Avoiding Common ICU Errors
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Publication Date: 2006
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ISBN/ISSN: 9780781767392

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This pocket book succinctly describes 318 errors commonly made by attendings, residents, interns, nurses, and nurse-anesthetists in the intensive care unit, and gives practical, easy-to-remember tips for avoiding these errors. The book can easily be read immediately before the start of a rotation or used for quick reference on call.

Each error is described in a short, clinically relevant vignette, followed by a list of things that should always or never be done in that context and tips on how to avoid or ameliorate problems. Coverage includes all areas of ICU practice except the pediatric intensive care unit.

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--Succinct, practical, easy-to-remember tips for avoiding 318 errors commonly made in the ICU
--Geared to the entire ICU staff, including attendings, residents, interns, nurses, and nurse-anesthetists
--Easy to read immediately before the start of a rotation or to use for quick reference on call
--Description of each error includes:
  • a short, clinically relevant vignette
  • a list of things that should always or never be done in that context
  • tips on how to avoid or ameliorate problems

--Covers all areas of ICU practice except the pediatric ICU. Topics include:
  • medications
  • devices, lines, tubes, catheters, drains, procedures
  • ventilators, airway, intubation, extubation
  • infectious disease
  • shock, fluids, electrolytes
  • neurological/neurosurgical intensive care
  • laboratory tests
  • nutrition
  • renal disease
  • blood
  • imaging and tests
  • pregnancy
  • burns
Elliott R. Haut MD
Assistant Professor of Surgery, Division of Critical Care and Trauma Surgery, Department of Surgery, The Johns Hopkins School of Medicine, The Johns Hopkins Hospital, Baltimore, MD

Lisa Marcucci MD
Attending Physician
Department of Surgery and Critical Care Medicine
Veterans Administration Hospital
Pittsburgh, Pennsylvania

Elizabeth A. Martinez MD, MHS
Assistant Professor, Anesthesiology/Critical Care Medicine and Surgery, Johns Hopkins University; Medical Director, Adult Post-Anesthesia Care Units, Johns Hopkins Medicine, Baltimore, MD

Jose I. Suarez MD
Associate Professor, Department of Neurology/Neurosurgery, Case Western Reserve University; Director, Neurosciences Critical Care, Department of Neurology/Neurosurgery, University Hospitals of Cleveland, Cleveland, OH

Anthony D. Slonim MD, DrPH
Senior Staff, Medicine and Pediatrics, Carilion Clinic; Professor, Virginia Tech-Carilion School of Medicine, Roanoke, VA


