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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
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80 Section 6: Vascular Surgical Critical Care
Q7. Following open repair of a ruptured AAA,
an 81-year-old man requires ventilatory
assistance. He has dilutional coagulopathy. Gastrointestinal (GI) bleeding
prophylaxis should result in:
A. No important reduction in GI bleeding
B. An important reduction in GI bleeding
C. An important reduction in GI bleeding
but may result in an increased incidence
of pneumonia
D. An important reduction in GI bleed-
ing without any increased incidence of
pneumonia
Q8. An 85-year-old man had open repair of a
ruptured AAA. He is in ICU 3 weeks following repair on mechanical ventilation,
renal replacement therapy, and pneumonia. He develops invasive candidiasis. The
optimal management consists of:
A. Nystatin
B. Voriconazole
C. Micafungin
D. Liposomal amphotericin B
Q9. A 68-year-old man had anterior resec-
tion for rectosigmoid cancer 5 days ago.
He developed massive swelling of the leg.
Duplex venous study showed acute deep
vein thrombosis involving the entire deep
venous system of the left lower extremity.
He was started on unfractionated heparin
with elevation of the left lower extremity. The following morning, the patient
became unresponsive with a heart rate of
132 beats/minute. He’s afebrile. His blood
pressure is 76/38 mmHg. Oxygen saturation is 90% with FiO2 100%, WBC count
13,000/mm3, HCT 36%, and serum creatinine 0.9 mg/dL. The patient was started
on a norepinephrine drip to maintain
systolic blood pressure above 80 mm. A
CT pulmonary actogram showed a large
thrombus in the main trunk extending to
both pulmonary arteries. What is the next
step in management?
A. Argatroban
B. Alteplase
C. Enoxaparin
D. Rivaroxaban
Q10. Following repair of a ruptured AAA,
a 78-year-old man is hypothermic.
He has received 14 units of packed cells,
6 units of fresh-frozen plasma, 5 units of
platelets, and is on ventilatory support.
Which of the following is the most effective method of active rewarming for this
patient?
A. Aluminum-lined head covers
B. Increase room temperature
C. Heating/cotton blankets and forced air
warming
D. Ventilator circuit heating
Q11. A 76-year-old man undergoes open repair
of a ruptured AAA. On the fourth postoperative day, the patient is in severe metabolic acidosis without response to sodium
bicarbonate supplements intravenously.
His blood pressure is 80 mm systolic. He is
intubated and is on assist control ventilation mode with FiO2 of 80% and PO2 of
70%. Serum lactate is 4 mmol/L and WBC
count is 16,000/mm3 with a shift to the
left. The next step in the management of
this patient is:
A. CT of the abdomen and pelvis
B. Stool for Clostridium difficile toxin
C. Laparotomy
D. Measurement of intraabdominal
pressure for possible compartment
syndrome
Q12. A 76-year-old man with diabetes melli-
tus, non-alcoholic cirrhosis, and chronic
kidney disease undergoes a femoral–
anterior tibial bypass for critical limb
ischemia. On postoperative day 2, he
developed a sudden onset of atrial fibrillation with a rapid ventricular response.
Despite rate control and diuresis, he
remains in atrial fibrillation 6 days later.
Which of the following risk factors is
useful in determining the initiation of
anticoagulation?
A. Diabetes mellitus
B. Chronic kidney disease
C. Liver cirrhosis
D. Persistent atrial fibrillation
Section 6: Vascular Surgical Critical Care 81
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Q13. A 75-year-old, 110-kg man intubated after
open repair of a large juxtarenal AAA
using a left retroperitoneal approach
becomes combative on the third postoperative day, striking at the staff and trying to
pull out the lines and endotracheal tube.
In addition to pain management, which
of the following is the best management
strategy?
