SEP Module Review Miscellaneous Questions

1
SEP Module ReviewMiscellaneous Questions

• Jonathan Warren, MD
• July 16, 2006

2
Question 01A

• 18 y/o female 45 minutes post-partum
• Acute SOB, tachycardia, hypotension
• Intubated
• T 38.5c, HR 140, RR 40, BP 70/50
• CXR diffuse bilateral alveolar infiltrates

3
Question 01A

• Abnormal labs
• PTT 34 sec
• Fibrinogen 75 mg/dL
• Hemodynamics
• PAOP 10 mmHg
• C.I. 1.9 L/min/m2

4
Question 01A

• What should be done next?
• Emergency hysterectomy
• Administer norepinephrine
• Administer furosemide
• Administer intravenous saline
• Administer methylprednisolone

5
Q01A Amniotic fluid embolism

• Syndrome usually occurs with labor and delivery,
  may also occur with uterine manipulation or
  uterine trauma
• Believed to be caused by amniotic fluid and
  particulate matter entering the circulation by
  uterine tears or via the endocervical veins.

6
Q01A Amniotic fluid embolism

• Clinical presentation
• Sudden dyspnea leading to ARDS
• Hypoxemia
• Cardiovascular collapse
• Seizures
• DIC in mother or fetus

7
Q01A Amniotic fluid embolism

• Disorders to be excluded
• Septic shock
• Pulmonary embolism
• Myocardial infarction
• Tension pneumothorax
• Abruptio placentae
• Aspiration pneumonia
• HELLP syndrome

8
Q01A Amniotic fluid embolism

• Treatment is supportive
• Mechanical ventilation/oxygen
• Intravenous fluids
• Pressors
• Inotropes
• Corticosteroids and hysterectomy are of no proven
  benefit

9
Question 06A

• The fiduciary relationship between physician and
  patient is based upon the ethical principles of
  autonomy, beneficence, and
• A. Altruism
• B. Entitlement
• C. Distributive justice
• D. Non-maleficence
• E. Risk management

10
Q06A Principles of Medical Ethics

• There are five basic principles of biomedical
  ethics
• Beneficence promotion of benefits over burdens.
• Non-maleficence do no harm
• Patient autonomy patient independence.
• Justice impartiality, equal distribution of
  resources (this is a societal role).
• Fidelity faithfulness, keeping promises.

11
Question 07A

• Hemodynamic data
• RA 6 mmHg
• PAP 23/12 mmHg
• MPAP 15 mm Hg
• PAOP 7 mmHg
• C.O. 5 L/min
• PVR 128 dynes.sec/cm5
• MAP 86 mmHg
• SVR 640 dynes.sec/cm5

12
Question 07A

• Data most compatible with
• A. RV infarction
• B. LV infarction
• C. Sepsis
• D. Pulmonary embolism
• E. Calculation error

13
Q07A Hemodynamic Data Errors

• All values are within normal limits EXCEPT the
  SVR.
• Normal range SVR 770-1600.
• SVR (MAP-RA)x80
• CO
• (86-6)x80
• 5
• 1280
• SVR calculated incorrectly !!

14
Question 08A

• Which complication is most likely to follow from
  prolonged saline flush of radial artery catheter
  when pressurized vascular flushing device is
  used?
• (A) Volume overload
• (B) Hemolysis
• (C) Retrograde embolization
• (D) Excess anticoagulation
• (E) Sepsis

15
Q08A Arterial catheter complications

• Three primary complications of arterial
  catheters
• Bleeding
• Distal ischemia
• Thrombosis
• Embolization
• Mechanical obstruction
• Infection
• Less common peripheral nerve injury,
  arteriovenous fistula, pseudoaneurysm

16
Q08A Bleeding complications

• Aggravated by
• Coagulopathy
• Poor technique
• Extreme hypertension

17
Q08A Ischemia

• Aggravated by
• Poor catheter selection (too large)
• Thrombosis/embolism due to use of non-heparin
  flush solutions (Caution HIT)
• Air embolism due to excessive flushing
• Use of end-artery (e.g. brachial artery)

18
Q08A Infection

• Incidence 2-8
• Aggravated by
• Poor insertion technique
• Prolonged catheter placement
• Poor site care
• Contaminated flush solutions
• Frequent stopcock manipulations and blood
  sampling from catheter.
• Superficial infections are more common than
  episodes of catheter-related sepsis

