patient does not require double Pseudomonas coverage assuming he is in an intensive care unit that has antimicrobial resistance defined as < 10% of gram‐negative isolates resistant to an agent considered for monotherapy. Fluoroquinolones and aminoglycosides (Answers A & B) should not be used as monotherapy for gram‐negative coverage for ventilator‐associated pneumonia. Answers D and E are both reasonable treatments for community‐acquired pneumonia but are not appropriate for ventilator‐associated pneumonia. In this case, cefepime would be preferred to piperacillin‐tazobactam for gram‐negative coverage as cefepime has CNS penetration and this patient has had neurosurgical intervention.Answer: CKalil AC, Metersky ML, Klompas M,et al. Management of adults with hospital‐acquired and ventilator‐associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63 (5): e61–e111.Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital‐acquired pneumonia and ventilator‐associated pneumonia: guidelines for the management of hospital‐acquired pneumonia (HAP)/ventilator‐associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017; 50 (3):1–26. PMID: 28890434.
22 A 33‐year‐old man, otherwise healthy, has acute appendicitis and will be undergoing a laparoscopic appendectomy. He mentions both his father and brother have been diagnosed with malignant hyperthermia. The patient has never had surgery before and has not been tested for the gene. Which is the best plan for anesthesia?Succinylcholine followed by isofluraneSuccinylcholine followed by desfluraneRocuronium followed by sevofluraneRocuronium followed by propofolRocuronium followed by nitrous oxideMalignant hyperthermia is a rare autosomal dominant disorder which is characterized by skeletal muscle hypermetabolism following exposure to halogenated anesthetics, succinylcholine, or rarely, physiologic stress. The mutation is often found on the RYR1 gene. Exposure to halogenated gasses or succinylcholine causes uncontrolled release of calcium from the sarcoplasmic reticulum leading to sustained muscle contraction. Signs and symptoms are tachycardia, tachypnea, hypoxemia, hypercarbia, metabolic acidosis, hyperkalemia, cardiac dysrhythmias, hypotension, skeletal muscle rigidity, and hyperthermia. Earliest signs are often hypercarbia and tachypnea followed by hyperthermia. Treatment is to stop the inciting agent, call for help, administer dantrolene 2.5 mg/kg until the reaction subsides, increase tidal volume, start aggressive cooling measures, treat arrythmias (avoid calcium channel blockers), check electrolytes, and continue dantrolene 1 mg/kg every 4 hours for 24 to 48 hours. The gold standard test is the caffeine halothane contracture test. As this requires a muscle biopsy, genetic testing is becoming more common.Succinylcholine and the halogenated gasses (isoflurane, desflurane, and sevoflurane) are known triggers for malignant hyperthermia, and should be avoided in this patient (Answers A, B, C). While nitrous oxide (Answer E) is not a halogenated gas, it is not typically used with laparoscopic surgeries as there is concern for bowel distension.Answer: DWatt S, McAllister RK . Malignant Hyperthermia. Stat Pearls Publishing . 2020Ruffert H, Bastian B, Bendixen D, et al. Consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients from the European Malignant Hyperthermia group. Br J Anaesth. 2021; 126(1):120–130. doi: https://doi.org/10.1016/j.bja.2020.09.029. Epub 2020 Oct 31. PMID: 33131754
11 Transfusion, Hemostasis, and Coagulation
Lindsey Karavites, MD and Kazuhide Matsushima, MD
Division of Acute Care Surgery, University of Southern California, LAC+USC Medical Center, Los Angeles, CA, USA
