This bread-and-butter ICU topic has appeared in the exams many times. The most thorough exploration was afforded by Questions 2a, 2b, 2c and 2d from the second paper of 2003. Question 26 from the first paper of 2006 asks again about specific features of history which would be important, and Question 18 from the first paper of 2012 discusses antibiotic management and prognostic issues. Question 7 from the second paper of 2012 looks indepth at the causes of treatment failure, and the investigations for treatment-refractory pneumonia.
>Pneumocystis are unicellular fungi that survive in most adult human lungs as obligate intracellular parasites, causing no disease. They are opportunistic pathogens that affect mostly the immunocompromised host. Diagnosis depends on microscopy and PCR of deep lung samples, as this organism cannot be cultured.
This collection of trials and guidelines about gastroenterology and hepatology has also ended up with all of general surgery in it, because there was nowhere else to put it. It is separated into "liver stuff", "gut stuff" and "general abdominal surgical stuff"as these are the broad categories into which the material has seemingly organised itself. The CICM Second Part exam candidate will always be at risk of being expected to know about these common problems.
This chapter deals with the investigations and resuscitation of massive gastrointestinal bleeding. For the purposes of having a firm definition, anything below the ligament of Treitz is taken as the "lower" tract. In terms of relevance for the CICM fellowship, massive GI bleeding is probably not a high-yield subject matter (even though it forms a major part of our daily workload). Historically, it has appeared in several SAQs. Question 1 from the first paper of 2017 was all about the causes and management of a massive variceal haemorrhage. The much older Question 1a and Question 1b from the second paper of 2001 also offered us an exsanguinating alcoholic, but the real fun began when in the last part of the SAQ the wife asked whether he was going to survive (see Staging and prognosis of chronic liver disease in ICU).
The femoral vein lies within the femoral triangle. The superior border of the triangle is formed by the inguinal ligament. The medial border is formed by the adductor longus, and the lateral border by the sartorius muscle. The apex is formed by the sartorius crossing the adductor longus muscle. The roof is composed of the skin, subcutaneous tissue, the cribriform fascia, and the fascia lata.The floor is formed of underlying adductor longus, adductor brevis, pectineus, and iliopsoas muscles. Lateral to the femoral vein is the femoral artery in a fibrous sheath. Medial to the femoral vein is the fatty lymphatic contents of the femoral sheath.
Neuromuscular junction blockers act by depolarising and inactivating the motor endplate, or by competitive antagonism of acetylcholine. They are a group of small molecules which are generally highly water soluble, poorly protein bound and generally unstable (breaking down spontaneously). Most of them are cleared by a combination of renal and hepatic mechanisms. The speed of onset of these agents is inversely proportional to their potency.
Complications of tracheostomy can be separated into immediate, early and late. Of the immediate complications, several are unique to the percutaneous technique. Early complications consist mainly of tube blockages and dislodgement; in the long term damage to the trachea and erosion through its walls become the dominant complications.
Hand washing in the ICU is one of those basic things which we never expect to be asked about. It falls into the spectrum of Strategies to Prevent the Transmission of Multi-resistant Organisms, and the scientific foundations of this topic are discussed elsewhere. There, the reasons for hand washing and PPE are explored in some depth. This chapter is more about the administrative and bureaucratic aspects of implementing hygiene and infection control measures. The college examiners love that stuff, as they are often directors of units for whom hand hygiene is an important part of routine quality assurance. As a junior staff specialist or post graduate fellow, the exam candidate is expected to demonstrate a keen interest in this tedious business.
>Legionella are Gram-negative aerobic intracellular parasites who mistake your macrophages for their normal hosts, freshwater amoebae. Legionella creates a syndrome including an "atypical" pneumonia and which has many systemic manifestations ranging all the way to multiorgan system failure.
Having your blood pumped artificially in a non-pulsatile fashion is a perverse physiological state which results in a series of post-operative problems. This chapter focuses on the complications of cardiopulmonary bypass which occur in the context of coronary artery bypass graft surgery.
The general question "why is this patient passing no urine" comes up rather frequently. The ADQI definition of oliguria is a urine output less than 0.3 mL/kg per hour for at least 24 hours. In brief, the causes are decreased intravascular volume (thus decreased renal perfusion), decreased renal perfusion with normal volume (eg. sepsis or other sorts of distributive shock), renal vascular insufficiency (including microvascular vasoconstriction, eg. by ACE-inhibitors), acute tubular necrosis and mechanical urinary tract obstruction.
The idea behind these is that there may be a benefit in summing up all the evidence from several similar trials, analysing all of it together. This way, as the sample numbers grow, more subtle treatment effects may surface (because smaller trials may have been underpowered and thus many type 2 errors may have been committed).
However, the statistical analysis of the evidence in a meta-analysis of trials can occasionally produce results which contradict the actual trials. One is left wondering: which methodology is flawed? Whose statistics are faulty?
Until Question 8 from the second paper of 2023 this topic had never been a CICM SAQ. This "storm" concept has no fixed scientific definition. VT storm can be managed with drugs, of which the first line agents are amiodarone, lignocaine and beta-blockers. Second line drug therapy may include phenytoin and other class 1 agents like mexilitine. Cardioversion and overdrive pacing are valid options. Lastly, one may resort to stellate ganglion blockade, thoracic epidural, and radiofrequency ablation. Invasive surgical procedures like thoracic sympathectomy and endocardial resection are reserved for special cases which can benefit from neither drugs nor RFA.
Dyssynchrony is the effect of the patients respiratory demands not being appropriately met by the ventilator. The patient has their own idea about how to breathe, and the machinery supporting them, instead of making breathing easier, interferes with respiration and increases the work of breathing. Patient-ventilator dyssynchrony has occasionally appeared in the past papers. Question 11 from the second paper of 2001 discussed the topic in a broad "what is it and what's your management" sort of way. On the other hand, Question 21 from the first paper of 2007 was weird - it discussed the reasons for apparent triggering in a brain-dead patient, which is a dyssynchrony of a sort, as it represents inappropriate auto-triggering by the ventilator.