19
Q08A Which complication most likely?

• Look carefully at question Which complication
  is most likely to follow from prolonged saline
  flush.
• Volume overload hard to rationalize
• Hemolysis could occur with hypotonic flush
  solution, not usually used
• Retrograde embolization is possible
• Excess anticoagulation is unlikely unless pt had
  a problem with heparin clearance, or erroneous
  preparation of heparin flush solution
• Sepsis unlikely to result from excessive flushing
  alone

20
Question 20A

• 65 year old female
• history of advanced COPD
• acute respiratory failure
• intubated on mechanical ventilation
• Height 157 cm
• weight 70kg
• moderately obese

21
Question 20A

• Daily nutritional support?
• 1200 Kcal and 70 g protein
• 1200 Kcal and 140 g protein
• 1800 Kcal and 90 g protein
• 2500 Kcal and 120 g protein

22
Q20A Nutritional Support in the ICU

• Nutrition requirements in critically ill patients
  are estimated by a number of methods
• (1) Empiric methods (e.g. ACCP or ASPEN
  guidelines)
• (2) Calculations (e.g. Harris-Benedict equations)

23
Q20A Nutritional Support in the ICU

• EMPIRIC METHOD
• Caloric requirements
• Minimal stress 25 kcal/kg/day
• Single organ failure, uncomplicated trauma, small
  burns
• Moderate stress 30 - 35 kcal/kg/day
• Severe sepsis
• Severe stress 40 - 45 kcal/kg/day
• Extensive burns, multiple trauma

24
Q20A Nutritional support

• Protein requirements
• Minimal stress 1.3 g/kg/day
• Moderate stress 1.5 - 1.7 g/kg/day
• Severe stress 2.0 g/kg/day

25
Q20A Nutritional support

• This patient would be classified as minimally
  stressed, having a single organ failure (lungs)
  and the absence of hemodynamic instability.
• Caloric requirements
• 25 kcal/kg/day x 70 kg 1750 kcal/day
• Protein requirements
• 1.3 g/kg/day x 70 kg 91 g/day

26
Q20A Nutritional support

• Harris-Benedict equations estimate basal caloric
  requirements (protein, CHO, fat), modified by a
  stress factor (usually approximately 20 for
  ICU patients).
• Men
• BMR 66 13.7(W) 5(H) - 6.8(A)
• Women
• BMR 655 9.6(W) 1.7(H) - 4.7(A)
• In this patient, estimated total energy needs by
  H-B
• BMR x 1.2 (655 672 267 306) x 1.2
• 1546 total calories (pro CHO
  fat)

27
Question 28A

• previously healthy 50 year old male
• sepsis
• fever (39.1oC)
• lethargic, poorly responsive
• normal CT brain
• normal CSF

28
Question 28A

• Most likely EEG findings?
• Classic sleep-stage architecture with normal
  distributions of non-REM and REM stages
• Normal REM activity with circadian temperature
  correlation and progressive duration in the
  second half of the night
• Distinguishable sleep transients such as sleep
  spindles and K complexes interspersed throughout
  the 24-hour circadian period
• Slowing with intermittent theta and delta
  waveforms and no definable sleep or wake periods

29
Q28A Normal sleep architecture

• Five recognized sleep stages
• REM sleep muscle atonia, characteristic eye
  mvmts, low-voltage mixed frequency EEG. No sleep
  spindles or K-complexes.
• Stage I low-voltage mixed frequency EEG no
  sleep spindles, K-complexes, or delta waves.
• Stage II mixed voltage/frequency EEG sleep
  spindles, K-complexes delta waves
  record.
• Stage III/IV higher voltage/lower frequency EEG
  sleep spindles, K-complexes delta waves 20 of
  record.

30
Q28A Normal sleep architecture

• REM sleep alternately cycles with non-REM sleep
  every 90 minutes on average
• Stage III/IV sleep most prominent during first
  1/3 of sleep
• REM sleep most prominent during last 1/3 of sleep
• Stage III/IV sleep is generally considered the
  restorative sleep
• Role of REM sleep uncertain, but may act in
  memory and learning consolidation and/or serve a
  memory housekeeping function

31
Q28A Sleep in Critical Illness

• Four early studies looked at sleep in critical
  illness
• Richards K, Bairnsfather L. Heart Lung, 1988
• Broughton R, Baron R. Electroenceph Clin
  Neurophysiol, 1978
• Aurell J, Elmquist D. BMJ, 1985
• Hilton B. J Adv Nurs, 1976.