A. Haloperidol 10 mg intravenously every
6 hours
B. Lorazepam 5 mg intravenously every
6 hours
C. Dexmedetomidine 0.7 μg/kg/hr intrave-
nous infusion
D. Propofol (Diprivan) 10 mg/mL targeted
controlled infusion
Q14. A 63-year-old man with a long-standing
history of cigarette smoking presents for
preoperative evaluation for a femoralpopliteal bypass for ischemic rest pain,
which is scheduled for 4 weeks. With
respect to smoking cessation and its effect
on the postoperative course:
A. There is no outcome difference between
smokers and non-smokers who undergo
elective surgery
B. Perioperative smoking cessation reduces
the incidence of surgical site infection
C. A remote smoking history does not
increase the risk of long-term healing
complications
D. Smoking cessation less than 2 months
before surgery results in an increase in
postoperative complications
Q15. An 82-year-old man is 6 days postopera-
tive following open repair of a ruptured
AAA with a horseshoe kidney. His BMI is
less than 30, and he is critically ill with
multiple organ failure. The recommended
caloric requirements for this patient are:
A. 20 kcal/kg/day
B. 25 kcal/kg/day
C. 30 kcal/kg/day
D. 12 kcal/kg/day
82 Section 6: Vascular Surgical Critical Care
RATIONALE 1–15
1. RATIONALE
Pulmonary complications have been reported in up to 80% of postoperative patients undergoing open vascular reconstruction. Risk factors for pulmonary complications include advanced
age, male gender, current or former smoking history, history of chronic obstructive pulmonary
disease, acuity of the procedure, more complex operation, obesity, and higher American Society
of Anesthesiologists classification. Acute respiratory failure may manifest as hypoxemia due to
difficulty with oxygenation or difficulty with ventilation leading to hypercapnia. Management
includes identification and correction of the underlying cause resulting in the persistence of
respiratory failure and significant underlying systemic inflammatory response. The patient may
develop acute respiratory distress syndrome (ARDS), which is defined as acute onset (within
1 week) of bilateral lung opacity with exclusion of cardiogenic pulmonary edema. A P/F ratio
(PO2/FiO2) of 300–200 is mild, 200–100 is moderate, and <100 is severe ARDS with PEEP equal to
or greater than 5 cm of water. Management of ARDS revolves around protective lung ventilation
with a decreased tidal volume (4–6 mL/kg) and limitation of plateau pressure (<35 cm water).
Correct Answer A 4–6 mL/kg
Reference
Johnson, R. G., Arozullah, A. M., Neumayer, L., Henderson, W. G., Hosokawa, P., & Khuri, S. F. (2007).
Multivariable predictors of postoperative respiratory failure after general and vascular surgery:
results from t he patient safet y in surgery st udy. J Am Coll Surg, 204(6), 1188–1198. PMID: 17544077
2. RATIONALE
Preload responsiveness may be difficult to determine accurately in a critical care setting after a
major intraabdominal surgery. Several modalities are available, and there is a preponderance
of evidence for the use of bedside ultrasonography (BCU). In spontaneously breathing patients,
a stroke volume increase of more than 12% during passive leg raising is highly suggestive of
fluid responsiveness. A cutoff value of 15% change in inferior vena cava (IVC) diameter between
inspiration and expiration and positive pressure ventilation accurately separates patients who
will respond to f luid administration in contrast to those who will not. Passive leg raising and
IVC collapsibility measures are unable to predict fluid responsiveness in patients with intraabdominal hypertension. Recent data has suggested that central venous pressure does not correlate with fluid resuscitation. Overly aggressive crystalloid-based resuscitation may result in
untoward outcomes.
Correct Answer D Bedside cardiac ultrasonography
Reference
Levitov, A., Frankel, H. L., Blaivas, M., et al. (2016). Guidelines for the appropriate use of bedside gen-
eral and cardiac ultrasonography in the evaluation of critically Ill patients-Part II: cardiac ultrasonography. Crit Care Med, 44(6), 1206–1227. PMID: 27182849
3. RATIONALE
Recommendations from the Infectious Diseases Society of America and the American
Thoracic Society supported by well-controlled randomized trials showed that a short
Section 6: Vascular Surgical Critical Care 83
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course of 7–8 days is as safe and effective as 14–15 days of antibiotics. The chest X-ray
findings may be abnormal due to other causes such as atelectasis or pleural effusion.