ISBN/ISSN: 9780781767392
Product Format: Softbound
Trim Size: 5 x 8
Pages: 896
Pub Date: 2006
Weight: 1.95
 MEDICATIONS
1 Monitor patients who have received intrathecal preservative-free
morphine. Melvin K. Richardson, MD................................. 2
2 Know the characteristics of the narcotics you prescribe.
Nirav G. Shah, MD.......................................................... 4
3 Consider clonidine to combat effects of drug withdrawal.
Melvin K. Richardson, MD................................................. 6
4 Strongly consider prophylaxis for alcohol withdrawal.
Bradford D. Winters, MD, PhD............................................ 8
5 Avoid concomitant use of steroids, neuromuscular blockade,
and aminoglycosides to lessen the risk of critical illness
myopathy. Timothy M. Moore, MD, PhD.............................. 11
6 Use prophylaxis for the immediate side effects of steroids.
D. Joshua Mancini, MD and Rajan Gupta, MD....................... 14
7 Speci?cally query for previous steroid use.
Lisa Marcucci, MD and Prasert Sawasdiwipachai, MD............. 16
8 Do not use succinylcholine in patients with burns, paralysis, or
other high potassium states. Eugenie S. Heitmiller, MD........... 18
9 Consider using cisatracurium for neuromuscular paralysis in
patients with hepatic and renal failure.
Muhammad I. Durrani, MD................................................ 20
10 Remember that there are two “Neos”.
Nancy Sokal Hagerman, MD.............................................. 23
11 Treat neuroleptic malignant syndrome as an emergency and
remember its presentation may not be dose-dependent.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 25
12 Remember that malignant hyperthermia may not have
hyperthermia. Nancy Sokal Hagerman, MD......................... 29
13 Remember that amiodarone causes hypothyroidism.
Benjamin S. Brooke, MD.................................................... 32
14 Do not use amiodarone to rate control chronic atrial ?brillation.
Bradford D. Winters, MD, PhD............................................ 34
15 Exercise care in the use of amiodarone and alternative
antiarrhythmics for the treatment of atrial ?brillation.
Muhammad I. Durrani, MD and Alan Cheng, MD................... 36
16 Be aware that furosemide contains a sulfa moiety.
Ardalan Minokadeh, BS and Anushirvan Minokadeh, MD......... 39
17 Carefully observe the clinical response to intermittent
furosemide dosing when deciding on additional doses.
Melissa S. Camp, MD........................................................ 41
18 Do not administer methylene blue if there is possible
gastrointestinal absorption. Beverly J. Newhouse, MD and
Anushirvan Minokadeh, MD............................................... 43
19 Be alert for metabolic acidosis in patients on lorazepam drips.
Yasir M. Akmal, MD........................................................ 45
20 Be alert for the development of cyanide toxicity when
administering nitroprusside. E. David Bravos, MD................ 48
21 Administer beta-blockade initially before administering “other”
antihypertensives when treating aortic dissection.
Eric S. Weiss, MD............................................................. 50
22 Do not use vasopressin in patients with heart failure or
mesenteric ischemia. Benjamin S. Brooke, MD...................... 52
23 Remember that cardiac pressors do not work in a low-pH
environment. Bradford D. Winters, MD, PhD........................ 54
24 Consider thrombolytics in ST-elevation myocardial infarction if
percutaneous coronary intervention is not available or delayed.
Julius Cuong Pham, MD..................................................... 56
25 Consider the use of glycoprotein IIb/IIIa inhibitors in unstable
coronary syndromes. Andrew L. Rosenberg, MD.................... 59
26 Strongly consider low-molecular-weight heparin in the
treatment of unstable angina and non—ST-elevation myocardial
Infarction. Julius Cuong Pham, MD.................................... 62
27 Strongly consider using glycoprotein IIb/IIIa inhibitors as an
added treatment to stenting in acute myocardial infarction.
Nirav G. Shah, MD.......................................................... 65
28 Consider nesiritide in acutely decompensated heart failure.
Jacqueline Janka, MD........................................................ 67
29 Be aggressive in considering reperfusion therapy in acute
myocardial infarction. Anthony D. Slonim, MD, DrPH............ 69
30 Strongly consider starting an angiotensin-converting enzyme
inhibitor or angiotensin receptor blocker after myocardial
infarction. Ying Wei Lum, MD........................................... 71
31 Use prophylaxis for erosive gastritis appropriate patient.
Rachel Bluebond-Langner, MD............................................ 74
32 Beware of metabolites. Bradford D. Winters, MD, PhD............ 76
33 Do not use erythromycin as a prokinetic agent in patients on
tacrolimus (or cyclosporine). Matthew J. Weiss, MD............... 78
34 Consider use of enoxaparin over unfractionated heparin in
trauma patients. Suneel Khetarpal, MD and
Barbara Haas, MD........................................................... 80
35 Maintain tight glucose control in the intensive care unit.
Michael J. Moritz, MD...................................................... 82
36 Do not use subcutaneous insulin in the intensive care unit
population. Kristin Shipman, MD and Heidi L. Frankel, MD... 84
37 Do not use insulin glargine in the intensive care unit without also
giving a shorter-acting insulin form.
Kristin Shipman, MD and Heidi L. Frankel, MD..................... 85
38 Remember that patients with insulin de?ciency require basal
insulin even when they are NPO.
Kathleen A. Williams, RN, MSN, CRNP and
Sherita Hill Golden, MD, MHS........................................... 86
39 Look for medication-induced causes of hyperglycemia in
intensive care patients. Edward T. Horn, PharmD.................. 88
40 Do not use midazolam and lorazepam interchangeably in the
intensive care unit. M. Craig Barrett, PharmD and
Ronald F. Sing, DO........................................................... 90
41 Try to avoid using benzodiazepines for sleep in the intensive care
unit, especially in the elderly. Bryan A. Cotton, MD............... 92
42 Remember that activated protein C is not as useful for sepsis as
once hoped. Ronald W. Pauldine, MD.................................. 95
43 Know the alternate routes for administration of cardiopulmonary
resuscitation medications. Eric M. Bershad, MD and
Jose I. Suarez, MD........................................................... 97
44 Alkalinize the urine in tricyclic antidepressant overdose.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 99
45 Check triglyceride level in patients on propofol drips.
Amisha Barochia, MD....................................................... 101
46 Be alert for drug-related pancreatitis in HIV/AIDS patients and
consider a period of proximal bowel rest.
Lawerence Osei, MD.......................................................... 104
47 Consider the use of ?uconazole prophylaxis in intensive care
patients with severe pancreatitis, abdominal sepsis, or need for
multiple abdominal surgeries. Lisa Marcucci, MD.................. 107
48 Have a high threshold for administering vitamin K intravenously.
Michael J. Moritz, MD...................................................... 109
49 Do not use benzocaine spray: It increases the risk of
methemoglobinemia. Kelly Grogan, MD.............................. 111
50 Know which weight to use when dosing medications.
Edward T. Horn, PharmD................................................... 116
51 Beware of intensive care unit medications that can increase serum
potassium and cause hyperkalemia. Adam R. Berliner, MD and
Derek M. Fine, MD........................................................... 119
52 Administer acetazolamide (diamox) on a one-time dose schedule
only. Ying–Wei Lum, MD.................................................. 
53 Check an electrocardiogram for long QT interval before giving
haloperidol. Shaytone Nichols, MD..................................... 125
54 Do not use ipratropium in meter-dose inhaler form in patients
with nut allergies. J. Gregory Hobelmann, MD....................... 127
55 Be cautious in using ketorolac in patients with marginal urine
output or renal function. Angela D. Shoher, MD.................... 129
56 Do not crush sevelamer hydrochloride (renagel) to place down a
nasogastric or feeding tube. Ashita Goel, MD........................ 131
57 Remember that many commonly used intensive care unit drugs
should not be used in porphyria.
J. Gregory Hobelmann, MD................................................ 133

