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resume warfarin POD 1.Stop warfarin 3 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day before surgery, resume warfarin POD 2.Stop warfarin 3 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day before surgery, resume warfarin POD 5.Stopping anticoagulation medication prior to surgery must be weighed against the risk of thromboembolic events and the surgical bleeding risk. This patient has a high CHA2DS2‐VASc score of 7 (hypertension ‐1, age > 75 ‐ 2, diabetes ‐1, stroke ‐2, and vascular disease ‐1) and is high risk for thromboembolic events, and therefore, should not have anticoagulation stopped completely (Answer A). This patient should be placed on enoxaparin therapy, which should be stopped the day before surgery (Answer C) and warfarin should be started POD 1, provided no/minimal bleeding risk. Weight‐based enoxaparin should also be restarted 12–24 hours after surgery depending on bleeding risk, as it will take multiple days for warfarin to reach therapeutic levels.BRIDGE trial anticoagulation protocolDay (around procedure)Protocol−5Stop warfarin−3Start bridging agent (LMWH)−1Stop bridging agent 24 hours prior to procedure0Procedure1Resume warfarin within 24 hours, resume bridging agent within 12 to 24 hours for low risk bleed2 to 3Resume bridging agent within 48–72 hours for high‐risk procedure5 to 10Stop bridging agent when INR > 2Answer: CBarnes GD, Mouland E . Peri‐procedural management of oral anticoagulants in the DOAC Era. Prog Cardiovasc Dis. 2018; 60 (6):600–606.

      15 A 45‐year‐old woman pedestrian was struck by a motor vehicle. She has a history of COPD and a penicillin allergy. She sustained bilateral rib fractures with a flail segment on the left, left pulmonary contusion, left diaphragmatic injury (status‐post repair), and left open tibia and fibula fractures (also status‐post repair). She was admitted to the surgical ICU 8 days ago. She has been difficult to wean from the ventilator and has had a central line and left chest tube in place since admission. She began spiking fevers 2 days ago and is now requiring vasopressors. Empiric cefepime, metronidazole, and vancomycin were started, but clinically she has not improved. Her bronchoalveolar lavage (BAL) and blood cultures have come back positive for Candida with species pending. What is the best treatment choice for this patient currently?Continue current antibiotics and give more time to improveFluconazole 200 mg IV dailyVoriconazole 4 mg/kg IV dailyCaspofungin 70 mg IV x1 followed by 50 mg IV dailyFlucytosine 50 mg/kg IV q6 hoursEmpiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever. This patient is not improving and cultures indicate fungal bacteremia and ventilator‐associated pneumonia (VAP), thus, continuing the current antibiotic regimen would not treat this patient. Empiric antifungal therapy should be started as soon as possible in patients who have risk factors and who have clinical signs of septic shock. The preferred empiric therapy for suspected candidiasis in nonneutropenic patients in the ICU is an echinocandin (micafungin 100 mg IV daily, caspofungin 70 mg IV × 1 followed by 50 mg IV daily, anidulafungin 200 mg IV × 1 followed by 100 mg IV daily). Thus, Answer D is correct. Fluconazole at higher doses 800 mg IV ×1 followed by 400 mg IV daily is an acceptable alternative for patients who have not had recent azole exposure. B is incorrect because the dose is subtherapeutic. Voriconazole is used in much higher doses (6 mg/kg) BID × 2 then 3 mg/kg BID, but offers little advantage over fluconazole as initial therapy. Voriconazole is recommended as step‐down therapy for selected cases of candidemia due to Candida krusei, for additional mold coverage and for neutropenic patients. Flucytosine is usually used in combination with other antifungals and reserved for very severe infections. It is used more commonly in combination with amphotericin B for central nervous system candidiasis. In addition, higher doses (100–200 mg/kg) in 4 doses over 24 hours are recommended.Answer: DPappas PG, Kauffman CA, Andes AR, et. al. Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2016; 62 :e1–50.

