SESATS Critical Care Flashcards
Safety culture in CTS is characterized by what (in comparison to the aviation industry)?
A cognitive load that differs for the various CTS team members throughout the course of an operative episode.
A Just Culture in CTS refers to what?
The impact of the system on the performance of error in addition to at-risk behaviors of the individual and the subsequent impact on safety.
There is a balance between these two entities in safety culture.
Cardiac surgical teams demonstrated a more positive safety environment compared to other surgical teams.
Describe an ideal reporting system in references to near miss events and errors.
The ideal incident reporting system will deliver feedback to the reported when these events have been investigated, but when the reporter is not actively participating during the process. This ensures the reporter was heard and can facilitate further reporting to improve the system.
What are error taxonomies and how are they used?
Used to classify errors so that the causal path from active failure to latent error can be followed.
The aviation industry is famous for near miss reporting, but healthcare complexity doesn’t lend itself well to a simple model of error reporting.
What is first-line therapy for patients with postop atrial fibrillation (s/p cardiac surgery)?
Medical rate control w/ AV nodal blockers. Beta blockers is preferred.
In postop a-fib after cardiac surgery, what can be added to beta blockade if additional rate control is warranted?
Non-dihydropyridine Ca channel blocker (preferred over digoxin).
Examples: verapamil, diltiazem.
Cause less vasodilation and more suppression of SA and AV nodes.
What role does digoxin have in patients w/ postop a-fib after cardiac surgery?
Can be useful if hypotension precludes further escalation of beta blocker or Ca channel blocker
In postop cardiac surgery pts w/ a-fib what can be considered if rate control is not tolerated or ineffective or in those who remain very symptomatic?
Anti-arrhythmic drugs, electrical cardioversion, or a combination.
Amiodarone is the preferred drug if hemodynamically stable.
POD3 CABG, a patient has dyspnea and hypotension w/ tachycardia. EKG shows sinus. Echo shows anterior pericardial effusion. How do you manage?
Cardiac tamponade w/ significant hemodynamic compromise needs emergent mediastinal re-exploration.
During mitral valve surgery, what coronary vessel is at risk?
L circumflex artery
After mitral valve surgery, when coming off bypass, the patient was hypotensive and tachycardic. TEE shows hypokinesis of the inferior and inferior-lateral walls. There is ST elevation. What happened, and what should be done?
L circumflex injury. Emergency bypass grafting or suture correction.
What if a L circumflex injury is discovered postop after mitral valve surgery - how do you manage?
PCI if the vessel is not completely ligated. If complete ligation has occurred, a re-operation should be done - either correction of the suture or bypass.
What are guideline recommendations for oral anticoagulation in POAF (postop afib)?
Check CHA2DS2VASc score. If 2 or >, then OAC (oral anticoag) should be considered. This is for persistent afib after 48-72 hrs.
Heparin bridge to warfarin, then TEE guided cardioversion.
When should non-vit K oral AC be resumed after cardiac surgery?
Use caution - rapid onset can cause significant bleeding and bowel dysmotility can affect the absorption. Usually resume NOAC after 2-3 days postop, when hemostasis is confirmed, and chest tubes and pacing wires are out.
A patient undergoes catheter-based cryo-ablation for a-fib, then returns to ED 3 wks later w/ fever, chest pain, and acute focal neuro deficits. CTA head/neck/chest shows air adjacent to the L atrium and pneumomediastinum. What is the major concern?
Atrio-esophageal fistula (AEF)
A patient undergoes catheter-based cryo-ablation for a-fib, then returns to ED 3 wks later w/ fever, chest pain, and acute focal neuro deficits. CTA head/neck/chest shows air adjacent to the L atrium and pneumomediastinum. How do you manage?
Atrio-esophageal fistula.
BS abx, and strict NPO.
Emergency L atrium and esophageal repair.
In septic shock, what is the first-line management for hypotension (assume appropriate abx, source workup, and labs obtained)?
Fluid resuscitation - 30ml/kg within 3 hrs.
In septic shock (assume appropriate abx, source workup, and labs obtained), what is the role of albumin in fluid resuscitation in an ARDS presentation?
Albumin w/ crystalloid should be considered in the presence of ARDS. There is a small but non-significant survival improvement and earlier MAP improvement.
In septic shock, if pressors are required, what is the first choice?
norepinephrine
If a patient is in septic shock and not responding to fluid resuscitation or multiple pressors, what else can be used?
Hydrocortisone at 200 mg/day. Assume relative adrenal insufficiency.
In a patient with septic shock, what is usually the second line for pressors?
Vasopressin (0.03 or 0.04 units/min)
What are thoracic surgery burnout rates when compared to other specialties?
Fall within reported average (along w/ gen surg at 40-50%). EM and primary care have higher rates.
Is burnout related to patient outcomes? How is burnout measured?
