Читать книгу Surgical Critical Care and Emergency Surgery - Группа авторов - Страница 14

Jared Sheppard, MD, Jeffrey P. Coughenour, MD, and Stephen L. Barnes, MD

Division of Acute Care Surgery, Department of Surgery, University of Missouri, Columbia, MO, USA

1 A 57‐year‐old man with a history of hypertension, hyperlipidemia, obstructive sleep apnea, and obesity (BMI 45 kg/m2) is in your step down unit following a motor vehicle crash (MVC) 3 days ago, in which he sustained multiple bilateral rib fractures with associated pulmonary contusions. Initially, he required only nasal cannula to maintain a SpO2 of 92%, but now requires heated high‐flow nasal cannula at 70 L/min and 100% FiO2, with a saturation of 86%. The decision is made to intubate. After giving RSI, you perform bag/mask ventilation to preoxygenate; however, you note significant difficulty with increasing his SpO2. Which one of the following predicts difficulty of bag/mask ventilation?Age > 40 yearsBMI > 35 kg/m2Neck circumference > 30 cmFacial hairDenturesEffective oxygenation and ventilation, while important, may be impossible in certain patient populations. While there is some dispute as to which factors are most predictive of bag‐mask ventilation failure, Cattano et al. found the following to predict difficulty in BVM in the general surgical population: Age greater than 50 years old, BMI greater than 35, neck circumference greater than 40 cm, history of obstructive sleep apnea, history of difficult intubation, facial hair, and perceived short neck.Answer: BSaghaei M, Shetabi H, Golparvar M. Predicting efficiency of post‐induction mask ventilation based on demographic and anatomical factors. Adv Biomed Res. 2012; 1:10. doi: 10.4103/2277‐9175.96056. Epub 2012 May 11. PMID: 23210069; PMCID: PMC3507007.Cattano D, Killoran PV, Cai C, Katsiampoura AD, Corso RM, Hagberg CA. Difficult mask ventilation in general surgical population: observation of risk factors and predictors. F1000Res. 2014; 3:204. Published 2014 Aug 27. doi: 10.12688/f1000research.5131.1.

2 A 78‐year‐old woman with a history of COPD (80 pack‐year history of cigarette smoking), peripheral vascular disease, hyperlipidemia, and malnutrition is admitted to your surgical ICU following a Whipple procedure for pancreatic adenocarcinoma, and remains intubated due to a mixed respiratory and metabolic acidosis. A medical student on service in the ICU asks if perioperative smoking cessation would have been of any value in this patient. You respond:Any amount of smoking cessation prior to a major operation has been shown to improve surgical site infection.Smoking cessation for at least 8 weeks duration has been shown to decrease cardiovascular complications.Smoking cessation for at least 4 weeks preoperatively reduces respiratory complications and wound‐healing complications.Smoking cessation for 4 weeks only decreases wound‐healing complications, but does not have a significant effect on respiratory complications.Smoking cessation for 2 weeks shows some reduction in wound‐healing and respiratory complications.Smoking history drastically increases the chance of perioperative complication, especially in regard to wound‐healing and respiratory complications. Wong et al. showed that 4 weeks of abstinence improved respiratory outcomes, while 2–3 weeks abstinence improved wound‐healing complications without a significant effect on respiratory status. Mills et al. conducted a systematic review of randomized trials on smoking cessation and found that while 4 weeks smoking cessation had a significant improvement over less than 4 weeks, there was a nearly 20% increase in magnitude of effect for each week of cessation.Answer: CMills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta‐analysis. Am J Med. 2011; 124(2):144–154.e8. doi: 10.1016/j.amjmed.2010.09.013. PMID: 21295194.Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short‐term preoperative smoking cessation and postoperative complications: a systematic review and meta‐analysis. Can J Anaesth. 2012; 59(3):268–279. doi: 10.1007/s12630‐011‐9652‐x. Epub 2011 Dec 21. PMID: 22187226.

