The following vignette applies to questions 1–5. An 88‐year‐old man is admitted to the intensive care unit after sustaining a fall down a flight of stairs. On presentation, he has a GCS of 13, a heart rate of 78 beats/min, blood pressure of 152/76, and oxygen saturation of 94% on 4 L of oxygen by nasal cannula. His medical history is significant for atrial fibrillation for which he takes metoprolol and warfarin. His international normalized ratio (INR) is 2.5. Imaging studies reveal a 4‐mm right‐sided subdural hematoma, and fracture of right ribs 3–10.

1. Which of the following is the most effective treatment for reversing the patient’s hypocoagulopathy?
   
   
   
   1. Fresh frozen plasma
      
   2. Vitamin K
      
   3. Platelets
      
   4. Prothrombin Complex Concentrate
      
   5. Cryoprecipitate
   
   

   Elderly patients are at particular risk of poor outcomes after traumatic brain injury given the frequency of prescribed anticoagulant medications superimposed upon underlying frailty and other comorbidities. Therapeutic anticoagulation with warfarin poses an increased risk of mortality in these patients. Fresh frozen plasma (FFP) (answer A) and Vitamin K (answer B) have long been standard therapy for reversing the anticoagulant effects of warfarin. However, more recent literature and guidelines demonstrate increased rapidity and greater efficacy of prothrombin complex concentrate (PCC) in reversing warfarin, as well as a reduction in mortality associated with bleeding (answer D). Therefore, use of prothrombin complex concentrate has become the recommended guideline for reversing the coagulopathy caused by warfarin in bleeding patients. Although platelets (answer C) and cryoprecipitate (answer E) are useful as part of overall hemostatic resuscitation in the bleeding patients, they do not specifically reverse the effects of warfarin. Fresh frozen plasma, while effective at reversing the effects of warfarin, takes significantly longer to achieve its effect and may be beneficial in settings where volume resuscitation of the bleeding patient is also required due to its colloid properties. Vitamin K is also useful in counteracting the effects of warfarin, but its effects are not only delayed when compared to PCC but also long‐lasting, which can complicate the need to resume therapeutic anticoagulation with warfarin.

   
   

   Answer: D

   
   

   Frontera JA, Gordon E, Zach V et al. (2014) Reversal of coagulopathy using prothrombin complex concentrates is associated with improved outcome compared to fresh frozen plasma in warfarin‐associated intracranial hemorrhage. Neurocritical Care. 2014 Dec; 21(3):397–406.

   
   

   Chai‐Adisaksopha C, Hills C, Siegal DM et al (2016) Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta‐analysis. Thrombosis and Haemostasis. 2016 Oct 28; 116(5):879–890.

   
   

   Edavettal M, Rogers A, Rogers F et al (2014) Prothrombin complex concentrate accelerates international normalized ratio reversal and diminishes the extension of intracranial hemorrhage in geriatric trauma patients. American Surgeon. 2014 Apr; 80(4):372–376.

   
   
2. Which of the following represents the optimal analgesic regimen for treatment of the patient’s rib fractures?
   
   
   
   1. Patient Controlled Analgesia (PCA) with intravenous morphine
      
   2. Regional (thoracic epidural, intramuscular, or paravertebral) anesthesia
      
   3. Oral opioid analgesia supplemented by intravenous acetaminophen
      
   4. Nonsteroidal anti‐inflammatory drugs (NSAID)
      
   5. Oral opioid analgesia supplemented by transdermal lidocaine
   
   

   Although opioids form the cornerstone of analgesia in the treatment of pain arising from trauma‐associated injuries, the elderly are particularly vulnerable to the deleterious effects of opioids including respiratory depression and delirium. A PCA with morphine (answer A) can be used, but with significant risks of long‐acting opioid side effects due to the long half‐life of morphine. Oral opioid analgesia (answer C) may be effective in the subacute phase of injury associated pain but cannot be easily titrated to effect, and intravenous acetaminophen is ineffective as a primary agent. NSAIDS (answer D) are not recommended as primary agents of analgesia due to the potential for exacerbating coagulopathy and causing acute kidney injury. Transdermal lidocaine (answer E) is not effective for the treatment of rib fractures as it does not produce enough of a systemic effect. Although often prescribed, the only approved indication for transdermal lidocaine is for herpetic lesions. Transdermal lidocaine does not penetrate tissues to the bony level to produce local anesthesia. Regional techniques in the form of thoracic epidural, paravertebral, and intercostal analgesic delivery have become evidence‐based, favored approaches to providing optimal pain control, while reducing the delirium associated with systemic opioid analgesics (answer B).

