s workup, but at this junction in his care, allowing the ileus 16  N u t r i t i o n   •   19   to resolve would be more appropriate If further workup is required, oral contrast with Gastrografin may aid both in diagnosis of the degree of obstruction and in resolving an obstruction owing to its osmotic effect Antibiotics to treat the urinary tract infection would be the most helpful option out of the choices given for this specific presentation Vincent J, Abraham E, Moore F et  al Textbook of critical care, 7th edition Philadelphia: Elsevier; 2017, pp 103–​104 Keyword: Ileus This patient is demonstrating the overall electrolyte derangements consistent with refeeding syndrome Refeeding syndrome is manifested by acute reduction in many of the electrolytes, which are principally intracellular, including potassium, sodium, magnesium, and phosphorus Additionally, water balance may be altered, and thiamine deficiency can occur The patient appears to have a hypovolemic hyponatremia, and her weakness suggests hypophosphatemia Hypertonic saline may improve the lab results but is not indicated given her volume status and does not address the underlying problem Reducing tube feedings to less than 500 kcal/​day is indicated when signs of refeeding syndrome are noted Hemodialysis does not have a role in managing a patient with refeeding syndrome R E F E R E NC E Miraflor E, Green A Small bowel obstruction In: Harken A, Moore E, eds Abernathy’s surgical secrets, 7th edition Philadelphia: Elsevier; 2018 ANSWER: C Diarrhea is a common presentation in the ICU and has many potential causes Overfeeding is a common cause of diarrhea and occurs in 33% of ICU patients In this case, a 70-​kg patient is being fed slightly less than 25 kcal/​kg per day; it is important to note that this is following a calculation of her ideal body weight, which is 70 kg based on a height of 175 cm [ideal body weight = height (cm) –​100 (in males). . . or = height (cm) –​105 (in females) Therefore, this diarrhea is not resulting from overfeeding, and reduction in tube feeding amount is unlikely to be helpful Undigested proteins can lead to diarrhea, especially when postpyloric tubes are being used; in this case, the KUB demonstrates a tube that is in the stomach High fructose may lead to this as well (no indication of this based on the question), and gastrointestinal tract atrophy may cause diarrhea as well Although the patient is on acetaminophen, an antipyretic would not likely suppress a C. difficile mega colonic fever, and therefore vancomycin would not be appropriate (although it remains the preferred first-​line therapy) Given the previous discussion, sorbitol-​containing drugs are the most likely way to resolve or reduce this patient’s diarrhea and related malabsorption Sorbitol is considered inert by the US Food and Drug Administration and is frequently added to medications to provide sweetness and texture However, just 10 to 20 grams of sorbitol can cause diarrhea; this amount can be contained in just two to three doses of medication Oral cimetidine contains sorbitol and would therefore likely worsen the patient’s presentation Keyword: Malabsorption R E F E R E NC E S Btaiche IF, Chan LN, Pleva M, Kraft MD Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients Nutr Clin Pract 2010;25(1):32–​49 ANSWER: A Keyword: Refeeding syndrome R E F E R E NC E Vincent J, Abraham E, Moore F et  al Textbook of critical care, 7th edition Philadelphia: Elsevier; 2017, p. 207 10 ANSWER: B Propofol contains 1.1 kcal/​ mL of lipid-​ based calories Given the frequency of propofol’s use as a sedation agent in the ICU, understanding and being able to calculate the degree to which propofol may affect nutrition is important and frequently germane to the content of daily rounds The calculation of propofol’s calories is manifested by: [(Propofol mcg/​kg/​min) × (patient weight in kg) × (60 min)] × (1 mg/​1000 mcg) = hourly mg of propofol So, by entering the information from the question stem: [(50 mcg/​kg/​min) × (100  kg) × (60 min)/​1000]  =  (50 × 100 × 60)/​1000 = (300,000)/​1000 = 300 mg Since propofol is only available in a concentration of 10 mg/​ mL, one can immediately determine that the actual pump rate of propofol for this patient is 30 mL/​hour, which effectively means that the patient is receiving 30 kcal/​hour of propofol, or 720 kcal/​day After knowing this information, and then knowing from the indirect calorimetry report shown that the patient has an REE of about 2110 kcal/​day, 19 4  •  A n e s t h e s i o l o g y C r i t i c a l Ca r e B oa r d  Re v i e w   the patient only needs the remaining calories not provided by propofol [2110 kcal (REE) –​720 kcal (propofol)], which is 1390 kcal Anything more that this would, by definition, be overfeeding Keyword:  Enteral and parenteral nutrition (formula, caloric intake) 11 ANSWER: D Because a postpyloric tube bypasses the stomach and potentially the duodenum, there is less stimulation of the exocrine function of the pancreas while still maintaining the intestinal barrier In either case, guidelines still recommend feeding in acute pancreatitis because several meta-​analyses demonstrate a reduction in length of stay and complications While a nasojejunal tube may be smaller, placement is not easier compared with placement of a gastric tube because a gastric tube may be placed at the bedside by most hospital personnel with a minor amount of training It should be noted that 1% of feeding tube insertions go into the trachea and that a chest radiograph is required before use of a feeding tube (auscultating for bowel sounds with a push of air can be misleading) Feeding into the stomach is more physiological and allows the intrinsic digestive process to regulate gastric emptying and to introduce food into the small bowel Valentine et  al demonstrated that gastric feeding is also thought to reduce gastric pH compared with postpyloric feeding Unless the presentation is consistent with gastric ileus, there is no difference in the rate of aspiration between gastric and duodenal feeding Keyword: Enteral tubes R E F E R E NC E S Marik PE, Zaloga GP Gastric versus post-​pyloric feeding: a systematic review Crit Care 2003;7:R46–​R51 Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology American College of Gastroenterology guideline:  management of acute pancreatitis Am J Gastroenterol 2013;108(9):1400–​1416 Valentine RJ, Turner WW Jr, Borman KR, Weigelt JA Does nasoenteral feeding afford adequate gastroduodenal stress prophylaxis? Crit