SESATS Critical Care Flashcards
1
Q
Safety culture in CTS is characterized by what (in comparison to the aviation industry)?
A
A cognitive load that differs for the various CTS team members throughout the course of an operative episode.
2
Q
A Just Culture in CTS refers to what?
A
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.
3
Q
Describe an ideal reporting system in references to near miss events and errors.
A
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.
4
Q
What are error taxonomies and how are they used?
A
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.
5
Q
What is first-line therapy for patients with postop atrial fibrillation (s/p cardiac surgery)?
A
Medical rate control w/ AV nodal blockers. Beta blockers is preferred.
6
Q
In postop a-fib after cardiac surgery, what can be added to beta blockade if additional rate control is warranted?
A
Non-dihydropyridine Ca channel blocker (preferred over digoxin).
Examples: verapamil, diltiazem.
Cause less vasodilation and more suppression of SA and AV nodes.
7
Q
What role does digoxin have in patients w/ postop a-fib after cardiac surgery?
A
Can be useful if hypotension precludes further escalation of beta blocker or Ca channel blocker
8
Q
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?
A
Anti-arrhythmic drugs, electrical cardioversion, or a combination.
Amiodarone is the preferred drug if hemodynamically stable.
9
Q
POD3 CABG, a patient has dyspnea and hypotension w/ tachycardia. EKG shows sinus. Echo shows anterior pericardial effusion. How do you manage?
A
Cardiac tamponade w/ significant hemodynamic compromise needs emergent mediastinal re-exploration.
10
Q
During mitral valve surgery, what coronary vessel is at risk?
A
L circumflex artery
11
Q
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?
A
L circumflex injury. Emergency bypass grafting or suture correction.
12
Q
What if a L circumflex injury is discovered postop after mitral valve surgery - how do you manage?
A
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.
13
Q
What are guideline recommendations for oral anticoagulation in POAF (postop afib)?
A
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.
14
Q
When should non-vit K oral AC be resumed after cardiac surgery?
A
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.
15
Q
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?
A
Atrio-esophageal fistula (AEF)
16
Q
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?
A
Atrio-esophageal fistula.
BS abx, and strict NPO.
Emergency L atrium and esophageal repair.
17
Q
In septic shock, what is the first-line management for hypotension (assume appropriate abx, source workup, and labs obtained)?
A
Fluid resuscitation - 30ml/kg within 3 hrs.
18
Q
In septic shock (assume appropriate abx, source workup, and labs obtained), what is the role of albumin in fluid resuscitation in an ARDS presentation?
A
Albumin w/ crystalloid should be considered in the presence of ARDS. There is a small but non-significant survival improvement and earlier MAP improvement.
19
Q
In septic shock, if pressors are required, what is the first choice?
A
norepinephrine
20
Q
If a patient is in septic shock and not responding to fluid resuscitation or multiple pressors, what else can be used?
A
Hydrocortisone at 200 mg/day. Assume relative adrenal insufficiency.
21
Q
In a patient with septic shock, what is usually the second line for pressors?
A
Vasopressin (0.03 or 0.04 units/min)
22
Q
What are thoracic surgery burnout rates when compared to other specialties?
A
Fall within reported average (along w/ gen surg at 40-50%). EM and primary care have higher rates.
23
Q
Is burnout related to patient outcomes? How is burnout measured?
A
Yes. Degree of burnout is strongly associated w/ medical errors.
Maslach Burnout Inventory examines three components: emotional exhaustion, depersonalization, decreased sense of accomplishment.
24
Q
What is the best study for diagnosis of lower extremity DVT in a high-risk pt w/ previous hx of DVT?
A
US duplex
25
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.
26
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.
27
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.
28
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.
29
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.
30
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.
31
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.
32
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**.
33
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).
34
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.
35
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.
36
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.
37
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.
38
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.
39
What are some key predictors of failure of VA ECMO?
