Читать книгу Surgical Critical Care and Emergency Surgery - Группа авторов - Страница 12

Ilya Shnaydman, MD and Matthew Bronstein, MD

Division of Trauma and Acute Care Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY, USA

1 A 78‐year‐old woman recently discharged from the hospital after ventral hernia repair presents to the emergency department with a 5‐day history of fever, chills, and productive cough. The patient's family reports poor oral intake and altered mental status. The patient's vital signs are temperature 38.5 °C; heart rate 125 beats/min; respiratory rate 30 breaths/min; blood pressure 80/60 mm Hg; and oxygen saturation 85% on room air. A chest radiograph demonstrates multifocal pneumonia and the urinalysis shows leukocyte esterase and nitrites. She is appropriately volume resuscitated and requires norepinephrine to maintain a mean arterial blood pressure of 65 mm Hg. Her serum lactate is 4 mmol/L.The patient's clinical condition can best be defined as:Sepsis.Septic Shock.Severe Sepsis.Multiorgan dysfunction syndrome.Systemic inflammatory response syndrome (SIRS).The Society of Critical Care Medicine task force produced the new definition for sepsis and septic shock (Sepsis‐3) in 2016. Sepsis is defined as life‐threatening organ dysfunction caused by a dysregulated host response to infection. This is identified by a score of 2 points or more on the Sequential Organ Failure Assessment (SOFA) score and is associated with 10% mortality or greater. Patients with septic shock are defined as requiring a vasopressor to maintain a MAP > 65 mmHg and having a serum lactate level >2 mmol/L in the absence of hypovolemia and is associated with 40% mortality or greater (choice B). Severe sepsis (choice C) and Multiorgan dysfunction syndrome (choice D) are not definitions recommended by the new guidelines. SIRS (choice E) is defined as two of the following: tachycardia (HR > 90 bpm), tachypnea (RR > 20 breaths/min), fever (>39 °C or <36 °C), and leukocytosis (WBC > 12 or <4 or >10% bands). SIRS would be correct if there was no identified or suspected source. A quick bedside score, qSOFA, can also be used (respiratory rate > 22/min, altered mental status or systolic blood pressure 100 mmHg or less). Using these new definitions, the patient has Septic Shock (choice B).Answer: BGyawali B, Ramakrishna K, Dhamoon, A. Sepsis: the evolution in definition, pathophysiology, and management. SAGE Open Med. 2019; 7:205031211983504. doi: https://doi.org/10.1177/2050312119835043.Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis‐3). JAMA. 2016; 315(8):801.

2 What is the first step in the initial management of the patient in the above question?Antibiotic Therapy.Transfer to Intensive Care Unit.Intravenous fluid bolus.Checking serum lactate level.Supplemental oxygen administration.Just as in trauma, the initial management of any critically ill patient should involve establishing an adequate airway, evaluating breathing (which may require supplemental oxygen and/or mechanical ventilation), and restoring adequate perfusion with volume resuscitation and/or vasopressors (choice E). The patient will also require antibiotics (choice A), ICU care (choice B), intravenous fluids (choice B) as well as measurement of serum lactate (choice D).Answer: ERhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43(3):304–377.Holmes CL, Walley KR. The evaluation and management of shock. Clin Chest Med. 2003; 24(4):775–789.