Care Med 1986;14(7):599–​601 12 ANSWER: C With TPN administration, glucose is expected to move intracellularly with an accompanied movement of potassium; therefore, potassium levels will decrease, not increase Similarly, because phosphate also follows glucose in order to participate in glucose metabolism, hypophosphatemia may occur when TPN is initiated Hypercapnia may be produced with excess carbohydrate retention associated with overfeeding in general, which is seen in patients on TPN The lipids (including oleic acid) that are administered with TPN are thought to promote inflammation; in fact, when acute respiratory distress syndrome must be instigated in animal models in order to achieve basic science research, administration of oleic acids is a means to achieve this goal In general, since lipid emulsions used in TPN have an abundance of oxidizable lipids, an inflammatory response should be expected Because TPN is associated with discontinuation of fat content in the gut, the gallbladder is no longer required to contract This process leads to sludge buildup in the gallbladder, which in time leads to acalculous cholecystitis Keyword: Acalculous cholecystitis R E F E R E NC E Marino P The ICU book Philadelphia:  Wolters Kluwer Health/​ Lippincott Williams & Wilkins; 2014, pp. 881 13 ANSWER: A The patient has symptoms consistent with a gastric ileus, which is common and even expected following abdominal surgery Placement of a duodenal feeding tube could be helpful in bypassing the region of the ileus, although this would need to be done slowly to ensure that the patient tolerates feeding appropriately TPN could be used in this patient, although given a high rate of complications, infection, intestinal barrier breakdown, and so forth (see earlier question), TPN is not normally started until after to 7 days of no nutrition (unless it is expected that the lack of nutrition would be prolonged) Additionally, the patient would have to have central access in order to receive TPN This is because the final concentration of TPN is commonly about 35% dextrose, which has a relative osmolality of 1800 mOsm/​kg water; this concentration is poorly tolerated in the veins, necessitating a central line for administration Once infused centrally, TPN is immediately diluted in the higher flow blood of the vena cava or femoral vein Indirect calorimetry could be useful in determining caloric needs of the patient but would not be helpful in achieving nutrition, making this choice not an ideal next step Resuming gastric feeding may be possible eventually, 16  N u t r i t i o n   •   19   but with high gastric residual and output being reported, this is not the appropriate time to initiate gastric feeding Keyword: Enteral nutrition R E F E R E NC E Morgan S, Weinsier R, eds Fundamentals of clinical nutrition, 2nd edition St Louis: Mosby; 1998, p. 201 14 ANSWER: D Cimetidine is a histamine-​2 receptor antagonist, a commonly used class of medications to achieve ulcer prophylaxis, and has been demonstrated to be more effective than sucralfate alone Additionally, sucralfate is a cytoprotective agent, which works by forming a protective layer physically in the stomach Because of this mechanism, no change in gastric pH is expected, which can be helpful in maintaining normal flora Sucralfate is not the best choice for a second reason: it does not work unless administered in the stomach or orally, and it does not have an effect if given in a postpyloric tube Antacids have not been demonstrated to be an adequate prophylactic agent and therefore should not be used Enteral nutrition is considered by some as an option to reduce the risk for gastric bleeding; however, this has not been demonstrated consistently in the literature, possibly because it is challenging to consistently provide nutrition in the critical care setting In this case, the question stem indicated frequent trips to the operating room; this patient would not realistically be able to benefit from the tube feedings that he eventually receives because of the intermittent nature of his feeding schedule Keywords:  Gastrointestinal Malabsorption motility 15 ANSWER: D Trace elements such as selenium and zinc are commonly deficient in critically ill patients, and their repletion has minimal risks when dosed properly Repletion should be based on levels assessed, and parenteral nutrition solution is not the ideal source for the entirety of the trace elements administered (the volumes would be too high); therefore, many of these supplements are given separately intravenously and cannot be given by nasogastric tube Selenium and zinc levels are best checked between and 10 days if the level is not known at baseline Multiple observational studies have evaluated underfeeding as a mechanism of caring for critically ill patients It generally appears that there may be a role in underfeeding around 80% or slightly less in many critically ill patients, but this has not been evaluated with a randomized control trial; current trials link increased length of stay with exceeding 80% of calorie goals Currently, it appears that there is no mortality benefit, but there is a benefit in reducing infectious complication when enteral nutrition is chosen over parenteral nutrition; therefore, early TPN would not be the best choice Arginine supplementation has been demonstrated to improve wound healing immune function in humans and animals The mechanisms of this benefit include effects mimicking growth hormone, stimulation of T cells, availability of collagen molecules, and substrate for the generation of nitric oxide The problem is that arginine in sepsis is contraindicated because of worsening of septic shock in canine studies Currently, arginine is not recommended in the setting of septic shock, as is the case in this patient Keyword:  Enteral and parenteral nutrition (formula, caloric intake) dysfunction; R E F E R E NC E Deutschman C, Neligan P Evidence-​based practice of critical care Philadelphia: Saunders; 2010, p. 487 R E F E R E NC E S Deutschman C, Neligan P Evidence-​based practice of critical care Philadelphia: Saunders; 2010, pp 461–​477 Hise ME, Halterman K, Gajewski BJ et al Feeding practices of severely ill intensive care unit patients: an evaluation of energy sources and clinical outcomes J Am Diet Assoc 2007;107:458–​4 65 19 6  •  A n e s t h e s i o l o g y C r i t i c a l Ca r e B oa r d  Re v i e w   INDEX Tables, figures, and boxes are indicated by t, f, and b following the page number For the benefit of digital