Low EF, DM, BP <90 sys, metabolic acidosis, age, prolonged CPB time.
40
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.
41
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.
42
What medication can reduce the duration of delirium in intubated patients?
Dexmedetomidate (Precedex)
43
If there is a high pre-test suspicion of HIT (4Ts: plt dec 1/2 or <150K, 5-10 days s/p heparin, thrombosis, necrotic lesions, systemic sx/anaphylactoid rxn, no other causes), what should be done?
Discontinue all heparin products (including enoxaparin), send a platelet factor 4 assay to confirm the diagnosis, and begin argatroban (don't wait for assay to result).
44
The majority of cases of postop mediastinitis (within 30 days of sternotomy) are caused by what organism?
1) MSSA, then 2) MRSA
45
A patient s/p cardiac surgery presents with postop mediastinitis within 30 days. How do you manage antibiotics?
Get cultures and start empiric broad coverage IV abx that cover MRSA. Promptly de-escalate once cultures result.
46
A patient is s/p multiple GSW to the chest 4 days ago tx w/ chest tubes. He is more septic w/ foul green output from R chest tube. CT shows undrained heterogenous collection w/ rim enhancement, and esophagram shows leak to the R chest. What is the diagnosis?
delayed recognition of esophageal perforation causing empyema and sepsis
47
A patient is s/p multiple GSW to the chest 4 days ago tx w/ chest tubes. He is more septic w/ foul green output from R chest tube. CT shows undrained heterogenous collection w/ rim enhancement, and esophagram shows leak to the R chest. What is the management?
sepsis protocol - cultures, abx, fluids
timely source control of the empyema and the leak - right thoracotomy for wide pleural drainage and evaluation and management of the esophageal perforation - temporizing measure is probably the most safe; primary repair in a delayed setting is risky as is esophagectomy w/ primary anastomosis in a pt w/ sepsis
48
A patient with ARDS is put on the vent. What are the tolerable ABG parameters?
TV
PaCO2
pH
FiO2 preferred for pO2 goal
Plateau P in cm H2O
TV 4-8 ml/kg.
PaCO2 <65
pH >7.15
FiO2 <60 preferred for goal pO2 >55
PEEP for plateau P < 30 cm H2O
49
A patient with ARDS is put on the vent but is still not oxygenating well despite good vent management, what other adjuncts can be added?
Prone positioning and paralysis.
50
A patient with ARDS is put on the vent but is still not oxygenating well despite good vent management, paralysis, iNO, and proning. What else can be done?
VV ECMO
51
What pulmonary abnormalities (ie bad ABG parameters) can increase pulmonary vascular resistance (eg in the setting of an intubated patient w/ ARDS)?
Hypoxia, hypercarbia, acidosis.
This **inc PVR** response is to **maintain V/Q match** by shunting blood away from hypoxic areas.
Improve these parameters if a patient has pulmonary HTN and is showing signs of RV dysfunction.
52
A patient has RV dysfunction and pulm HTN.
Hypoxia, hypercarbia, and acidosis are corrected.
What are good critical care medical mgmt options?
Dobutamine and PDE inhibitors (milrinone) can be added to improve contractility and reduce PVR.
Be aware that they have systemic effect and can cause hypotension.
53
A patient has RV dysfunction and pulm HTN. Hypoxia, hypercarbia, and acidosis are corrected. The patient is requiring multiple pressors. What are good medical mgmt options?
This pt is hypotensive.
Inhaled vasodilators (NO or prostacycline) will provide a local pulmonary vascular resistance reducing effect as opposed to systemic medications like dobutamine or milrinone.
54
How is the PaO2/FiO2 ratio calculated? What is it used for?
PaO2/FiO2 as an absolute number (not percentage). It is used to determine severity of ARDS.
55
What are the classifications of ARDS?
P/F ratio:
201-300 - mild
101-200 - moderate
0-100 - severe
56
How long do antibiotics need to be continued for pneumonia?