3 A 59‐year‐old man with no significant past medical history is referred to your clinic for evaluation of an umbilical hernia. On exam, he has a reducible but tender umbilical hernia with an approximately 2 cm fascial defect. The decision is made to perform open repair. In preparation for his upcoming operation, what testing (if any) is indicated?No testing is neededChest x‐ray CChest x‐ray, EKG DChest x‐ray, EKG, CBC EChest x‐ray, EKG, CBC, BMPAppropriate perioperative cardiovascular evaluation is imperative for quality patient care. While traditionally certain tests were indicated solely based on patient's age, this practice has begun to fall by the wayside. According to current guidelines, a chest x‐ray should be obtained for patients with signs or symptoms of cardiopulmonary disease, patients with COPD without a CXR in the past 6 months, and patients who smoke or who have had recent upper respiratory tract infections. EKG should be obtained for patients with signs and symptoms of cardiovascular disease. A CBC is indicated for patients at risk of anemia based on their history and physical exam, and those in whom significant blood loss is anticipated. BMP should be reserved for patients at risk of electrolyte abnormalities or renal impairment. A UA should be performed in patients undergoing urologic procedures or implantation of foreign material. A pregnancy test should be ordered for all women of reproductive age.Answer: AFeely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF. Preoperative testing before non‐cardiac surgery: guidelines and recommendations. Am Fam Physician. 2013; 87(6):414–418. PMID: 23547574.Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol. 2017; 33(1):17–32. doi: 10.1016/j.cjca.2016.09.008. Epub 2016 Oct 4. Erratum in: Can J Cardiol. 2017 Dec;33(12):1735. PMID: 27865641.Siddaiah H, Patil S, Shelvan A, Ehrhardt KP, Stark CW, Ulicny K, Ridgell S, Howe A, Cornett EM, Urman RD, Kaye AD. Preoperative laboratory testing: implications of “Choosing Wisely” guidelines. Best Pract Res Clin Anaesthesiol. 2020; 34(2):303–314. doi: 10.1016/j.bpa.2020.04.006. Epub 2020 Apr 22. PMID: 32711836.

4 A 67‐year‐old woman with a history of atrial fibrillation, that is rate‐controlled with metoprolol, presents with an acute episode of Hinchey III diverticulitis with associated peritonitis on exam. She is taken emergently to the operating room. Regarding perioperative beta blockade, which of the following is true?While there is considerable controversy regarding initiating beta blockade in patients not currently on beta blockade, patients receiving a beta blocker should be continued on their home dose perioperatively.Initiation of beta blockade during the perioperative period has been shown to reduce cardiovascular complications, while not changing overall mortality.Initiation of a beta blockade during the perioperative period has been shown to reduce cardiovascular complications and improve mortality.Patients with known CAD not currently on beta blockade and undergoing a high‐risk operation should be initiated on a high‐dose beta blocker.Perioperative beta blockade should only be given to patients undergoing high‐risk cardiac surgery, regardless of home prescription.Following Mangano's publication, beta blockade was considered one of the most effective means of protecting patients from adverse cardiac events during noncardiac surgery. However, results were mixed in various trials that followed. The POISE trial was conducted as an attempt to demonstrate conclusive evidence for or against perioperative beta blockade. The trial, published in 2008, demonstrated cardiac protection, but also showed an increase in mortality, CVA, and hypotension in patients initiated on beta blockade in the immediate preoperative period. However, this study implemented high doses of beta blockade, and was thus criticized. Studies that followed have had mixed and similarly criticized results. What has been consistently shown is that there is benefit in continuing home beta blockade, and new beta blockade should likely be initiated in patients with high cardiac risk undergoing high‐risk procedures, but high‐dose beta blockade should be avoided.Answer: APOISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of extended‐release metoprolol succinate in patients undergoing non‐cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008; 371(9627):1839–1847. doi: 10.1016/S0140‐6736(08)60601‐7. Epub 2008 May 12. PMID: 18479744.Foex P, Sear JW. II. β‐Blockers and cardiac protection: 5 yr on from POISE. Br J Anaesth. 2014; 112(2):206–210. doi: 10.1093/bja/aet437. Epub 2013 Dec 15. PMID: 24343158.Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996; 335(23):1713–1720.

5 A 63‐year‐old man with a history of CAD status post CABG, HLD, HTN, and COPD is seen in your clinic for evaluation of a symptomatic right inguinal hernia, and the decision is made to perform an open repair. He states that he has had no shortness of breath or noted any cardiopulmonary symptoms. The patient asks if he should continue his daily aspirin and statin before his operation (scheduled for 14 days from now). You advise him:There are significant cardioprotective effects in continuing his statin through the perioperative period; however, he should hold his aspirin due to potential bleeding risk.Due to his history of CAD, he should continue his aspirin and statin, and should be started on a beta blocker in anticipation of his operation.The patient should continue his aspirin until 5 days before his operation, and should continue his statin through the perioperative period.While there is incomplete agreement, most expert panels recommend continuing aspirin for vascular procedures only, and continuing a statin throughout the perioperative period.The patient should continue his aspirin and statin and does not need to start a beta blocker.Perioperative aspirin should be continued for cardiac risk reduction unless there is a prohibitive bleeding risk. Statins have repeatedly demonstrated cardioprotective benefits in the perioperative period through an incompletely defined mechanism. Most evidence had shown benefit to statin use, but primarily in the vascular and cardiac surgery cohort. In 2017, London et al. demonstrated a significant risk reduction in 30‐day all‐cause mortality in patients exposed to statin on the day of surgery or the day following surgery, who underwent vascular, general, neurosurgical, orthopedic, thoracic, urologic, or otolaryngologic procedures.Answer: EHolt NF. Perioperative cardiac risk reduction. Am Fam Physician. 2012; 85(3):239–246. PMID: 22335263.London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017; 177(2):231–242. doi: 10.1001/jamainternmed.2016.8005. PMID: 27992624.