3 An 80‐year‐old man is admitted to the surgical intensive care unit with perforated diverticulitis after a Hartmann procedure. He has received appropriate fluid resuscitation but is requiring high doses of norepinephrine and vasopressin. His labs are significant for white blood cell count 18 000/μL and hemoglobin 10 g/dL. Bedside critical care ultrasound demonstrates a non‐collapsible inferior vena cava and an appropriate ejection fraction.The next best intervention should be:Transfusion of 2 units packed red blood cells.Continued fluid resuscitation.Addition of Epinephrine.Initiation of stress dose steroids.Placement of intra‐aortic balloon pump.Intravenous “low dose” corticosteroids (200 mg hydrocortisone daily) are recommended in patients with sepsis in which adequate fluid resuscitation and vasopressor therapy are unable to restore hemodynamic stability. Steroid use should also be considered in patients at risk of adrenal dysfunction due to exogenous steroid use. Packed red blood cell transfusion is recommended only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances, such as myocardial infarction, severe hypoxemia, or acute hemorrhage (choice A). Additional intravenous fluids would not be helpful if the patient is already adequately fluid resuscitated as evidenced by his non‐collapsible inferior vena cava (choice B). Intra‐aortic balloon pump and epinephrine can be useful in cardiogenic shock, but the patient has an appropriate ejection fraction, indicating the absence of cardiogenic shock (choice C/E).Answer: DAnnane D, Renault A, Brun‐Buisson C, et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018; 378(9):809–818.Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43(3):304–377.Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014; 40(12):1795–1815.Hébert PC, Wells G, Blajchman, MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999; 340(6):409–417. doi: https://doi.org/10.1056/NEJM199902113400601. Erratum in: N Engl J Med 1999 Apr 1;340(13):1056. PMID: 9971864.

4 A 64‐year‐old man presents with left lower quadrant abdominal pain and fever. His exam does not show peritonitis. He has a white blood cell count of 16 000/μL. He undergoes CT abdomen & pelvis and is found to have diverticulitis with a 3 cm pelvic abscess. He is immediately started on antibiotics and undergoes percutaneous drainage by interventional radiology. How long should antibiotic therapy be continued?7 days4 days10 daysUntil his symptoms and fever resolveUntil his leukocytosis resolvesDuration of therapy for complicated intra‐abdominal infections is a frequent problem to manage for the acute care and critical care surgeon. Antimicrobial therapy guidelines continue to evolve from high‐quality evidence. Traditionally, surgeons have treated patients until all evidence of SIRS have resolved, typically for 1–2 weeks (choice A/C/D/E). The Study To Optimize Peritoneal Infection Therapy (STOP‐IT) trial was a multicenter randomized trial that examined 4 day therapy vs. 2 days after the resolution of physiologic abnormalities related to SIRS. The primary endpoint was surgical site infection, recurrent intra‐abdominal infection, or death. There was no significant difference between the groups, so they concluded that a 4 day duration of antibiotic therapy was sufficient after obtaining source control.Answer: BSawyer RG, Claridge JA, Nathens AB, et al. Trial of short‐course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015; 372(21):1996–2005.

5 A 55‐year‐old male trauma patient who remained intubated 4 days after laparotomy undergoes bronchoscopy for suspected mucous plugging seen on a chest radiograph. Purulent secretions are encountered and a bronchoalveolar lavage (BAL) and quantitative culture is performed.Which of the following supports a diagnosis of ventilator associated pneumonia (VAP)?Negative gram stain but high clinical suspicion.Protected brush specimen culture growing 102 CFU.Bronchoscopic BAL culture growing 103 CFU.Endotracheal aspirate growing 104 CFU.Bronchoscopic BAL culture growing 105 CFU.Pulmonary cultures can be obtained via bronchoscopy BAL, protected brush specimen (PSB) or blind tracheal suctioning. The following criteria confirm a diagnosis of VAP: blind tracheal suctioning (endobronchial aspirate) ≱ 105 CFU, PSB ≱ 103 CFU, bronchoscopic BAL ≱ 104 CFU (choice E). The trauma literature supports a diagnosis of VAP with BAL ≱ 105 CFU/mL, while CDC uses ≱ 104 CFU/mL.Answer: EKalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital‐acquired and ventilator‐associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of America and the American thoracic society. Clin Infect Dis. 2016; 63(5):e61–e111.Martin‐Loeches I, Rodriguez AH, Torres A. New guidelines for hospital‐acquired pneumonia/ventilator‐associated pneumonia: USA vs. Europe. Curr Opin Crit Care. 2018; 24(5):347–352.Croce MA, Fabian TC, Mueller EW, et al. The appropriate diagnostic threshold for ventilator‐associated pneumonia using quantitative cultures. J Trauma: Inj, Infect, Crit Care. 2004; 56(5):931–936.National Healthcare Safety Network, Center for Disease Control. Pneumonia (Ventilator‐Associated [VAP] and Non Ventilator‐Associated Pneumonia [PNEU]) Event. Table 5: Threshold Values for Cultured Specimens Used in the Diagnosis of Pneumonia, 2021.Rea‐Neto A, Youssef N, Tuche F, et al. Diagnosis of ventilator‐associated pneumonia: a systematic review of the literature. Crit Care. 2008; 12(2):R56.