Normalization of pulmonary infiltrates caused by pneumonia often lags behind the resolution of pneumonia. Continuation of antibiotics for a prolonged period is not necessary and
may result in side effects.
Correct Answer C 7–8 days
Reference
Zilahi, G., McMa hon, M. A., Povoa, P., & Martin-Loeches, I. (2016). Durat ion of antibiotic t herapy in the
intensive care unit. J Thorac Dis, 8(12), 3774–3780. PMID: 28149576
4. RATIONALE
The optimal time to liberate a patient from the ventilator is often difficult to determine and
should be addressed on a frequent basis to decrease the time for ventilator assistance. The
benefits are the decreased length of ICU length of stay as well as decrease in morbidity and
mortality. There is often an overuse of sedation in managing patients on ventilatory support.
Patients should preferably receive intermittent sedation as needed. Regardless of the time on
the ventilator, the use of spontaneous breathing trials in conjunction with a protocol of daily
sedation holidays has the greatest effect in decreasing the days that patient is on ventilatory
support. Regardless of the medications used or mode of ventilation, protocols that discontinue sedation and allow for early extubation lead to improved outcomes. Early tracheostomy
after laparotomy for aneurysm repair should not be performed. The weaning parameters for
extubation include adequate tidal volume, appropriate vital capacity, appropriate negative inspiratory force, and rapid shallow breathing index (<105) to help predict successful
extubation.
Correct Answer D Daily sedation holiday
Reference
Juern, J. S. (2012). Removing the critically ill patient from mechanical ventilation. Surg Clin North Am,
92(6), 1475–1483. PMID: 23153880
5. RATIONALE
According to the guidelines published by the Infectious Diseases Society of America, either
oral fidaxomicin or oral vancomycin is the drug of choice for Clostridioides difficile colitis.
Metronidazole should be used only in mild-to-moderate disease in younger patients who have
no or only low risk factors for the recurrence of C. difficile colitis. Elderly and immunocompromised patients are at greater risk for recurrence. Fecal microbiota transplantation should be
offered to patients with frequent recurrences of C. difficile infection.
Correct Answer C 200 mg of oral fidaxomicin two times a day
Reference
McDonald, L. C., Gerding, D. N., Johnson, S., et al. (2018). Clinical practice guidelines for clostrid-
ium difficile infection in adults and children: 2017 update by the Infectious Diseases Society
of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis,
66(7), e1–e48. PMID: 29462280
84 Section 6: Vascular Surgical Critical Care
6. RATIONALE
The effects of storage (time) and leukocyte content probably interact since a longer storage duration is thought to cause a greater accumulation of leukocyte-derived cytokines and red blood
cell (RBC) injury. A randomized assignment of two groups of mixed surgical patients Group A
(fresh stored less than 1 week) and Group B (stored more than 3 weeks) were transfused. Both
groups had an increase in hemoglobin concentration. From a randomized assignment into
two groups, with group A receiving fresh and group B receiving aged RBC transfusion, in both
groups RBC transfusion caused an increase in hemoglobin concentration. RBC transfusions
increased the functional capillary density in group A (fresh RBC), while functional capillary
density (FCD) remained unaffected in group B (aged RBCs). Fresh non-leukoreduced RBC transfusions, but not RBCs stored for more than 3 weeks, were effective in improving microcirculatory perfusion by elevating the number of perfused microvessels in mixed surgical patients.
Correct Answer D Fresh non-leukoreduced RBC transfusion
Reference
Ayhan, B., Yuruk, K., Koene, S., et al. (2013). The effects of non-leukoreduced red blood cell transfu-
sions on microcirculation in mixed surgical patients. Transfus Apher Sci, 49(2), 212–222. PMID:
23402838
7. RATIONALE
The results from a meta-analysis of 72 published trials comprising 12,660 patients that compared GI bleeding prophylaxis with proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate showed that for patients at highest risk (>8%) or high risk (4%–8%)
for bleeding, both PPIs and H2RAs probably reduce clinically important GI bleeding compared
with placebo or no prophylaxis. Both will increase the risk of pneumonia as compared with no
prophylaxis. It is likely that neither affects mortality and morbidity as a result of Clostridium difficile infection, length of ICU stay, or duration of mechanical ventilation.
