As prepared by Bevan Roodenburg, here are the practice written questions from a recent CICM Second Part exam practice session at The Alfred ICU, with recommended reading from LITF.com’s Critical Care Compendium and other FOAM sources:
Q1. (CICM SAQ 2011.1 Q2)
Answer the following questions about transjugular intrahepatic portosystemic shunts (TIPS):
- What is a TIPS procedure and why is it used in patients with portal hypertension?
- What are 2 recognised indications for this procedure?
- Excluding mortality list 5 COMMON complications of TIPS procedure
- Describe one classification system used in assessing severity of chronic liver disease and outline its utility.
Learn more here:
Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure
Q2. (CICM SAQ 2011.1 Q7)
As director of ICU, the general manager of your hospital asks you to review your current infection control policy following an increase of 200% in the number of newly acquired VRE infections during an ICU admission in the past 2 months.
Outline your approach to this request.
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Q3. (CICM SAQ 2011.1 Q8)
3.1.
A 40 year old previously well male presents with a ruptured appendix and associated peritonitis (Day 0). He returns to theatre 3 days later with ischaemic colitis and requires a right hemicolectomy. At laparotomy, he is noted to have extensive thrombosis in his superior mesenteric vein and portal vein. Attempts to anticoagulate him postoperatively (day 5 onwards) with intravenous heparin have been unsuccessful.
His post op haematology results are as follows:
| Day 0 | Day 1 | Day 3 | Day 5 | Day 7 | Day 9 | Range | |
| INR | 1.2 | 1.7 | 1.8 | 1.6 | 0.8-1.3 | ||
| APTT | 36 | 38 | 36 | 28* | 31* | 37* | 24-35 |
| Fibrinogen | 5.8 | 1.8 | 1.4 | 1.7 | |||
| INR Mix | 1.9 | 0.8-1.3 | |||||
| APTT Mix | 32.5 | 30-40 | |||||
| D Dimer | >4 | <0.5mg/L |
* On I.V. heparin. APTT therapeutic range for I.V. heparin therapy: 60 – 90 seconds
Additional tests performed on Day 7:
Tests of hypercoagulability (plasma)
Antithrombin (functional) 20% (Reference: 80 – 120%)
Factor assays (plasma)
Factor VIII 4.10 IU/ml (Reference: 0.5 – 1.5)
Anti-Factor Xa assay (plasma)
Anti-Factor Xa 0 IU/ml (Reference for IV heparin therapy: 0.3 – 0.7)
- What are the possible factors preventing therapeutic anticoagulation in this patient?
- List 2 strategies to effect anticoagulation with intravenous heparin.
3.2.
A 28 year old man presented with a persistent epistaxis to the emergency department.
The coagulation profile was as follows:
| Test | Value | Reference Range |
| INR | 1.2 | 0.8-1.3 |
| APTT | 50 | 25-39 |
| Platelets | 250 x 10^9 / L | 150-350 |
| Bleeding time | 16 minutes | 2-8 |
| Fibrinogen | 3 g/L | 1.5-4 |
| FDPs | <10mg/L | 0-10 |
| Thrombin clotting time | 15 seconds | 12-17 |
- What is the most likely diagnosis?
- What would you confirm your diagnosis?
3.3.
A 50 year old female presents with a right deep vein thrombosis and haemoptysis.
These blood results are from her admission:
| Test | Value | Reference Range |
| PT | 12 seconds | 12-14 |
| APTT | 69 seconds | 34-38 |
| Thrombin time | 16 seconds | 14-18 |
| APTT Mixing test | 60 seconds |
- What is the APTT mixing test and what is its significance in this patient?
Learn more here:
You can access all the previous practice questions since 2014 here:
https://docs.google.com/document/d/1_Ta8IvVaVtc5Il7-kJwj6qKGu54OmifJGRUWCXud8dY/edit
See this link on INTENSIVE for exam resources:
//intensiveblog.com/resources/#3