users, indexed terms that span two pages (e.g., 52–53) may, on occasion, appear on only one of those pages 4Ts scoring system, 38 ABCDEF bundle, 1, 7–​8 abdominal compartment syndrome, 47, 57 abdominal wall contusion, 3, 72–​73 abscess cerebral abscess, 5, 16–17 infectious pyogenic liver abscess, 54 absent H reflex, 3, 12 acalculous cholecystitis, 190, 195 acid-​base abnormalities diabetic ketoacidosis (DKA), 166, 169, 173, 177 hyperkalemia, 165, 171 hypomagnesemia, 167–​68, 175 hyponatremia, 165, 166 hypophosphatemia, 167, 173 metabolic acidosis, 168, 175, 175t respiratory acidosis, 166, 170, 172,  177–​78 Acinetobacter baumannii, 89–​9 0, 98 acquired hemophilia, 36–​37 activated PCC (aPCC), 26–​27, 37 acute flaccid paralysis, 3, 13 acute inflammatory demyelinating polyneuropathy (AIDP), 12, 13 acute liver failure (ALF), 44, 50–​51 acute-​onset abdominal pain, 46, 55 acute pancreatitis, 48, 58 acute promyelocytic leukemia, 35 acute respiratory distress syndrome (ARDs), 126, 130–​31 acute Stanford type A aortic dissection, 151–​52, 161–​62, 161–​62f acute suction event, 152, 163, 163f acute variceal bleed, 46, 55 ADAMTS13,  35–​36 adrenal insufficiency, 17, 100, 103 advanced trauma life support (ATLS), 61,  66–​67 AEDs (antiepileptic drugs), 16 AIDP (acute inflammatory demyelinating polyneuropathy), 12, 13 Alberta Stroke Program Early Computed Tomography (ASPECT), 2, 10–​11 ALF (acute liver failure), 44, 50–​51 all-​transretinoic acid (ATRA), 25, 35 altered mental status coma, 1, 7 delirium and hallucinations, 1, 7–​8 hypoxic/​metabolic encephalopathy, 8 microangiopathic hemolytic anemia and thrombocytopenia, 26, 35–​36 American Spinal Cord Injury Association (ASIA) Impairment Scale, 14 amniotic fluid embolus, 20, 22 ANA (anti-​nuclear antibody) test, 107, 111 anaerobic bacteria, 90, 98 anastomotic leak, 46–​47, 56 aneurysms, 2, 10 angiography catheter angiography, 8–​9 CTA (CT angiography), 2, 10 in delayed cerebral ischemia (DCI), 18 digital subtraction angiography, 10 ANOVA, 116, 120 anoxic brain injury, 8–​9 antibiotics contraindicated in G6PD deficiency, 88,  95–​96 for ESBL-​producing Enterobacteriaceae, 89, 97 for gram-​negative organisms, 89f, 89, 96 for intra-​abdominal infections, 90, 98 in peripartum infection, 19, 21 for spirochetal and rickettsial infections, 90, 90f, 99 for tuberculosis treatment, 88, 95 anti-​CCP (anti–​c yclic citrullinated peptide) antibody, 107, 111 anticoagulants enoxaparin overdose, 29, 40–​41 management strategies, 41–​4 reversal of, 17, 24, 32 reversal with idarucizumab, 29 thrombin inhibitors, 40 anticonvulsants arresting seizures with, 2, 9 cognitive outcomes with long-​term treatment, 10 in eclampsia, 5, 16, 21 antidepressants lithium side effects, 88, 94–​95 selective serotonin reuptake inhibitor (SSRI) overdose, 87–​88, 93–​94 tricyclic antidepressant (TCA) overdose, 60–​61, 65–​6 6, 88, 94 antiepileptic drugs (AEDs), 16 antimicrobials in acute pancreatitis, 48, 58 in burn patients, 79, 83 contraindicated in G6PD deficiency, 88,  95–​96 empiric management of early-​onset VAP, 89, 89f, 96–​9 7,  96–​9 7b encephalitis, empiric therapy, 90, 98 ESBL-​producing Enterobacteriaceae, 89, 97 esophageal candidiasis, 88, 95 in infected pseudocysts, 47, 57 in infectious encephalitis/​meningitis, 3, 9–​10, 12 intra-​abdominal infections, 90, 98 multidrug-​resistant Acinetobacter baumannii, 89–​9 0, 98 pinworm infection, 91, 99 spirochetal and rickettsial infections, 90, 90f, 99 spontaneous bacterial peritonitis, 44, 50, 108, 113 surgical site infections (SSIs), 89f, 89, 96 tuberculosis treatment, 88, 95 anti-​nuclear antibody (ANA) test, 107, 111 antiplatelet agents, 17, 41–​4 2, 136–​37,  143–​4 antipsychotics ICU delirium, 87, 93 not recommended in delirium, 7–​8 anti-​retroviral (ART) medication in decreased renal function, 107, 110 initiation of, 107, 110 aPCC (activated PCC), 26–​27, 37 apnea crescendo-​decrescendo respiratory pattern, 7 post-​hyperventilation apnea, 1 reflective of brainstem pathology, 7 apneustic breathing, 7 ARDS (acute respiratory distress syndrome), 126, 130–​31 ART (anti-​retroviral) medication in decreased renal function, 107, 110 initiation of, 107, 110 arterial catheters, 181, 185 ASIA (American Spinal Cord Injury Association) Impairment Scale, 14 ASPECT (Alberta Stroke Program Early Computed Tomography), 2, 10–​11 aspirin, 41–​4 2, 136–​37, 144 asystole, 133–​3 4, 138 ATACH trial, 17 ataxic breathing, 7 ATLS (advanced trauma life support), 61,  66–​67 ATRA (all-​transretinoic acid), 25, 35 atrial fibrillation, 133, 138, 148, 153 atrioventricular nodal re-​entry tachycardia (AVNRT), 134, 138–​4 atrioventricular re-​entry tachycardia (AVRT), 134, 138–​4 AVNRT (atrioventricular nodal re-​entry tachycardia), 134, 138–​4 AVRT (atrioventricular re-​entry tachycardia), 134, 138–​4 in eclampsia, 16 biologic, chemical, and nuclear exposures, 60, 64, 64t biostatistics categorical tests, 116, 120, 120f odds ratios, 117, 122 regression analysis, 118–​19, 118–​19f relative risk, 117, 122 type and type errors, 116, 120 variable types, 116, 120 blast injuries, 61, 68, 68t bleeding disorders See also coagulopathies postpartum hemorrhage, 19, 21 recalcitrant postpartum hemorrhage, 19, 21 blood transfusions See transfusion management blunt cardiac injury (BCI), 61, 68 bowel injury, traumatic, 72–​73, 72t brachiocephalic artery, 152, 183, 186–​187 brain death brain-​dead donors, 13 diagnosis, 1, 8–​9 ethics, 115 vasoactive drugs in, 118 brainstem infarction See stroke Brugada syndrome, 135–​36, 142 Budd-​Chiari syndrome, 45, 53–​5 burn management and complications carbon monoxide poisoning, 79, 80, 83,  85–​86 chemical burns (hydrofluoric acid), 78,  84–​85 consensus formula (burn resuscitation), 78, 81 cyanide poisoning, 79, 84 deep vein thrombosis and pulmonary embolism, 78, 82 escharotomies, 79, 83 fire-​related inhalation injury, 80, 85 hypermetabolic response, 78, 81–​82 indication of resuscitation end point, 78, 82 metabolic acidosis, 79, 83 occlusion of the distal airways due to cast formation, 80, 86 overresuscitation, 78, 81 topical applications for burn treatment, 78, 81 bacterial meningitis, 2, 9–​10 basal and stress energy requirements, 188, 192 B-​cell lymphoma (mediastinal), 27, 27f, 37 BCI (blunt cardiac injury), 61, 68 benzodiazepines arresting seizures with, 9 delirium associated with, 7–​8 CAM-​ICU assessment tool, 7–​8 , 115, 119 candidiasis, esophageal, 88, 95 carbon monoxide poisoning, 80, 85–​86 carboxyhemoglobin clinical presentation, 34–​35 diagnosis, 25, 34 measurement, 