32
Q28A Sleep in Critical Illness

• Altered sleep architecture
• predominance of Stage I and II sleep
• decreased or absent Stage III, IV, and REM sleep
• shortened REM periods
• sleep fragmentation
• Abnormal sleep distribution
• up to 50 of total sleep time occurred during the
  day

33
Q28A Sleep in Critical Illness

• Freedman et al. Am J Respir Crit Care Med 2001
• Studied critically ill patients with primarily
  medical illnesses
• Patients were excluded if heavily sedated, if
  stuporous or comatose, or if prior history of
  dementia

34
Q28A Sleep in Critical Illness

• Freedman et al
• Abnormal sleep architecture
• predominance of stage I sleep
• decreased or absent stage II, III, IV, and REM
  sleep
• Sleep was equally distributed between day and
  night

35
Q28A Sleep in Sepsis

• Freedman et al
• Five patients had sepsis, and all had similar EEG
  findings
• low voltage mixed frequency EEG
• intermittent and variable amounts of theta and
  delta waves
• same EEG pattern present whether eyes were open
  or closed
• no evidence of definable sleep no sleep
  spindles, K-complexes, or REM activity

36
Q28A EEG in Sepsis Encephalopathy

• These findings are consistent with the EEG
  abnormalities of sepsis-induced encephalopathy.
• Young et al (J Clin Neurophysiol 1992).

37
Question 55A

• 50 y/o male
• Altered mental status
• Livedo reticularis
• Acrocyanosis
• Chronic CHF due to idiopathic dilated
  cardiomyopathy.

38
Question 55A

• Temp 40c
• BP 95/60
• Hgb 10 g/dL
• Serum bicarb 10 mEq/L
• Venous lactate 3.6 mEq/L
• ABG pH 7.20, pCO2 24, pO2 60
• PA catheter
• PAOP 30 mmHg, C.O. 2 L/min

39
Question 55A

• Most effective means of improving tissue
• hypoxia?
• Reducing body temp to 37c
• Increasing Hgb to 14.0 g/dL
• Increasing arterial pO2 to 120 mmHg
• Sodium bicarbonate to increase arterial pH to
  7.45
• Dobutamine to increase C.O. to 3 L/min

40
Q55A Oxygen delivery and consumption

• Oxygen delivery determined by
• rate of oxygen supply (C.O.)
• oxygen content of blood (Hgb, pO2)
• ease of release of oxygen from Hgb (pH, temp)
• Oxygen consumption determined by tissue demands
  (metabolic rate, accumulated deficits)
• temperature
• muscle activity

41
Q55A pH and Temp effects on Hgb

• pH and temperature both have an effect of the
  affinity of hemoglobin for oxygen.
• Lower pH reduced oxygen affinity
• Higher temperature reduced oxygen affinity
• Thus lowering patients temp and increasing pH
  would improve oxygen content of Hgb but reduce
  its release at the tissue level (Hgb has higher
  oxygen affinity).
• These effects are generally small.

42
Q55A Temperature effects on oxygen demand

• Lowering body temperature reduces oxygen
  consumption by reducing metabolic rate.
• This effect can be substantial, but are generally
  unquantified.

43
Q55A Oxygen Delivery

• DO2 CaO2 x CO x 10
• DO2 oxygen delivery
• CaO2 arterial oxygen content
• (1.34 x Hgb x SaO2) (0.0031 x PaO2)
• CO cardiac output

44
Q55A Oxygen Delivery

• DO2
• (1.34 x Hgb x SaO2) (0.0031 x PaO2) x CO x 10
• Changes in Hgb, SaO2 and CO result in relatively
  large proportional changes in oxygen content.
• Changes in PaO2 result in relatively small
  changes in oxygen content.

45
Q55A Oxygen Delivery

• DO2
• (1.34 x Hgb x SaO2) (0.0031 x PaO2) x CO x 10
• An increase in Hgb from 10 g to 14 g results in a
  40 increase in oxygen (content and) delivery.
• An increase in CO from 2 L/min to 3 L/min results
  in a 50 increase in oxygen delivery.
• An increase in PaO2 from 60 torr to 120 torr
  results in a negligible increase in oxygen
  delivery.