6 The BAL culture from the patient above grows an extended spectrum beta lactamase (ESBL) producing strain of Klebsiella. Which antibiotic would be most likely to be effective?Piperacillin/tazobactamVancomycinAmpicillin/sulbactamCefepimeMeropenemCefepime and piperacillin/tazobactam demonstrate antipseudomonal activity but have limited activity against ESBL organisms (choice A/D). Vancomycin has no activity against Klebsiella (choice B). Ampicillin/sulbactam is not effective for ESBL organisms or Pseudomonas (choice C). Carbapenems are first‐line therapy for extended‐spectrum beta‐lactamase (ESBL) organisms (choice E).Answer: EHarris PNA, Tambyah PA, Lye DC, et al. Effect of piperacillin‐tazobactam vs meropenem on 30‐day mortality for patients with E coli or Klebsiella pneumoniae bloodstream infection and ceftriaxone resistance. JAMA. 2018; 320(10):984.

7 What is the next best step in management?A 52‐year‐old woman presents to the emergency department with right upper quadrant pain and weakness. On admission, her vital signs are temperature 39 °C; heart rate 130 beats/min; respiratory rate 22 breaths/min; blood pressure 80/50 mm Hg; oxygen saturation 97% on room air. On examination, she is disoriented and her skin is jaundiced. Laboratory studies demonstrate white blood cell count 20 000/μL and an elevated bilirubin. Ultrasound examination reveals cholelithiasis and intrahepatic biliary ductal dilatation.Emergent laparoscopic cholecystectomy.GI consultation.Parenteral antibiotic.ICU admission.Emergent MRCP.The patient is in septic shock from cholangitis. The Surviving Sepsis Campaign Guidelines recommend administration of IV antimicrobials to be initiated as soon as possible after recognition of sepsis and within 1 hour for both sepsis and septic shock (choice C). They recommend obtaining microbiological cultures prior to starting antimicrobial therapy; if doing so, results in no substantial delay in the start of antimicrobials. For fluid resuscitation, the guidelines recommend 30 mL/kg of IV crystalloid be given within the first 3 hours. The patient will require emergent decompression of the biliary tract with either ERCP (choice B), PTC, or surgical common bile duct decompression. While these choices would address source control, it would take time and initiating antibiotics should be done first. The patient should undergo cholecystectomy (choice A) during that hospitalization (non‐emergently) after bile duct decompression, the cholangitis has resolved and the patient has stabilized. This patient is appropriate for admission to the ICU (choice D), but this would not be the next best step.Table 5.1 Threshold values for cultured specimens used in the PVAP definition.Specimen collection/techniqueValuesLung tissue≥104 CFU/g tissue^*Bronchoscopically (B) obtained specimensBronchoalveolar lavage (B‐BAL)≥104 CFU/mL^*Protected BAL (B‐PBAL)≥104 CFU/mL^*Protected specimen brushing (B‐PSB)≥103 CFU/mL^*Nonbronchoscopically (NB) obtained (blind) specimensNB‐BAL≥104 CFU/mL^*NB‐PSB≥103 CFU/mL^*Endotracheal aspirate (ETA)≥105 CFU/mL^*CFU = colony‐forming units, g = gram, mL = milliliter.* Or corresponding, semiquantitative result (see FAQ no. 24 at the end of this protocol).Answer: CRhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017; 43(3):304–377.Mayumi T, Okamoto K, Takada T, et al. Tokyo guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25(1):96–100.

