As prepared by Aidan Burrell, 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.
You are called to a 64-year-old patient day 2 post-CABG with hyperactive delirium. Compare and contrast the use of different pharmacological classes in the treatment of this condition (10 marks).
Agitation due to psychosis Agitation due to psychosis 2nd line if medical related Delirium EPSE/dystonic drug reaction Less hypotension MIND-USA NEJM 2018 (No difference cw placebo) Quetiapine trial CCM 2010 – 36 adults – reduced delirium, more d/c home Also could discuss ketamine, propofol References
Typical antipsychotic eg haloperiodol
Atypical antipsychotic eg quetiapine, olanzapine, risperidone
Alpha agonists eg dex/clonidine
Benzos eg midazolam
Considerations
Medical related delirium
Medical related delirium
Medical related delirium
Withdrawl drugs/alcohol.
Mechanism
Dopamine 2 antagonist
Dopamine antagonist (plus other receptors)
Alpha adrenoceptor agonists (Dex A2)
Enhance GABA
IV/IM
Yes/Yes
Quetiapine not IV not/olanzapine IM only
Yes/No
Yes/Yes
Time to effect
Fast
Fast only if IV available
Fast
Very fast
Side effects
Prolonged QT/Torsades
Hypotension after IM
Bradycardiac arrest
Respiratory depression, worsening of delierium
Evidence
HOPE trial LANCET resp med 2013 (More oversedation with haloperidol)
MIND-USA NEJM 2018 (No difference)
DahLIA Trial JAMA 2016
Q2.
A patient arrives in your ICU following major abdominal surgery with the following ventilator settings:
Fio2 0.6
PEEP 5
Volumes 9ml/kg PBW.
Plateau pressure 31
RR 22
Discuss any changes you will make to the ventilator, and any evidence to support your decisions (10 marks).
It is important to distinguish between ARDS and non ARDS hypoxic respiratory failure (CXR, echo, PF ratio etc as per Berlin criteria) The risk of ventilator associated lung injury is probably much higher in ARDS than non ARDS patients, and stricter targets are required in ARDS In practice both patients groups are often similarly managed. See also: References https://lifeinthefastlane.com/ccc/protective-lung-ventilation/ Amato MBP, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372(8):747–55. [pubmed] Futier E, Constantin J-M, Paugam-Burtz C, et al. A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery. N Engl J Med 2013;369(5):428–37. [pubmed] Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. American Journal of Respiratory and Critical Care Medicine. 2017;195(9):1253–63. [pubmed] Serpa Neto A, Simonis FD, Barbas CSV, et al. Association between tidal volume size, duration of ventilation, and sedation needs in patients without acute respiratory distress syndrome: an individual patient data meta-analysis. Intensive Care Med 2014;40(7):950–7. [pubmed] Writing Group for the PReVENT Investigators, Simonis FD, Serpa Neto A, et al. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA 2018;320(18):1872–80. [pubmed]
Q3.
A patient on day 5 of ECMO develops mucosal bleeding. The patient is on 800Units/hr of heparin:
The following blood tests
- Hb 90
- Plt 100
- INR 1.4
- APTT 48
- Fibrinogen 0.9
- D-dimer 5
- What are the possible causes of the bleeding? (3 marks)
- What tests could be done to confirm your diagnosis? (3 marks)
- Discuss your approach to management (4 marks)
Hyperfibrinolysis, heparin related less likely given APTT 48, DIC also less likely as platelets are not that low FDP, D dimer, Free Hb, TEG/Rotem, platelet function Change circuit to treat cause References Thomas J, Kostousov V, Teruya J. Bleeding and Thrombotic Complications in the Use of Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2018;44(1):20–9. [pubmed] Faraoni D, Levy JH. Algorithm-based management of bleeding in patients with extracorporeal membrane oxygenation. Crit Care 2013;17(3):432. [pubmed] (includes ROTEM images of hyperfibrinolysis)
Reduce heparin and APTT target
Consider FFP
Cryoprecpiritate to aim fibrinogen >1.0
Consider tranexamic acid
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