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