6 A 34‐year‐old woman arrives in your trauma bay following an MVC in which she was the ejected driver. She was unresponsive at the scene, with hypotension and tachycardia noted by EMS. Upon arrival to the trauma bay, she has a GCS of 6 with a HR of 130, BP 106/89, SpO2 of 91% on facemask, and has a respiratory rate of 28. She has scattered abrasions on her trunk, and FAST exam demonstrates fluid in the RUQ, as well as a gravid uterus. Which of the following is true in regard to this patient's pregnancy?Her pulmonary status and likelihood of first attempt success at intubation are unchanged compared to a nonpregnant counterpart.A chest tube should be placed approximately 3–4 rib spaces higher than in the nonpregnant patient.She is more susceptible to metabolic acidosis than a nonpregnant counterpart.This patient likely has a higher end‐tidal CO2 than a nonpregnant patient.Her risk of intra or retroperitoneal hemorrhage is lower than in a nonpregnant patient.The physiologic changes of pregnancy are important to know, especially in the trauma patient, and are summarized below:Pulmonary: Pregnancy is associated with increased airway edema, O2 consumption, and decreased RV and FRC. Therefore, intubation is technically more difficult and a patient may require a smaller endotracheal tube and additional airway adjuncts for successful airway management. It is important to properly preoxygenate prior to intubation. Increased tidal volume and minute ventilation lead to a compensated respiratory alkalosis, and elevation of the diaphragm in a gravid uterus requires chest tubes to be placed 1–2 rib spaces higher than in the nonpregnant patient.GI: Decreased gastric emptying and LES tone lead to increased risk of aspiration.CV: Increased plasma volume can delay recognition of hemorrhagic shock. Increased HR and decreased BP can alter the clinical picture in evaluating hypovolemic shock. Increased uterine and bladder blood flow, as well as increased vascular congestion, increased the risk of maternal hemorrhage with direct abdominal injury or retroperitoneal bleeding.Renal: To compensate for pregnancy‐associated respiratory alkalosis, the kidneys increase bicarbonate excretion. This leads to a decreased HCO3, effectively reducing the capacity to buffer against a metabolic acidosis.Answer: CSakamoto J, Michels C, Eisfelder B, Joshi N. Trauma in pregnancy. Emerg Med Clin North Am. 2019; 37(2):317–338. doi: 10.1016/j.emc.2019.01.009. Epub 2019 Mar 8. PMID: 30940375.Mendez‐Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013; 209(1):1–10. doi: 10.1016/j.ajog.2013.01.021. Epub 2013 Jan 17. PMID: 23333541.Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med. 2005; 33(10 Suppl):S347–S353. doi: 10.1097/01.ccm.0000183164.69315.13. PMID: 16215358.

7 A 28‐year‐old man presents to the trauma bay following a motorcycle crash in which he sustained significant head trauma. A CT brain from the referring facility demonstrates a large left‐sided subdural hemorrhage with midline shift, and the patient has a GCS of 7, with a laryngeal‐mask airway in place due to EMS being unable to perform endotracheal intubation. You prepare to establish a definitive airway in the trauma bay. Regarding induction medication selection in patients with traumatic brain injury (TBI), the optimal agents are:MidazolamPropofolEtomidateKetamineBoth C and DWhile there are no absolute contraindications to any of the above medications for RSI in patients with TBI, the practitioner should be very aware of the consequences of each agent. Midazolam and propofol are both associated with a significant incidence of post‐induction hypotension, subsequently worsening CPP and possibly increasing secondary brain injury. In fact, episodes of hypotension as short as 10 minutes have been shown to increase mortality in patients with TBI. However, administration of adequate oxygenation is also key – SpO2 of less than 90% is also associated with increased mortality. Etomidate and ketamine, on the other hand, have a significantly decreased incidence of post‐administration hypotension and would be preferred for induction.Answer: EShriki J, Galvagno SM Jr. Sedation for rapid sequence induction and intubation of neurologically injured patients. Emerg Med Clin North Am. 2021; 39(1):203–216. doi: 10.1016/j.emc.2020.09.012. Epub 2020 Oct 31. PMID: 33218658.