1 57‐year‐old man was brought into the trauma bay after a witnessed fall from his third‐floor apartment onto the sidewalk. He is lethargic but arousable with blood pressure 80/40 mmHg and heart rate 135 beats/min. He is noted to have a scalp laceration and bilateral lower extremity deformities with significant blood loss noted at the scene. What is one advantage of selecting low titer whole blood for his resuscitation over component therapy?24‐hour survival benefit in the severely injured.Decreased 24‐hour total transfusion requirement.Cost effectiveness of prolonged time to product expiration.Decreased transfusion reactions due to standardized safe antibody titer levels.No risk of post‐transfusion hemolysis.Increasing retrospective data from the military medical community for use of whole blood in resuscitation have led to similar efforts in civilian trauma patients. Low titer whole blood may have institution specific definitions; however, it is generally considered unseparated blood collected from a donor with low titers of Ig M and/or IgG anti‐A and anti‐B. Implementation of cold‐stored low‐titer anti‐A and anti‐B group O whole blood (LTOWB) transfusion strategies are in place in civilian trauma centers but further prospective data are necessary to examine discrete comparisons of whole blood without simultaneous use of components, verification of appropriate safety, and determination of cost–benefit analyses. To date, the only randomized controlled pilot trial comparing the use of whole blood to component therapy demonstrated that those receiving whole blood required fewer blood products at 24 hours with no difference in mortality. Another recent study comparing between LTOWB vs. component therapy showed that the use of LTOWB was significantly associated with a reduction in post‐emergency department blood transfusion and improved 30‐day survival. Additional advantages include ease of use with single bag product storage, reduced human error with administration, decreased transfusion reactions, although no standard safe antibody titer levels have been established, as well as avoidance of excessive volume, additives and anticoagulants.Answer: BCotton, B.A, Podbielski, J., Camp, E., et al. (2013) Early Whole Blood Investigators: A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg ,258 (4), 527–532.Williams, J., Merutka, D., Bai, Y., et al. (2019) Safety profile and impact of low‐titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg , 88 (1), 87–93.
2 When massive transfusion is indicated, the American College of Surgeons Trauma Quality Improvement Program currently recommends one unit of apheresis platelets to be given following the administration of how many units of packed red blood cells (PRBCs) in the setting of balanced component 1:1–1:2 (Plasma/PRBCs) resuscitation?12468Evidence currently supports a balanced transfusion strategy that targets a plasma:PRBC ratio approaching 1:1. There is no apparent increase in respiratory complications in the 1:1 group, despite prior retrospective associations between increased plasma transfusion and acute respiratory distress syndrome (ARDS). The latest massive transfusion guidelines from American College of Surgeons Trauma Quality Improvement Program (ACS‐TQIP) recommends a 1:1–1:2 (plasma/RBCs) transfusion ratio with one unit of apheresis platelets given for every 6 units of RBCs transfused.Answer: DCryer, H.G., Nathens, A.B., Bulger, E.M. (2014), American College of Surgeons Trauma Quality Improvement Program Massive Transfusion in Trauma Guidelines. facs.org/‐/media/files/quality‐programs/trauma/tqip/transfusion_guildelines.ashx.
3 A 75‐year‐old woman with cirrhosis arrives in the trauma bay after being hit by a car while crossing the street. Her initial work up revealed two left‐sided rib fractures and a grade 3 splenic laceration without evidence active extravasation. She is hemodynamically stable and her initial laboratory tests reveal a hemoglobin of 9.5 g/dL, hematocrit of 29%, platelet count of 125 000/mm 3 , and international normalized ratio of 3.1. While being managed nonoperatively in the intensive care unit, she becomes hypotensive. 1 unit of packed red blood cells (PRBCs) and 1 unit of fresh frozen plasma (FFP) are transfused. Shortly after the transfusions are completed, she develops tachycardia and dyspnea requiring supplement oxygen. Which of the following is the most diagnostic of transfusion‐associated acute lung injury (TRALI) as the source of her new oxygen requirement?Bilateral infiltrate on chest radiographyHeart Rate: 135PaO2/FiO2: 300Systolic Blood Pressure: 90Temperature 37.9The differential diagnosis of respiratory distress is broad in the setting of polytrauma, especially in those with known rib fractures and those requiring transfusions. Transfusion‐related acute lung injury (TRALI) is defined by the documentation of acute hypoxemia with PaO2/FIO2 ratio (P/F) of less than 300 mm Hg, bilateral infiltrates on chest radiograph (in