Session 2: Ambulatory Care and Critical Care Answer Explanations

Transcription

1 Session 2: Ambulatory Care and Critical Care Answer Explanations Ambulatory Care 1. Answer C: Not well controlled. Her nighttime symptoms fall under the not well controlled category, even though her FEV 1, daytime symptoms, short-acting β-agonist (SABA) use, and lack of activity limitations fall under the well-controlled category of asthma control. The most severe category is what determines control. i. National Institutes of Health (NIH) National Heart Lung and Blood Institute (NHLBI). National Asthma Education and Prevention Program (NAEPP) Guidelines. NAEPP Expert Panel Report 3. NIH Publication July Available at Accessed September 26, Answer D: Increase fluticasone to 110 mcg MDI 2 puffs twice daily. Because her asthma is not well controlled, the asthma treatment should be stepped up one step. She is currently on step 2 therapy and should move up to step 3, which is either medium-dose ICS alone or low-dose ICS plus LABA. Fluticasone 110 mcg 2 puffs twice daily is a medium-dose ICS. i. National Institutes of Health (NIH) National Heart Lung and Blood Institute (NHLBI). National Asthma Education and Prevention Program (NAEPP) Guidelines. NAEPP Expert Panel Report 3. NIH Publication July Available at Accessed September 26, Answer B: Patient group B. He is in GOLD risk group B (low risk, more symptoms) because of his mmrc score, FEV 1, and lack of exacerbations or hospitalizations. i. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014 Revision. Available at Accessed September 26, Answer B: Start inhaled salmeterol 50 mcg/puff 1 puff twice daily. The GOLD guideline recommend as preferred treatment for COPD patients in patient group B either a long-acting anticholinergic or a LABA. Inhaled corticosteroids (ICSs) are not indicated until a patient is group C or D. ICSs are never indicated as monotherapy for COPD. i. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014 Revision. Available at Accessed September 26,

2 5. Answer C: Febuxostat should be initiated. ULT is indicated in patients with tophi, two or more gouty attacks per year, stage 2 chronic kidney disease (CKD) or worse, or past urolithiasis. Because this patient has two gouty attacks per year, ULT is indicated. Xanthine oxidase inhibitors (XOIs) such as febuxostat and allopurinol are first-line ULT. Probenecid is an alternative first-line ULT that should be used if XOIs are contraindicated or not tolerated. Pegloticase is not first line in any case, and it should be used only in patients with severe gout refractory to or intolerant of other ULTs. i. Khanna D, Fitzgerald JD, Khanna PP, et al American College of Rheumatology Guidelines for Management of Gout. Part 1. Systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res 2012;64: Answer D: Start allopurinol now and continue colchicine for 6 months after achieving target urate level, as long as tophi are resolved. ULT can be started during an acute attack, as long as anti-inflammatory therapy is given and continued as prophylaxis. Prophylaxis of acute gout with anti-inflammatory agents should continue for the greater of: 6 months, 3 months after achieving target serum urate level if no tophi, or 6 months after achieving target serum urate level if tophi were previously present but are now resolved. However, continue prophylaxis if any clinical evidence of gout disease activity exists. Because this patient has tophi, colchicine should be continued for 6 months after target urate level is achieved if tophi are resolved. i. Khanna D, Khanna PP, Fitzgerald JD, et al American College of Rheumatology guidelines for management of gout. Part 2. Therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res 2012;64: Answer C: Vaccinate with PCV13 today, then revaccinate with PPSV23 again in 6 12 months. In 2014, the Centers for Disease Control and Prevention issued new guidelines for use of PCV13 and PPSV23 in people who previously received PPSV23 before age 65 years who are now aged 65 years: Vaccinate with PCV13 1 year after receipt of PPSV23, and revaccinate with PPSV23 in 6 12 months after PCV13, as long as 5 or more years has passed since the previous PPSV23. i. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged 65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2014;63(37): Available at Accessed October 10, Critical Care 8. Answer B: Monitor blood glucose every hour and treat as necessary to prevent hypoglycemia and hyperglycemia. 2