8 A 32‐year‐old man with a 4 year smoking history (without COPD), hypertension controlled with losartan, and well‐controlled type I diabetes mellitus is about to undergo emergent exploratory laparotomy for perforated appendicitis. Prior to making incision, the circulating nurse asks you to declare an American Society of Anesthesiologists (ASA) classification for this operation. The correct answer is:22E33E4The American Society of Anesthesiologists developed this simple scale to describe the degree of a patient's medical illness. The numeric system was designed to ease communication between providers, provide a common language for documentation, and ease data abstraction for research. Because of variation among providers, it should not be used as the sole determinant of patient status and is not meant to act as an evaluation of perioperative risk.ASA 1: Healthy patient; good exercise tolerance, excludes extremes of age.ASA 2: Mild systemic disease, Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well‐controlled DM/HTN, mild lung disease.ASA 3: Severe systemic disease, Substantive functional limitations; one or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.ASA 4: Severe systemic disease, at least one severe disease that is poorly controlled or at end stage; possible risk of death; Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis.ASA 5: Moribund patients not expected to survive more than 24 hours without surgery; ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.ASA 6: Brain‐dead patients undergoing organ or tissue procurement procedures for transplantation.An “E” is added to any case designated emergent.The patient above has well‐controlled disease of more than one body system, and requires emergent surgery, earning the designation ASA 2E.Answer: BHurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, Abouleish AE. Adding examples to the ASA‐physical status classification improves correct assignments to patients. Anesthesiology. 2017; 126:614–622.Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status – historical perspectives and modern developments. Anaesthesia 2019; 74:373–379.

9 You are waiting for your patient to arrive in the OR for a planned right inguinal hernia repair when anesthesia alerts you that they think you should reschedule your elective procedure due to uncontrolled hypertension. The patient currently has a BP of 178/100, and his only significant medical history is obesity, HTN, and HLD. He states that he has known about his hypertension for several months, but has not yet started his losartan that his PCP prescribed for him. He initially presented to the ED 3 days ago due to significant pain with his hernia and not being able to reduce it himself. Eventually, the surgical intern on call was able to reduce the hernia and the patient was discharged home. What is the appropriate course of action in this situation?Cancel the case and reschedule for after he achieves better control with his prescribed regimen.Admit the patient overnight for control of his blood pressure, with plans to operate the following day if he has responded to IV therapy.Have a thorough discussion with the patient regarding risks and benefits, and proceed with the operation.Administer high‐dose beta blockade and, if successful, proceed with the operation.This acute hypertension is likely due to pain and will likely resolve with sedation. Therefore, no intervention is needed.While broadly encountered in the surgical population, there are no universal guidelines for case cancelation with hypertension in noncardiac cases. Based on risk stratification for adverse cardiac outcomes, several studies have shown that there is no benefit to delaying operations with stage 2 hypertension and accompanying target organ damage, or stage 3 hypertension (BP >180/110) without organ damage. In this scenario, the risk of delaying an operation (bowel incarceration, strangulation, or perforation, etc.) likely outweighs the risks of suffering a perioperative adverse outcome due to chronic hypertension. Sudden reduction in BP (as in choice B and D) can decrease perfusion pressure and are not recommended.Answer: CSear JW. Perioperative control of hypertension: when will it adversely affect perioperative outcome? Curr Hypertens Rep. 2008; 10(6):480–487. doi: 10.1007/s11906‐008‐0090‐2. PMID: 18959836.Vázquez‐Narváez KG, Ulibarri‐Vidales M. The patient with hypertension and new guidelines for therapy. Curr Opin Anaesthesiol. 2019; 32(3):421–426. doi: 10.1097/ACO.0000000000000736. PMID: 31048597.