Correct Answer C An important reduction in GI bleeding but may result in an increased
incidence of pneumonia
Reference
Wang, Y., Ye, Z., & Ge, L. (2020). Efficacy and safety of gastrointestinal bleeding prophylaxis in criti-
cally ill patients: systematic review and network meta-analysis. BMJ, 368, l6744. PMID: 31907166
8. RATIONALE
Invasive candidiasis is present in seriously ill patients. A double-blind, randomized, multinational, non-inferiority trial to compare micafungin (100 mg/day) with liposomal amphotericin
B as the first-line treatment of candidemia and invasive candidiasis included 267 patients
randomly assigned to receive liposomal amphotericin B and 264 randomly assigned to received
micafungin. Treatment success was observed in 89.6% patients treated with micafungin and
89.5% treated with liposomal amphotericin B. Efficacy was independent of the Candida species
and the primary site of infection as well as neutropenic status, APACHE II score, and whether a
catheter was removed or replaced during the study. There were fewer treatment-related adverse
events, including those that were serious or led to treatment discontinuation, with micafungin
than there were with liposomal amphotericin B, concluding that micafungin was as effective
Section 6: Vascular Surgical Critical Care 85
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and caused fewer adverse events than liposomal amphotericin B as the first-line treatment of
candidemia and invasive candidiasis.
Correct Answer C Micafungin
Reference
Kuse, E. R., Chetchotisakd, P., da Cunha, C. A., et al. (2007). Micafungin versus liposomal ampho-
tericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial.
Lancet, 369(9572), 1519–1527. PMID: 17482982
9. RATIONALE
Pulmonary embolism (PE) is a life-threatening complication of acute deep venous thrombosis. The appearance of a clot on CTA of the chest is suggestive that this patient has developed
saddle embolus resulting in complete cardiovascular collapse and sudden onset of hypoxia,
severe hypotension, and right heart strain. In a patient with PE but without any changes in
hemodynamic status, the treatment of choice is heparin. In patients with hypotension, systemic
thrombolytic therapy is recommended. Thrombolytic therapy can reduce mortality or recurrent embolism by 55% compared with heparin alone. The disadvantages include an obligatory 2-hour infusion with contraindications to systemic thrombolysis in 50% of patients and
major bleeding complications in 20% of patients. Catheter-assisted pulmonary embolectomy
allows significantly reduced doses of thrombolytic directly into the pulmonary artery using
tenecteplase and tissue plasminogen activator (tPA). Catheter-based thrombectomy with use
of the Angiojet rheolytic thrombectomy catheter (Medrad Interventional, Warrendale, PA) has
a reported mortality in patients with massive PE ranging from 12% to 25%. Ultrasound-assisted
therapies using the EKOS device (EKOS Endovascular System, Boston Scientific, Boston, MA)
using a much smaller amount of tPA included in the ULTIMA (ultrasound-assisted, catheterdirected thrombolysis for acute and intermediate risk pulmonary embolism) study. The study
conclusion was that ultrasound-assisted, catheter-directed thrombolysis using fixed-dose
recombinant tPA (rtPA) is superior to heparin alone in improving right ventricle function in
patients with submassive PE, without any increase in bleeding complications.
Correct Answer B Alteplase
Reference
Kucher, N., Boekstegers, P., Müller, O. J., et al. (2014). Randomized, controlled trial of ultrasound-
assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism.
Circulation, 129(4), 479–486. PMID: 24226805
10. RATIONALE
Hypothermia is detrimental in patients with massive blood loss from a ruptured AAA because
it may result in coagulopathy. Active internal warming is the most effective route of rewarming
and can be performed with continuous arteriovenous rewarming and cardiopulmonary bypass,
but these cannot be performed in this patient. Heating blankets and forced air warming are
most effective, providing about 20 kcal/hr room warming, and the use of aluminum-lined head
covers is another passive rewarming technique.