8 A 45‐year‐old man is recovering in the surgical ICU after an exploratory laparotomy and small bowel resection for small bowel obstruction. On postoperative day 7, he is still unable to tolerate enteral nutrition and is started on total parenteral nutrition through his existing central line. Due to leukocytosis and persistent fevers, blood cultures demonstrating Candida glabrata fungemia were obtained on postoperative day 12.What is the next best step?Remove the central line and immediately start fluconazole.Remove the central line, start fluconazole, and initiate peripheral parenteral nutrition.Remove the central line, start micafungin, obtain ophthalmology consultation.Repeat blood cultures.Obtain a CT scan.Candidemia is usually the result of a central line‐associated bloodstream infection. The Infectious Diseases Society of America (IDSA) currently recommends that all patients with documented candidemia undergo at least one dilated eye examination to rule out intraocular involvement. Intraocular candidiasis may require intravitreal antifungal therapy and/or vitrectomy. Candida glabrata is intrinsically resistant to azoles such as fluconazole (choice A), thus the antifungals of choice for Candida glabrata are echinocandins such as micafungin. Removal of the central line is appropriate, but appropriate treatment for candidemia (micafungin) is also required (choice B). Repeat cultures are also appropriate, but not the next best step as it does not treat the candidemia (choice D). A CT scan may be warranted to exclude an intra‐abdominal source, but would not be the next best step (choice E).Answer: CRodrigues CF, Silva S, Henriques M. Candida glabrata: a review of its features and resistance. Eur J Clin Microbiol Infect Dis. 2014; 33(5):673–688.Pappas, PG, Kauffman, CA, Andes, D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48:503–535.

9 A 65‐year‐old woman with infected necrotizing pancreatitis and hypotension requires 6 L of crystalloid in her resuscitation. On physical exam, she is edematous and remains hypotensive.The major cause of vasodilation in sepsis appears to be mediated by:Up‐regulating fibrinolysis.ATP‐sensitive potassium channels in smooth muscle.ATP‐sensitive calcium channels in smooth muscle.Increase in vasopressin.G‐arginine.The major cause of vasodilation in sepsis appears to be mediated by ATP‐sensitive potassium channels in smooth muscle. The result of their activation is increased permeability of vascular smooth muscle cells to potassium, and hyperpolarization of the cell membranes, preventing muscle contraction, leading to vasodilation. There is a relative deficiency of vasopressin in early sepsis. The endothelium is an endocrine organ, capable of regulating the function of the microcirculation and producing nitric oxide (NO), an endogenous vasodilator. Its major effects are to cause local vasodilation and inhibition of platelet aggregation. NO is produced from l‐arginine by nitric oxide synthetase (NOS), and its actions are mediated by cGMP. There are two forms of the enzyme NOS, a constitutive form, produced as part of the normal regulatory mechanisms, and an inducible form, whose production appears to be pathologic. Inducible NOS (iNOS) is an offshoot of the inflammatory response, by TNF and other cytokines. It results in massive production of NO, causing widespread vasodilation (due to loss of vasomotor tone) and hypotension, which is hyporeactive to adrenergic agents. NO has a physiological antagonist, endothelin‐1, a potent vasoconstrictor whose circulating level is increased in cardiogenic shock and following severe trauma.Answer: BJackson WF Ion channels and vascular tone. Hypertension. 2000; 35(1 Pt 2):173–178.Quayle, JM, Nelson, MT, Standen, NB ATP sensitive and inwardly rectifying potassium channels in smooth muscle. Physiol Rev. 1997; 77(4):1165–1232.

10 The removal of a central venous catheter alone could be effective in the treatment of a central line‐associated bloodstream infection in which of the following organisms?PseudomonasE. coliStaphylococcus aureusKlebsiella pneumoniaStaphylococcus epidermidisWhen treating catheter‐related bloodstream infections (CLABSI), several factors are important to consider in the treatment algorithm. Staphylococcus epidermidis is often a contaminate and tends to behave in a nonvirulent manner. However, it is known to cause biofilms, so catheters must be removed. The use of antibiotics in a short course may be beneficial depending on the clinical condition of the patient.Answer: EPérez Parra A, Cruz Menárquez M, Pérez Granda MJ A simple educational intervention to decrease incidence of central line‐associated bloodstream infection (CLABSI) in intensive care units with low baseline incidence of CLABSI. Infect Control Hosp Epidemiol. 2010; 31(9):964–967.Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter‐related bloodstream infections in the ICU. N Engl J Med. 2006; 355(26):2725–2732. Erratum in: New England Journal of Medicine (2007) 356 (25), 2660.