Yes. Degree of burnout is strongly associated w/ medical errors.
Maslach Burnout Inventory examines three components: emotional exhaustion, depersonalization, decreased sense of accomplishment.
What is the best study for diagnosis of lower extremity DVT in a high-risk pt w/ previous hx of DVT?
US duplex
A patient presents w/ sepsis after RLL lobectomy and is found to have a complex pleural space infection consistent w/ post-lung resection empyema. How do you manage?
Sepsis - bs abx, crystalloids, check lactate, get cultures. Norepinephrine (Levophed) if not responsive to fluids.
Pleural debridement and drainage of the infected pleural space.
A patient s/p CABG w/ BIMA presents w/ deep sternal wound infection and sternal separation. How do you manage?
Debridement (may require repeat). NPWT should be added. When wound is clean and granulating, add muscle flap or omental flap for closure.
The fundamental principal of informed consent is based on what right and what ethical principal?
The right to self-determination and the ethical principal of patient autonomy.
What is the concept behind the RCA^2?
Help orgs learn to ID and implement sustainable systems-based actions to improve safety.
System changes are more durable compared to education.
Actions taken after analysis should be verified in their sustainability and ability to improve outcomes.
An immediate postop cardiac surgery pt has hypoxemia and bilateral atelectasis despite 100% FiO2, what can be added to improve hypoxia?
Inc PEEP. iNO.
May need to rule out edema, effusion, and PTx if this does not improve.
If all causes ruled out, ARDS is likely w/ hypoxia on 100% FiO2.
May need VV ECMO.
What is the most common hospital-associated infection?
catheter-associated UTI (75% of hospital UTIs are assd w/ Foleys). Remove them as soon as not needed.
A patient has descending necrotizing mediastinitis after a surgery for tonsillar abscess. How do you manage?
Wide debridement w/ low threshold for re-operation.
Transcervical and transthoracic approaches may both be required.
A cervical approach with bilateral chest tubes may be best initial intervention, but thoracotomy allows widest drainage.
If the CT scan shows infection below the 4th interspace or below the carina, a thoracotomy will be needed.
A patient w/ poorly controlled DM presents with DKA and is found to have a pulmonary zygomycotic infection. How do you manage?
Previously known as mucormycotic infection. Presents as DKA or immunosuppressed pt w/ gram + rods in the infected fluid w/ necrosis.
Tx: Antifungals (amphotericin B) and aggressive early surgical debridement (up to pneumonectomy).
Control DKA and reverse immunosuppression.
May require GM-CSF if leukopenia.
What is the management for retained traumatic hemothorax despite CTb placement in stable pt?
CT scan to eval anatomy.
Early VATS is the most efficacious (24-48 hrs).
A patient ingests lye, and becomes septic. Imaging shows evidence of perforation. How do you manage?
Laparotomy, L thoracotomy, and cervical fistula.
Lye will create a full thickness burn.
The thorax should be explored. Don’t try to do transhiatal.
A fistula is safer. Don’t try to recreate GI continuity in a septic patient.
Don’t forget the J-tube.
A patient postop cardiac surgery is intubated d/t hypoxia. Infection and pre-existing conditions are ruled out. CXR is clear. What must be evaluated?
Eval for PE w/ CT pulm angiogram.
A patient is s/p trans-septal approach for mitral valve surgery. Pt is unable to wean from vent d/t ARDS, pulm HTN, and hypoxemia.
What must be considered?
What is the workup?
L to R shunt d/t residual atrial septal defect.
Get TTE. TEE if first is nondiagnostic.
Can calculate Qp/Qs.
CTA to r/o PE can be considered after ASD ruled out.
Pt is s/p MV surgery w/ elevated PA pressures requiring milrinone and iNO. Manage postop pulm htn after cardiac surgery as pt transitions to home.
Add sildenafil.
Characteristics of high reliability organizations (in reference to safety science) include what?
Anticipation of error, and containment of error. HROs are concerned with failure, have a reluctance to simplify, and have an awareness of how small changes can affect the entire system.
What are some key predictors of failure of VA ECMO?
Low EF, DM, BP <90 sys, metabolic acidosis, age, prolonged CPB time.
A trauma patient develops severe hypoxemia as a result of bilateral pulmonary contusion. What is the next best step?
Increase the PEEP, with the goal of decreasing FiO2.
Control pain.
Don’t fluid overload.
Be ready for ARDS treatment.
A trauma patient develops severe hypoxemia as a result of bilateral pulmonary contusion. FiO2 is 100, and increased PEEP does not work. What is the next best step?
Prone positioning and NM blockade for the 1st 48 hrs are salvage therapies associated with survival.
Start considering VV ECMO.
What medication can reduce the duration of delirium in intubated patients?
Dexmedetomidate (Precedex)