Correct Answer C Heating/cotton blankets and forced air warming
86 Section 6: Vascular Surgical Critical Care
Reference
Warttig, S., Alderson, P., Campbell, G., & Smith, A. F. (2014). Interventions for treating inadvertent
postoperative hypothermia. Cochrane Database Syst Rev, (11), CD009892. PMID: 25411963
11. RATIONALE
Persistent acidosis with elevated lactate levels suggests intestinal ischemia, most likely colon
infarction. Clinically significant colon ischemia occurs in 1%–2% of patients following abdominal aortic aneurysm (AAA) repair and is more common after repair of a ruptured AAA, resulting in 50%–75% mortality. The mortality can be as high as 90% if bowel resection is required.
The presence of early postoperative diarrhea, melena, and hematochezia mandates fiberoptic
sigmoidoscopy. Persistent metabolic acidosis following repair of ruptured AAA is an ominous
finding, and the patient should undergo emergent laparotomy.
Correct Answer C Laparotomy
Reference
Chaikof, E. L., Dalman, R. L., Eskandari, M. K., et al. (2018). The Society for Vascular Surgery practice
guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg, 67(1), 2–77.
e72. PMID: 29268916
12. RATIONALE
Initial management of atrial fibrillation with a rapid ventricular response is directed to
obtain ventricular rate control, correct electrolytes (potassium and magnesium), and
of the necessity for cardioversion. Thromboembolic risk is increased when atrial fibrillation is sustained longer than 48 hours. The risk of hemorrhage may outweigh the risk
of a thromboembolic event in patients with postoperative atrial fibrillation of less than
48 hours’ duration. Factors supporting anticoagulation are (a) CHADS/CHA2 DS2-VASC
score of greater than 2, (b) age >75, (c) congestive heart failure, (d) hypertension, and
(e) diabetes mellites, which all have a score of 1 point each. Stroke/TIA and thromboembolism have a score of 2 points. Based on the score, the approximate annual stroke risks are
as follows: Score <1 (low), score 2–3 (intermediate), score 4–6 (high), with a stroke risk of
4% with score <1; stroke risk of 5%–6% with an intermediate score (2–3), and 18% stroke risk
with a high score (4–6).
Correct Answer A Diabetes mellitus
Reference
Hsu, J., Maddox, T., Kennedy, K., et al. (2016). Oral anticoagulant therapy prescription in patients with
atrial fibrillation across the spectrum of stroke risk: insights from the NCDR PINNACLE registr y.
JAMA Cardiol, 1(1), 55–92. PMID: 27437655
13. RATIONALE
This patient with hyperactive delirium represents with an insidious hospital-acquired complication resulting in increased mortality and prolonged length of stay in the hospital and in
the intensive care unit. Risk factors include preexisting dementia, uncontrolled pain, sleep
deprivation, sepsis, and advanced age. Out of the proposed medications in the question,
Section 6: Vascular Surgical Critical Care 87
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dexmedetomidine infusion is the best option, but it may cause bradycardia. Benzodiazepines
are contraindicated for postoperative delusions. Haloperidol may result in torsade de pointes.
Correct Answer C Dexmedetomidine 0.7 μg/kg/hr intravenous infusion
Reference
Barr, J., Fraser, G. L., Puntillo, K., et al. (2013). Clinical practice guidelines for the management of pain,
agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1),
263–306. PMID: 23269131
14. RATIONALE
Smoking has a negative effect on postoperative morbidity. Postoperative healing complications
are increased in smokers as well as in former smokers compared with those patients who do
not or have not ever smoked. There is a decrease in surgical site infection when a smoker stops
smoking at least 4 weeks before surgery, but other healing problems are not reduced. Patients
should try to stop smoking as early as possible. Health professionals should advise smokers to
quit at least any time before surgery. The adverse effect of smoking on surgical site infections is
due to (a) vasoconstriction, (b) impaired inflammatory response such as oxidative burst, and (c)
delay of a proliferative healing phase with altered collagen metabolism.