35 treatment, 33, 35 19   cardiac contusion, 61, 68 cardiovascular system, mechanical support and resuscitation acute Stanford type A aortic dissection, 151–​52, 161–​62, 161–​62f acute suction event, 152, 163, 163f Eisenmenger syndrome, 150, 156–​57 EMCOs, 148, 153–​5 endocarditis, 149, 155 heparin, 137, 146–​47, 148, 153 HIT (heparin-​induced thrombocytopenia), 151, 159 IABPs (intra-​aortic balloon pump), 149, 154 left-​to-​right intracardiac shunt, 150, 156 PEA (pulseless electrical activity), 135, 141, 150, 157 perioperative myocardial infarction (PMIs), 151, 160 peripheral vascular disease, 152, 162–​63 right ventricular dysfunction, 149, 155 SAM, 152, 164 septic shock, 151, 159–​6 in-​stent thrombosis of DES, 151, 161 symptomatic ICH, 150, 158 TEG (thromboelastogram) test, 150, 157–​58,  158f transplant rejection, 149–​50, 155–​56 Wolff-​Parkinson-​W hite (WPW) syndrome, 142–​4 3, 148, 153 cardiovascular system, physiology and management antiplatelet agents, 136–​37, 143–​4 asystole, 133–​3 4, 138 atrial fibrillation, 133, 138 Brugada syndrome, 135–​36, 142 heart block, 134–​35, 140 heparin, 137, 146–​47, 148, 153 HIT (heparin-​induced thrombocytopenia), 151, 159 PEA (pulseless electrical activity), 135, 141, 150, 157 prognostication following cardiac arrest, 1 pulmonary hypertension, 137, 145 SVT/​tachyarrhythmias, 134,  138–​4 ventricular fibrillation/​ventricular tachycardia, 135, 141–​4 warfarin, 137, 146 Wolff-​Parkinson-​W hite (WPW) syndrome, 142–​4 3, 148, 153 cardiovascular system, trauma management REBOA for trauma, 63, 76–​7 subclavian artery injury, 63, 77 categorical tests, 116, 120, 120f catheter angiography, 8–​9 catheter-​a ssociated urinary tract infections (CAUTIs), 165, 171 CD4 counts ART initiation, 107, 110 HIV-​specific immunity and, 106, 110 central nervous system (CNS) diagnoses and management abscess, 5, 16–17 acute flaccid paralysis, 3, 13 AIDP (acute inflammatory demyelinating polyneuropathy), 12, 13 altered mental status (coma), 7 altered mental status (delirium, hallucinations), 1, 7–​8 , 20, 22, 87, 93, 115, 119 altered mental status (hypoxic/​ metabolic encephalopathy), 1, 8 brain death, 1, 8–​9, 13, 115, 118 Charcot-​Marie-​Tooth syndrome, 3, 13 delayed cerebral ischemia (DCI), 18 epidural hemorrhage, 2, 11 Guillain-​Barré syndrome (GBS), 8–​9, 12, 13 herpes simplex virus encephalitis (HSE), 3, 12 infectious encephalitis/​meningitis, 2, 9–​10,  13 neuromuscular disease and myasthenia gravis, 3, 11–​12 pituitary disorders, 5, 17 SAH (spontaneous subarachnoid hemorrhage), 6, 10, 17, 18 seizures and status epilepticus, 2, 5, 9, 16 spinal cord injury, 14 spinal epidural abscess (SEA), 4 stroke (embolic/​thrombotic and ischemic), 2, 4, 10–​11, 15 stroke (hemorrhagic), 5, 17 traumatic brain injury (TBI), 14–​16 vascular malformations, 6, 18 cerebral abscess, 5, 16 cerebral angiography, 18 cerebral blood flow testing, 8–​9 cerebral compliance, 16 cerebral salt wasting (CSW), 100, 103–​4 cerebral vasospasm, 18 CETPH (chronic thromboembolic pulmonary hypertension), 137, 145 Charcot-​Marie-​Tooth syndrome, 3, 13 chemical burns (hydrofluoric acid), 78,  84–​85 chest trauma, 61, 69, 125, 128–​29 chest tube placement, 179, 183 Cheyne-​Stokes respirations, 7 Chiari I malformation (CIM), 92–​93 Child-​Turcotte-​Pugh scoring system, 46, 54 "chocolate brown" blood, 24–​25, 33 cholecystitis, 47, 58 chorioamnionitis., 21 chronic thromboembolic pulmonary hypertension (CETPH), 137, 145 cilostazol, 136–​37, 144 CIM (Chiari I malformation), 92–​93 CIM (critical illness myopathy), 13 CIP (critical illness polyneuropathy), 13 cisatracurium (benzylisoquinoline), 92 citrate toxicity, 24, 31 clopidogrel, 41–​4 2, 136–​37, 144 coagulation factor deficiencies, 17 coagulation studies hemophilia, congenital, 28, 37–​38 MELD score, 44, 52 mixing study, 36 coagulopathies due to hypoxic hepatitis, 43, 49 hemophilia, congenital, 28, 37–​38 non-​vitamin K oral anticoagulant reversal, 29, 40 postpartum hemorrhage, 19, 21 recalcitrant postpartum hemorrhage, 19, 21 trauma-​induced coagulopathy, 61, 67 vitamin K coagulopathy, 25, 33, 33t colonic pseudo-​obstruction (Ogilvie syndrome), 48, 58–​59 compartment syndrome, 47, 57 consensus formula (burn resuscitation), 78, 81 continuous renal replacement therapy (CRRT), 168, 169, 175, 176 contrast-​induced nephropathy, 167, 174 critical illness myopathy (CIM), 13 critical illness polyneuropathy (CIP), 13 CRRT (continuous renal replacement therapy), 168, 169, 175, 176 cryoprecipitate, 19, 21, 32, 36 CSF pleocytosis, 13 CSW (cerebral salt wasting), 100, 103–​4 CT angiography (CTA), 2, 2f, 10 daily sedation interruptions, 7–​8 DAWN trial, 10–​11 DCI (delayed cerebral ischemia), 18 delirium and hallucinations delirium assessment, 115, 119 ICU delirium, 87, 93 treatment, 1, 7–​8 delivery See obstetric critical care dense MCA (middle cerebral artery) sign, 2 dexamethasone in herniation from vasogenic edema, 16 ineffective in aneurysmal SAH, 10 in infectious encephalitis/​ meningitis,  9–​10 dexmedetomidine, 7–​8 , 22 diabetes insipidus (DI), 3, 13, 100, 103 diabetes mellitus, 100, 103 diabetic ketoacidosis (DKA), 100, 103, 166, 169, 173, 177 diarrhea, nausea, and vomiting, 189, 193 DIC (disseminated intravascular coagulation), 31, 35, 36 diffusion-​weighted imaging (DWI), 5 digital subtraction angiography, 10 dilutional thrombocytopenia, 31 dipyridamole, 136–​37, 144 disseminated intravascular coagulation (DIC), 31, 35, 36 DIT (drug-​induced immune thrombocytopenia), 39 DKA (diabetic ketoacidosis), 100, 103, 166, 169, 173, 177 drowning, fatal and near, 60, 64–​65 drug-​induced immune thrombocytopenia (DIT), 28, 39 DWI (diffusion-​weighted imaging), 5 early-​onset VAP (ventilator associated pneumonia), 89, 89f, 96–​9 7,  96–​9 7b echocardiography, 180, 184 eclampsia (postpartum seizures), 19–​20,  21 Eisenmenger syndrome, 150, 156–​57 electroencephalography (EEG) in infectious encephalitis/​meningitis, 2, 9–​10, 12 malignant findings indicating poor prognosis, 8 in traumatic brain injury (TBI), 15 emboli amniotic fluid embolus, 20, 22 deep vein thrombosis and pulmonary embolism, 78, 82 fat embolism syndrome (FES), 124, 127 stroke (embolic/​thrombotic and ischemic), 2, 4, 10–​11, 15 embolic/​thrombotic stroke, 2, 10–​11 EMCOs, 148, 153–​5 encephalitis empiric therapy for, 90, 98 herpes simplex virus encephalitis (HSE), 3, 12, 98–​99 infectious, 2, 2f, 9–​10, 13 endocarditis infectious, 149, 155 prophylaxis, 107, 112 19 8  •   I n d e x endocrinology adrenal insufficiency, 100, 103 cerebral salt