   
   

   Answer: B

   
   

   O’Connell KM, Quistberg DA, Tessler R et al. (2018) Decreased risk of delirium with use of regional analgesia in geriatric trauma patients with multiple rib fractures. Annals of Surgery 2018 Sep; 268(3):534–540.

   
   

   Jensen CD, Stark JT, Jacobson LL et al. (2017) Improved outcomes associated with the liberal use of thoracic epidural analgesia in patients with rib fractures. Pain Medicine. 2017 Sep 1; 18(9):1787–1794.

   
   

   Peek J, Smeeing DPJ, Hietbrink F et al. (2019) Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta‐analysis. European Journal of Trauma and Emergency Surgery. 2019 Aug; 45(4):597–622.

   
   
3. Twenty‐four hours after admission to the ICU, the patient becomes agitated and confused, with an increase in heart rate to 110 beats/min. Repeat CT scan of the head demonstrates no worsening of the subdural hematoma. Which of the following medications should be avoided in managing this agitated, delirious elderly patient?
   
   
   
   1. Risperidone
      
   2. Quetiapine
      
   3. Lorazepam
      
   4. Haloperidol
      
   5. Dexmedetomidine
   
   

   Delirium among elderly patients, particularly those admitted to an ICU setting, is often underdiagnosed and multifactorial in etiology. Sun‐downing and delirium in the elderly patient is often unavoidable, but the hallmark of treatment is understanding of the etiology and symptomatic management. Investigating the underlying cause (e.g. inadequate analgesic effect) and prevention strategies remain the cornerstones of treatment approaches. Assessment and screening for delirium is recommended at regular intervals using measures such as the Confusion Assessment Method for the ICU (CAM‐ICU). When prevention strategies such as reorientation, optimizing analgesia and nutrition, reducing physical restraints, and promoting good sleep hygiene are not sufficient, pharmacologic therapy may be required for managing acute episodes of delirium. Atypical antipsychotic medications such as haloperidol (answer D) (recommended for short term treatment of acute delirium by the Society of Critical Care Medicine), risperidone (answer A), and quetiapine (answer B) may provide short‐term benefit in the acute setting, albeit requiring caution with respect to polypharmacy and cardiac side effects. In ICU patients with delirium unrelated to alcohol and benzodiazepine withdrawal, continuous infusions of dexmedetomidine (answer E) may be used for sedation to reduce the duration of delirium. Benzodiazepines such as lorazepam, however, are associated with significant risk in the elderly given its amnestic properties, effects on respiratory drive, its long half‐life and active metabolites and should be avoided (answer C).

   
   

   Answer: C

   
   

   Devlin JW, Skrobik Y, Gelinas C et al. (2018) Executive summary: clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine : September 2018; 46(9):1532–1548.

   
   

   Girard TD, Pandharipande PP, Ely EW. (2008). Delirium in the intensive care unit. Critical Care ; 12(suppl. 3):S3.

   
   

   Ouimet S, Kavanagh BP, Gottfried SB et al. (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine ; 33:66–73.

   
   
4. Despite optimizing analgesia, pulmonary hygiene measures, and management of delirium, the patient’s respiratory function and his ability to protect his airway deteriorate to the point of requiring endotracheal intubation and the initiation of mechanical ventilation. Twelve hours after the initiation of mechanical ventilation, arterial blood gas demonstrates a p/f ratio of 190. When managing the patient’s mechanical ventilator, which of the following is true?
   
   
   
   1. Chest wall compliance will be increased due to weakening of connective tissue and loss of muscle strength.
      
   2. Higher tidal volumes should be utilized in order to overcome the loss of alveolar elasticity.
      
   3. Positive end‐expiratory pressure (PEEP) is important to overcome the greater tendency of alveolar collapse at higher volumes.
      
   4. Airway pressure release ventilation (APRV) is unlikely to increase alveolar recruitment for the treatment of ARDS in the elderly.
      