11 A 60‐year‐old woman is admitted to the ICU from the operating room after undergoing an emergent right colectomy and end ileostomy for a perforated gangrenous cecum. Over the next 12 hours, she has escalating vasopressor requirements despite being adequately fluid resuscitated and is started on stress dose steroids. Despite all these measures, she remains in refractory shock. The addition of which therapeutic can best improve this patient's arterial pressure?Nitric oxide synthase inhibitor 546C88Angiotensin IIFludrocortisoneVitamin CHypertonic salineThe ATHOS‐3 trials found that in patients with severe vasodilatory shock on high‐dose catecholamine‐based vasopressors and vasopressin, the administration of angiotensin II is associated with a 45% absolute increase in MAP response when compared to placebo. It has subsequently been approved for the treatment of refractory vasodilatory shock. Angiotensin II is a naturally occurring hormone secreted as part of the renin‐angiotensin system that results in powerful systemic vasoconstriction. Angiotensin II is contraindicated in patients on ACE inhibitors. Nitric oxide synthase inhibitor 546C88 increased blood pressure in patients with septic shock but was associated with more frequent cardiovascular side effects and increased 28‐day mortality (choice A). Fludrocortisone when used in conjunction with hydrocortisone has been demonstrated in the APROCCHSS trial to reduce mortality; however, it did not show an increase in MAP and subsequent trials questioned fludrocortisone's efficacy (choice C). Vitamin C has been shown to decrease organ dysfunction and mortality when administered early in combination with hydrocortisone and thiamine for patients with septic shock; however, it has not been shown to directly increase MAP (choice D). Hypertonic saline would increase intravascular volume, but would have no benefit in a patient who has been adequately resuscitated (choice E).Answer: BKhanna A, English SW, Wang XS, et al. Angiotensin II for the treatment of vasodilatory shock. N Engl J Med. 2017; 377(5):419–430. doi: https://doi.org/10.1056/NEJMoa1704154. Epub 2017 May 21. PMID: 28528561.López A, Lorente JA, Steingrub J, et al. Multiple‐center, randomized, placebo‐controlled, double‐blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med. 2004; 32:21–30.Annane D, Renault A, Brun‐Buisson C, et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018; 378(9):809–818. doi: https://doi.org/10.1056/NEJMoa1705716. PMID: 29490185.Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before‐after study. Chest. 2017; 151(6):1229–1238. doi: https://doi.org/10.1016/j.chest.2016.11.036. Epub 2016 Dec 6. PMID: 27940189.

12 A 71‐year‐old man with a history of poorly controlled diabetes presents to the ED for a foul‐smelling left lower extremity. He is found to be hypotensive and tachycardic with altered mental status. He is admitted to the ICU in septic shock and is awaiting the OR for amputation. CMS has core measures for septic shock and requires that the patient's volume status be reassessed within 6 hours of admission.Which of the following assessments qualifies for full reassessment?Straight leg raisePoint of care ultrasoundWedge pressureCentral venous pressureComprehensive physical examThe Centers for Medicare and Medicaid Services core measures require either a comprehensive physical examination or two other measures of volume status. The comprehensive physical examination must include either: focused examination documented by provider that includes vital signs (including blood pressure, pulse, respiratory rate, and temperature), cardiopulmonary examination (heart and lung), capillary refill evaluation, peripheral pulse evaluation, and skin examination; or two of the following: central venous pressure measurement, central venous oxygen measurement, bedside cardiovascular ultrasound, passive leg raise, or fluid challenge.Answer: EFord, H. Severe Sepsis and Septic Shock: Management Bundle. Centers for Medicare and Medicaid Services, 2020.ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol based care for early septic shock. N Engl J Med. 2014; 370(18):1683–1693.ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal‐directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371(16):1496–1506.

