Multiprofessional Critical Care Review: Adult (2023)-Question and Answer Session 5

Question and Answer Session 5

Pdf Summary

A 52-year-old woman admitted to the ICU after middle cerebral artery aneurysm clipping should be prescribed nimodipine to prevent cerebral vasospasm and delayed cerebral ischemia. In addition to nimodipine, the appropriate action to prevent cerebral vasospasm and delayed cerebral ischemia in this patient is to maintain euvolemia and mean arterial blood pressure greater than 90 mm Hg. Hypervolemia and maintaining systolic blood pressure greater than 180 mm Hg are not indicated for cerebral vasospasm/delayed cerebral ischemia prophylaxis. The patient's history of smoking and severity of the aneurysm indicate the need for aggressive treatment.<br /><br />In a 49-year-old woman admitted to the ICU after a Whipple procedure for pancreatic cancer, the most appropriate initial treatment for severe pain and moderate anxiety is fentanyl and midazolam. Narcotics such as fentanyl, morphine, and hydromorphone are first-line analgesics for pain management. Anxiety can be treated with short-acting IV benzodiazepines, such as lorazepam. Dexmedetomidine and haloperidol, morphine and etomidate, and ketorolac and propofol are not the recommended combinations for initial treatment in this scenario.<br /><br />In a 73-year-old man presenting to the emergency department after being assaulted, an indication for the placement of an intracranial pressure (ICP) monitor is the presence of a diffuse subarachnoid hemorrhage on the CT scan. Patients with severe traumatic brain injury (TBI) with abnormal head CT or normal head CT but with age over 40 years, unilateral or bilateral motor posturing, or one or more episodes of hypotension should have ICP monitoring. Age older than 65 years, open skull fracture, need for mechanical ventilation, and nonoperative liver laceration are not direct indications for ICP monitoring in patients with severe TBI.<br /><br />In a 41-year-old man admitted to the ICU with a severe traumatic brain injury (TBI), prophylactic cooling or decompressive craniectomy is not recommended. Treatment of elevated intracranial pressure (ICP) should be tailored to each patient and guided by monitoring techniques. Maintenance of normal intracranial pressure and cerebral perfusion pressure, prevention of secondary brain injury, and optimization of cerebral oxygenation are key considerations in the management of severe TBI. The use of therapeutic hypothermia, methylprednisolone, and decompressive craniectomy in this patient is not recommended.<br /><br />In a 27-year-old woman who is 10 weeks pregnant and has developed a generalized tonic-clonic seizure disorder, levetiracetam is the most suitable maintenance antiepileptic drug during pregnancy. Valproate, phenytoin, and phenobarbital are associated with an increased risk of birth defects, while levetiracetam has been shown to have a lower risk of teratogenic effects. Therefore, levetiracetam should be considered the first-line antiepileptic drug in this pregnant patient.<br /><br />In a patient with a devastating bi-hemispheric brain injury, fiberoptic-assisted intubation is the first choice of technique for intubation. Fiberoptic-assisted intubation allows visualization of the airway anatomy and precise placement of the endotracheal tube, which is crucial in difficult airway situations. Direct laryngoscopy following the administration of succinylcholine or rocuronium, or video laryngoscopy following the administration of rocuronium, are also possible approaches, but if there is a concern of a difficult airway, fiberoptic-assisted intubation is preferred.<br /><br />In a patient with multisystem organ failure and a poor prognosis requiring removal of advanced life support, the daughter's interaction with the staff is best described by the ethical principle of substituted judgment. Substituted judgment allows a surrogate decision-maker to make decisions on behalf of a patient who lacks decision-making capacity based on the patient's values and preferences. Paternalism, nonmaleficence, power of attorney, and legal moralism do not fully capture the daughter's role in this scenario.<br /><br />In a patient with worsening respiratory distress despite high-flow oxygen therapy, tracheal intubation facilitated by video laryngoscopy would be expected to improve the glottic view. While video laryngoscopy does not necessarily improve intubation success rate, reduce post-intubation complications, or reduce time to successful intubation compared to direct laryngoscopy, it does offer an improved view of the glottis, which can be beneficial in challenging airway situations.<br /><br />In a patient who has received neuromuscular blockade and is no longer overbreathing the ventilator, the most appropriate recommendation to evaluate the degree of paralysis is to check the post-tetanic count. A post-tetanic count is performed to assess the degree of paralysis after neuromuscular blockade. A patient with no twitches in the post-tetanic count has a profound degree of paralysis, while a patient with approximately 2-3 twitches out of 4 still present on train-of-four stimulation is considered adequately paralyzed. Changing the nerve stimulator electrode placement, increasing the train-of-four stimulating current, replacing the nerve stimulator, or changing electrode polarity are not indicated in this situation.

Keywords

nimodipine

cerebral vasospasm

delayed cerebral ischemia

euvolemia

Whipple procedure

severe pain

fentanyl

midazolam

intracranial pressure

levetiracetam

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