10 A 51‐year‐old man with alcoholic cirrhosis (MELD 19, weight = 50 kg) and a history of failed ventral hernia repair 7 years ago presents to the ED with severe abdominal pain, tachycardia, and acidosis. CT scan demonstrates incarcerated ventral hernia with surrounding air and fluid, consistent with perforated viscus. Laboratory studies are significant for a WBC of 17 000/mm3, Hgb of 12 g/dL, INR 3.1, and CO2 of 15 mEq/L. Your chief resident asks what you would like to do prior to proceeding to the operating room to lower his bleeding risk. You respond:Administer 2u fresh frozen plasma (FFP).While the data are preliminary, prothrombin complex concentrate (KCentra) has shown encouraging results and may be of benefit.Administer 10 mg IV Vitamin K. Administer 15 mcg DDAVP.Proceed directly to the operating room as the emergent nature of his operation prohibits the time required to reverse his mildly elevated INR.Clearly, this patient requires an emergent operation, but requires reduction in his bleeding risk by treatment of his coagulopathy; accomplishing this is far from simple, however. Historically, reversal of coagulopathy of chronic liver disease (CCLD) was accomplished with FFP, with a dose of 10–15 mL/kg (which in this patient equates to 750 mL, and since there are 250 mL/unit of FFP, this would be 3 units). However, the data have fairly consistently shown that reversal of coagulopathy with FFP in this patient population is unreliable at best, with only transient changes in bleeding risk. Supratherapeutic doses of FFP can be given with slightly improved reversal; however, this exposes the patient to significant risk of volume overload, and should be avoided. IV vitamin K can be used to augment this reversal, but would be less effective in an emergent situation than FFP. DDAVP would be given at a rate of 3 mg/kg for treatment of uremic platelet dysfunction, but would be ineffective in correcting the INR in the above patient. A small study did demonstrate equivalence between DDAVP and FFP in bleeding reduction in patients with CCLD undergoing dental extraction, but there is currently no evidence to support DDAVP for acute reversal in this situation; furthermore, as previously mentioned, FFP is an unreliable reversal agent and so should not be the gold standard to which DDAVP is compared. PCC (KCentra) has more recently come to the market, and while there are no large‐scale trials evaluating its role in coagulopathy of CCLD, several case reports and small studies have shown promising results. However, more research into its efficacy is needed.Answer: BHarrison MF. The misunderstood coagulopathy of liver disease: a review for the acute setting. West J Emerg Med. 2018; 19(5):863–871. doi: 10.5811/westjem.2018.7.37893. Epub 2018 Aug 8. PMID: 30202500; PMCID: PMC6123093.Kujovich JL. Coagulopathy in liver disease: a balancing act. Hematology Am Soc Hematol Educ Program. 2015;2015:243–249. doi: 10.1182/asheducation‐2015.1.243. PMID: 26637729.Pereira D, Liotta E, Mahmoud AA. The use of Kcentra® in the reversal of coagulopathy of chronic liver disease. J Pharm Pract. 2018; 31(1):120–125. doi: 10.1177/0897190017696952. Epub 2017 Mar 15. PMID: 29278982.Lesmana CR, Cahyadinata L, Pakasi LS, Lesmana LA. Efficacy of prothrombin complex concentrate treatment in patients with liver coagulopathy who underwent various invasive hepatobiliary and gastrointestinal procedures. Case Rep Gastroenterol. 2016; 10(2):315–322. doi: 10.1159/000447290. PMID: 27482190; PMCID: PMC4945807.

11 A 43‐year‐old woman presents to your trauma bay following an MVC. She is evaluated by standard ATLS protocol and is found to be hypotensive, tachycardic, and diaphoretic with a GCS of 14. FAST exam reveals fluid in Morrison's pouch. While preparing to bring the patient to the OR for exploration, the patient's husband alerts you that the patient takes rivaroxaban (Xarelto) for a provoked deep vein thrombosis 2 months ago. How should you proceed with her care?Administer prothrombin complex concentrate (PCC) and proceed to the operating room for exploration.Administer 15 mL/kg of FFP and proceed to the operating room for exploration.Proceed to the operating room immediately as hemodialysis is the only effective method of rivaroxaban (Xarelto) reversal.Administer platelets and proceed to the operating room for exploration.Administer protamine and proceed to the operating room for exploration.This patient requires an immediate operation to address her hemorrhagic shock. While proceeding to the operating room should not be delayed, her medication‐induced coagulopathy should obviously be addressed. First‐line reversal of direct factor Xa inhibitors (such rivarobaxan) is accomplished with prothrombin complex concentrate (PCC). Vitamin K antagonists (warfarin) is reversed with PCC first‐line, and FFP as second‐line therapy. Oral direct‐thrombin inhibitors such as dabigatran are reversed with PCC first‐line, with hemodialysis as second‐line therapy. Heparin and LMWH can be temporarily and partially reversed with protamine. Aspirin and Plavix are treated with platelet transfusion, with desmopressin as a second‐line option.Answer: AMcCoy CC, Lawson JH, Shapiro ML. Management of anticoagulation agents in trauma patients. Clin Lab Med. 2014; 34(3):563–574. doi: 10.1016/j.cll.2014.06.013. Epub 2014 Jul 19. PMID: 25168942.