7-10 days. Even for septic and intubated patients.
57
A patient s/p Ivor Lewis esophagectomy becomes septic and is unstable despite maximum medical management. Upper endoscopy shows large anastomotic dehiscence and proximal gastric conduit ischemia. What is the management?
Sepsis management: access and monitoring, labs including cultures and lactate, resuscitation w/ fluid and pressors, imaging, abx.
Esophageal exclusion with removal of the intrathoracic esophagus and devitalized stomach. L neck esophagostomy, and replacement of the stomach into the abdomen.
- Should not redo anastomosis in unstable patient.
- Should not do stent in necrotic tissue that requires debridement.
Colon interposition and super-charged jejunum can be used if the patient 4-6 mo after exclusion.
58
What did JCOG-9907 show about OS in patients w/ infectious complications after esophagectomy?
OS is shorter. Therefore, avoiding and not just successfully treating postop infections may improve survival.
59
For outpatient cardiac surgery, what abx regimen can be given to reduce staph colonization (including MRSA)?
Topical nasal mupirocin BID for 5 days before surgery.
Ancef is given within 60 mins of incision.
60
Most common cause of readmission after lobectomy?
postop infection - pna, wound, etc
61
For patients w/ VKA-associated major bleeding, rapid reversal of anticoagulation is best achieved by what (CHEST guidelines)?
4-factor PCC (as opposed to plasma). Add vit K 5-10 mg via IV slow injection should be added (as opposed to factors alone).
If 4-factor PCC is not available, plasma 10-15 ml/kg can be given.
62
What is the reversal agent for the direct thrombin inhibitor dabigatran?
Idarucizumab
63
Do all patients with subsegmental PE require anticoagulation?
CHEST guidelines: in pts w/ subsegmental PE, without proximal DVT, w/ low risk for recurrence, or have high bleeding risk... surveillance is suggested over anticoagulation
64
In patient with subsegmental PE, what should be done next?
Screen for VTE risk (active cancer, recent, surgery, hospitalized, reduced mobility, low CP reserve).
Almost all CTS patients will need anticoagulation.
Get BLE duplex scans for proximal DVT.
65
Ivor Lewis pt POD4 has bilious drainage from JP drain. He becomes septic and hypotensive. CXR shows opacification of the R chest w/ mediastinal shift to the L. He is intubated w/o incident, and started on abx and fluids. What is the next step?
This is likely a poorly drained empyema from conduit complication. R chest tube placement.
Book for R thoracotomy.
66
A postop VATS lobectomy pt is DC w/ a CTb for air leak. They return septic, and CT shows large loculated heterogenous fluid collection and large amount of apical pleural space. What is your assessment and plan?
Empyema, trapped lung, possible BPF.
Cultures, BS abx, IVF.
Redo VATS drainage & decortication of the lung (pigtail drainage can get fluid samples, but definitive treatment is lacking).
Make sure to do bronch to eval bronchial stump.
67
A postop VATS lobectomy pt is DC w/ a CTb for air leak. They return septic, and CT shows large loculated heterogenous fluid collection and large amount of apical pleural space. VATS is planned, and bronchoscopy during DL ETT placement is done showing a BPF. How does this affect your surgery?
Will likely need open approach with repair and buttress of the BPF. If space will not fill, may need more to fill it (lat flap, omentum).
68
Steroid-dependent COPD pt presents w/ acute resp failure and is intubated.
1 wk later, he is febrile, and CT scan shows lobar opacification w/ central cavitation.
Vent settings are high.
What is the best next diagnostic step?
What is safest in a sick pt?
Flexible bronch w/ lavage and brushings - high yield for infx dx and relatively safe.
VATS and even IR procedures would be difficult in patients w/ ongoing high oxygenation and vent requirements.
69
A postop lobectomy pt develops a-fib with RVR postop. Chest tubes were removed yesterday. CXR shows a new large pneumothorax with mediastinal shift. The patient goes into RVR, and becomes hypotensive. What is the next best step?
