Papers and Guidelines

Question 1

Workup and management of postop a-fib that is acutely unstable. (Critical Care Net)

Answer 1

EKG confirms. Check and replace lytes.

Synchronized cardioversion if acute instability.

If the patient was already on pressors and requirements have not gone up, give amio bolus (300 over 1 hr) and start drip (1mg/min then wean over 24 hrs).

Question 2

Management of postop a-fib that is stable. (Critical Care Net)

Answer 2

EKG confirms. Check and replace lytes. COPD or HF?

• No: metoprolol 5 q5 min x3, then amio if no NSR
• COPD: calcium channel blocker
• HF: amiodarone

Question 3

What is HELLP syndrome? Incidence? Pathogenesis?

Answer 3

Hemolysis w/ microangiopathic features on blood smear, elevated liver enzymes, low platelets. It is possibly a severe form of pre-eclampsia. Can cause hepatic manifestations - infarction, hemorrhage, rupture.

0.1-0.2% of all pregnancies. 10-20% of pregnancies w/ pre-eclampsia.

Likely d/t abnormal placental placement.

Question 4

Pregnant patient in 3rd trimester w/ abdominal pain/tenderness midepigastrum/RUQ/below sternum. Nausea/vomiting/malaise.

Sign/symptom Frequency, percent

• Proteinuria 86 to 100
• Hypertension 82 to 88
• RUQ/epigastric pain 40 to 90
• Nausea, vomiting 29 to 84
• Headache 33 to 61
• Visual changes 10 to 20
• Jaundice 5

Answer 4

HELLP Syndrome

Question 5

Workup and Diagnosis of HELLP

(UpToDate)

Answer 5

• DDx: acute fatty liver of pregnancy , intra-abdominal acute dz, HUS/TTP
• CBC: PLT <100K
• peripheral smear showing microangiopathic features
• Bilirubin >1.2
• LFTs: AST >2x upper limit
• Chem 10 - check Cr

Question 6

Management of HELLP

(UpToDate)

Answer 6

• stabilize mother
• assess fetal - possible prompt delivery w/ C-section
• tx HTN: labetalol, hydralazine, nifedipine; last resort nitroprusside
• tx preeclampsia: Mg IV 4g bolus then 2g/hr, monitor reflexes and serum Mg
• deliver the baby: >34 wks, <23 wks, fetal demise, MODS, DIC
• tx thrombocytopenia: transfuse platelets if bleeding
• manage elevated LFTs: CT/MRI to check for hematoma or infarct

Question 7

In adult patients with severe trauma, should an MT/DCR protocol versus no MT/DCR protocol be used to decrease mortality or total blood products used?

What is the ABC score?

(EAST)

Answer 7

Rec the development and implementation of an MT/DCR protocol for the management of severely injured trauma patients.

ABC score: 2/4 activates MTP

• penetrating mechanism
• systolic <90
• HR > 120
• FAST positive

Some advocate if HR > SBP, then they will likely benefit from blood.

Question 8

In adult patients with severe trauma, should a high ratio of PLAS:RBC and PLT:RBC versus a low ratio be administered to decrease mortality or total blood products used?

(EAST)

Answer 8

Preparing MT packs or pre-positioning blood products in the trauma resuscitation bay in a 1:1:1 ratio (e.g., 6 units PLAS, 1 unit apheresis PLT, and 6 units RBC) can help avoid a significant ratio imbalance during the early empiric resuscitation phase.

Question 9

Management of AKI

Answer 9

• UA can help determine causes, likely d/t hypovolemia in postop pts; FENA; renal ultrasound
• ID life threatening conditions:
  
  • volume - resuscitate MAP w/ non-K fluid
    
    • lasix if overloaded and oliguric
    • dialysis if cannot diurese (anuric) and overloaded
  • hyperK - EKG; if >5.5 do C BIG K Di (if making urine)
    
    • dialysis if >6.5
  • metabolic acidosis - bicarb in non-gap acidosis (if no overload)
    
    • dialysis if pH <7.1
  • dialysis for uremia, neuropathy, AMS
• treat other conditions:
  
  • hyperPh - phoslo if phos >6
  • anuria may require CRRT

Question 10

In patients with suspected BTAI (P), should CT of the chest with intravenous contrast (I) be used versus conventional catheter-based angiography (C) for the identification of clinically significant injury (O)?

(EAST)

Answer 10

CT chest w/ con is a useful diagnostic tool for both screening and diagnosis of BTAI

Question 11

SCIP Protocols

Answer 11

1. ppx abx within 1 hr
2. ppx abx selection for surgical patients
3. ppx abx DC within 24 hrs after end of surgery
4. cardiac surgery pts w/ controlled 6am postop glucose
5. appropriate hair removal
6. catheter out POD1 or POD2
7. perioperative temperature management
8. beta blockers started on patients w/ home med
9. VTE within 24 hrs prior and 24 hrs postop

Question 12

SCIP 2 - perioperative abx ppx selection

Answer 12

• Ancef 2g q4h works for the following
  
  • cardiac - S aureus, S epi
  • gastroduodenal - GNB, GPC
    
    • no need if low risk (no entry into lumen, not obese, no obs)
  • biliary - GNB, enterococci, clostridia
  • hernia - aerobic GPC
• Add metronidazole 500mg x1
  
  • small intestine - GNB, GPC, anaerobes, enterococci
  • appendectomy - GNB, anaerobes, enterococci
  • colorectal - GNB, anaerobes, enterococci
• Genitourinary needs cipro or bactrim
• Gynecological needs ancef
• ENT needs ancef; clean-contaminated add metronidazole
• NSGY needs ancef
• Ortho needs ancef
• Thoracic needs ancef
• Vascular needs ancef
• Perc does not need abx
• Breast cancer procedures need ancef

Question 13

How do you manage postoperative urinary retention?

Answer 13

• H&P - bladder fullness, low abd discomfort; inability to void 4-6 hours after removal of the Foley
• Bladder scan
  
  • If <0.5 ml/kg/hr (or 600 ml) and asx - may be hypovolemic
  • if >0.5 ml/kg/hr (or 600 ml) or discomfort - do I/O catheter
• I/O catheter
  
  • >400 ml/15 min - leave catheter, start flomax, o/p urology f/u
  • <400 ml/15 min - 6 hr spontaneous voiding trial

Question 14

Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment

^{(JAMA 2018)}

• Berlin criteria
• Berlin definition of 3 ARDS categories
• Prone positioning
• Vent management

Answer 14

• Berlin criteria: lung injury within 1 week, CXR w/ bilateral opacities not d/t CHF/overload
• ARDS categories (PaO2/FiO2): mild 200-300, moderate 100-200, severe <100; PEEP >5
• Management: TV 6 ml/kg predicted BW, increase PEEP for oxygenation
  
  • ​PaO2/FiO2 <150 - deep sedation and prone positioning, NB blocker
  • <80 - case by case - VV ECMO, HFOV

Question 16

Warfarin Reversal - elevated INR >1.5 and bleeding

http://www.surgicalcriticalcare.net/Guidelines/Warfarin%20Reversal%202017.pdf

Answer 16

• ​Hold warfarin
• 4F PCC 1000 units over 15 mins, recheck INR in 30 min
  
  • ​FFP also ok; 2 units for mod, 4 units for high risk; ​recheck INR in 1 hr
• Vit K based on current INR and risk of bleeding, if no more warfarin need
  
  • IV reserved for high bleeding risk, avoid IM
  • no vit K if prosthetic heart valve