13 A 63‐year‐old man with a past medical history of depression for which he takes citalopram is admitted to the ICU following a motor vehicle collision. He also has a history of anaphylaxis to cephalosporins and vancomycin. After 10 days in the ICU, he remains intubated and develops a fever to 39.9 °C. Laboratory analysis shows hemoglobin level of 7.3 g/dL, white blood cell count 1500/μL, and platelet count 40 000/μL. Blood cultures from peripheral blood and central venous catheters rapidly grow gram‐positive cocci in clusters. Rapid molecular assay identifies the organism in the blood as methicillin‐resistant Staphylococcus aureus. Sensitives are pending.After removal of the central venous catheter, the best antibiotic for this patient is?LinezolidPiperacillin/tazobactamMeropenemDaptomycinVancomycinDaptomycin and vancomycin are good options for MRSA bacteremia. However, with the patient's history of anaphylaxis to vancomycin (choice E), daptomycin is preferred. Linezolid is not FDA‐approved for Staphylococcus aureus bacteremia as no significant data exist. Adverse effects of Linezolid include worsening pancytopenia/thrombocytopenia (choice A). Linezolid can also interact with selective serotonin reuptake inhibitors (SSRIs) and other drugs that may increase serotonin levels. This patient is taking SSRIs (citalopram) and linezolid can predispose the patient to a higher risk of serotonin syndrome. If a strain of Staphylococcus is resistant to oxacillin or methicillin, it is resistant to all ß‐lactam antibiotics, including penicillins, cephalosporins, and carbapenems (choice B/C). Piperacillin/tazobactam, ampicillin/sulbactam, and meropenem do not have activity against MRSA. Also, with the patient's history of anaphylaxis secondary to cephalosporins, caution must be taken when administering penicillins or carbapenems.Answer: DThwaites GE, Edgeworth JD, Gkrania‐Klotsas E, et al. Clinical management of Staphylococcus aureus bacteraemia. Lancet Infect Dis. 2011; 11(3):208–222.Woytowish MR, Maynor LM . Clinical relevance of linezolid‐associated serotonin toxicity. Ann Pharmacother. 2013; 47(3):388–397.Kelkar PS, Li JT . Cephalosporin allergy. N Engl J Med. 2001; 345(11):804–809.

14 A 73‐year‐old man is admitted to the surgical ICU after ground level fall leading to a subdural hematoma. The patient's Glasgow coma score is 15. On admission, he required placement of a urinary catheter. Three days into hospitalization, although asymptomatic, he developed a fever which prompted a urinalysis and urine culture to be sent during his workup. The urinalysis demonstrates budding yeast and the culture grows 103 CFU Candida albicans.What is the next best step?Start fluconazoleStart micafunginObtain ophthalmology consultationRemove the urinary catheterFlush the foley Funguria is commonly seen in patients in the ICU. The most common pathogen is Candida species. Risk factors include an indwelling urinary catheter, immunosuppression, diabetes, TPN, and recent urologic procedures. In an asymptomatic patient, most candiduria is colonization and observation without antifungals is appropriate. This is confirmed by the urine culture demonstrating < 105 CFU. If a risk factor such as indwelling urinary catheter is present, the catheter should be removed or exchanged if still needed (Choice D). Persistent candiduria should prompt renal ultrasound or CT evaluation. Patients with candidemia should have an ophthalmologic evaluation to evaluate for endophthalmitis (choice C). Candida albicans is usually responsive to fluconazole (choice A), while other candida organisms such as glabrata should be treated with micafungin (choice B). Flushing the foley would not help with candiduria (choice E).Answer: DKauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections‐‐diagnosis. Clin Infect Dis. 2011; 52 Suppl 6:S452–S456.Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America Clin Infect Dis. 2009; 48:503–535.

