Accp-Seek: Assessment in Critical Care and Pulmonology- Self-Education and Evaluation of Knowledge, Vol. 22: Critical Care Medicine

278 Pages·2012·423.295 MB·English

by  American College of Chest Physicians

ACCP-SEEK
CRITICAL CARE MEDICINE
Assessment in Critical Care and Pulmonology
Self-Education and Evaluation of Knowledge
Volume
XXII
AfvIERCICAHN CEOLLSEGE'rOF
ACCP-SEEK
CRITICAL CARE MEDICINE
Assessment in Critical Care and Pulmonology
Self-Education and Evaluation of Knowledge
Volume
XXII
AMERCICAHN CEOLLSEGETOF
TheAmericanCoIIegeofChestPhysicians ("ACCP") anditsofficers,
rcgcnts, cxccutivecommitteemembers,members,relatedentities, employees,
representatives,andotheragents (collectively,"ACCPParties') arenot
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cmploycddrug.
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-
0 2012 by the American College of Chesi Physicians
ISBN
978-0-916609-11-5
Allrightsreserved.Nopariofthispublicationmaybereproduced,storedin
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li
Table of Contents
ACCP-SEEf Volume XUI.. Critical Care Mediczne Editorial Board.......................... .iv
Chair and Vice-Chair Biogr2phies...........-..-.-.
ContinuingMedicalEducation. .vi
Product Dcscription ......-.-.-.. .vi
Goals...... .vi
Learning Objectives..... .vi
Financial .vii
Disclosure..............
Abbreviations . .viii
Study
QUeStiOnS...................
Response Key, Rationale, and References.... 101
Laboratory Reference Values......... .257
KeyWOrdS Index................. .267
ACCP_SEEKO Volume XXII: Critical Care Medicine Editorial Board
CurtisN. Sessler,MD, FCCP-ChAir,Editorin Chief JosephE. Parrillo,MD, FCCP-Vice-ChLzir, DeputyEditor
Professor of Medicine
OrhanMurcnProfc550rofMedicine
DivisionofPulmonaryandCriiicalCareMedicine RobertWoodJohnsonMedicalSchool
UniversiryofMedicineandDencistryofNewJersey
Director, CenicrforAdultCriticalCare
ProfessorandChairman, DepartmentofMedicine
MedicalCollegeofVirginiaHospitals
CooperMedicalSchoolofRowanUniversi
VirginiaCommonwcalihUniversiryHealthSystem
Chief, DepartmentofMedicine
Richmond,VA
EdwardD.Viner,MD,Chair, DeparimentofMedicine
CooperUniversiryHospital
Camden,NJ
COLLisaK.Moores, MC,USA, FCCP
MichaelH. Baumann,MD,MS, FCCP
AssistantDeanforClinicalSciences
ChiefQualiryOfficer
Professor of Medicine
ProfessorofMedicine
TheUniformedServicesUniversiryoftheHealthSciences
UniversityofMississippiMedicalCenter
DivisionofPulmonary,CriticalCare, andSleepMedicine Bethesda,MD
Pulmonary, CriticalCare,andSleepMedicineService
Jackson,MS
WallerReedNaiionalMiliiaryMedicalCenter
DavidL. Bowton,MD,FCCP Washington,DC
Professor2ndHead, SectiononCriticalCare
LTC(P)AlexanderS.Niven,MC,USA, FCCP
DepartmentofAnesthesiology
Associate Professor of Medicine
WakeForesiUniversirySchoolofMedicine
TheUniformedServicesUniversiryoftheHealthSciences
Winston-Salem,NC
Bethesda,MD
ProgramDirecror, InternalMedicine
FredricL. Ginsberg,MD, FCCP
AssistantProfessorofMedicine MadiganHealthcareSystem
CooperMedicalSchoolofRowanUniversiry Tacoma,WA
Director, HeartFailureProgram
PaulM.Palevsky, MD,FCCP
Director,NuclearCardiology
Chief,RenalSection
CooperUniversiryHospital
VA Pittsburgh Healthcare System
Camden,NJ
ProfessorofMedicineandClinicalandTranslationalScience