DEVICES/LINES/TUBES/CATHETERS/DRAINS/PROCEDURES
58 Do not insert, change, or remove a central line with the patient
sitting up. Aaron Bransky, MD and Heidi L. Frankel, MD....... 136
59 Avoid central access in the right internal jugular in cardiac
transplant patients if possible. Benjamin S. Brooke, MD.......... 138
60 Place the tip of a central venous catheter at the junction of the
superior vena cava and atrium. Jayme E. Locke, MD.............. 139
61 Do not remove the intravenous catheter used for plasmapheresis
immediately after the last treatment. Kelly Olino, MD............ 141
62 Never thread a triple-lumen through a cordis.
Bradford D. Winters, MD, PhD............................................ 143
63 Be meticulous in technique when inserting and caring for central
venous access catheters in the intensive care unit to lower the
incidence of infection. Lisa Marcucci, MD........................... 145
64 In a patient with a previously placed vena cava ?lter, do not use
the J-tip on the guidewire when using the Seldinger technique
to place a central venous catheter. Lisa Marcucci, MD and
Awori J. Hayanga............................................................. 148
65 Do not “whip the tip” when testing a pulmonary catheter before
insertion. Rachel Bluebond-Langner, MD.............................. 150
66 Remove kinked or coiled pulmonary artery catheters.
Hari Nathan, MD............................................................ 152
67 Remove a pulmonary artery catheter in patients with new-onset
ventricular arrhythmias and in most atrial arrhythmias.
William R. Burns, MD....................................................... 154
68 Remember that in normal physiology the wedge pressure is less
than the pulmonary artery diastolic pressure.
Jose M. Rodriguez-Paz, MD............................................... 156
69 Do not use pulmonary artery catheter measurements in tricuspid
regurgitation. Dimitris Stefanidis, MD, PhD and
Ronald F. Sing, DO........................................................... 159
70 Always turn on a pacing pulmonary artery catheter prior to
?oating the device. Bradford D. Winters, MD, PhD................. 161
71 Make sure any Cordis in place is the correct size when emergently
?oating a transvenous pacing wire. Christina L. Cafeo, RN, MSN,
David G. Hunt, RN, BSN and Peter J. Pronovost, MD, PhD...... 164
72 Try placing a skin lead to act as a ground wire if pacing wires are
not functioning correctly postoperatively.
Tammy M. Slater, CRNP................................................... 166
73 Know the backup mechanism of action and requirements for
electrical cardioversion and anticoagulation for ventricular assist
devices. Elizabeth A. Martinez, MD, MHS........................... 168
74 Place the de?brillator in synchronous mode when cardioverting.
Angela D. Shoher, MD....................................................... 171
75 Turn off the synchronization mode on the de?brillator if there
is no recognized R wave. Nirav G. Shah, MD....................... 173
76 Do not rule out the presence of a myocardial infarction by a
normal electrocardiogram. Jose M. Rodriguez-Paz, MD.......... 175
77 Do not use the 3 or 5 lead ECG monitor as a
12-lead electrocardiogram. Tuhin K. Roy, MD, PhD.............. 178
78 Put a board under the patient when doing chest compressions.
Elizabeth A. Hunt, MD, MPH and
Cameron Dezfulian, MD.................................................... 184
79 Know the pacemaker alphabet soup.
Elizabeth A. Martinez, MD, MHS....................................... 186
80 Do not use cooling blankets to cool.
Iosi?na Giannakikou, MD.................................................. 189
81 Do not place femoral arterial lines or venous catheters above the
inguinal ligament or below the thigh crease.
Susanna L. Matsen, MD.................................................... 191
82 Consider respiratory variation on the arterial-line monitor
tracing as a sign of hypovolemia. James F. Weller, MD............. 193
83 Caution when using low-molecular-weight heparin in patients
with epidurals. Awori J. Hayanga, MD and Elliott R. Haut, MD 195
84 Administer epidural test doses. Rahul G. Baijal, MD............. 197
85 Consider an intravenous naloxone drip for treatment of pruritus
associated with epidural analgesia.
J. Gregory Hobelmann, MD................................................ 199
86 Be meticulous when dosing bupivacaine in patients with both
epidural and pleural catheters. Patricia M. Veloso, MD........... 201
87 Do not dismiss rib fractures as trivial and consider an epidural
catheter for pain control in multiple rib fractures.
Bryan A. Cotton, MD........................................................ 203
88 Use a two-step technique with radiographic con?rmation when
placing a feeding tube. Julius Cuong Pham, MD..................... 206
89 Perform doppler ultrasound before placing sequential
compression devices. Bradford D. Winters, MD, PhD.............. 208
90 Consider changing the Foley catheter when a patient has a
urinary tract infection. Melissa S. Camp, MD........................ 210
91 Do not ?ush ureteral stents if a urological consultation is
available. Jennifer Miles-Thomas, MD.................................. 212
92 Make sure the cuff (pilot balloon) is completely de?ated on a
cuffed tracheostomy tube before a Passy-Muir speaking valve is
placed. Molly B. Campion, MS........................................... 213
93 Know the clinically important issues with using an intra-aortic
balloon pump. Elizabeth A. Martinez, MD, MHS.................. 215
94 Remember that right heart failure is a common and important
complication/management challenge following placement of a
left ventricular assist device. Andrew L. Rosenberg, MD........... 218
95 Know the common problems associated with cardiopulmonary
support using extracorporeal membrane oxygenation.
Andrew L. Rosenberg, MD.................................................. 221
96 Treat “wrinkling” in the Abiomed diaphragm as a possible sign
of hypovolemia. Frank Rosemeier, MD................................. 224
97 Administer antibiotics before placing a chest tube in trauma
patients. Peter G. Thomas, DO and Patrick K. Kim, MD.......... 226
98 Be suspicious of a large persistent air leak in a chest tube.
David T. Efron, MD.......................................................... 228
99 Treat any milky ?uid coming from the chest or abdomen as
chylous until proven otherwise. D. Joshua Mancini, MD and
Rajan Gupta, MD............................................................. 231
100 Know the conditions that cause an inaccurate pulse oximetry
reading. Eliahu S. Feen, MD and Jose I. Suarez, MD.............. 233
101 Remember that pulse oximetry is inaccurate at lower saturation
levels. Nirav G. Shah, MD................................................ 236
102 Consider placing an intracranial pressure monitor in patients
with Glasgow coma scale ≤8. Jose I. Suarez, MD.................. 238
103 Know how to use the Licox System to measure brain tissue
oxygenation. Aaron Bransky, MD and Heidi L. Frankel, MD... 241

