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A 56-year-old female who had a total abdominal hysterectomy via laparoscopy for fibroids and heavy vaginal bleeding is being evaluated on the second post-op day. Her pain is well-controlled, and she is eating a normal diet. Her major complaint is bilateral ankle swelling, stating, "my socks are too tight." What is the most likely cause of this symptom?
Rationale
Your answer is correct.
Vasopressin (or antidiuretic hormone) is secreted by the body in response to stress or shock. Increase of vasopressin is a well-known phenomenon after surgical procedures. It can cause water retention in postoperative patients and can explain the mild lower extremity swelling in this patient. While it is possible this patient got more fluid than necessary in the operating room, this is not the best answer available. Signs and symptoms of a DVT include unilateral lower extremity swelling, redness, and pain, especially with dorsiflexion of the foot. Because this swelling is bilateral, a DVT is not the highest differential diagnosis.
Your answer is incorrect.
Vasopressin (or antidiuretic hormone) is secreted by the body in response to stress or shock. Increase of vasopressin is a well-known phenomenon after surgical procedures. It can cause water retention in postoperative patients and can explain the mild lower extremity swelling in this patient. While it is possible this patient got more fluid than necessary in the operating room, this is not the best answer available. Signs and symptoms of a DVT include unilateral lower extremity swelling, redness, and pain, especially with dorsiflexion of the foot. Because this swelling is bilateral, a DVT is not the highest differential diagnosis.
A 79-year-old female is admitted to the ICU after repair of a pathologic femur fracture with an estimated blood loss of 1.2 L. She is oxygenating well on room air, is hemodynamically stable, and is appropriately alert and oriented. Physical examination is remarkable for incision site tenderness and signs of malnutrition. Laboratory studies reveal normal electrolytes, normal liver function tests, normal TSH and T4, and decreased levels of T3. What would be the most appropriate management of her deranged thyroid function test?
Rationale
Your answer is correct.
Rationale: Euthyroid sick syndrome (ESS), also known as nonthyroidal illness syndrome, is often seen in patients with severe critical illness, deprivation of calories, and following major surgeries. Common causes include infection, trauma, cardiopulmonary bypass, and malignancy. Although the exact mechanism is not known, one possible hypothesis is that the presence of thyroid binding hormone inhibitor in serum and body tissues inhibits the binding of thyroid hormone to thyroid-binding protein. Cytokines such as interleukin 1, interleukin 6, tumor necrosis factor alpha, and interferon-beta may affect the hypothalamus and pituitary, thus inhibiting TSH, thyroid-releasing hormone, thyroglobulin, T3, and thyroid binding globulins production have also been implicated. ESS has been classified as (1) low T4 syndrome, (2) low T3-low T4 syndrome, (3) high T4 syndrome, and (4) other abnormalities. Low serum total T3 is the most common abnormality in ESS, and it is seen in about 70% of hospitalized patients. Both low T3 and the T4 syndromes are observed in critically ill patients admitted to intensive care units. Low-serum total T4 correlates with a bad prognosis; the probability of death correlates with the level of serum total T4. When total T4 levels drop below 4 µg/dL, the probability of death is approximately 50%, and when serum T4 levels are below 2 µg/dL, the probability of death reaches 80%. Thyroid hormone replacement is not needed in patients with ESS (Choices B and C), and there is no role of steroids in the management of ESS (Choice D). Treatment and management of underlying medical illness is sufficient (Choice A).
Your answer is incorrect.
Rationale: Euthyroid sick syndrome (ESS), also known as nonthyroidal illness syndrome, is often seen in patients with severe critical illness, deprivation of calories, and following major surgeries. Common causes include infection, trauma, cardiopulmonary bypass, and malignancy. Although the exact mechanism is not known, one possible hypothesis is that the presence of thyroid binding hormone inhibitor in serum and body tissues inhibits the binding of thyroid hormone to thyroid-binding protein. Cytokines such as interleukin 1, interleukin 6, tumor necrosis factor alpha, and interferon-beta may affect the hypothalamus and pituitary, thus inhibiting TSH, thyroid-releasing hormone, thyroglobulin, T3, and thyroid binding globulins production have also been implicated. ESS has been classified as (1) low T4 syndrome, (2) low T3-low T4 syndrome, (3) high T4 syndrome, and (4) other abnormalities. Low serum total T3 is the most common abnormality in ESS, and it is seen in about 70% of hospitalized patients. Both low T3 and the T4 syndromes are observed in critically ill patients admitted to intensive care units. Low-serum total T4 correlates with a bad prognosis; the probability of death correlates with the level of serum total T4. When total T4 levels drop below 4 µg/dL, the probability of death is approximately 50%, and when serum T4 levels are below 2 µg/dL, the probability of death reaches 80%. Thyroid hormone replacement is not needed in patients with ESS (Choices B and C), and there is no role of steroids in the management of ESS (Choice D). Treatment and management of underlying medical illness is sufficient (Choice A).