RonaldF. Grossman,MD, FCCP UniversiryofPittsburghSchoolOFMedicine
ProfessorofMedicine,Universiryot-'foronto Piitsburgh,PA
Respirologisi,CreditValleyHospital
ChristianE. Sandrock, MD,MPH,FCCP
Mississauga,ON,Canada
Associare Professor of Medicine
MedicalDirecior,ICU
JesseB. H211,MD,FCCP
ProfessorofMedicine,Anesthesia, andCriticalCare DivisionofInfectiousDiseases
DivisionofPulmonaryandCriticalCare
TheUniversiryofChicago
UCDavisSchoolofMcdicine
PritzkerSchoolofMedicinc
HcalthOfficer,YoloCounty
Chicago,IL
State OF California
StephanieM.Levine,MD, FCCP Davis, CA
ProfessorofMedicine
DivisionofPulmonaryandCritlC21CareMedicine Gregor},A.Schmidt,MD, FCCP
Professor,DivisionofPulmonary,CriticalCare, and
Director,PulmonaryandCriticalCareTrainingProgram
Universiry of Texas Health Science Center - San Antonio OccupationalMedicine
DepartmentofInternalMedicine
SanAntonio,TX
UniversiryofIowa
NeilR.M2cInryre,MD, FCCP IowaCiry,LA
ProfessorofMedicine
DivisionofPulmonaryandCriticalCareMedicine ArthurP.Wheeler, MD, FCCP
AssociateProfessorofMedicine
DukeUniversiryMedicdCenrer
Division of Allergy, Pulmonary, and Critical Care
Durham,NC
Director,MedicalIntensiveCare
Vanderbilt Universiry
Nashville,TN
iv
Curtis N. Sessler, MD, FCCP Joseph E. Parrillo, MD, FCCP
CurtisN. Sessler, MD, FCCP, istheOrhanMurenProfessor JosephE. Parrillo, MD, FCCP, isProfessorofMedicineand
Chairman, DepartmentofMedicine, CooperMedicalSchool
-IledicineatVirginiaCommonwealthUniversiry (VCU)
ofRow2nUniversiry; Chief, DepartmentofMedicine, Edward
kkalthSystcmintheDivisionofPulmonaryandCritical
D.Viner, MD, Chair,DepartmentofMedicine" andDirector,
c�teMedicine. Dr. Sessleris DirectoroftheCenterforAdult
Ciiic21Care, aswellasMedicalDirectorofCritic21Careand CooperHeartInstitute, CooperUniversityHospital, in
.Iledical Respiratory ICU at the Medical College of Virginia Camden,NewJersey. Dr. Parrilloisboard-certifiedininternal
medicine, allergyandimmunology, cardiovasculardisease, and
iials of VCU.
criticalcaremedicine.
ed
Scsslerisanenthusiasticclinicianandeducatorwhohas
Dr. Parrillo has authored or coauthored more than 1,030
knl avarietyofteachingawardsatVCU, includingthe
ofMedicineEducationalInnovationAward. Dr. Sessler manuscripis,chapters, reviews,editorials, books, andabstracts.
ledagroup thatdevelopedandvalidatedtheRichmond Hismajorareasofinterestarecardiacfunctioninsepsis,
-Iu2tion-Sedation Scale. Hehaspublishedmorethan 300 cardiovascularperformanceinshock, pathogenesisand
treatmentofseveredilatedcardiomyopathy, myocarditis, and
book ch2Pters, books, 2b,st.r2cts, and CDS on topics
iDdudeICUsedation, mechanicalventilation,procedural thecriiicallyillcardiovascularpatient. Dr. Parrillo is apast
rytency) andinfectioncontrol. Hehas alsoservedona presidentoftheSocieryofCritical CareMedicine (SCCM)
of multisociery task forces addressing research, training andhasservedaseditor-in-chiefofCriticalCareMedicine
since 1996. Additionally, he is the editor of one of the major
£llEwency,workforceshortage, andreimbursement. He
PresidentoftheVirginiaThoracicSocieryandhas standardiextbooks, CritlcalCareMedicine..Diagnosisand
on sevcral committees for the US Food and Drug ManagementintheAdult.
oEM�[�li0n, includingservingaschairofthePulmonary
Dr. ParrillohasservedontheAmerican BoardofInternal
-41kryDrugAdvisoryCommittee.