wasting (CSW), 100,  103–​4 diabetes insipidus, 100, 103 diabetes mellitus, 100, 103 hyperthyroidism, 101, 101f,  104–​5 management strategies steroids, 101, 104 myxedema, 101–​2 , 105 panhypopituitarism, 101, 104 SIADH (syndrome of inappropriate antidiuretic hormone secretion), 100, 103 end-​of-​l ife care, 116–​17,  122 endoscopy, with therapeutic intervention, 45, 53 endotracheal intubation in acute asthma exacerbation, 20, 22 in myasthenic crisis, 3, 11–​12 in spinal cord injury, 14 enoxaparin overdose, 29, 40–​41 enteral and parenteral nutritional support, 188, 190, 191, 192–​93, 194–​95, 196 enteral nutrition, 190–​91, 195–​96 enteral tubes, 190, 195 Enterobacteriaceae, ESBL-​producing, 89, 97 Enterobius vermicularis (pinworm), 91, 99 epidural hemorrhages, 2, 11 ESBL-​producing Enterobacteriaceae, 89, 97 esophageal candidiasis, 88, 95 EVD (external ventricular drain), 5, 18 evoked potential, 8 evoked potentials, 1 explosives, 61, 68, 68t external ventricular drain (EVD), 5, 18 factor inhibitors, 26–​27, 36–​37 factor replacement four-​factor PCC (prothrombin complex concentrate), 25, 32, 33, 36 hemophilia, congenital, 28, 37–​38 management strategies, 31 recombinant activated factor vIIa, 19, 21, 36 recombinant factor IX, 37 factor VIII antibodies, 36–​37 factor VIII inhibitor bypassing activity (FEIBA), 37 FAST (focused assessment with sonography for trauma), 61, 62, 66–​67, 71–​72, 181,  185–​86 fat embolism syndrome (FES), 124, 127 FEIBA (factor VIII inhibitor bypassing activity), 37 FES (fat embolism syndrome), 124, 127 FFP (fresh frozen plasma) versus cryoprecipitate, 19, 21, 32 versus idarucizumab, 40 versus PCC, 33 in TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 fire-​related inhalation injury, 80, 85 first-​person authorization (FPA), 115–​16,  119 flail chest, 61, 69, 125, 128–​29 FLAIR (fluid attenuated inversion recovery), 16 fluid and electrolyte management, 169, 177 fluid attenuated inversion recovery (FLAIR), 16   fluid creep, 78, 81 focal-​onset seizures, 9 focused assessment with sonography for trauma (FAST), 61, 62, 66–​67, 71–​72, 181,  185–​86 folic acid levels, 35 four-​factor PCC (prothrombin complex concentrate), 25, 32, 33, 36 FPA (first-​person authorization), 115–​16,  119 fresh frozen plasma (FFP) versus cryoprecipitate, 19, 21, 32 versus idarucizumab, 40 versus PCC, 33 in TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 futility, 122 G6PD deficiency, 88, 95–​96 gallbladder disease, 47, 58 gastroenterology abdominal compartment syndrome, 47, 57 abdominal wall contusion, 72–​73, 72t acute liver failure (ALF), 44, 50–​51 acute pancreatitis, 48, 58 acute variceal bleed, 46, 55 anastomotic leak, 46–​47, 56 bacterial infections, 44, 50 Budd-​Chiari syndrome, 45, 53–​5 gallbladder disease, 47, 58 hemolytic transfusion reaction, 43,  49–​50 hepatitis, 45, 52–​53 hepatopulmonary syndrome, 44, 52 hepatorenal syndrome, 44, 45, 52, 53 hypoxic hepatitis, 43, 49 indications for TIPS, 45, 53 infected pseudocysts, 47, 57 ischemic hepatitis, 43, 49 Ogilvie syndrome (colonic pseudo-​ obstruction), 48, 58–​59 peritoneal carcinomatosis, 44, 51 portal hypertension, 46, 54 portal hypertension (ascites and caput medusae), 51 psoas abscess, 47, 56 pyogenic liver abscess, 46, 54 refeeding syndrome, 46, 55–​56 sudden-​onset abdominal pain, 46, 55 gastrointestinal (GI) hemorrhage lower, 44, 45, 51, 53 management strategies, 55 upper, 44, 45, 51, 53 gastrointestinal motility dysfunction, 191, 196 GBS (Guillain-​Barré syndrome), 8–​9, 12, 13 Glasgow Coma Scale (GCS) score, 4 glucocorticoids in CSW and SIADH, 101, 104 efficacy in spinal cord injury, 14 in infectious encephalitis/​ meningitis,  9–​10 in myasthenia gravis, 11 graft-​versus-​host disease  (GVHD) diagnosis, 106, 109 manifestations, 106 target organs, 109 treatment, 106, 109 gram-​negative organisms antibiotics for, 89f, 89, 96 ESBL-​producing Enterobacteriaceae, 89, 97 gray-​white differentiation, loss of, 8–​9 Guillain-​Barré syndrome (GBS), 8–​9, 12, 13 GVHD (graft-​versus-​host disease) diagnosis, 106, 109 manifestations, 106 target organs, 109 treatment, 106, 109 HART See ART (anti-​retroviral) medication HBO (hyperbaric oxygen), 33, 35 HCAHPS performance measures, 115, 118 head injury, 14–​15 See also traumatic brain injury (TBI) heart block, 134–​35, 140 HELLP (hemolysis, elevated liver enzymes, and low platelet count), 19–​20,  21 hematologic and oncologic disorders B-​cell lymphoma, 27, 27f, 37 carbon monoxide poisoning, 25, 34–​35 disseminated intravascular coagulation (DIC), 35 drug-​induced immune thrombocytopenia (DIT), 28, 39 enoxaparin overdose, 29, 40–​41 factor inhibitors, 26–​27, 36–​37 hemophilia, congenital, 28, 37–​38 Heparin Induced Thrombocytopenia (HIT), 28, 38–​39 hyperleukocytosis, 27, 27f, 37 IVC (inferior vena cava) filters, 30, 42 methemoglobinemia, 24–​25, 32–​33,  32t non-​vitamin K oral anticoagulant reversal, 29, 40 PCV (polycythemia vera), 29, 39 reversing effects of anticoagulants, 24, 32 TEG (thromboelastogram) test, 29, 29f, 41– ​4 2, 41f, 41t transfusion management, 24, 31 TTP (thrombotic thrombocytopenic purpura),  35–​36 tumor lysis syndrome, 24, 31 vitamin K antagonist reversal, 25, 33, 33t hemoglobin abnormalities See hematologic and oncologic disorders hemolytic transfusion reaction, 43, 49–​50 hemophilia, congenital, 28, 37–​38 hemorrhagic shock, 61, 66–​67 hemorrhagic stroke, 2, 5, 10, 17 heparin, 29, 33, 40–​41, 137, 146–​47, 148, 153 Heparin Induced Thrombocytopenia (HIT), 28, 38–​39, 151, 159 hepatic dysfunction/​failure (acute and chronic) acute liver failure (ALF), 44, 50–​51 hepatic trauma, 62, 70–​71 hepatitis, 45, 52–​53 hepatopulmonary syndrome, 44, 52 hypoxic hepatitis, 43, 49 indications for TIPS, 45, 53 ischemic hepatitis, 43, 49 laboratory studies, 51 hepatopulmonary syndrome, 44, 52 hepatorenal syndrome, 44, 45, 52, 53 herpes encephalitis, 2, 9–​10 HIT (Heparin Induced Thrombocytopenia), 28, 38–​39, 151, 159 HIV/​A IDs CD4 counts, 106, 110 diagnosis, 108, 114 target cells, 106, 110 treatment, 107, 110 holidays (daily sedation interruptions),  7–​8 HSE (herpes simplex virus encephalitis), 3, 12 HUS (hemolytic uremic syndrome), 35 hyperacute renal transplant rejection, 169, 176 hyperglycemia, 100, 103 hyperkalemia, 165, 171 hyperleukocytosis, 27, 27f, 37 hypermetabolic response, 78, 81–​82 hyperthyroidism, 101, 101f,  104–​5 hypocalcemia, 167, 175 hypomagnesemia, 167–​68, 175 hyponatremia, 165, 171 hypo-​osmolar fluids, 166, 172, 172t hypophosphatemia, 167, 173 hypothermia frostbite injuries, 78–​79, 