12 You evaluate a 74‐year‐old woman with a history of asthma and COPD who is brought to the trauma bay by EMS following a fall down a flight of stairs. Per EMS report, the patient had a GCS of 13 upon arrival for confused speech and localizing to pain only, and was initially hemodynamically normal. However, during transport, the patient became hypotensive and tachycardic. FAST exam in the trauma bay reveals fluid in the bilateral upper quadrants, as well as the pelvis, and she is taken immediately to the OR for exploration. During the operation, you are alerted that her thromboelastography (TEG) results are as follows:R (reaction time): ElevatedK (kinetics): Increasedα Angle: DecreasedMA (maximum amplitude): DecreasedLY30 (clot lysis): NormalBased on these results, what intervention (if any) should be given?Platelets onlyFFP and plateletsTXA onlyCryoprecipitate, platelets, and FFPCryoprecipitate, FFP, and TXAThis patient has an elevated reaction time (indicating that clot is taking longer than normal to form – which is a problem with coagulation factors, and as such should be treated with FFP), as well as an increased K (indicating the clot takes longer to reach a fixed strength – which indicates a fibrinogen deficiency and is thus treated with cryoprecipitate), and a decreased Alpha angle (indicating an elevated time of fibrin accumulation – which is a function of fibrinogen and platelet number, and is thus treated with cryoprecipitate and platelet transfusion). Additionally, the MA is decreased, indicating a decreased clot strength owing to platelet dysfunction, which can be addressed with platelet transfusion. An elevated LY30 indicates hyperfibrinolysis, which is reversed with TXA; however, the LY30 is normal in this patient.Answer: DSchmidt AE, Israel AK, Refaai MA. The utility of thromboelastography to guide blood product transfusion. Am J Clin Pathol. 2019; 152(4):407–422. doi: 10.1093/ajcp/aqz074. PMID: 31263903.13

13 You are called to the intensive care unit to assist with a difficult airway in a patient with a sudden decline in mental status. The anesthesia resident has attempted intubation twice without success, and states he was unable to visualize the vocal cords on direct laryngoscopy. He is currently providing oxygenation and ventilation with bag‐valve mask, and the SpO2 is 91% and slowly rising. Which of the following should be performed?Consider placing a rescue device, such as laryngeal mask airway.Reattempt direct laryngoscopy with a different blade.Attempt to intubate over a blindly placed bougie.Continue with bag‐mask ventilation until fully preoxygenated.All of the above.Establishment of an airway is critical in a patient who is unable to protect their airway. When difficulty is encountered, call for help, and follow your institution's difficult airway algorithm. Since more than 2 passes at intubation is associated with a significant increase in aspiration, hypothermia, and cardiac arrest, attempts should be made to optimize first‐attempt success rate. This includes using an appropriate blade for direct laryngoscopy, providing adequate pre‐oxygenation, optimizing hemodynamics, and choosing appropriate medication. A definitive airway is not always immediately needed – if appropriate oxygenation/ventilation is achieved with a laryngeal mask airway, then it should be used until a definitive airway is needed or ready to be placed.Answer: EEdelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia. 2019; 74(9):1175–1185. doi: 10.1111/anae.14779. Epub 2019 Jul 21. PMID: 31328259.Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth 2016; 117 Suppl 1:i60–i68. doi: 10.1093/bja/aew061. Epub 2016 May 24. PMID: 27221259.

14 In the above patient, after placing an LMA, the patient begins to desaturate, and you notice that there is limited chest wall rise with inspiration. You then attempt another pass at direct laryngoscopy, and while you can see the vocal cords, you cannot pass the endotracheal tube. While attempting to provide adequate bag‐mask ventilation, the patient has an SpO2 of 78% which does not rise. The most appropriate next step is to:Proceed with cricothyroidotomyReplace the LMAProceed with percutaneous tracheostomyProceed with open tracheostomyRe‐dose your paralytic to improve ease of ventilation with bag‐mask ventilationThis difficult airway has now become a failed airway, and prompt action is needed to establish an airway before the patient arrests. A surgical airway is indicated. While tracheostomy could be performed, a cricothyroidotomy is still the procedure of choice given the more easily identifiable anatomy and closer proximity of skin to tracheal lumen.Answer: AEdelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia 2019; 74(9):1175–1185. doi: 10.1111/anae.14779. Epub 2019 Jul 21. PMID: 31328259.Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016; 117 Suppl 1:i60–i68. doi: 10.1093/bja/aew061. Epub 2016 May 24. PMID: 27221259.