Suspect BPF and tension PTX. Chest tube to a suction-free passive drainage system.
Hemodynamic changes may be d/t a-fib w/ RVR, but the tension PTX is likely causing the a-fib, which may resolve after release of the tension.
If it doesn't, cardiovert.
70
A postop lobectomy is found to have BPF involving a large portion of the stump after an episode of tension PTX. How do you definitively manage?
If minimal contamination in a stable patient, do primary closure w/ muscle reinforcement.
Consider modified Clagett procedure if severe contamination.
71
A smoker/drinker w/ poor dentition presents w/ large pulmonary cavitary mass. Bronch and CT biopsy show sulfur granules and filamentous shapes. What is the diagnosis and management?
Actinomyces - facultative, anaerobic G+. Slow growing. Found in oral cavity.
It causes a chronic, suppurative granulomatous disease.
Tx is IV penicillin G 4-6 wks, then PO penicillin V for 6-12 mo.
72
A CABGx4 w/ nl preop EF and uncomplicated surgery has hypotension. CXR is ok and CT output is low. He is not on inotropes. CVP is 8, CI is 1.8, and PA pressure is 24/12. What should be done next?
Assess volume status, and give fluids before inotropes.
73
A postop CTS pt develops an irregular, narrow complex tachycardia w/ a rate >120. BP is nl. What is the diagnosis and management?
Atrial fibrillation. With RVR.
Metoprolol is first line. Amiodarone bolus and infusion if that fails.
Amiodarone first if EF <40.
Ca channel blocker first if COPD.
Cardioversion would be if the pt is unstable.
74
What is the timing for broad-spec abx in a septic patient?
After cultures, within the first hour.
Every hour delay in abx increases mortality.
75
POD4 CABG patient begins having significant ST elevation (>2mm) in a specific region (eg II, III, aVF). Borderline hypotensive w/ otherwise normal vitals.
What is the best next step in management?
Should the OR be the first step?
What about Nitro?
Emergency coronary arteriography to assess patency.
Early graft failure is uncommon.
Peri-op MI is associated w/ adverse short/long-term outcomes.
Do not go to OR without identifying the lesion. Do not give nitro in someone who is borderline hypotensive.
76
POD0 cardiac transplant is worsening w/ the following hemodynamics.
BP 100/60; CVP 20; PAP 50/30; PCWP 10; CI 1.7.
CT output min.
On milrinone 0.5 and levophed 10.
What is your assessment/plan?
RV dysfunction with cardiac failure.
CVP rules out a preload issue (no fluids).
Nl PCWP makes LV failure unlikely (IABP or LVAD unlikely to help much).
Check SVR and echo.
Start inhaled prostacyclin (PGI2) for pulmonary vasodilation. 50 ng/kg/min.
77
POD1 CABG w/ hx HTN on ACE inh and nl preop EF had following vitals:
MAP 50, CVP 5, CI 4.
So pressors up to vaso 0.04 and levo 20.
Now MAP 55.
What's assessment/plan?
Vasoplegic syndrome refractory to pressors.
Methylene blue 2 mg/kg.
Inh guanylate cyclase => c-GMP dec => smooth muscle relaxation.
In this scenario, vaso and levophed are about as high as they should go. It's likely too early in the course for adrenal insufficiency (usually presents in septic patients who are placed on pressors and stop responding).
78
POD0 CABG MVr pt w/ drips/vitals as follows:
Mil 0.25. BP 110/65. HR 92. CVP 8. PAP 40/20. PCWP 16. CI 2.4.
4 hrs later, he is in PEA w/ sinus rhythm in the 90s.
Minimal CTb output.
Assessment/Plan?
Diffx includes: tension PTx, tamponade, bleeding.
Can do a quick echo and get set up for a bedside sternotomy.
Lines and meds too.
