The first step in treating a 70-kg patient with a platelet count of 12,000 due to heparin-induced thrombocytopenia is:
Thrombocytopenia may require platelet transfusion for a platelet count less than 20,000/mL when invasive procedures are performed, or when platelet counts are low and ongoing bleeding from raw surface areas persists. One unit of platelets will increase the platelet count by 5000 to 7500/mL in adults. It is important to delineate the cause of the low platelet count. Usually there is a self-limiting or reversible condition such as sepsis. Rarely, it is due to heparin-induced thrombocytopenia I and II. Complications of heparin-induced thrombocytopenia II can be serious because of the diffuse thrombogenic nature of the disorder. Simple precautions to limit this hypercoagulable state include saline solution flushes instead of heparin solutions and limiting the use of heparin -coated catheters. The treatment is anticoagulation with synthetic agents such as argatroban.
VAP in ventilated ICU patients reaches a 70% probability at:
Pneumonia is the second most common nosocomial infection and is the most common infection in ventilated patients. VAP occurs in 15 to 40% of ventilated ICU patients, with a probability rate of 5% per day, up to 70% at 30 days. The 30-day mortality rate of nosocomial pneumonia can be as high as 40% and depends on the microorganisms involved and the timeliness of initiating appropriate antimicrobials Protocoldriven approaches for prevention and treatment of VAP are recognized as beneficial in managing these difficult infectious complications.
Which of the following is the only thing that has been shown to decrease wound infections in surgical patients with contaminated wounds?
No prospective, randomized, double-blind, controlled studies exist that demonstrate antibiotics used beyond 24 hours in the perioperative period prevent infections. Prophylactic use of antibiotics should simply not be continued beyond this time. Irrigation of the operative field and the surgical wound with saline solution has shown benefit in controlling wound inoculum. Irrigation with an antibiotic-based solution has not demonstrated significant benefit in controlling postoperative infection.
Tracheostomy may decrease the incidence of VAP, overall length of ventilator time, and the number of iCU patient days when performed:
Although not without risk, tracheostomy decreases the pulmonary dead space and provides for improved pulmonary toilet. When performed before the 1Oth day of ventilatory support, tracheostomy may decrease the incidence of VAP, the overall length of ventilator time, and the number of ICU patient days.
Which of the following is a dominant cytokine in the pathogenesis of systemic inflammatory response syndrome (SIRS)?
The systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndrome (MODS) carry significant mortality risks (Table below).
Mortality associated with patients exhibiting two or more criteria for systemic inflammatory response syndrome (SIRS):
Specific criteria have been established for the diagnosis of SIRS (Table below),
Inclusion criteria for the systemic inflammatory response syndrome:
but two criteria are not required for the diagnosis of SIRS: lowered blood pressure and blood cultures positive for infection. SIRS is the result of proinflammatory cytokines related to tissue mal perfusion or injury.
The dominant cytokines implicated in this process include interleukin (IL)-1, IL-6, and tissue necrosis factor (TNF). Other mediators include nitric oxide, inducible macrophagetype nitric oxide synthase, and prostaglandin 12.
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