Table of Contents

The college describes a non-inferiority trial as "an active control trial which tests whether an experimental treatment is not worse than the control treatment by more than a specified margin". This is almost exactly the first sentence of an excellent article by Steven Snapinn (2000), which is therefore the most sensible single reference to be recommended to time-poor exam candidates. The college question also asked for details of why one might run a non-inferiority trial, and what the limitations of such a trial might be. The objective of this chapter is to render this difficult topic into small chunks for easy storage, for the 95.9% of exam candidates who couldn't answer Question 24 in the second paper of 2018.

To the extreme distress of many candidates, the TEG had come up recently in Question 26 from the second paper of 2014, and again in Question 8 from the second paper of 2015. The best summary to guide the time-poor candidate can be found (as always) at the Practical Haemostasis website. The LITFL TEG/ROTEM page is also an excellent balance between detail and brevity. The aim of this chapter is not to supersede these outstanding resources, but rather to act as a footnote for them, and to expand on key issues in a way which renders this complex topic easily understood by somebody who has not slept or eaten for some days.

DVT is common among ICU patients, and no matter how you measure DVT risk, ICU patients always end up in the highest risk category. They are also usually in the higher risk category for bleeding complications, which makes things interesting. The management of DVT in this group consists of anticoagulation and - if the situation calls for it- thrombolysis or clot retrieval.

Question 2 from the first paper of 2003 and Question 10 from the first paper of 2010 discuss thromboprophylaxis in the ICU. One question was a straightforward "critically evaluate" piece, and the other was related more to the setting of neurotrauma. The delicate issue of giving chemical anticoagulants to somebody who has bled into the brain is discussed in the separate chapter on thromboprophylaxis in neurosurgical patients. The summary below is derived largely from the excellent LITFL page on this subject, as well as from a nice recent article (Boonyawat and Crowther, 2015).

In the field of airway management, no topic is more divisive than the merits of videolaryngoscopy. Proponents defend the technology and opponents assail it with equally valid arguments, and the differences in opinion are not purely ideological. These devices have their advantages and disadvantages. Videolaryngoscopes may be making things easier, but they are expensive, and there is concern regarding the loss of airway skills.

Question 21.3 from the first paper of 2015 presents us with a story of a foreign sailor who was found unconscious. Immediately a sour flavour of intoxication and despair permeates through the case scenario. Prior to his descent into coma, he complained of visual disturbance. A "snowstorm", you might wonder. A gas is then offered, and the high anion gap found therein helps to form the impression of a methanol overdose. Toxic alcohols receive a more enthusiastic treatment elsewhere (Methanol and the other toxic alcohols, from the Acid-Base Disturbances collection of notes). This brief revision chapter is focused on answering CICM SAQs on toxic alcohol ingestion, or wherever a high anion gap metabolic acidosis raises such a differential.

CICM fellowship SAQs about this topic are generally of two varieties. Most recent SAQs are short, worth little in terms of marks, and satisfied by the candidate merely identifying the disorder as a metabolic alkalosis, or possibly throwing around a few differentials. Most older SAQs trend to the thoughtfully physician-like answer, asking the candidate to articulate their approach to diagnosis of metabolic alkalosis.

In order to be decannulated successfully, the reason for the tracheostomy needs to have resolved, and the patient must meet certain criteria. They must have a patent upper airway, they must have a manageable amount of secretions and the neuromuscular capacity to clear them, their level of consciousness must be sufficient to permit cooperation with care, and their oxygen requirements should not be high. Following decannulation, the stoma is expected to close slowly, over the course of about one week.