46
Question 58A

• 45 year old male
• small cell ca, undergoing treatment
• acute SOB and chest pain
• CXR tumor markedly reduced in size
• Hypoxemia, respiratory alkalosis
• large bilateral pulmonary emboli

47
Question 58A

• morphine given for pain management
• pt develops respiratory failure and now needs
  intubation/mechanical ventilation
• Patient states he does not want heroic measures
  despite reversibility of condition
• appears mentally competent

48
Question 58A

• What next?
• A. Administer addl morphine and oxygen
• B. Discontinue morphine
• C. Discontinue oxygen and other support
• D. Restrain patient and proceed with intubation
  and mechanical ventilation
• E. Obtain psychiatric consultation

49
Q58A Patient Autonomy and End-of-Life
Decision-Making

• Current medical practice operates largely under
  the Enhanced Patient Autonomy Model
• It is a compromise between
• Paternalism (patient is a recipient of care).
• Patient independence (pure autonomy).
• There is collaborative decision-making
• Patient goals and values are identified.
• Physician knowledge and expertise is shared with
  patient
• Ultimately, a competent patient makes his/her own
  decisions.
• Patient comfort is always a priority

50
Q58A Patient Autonomy and End-of-Life
Decision-Making

• The determination of competence does not
• usually require a psychiatric evaluation or
• court hearing.

51
Question 20B

• 82 year old female nursing home resident
• bedridden
• aphasic following stroke 2 years ago
• contractures, decubitus ulcers
• apnea following aspiration of tube feedings
• complete heart block, HR 45 bpm

52
Question 20B

• patients son states everything should be done
  for her
• admitted to ICU, temporary pacemaker placed
• develops progressive renal failure and
  intermittent apneas with associated hypoxemia
• son continues to insist that everything be done
  for his mother

53
Question 20B

• What next?
• Transfer patient to another hospital
• Ask the patients son for permission to implant a
  permanent pacemaker, intubate, and perform
  hemodialysis
• Tell the son that more aggressive interventions
  are unlikely to be of medical benefit and are not
  advisable for his mother
• Do not offer to implant a permanent pacemaker,
  intubate, or perform hemodialysis, and tell the
  son that everything is being done
• Obtain a court order not to attempt resuscitation
  for this patient

54
Q20B Autonomy vs. Futility

• Few therapies or interventions are truly
  physiologically futile. Rather, they may be of
  only temporary benefit, or have a low probability
  of success.
• Patients or substitute decision-makers have the
  right of autonomy, that is, the right to choose
  among therapies and to refuse any treatment.

55
Q20B Autonomy vs. Futility

• Given the clinical situation, the physician might
  conclude that the primary goal in this situation
  is non-maleficence, that is, do no harm. This
  may translate into a desire to limit therapeutic
  modalities that may prove of limited clinical
  value but may cause additional pain or suffering.
• If the physician takes this position, yet the
  patient or substitute decision-maker wishes
  aggressive therapy, then the principles of
  patient autonomy and physician non-maleficence
  are in conflict.

56
Q20B Autonomy vs. Futility

• At this point, the physician has an obligation to
  determine the basis of the sons treatment
  requests. Once done, the following may occur
• Education, clergy input, social services input,
  and/or ethics committee consultation may prove
  useful in modifying the sons understanding of
  the situation and his choices for therapy.
• Alternatively, the physician may move towards the
  sons position.

57
Q20B Autonomy vs. Futility

• Transfer to another facility or to another
  physicians care should be considered only after
  all other avenues have been exhausted and there
  remains a conflict between the requested
  treatment and the physicians ability to comply
  with these requests on moral or ethical grounds.

58
Q20B Autonomy vs. Futility

• The need to involve the courts in these matters
  is rare.
• During the time that attempts are being made to
  resolve the conflict, it is the physicians
  responsibility to continue to provide all
  reasonable medical care, and to avoid abandoning
  the patient and surrogate(s).
• In addition, the physician must remain honest and
  forthright with the patient/surrogate(s)
  regarding the plan of care.