MedicineTestandPolicyCommiiiee,writingtheceriifying
knler is an active member of the ACCP. He has served examinationsincritlc21caremedicine.AttheACCP,
PKMrd of Regents 2nd as Chair of Ihe Critical Care Dr. Parrillohasservedonthe CHESTeditorialboardandas
Chair of thc Council of Sections, Chair of the Critical 2memberoftheACCP PraciiceManagementCommittee.
5titute, andProgramChairforIhe2003 CHEST In February 2012, Dr. Parrillo received the SCCM Lifetime
eeting. Hereceivedthe RogerC. BoneMemorial AchievementAwardinrecognitionofhisextraordinary
contributionsto thefieldofcriticalcare.
Tandd in 201 O. He is 2 member of the ediiorial board
isseciionco~editorforContemporaryReviews
, tsx31 Care Medicine. This is his I Ith year serving on the
Ix)ardofthecriticalcareandpulmonarymedicine
ot ACCP-SEEK.
Continuing Medical Education If you have questions, send an e-mail to [email protected]
orcalltheCMEverificationmailboxat [phone]for
TheAssessmentinCriticalCareandPulmonologySelf-
support.
EducaiionandEvaluationofKnowlcdgc (ACCP-SEEK) is
aself-studyopportuniryavailableasaprintedmonograph This volume of ACCP-SEEK was made available in August
2ndan iPad° oriPhone° applicationforpulmonary, critical 2012. The CME for this product is valid through December
care, andsleep medicinephysiciansandfelIows-in-training. 31, 2014.
It fulfills an educ2tion21 need by providing the12test advances
inpulmonary) criiical care,andsleepmedicineposedto ProductDescription
thelearneras case-basedquestionsonavarietyofdiseases,
proccdurcs, and disordcrs. ThcAmericanCollcgcofChest ACCP-SEEKisdesignedto stimulateandchallenge
Physicians (ACCP) hasidentifiedaneducationalneedto chelearners clinicalIhoughtprocessesregardingrecall,
updateandreviewexisiingknowledgeandskills, presentnew interpretation, andproblem-solvingskills. Thecase-based
information, andprovideapreparationtoolforphysicians questionscontainhistories, laboratoryresults, andimages,
preparingforboardexaminaiions. Eachquestionshouldtake 2ndtheyprovide education concerningcurrentdiagnosticand
treatment strategies. Each volume of ACCP-SEEK contains
Ih¢ user approximately 15 to 20 minutes to review thoroughly,
researchtheappropriateresponse, identifythecorresponding newquestions, answers, andrationales, inadditiontoselections
correctresponse, andreviewthcrationaleforthecorrect fromthepreviousvolumesconsideredbytheeditorsto be
andincorrectanswerchoices.ACCP-SEEie VolumeXUI.. amongthebest-designedandbest-writtenicems. Therationales
Critic¢zI CAre Medicine contains 180 questions in the book and providethoroughexplanationsandreasoningforthecorrect
20 questionsasanonlineposttestassessmenttoobtainthe andincorrectanswers. TheACCP-SEEKseriesisusedmost
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incertifyingandrecertifyinginpulmonary, criticatcare, and
TheACCPisaccrediiedbytheAccrediiationCouncilfor sleep subspecialties.
ContinuingMedicalEducationtoprovidecontinuingmedical
Goals
educationforphysicians.
ThegoalsoftheACCP-SEEKprogramareasfollows:
TheACCPdesignatesthisenduringmaierialforamaxtmum
of50AMAPRA Category I CreJzts . Physicians shoLdd Provideaself-assessmentprogramforpracticingspecialists
claimonlythecreditcommensuratewiththeextenioftheir
inpulmonary, criticalcare, andsleepmedicinedesignedto
participationintheactivity. ThisproductfulfillsACCP reinforcetrainingandexperience, disseminaieimportantnew
Learning Category IV- Case- and Problem-Based Learning.
knowledgeinthefields, andidentifyareasofstrengthsand
weaknesseswithinspecific2reasofdiseaseand/orprocedural
ToobtainyourCMEcertificate,youwillneedtoenieraCME
knowledge.
access codc.Youmayobtaintheaccesscodebysuccessfully
completingtheposttestassessmentavailableodineatwww.