VENTILATORS/AIRWAY/INTUBATION/EXTUBATION
104 Preoxygenate patients before intubation.
Rahul G. Baijal, MD......................................................... 244
105 Use cricoid pressure when performing rapid sequence intubation
or bag-mask ventilation. Rahul G. Baijal, MD...................... 246
106 Do not use the presence of end-tidal CO2 to rule out esophageal
intubation. Patricia M. Veloso, MD..................................... 249
107 Have a low threshold for contacting the most experienced
available airway professional in patients with diseases associated
with dif?cult airways. Lauren C. Berkow, MD....................... 251
108 Always use a vertical incision when performing a
cricothyroidotomy. Brandon R. Bruns, MD
and Heidi L. Frankel, MD.................................................. 254
109 Use bronchoscopic guidance for bedside percutaneous
dilatational tracheostomy (PDT).
Susanna L. Matsen, MD and Elliott R. Haut, MD................... 256
110 Consider early tracheostomy in select patients. Konstantinos
Spaniolas, MD and George G. Velmahos, MD, PhD.................. 259
111 Position the tip of the endotracheal tube 4 centimeters above the
carina. Leo Hsiao, DO....................................................... 261
112 Remember that even a fully in?ated cuff on the endotracheal
tube is not adequate protection against aspiration.
Ashita Goel, MD.............................................................. 264
113 Do not overin?ate the endotracheal cuff.
Gregory Dalencourt, MD and
Elizabeth A. Martinez, MD, MHS....................................... 267
114 Check for a cuff leak before extubation in patients who might
have airway edema E. David Bravos, MD............................. 269
115 Know how to measure plateau pressure when using
pressure-regulated volume control ventilation mode and know
what to do with the value once it is obtained.
David N. Hager, MD......................................................... 271
116 Use plateau or mean pressure as a more accurate assessment of
barotrauma than peak pressure. W. Benjamin Kratzert, MD and
Anushirvan Minokadeh, MD............................................... 275
117 Consider airway pressure release ventilation for delivering an
open-lung strategy. Anthony D. Slonim, MD, DrPH............... 277
118 Remember that static compliance of the respiratory system is not
the same thing as dynamic compliance. Nirav G. Shah, MD.... 279
119 Remember that recruitment of alveoli using an increased level of
positive end-expiratory pressure can take 6 to 12 hours.
David N. Hager, MD......................................................... 281
120 Have a high suspicion of auto positive end-expiratory pressure
when attempting to wean patients with chronic obstructive
pulmonary disease. Jose M. Rodriguez-Paz, MD.................... 284
121 Be cautious in using positive end-expiratory pressure after
single-lung transplants. Eric S. Weiss, MD and
Ashish S. Shah, MD.......................................................... 287
122 Select an initial pressure setting that is just slightly higher than
the patient’s peak pressure when attempting a pressure support
wean. Anthony D. Slonim, MD, DrPH................................. 289
123 Do not reverse neuromuscular blockade unless the patient is
warm. James F. Weller, MD............................................... 291
124 Use glycopyrrolate before using neostigmine when reversing
neuromuscular blockade. Leo Hsiao, DO.............................. 294
125 Do not attempt to reverse neuromuscular blockade if there are
no twitches. E. David Bravos, MD...................................... 296
126 Remove continuous positive airway pressure and bilevel positive
airway pressure masks periodically.
Bradford D. Winters, MD, PhD........................................... 298
127 Empirically cover the common nosocomial microbes in
ventilator-associated pneumonia until the cultures are returned.
Anthony D. Slonim, MD, DrPH........................................... 300
128 Keep the head of bed elevated at least 30 degrees for intubated
patients if no contraindications exist.
Deborah B. Hobson, BSN and
Sean M. Berenholtz, MD, MHS.......................................... 303
129 Treat ventilator-associated pneumonia for 8 days.
B. Robert Gibson, MD........................................................ 305
130 Do not routinely extubate on clinical picture alone.
Ronald W. Pauldine, MD.................................................... 310
131 Consider using heliox in the mechanically vented asthmatic
patient. Anthony D. Slonim, MD, DrPH............................... 313