82 during massive blood transfusion, 31 hypoxic hepatitis, 43, 49 hypoxic/​metabolic encephalopathy, 8 IABPs (intra-​aortic balloon pump), 149, 154 ICH (intracerebral hemorrhage), 17, 26, 28, 32, 36, 37–​38 See also hemorrhagic stroke ICP (intracranial pressure) lowering,  15–​16 measuring, 15 ICU delirium, 87, 93 ICU ethics See ethics ICU management See management ileus, 189, 193–​94 immune thrombocytopenia, 35, 36, 39 immunology and infectious diseases endocarditis, prophylaxis, 107, 112 GVHD, diagnosis, 106, 109 GVHD, manifestations of, 106 GVHD, target organs, 109 GVHD, treatment, 106, 109 HIV/​A IDs, CD4 counts in, 106, 110 HIV/​A IDs, diagnosis, 108, 114 HIV/​A IDs, target cells, 106, 110 HIV/​A IDs, treatment, 107, 110 immunosuppression, 107, 112 mixed connective tissue disorders, 107, 111 rheumatoid arthritis, diagnosis, 107, 111 rheumatoid arthritis, disease course, 107, 111 SLE, diagnosis, 113 SLE, pathophysiology, 112–​13 spontaneous bacterial peritonitis, 108, 113 immunosuppression, 107, 112 impaired providers, 121–​22 indirect calorimetry, 188, 192 infectious encephalitis/​meningitis, 2f, 3, 9–​10, 12, 13 infectious pyogenic liver abscess, 46, 54 inhalation injury, fire-​related, 80, 85 in-​stent thrombosis of DES, 151, 161 innominate artery See brachiocephalic artery INTERACT2 trial, 17 intermittent hemodialysis vs CRRT, 169, 176 interventional radiology, 18 intra-​abdominal infection, 90, 98 intraosseous line placement, 179–​80, 183   I n d e x  •  19 intubation See also endotracheal intubation in myasthenic crisis, 3, 11–​12 in spinal cord injury, 14 ischemic hepatitis, 43, 49 ischemic stroke, 2, 10–​11 IVC (inferior vena cava) filters, 30, 42 IVIG (IV immunoglobulin) in immune thrombocytopenia, 26, 35, 36 in myasthenic crisis, 3, 12 jugular venous saturation, 4, 15 laryngeal edema, 180–​81, 186 left-​to-​right intracardiac shunt, 150, 156 leukapheresis, 27, 37 leukemia, 27, 35, 37 leukocytosis, 27, 27f, 37 life support and resuscitation hemorrhagic shock, 61, 66–​67 trauma induced coagulopathy, 61, 67 liver transplantation, 44, 45, 52, 53 LMA supraglottic devices, 180, 184–​85 LMWH (low-​molecular-​weight heparin), 29, 40–​41, 137, 146–​47, 148, 153 lumbar puncture, 3, 9–​10, 181, 186 lupus nephritis, 168–​69, 176, 176t Maddrey Discrimination Score, 45, 52–​53 MAGIC DR mnemonic, 16 magnesium sulfate, 5, 16, 19–​20, 21 malabsorption, 46, 55–​56, 189–​91, 194, 196 management CAM-​ICU assessment tool, 115, 119 HCAHPS performance measures, 115, 118 patient advocacy, 117, 122–​23 QA/​QI, patient safety, 116, 121 mannitol in eclampsia, 19–​20, 21 lowering ICP with, 5, 15–​16 massive transfusion, 61, 67 mechanical thrombectomy, 10–​11 mediastinitis initial management, 124–​25, 128 treatment, 124–​25, 128 medullary lesions caudal, 7 rostral, 7 megaloblastic anemia, 35 MELD score, 44, 52 meningitis, 2, 2f, 3, 9–​10, 12, 13 mesenteric injuries, 72t mesenteric ischemia, 46, 55 metabolic acidosis, 79, 83, 168, 175, 175t metabolic assessment, 188, 192 metabolic derangement differential diagnosis, 8–​9 hypoxic/​metabolic encephalopathy, 8 respiratory pattern associated with, 1, 7 methemoglobinemia, 24–​25, 32–​33, 32t, 35 methotrexate, 107, 112 methylene blue, 24–​25, 33 microangiopathic hemolytic anemia, 21 mixed connective tissue disorders, 107, 111 MMP-​3 (metalloproteinase-​3), 107, 111 Monro-​Kellie doctrine, ​16 Morel-​Lavallée lesions, 62, 63, 75–​76 mucus plugging, 179, 182 multidrug-​resistant Acinetobacter baumannii, 89–​9 0, 98 multiple organ failure, 87, 92–​93   muscular and soft tissue injury (Morel-​ Lavallée lesions), 62, 63, 75–​76 myasthenia gravis, 3, 11–​12 mycoplasma infections, 21 myxedema, 101–​2 , 105 NASCIS (National Acute Spinal Cord Injury Studies), 14 NCS/​E MG (nerve conduction study/​ electromyography), 3 near-​d rowning freshwater, 60, 65 saltwater, 60, 64–​65 neck pounding, 134, 138–​4 nerve agents, 60, 64, 64t neuromuscular disease, 3, 11–​12 neuronal injury, 15 neuron-​specific enolase, 8 neuroprotectants, 14 nitrogen balance, 188, 192 NKHC (nonketotic hyperglycemic coma), 100, 103 NOACs (novel oral anticoagulants), 29, 40, 137, 146 nonconvulsive status epilepticus, 10 nonparametric statistical tests, 116, 120 non-​vitamin K oral anticoagulants, 29, 40, 137, 146 NPDB (National Practitioner Data Bank),  121–​22 NSTEMI-​ACS, 136–​37,  143–​4 nuclear medicine studies, 8–​9 nutrition acalculous cholecystitis, 190, 195 basal and stress energy requirements, 188, 192 diarrhea, nausea, and vomiting, 189, 193 enteral and parenteral nutritional support, 188, 190, 191, 192–​93, 194–​95,  196 enteral nutrition, 190–​91, 195–​96 enteral tubes, 190, 195 gastrointestinal motility dysfunction, 191, 196 ileus, 189, 193–​94 malabsorption, 189–​9 0, 194 nitrogen balance, 188, 192 nutritional deficiencies, 188–​89, 193 nutritional support in acute pancreatitis, 48, 58 refeeding syndrome, 190, 194 nutritional assessment, 51 nutritional deficiencies, 188–​89, 193 obstetric critical care acute asthma exacerbation, 20, 22, 23 amniotic fluid embolus, 20, 22 HELLP syndrome, 19–​20, 21 hyperactive delirium, 20, 22 peripartum infection, 19, 21 postpartum hemorrhage, 19, 21 postpartum seizures (eclampsia), 19–​20,  21 recalcitrant postpartum hemorrhage, 19, 21 withdrawal symptom management, 20, 22 oculovestibular reflex testing (cold calorics), 1 odds ratios, 117, 122 Ogilvie syndrome (colonic pseudo-​obstruction), 48,  58–​59 oral thrombin inhibitors, 29, 40 organ donation, 115–​16, 119 orthopedics muscular and soft tissue injury (Morel-​Lavallée), 62, 63, 75–​76 orthopedic trauma, 62–​63, 74 pelvic trauma, 63, 74–​75, 74–​75f OSA (obstructive sleep apnea), 125, 129 outcome and performance measures, 115, 118 overdose enoxaparin overdose, 29, 40–​41 selective serotonin reuptake inhibitor (SSRI) overdose, 87–​88, 93–​94 tricyclic antidepressant (TCA), 60–​61, 65–​6 6, 88, 94 overresuscitation, 78, 81 pain management See sedation, pain management, and pharmacology pancreatitis, 48, 58 panhypopituitarism, 101, 104 parametric statistical tests, 116, 120 patient advocacy, 117, 122–​23 patient autonomy, 116, 121–​22 patient safety, 116, 121 PCC (prothrombin complex concentrate), 25, 32, 33, 36 PCCD (pelvic circumferential compression device), 60f PCR (polymerase chain reaction) testing, 3, 12 PCV (polycythemia vera), 29, 39 PEA (pulseless electrical activity), 135, 141, 150, 157 pelvic trauma, 63, 74–​75, 74–​75f perforations, 46, 55 pericardial effusion, 27f pericardial FAST exam, 62, 71–​72 peripartum infection, 19, 21 peripheral