3 While cooling, patients often experience hyperglycemia, followed by hypoglycemia during rewarming. Frequent blood glucose checks and an insulin infusion are the best ways to prevent extremes of blood glucose during targeted temperature management (Answer B). Neuromuscular blockade should be used only when other methods of shivering control (such as sedatives) have failed (Answer A). Hypokalemia is often encountered during the cooling phase, but during rewarming patients shift potassium extracellularly, and hyperkalemia can occur. Aggressive repletion of potassium during the cooling phase can cause life-threatening hyperkalemia later (Answer C). Sedative requirements are often reduced in hypothermia (Answer D). s i. Nunnally ME, Jaeschke R, Bellingan GJ, et al. Targeted temperature management in critical care: a report and recommendations from five professional societies. Crit Care Med 2011;39: ii. Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug disposition, metabolism, and response: a focus of hypothermia-mediated alterations on the cytochrome P450 enzyme system. Crit Care Med 2007;35(9): Answer C: Start enteral nutrition within 48 hours of ICU admission. Many patients may not tolerate enteral nutrition during hypothermia because of ileus, but this is not an indication for parenteral nutrition, because targeted temperature management will last only 24 hours (Answer A). In critically ill obese patients, feeding at 60% 70% of goal, or kcal/kg, has been shown to improve outcomes compared with fully meeting caloric goals (Answer B). Current guidelines recommend initiation of enteral nutrition within hours of ICU admission, which will still be appropriate for the patient after she is rewarmed (Answer C). Protein intake of g/kg is recommended for critically ill patients (Answer D). s i. Martindale RG, McClave SA, 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 and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med 2009;37: ii. Dickerson RN, Boschert KJ, Kudsk KA, et al. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition 2002;18: Answer A: Famotidine 20 mg intravenously once daily. The patient meets criteria for stress ulcer prophylaxis because she is expected to be intubated for 48 hours (Answer B). The safest, most evidence-based and cost-effective therapy is famotidine (Answer A). Sucralfate has been shown to be inferior to histamine receptor antagonists in clinical trials (Answer C). PPIs, although commonly used, have less data than histamine receptor antagonists for the prevention of stress-related mucosal disease and carry additional side effects and higher costs (Answer D). 11. Answer C: Anion gap metabolic acidosis. The patient presents with a primary metabolic acidosis (lactic acidosis) and an anion gap of 22 (133 [ ]) (Answer C). 3

4 i. Berend K, de Vries AP, Gans RO. Physiological approach to assessment of acid base disturbances. N Engl J Med 2014;371: Answer A: 1000 ml lactated Ringer s intravenous bolus. The patient has vasodilatory shock (septic shock) and requires volume resuscitation before vasopressor initiation (Answer D). Hydroxyethyl starch has been shown to increase mortality in sepsis and is not recommended (Answer B). There is no evidence that colloids are any more efficacious that crystalloids, and they are more expensive (Answer C). The Surviving Sepsis Guidelines recommend initial resuscitation with crystalloids, and recent evidence supports the use of balanced solutions such as lactated Ringer s (Answer A). s i. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350: ii. Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA 2013;309(7): iii. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: Crit Care Med 2013;41: Answer D: Heparin 5000 units subcutaneously twice daily. The patient is at high risk of VTE because of limited mobility, sepsis, and advanced age. Mechanical prophylaxis alone is not sufficient in high-risk patients (Answer C). Fondaparinux is contraindicated in patients with a CrCl less than 30 ml/minute (Answer A). Although there are recommendations for enoxaparin in patients with a CrCl less than 30 ml/minute, this dose (40 mg) is too high for the patient s estimated CrCl (Answer B), and low-dose subcutaneous heparin would be a safer option (Answer D). s i. Guyatt GH, Akl EA, Crowther DD, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 suppl):7s-47s. ii. Nutescu EA. Assessing, preventing, and treating venous thromboembolism: evidencebased approaches. Am J Health Syst Pharm 2007;64(suppl 7): Answer B: Start quetiapine 25 mg twice daily. The patient s confusion and agitation are caused by ICU delirium. In this situation, precipitating medications, such as lorazepam, should be avoided (Answer D). Even though dexmedetomidine is associated with a lower incidence of delirium when used for sedation, there are no data on the treatment of delirium with dexmedetomidine (Answer A). The patient is not aggressive or dangerous, so acute treatment with intravenous haloperidol would not be indicated (Answer C). Quetiapine has been shown to decrease the duration of delirium in critically ill patients and can be safely given orally (Answer B). 4

5 i. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41: