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.
8 Acute Respiratory Failure and Mechanical Ventilation
Adrian A. Maung, MD1 and Lewis J. Kaplan, MD2,3
1 Yale School of Medicine, New Haven, CT, USA
2 Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
3 Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
1 A 73‐year‐old woman is admitted to the intensive care unit after undergoing exploratory laparotomy and subtotal colectomy for C. diff colitis. Her past medical history is significant for smoking and clinically severe obesity with BMI 44.6 (height 160 cm, and weight 114 kg). She is hypotensive on a norepinephrine drip and mechanically ventilated on assist control volume mode of ventilation. The most appropriate initial tidal volume setting is:1100 mL684 mL312 mL520 mL912 mLThe patient is at risk for developing acute respiratory distress syndrome based on her clinical condition as well as risk factors of smoking and morbid obesity. Low tidal volume ventilation, as described by ARDSnet, was the first intervention demonstrated to improve mortality in those with ARDS. Initial tidal volumes should be set at 6–8 mL/kg based on predicted (ideal) body weight. Based on the patient’s height 160 cm, her predicted body weight is 52 kg thus answer C is the correct choice. Choice A is based on 10 mL/kg and actual weight. Choice B is 6 mL/kg but based on actual weight. Choice D is based on 10 mL/kg and ideal body weight and Choice E is 8 mL/kg and actual body weight.Answer: CBrower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000; 342(18):1301–1308Khan YA and Ferguson ND . What is the Best Mechanical Ventilation Strategy in ARDS in Evidence‐Based Practice of Critical Care , 3rd Edition Elsevier 2020.
2 48‐year‐old man has acute respiratory failure after a motorcycle crash. He is on low tidal volume, high PEEP ventilation with FiO2 100% and his PaO2 is 50 mm Hg. He is started on inhaled nitric oxide (NO). Based on the current evidence, the role of NO in acute respiratory failure is best characterized as:decreased mortality.improved oxygenation but not mortalitydecreased rate of acute kidney injuryNO has no effect on oxygenationroutine ARDS managementCurrent clinical evidence does not support a role for inhaled NO in the routine management of ARDS. Although inhaled NO may improve oxygenation, it has not been shown to improve mortality (Answer B). NO has also been associated with increased rates of acute kidney injury.Answer: BGebistorf F, Karam O, Wetterslev J, et al. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev. 2016;(6):CD002787.Ruan SY, Huang TM, Wu HY, et al. Inhaled nitric oxide therapy and risk for renal dysfunction: a systematic review and meta‐analysis of randomized trials. Crit Care. 2015; 19:137.
3 27‐year‐old man with ARDS after debridement for necrotizing soft tissue infection of the perineum has worsening hypoxemia with PaO2 90 mm Hg on 90% FiO2 despite optimal low tidal volume ventilator settings and neuromuscular blockade. The next most appropriate step in his management would be: Inhaled nitric oxideHigh dose steroidsECMO rescueProne positioningContinue current management and start prone positioning if there is no improvement after 72 hours.Clinical evidence supports the use of early prone positioning in patients with severe ARDS (answer D). The PROSEVA trial published in 2013 demonstrated an improved 28‐day mortality with 16 hours of prone positioning per day (16% in the prone group vs 32.8% in control group). Most of the research has focused on early rather than a rescue role for severe ARDS and therefore waiting for 72 hours (choice E) would not be appropriate. Inhaled nitric oxide (choice A) has not been associated with improved outcomes. ECMO (choice C) has a role in the management of refractory hypoxemia but would not be the next step in the management of this patient. The role of early steroids remains controversial but there is no benefit to late (after 14 days) (choice B) steroid administrationAnswer: DGuérin C and Reignier J . PROSEVA study group. “Prone positioning in severe acute respiratory distress syndrome”. N Engl J Med. 2013; 368(23):2159–68. PMID: 23688302.Guérin C, Albert RK, Beitler J, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med. 2020; 46(12):2385–2396. Epub 2020 Nov 10. PMID: 33169218; PMCID: PMC7652705.
4 56‐year‐old woman who was initially admitted with necrotizing pancreatitis develops acute respiratory distress and hypotension. She is intubated and admitted to the intensive care unit. Over the next 24 hours, she is given 10 L of crystalloid for persistent hypotension and oliguria. She is on assist control volume‐cycled ventilation (tidal volume 6 mL/kg, FIO2 30%, PEEP of 5) with an SpO2 of 98%. The ventilator is alarming for high pressure. Measurement of the pressures reveals a high peak airway pressure and a normal plateau pressure. The next step in management would be to:Decompressive laparotomy for abdominal compartment syndromeNeuromuscular blockade by continuous infusionChange to pressure support ventilation modeAdjust the ventilator alarm settings thresholdsInhaled bronchodilator therapyElevated airway pressure can occur secondary to different pathologies that affect
