Multiprofessional Critical Care Review: Adult (2023)-Question and Answer Session 4

Question and Answer Session 4

Pdf Summary

The first scenario presents a 70-year-old man with end-stage chronic obstructive pulmonary disease (COPD) who presents to the emergency department with acute-on-chronic dyspnea, hypoxia, and hypercarbia. After an unsuccessful trial of noninvasive ventilation, he is intubated for respiratory failure. The most likely cause of his elevated airway pressures is intrinsic positive end-expiratory pressure (auto-PEEP) due to obstructive airway dysfunction.<br /><br />In the second scenario, a 40-year-old man presents with acute onset of shortness of breath after a recent trans-Atlantic flight. He has risk factors for pulmonary embolism (PE) and a high pretest probability. The most appropriate next step would be to start parenteral therapeutic anticoagulation while awaiting diagnostic test results, followed by a CT pulmonary angiogram to confirm the diagnosis of PE.<br /><br />The third scenario involves a 36-year-old woman with cervical cancer who is admitted to the ICU in septic shock. She is intubated on day 2 due to acute respiratory distress syndrome. The next best step to improve her outcome would be to place her in the prone position, as early prone positioning has been shown to reduce mortality in severe acute respiratory distress syndrome.<br /><br />The fourth scenario presents an 82-year-old woman with altered mental status, productive cough, and shortness of breath. She has a high pretest probability of an acute pulmonary embolism (PE) based on her risk factors and clinical presentation. The most appropriate next step would be to start parenteral therapeutic anticoagulation while awaiting diagnostic test results, followed by a CT pulmonary angiogram to confirm the diagnosis of PE.<br /><br />The fifth scenario involves a patient with MRSA bacteremia that has not improved with vancomycin therapy. The most appropriate antimicrobial for this patient at this time would be quinupristin/dalfopristin as salvage therapy for MRSA bacteremia that has failed vancomycin therapy and/or when there is reduced susceptibility to vancomycin and/or daptomycin.<br /><br />In the sixth scenario, a patient with ventilator-associated pneumonia (VAP) caused by a piperacillin/tazobactam-sensitive Escherichia coli is being treated with piperacillin/tazobactam. The patient should be treated for a total duration of 7 days for the VAP.<br /><br />The seventh scenario presents a patient who has been on mechanical ventilation for 8 days and is unable to be liberated. He has developed a new fever and increasing edema. The most likely cause of his worsening respiratory failure is late-onset ventilator-associated pneumonia and/or health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA). The treatments that should be eliminated from consideration for this patient are daptomycin and telavancin, as they are not recommended for HA-MRSA treatment. Linezolid and vancomycin are both appropriate choices for MRSA treatment.<br /><br />In the eighth scenario, the best next intervention to improve outcome in a patient recovering from acute respiratory distress syndrome who remains ventilator dependent would be to institute mobilization and physical therapy. Early physical therapy in the ICU has been shown to improve quality of life, physical function, and respiratory muscle strength, and increase ventilator-free days.<br /><br />The ninth scenario involves a patient with acute hypoxic respiratory failure who is being treated with non-rebreather mask. The next best option for managing the patient's acute hypoxic respiratory failure would be to start the patient on humidified high flow oxygen. Humidified high flow oxygen has been shown to reduce mortality and need for mechanical ventilation in acute hypoxemic respiratory failure.<br /><br />The tenth scenario presents a patient with massive pulmonary embolism and impending cardiac arrest. The next best step in management would be to administer tenecteplase 40 mg IV push over 5 seconds. Tenecteplase is a fibrinolytic agent that can rapidly dissolve the clot in a patient with massive pulmonary embolism.<br /><br />In the eleventh scenario, a patient with acute hypoxic respiratory failure who is intubated and on non-rebreather mask is not adequately oxygenating. The next best option for managing the patient's acute hypoxic respiratory failure would be to start non-invasive positive pressure ventilation.<br /><br />In the twelfth scenario, a patient with empyema is being treated with intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (t-PA). After receiving this treatment twice per day for 3 days, the expected outcome would be improved drainage of infected pleural fluid.<br /><br />In the thirteenth scenario, a patient with delirium who is currently receiving lorazepam for sedation should be transitioned from lorazepam to dexmedetomidine. Dexmedetomidine is recommended for patients with delirium as it has shown beneficial effects in reducing delirium and improving outcomes.<br /><br />The fourteenth scenario involves a patient with MRSA bacteremia that has not improved with vancomycin therapy. The most appropriate antimicrobial for this patient at this time would be quinupristin/dalfopristin, as it is recommended as salvage therapy for MRSA bacteremia that has failed vancomycin therapy and/or when there is reduced susceptibility to vancomycin and/or daptomycin.<br /><br />The fifteenth scenario presents different clinical scenarios, and the most appropriate use of noninvasive ventilation after extubation would be in a 68-year-old woman who was intubated 3 days ago for exacerbation of chronic obstructive pulmonary disease. NIV can be used as a primary treatment modality for acute respiratory failure or to reduce the risk of reintubation after extubation in patients with chronic obstructive pulmonary disease exacerbation.<br /><br />These summaries provide an overview of the key points in each scenario. It is important to refer to the original document for the complete details and any additional information.

Keywords

COPD

dyspnea

intubation

anticoagulation

septic shock

prone position

MRSA bacteremia

VAP

respiratory failure

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