      16 A 63‐year‐old woman is receiving rivaroxaban following a pulmonary embolism she had 5 months ago. She also has hypertension and hyperlipidemia. She has normal renal function. She will be undergoing a mastectomy with sentinel lymph node biopsy for stage 2 ductal carcinoma. How should her rivaroxaban be managed in the perioperative period?Last dose of the DOAC prior to elective procedureAgentRenal clearanceLow bleed riskHigh or unknown bleed riskRivaroxaban, apixaban, edoxabanCrCl > 30 mL/min>24 hours>48 hoursCrCl 15–29 mL/min>36 hours>72 hoursCrCl < 15 mL/min>48 hoursData lackingDabigatranCrCl > 80 mL/min>24 hours>48 hoursCrCl 50–80 mL/min>36 hours>72 hoursCrCl 30–49 mL/min>48 hours>96 hoursCrCl 15–29 mL/min>72 hours>120 hoursCrCl < 15 mL/minUnknownUnknownStop rivaroxaban 5 days before surgery and restart POD 1.Stop rivaroxaban 2 days before surgery and restart POD 1.Stop rivaroxaban 5 days before surgery, start weight‐based enoxaparin, and restart POD 1.Stop rivaroxaban 2 days before surgery, start weight‐based enoxaparin, and restart POD 2.Stop rivaroxaban day of surgery and restart POD 2.This patient is at intermediate risk for thromboembolic events and should stop anticoagulation in the perioperative period without significant consequence. The direct‐acting oral anticoagulants (DOACs) rarely need bridging therapy (Answers C & D). Provided normal renal function, rivaroxaban should be eliminated entirely by 35–55 hours, since its half‐life is 7–11 hours (4–5 half‐lives for 95% elimination). A mastectomy has a higher risk of bleeding compared to some other surgeries, thus, rivaroxaban should be stopped 2 days prior to surgery and resumed POD 1 provided no bleeding complications.Answer: BBarnes GD, Mouland E . Peri‐procedural management of oral anticoagulants in the DOAC Era. Prog Cardiovasc Dis. 2018; 60 (6):600–606.

      17 A 45‐year‐old man was involved in a high‐speed motor vehicle crash and has the following injuries: intraparenchymal hemorrhage, diffuse axonal injury, T4 vertebral body fracture, T4 paraplegia, and multiple bilateral rib fractures. On hospital day 9, the patient remains intubated, spikes a fever, and has thick secretions from the endotracheal tube. Subsequent bronchial alveolar lavage is performed, and the culture grows vancomycin‐ resistant enterococcus (VRE). Blood cultures also grow 2/2 bottles with VRE. Which is the best choice of antibiotic to use?CefepimeLinezolidDaptomycinPiperacillin‐tazobactamMeropenemVancomycin‐resistant enterococci (VRE) was first reported in 1986 and cases have been increasing in the ICU. In 2006 in the US, the rate of VRE was 0.6 per 1000 admissions. There is an increased risk of mortality with VRE bacteremia and treatment should be started promptly. Effective treatments for VRE include quinupristin‐dalfopristin, linezolid, daptomycin, tigecycline, teicoplanin, and telavancin. Linezolid and daptomycin are the two most commonly used antibiotics in the US for VRE. Linezolid (Answer B) is an oxazolidone that binds to the 50S ribosomal subunit, has been approved by the FDA for VRE treatment, has better tissue penetration than other antibiotics, especially lung penetration, and is bacteriostatic. Linezolid can suppress bone marrow, is expensive, and can interact with psychiatric medications, particularly monoamine oxidase inhibitors (MAOIs). Daptomycin (Answer C) is a novel cyclic lipopeptide that inhibits DNA and RNA synthesis and is bactericidal. It is not approved by FDA for VRE infections, though it is recognized as an appropriate treatment for some VRE infections; however, it should not be used to treat pneumonia because it is inactivated by alveolar surfactant. Daptomycin may cause Clostridium difficile, rhabdomyolysis, and thrombocytopenia. A meta‐analysis showed linezolid treatment for VRE bacteremia had a lower mortality compared to daptomycin. Cefepime, piperacillin‐tazobactam, and meropenem are not indicated for VRE.Answer: BPrematunge C, MacDougall C, Johnstone J, et al. VRE and VSE bacteremia outcomes in the Era of effective VRE therapy: a systematic review and meta‐analysis. Infect Control Hosp Epidemiol. 2016; 37 (1):26–35.Chuang Y‐C, Wang J‐T, Lin H‐Y,et al. Daptomycin versus linezolid for treatment of vancomycin‐resistant enterococcal bacteremia: systematic review and meta‐analysis. BMC Infectious Diseases. 2014; 14 :687–695.Kalil AC, 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. PMID: 27418577.

      18 Which of the following is the best practice to prevent antibiotic resistance in the ICU?Initially treating a septic shock patient of unknown etiology with monotherapy quinolones.Continuing antibiotics for at least 7 days for intra‐abdominal sepsis after source control.Continuing vancomycin in a patient with ventilator‐associated pneumonia due to E. coli.De‐escalation of antibiotics based on culture results.Decrease the infusion

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