59
Question 48B

• Which of the following contributes most to the
  cost of care in the ICU?
• (A) Personnel expenses
• (B) Pharmaceutical agents
• (C) Diagnostic testing facilities
• (D) Supplies
• (E) Admission and discharge control

60
Q48B Cost control in the ICU

• ICUs have historically consumed disproportionate
  amounts of hospital budgets.
• Labor, capital, pharmaceutical, and supply costs
  are high, and are likely to grow higher as the
  general population ages, the nursing labor force
  shrinks, salaries increase, and technology grows
  in both power and scope.

61
Q48B Cost control in the ICU

• ICU directors and managers must undertake careful
  cost-benefit analyses and encourage the practice
  of evidence-based medicine.
• New drugs and technologies will be even more
  expensive than todays options, yet may
  ultimately prove cost-effective by reducing
  morbidity and mortality, reducing errors, and
  reducing the need for invasive procedures, and
  reducing length of stay.

62
Q48B Cost control in the ICU

• Historically, the three largest contributors to
  ICU cost have been labor, capital expenses, and
  pharmaceuticals and supplies, with labor
  consistently leading the list.
• Because of this, ICU nurse staffing has often
  been the first area to feel the budgetary axe.
• This has frequently proven counter-productive,
  especially in terms of patient safety, quality of
  care, and long term costs.

63
Q48B Cost control in the ICU

• It is important that ICU directors and managers
  view personnel costs in the context of a larger
  picture of patient safety and quality of care.

64
Question 50B

• 55 y/o previously healthy male
• Acute anterior MI
• Diaphoretic and lethargic
• HR 110/min
• BP 85/65 mmHg
• Crackles, no murmur
• Hgb 14 g/dL
• Urine output 20 mL/hr

65
Question 50B

• Pulmonary artery catheter data
• Right atrial pressure 10 mmHg
• Pulmonary artery pressure 50/30 mmHg
• PAOP 25 mmHg
• C.I. 4.6 L/min/m2
• PaO2 65 torr
• PvO2 27 torr

66
Question 50B

• Explain the findings?
• (A) Severe tricuspid regurgitation
• (B) Right-to-left shunt
• (C) Left-to-right shunt
• (D) Injectate volume for C.O. too large
• (E) Injectate volume for C.O. too small

67
Q50B Hemodynamic Data Errors

• Question What is the clinical diagnosis?
• Answer Cardiogenic shock.
• Question Does the observed hemodynamic data
  support the diagnosis?
• Answer No.
• Question What is the problem?
• Answer Cardiac index is too high.

68
Q50B Hemodynamic Data Errors

• Choice (A) Severe tricuspid regurgitation
• would cause high right atrial pressure, here
  measured as normal.
• would not cause high cardiac index.

69
Q50B Hemodynamic Data Errors

• Choice (B) Right-to-left shunt
• would cause low PaO2, here measured as normal.
• may lower cardiac index

70
Q50B Hemodynamic Data Errors

• Choice (C) Left-to-right shunt
• would cause high PvO2, here measured as low.
• could cause high right atrial pressures,
  (depending upon location of shunt), here measured
  as normal.
• may lower cardiac index.

71
Q50B Hemodynamic Data Errors

• Choice (D) Injectate volume too large
• Choice (E) Injectate volume too small
• Examine how the thermodilution cardiac output is
  determined.

72
Q50B Hemodynamic Data Errors

• Thermodilution cardiac output
• Thermister at tip of PA catheter dynamically
  measure the decrease in blood temperature as a
  known volume of injectate at known temperature
  passes by.
• The area under the injectate temperature curve
  correlates with cardiac output.
• Large area indicates low cardiac output
• injectate too large or too cool can mimic this
• Small area indicates high cardiac output
• injectate too small or too warm can mimic this

73
Question 52B

• Continuous rotational (kinetic) bed therapy in
  critically ill patients
• Decreases the incidence of nosocomial pneumonia
  in high-risk patients?
• Decreases lower respiratory tract colonization by
  resistant G(-) bacilli?
• Decreases systemic oxygen consumption in septic
  shock?
• Increases systemic oxygen delivery in acute
  respiratory failure?
• Decreases incidence of ARDS in patients with two
  or more risk factors?

74
Q52B Kinetic bed therapy

• Benefits and efficacy of kinetic bed therapy are
  controversial.
• Four large prospective, randomized, controlled
  trials published to date evaluating benefits and
  efficacy.
• Three less powerful studies also published.

75
Q52B Kinetic bed therapy

• Fink et al, Chest 1990.
• 99 critically ill blunt trauma patients
• Significant decrease in lower respiratory tract
  infection in treated patients as compared to
  control group.

76
Q52B Kinetic bed therapy

• de Boisblanc et al, Chest 1993.
• 124 medical ICU patients
• Significant reduction in development of pneumonia
  within the first five ICU days as compared to
  control group.

77
Q52B Kinetic bed therapy

• Clemmer et al, Critical Care Med 1990.
• 40 critically ill severe head injury patients
• No advantages with rotational therapy over
  conventional therapy
• No significant difference in mortality, CNS
  morbidity,hospital or ICU length of stay, or
  pulmonary pathology.

78
Q52B Kinetic bed therapy

• Traver et al, Journal Critical Care 1995.
• 103 critically ill med/surg ICU patients
• No significant difference in ventilator days,
  hospital length of stay, or incidence of
  pneumonia.
• Strong trend toward improved survival in treated
  patients with APACHE II scores 20. Trend
  appeared to be unrelated to pulmonary status.

79
Q52B Kinetic bed therapy

• Studies by
• Gentilello et al, Crit Care Med 1988.
• Whiteman et al, Am J Crit Care 1995.
• Kelley et al, Stroke 1987.
• Two found reduction in lower respiratory tract
  infection with kinetic therapy no reduction in
  morbidity or mortality.
• One found a reduction in all hospital acquired
  infections.

80
Q52B Kinetic bed therapy

• No studies published to date have shown an
  advantage with kinetic therapy in
• preventing lower respiratory tract colonization
  with antibiotic-resistant organism
• improving oxygen delivery or consumption
• reducing the incidence of ARDS

81
Question 54B

• Which statement is correct regarding measurement
  of D-dimer?
• ELISA is a more sensitive method than latex
  agglutination.
• Latex agglutination is a multiple-step method
  that takes several hours to yield results.
• Pulmonary embolism can be reliably excluded if
  D-dimer level is normal by latex agglutination.
• A D-dimer level above 500 ng/mL has a negative
  predictive value of 99 for pulmonary embolism.

82
Q54B Quantitative D-dimer and Thromboembolic
Disease

• Fibrin is the glue of blood clots, and is
  stabilized through covalent cross-linking by the
  action of activated Factor XIII.
• Plasmin is an enzyme that lyses cross-linked
  fibrin, releasing soluble fragments into the
  plasma. One of these fragments is the D-dimer.
• Because the coagulation process is a dynamic
  balance between clot formation and clot lysis,
  D-dimer levels serve as an indirect indicator of
  thrombotic activity.

83
Q54B Quantitative D-dimer and Thromboembolic
Disease

• Quantitative D-dimer assays have been shown to
  have sufficient sensitivity to have a negative
  predictive value for thromboembolic disease, and
  can be used to exclude DVT and PE if levels are
  normal and clinical suspicion is low.
• On the other hand, if the D-dimer level is
  elevated, a clotting process is documented.
  However this finding is non-specific, and may
  indicate either thromboembolic disease or other
  clinical condition such as DIC, trauma,
  pregnancy, cancer, post-surgery, etc.

84
Q54B Quantitative D-dimer and Thromboembolic
Disease

• The enzyme-linked immunosorbent assay (ELISA) has
  been shown to have a higher sensitivity than
  latex agglutination, and thus is more reliable in
  ruling out thromboembolic disease.
• Latex agglutination has a higher specificity than
  ELISA, thus more strongly predicts active
  thrombolysis.

85
Q54B Quantitative D-dimer and Thromboembolic
Disease

• The ELISA requires specialized equipment and
  training, and the assay is time-consuming.
• Latex agglutination is a rapid test that has been
  evaluated for rapid screening of thromboembolic
  disease. It is not sensitive enough as a single
  test to exclude disease.
• Some newer rapid immunofiltration tests have
  shown relatively high reliability in excluding
  thromboembolic disease.
• Kline et al, Chest 2006

86
Q54B Quantitative D-dimer and Thromboembolic
Disease

• The most commonly studied D-dimer cut-off value
  for excluding thromboembolic disease is 500
  ng/mL. Levels below this as measured by ELISA
  virtually exclude DVT and PE when clinical
  suspicion is low.
• Rathbun et al, Chest 2004
• Druip et al, Ann Int Med 2003
• Stein et al, Ann Int Med 2004

87
Question 60B

• 50 y/o male
• Severe pneumonia and respiratory failure
• Mechanical ventilation
• Extensive invasive monitoring in place
• Other monitoring tools available
• Sustains cardiac arrest, CPR initiated.

88
Question 60B

• Which most useful in monitoring the adequacy of
  circulatory support during CPR?
• Blood pressure
• Arterial PO2
• Arterial PCO2
• PA systolic pressure
• End-tidal CO2

89
Q60B Cardiopulmonary Resuscitation

• The adequacy of circulation is correlated with
  the adequacy of cardiac output and systemic blood
  flow.
• Cardiac output is determined mainly by heart rate
  and the difference between right atrial and
  aortic diastolic pressures.

90
Q60B Cardiopulmonary Resuscitation

• During CPR, the aorta and right atrium experience
  the same intrathoracic pressures. Hence systemic
  and pulmonary arterial pressures correlate poorly
  with cardiac output during CPR, even during high
  compression pressures.

91
Q60B Cardiopulmonary Resuscitation

• Even with the best CPR, cardiac output is
  suboptimum. Metabolic by-products accumulate at
  the tissue level, including lactic acid and CO2.
• As cardiac output improves, lactic acid and CO2
  are washed out of the tissues into the venous
  circulation. These can be detected as elevated
  arterial and venous lactate levels, and elevated
  exhaled (end-tidal) CO2.

92
Q60B Cardiopulmonary Resuscitation

• Arterial PO2 and PCO2 do not reflect the adequacy
  of cardiac output.
• Arterial PO2 is a reflection of the adequacy of
  oxygen exchange in the lungs, and is poorly
  affected by oxygen flux at the tissue level.
• Arterial PCO2 is a reflection of the adequacy of
  carbon dioxide elimination in the lungs
  (ventilation), and is not greatly affected by
  carbon dioxide flux at the tissue level.

93
Question 09R

• 30 y/o male
• Stab wound to chest with hemoptysis and
  pneumothorax
• Admitting physician comes across information that
  the patient likely committed a serious crime
  (murder)
• Police arrive at hospital without court order or
  search warrant

94
Question 09R

• Health Insurance Portability and Accountability
  Act (HIPAA) permits release to police of which
  patient information?
• HIV status
• Results of DNA analysis
• Blood specimens for evidentiary purposes
• Name, type of injury, date and time of treatment,
  and description of physical characteristics

95
Q09R HIPAA

• In 1996 the Health Insurance Portability and
  Accountability Act (HIPAA) was signed into law.
• Set up Federally mandated health industry data
  standards that were enacted to help reduce
  healthcare costs.

96
Q09R HIPAA

• The Privacy Rule section of HIPPA established
  Federal protection of certain health information.
  This protection included, in part, the adoption
  of security and privacy standards appropriate for
  individually identifiable healthcare information.
  The Privacy Rule did not replace more strict
  Federal and State laws that granted greater
  privacy protections.

97
Q09R HIPAA

• In 2002 the Privacy Rule was modified to allow
  the flow of information needed to provide and
  promote high quality health care and to protect
  the publics health and well-being.
• Current Privacy Rule protects all individually
  identifiable health information that relates to
• the individuals past, present, or future
  physical or mental health or condition
• the provision of healthcare to the individual
• the past, present, or future payment for the
  provision of healthcare to the individual

98
Q09R HIPAA

• The Privacy Rule also protects any information
  for which can be used to identify the individual
  (name, address, SS, birth date, etc.).

99
Q09R HIPAA

• Exceptions to Privacy Rule
• When requested by the individual or their
  personal representative
• When requested by DHHS for compliance or
  enforcement actions
• To treatment, payment and Health Care Operations
• Public Interest and Benefit Activities
• Limited information for the purposes of research
  or the public health.
• Entities may rely upon professional ethics and
  best judgment in decisions on disclosure
• Written consent is not required for these
  exceptions.