Bedside sternotomy (prompt resternotomy) would address all of these and allow for cardiac massage.
79
In futile care decisions, when a patient is of limited capacity, health care decisions may be delegated.
What is the hierarchy of the decision makers?
Directed decision making (living will).
Delegated decision making (power of attorney)
Devolved decision making (surrogate determined by state law)
Displaced decision making (court, guardian)
Deferred decision making (physician)
80
What can be added to the pain regimen in the perioperative period to reduce opioid use?
Acetaminophen
NSAIDs
Gabapentin
Ketamine (NMDA receptor) - assd w/ hallucinations and nightmares.
Lidocaine (membrane stabilizers) - limited to intraop.
clonidine (a-2 agonists) - not for postop; used w/ regional peripheral neural blockade.
dexmedetomidate
Periop pain can result in hyperalgesia and central sensitization.
81
What are some risk factors associated with development of prolonged opioid use in thoracic surgery?
Open procedures, younger age, low SE status, DM, CHF, pulmonary disease, use of preop benzodiazepines, SSRIs, and ACE inh.
82
What is a good, proven non-opioid outpatient pain regimen that can be used in a patient with kidney disease?
Tylenol and aspirin.
Avoid ibuprofen in kidney disease patients, gabapentin works best with opioids as a potentiator, lidocaine patches have not been proven to be of benefit.
83
What is the tidal volume shown to improve mortality in ARDS patients?
6 ml/kg. Low TV, lung protective strategy.
High PEEP is harmful. APRV and high-frequency oscillatory ventilation have not shown benefit.
84
How do you obtain plateau pressure? And what is the plateau pressure goal in an ARDS patient?
What about PaO2 and pH?
Inspiratory hold.
< 30 cm H20.
Also: PaO2 can be as low as 55 to avoid increasing FiO2/PEEP too high, pH can be as low as 7.3 with permissive hypercapnia (as long as not long-term).
85
Explain the pathology of limited expiratory flow in vent patients. How do you improve this in ventilated patients?
Inc RR (ARDS pts w/ low TV) OR decreased elasticity (COPD)
=> impedance to exhale to FRC.
=> dynamic hyperinflation and air trapping.
=> inc pCO2.
Tx: dec minute ventilation by dec RR to allow time for exhalation to dec air trapping to improve pCO2.
86
What change in settings can worsen air trapping (and inc CO2) in mechanically ventilated patients?
Increasing RR, increasing extrinsic PEEP, increasing inspiratory:expiratory ratio.
87
COPD pt develops acute exacerbation and PTX, so chest tube placed. He has hypercapnic resp failure w/ pCO2 of 65 and pH of 7.2. He doesn't want to be intubated. What can be done?
Bilevel positive airway pressure.
CPAP is more uncomfortable. High-flow O2 can lower respiratory drive and inc pCO2.
Nasal intermittent positive pressure ventilation is for neonates.
88
What is cor pulmonale?
Deleterious change in the structure and fct of the RV brought on by a primary lung dz causing R HF.
89
What are the two most common causes of acute cor pulmonale?
ARDS and acute PE
Cor pulmonale - enlargement and failure of the RV in response to inc pressure from the pulmonary system
90
What is the pathophys of pulm htn in ARDS?
Hypoxic pulm vasoconstriction is main one (physiologic response to optimize ventilation and perfusion matching by vasoconsx flow to hypoxic alveoli to divert to more oxygenated alveoli).
Positive pressure vent, hypercarbia, atelectasis, thrombus, and pulm vasoconstrictors also contribute.
Rare that PH is bad enough in ARDS to cause acute cor pulmonale.
91
How can you recognize acute cor pulmonale on an echo in a ventilated pt w/ pulm htn and ARDS?
Echo shows dilated RV w/ reduced contractility of the free wall, paradoxical motion of the IV septum, and tricuspid regurgitation.
92
How do you manage pulm HTN causing cor pulmonale in pts w/ ARDS?