Correct Answer B Perioperative smoking cessation reduces the incidence of surgical site
infection
Reference
Myers, K., Hajek, P., Hinds, C., & McRobbie, H. (2011). Stopping smoking shortly before surgery and
postoperative complications: a systematic review and meta-analysis. Arch Intern Med, 171(11) ,
983–989. PMID: 21403009
15. RATIONALE
Most critically ill patients in the intensive care unit with sepsis, massive trauma, burns, or multiple organ system failure should receive 30 kcal/kg/day of nutritional support in 24 hours with
a BMI of 30 or less. Patients who are sedated and are on mechanical ventilation will have a lower
energy expenditure, and their requirement is only 20 kcal/kg/day. In patients with a BMI greater
than 30, caloric intake should exceed 60%–70% of targeted energy requirements, or 11–14 kcal/
kg actual body weight per day.
Correct Answer C 30 kcal/kg/day
Reference
Barton, R. G. (2019). Nutrition support. In J. E. Parillo & R. P. Dellinger (Eds.), Critical care medicine:
principals of diagnosis and management in the adult (5th ed., pp. 1273–1286). Philadelphia, PA:
Elsevier Saunders.
MCQs 1–8
SECTION 7: THORACIC OUTLET
SYNDROME
Q1. In patients with neurogenic thoracic out-
let syndrome with an associated cervical
rib, optimal decompression of the thoracic outlet consists of:
A. Removal of the cervical rib and
scalenectomy
B. Removal of the first rib only
C. Removal of the first rib, scalenectomy,
and removal of cervical rib
D. Removal of the cervical rib with staged
removal of the first rib
Q2. A 32-year-old man undergoes left first rib
resection for neurogenic thoracic outlet
syndrome and presents to the outpatient
clinic with a winged scapula on the left
side. The nerve injury responsible for this
appearance is:
A. Thoracodorsal nerve
B. Intercostal brachial nerve
C. Long thoracic nerve
D. Lower cord of brachial plexus
Q3. A 30-year-old man undergoes right
first rib resection via a supraclavicular
and infraclavicular incision for venous
thoracic outlet syndrome and presents
with recurrent swelling of the right upper
extremity 6 months later. Venous duplex
study shows long segmental occlusion of
the subclavian and axillary vein. The best
treatment option is:
A. Stenting
B. Open thrombectomy
C. Compression sleeve
D. Anticoagulation
Q4. Arterial thoracic outlet syndrome rep-
resents what percentage of patients of
thoracic outlet syndrome?
A. <1%
B. 1%–3%
C. 4%–5%
D. 6%–8%
Q5. The incidence of recurrent neurogenic
thoracic outlet syndrome after thoracic
outlet decompression using a supraclavicular approach is approximately:
A. 2%
B. 3%–4%
C. 5%
D. >5%
Q6. The incidence of brachial plexus injury in
surgery for thoracic outlet syndrome can
be increased by the following factors:
A. Anatomic variations and pathological
findings
B. Intraoperative bleeding
C. Preoperative repetitive hyperextension
neck trauma
D. Anatomic variations, intraoperative
bleeding, and preoperative repetitive
hyperextension neck trauma
Q7. The number of patients with neurogenic
thoracic outlet syndrome who exhibit
physical findings that are isolated to the
subcoracoid space is:
A. Up to 10%
B. Up to 20%
C. Up to 25%
D. Up to 30%
DOI: 10.1201/9781003389897-7
Section 7: Thoracic Outlet Syndrome 89
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Q8. As compared to the supraclavicular
approach, the advantage of the transaxillary first rib resection is:
A. Incision in the hidden axillary space and
sufficient exposure for resection of the
first rib
B. Incision in the hidden axillary space and
sufficient exposure for the resection of
both the first rib and cervical rib
C. Ability to form complete brachial plexus
neurolysis
D. Ability to perform subclavian vein recon-
struction in patients with venous thoracic
outlet syndrome
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