Assistthepracticingspecialistandindividuat-in-training
chestnet.org/seek22posttesi.
withpreparingforcertification andrecertificationexaminations
sponsoredbythemedicalspecialryboard.
Afteryouhavesuccessfullycompletedtheposttestactivityand
obtainedtheCMEaccesscode, followthestepsbelow:
Learning Objectives
l. Visit www.chestnet.org. Click on the "Claim CME" link at Bycompletingthequestions, reviewingtherationales, and
thetop ofthepage. Then clickthe"CMECertificates button completingtheposttestassessment, partlclP2ntsshouldbe
attherightside ofthepage. ableto:
2. EnteryourACCPidentificationnumberore-mailaddress l. Facilitate self-directed learning efforts, targeting content
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3. IfyoupurchasedtheproducifromtheACCPwebsite, click
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vi
Financial Disclosure NeilR. MacInryre, MD, FCCP
Universitygrantmonies: NationalInstitutes ofHealth (ARDS
ThcAmcricanCollcgcofChc5tPhysicians (ACCP) remains
Network, LOTTstudy)
stronglycommiitedtoprovidingthebestavailableevidence-
Consultantfee: CareFusion, Breathe,Trudell
basedclinicalinformationto pariicipantsofthiseducational
Speakerbureau: ForestPharmaceuiicaLs
activityandrequires an opendisclosureofanypotential
confliciofinicrc51idcntificdbyourcommittccmembers. It PaulM. Palevsky,MD, FCCP
isnottheintentoftheACCPto eliminateallsituationsof Grant monies (from industry-related sources): Spectr21
potentialconflictofinterest, butraiher10enable thosewhoare Diagnostics
workingwiththeACCP torecognizesituationsthatmaybe
Consultantfee:sanofi-aventis
subjectto questionbyothers.AlldisclosedconflictsOFinterest Advisorycommittee: CytoPheryK
arcrcviewcdbyIhccducationalactivitycoursedirector/chair,
theEducationCommittee, ortheConfiictofInterestReview JosephE. Parrillo, MD, FCCP
Commiitceto ensurcthatsuchsituationsarcproperlyevaluated Universirygrantmonies: Salem HealthandWellness
and, ifnecessary, resolved. TheACCPeducationalstandards Foundation
pertainingto conflictofinteresiareintendedtomaintain Consultantfee: DataandSafetyMonitoringBoardand
theprofessionalautonomyoftheclinicalexpertsinherent ProtocolReviewCommitteefortheClinicalHeartFailure
inpromotingabalancedpresentationofscience.Through ResearchNetworkoftheNationalHeart, Lung, andBlood
ourreviewprocess, allACCP CMEactivitiesareensuredof Institute
independent, objective, scientifically balanced information. Advisorycommitcee: Sangart;Artisan; CycoSorbents
Di5closurcofanyornorclationships ismadeavailableforall
educational activities. ChristianE. Sandrock,MD, MPH, FCCP
Grant monies (from sources other than industry): Centers for
The following editorial board members of ACCP-SEEf DiseaseControl, NationalInstitutes ofHealth
VolumeXVI.. CriticalCareMedicznehavedisclosedtothe Consultantfee: Pfizer, Estellas
ACCP thatarelationship doesexistwiththerespective Speakerbureau: Pfizer, Estallas
company/organizationasitrelates 10 theirquesiioncontent Advisorycommittee= Pfizer
materialandshouldbecommunicatedtotheparticipantsof
thiseducationalactivity: GregoryA. Schmidt,MD, FCCP
Grant monies (from indusiry-re12ted sources): Agennix
DavidL. Bowton, MD, FCCP (tatactoferrin); Altor Bioscience (ALT-836); Spectral
Grant monies (from sources other than industry): Nationat Di2gnostics (endotoxinassay)