100
Q09R HIPAA

• 12 Public Interest and Benefits exceptions
• As required by law
• Public Health activities
• Victims of abuse, neglect, or domestic violence
• Health oversight activities
• Judicial and administrative proceedings
• Law enforcement purposes
• Decedents
• Organ or tissue donation
• Research if IRB waiver
• Serious threat to health or safety of person or
  public
• Essential government functions
• Workers compensation

101
Q09R HIPAA

• Law enforcement purposes (details)
• Court orders, subpoenas, warrants, etc.
• To identify or locate a suspect, fugitive,
  material witness, or missing person
• In response to law enforcement officials request
  for information about a crime victim
• When protected information is evidence of a crime
  that occurred on the premises
• By a covered health care provider in a medical
  emergency not occurring on the premises and if
  necessary to inform law enforcement about the
  commission and nature of a crime, location of a
  crime or crime victim(s), and the perpetrator of
  the crime

102
Question 12R

• Which central venous catheter site has the lowest
  combined risk for infection and thrombosis?
• Femoral vein
• Internal jugular vein
• Subclavian vein

103
Q12R Complications of Central Venous Catheters

• Central venous catheters are associated with a
  significant incidence of complications such as
  local and blood stream infections, bleeding, and
  thrombosis.
• These complications can be minimized by using
  appropriate catheters, insertion sites, insertion
  techniques, and post-insertion site care.
• The relative risks of infection and thrombosis
  with respect to insertion site have been
  evaluated in a number of clinical studies.

104
Q12R Complications of Central Venous
Catheters

• Catheters inserted into the internal jugular vein
  have been associated with a higher risk of
  infection than those inserted into the subclavian
  or femoral veins.
• Mermel et al, Am J Med 1991
• Heard et al, Arch Int Med 1998
• Richet et al, J Clin Microbiol 1990

105
Q12R Complications of Central Venous
Catheters

• Femoral venous catheters have shown relatively
  high colonization rates in adult patients.
• Goetz et al, Infect Control Hosp Epidemiol 1998
• Merrer et al, JAMA 2001

106
Q12R Complications of Central Venous
Catheters

• Femoral venous catheters have been associated
  with a higher risk of deep venous thrombosis than
  with internal jugular or subclavian sites.
• Merrer et al, JAMA 2001
• Joynt et al, Chest 2000
• Mian et al, Acad Emerg Med 1997
• Durbec et al, Crit Care Med 1997
• Trottier et al, Crit Care Med 1995

107
Q12R Complications of Central Venous
Catheters

• Therefore, in adult patients the subclavian site
  is preferred for central venous catheter
  insertion because it has the lowest combined risk
  for infection and thrombosis.

108
Question 59R

• 51 y/o male
• 80 kg
• Ruptured diverticulum with colonic resection 5
  days ago
• Sepsis, MOSF
• Receiving standard enteral nutrition at 10 mL/hr
  (has 1 kcal/mL)

109
Question 59R

• What should you order next?
• Advance current nutrition preparation as
  tolerated
• Change to an enhanced preparation of glutamine,
  arginine, antioxidant, and omega-3 fatty acids
• Begin supplemental total parental nutrition
• Add daily parenteral administration of lipid
  suspension

110
Q59R Nutrition in the Critically Ill

• The early and adequate replacement of nitrogen
  and caloric requirements by the enteral route in
  critically ill patients has repeatedly been shown
  to decrease morbidity (but not mortality).
• Peter et al, Crit Care Med 2005
• Barr et al, Chest 2004
• Merik PE, Zaloga GP, Crit Care Med 2001
• In general, enteral nutrition is preferred over
  parenteral nutrition because PN has been
  associated with increased complications such as
  catheter-related infection and thrombosis.

111
Q59R Nutrition in the Critically Ill

• The risks of gastric aspiration can be minimized
  by using prokinetic agents (metoclopramide), and
  by keeping the HOB elevated 30.
• Heyland et al, JPEN 2003
• Parenteral nutrition is acceptable when the
  enteral route is unavailable.

112
Q59R Nutrition in the Critically Ill

• Immunonutrition has not shown benefits in
  critically ill patients, except in select groups
  (such as burns).
• Kieft et al, Intensive Care Med 2005
• Heyland et al, JAMA 2001
• Immunonutrition increased mortality in one study.
• Bertolini et al, Intensive Care Med 2003

113
Q59R Nutrition in the Critically Ill

• Essential fatty acid and other lipid requirements
  are generally satisfied by standard commercial
  preparations. The use of intravenous lipid
  supplements is therefore not necessary when the
  enteral route is available.