INFECTIOUS DISEASE
132 Consider parvovirus b19 infection in patients with anemia or
pancytopenia. Jayme E. Locke, MD..................................... 316
133 Consider prophylactic antibiotics when leeches are applied to
free ?aps. Benjamin A. Mandel, MD.................................... 317
134 Treat methicillin-resistant staphylococcus aureus with a
minimum of 14 days of antibiotics.
Iosi?na Giannakikou, MD.................................................. 319
135 Be alert for thrombocytopenia and neutropenia with linezolid.
Shaytone Nichols, MD....................................................... 321
136 Have a high threshold for using caspofungin and voriconazole in
patients with liver disease. Leo Hsiao, DO............................ 323
137 Do not use caspofungin or voriconazole to treat yeast in the urine
because a very small amounts of these drugs are excreted in the
urine. Harjot K. Singh, MD and Lesia K. Dropulic, MD.......... 326
138 Administer a dose of antibiotic before the bile system is
instrumented or manipulated. Kelly Olino, MD..................... 328
139 Administer an antibiotic before urinary tract obstruction is
relieved. Jennifer Miles-Thomas, MD................................... 330
140 Remember thatenterococcus is a rare invasive pulmonary tract
infection. Aruna K. Subramanian, MD................................ 332
141 Know how to calculate the clinical pulmonary infection score.
B. Robert Gibson, MD........................................................ 334
142 Remember that lack of positive blood cultures does not rule out
bacterial endocarditis. Harjot K. Singh, MD and
Aruna K. Subramanian, MD............................................... 337
143 Treat black lips or a black spot on the oral mucosa as a surgical
emergency. Aruna K. Subramanian, MD.............................. 340
144 Check for cryptosporidium in immunosuppressed patients with
chronic, severe, or refractory diarrhea.
Ala’ S. Haddadin, MD....................................................... 343
145 Pay attention to the morphology reported by the microbiology
lab for fungal cultures. Shelley S. Magill, MD and
William G. Merz, PhD....................................................... 346
146 Consider possible fungal infection in patients with hypothermia
and bradycardia. Suneel Khetarpal, MD and
Andrew J. Kerwin, MD...................................................... 348
147 Give special consideration to the extended-spectrum
beta-lactamase-producing organisms before administering
antibiotics. John J. Lewin III, PharmD................................ 350
148 Have a high threshold for thoracentesis when looking for a source
of infection. Deba Sarma, MD........................................... 352
149 Aim for a peak of ten times the minimum inhibitory
concentration (MIC) to kill pseudomonaswhen using an
aminoglycoside. Edward T. Horn, PharmD........................... 355
150 Know the de?nition of a catheter-related bloodstream infection.
Bradford D. Winters, MD, PhD............................................ 358
151 Strongly consider stopping prophylactic antibiotics after
24 hours in penetrating abdominal trauma.
Konstantinos Spaniolas, MD and
George C. Velmahos, MD, PhD............................................ 360
152 Use clindamycin in necrotizing fasciitis to cover group a
streptococcus. Carrie A. Sims, MD, MS and
Patrick K. Kim, MD......................................................... 362
153 Be cautious in using antibiotics for uninfected pancreatitis.
Benjamin Braslow, MD...................................................... 364
154 Wash your hands. Sandra Swoboda, RN, MSN...................... 369
155 Consider ventriculoperitoneal shunt infection in patients with
sepsis. Jose I. Suarez, MD................................................. 373
156 Recognize that vancomycin has very poor central nervous system
penetration. Eliahu S. Feen, MD and Jose I. Suarez, MD........ 378
157 Be alert for seizures with imipenem use.
Anthony D. Slonim, MD, DrPH .......................................... 380
158 Remember if there is a normal platelet count it cannot be
hantavirus pulmonary syndrome.
Anthony D. Slonim, MD, DrPH........................................... 382
159 Consider empiric helicobacter pylori treatment when
gastric or duodenal ulcers are found.
Anthony D. Slonim, MD, DrPH........................................... 384