1) Address underlying cause - often hypoxia causing physiologic pulm vasoconstriction for vent/perfusion matching. Ie optimize the vent settings.
2) Address contributing causes like hypercarbia, acidosis.
3) Dobutamine and prostacyclin can be used to treat pulmonary htn. INO and sildenafil are also options.
4) Consider CT chest to r/o PE as contributing.
5) If severely unstable, can use ECMO to offload the right side.
93
A postop transhiatal esophagectomy develops hypoxia despite nasal cannula. Discuss the use of positive pressure ventilation and management of hypoxia?
Contraindicated d/t fresh cervical anastomosis.
Consider high-flow nasal oxygen therapy instead.
May require intubation and diuresis depending eval.
94
The Awakening and Breathing Controlled Trial found what in regard to ICU intubated patients?
Sedation interruption (spontaneous awakening trials) w/ spontaneous breathing trials were better than unit standard sedation with daily spontaneous breathing trials.
4-day reduction in ICU and hospital stays.
14% absolute risk reduction for survival at 1 year (NNT of 7 to save a life).
Self-extubation was higher, but reintubation was similar.
95
A pneumonectomy patient recovers and is undergoing surveillance. He develops dyspnea and cough and is hospitalized multiple times for pna. He is recovered but has inspiratory stridor. CT shows mediastinal shift and rotation into the pneumonectomy space with distention and herniation of the other lung.
What is the diagnosis?
Pathophysiology?
Surgical plan?
Postpneumonectomy syndrome.
This can cause extrinsic compression of the distal trachea d/t pressure over the vertebral column. Rarely it can cause dysphagia through compression of the esophagus.
Tx: surgically reposition the mediastinum and fill the pneumonectomy space with a saline implant.
Bronchoscopy to check for patency and stability before closure is important.
CXR intraop may help as well.
96
Before beginning abx for a septic pneumonia patient, what must be done?
Obtain lactate, CBC, cultures.
Consider art line and central line.
97
What is required for the definitive diagnosis of a deep sternal wound infection?
Any of the following:
1) organism isolated from mediastinal tissue or fluid
2) evidence of mediastinitis seen on operation (subjective)
3) EITHER chest pain, sternal instability, or fever PLUS... EITHER purulent mediastinal drainage, positive blood culture, or positive mediastinal culture
98
In a CABG pt that used BIMAs, what will increase risk for DSWI (per Ohira, et al)?
Female, DM, chronic lung disease, renal failure, liver dysfunction, EF <60, shock, re-operation, pre-op IABP use, increased OR time.
99
How is "new persistent opioid use after surgery" defined?
Continued opioid Rx fulfillment >90 days after surgery.
100
What comorbidity has the strongest association with "new persistent opioid use after surgery"?
pulmonary disease, followed by heart failure
no association: CAD, CVD, HTN, CKD
101
What pre-operative medication has the strongest association w/ "new persistent opioid use after surgery"?
SSRI, then ACE-inh and benzodiazepines
no association: beta-blockers, statins, ARBs
high periop opioid dosage has fairly small effect (OR 1.14)
102
What major surgical incision has the highest risk for "new persistent opioid use after surgery"?
Thoracotomy, followed by minimally invasive lung resection.
Not a major risk factor: sternotomy.
103
PCWP is an estimate of the pressure in what heart chamber?
left atrium
104
What would LV dysfunction do to PCWP?
Increase it.
105
What IV drug was shown to reduce opioid use after CABG?
Ketamine. Careful for hallucinations.
Other ERAS stuff:
- preop tylenol and gaba
- intraop local anes
- postop multimodal
106
In futile care decisions, when a patient is of limited capacity, health care decisions may be delegated.
What is the hierarchy of the decision makers?
Directed decision making (living will).
Delegated decision making (power of attorney).
Devolved decision making (surrogate determined by state law).
Displaced decision making (court, guardian).
Deferred decision making (physician).