15 A 65‐year‐old man is in your intensive care unit following a motor vehicle crash in which he sustained pelvic fractures requiring percutaneous fixation, fractures of left ribs 1–7, and associated pulmonary contusions. His pain is well‐controlled, and he is deemed fit to discharge to inpatient rehabilitation. Due to his pelvic fracture pattern, your orthopedic colleague requests that the patient be placed on DVT prophylaxis with warfarin for 6 weeks from the date of operation. Assuming anticoagulation is beneficial in this patient, your response should be:Place the patient on warfarin, and ensure an INR of 2–2.5.Place the patient on a NOAC.Place the patient on dual anti platelet therapy with aspirin and plavix.Place the patient on twice daily lovenox.Place the patient on aspirin alone.Many patients were historically were started on anticoagulation for the prevention of DVTs following orthopedic operations of the lower extremities. Over the past decade or so, there has been a trend to anticoagulate these patients with agents other than warfarin, due to fewer complications from bleeding, as well as decreased incidence of VTE in patients treated with alternate therapy. Aspirin has increasingly been studied as an alternate to low‐molecular weight heparin and NOACs due to increased simplicity of administration, and multiple large‐scale trials have shown aspirin to be non‐inferior to other forms of anticoagulation.Answer: ESimes J, Becattini C, Agnelli G, Eikelboom JW, Kirby AC, Mister R, Prandoni P, Brighton TA ; INSPIRE Study Investigators (International Collaboration of Aspirin Trials for Recurrent Venous Thromboembolism). Aspirin for the prevention of recurrent venous thromboembolism: the INSPIRE collaboration. Circulation. 2014; 130(13):1062–1071. doi: 10.1161/CIRCULATIONAHA.114.008828. Epub 2014 Aug 25. PMID: 25156992.Anderson DR, Dunbar MJ, Bohm ER, Belzile E, Kahn SR, Zukor D, Fisher W, Gofton W, Gross P, Pelet S, Crowther M, MacDonald S, Kim P, Pleasance S, Davis N, Andreou P, Wells P, Kovacs M, Rodger MA, Ramsay T, Carrier M, Vendittoli PA. Aspirin versus low‐molecular‐weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013; 158(11):800–806. doi: 10.7326/0003‐4819‐158‐11‐201306040‐00004. PMID: 23732713.Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low‐dose aspirin is adequate for venous thromboembolism prevention following total joint arthroplasty: a systematic review. J Arthroplasty. 2020; 35(3):886–892. doi: 10.1016/j.arth.2019.09.043. Epub 2019 Oct 5. PMID: 31733981.

16 You are in the trauma bay during 5 simultaneous trauma activations. In order to most judiciously utilize your blood bank's resources, you are attempting to predict which patients will require a massive transfusion protocol (MTP). Which of the following patients is most likely to require MTP?A 19‐year‐old man with a GSW to the abdomen with negative FAST, SBP of 110 mm Hg, and HR of 100 beats/min.A 23‐year‐old woman involved in an MVC, with a positive FAST, SBP of 110 mm Hg, and HR of 100 beats/min.A 49‐year‐old man with a GSW to the abdomen with a negative FAST, SBP of 94 mm Hg, and HR of 115 beats/min.A 32‐year‐old man who was assaulted, with a positive FAST, SBP of 98 mm Hg, and HR of 130 beats/min.A 44‐year‐old woman with a stab wound to the LUQ with a negative FAST, SBP of 98 mm Hg, and HR of 110 beats/min. Identifying patients who will likely require MTP is essential in the trauma bay. The Assessment of Blood Consumption (ABC) scoring system relies on 4 non‐weighted dichotomous parameters: penetrating mechanism, positive Focused Assessment with Sonography for Trauma (FAST), arrival systolic blood pressure (SBP) of 90 mm Hg or less, and arrival heart rate of 120 bpm or greater. Each positive parameter is given a score of 1, and the total score is evaluated out of 4. A score of 2 or greater predicts the need for MTP with a sensitivity of 75% and a specificity of 86%.Answer: DMaegele M, Brockamp T, Nienaber U, Probst C, Schoechl H, Goerlinger K, Spinella P. Predictive models and algorithms for the need of transfusion including massive transfusion in severely injured patients. Transfus Med Hemother. 2012; 39(2):85–97. doi:10.1159/000337243.Cotton BA, Dossett LA, Haut ER, Shafi S, Nunez TC, Au BK, Zaydfudim V, Johnston M, Arbogast P, Young PP. Multicenter validation of a simplified score to predict massive transfusion in trauma. J Trauma. 2010; 69(Suppl 1):S33–S39. doi: 10.1097/TA.0b013e3181e42411. PMID: 20622617.