15 A 59‐year‐old woman is admitted to the ICU after a sigmoid colectomy for perforated diverticulitis with end colostomy. On postoperative day 4, she is now having fever and chills. Two blood cultures are positive for vancomycin‐resistant Enterococcus faecium. She is started on IV daptomycin.Which of the following laboratory parameters should be monitored for daptomycin toxicity?Creatinine kinaseUric acidActivated partial thromboplastin timePlateletsAmylaseClinical trials for daptomycin showed decreased skeletal muscle activity and increases in creatinine kinase levels. Daptomycin is approved in dose range 4–6 mg/kg every 24 hours, in patients with a creatinine clearance greater than 30 mL/min. The Infectious Diseases Society of America (IDSA) has endorsed higher doses for bacteremia and endocarditis. It is recommended to monitor creatinine kinase levels once weekly while on therapy (choice A). Uric acid (choice B), Ptt (choice C), Platelets (choice D), and Amylase (choice E) are not affected by daptomycin.Answer: ABhavnani SM, Rubino CM, Ambrose PG, Drusano GL. Daptomycin exposure and the probability of elevations in the creatine phosphokinase level: data from a randomized trial of patients with bacteremia and endocarditis. Clin Infect Dis. 2010; 50(12):1568–1574.Arbeit RD, Maki D, Tally FP, et al. The safety and efficacy of daptomycin for the treatment of complicated skin and skin‐structure infections. Clin Infect Dis. 2004; 38(12):1673–1681.Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin‐resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011; 52(3):e18–e55.

16 Which of the following therapeutics has been found to help prevent Clostridium difficile‐associated diarrhea?Prophylactic metronidazoleVancomycin enemaEnteral nutritionProbioticsProton pump inhibitorsA recent Cochrane meta‐analysis and systematic review and meta‐analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing C. diff associated diarrhea. There is no evidence to suggest use of prophylactic oral, systemic or rectal antibiotic administration helps to prevent C. diff associated diarrhea. PPIs have been shown to be a risk factor for the development of C. diff.Answer: DGoldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile‐associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017; 12:CD006095.

17 A 24‐year‐old woman was involved in an ATV accident in which she collided with a tractor on her farm. She was found to have an extensive right lower extremity open fracture with large soft tissue defect and degloving injury. She was taken to the OR with orthopedics for washout and placement of external fixation. On hospital day 7, her wound was found to be black and necrotic appearing. Culture was found to be growing Mucormycosis. In addition to emergent surgical debridements, which of the following therapeutics should be initiated?FluconazoleAmphotericin BCaspofunginVoriconazoleLiposomal amphotericin BInvasive fungal infections such as mucormycosis are a rare but serious complication of traumatic injury characterized by fungal angioinvasion and resultant vessel thrombosis and tissue necrosis. Risk factors for development in invasive fungal infections include large contaminated wounds from soil, gravel, and plant matter. Prompt recognition of the invasive infection is key although may be difficult to diagnose at first. Early treatment with aggressive surgical debridement and antifungals are key. The treatment of choice is Amphotericin B. Liposomal Amphotericin B has been shown to be equally efficacious with less adverse effects such as nephrotoxicity and less catheter‐associated side effects (choice E). Fluconazole (choice A), Caspofungin (choice C), and Voriconazole (choice D) have no activity against Mucormycosis.TypeDescriptionType IClean wound <1 cm in diameter with simple fracture pattern and no skin crushingType IIA laceration >1 cm and <10 cm without significant soft tissue crushing. The wound bed may appear moderately contaminatedType IIIAn open segmental fracture or a single fracture with extensive soft tissue injury >10 cm. Type III injuries are subdivided into three typesType IIIAAdequate soft tissue coverage of the fracture despite high‐energy trauma or extensive laceration or skin flapsType IIIBInadequate soft tissue coverage with periosteal strippingType IIICAny open fracture that is associated with vascular injury that requires repairAnswer: EBaldwin K, Babatunde O, Huffman G, Hosalkar H . Open fractures of the tibia in the pediatric population: a systematic review. J. Child. Orthop. 2009; 3:199–208. doi: https://doi.org/10.1007/s11832‐009‐0169‐6.Lelievre L, Garcia‐Hermoso D, Abdoul H, et al. Posttraumatic Mucormycosis. Medicine. 2014; 93(24):395–404.Kronen R, Liang SY, Bochicchio G, et al. Invasive fungal infections secondary to traumatic injury. Int J Infect Dis. 2017; 62:102–111.

18 A 25‐year‐old man was brought to the emergency room intoxicated after he was found at the bottom of a staircase. His GCS was 7 and he was intubated for airway protection. Upon intubation, he was found to have particulate matter and bile staining in his airway. A nasogastric tube was placed and chest x‐ray confirms the position of the nasogastric and endotracheal tubes, but shows infiltrates in the right lower lobe. What is the most appropriate therapy for his aspiration?FluconazolePiperacillin/tazobactamVancomycinPiperacillin/tazobactam + vancomycinNo antimicrobial therapyAspiration is defined as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Aspiration pneumonitis (Mendelson's syndrome) is a chemical injury caused by the inhalation of sterile gastric contents, whereas aspiration pneumonia is an infectious process caused by the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria. Aspiration of gastric contents results in a chemical injury of the tracheobronchial tree and pulmonary parenchyma, causing an intense parenchymal inflammatory reaction. The prophylactic use of antibiotics in patients in whom aspiration is suspected or witnessed is not recommended. Similarly, the use of antibiotics shortly after aspiration in patients in whom a fever, leukocytosis, or a pulmonary infiltrate develops is discouraged, since the antibiotic may select for more resistant organisms in patients with an uncomplicated chemical pneumonitis. With the presence of particulate matter in the airway, strong consideration for performing diagnostic/therapeutic bronchoscopy is warranted.Answer: EMarik PE . Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001; 344(9):665–671. doi: https://doi.org/10.1056/NEJM200103013440908. PMID: 11228282.

19 A 65‐year‐old man is recovering in the surgical ICU following subtotal colectomy and end ileostomy for severe clostridium difficile infection. He is receiving enteral nutrition via a nasogastric tube. He is having persistent gastric residuals of 250 mL.Which of the following is the best next step in management?Discontinue enteral feeds for 2 hours and restart enteral nutrition at 50% of prior rate.Discontinue enteral feeds indefinitely and initiate TPN.Continue current rate of enteral feeding.Change to an elemental tube feed.Start promotility agents.Malnutrition is a major problem in the ICU. Critically ill patients are in a catabolic state requiring increased caloric demand. Trophic feeds in patients in septic shock have been demonstrated to lower mechanical ventilation days and length of stay. Enteral nutrition is frequently held for procedures, operations, and imaging studies. Multiple studies have shown that gastric residual volumes are unnecessary and only further contribute to malnutrition (choice A). TPN is not indicated with a functioning enteric tract (choice B). Elemental feeds are more costly and may help with absorption in patients with malabsorptive disease. They would have no effect on gastric motility (choice D). Promotility agents may decrease gastric residuals but do not affect mortality (choice E).Answer: CReignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator‐associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013; 309(3):249–256.Patel JJ, Kozeniecki M, Biesboer A, et al. Early trophic enteral nutrition is associated with improved outcomes in mechanically ventilated patients with septic shock: a retrospective review. J Intensive Care Med. 2016; 31(7):471–477.McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009; 33(3):277–316.

20 A 31‐year‐old woman is 32 weeks pregnant and works at a local grocery store at the deli counter. She presents to the hospital with high fevers, nuchal rigidity, and altered mental status. She is admitted to the ICU with the diagnosis of meningitis. CSF analysis is pending.What is the empiric antibiotic regimen of choice for this patient?Vancomycin and piperacillin/tazobactamVancomycin, ceftriaxone, and penicillin GVancomycin, ciprofloxacin, and ampicillinGentamicin, metronidazole, and amoxicillinVancomycin and cefotaximeStreptococcus pneumoniae followed by Neisseria meningitidis are the most common causative organisms for bacterial meningitis for the age group 16–50. Vancomycin and a third‐generation cephalosporin should be used as empiric antibiotics (choice E). In pregnancy, there is also a risk of Listeria monocytogenes meningitis. Listeria is a facultative anaerobic gram‐positive bacillus that is often transmitted via soft cheeses and smoked meats. The patient is at risk for this due to her occupation. Listeria is not susceptible to cephalosporins or vancomycin. A penicillin is necessary for adequate empiric coverage (choice B). Gentamicin and ciprofloxacin are pregnancy class D drugs and should be avoided during pregnancy (choice D).Answer: BAllerberger F, Wagner M. Listeriosis: a resurgent foodborne infection. Clin Microbiol Infect 2010; 16(1):16–23.Van de Beek D, de Gans J, Tunkel AR, Wijdicks EF . Community‐acquired bacterial meningitis in adults. N Engl J Med. 2006; 354(1):44–53.