CICM Second Part Exam Practice SAQs 21112018

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 Lifeinthefastlane.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).

  Typical antipsychotic eg haloperiodol Atypical antipsychotic eg quetiapine, olanzapine, risperidone Alpha agonists eg dex/clonidine Benzos eg midazolam
Considerations Medical related delirium

Agitation due to psychosis

Medical related delirium

Agitation due to psychosis

Medical related delirium

 

Withdrawl drugs/alcohol.

2nd line if medical related Delirium

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

EPSE/dystonic drug reaction

Less hypotension

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 cw placebo)

MIND-USA NEJM 2018 (No difference)

Quetiapine trial CCM 2010 – 36 adults – reduced delirium, more d/c home

DahLIA Trial JAMA 2016  

Also could discuss ketamine, propofol

References

  1. Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med 2018;
  2. Reade MC, Eastwood GM, Bellomo R, et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460-8. [pubmed]

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.

  • O2 Targets >92%
  • Protective lung ventilation with volume ?<6-8ml/Kg
  • PEEP 8-10
  • ?Driving pressure <14cm H20
  • Pl pre <30
  • Resp rate

See also:

References

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
  1.  What are the possible causes of the bleeding? (3 marks)
  2.  What tests could be done to confirm your diagnosis? (3 marks)
  3.  Discuss your approach to management (4 marks)

  1.  What are the possible causes of the bleeding? (3 marks)

    Hyperfibrinolysis, heparin related less likely given APTT 48, DIC also less likely as platelets are not that low

  2.  What tests could be done to confirm your diagnosis? (3 marks)

    FDP, D dimer, Free Hb, TEG/Rotem, platelet function

  3.  Discuss your approach to management (4 marks)

    Change circuit to treat cause
    Reduce heparin and APTT target
    Consider FFP
    Cryoprecpiritate to aim fibrinogen >1.0
    Consider tranexamic acid

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)


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
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