Insticutes ofHe21th/NationalInstituteonAging Advisorycommittee:AgencyforHealthcareResearchand
Grant monies (from industry-related sources): Covidien Qualiry(regardingprocalcitonin)
RonaldF. Grossman, MD, FCCP ArthurP.Wheeler, MD, FCCP
Grant monies (from industry-related sources): Universirygrantmonies: Eli Lilly
GlaxoSmithKline,Novartis Shareholder: CumberlandPharmaceuticals
G)nsultantfee: GlaxoSmithKline, Novariis, Nycomed,Abbott,
leick, Bayer The following editori21 board members of ACCP-SEEf
5ftherbureau: GlaxoSmithKline, Novartis,Nycomed,Abboti, VolumeXUI.. CriticalCareMedicinehaveindicatedto the
lerck, Bayer ACCPIhatnopotenrialconflictofinterestexistswith
-4dvisoryCommittee: GlaxoSmithKline, Novartis, Nycomed, anyrespectivecompany/organization, andthisshouldbe
-4btK)11, Mcrck, Baycr communicated to theparticipantsofthiseduc2tion21 activity:
B. Hall, MD, FCCP Michael H. Baumann, MD, MS, FCCP
Grant monies (from sources other than indusiry): National FredricL. Ginsberg, MD, FCCP
InstituiesofHealihP50 Grantsuppori StephanieM. Levine,MD, FCCP
knholder:Vanguard HealthCaremutualFund COLLisaK. Moores, MC, USA, FCCP
Fxluci2ryposiiion: BoardofDirectors,Amcric2nThoracic LTC(P)AlexanderS. Niven, MC, USA, FCCP
CurtisN. Sessler, MD, FCCP
Abbreviations
-
AAC - acuteacalculouscholecystitis HELLP = hemolysis, elevated liver enzymes, low plaielet
ACE angioiensin-convertingcnzymc count
-
ACLS advancedcardiovascularlifesupport HIT = heparin-induced thrombocytopenia
ACS - acuie coronary syndrome HLA = human leukocyte antigen
ACTH = adrenocorticotropichormone HME = human monocytotropic ehrlichiosis
ADH = aniidiurctichormone HPA = hypothalamic-pituitary-adrenal (axis)
ADHF = acutedecompensatedheartfailure HPF = high-power field
AG = aniongap HSV = herpes simplex virus
AGB = antiglomerularbasementmembrane HSV- I herpes simplex virus I
AHF = acuteheartfailure HTG = hypertriglyceridemia
AIP = acute interstitial pneumonia HUS hemolyiic uremic syndrome
AKI = acutekidneyinjury inspiratoryto expiratoryratio
alanineaminoiransferase IABP = intraaorticballoonpump
ANCA = antineutrophilcytoplasmicantibody IAP = iniraabdominalpressure
APRV= airwaypressure releaseventilation ICD = implantable cardioverter-defibrillator
aPTT = activatedpartialthromboplastintime ICH = intracerebral hemorrhage
ARB = angioiensin receptor blocker ICP = intracranial pressure
ASA = acetylsalicylicacid IHD = intermittent hemodialysis
AST = aspartateaminotransferase IIT = intensive insulin therapy
-
ASV adaptivesupportventilation INR = internationalnormalizedratio
ATPase = adenosinetriphosphatase IVC = inferiorvenacava
AUC = areaunderthecurve LAD = left anterior descending (coronary artery)
AV = atrioventricular LPL = lipoprotein lipase
BNP = B-rype natriuretic peptide LV = left ventricular
-
CABG coronaryarterybypassgraft LVAD = left ventricular assist device
CACP = cocaine-associatedchestpain microangiopathichemolyticanemia
CAG = correctedaniongap MAO = monoamineoxidase
CAP = communiry-acquiredpneumonia MAP = mean arterialpressure
CCB = calciumchannelblocker MH = malignanthyperthermia
CDAD = Clostridium difficile-associated diarrhea MIC = minimuminhibitoryconcentration
CK = creatinekinase MIC,, minimuminhibiioryconcentrationrequiredto
CI-AKI = contrast-induced2CUtekidneyinjury inhibit growth of 90 % of organisms