SHOCK/FLUIDS/ELECTROLYTES
160 Administer empiric broad-spectrum antibiotics when a patient
may be in septic shock. William R. Burn, MD....................... 388
161 Do not administer the cosyntropin test within 24 hours of using
etomidate. Meghan C. Tadel, MD....................................... 390
162 Switch from hydrocortisone to dexamethasone if the cosyntropin
stimulation test is to be administered.
Meghan C. Tadel, MD....................................................... 392
163 Use vasopressors instead of large-volume resuscitation in the
treatment of shock from massive pulmonary embolism.
Andrew L. Rosenberg, MD.................................................. 394
164 Consider the diseases that mimic septic shock in the differential
of this condition. Anthony D. Slonim, MD, DrPH.................. 396
165 Be alert for a large systemic in?ammatory response after back
surgery. Ashita Goel, MD.................................................. 398
166 Be alert for the development of abdominal compartment
syndrome. Awori J. Hayanga, MD...................................... 400
167 Treat abdominal pain out of proportion to physical exam as
mesenteric ischemia until proven otherwise. D. Joshua Mancini,
MD and Rajan Gupta, MD................................................. 403
168 Do not bolus ?uids that contain dextrose.
Awori J. Hayanga, MD...................................................... 406
169 Remember that diuresis may not be the best treatment for
hyperkalemia in the early post–cardiopulmonary bypass period.
Frank Rosemeier, MD, and
Elizabeth A. Martinez, MD, MHS....................................... 407
170 Remember that most patients receive mannitol when going
on the pump so postoperative urine output is not a marker
for volume status or perfusion after cardiac surgery.
Muhammad I. Durrani, MD................................................ 410
171 Do not use urine output as a measure of volume status in patients
who are cold. Juan N. Pulido, MD and
Daniel R. Brown, MD, PhD, FCCM..................................... 412
172 Be careful to not overhydrate postoperative liver-transplant
patients. Dorry L. Segev, MD and Warren R. Maley, MD........ 414
173 Remember that uremia alone rarely causes an anion gap to be
greater than 25. Laith R. Altaweel, MD............................... 416
174 Do not replete calcium in the setting of high phosphorus or
phosphorus in the setting of high calcium.
Mehmet S. Ozcan, MD and Praveen Kalra, MD...................... 418
175 Check postoperative and serial serum levels of phosphorus and
aggressively replete. Robert K. Michaels, MD, MPH.............. 420
176 Consider electrolyte disturbances when there is a change of
mental status. Nirav G. Shah, MD...................................... 422
177 Keep the serum potassium at high normal levels when
attempting to correct a metabolic alkalosis.
Eric S. Weiss, MD............................................................. 424
178 Do not replete calcium in rhabdomyolysis unless a patient is in
tetany. Anthony D. Slonim, MD, DrPH................................ 427
179 Consider excess chloride as a cause of an unexplained
non-anion-gap metabolic acidosis.
Anthony D. Slonim, MD, DrPH........................................... 429
180 Consider hyperchloremic metabolic acidosis to be a renal tubular
acidosis until proven otherwise if obvious sources of bicarbonate
losses like diarrhea, urinary diversions, and the administration
of chloride are not present. Anthony D. Slonim, MD, DrPH..... 431