   5. Positioning of the patient (prone or semi‐prone) to ameliorate V/Q mismatch is contraindicated in the elderly.
   
   

   Aging is associated with changes in pulmonary physiology, which includes blunting of the mucociliary reflex, decline in vital capacity, and reduction in chest wall compliance (answer A). Positive end‐expiratory pressure (PEEP) is helpful, particularly in the elderly, as the loss of airway and alveolar elasticity results in closure of alveoli at higher volumes (answer C). Alveolar recruitment in the form of airway pressure release ventilation (APRV) (answer D) has not been shown to improve mortality particularly when begun late after the diagnosis of acute respiratory distress syndrome (ARDS), but can be of benefit in improving oxygenation when used within the first 24 hours after diagnosis, and there is no limitation of APRV based upon age or the physiology of aging lungs. Positioning of the patient (particularly upright positioning with early mobilization) has been demonstrated to decrease oxygen consumption, and prone positioning (answer E) has been shown to be of benefit in improving oxygenation particularly in patients with ARDS, and there is no contraindication to prone positioning based on age. However, the use of high tidal volumes (answer B), particularly over a prolonged period of time, has been shown to result in over aeration of healthy lung tissue and barotrauma, which results in progressive lung injury and impaired pulmonary function.

   
   

   Answer: C

   
   

   Zhou Y, Jin X, Lv Y et al. (2017) Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome. Intensive Care Medicine 017 Nov; 43(11):1648–1659. doi: 10.1007/s00134‐017‐4912‐z.

   
   

   Villar J, Kacmarek RM, Perez‐Mendez L et al. (2006). A high positive end‐expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Critical Care Medicine 2006 May; 34(5):1311–8.

   
   

   Gee MH, Gottlieb JE, Albertine KT, et al. (1990). Physiology of aging related to outcome in the adult respiratory distress syndrome. Journal of Applied Physiology ; 69:822–829.

   
   
5. Ten days after the initiation of mechanical ventilation, the patient’s delirium has significantly improved. His pulmonary function has improved to the point of tolerating a spontaneous breathing trial, and he is extubated after meeting established parameters and criteria. However, 6 hours after extubation, the patient is noted to have poor respiratory effort and is unable to effective expectorate resulting in tachypnea and desaturation. He is re‐intubated successfully, is maintained on light sedation, and his family is informed. Which of the following should guide the decision‐making process of whether the patient should be considered for tracheostomy?
   
   
   
   1. The patient is intubated and therefore unable to participate in decision‐making. Therefore, the providers should act in the patient’s best interest.
      
   2. The patient is likely to fail repeated attempts at extubation, and therefore, a tracheostomy is the preferred approach irrespective of the patient’s previously expressed wishes.
      
   3. The patient’s health care proxy should make decisions on behalf of the patient in conjunction with the patient’s family, irrespective of the patient’s wishes.
      
   4. A shared decision model should be employed that is based on choice, option, and decision talk with both the patient and his health care proxy/family.
      
   5. A tracheostomy is unlikely to improve the patient’s overall quality of life and should not be offered.
   
   

   Decision‐making in the elderly can often be challenging, particularly in critical care settings where patients may require end‐of‐life decision‐making with limited capacity to fully engage in the process. Whereas patient autonomy is the overriding principle in medicine at large, end‐of‐life decision‐making for critically ill elderly patients with limitations in communication and sensorium can make the process difficult for patients, their families, and providers. Although providers are always tasked with acting in the best interest of the patient, a patient’s own wishes must be investigated using all means available including temporary cessation of stimuli and medications that can alter sensorium (answer A). The judgment of the treating health care provider team, while important in helping to guide and counsel patients and their families, cannot constitute the overriding rationale for decision‐making without focusing on the patient’s wishes (answers B and E). Discussions with health care proxies and surrogates, as well as the patient’s families, are of the utmost importance both ethically and legally. However, such discussions should be patient‐centered and actively involve the patient to the greatest extent that is possible (answer C). The shared decision‐making model that is based on choice, option, and decision talk rests on a process of deliberation and understanding that decisions should be influenced based on exploring and respecting the patient’s preferences, whether previously expressed or evolving (answer D).

   
   

   Answer: D

   
   

   Elwyn G, Frosch D, Thomson R et al (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine , Oct; 27(10):1361–1367.

   
   

   Ma J, Chi S, Buettner B et al (2019). Early palliative care consultation in the medical ICU: A cluster randomized crossover trial. Critical Care Medicine. Dec; 47(12):1707–1715.

   
   

   White DB, Angus DC, Shields AM et al. (2018). A randomized trial of a family‐support intervention in intensive care units. New England Journal of Medicine. Jun 21; 378(25):2365–2375.