blood smears diminished platelet count, 26f hyperleukocytosis, 27f microangiopathic hemolytic anemia with schistocytes, 21 promyelocytes, 25f schistocytes, 26f peripheral vascular disease, 152, 162–​63 peritoneal carcinomatosis, 44, 51 peritoneal dialysis, 167, 174 peritonitis, 44, 50 pharmacology See sedation, pain management, and pharmacology phenytoin arresting seizures with, 2, 9 cognitive outcomes with long-​term treatment, 10 pinworm (Enterobius vermicularis), 91, 99 pinworm (Enterobius vermicularis) infection, 91, 99 pituitary apoplexy, 5, 17 pituitary disorders, 5, 17 plasmapheresis/​plasma exchange in myasthenic crisis, 12 in TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 platelet abnormalities and dysfunction DDAVP dose for, 13 dilutional thrombocytopenia, 31 diminished platelet count, 26f drug-​induced immune thrombocytopenia (DIT), 28, 39 Heparin Induced Thrombocytopenia (HIT), 28, 38–​39 immune thrombocytopenia, 35, 36, 39 TEG (thromboelastogram) test, 29, 29f, 41– ​4 2, 41f, 41t in TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 PMIs (perioperative myocardial infarction), 151, 160 pneumococcal meningitis, 9–​10 Pneumocystis pneumonia, 88, 95–​96 pneumothorax, 126, 131–​32, 179, 180, 182–​83,  184 poisonings, 60–​61,  65–​6 poliomyelitis, 13 pontine injuries, 7 portal hypertension, 46, 51, 54 post-​hyperventilation apnea, 7 postpartum hemorrhage, 19, 21 postpartum seizures (eclampsia), 19–​20,  21 postrenal failure, 168, 175 prasugrel, 136–​37, 144 pre-​eclampsia, 19–​20,  21 pregnancy See obstetric critical care premature rupture of membranes, 19, 21 prerenal acute kidney injury, 166, 172 primary-​blast lung injury, 61, 68, 68t procedures arterial catheters, 181, 185 chest tube placement, 179, 183 echocardiography, 180, 184 FAST (focused assessment with sonography for trauma), 181, 185–​86 intraosseous line placement, 179–​80,  183 laryngeal edema, 180–​81, 186 LMA supraglottic devices, 180, 184–​85 lumbar puncture, 181, 186 mucus plugging, 179, 182 pneumothorax, 179, 180, 182–​83, 184 tracheostomy, 179, 180, 181, 182, 183, 186–​87, 186–​87f transtracheal tubes, 180, 185 protamine, 33 psoas abscess, 47, 56 pseudohyperkalemia, 122 PSVT (paroxysmal supraventricular tachycardia), 134, 138–​4 pulmonary system ARDs (acute respiratory distress syndrome), 126, 130–​31 fat embolism syndrome (FES), 124, 127 hepatopulmonary syndrome, 44, 52 mediastinitis, initial management, 124–​25,  128 mediastinitis, treatment, 124–​25,  128 obstructive sleep apnea (OSA), 125, 129 occlusion of the distal airways due to cast formation, 80, 86 pneumothorax, 126, 131–​32 primary-​blast lung injury, 61, 68, 68t pulmonary contusion, 61, 69, 125,  128–​29 pulmonary hypertension, 137, 145 tracheal/​bronchial injury, 62, 73 TRALI (transfusion-​related acute lung injury), 126, 131 venous air embolism, 124, 127–​2 ventilator-​a ssociated pneumonia (VAP), 125–​2 6,  130 ventilatory support, 125, 129–​30 pulse oximetry contraindication in carbon monoxide poisoning, 34 contraindication in methemoglobinemia,  32–​33 purple-​g love syndrome, 9 0  •   I n d e x P values, 116, 120 pyogenic liver abscess, 46, 54 QA/​QI (quality assurance/​quality improvement), 116, 121 RCA, 116, 121 REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta), 63,  76–​7 recalcitrant postpartum hemorrhage, 19, 21 recombinant activated factor vIIa, 19, 21, 36, 38 recombinant factor IX, 37 REDUCE trial, 7–​8 refeeding syndrome, 46, 55–​56, 190, 194 regression analysis, 118–​19, 118–​19f relative risk, 117, 122 RE-​LY (Randomized Evaluation of Long-​ Term Anticoagulation Therapy) Trial, 40 renal system/​renal acid-​base CAUTIs (catheter-​a ssociated urinary tract infections), 165, 171 contrast-​induced nephropathy, 167, 174 diabetic keto acidosis (DKA), 166, 169, 173, 177 fluid and electrolyte management, 169, 177 hyperacute renal transplant rejection, 169, 176 hyperkalemia, 165, 171 hypocalcemia, 167, 175 hypomagnesemia, 167–​68, 175 hyponatremia, 165, 171 hypo-​osmolar fluids, 166, 172, 172t hypophosphatemia, 167, 173 intermittent hemodialysis vs CRRT, 169, 176 lupus nephritis, 168–​69, 176, 176t metabolic acidosis, 168, 175, 175t peritoneal dialysis, 167, 174 postrenal failure, 168, 175 prerenal acute kidney injury, 166, 172 renal trauma, 61, 70, 166–​67, 173, 173t renal tubular acidosis (RTA), 169, 176 respiratory acidosis, 166, 170, 172,  177–​78 symptomatic hyponatremia, 167, 174 tumor lysis syndrome, 169–​70, 177 urethral injury, 62, 70 urolithiasis, 165–​6 6, 171–​72, 171–​72t renal trauma, 61, 70, 166–​67, 173, 173t respiratory acidosis, 166, 170, 172, 177–​78 respiratory failure ARDs (acute respiratory distress syndrome), 126, 130–​31 obstructive sleep apnea (OSA), 125, 129 respiratory patterns Cheyne-​Stokes respirations, 7 crescendo-​decrescendo repeating pattern, 1 post-​hyperventilation apnea, 7 reflective of brainstem pathology, 7 restricted diffusion, 5, 8, 17 resuscitation, in burn patients consensus formula, 78, 81 indication of resuscitation end point, 78, 82 overresuscitation in, 78, 81 revascularization,  10–​11 RE-​V ERSE AD study, 40 reversible posterior leukoencephalopathy syndrome, 16 RF (rheumatoid factor), 107, 111   rheumatoid arthritis diagnosis, 107, 111 disease course, 107, 111 Richmond Agitation and Sedation Scale,  7–​8 rickettsial infections, 90, 90f, 99 right ventricular dysfunction, 149, 155 rim-​enhancing lesions, 16 RTA (renal tubular acidosis), 169, 176 RUG (retrograde urethrogram), 62, 70 SAAG (serum ascites-​a lbumin gradient), 44, 51 SAH (spontaneous subarachnoid hemorrhage), 2, 6, 10, 17, 18 SAM, 152, 164 SBTs (spontaneous breathing trials), 7–​8 schistocytes in disseminated intravascular coagulation (DIC), 26f, 26, 35 in HELLP syndrome, 21 in TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 SEA (spinal epidural abscess), 14 sedation, pain management, and pharmacology CAM-​ICU assessment tool, 115, 119 early-​onset VAP (ventilator associated pneumonia), 89, 89f, 96–​9 7,  96–​9 7b encephalitis, empiric therapy for, 90, 98 encephalitis, HSV, 98–​99 ESBL-​producing Enterobacteriaceae, 89, 97 esophageal candidiasis, 88, 95 ICU delirium, 87, 93 intra-​abdominal infection, 90, 98 lithium side effects, 88, 94–​95 multidrug-​resistant Acinetobacter baumannii, 89–​9 0, 98 in multiple organ failure, 87 paralytic drugs, 87, 92–​93 pinworm infection, 91, 99 Pneumocystis pneumonia, 88, 95–​96 selective serotonin reuptake inhibitor (SSRI) overdose, 87–​88, 93–​94 in septic shock, 87, 87f, 92 spirochetal and rickettsial infections, 