NEURO
181 Be alert for new-onset cauda equina syndrome in patients with
sacral or spinal fractures or surgery and obtain emergent
neurosurgical consultation if suspected.
Michael J. Dorsi, MD........................................................ 434
182 Keep patients with dural tears ?at for 24–48 hours.
Jayme E. Locke, MD......................................................... 436
183 Know the status of cervical, thoracic, and lumbar spine stability
on all postoperative and trauma patients.
Rachel Bluebond-Langner, MD............................................ 438
184 Apply appropriate deep vein thrombosis prophylaxis to patients
with spinal cord injury. Jose I. Suarez, MD.......................... 441
185 Be alert for autonomic dysre?exia in intensive care unit patients
with a spinal cord injury. Jose I. Suarez, MD........................ 444
186 Consider the use of steroids for neurological trauma in blunt
spinal cord injury only.
Jacob T. Gutsche, MD and Patrick K. Kim, MD...................... 447
187 Start an early bowel regimen in patients after spinal cord injury.
Jose I. Suarez, MD........................................................... 449
188 Consider moderate hypothermia after cardiac arrest.
Bradford D. Winters, MD, PhD............................................ 451
189 Be vigilant for blunt cerebrovascular injury after trauma.
Michael D. Grossman, MD ................................................. 453
190 Have an extremely high threshold in giving antihypertensives in
head trauma. M. Craig Barrett, PharmD and
Ronald F. Sing, DO........................................................... 456
191 Do not give more than 7 days of antiseizure medication in head
trauma. B. Lauren Paton, MD and Ronald F. Sing, DO............ 458
192 Calculate the Glasgow coma scale using the best motor response.
D. Joshua Mancini, MD and Rajan Gupta, MD....................... 460
193 Use magnetic resonance imaging (not head computed
tomography) as the gold standard test for diffuse axonal injury.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 462
194 Remember that there is usually an upward drift in some
intracranial-pressure monitor readings the longer they have been
in place. Eliahu S. Feen, MD and Jose I. Suarez, MD.............. 464
195 Be aware that increasing positive end-expiratory pressure may
result in increasing intracranial pressure.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 467
196 Obtain a computed tomography scan of the head immediately
after any craniotomy or intracranial procedure if patient’s
neurologic examination is different from preoperative
assessments..
Jose I. Suarez, MD........................................................... 469
197 Consider last-ditch maneuvers to lower intracranial
hypertension in impending herniation. Eliahu S. Feen, MD and
Jose I. Suarez, MD........................................................... 471
198 Remember that patients undergoing barbiturate coma must have
adequate electrophysiological monitoring. Jose I. Suarez, MD. 474
199 Be alert for conversion of nonhemorrhagic (ischemic) stroke to
hemorrhagic stroke. Jose I. Suarez, MD............................... 476
200 Obtain a head computed tomography scan and lumbar puncture
in patients with human immunode?ciency virus or acquired
immunode?ciency syndrome and new-onset mental status
changes. Eric M. Bershad, MD and Jose I. Suarez, MD........... 479
201 Have a low threshold for obtaining an initial and repeat head
computed tomography scan after subarachnoid hemorrhage.
Eric M. Bershad, MD and Jose I. Suarez, MD........................ 482
202 Be alert for rebleeding in patients with subarachnoid
hemorrhage. Nirav G. Shah, MD....................................... 486
203 Remember that new electrocardiogram changes in a patient with
a subarachnoid bleed may be a sign of progression of the bleed.
Amisha Barochia, MD....................................................... 489
204 Consider the use of thrombolytic agents for treatment of acute
ischemic stroke. Nirav G. Shah, MD................................... 491
205 Consider absence of withdrawal to pain at 24 hours and absence of
eye re?exes at 72 hours post–cardiac arrest to be highly correlated
with permanent coma. Amisha Barochia, MD....................... 493
206 Remember that failure to recognize pituitary apoplexy can result
in a neurologic catastrophe. Eric M. Bershad, MD and
Jose I. Suarez, MD........................................................... 495
207 Do not perform a lumbar puncture on patients with posterior
fossa masses. Jose I. Suarez, MD........................................ 498
208 Evaluate for Guillain-Barre-syndrome in patients with acute ´
paralysis or respiratory failure and are?exia.
Jose I. Suarez, MD........................................................... 501
209 Start Early Plasmapheresis or Immunoglobulins in
Guillain-Barre-Patients. ´ Jose I. Suarez, MD......................... 505
210 Remember that patients with myasthenia gravis exacerbation
usually look well until just before they require intubation.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 508
211 Avoid using incentive spirometry in myasthenia gravis patients;
use intrapulmonary percussive ventilation or ?utter valve
instead. Eric M. Bershad, MD and Jose I. Suarez, MD............ 511
212 Remember that not all seizures are convulsive and obvious.
Jose I. Suarez, MD........................................................... 513
213 Treat status epilepticus as a medical emergency.
Laith R. Altaweel, MD...................................................... 515
214 Know the potential adverse effects of valproic acid.
Jose I. Suarez, MD........................................................... 517
215 Learn the cranial nerve examination as one can obtain a lot of
information even in comatose and poorly cooperative patients.
Eliahu S. Feen, MD and Jose I. Suarez, MD........................... 519
216 Do not squeeze the toenails or administer a painful stimulus
to the foot to test response to pain in comatose patients as this
may trigger a spinal re?ex that may be seen even in brain-dead
patients. Jose I. Suarez, MD.............................................. 528