   
   

   The following vignette applies to questions 6–8. A 79‐year‐old woman presents to the emergency department with progressive left lower quadrant abdominal pain for a period of 5 days that has worsened over the last 24 hours. On presentation, she has a heart rate of 88, a blood pressure of 84/45, and oxygen saturation of 92% on 3 L of oxygen by nasal cannula. Her medical history is significant for hypertension, diabetes, peripheral vascular disease, and hyperlipidemia for which she takes atenolol, metformin, clopidogrel, and a statin. She is afebrile and her white blood cell count is 17 k/mm³. A CT scan was obtained prior to surgical consultation and reveals pneumoperitoneum and intra‐abdominal free fluid. On exam, the patient has diffuse abdominal tenderness with guarding in the left lower quadrant.

   
   
6. Which of the following is true regarding the patient’s cardiac physiology?
   
   
   
   1. For patients with chronic hypertension, a normal mean arterial blood pressure improves organ perfusion.
      
   2. Tachycardia in response to shock can be blunted by β‐adrenergic blocking medications.
      
   3. Chronic atherosclerotic disease reduces systemic vascular resistance.
      
   4. Intravenous fluid hydration should be limited in this patient due to risks of cardiac dysfunction associated with aging.
      
   5. Cardiac afterload is decreased due to decreased elastin in large arteries.
   
   

   The natural aging process is accompanied by several important structural and physiologic changes in the cardiovascular system. Progressive arteriosclerosis and decreased elastin in the aorta and major vessels lead to increased systemic vascular resistance (answer C) and chronic hypertension. For patients with chronic hypertension, a typically “normal” mean arterial blood pressure may be inadequate to support organ perfusion (answer A). These same processes also lead to increased afterload (answer E), which in turn make the heart dependent on preload and even minor changes in volume status. In a state of sepsis, patients have cytokine‐mediated reduction in systemic vascular resistance owing to impaired capillary integrity. Irrespective of age, patients in states of sepsis and distributive shock require resuscitation of their intravascular volume (answer D), which is even more important in the elderly patient that is preload dependent. The typical response to sepsis and other inflammatory states is accompanied by tachycardia. However, patients being treated chronically with β‐adrenergic blocking medications may have heart rates that appear more “normal.” This blunted response to sepsis must be treated with caution as a “normal” heart rate in these instances is not indicative of the disease process at hand and cannot be used as an end‐point of resuscitation (answer B).

   
   

   Answer: B

   
   

   Nagappan R, Parkin G. (2003). Geriatric critical care. Critical Care Clinics ; 19 : 253–270.

   
   

   Menaker J., Scalea, TM. (2010). Geriatric care in the surgical intensive care unit. Critical Care Medicine ; 38(9):S452–S459.

   
   
7. The patient is taken to the operating room where she is found to have perforated diverticulitis with feculent peritonitis. She undergoes abdominal washout and sigmoid colon resection. Postoperatively, the patient is admitted to the ICU and is hypotensive despite 4 L of crystalloid bolus requiring the initiation of vasopressors. Her serum lactate is 4.
   

   Which of the following statements is correct?

   
   
   
   
   1. The addition of albumin to volume resuscitation in sepsis improves outcomes.
      
   2. There is benefit to hydrocortisone and fludrocortisone in the setting of septic shock with respect to improving mortality.
      
   3. Early use of a pulmonary artery catheter in the setting of severe sepsis reduces mortality.
      
   4. Antimicrobial therapy should be terminated after source control.
      
   5. Systemic vascular resistance is increased in the elderly with septic shock.
   
   

   The initial phase of shock resulting from sepsis is distributive in nature, irrespective of age or underlying cardiac pathophysiology. The hallmarks of treatment center around timely and effective source control with concomitant resuscitation guided by the Surviving Sepsis campaign. Albumin resuscitation (answer A) in addition to crystalloid resuscitation has not been shown to confer a benefit when compared to crystalloids alone. Similarly, the use of pulmonary artery catheters (answer C), although potentially helpful in guiding resuscitation, has not been demonstrated to be associated with a reduction in mortality. Although systemic vascular resistance is generally higher in the elderly (when compared to younger cohorts) due to atherosclerosis, sepsis causes an overall decrease in systemic vascular resistance due to cytokine‐induced increases in vascular permeability (answer E). Antimicrobial therapy, in settings of severe intra‐abdominal sepsis, should be continued for between 3 and 5 days (answer D) after source control in patients without severe organ dysfunction. More recent literature does indicate that a combination of hydrocortisone and fludrocortisone can lower mortality in septic shock, when compared to placebo (answer B).

   
   

   Answer: B

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