90, 90f, 99 surgical site infections (SSIs), 89f, 89, 96 tricyclic antidepressant (TCA) overdose, 88, 94 tuberculosis treatment, 88, 95 sedative hypnotics, 87, 87f, 92 seizure prophylaxis, 10 seizures, 2, 5, 9, 16 septic shock, 87, 87f, 92, 151, 159–​6 sexually transmitted diseases, 21 Sheehan syndrome, 17 shock hemorrhagic, 61, 66–​67 septic shock, 87, 87f, 92 SIADH (syndrome of inappropriate antidiuretic hormone secretion), 100, 103 skew deviation, 15 skull fracture, 11 SLE (systemic lupus erythematosus) diagnosis, 113 pathophysiology,  112–​13 sleep apnea, 125, 129 SPECT (single photon emission computed tomography),  8–​9 spinal cord injury proper management of, 4, 14 spinal epidural abscess (SEA), 4, 14 spirochetal infections, 90, 90f, 99 spontaneous bacterial peritonitis, 44, 50, 108, 113 SSEPs (somatosensory evoked potentials), 1, 8 SSIs (surgical site infections), 89f, 89, 96 SSRI (selective serotonin reuptake inhibitor) overdose, 87–​88, 93–​94 status epilepticus eclampsia (postpartum seizures), 16 nonconvulsive status epilepticus, 10 refractory to lorazepam, 2 treatment, 2, 9 steroids in CSW and SIADH, 101, 104 in myasthenia gravis, 3, 11–​12 in myasthenic crisis, 12 in spinal cord injury, 14 STICH trial, 17 stomach GI hemorrhage, lower, 44, 45, 51, 53 GI hemorrhage, upper, 44, 45, 51, 53 stroke embolic/​thrombotic and ischemic, 2, 4, 10–​11, 15 hemorrhagic, 2, 5, 10, 17 subclavian artery injury, 63, 77 subdural hematomas, 11 substance abuse brain death, 115, 118 end-​of-​l ife care, 116–​17,  122 impaired providers, 121–​22 managing withdrawal symptoms during delivery, 20, 22 organ donation, 115–​16, 119 patient autonomy, 116, 121–​22 succinylcholine, 92 sudden-​onset abdominal pain, 46, 55 sulcal effacement, 8 supraventricular tachyarrhythmias, 148, 153 SVT (supraventricular tachycardia), 134,  138– ​4 SVT/​tachyarrhythmias, 134,  138–​4 symptomatic hyponatremia, 167, 174 symptomatic ICH, 150, 158 TBI (traumatic brain injury) brain death in, 1, 8–​9 brain tissue oxygenation in, 4, 4f,  14–​15 contraindication for hypo-​osmolar fluids, 166, 172, 172t ICP monitoring in, 4 intracranial compliance, ​16 TCA (tricyclic antidepressant) overdose, 60–​61, 65–​6 6, 88, 94 TEG (thromboelastogram) test, 21, 29, 29f, 41–​4 2, 41f, 41t, 150, 157–​58,  158f thrombocytopenia dilutional thrombocytopenia, 31 drug-​induced immune thrombocytopenia (DIT), 28, 39 Heparin Induced Thrombocytopenia (HIT), 28, 38–​39 immune thrombocytopenia, 35, 36, 39 TTP (thrombotic thrombocytopenic purpura), 26, 35–​36 thrombolytics reversing effects of, 24, 32 in stroke treatment, 10–​11 thunderclap (sudden onset) headaches, 5, 6, 17, 18 thyroid function abnormalities hyperthyroidism, 101, 101f,  104–​5 hypothyroidism, 101–​2 , 105 thyroid storm, 101, 101f,  104–​5 tibial nerve H reflex, 3, 12 TIPS (transjugular intrahepatic portosystemic shunt), 45, 53 tirilazad mesylate, 14 tissue plasminogen activator (tPA), 10–​11 toxic ingestion, 60–​61, 65–​6 toxic mega colon, 48, 58–​59 tPA (tissue plasminogen activator), 24, 32 tracheal/​bronchial injury, 62, 73 tracheostomy, 179, 180, 181, 182, 183, 186–​87, 186–​87f TRALI (transfusion-​related acute lung injury), 126, 131 tranexamic acid, 21 transcranial Doppler, 8–​9, 15 transfusion management citrate toxicity, 31 DIC (disseminated intravascular coagulation), 31 dilutional thrombocytopenia, 31 fluid and electrolyte management, 169, 177 hemolytic transfusion reaction, 43,  49–​50 hypothermia, 31 initial decision to transfuse platelets, 61 TRALI (transfusion-​related acute lung injury), 126, 131 trauma-​induced coagulopathy, 67 transplant rejection cardiac, 149–​50,  155–​56 liver, 44, 45, 52, 53 renal, 169, 176 transtracheal tubes, 180, 185 trauma and disaster management abdominal wall contusion, 72–​73, 72t biologic, chemical, and nuclear exposures, 60, 64, 64t blast injuries, 61, 68, 68t cardiac contusion, 61, 68 chest trauma, 61, 69, 125, 128–​29 drowning, freshwater, 60, 65 drowning, saltwater, 60, 64–​65 gunshot wound, 62, 71–​72 hepatic trauma, 62, 70–​71   I n d e x  •  01 life support and resuscitation, 61,  66–​67 muscular and soft tissue injury (Morel-​ Lavallée), 62, 63, 75–​76 orthopedic trauma, 62–​63, 74 pelvic trauma, 63, 74–​75, 74–​75f pericardial FAST exam, 62, 71–​72 poisonings and toxic ingestion, 60–​61,  65–​6 REBOA for trauma, 63, 76–​7 renal trauma, 61, 70 subclavian artery injury, 63, 77 tracheal/​bronchial injury, 62, 73 urethral injury, 62, 70 trauma-​induced coagulopathy, 61, 67 Trichuris trichiura (whipworm), 91, 99 TTP (thrombotic thrombocytopenic purpura), 35–​36, 39 tuberculosis, 88, 95 tumor lysis syndrome, 24, 31, 169–​70, 177 type and type errors, 116, 120 urethral injury, 62, 70 urinary mycoplasma infections, 21 urolithiasis, 165–​6 6, 171–​72, 171–​72t uterine endometritis, 21 vancomycin, drug-​induced thrombocytopenia due to, 28, 39 VAP (ventilator-​a ssociated pneumonia), 89, 89f, 96–​9 7, 96–​9 7b, 125–​2 6, 130 variable types, 116, 120 variceal bleed, 46, 55 vascular diseases, 46, 55 vascular malformations, 6, 18 vasoactive drugs, 3, 13 vasopressors in brain death, 1, 3, 13 in delayed cerebral ischemia (DCI), 5, 18 in vascular malformations, 6, 18 venous air embolism, 124, 127–​2 ventilator associated pneumonia (early-​ onset VAP), 89f, 89, 96–​9 7, 96–​9 7b ventilatory support, 125, 129–​30 ventricular fibrillation/​ventricular tachycardia, 135, 141–​4 ventricular tachycardia/​fibrillation, 148, 153 vitamin K coagulopathy, 25, 33, 33t volume resuscitation, 13 volutrauma, 126, 131–​32 volvulus, 46–​47, 55, 56 von Willebrand disease, 35–​36 warfarin, 17, 25, 33, 137, 146, 148, 153 WBC (white blood cell) disorders acute promyelocytic leukemia, 35 hyperleukocytosis, 27, 27f, 37 leukapheresis, 27, 37 leukemia, 27, 35, 37 leukocytosis, 27, 27f, 37 reversible posterior leukoencephalopathy syndrome, 16 West Nile virus (WNV), 13 WPW (Wolff-​Parkinson-​W hite) syndrome, 142–​4 3, 148, 153   ... EFACE The Anesthesiology Critical Care Board Review was forged as a concept rooted in working to prepare critical care fellow physicians to take and be successful on the American Board of Anesthesiology. .. of Anesthesiology and Critical Care Medicine Vice Chair for Critical Care Medicine Program Director, Anesthesiology Critical Care Medicine Fellowship Medical Co-Director, Surgical Intensive Care. .. FCCM, FCCP ASSOCIATE PROFESSOR OF ANESTHESIOLOGY AND CRITICAL CARE MEDICINE VICE CHAIR FOR CRITICAL CARE MEDICINE PROGR AM DIRECTOR, ANESTHESIOLOGY CRITICAL CARE MEDICINE FELLOWSHIP M E D I C