A central venous catheter (CVC) is inserted in a patient with traumatic brain injury (TBI) for administration of hypertonic fluids. Which of the following measures has been shown to minimize the risk of central line-associated bloodstream infection (CLABSI)?
Rationale
Your answer is correct.
None of the measures listed (scheduled catheter exchanges, catheter replacements, or prophylactic antibiotics) have been shown to reduce the incidence of CLABSI.
Your answer is incorrect.
None of the measures listed (scheduled catheter exchanges, catheter replacements, or prophylactic antibiotics) have been shown to reduce the incidence of CLABSI.
A 44-year-old man with HIV is admitted to the ICU with severe community-acquired
pneumonia requiring mechanical ventilation. The patient is on an outpatient retroviral
regimen that includes a protease inhibitor; lopinavir/ritonavir; and a nucleoside reversetranscriptase
inhibitor, zidovudine. The patient has done very well with this regimen (viral
load is nondetectable), and his infectious disease physician recommends that he be kept on
this regimen during his ICU hospitalization. Which of the following drugs should be avoided
in this case?
Rationale
Your answer is correct.
With the widespread use of antiretroviral therapy in patients with HIV, it is important for the intensivist
to recognize some of the potential drug interactions and side effects of antiretroviral medications.
Decisions regarding continuation of antiretroviral therapy in patients admitted to the ICU should
be discussed with HIV experts. In addition, a team approach with consultation with a critical care
pharmacy specialist is important to avoid complications related to drug interactions. Common ICU
(rugs contraindicated with the use of non-nucleoside reverse-transcriptase inhibitors include midazolam
and triazolam. Common ICU drugs, contraindicated with the use of protease inhibitors include the
following: midazolam, triazolam, amiodarone, proton pump inhibitors (with atazanavir), histamine,
blockers, propafenone, and quinidine. Recognition of potential interaction between these medications
and retrovirals is important when treating patients with HIV in the ICU. In this case, of the given list,
midazolam would be contraindicated both with the protease inhibitor and the non-nucleoside reverse transcriptase inhibitors. In such a patient, alternatives to midazolam, such as lorazepam or oxazepam,
should be considered.
Your answer is incorrect.
With the widespread use of antiretroviral therapy in patients with HIV, it is important for the intensivist
to recognize some of the potential drug interactions and side effects of antiretroviral medications.
Decisions regarding continuation of antiretroviral therapy in patients admitted to the ICU should
be discussed with HIV experts. In addition, a team approach with consultation with a critical care
pharmacy specialist is important to avoid complications related to drug interactions. Common ICU
(rugs contraindicated with the use of non-nucleoside reverse-transcriptase inhibitors include midazolam
and triazolam. Common ICU drugs, contraindicated with the use of protease inhibitors include the
following: midazolam, triazolam, amiodarone, proton pump inhibitors (with atazanavir), histamine,
blockers, propafenone, and quinidine. Recognition of potential interaction between these medications
and retrovirals is important when treating patients with HIV in the ICU. In this case, of the given list,
midazolam would be contraindicated both with the protease inhibitor and the non-nucleoside reverse transcriptase inhibitors. In such a patient, alternatives to midazolam, such as lorazepam or oxazepam,
should be considered.
A 64-year old woman with congestive heart failure is now feeling better after 3 days of diuresis. Current cardiac medications include furosemide IV, amlodipine, valsartan, and spironolactone. Weight has decreased 8 kg and the patient is no longer requiring supplemental oxygen therapy. On physical examination, you note bilateral lower extremity edema to the mid shin and a jugular venous pressure of 10 mm Hg sitting upright at 90°. Blood pressure is 126/75 mm Hg. In the past 24 hours, the patient had 4 liters of urine output and lost 2 kg. Since admission, serum creatinine had improved to baseline (1.2 mg/dL) but this morning’s level has risen back to 1.5 mg/dL. What is the most appropriate management?
Rationale
Your answer is correct.
Rationale: The patient is clinically improving but has mildly increasing serum creatinine in the setting of an excellent diuretic response. As the patient still has objective signs of hypervolemia and is above her dry weight, intravenous loop diuretic therapy should be continued (choice A is correct). Leaving patients in acute decompensated heart failure (ADHF) hypervolemic to avoid mild increases in serum creatinine is associated with worse outcomes. This patient is a “warm and wet” ADHF phenoand not in need of an inotrope. Although not listed as a choice, there would be no need to add metolazone or otherwise increase diuretic therapy at this time.
Your answer is incorrect.
Rationale: The patient is clinically improving but has mildly increasing serum creatinine in the setting of an excellent diuretic response. As the patient still has objective signs of hypervolemia and is above her dry weight, intravenous loop diuretic therapy should be continued (choice A is correct). Leaving patients in acute decompensated heart failure (ADHF) hypervolemic to avoid mild increases in serum creatinine is associated with worse outcomes. This patient is a “warm and wet” ADHF phenoand not in need of an inotrope. Although not listed as a choice, there would be no need to add metolazone or otherwise increase diuretic therapy at this time.
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