17 A 37‐year‐old woman with a history of chronic cholecystitis undergoes a laparoscopic cholecystectomy which requires conversion to an open procedure due to significant inflammatory disease. The case is completed, and the patient is brought to PACU. While reviewing her postoperative labs, you note a blood glucose level of 190 mg/dL, as well as a mild acidosis and leukocytosis. In regard to her hyperglycemia, the following is true:The patient is at increased risk of surgical site infection, as well as overall mortality, but her risk is less than that of a known diabetic.The patient is at increased risk of surgical site infection, as well as overall mortality, but her risk is equal to that of a known diabetic.The patient is at increased risk of surgical site infection, as well as overall mortality, and her risk is higher than that of a known diabetic.The patient has an expected stress response to operation, and since she is not diabetic, no further intervention is required, and her risk of surgical site infection is not significantly increased.There is no clear correlation between isolated episodes of hyperglycemia in non‐diabetic patients, although there is a correlation for diabetic patients.There exists a dose‐dependent relationship between blood glucose levels above 180 mg/dL and postoperative complications, including surgical site infection, length of stay, and overall mortality. Interestingly, this effect is more pronounced in patients who are non‐diabetic than in patients who are diabetic. This is thought to possibly be due to several different causes, including a non‐treatment bias in non‐diabetics (patients with an established diagnosis of DM are more likely to receive insulin), and because hyperglycemia in non‐diabetic patients is likely an indicator of a significant stress response, correlating with worse outcome. Glucose control should be maintained below 180, but overly restrictive control has been shown to have worse outcomes, especially in critically ill patients.Answer: CKotagal M, Symons RG, Hirsch IB, Umpierrez GE, Dellinger EP, Farrokhi ET, Flum DR ; SCOAP‐CERTAIN Collaborative. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015; 261(1):97–103. doi: https://doi.org/10.1097/SLA.0000000000000688. PMID: 25133932; PMCID: PMC4208939.Thompson BM, Stearns JD, Apsey HA, Schlinkert RT, Cook CB. Perioperative management of patients with diabetes and hyperglycemia undergoing elective surgery. Curr Diab Rep. 2016; 16(1):2. doi: 10.1007/s11892‐015‐0700‐8. PMID: 26699765.

18 A 73‐year‐old woman with a history of rheumatoid arthritis (on 5 mg prednisone daily), carotid stenosis s/p carotid endarterectomy 4 years ago, and hypertension is in the ED with severe abdominal pain. Work up demonstrates diverticulitis with a significant amount of intra‐abdominal free air. You post her for an emergent exploration. Regarding perioperative management of her steroids, which of the following is true?She should receive 100 mg hydrocortisone/day for 2–3 days and resume normal oral therapy when she has return of bowel function.She should receive 25 mg hydrocortisone at induction, and an IV equivalent of her home prednisone daily following her operation.She should remain on the IV equivalent of her home prednisone.She should receive 25 mg hydrocortisone at induction, and 100 mg hydrocortisone/day for 2–3 days and then resume her home equivalent.She does not require any supplemental hydrocortisone and should hold her home dose.While “stress‐dose steroids” are frequently given to patients on long‐term glucocorticoid therapy due to fear of adrenal suppression, there is a fairly low yield of any data to support this. In patients who take less than 10 mg prednisone daily (or its equivalent), there is no indication for supplemental steroid in addition to whatever the patient's daily regimen is. For patients taking greater doses (>10 mg/day), there is no universally accepted regimen, but most recommendations are for 25–50 mg once on the day of surgery and continued at a similar rate for 2–3 days after surgery, with the goal to replace a physiologic dose of steroid. This can be assumed to be between 75–150 mg/day. If a patient has been off of daily steroids for greater than 3 months, they can be treated as if not on chronic steroids. Topical steroids are likewise not considered as necessitating perioperative steroid dosing.Answer: CMacKenzie CR, Goodman SM. Stress dose steroids: myths and perioperative medicine. Curr Rheumatol Rep. 2016; 18(7):47. doi: 10.1007/s11926‐016‐0595‐7. PMID: 27351679.Chilkoti GT, Singh A, Mohta M, Saxena AK. Perioperative “stress dose” of corticosteroid: pharmacological and clinical perspective. J Anaesthesiol Clin Pharmacol. 2019; 35(2):147–152. doi: 10.4103/joacp.JOACP_242_17. PMID: 31303699; PMCID: PMC6598572.