CKD = chronickidneydisease MRSA = meihicillin-resistant Staphylococcus aureus
CLD = clinicallaboratorydevice NAC = N-acetylcysteine
CMV = cytomegalovirus NAVA = neurally adjusted ventilatory assist
CPK = creatinephosphokinase NIHSS = National Institutes of Health Stroke Scale
CRBSI = catheter-relatedbloodstreaminfection NIPPV = noninvasivepositivepressureveniilacion
CRRT = continuousrenalreplacementtherapy NIV= noninvasiveventilation
CSF = cerebrospinal fluid NMBA= neuromuscularblockingagent
CVP = centralvenouspressure NMS = neurolepticmalignantsyndrome
DIC = disseminated intravascular coagulation NO = nitricoxide
DM-PM dermatomyositis-polymyositis NS = normalsaline
ECLS = extracorporeal life support NSM = neurogenicstunnedmyocardium
EEE = easternequincencephalitis NSTEMI = non-ST-segmentelevationmyocardialinfarction
EF = ejection fraction ODS = osmoticdemyelinationsyndrome
-
EGD =- esophagogastroduodenoscopy OSA obstructivesleep apnea
EMB endomyocardialbiopsy PA = pulmonary artery
EP = electrophysiology PAC = pulmonary artery catheter
ERCP = endoscopic retrograde cholangiopancreatography PACV = pressure assist-control ventilation
ESBL = extended-spectrum F-laciamase PAH = pulmonary arterial hypertension
-
EVR endovascularrepair PAOP = pulmonary artery occlusion pressure
FFP freshfrozenplasma PAV = proportional assist ventilation
FLAIR = fluid-attenuated inversion recovery PCI = percutaneous coronary intervention
FPP familiaIperiodicparalysis PD = pharmacodynamic
GBM = glomerularbasementmembrane PE = pulmonary embolism
GDH glucosedehydrogenase PEA = pulseless electrical activity
HEE = humanewingiiehrlichiosis PF4 - platelet factor 4
viii
PK - pharmacokineti SIADH = syndromeofinappropriatesecretionof
PMV = prolonged mechanical ventilation antidiuretichormone
POC - point of care SIMV = synchronizedintermittentmandatoryventilation
POPE = postobstructive pulmonary edema Sjvo, jugular venous oxygen saruration
PPI protonpump inhibitor ss serotonin syndrome
PQQ = pyrroloquinoline quinone SSRI = seleciiveserotoninreuptakeinhibitor
-
PRBC packedRBCS STEMI = ST-segment elevation myoc2rdial infarction
PRIS propofolinfusionsyndrome SVC = superiorvenacava
PRVC - pressure-regulated volume control SVR = systemicvascularresistance
PSE = porio-systcmic cncephalopaihy TBSA = totalbodysurfacearea
PT - prothrombin time TBW = totalbodywater
PVCM = paradoxicalvocal cordmotion TCA = tricyclicantidepressant
PVR = pulmonary vascular resistance TIPS = transjugular intrahepatic portosystemic shunt
renin-angioien5in-aldosterone systcm TNF = tumornecrosisfactor
-
RCe expiratorytimeconstant tPA = tissue plasminogen activator
RFST = rapidfour-step technique TPE = therapeutic plasma exchange
RMSF = RockyMountainspottedfever TPP = thyrotoxic periodic paralysis
ROSC = returnofspontaneous circulation TTP = thrombotic thrombocytopenic purpur2
RRT = renal replacementIherapy TXA = tranexamicacid
RSV= respiratorysyncytialvirus VACV = volume assist-control ventilation
rtPA = recombinant tlssue plasminogen activator VAP - ventilator-associated pneumonia
SAH = subarachnoidhemorrhage oxygenconsumption
SBT = spontaneous breathing trial WEE = westernequineencephalitisvirus
SCLC = smallcelllungcancer WNV = WestNilevirus
Scvo, centralvenous oxygensaturation WPW = Wolff-Parkinson-White (syndrome)