LABORATORY
217 Do not ascribe an increased serum lactate level to renal
insuf?ciency. Susanna L. Matsen, MD................................. 532
218 Do not treat lactic acidosis with bicarbonate.
Prasert Sawasdiwipachai, MD............................................. 534
219 Remember that postoperative hypertension can be a result of
increased pCO2. Melvin K. Richardson, MD.......................... 536
220 Do not use a normal arterial blood gas to rule out a pulmonary
embolism. David N. Hager, MD......................................... 538
221 Remember that argatroban increases international normalized
ratio but does not affect coagulation in the extrinsic system.
Kelly Grogan, MD............................................................ 542
222 Check serial methemoglobin levels in patients on inhaled nitric
oxide. Timothy M. Moore, MD, PhD................................... 546
223 Remember that troponin levels may be inaccurate as a measure
of cardiac damage in renal insuf?ciency.
Bradford D. Winters, MD, PhD............................................ 550
224 Ask the laboratory for a synergy panel in resistant Pseudomonas
infections. Harjot K. Singh, MD and
Sara E. Cosgrove, MD, MHS.............................................. 553
225 Obtain blood used for mixed venous oxygen testing from the
distal pulmonary artery catheter port.
Ala’ S. Haddadin, MD....................................................... 555
226 Check thyroid function in critically ill patients.
Meghan C. Tadel, MD....................................................... 558
227 Use an empty lab tube to check the viability of a stoma.
B. Robert Gibson, MD........................................................ 562
228 Never retest low serum glucose; treat immediately and then
prevent further episodes. Kathleen A. Williams, RN, MSN,
CRNP and Sherita Hill Golden, MD, MHS........................... 564
229 D-dimer levels can rule out but not rule in pulmonary embolism
in postoperative patients. Hari Nathan, MD......................... 567
230 Remember that diabetic ketoacidosis often begins with an
anion-gap metabolic acidosis. Nirav G. Shah, MD................. 568
231 Consider obtaining a serum b-type natriuretic peptide level in
the acutely dyspneic patient. Lawrence Osei, MD................... 570
232 Consider hypomagnesemia as a cause of refractory hypokalemia.
Anthony D. Slonim, MD, DrPH........................................... 572

NUTRITION
233 Be aware that enteral feeds can lower phenytoin levels.
Timothy M. Moore, MD, PhD and
Faramarz Zarfeshanfard, RPh............................................. 576
234 Consider early enteral feeding. Bryan A. Cotton, MD............. 579
235 Be alert for overfeeding. Jason Sperry, MD and
Heidi L. Frankel, MD........................................................ 582
236 Be alert for the development of refeeding syndrome.
William S. Hoff, MD......................................................... 584
237 Consider using elemental or semielemental feeds in patients with
albumin less than 2.5 grams per deciliter.
Ronald W. Pauldine, MD.................................................... 586
238 Consider enteral feedings in pancreatitis and enterocutaneous
?stulae. Christopher J. Sonnenday, MD, MHS....................... 588
239 Use the metabolic cart only when patients are on low vent
settings. Anthony D. Slonim, MD, DrPH.............................. 591
240 Use a dedicated, upper-body, single-lumen central venous
catheter for administration of parenteral nutrition.
Lisa Marcucci, MD........................................................... 593

RENAL
241 Be alert for hypophosphatemia in the intensive care unit patient
on dialysis. Adam R. Berliner, MD and Derek M. Fine, MD...... 596
242 Know the drugs that must be redosed after dialysis.
Edward T. Horn, PharmD................................................... 598
243 Remember that continuous venovenous hemodialysis can
obscure a temperature spike. Frank Rosemeier, MD................ 602
244 Clamp the dialysate line in continuous venovenous hemodialysis
immediately if it becomes pink tinged.
Anthony D. Slonim, MD, DrPH........................................... 604
245 Do not use continuous venovenous hemodialysis in the setting
of angiotensin-converting enzyme 2 and vice versa.
Anthony D. Slonim, MD, DrPH .......................................... 607
246 Do not give ?udrocortisone to patients on dialysis.
Anthony D. Slonim, MD, DrPH........................................... 609
247 Avoid the subclavian vein for central access of any type in a
dialysis patient or possible dialysis patient.
Michael J. Moritz, MD...................................................... 611
248 Use caution when using milrinone in renal failure.
Ying-Wei Lum, MD.......................................................... 614
249 Decrease the dose of ganciclovir in renal insuf?ciency.
Angela D. Shoher, MD....................................................... 616
250 Remember that trimethoprim-sulfamethoxazole (bactrim)
crystals can precipitate in the kidney and cause renal damage and
failure. Praveen Kalra, MD and Mehmet S. Ozcan, MD........... 618
251 Be aware that lipid-based amphotericin products are associated
with less renal toxicity than regular amphotericin but can still
cause renal injury. John J. Lewin III, PharmD....................... 620
252 Have a high level of suspicion for drug-induced acute interstitial
nephritis. Adam R. Berliner, MD and Derek M. Fine, MD........ 623
253 Consider rhabdomyolysis in the patient who develops oliguric
renal failure after a prolonged surgery where muscle compression
may have occurred. William R. Burn, MD........................... 626
254 Aim for 2 milliliters per kilogram per hour of urine output in
rhabdomyolysis. Awori J. Hayanga, MD and
Elliott R. Haut, MD.......................................................... 629
255 Do not attempt to convert oliguric to nonoliguric renal failure
with diuretics. Brandon R. Bruns, MD and
Heidi L. Frankel, MD........................................................ 631
256 Consider N-acetylcysteine or sodium bicarbonate prophylaxis
along with adequate hydration to combat contrast-induced
nephropathy. Michael J. Moritz, MD.................................. 633

BLOOD
257 Remember that transfusion-related acute lung injury is not dose
dependent. Ala’ S. Haddadin, MD...................................... 636
258 Know the signs of a transfusion reaction.
Eugenie S. Heitmiller, MD.................................................. 638
259 Have a high threshold in transfusing platelets, especially in
nonbleeding patients who are not preoperative.
Michael J. Haut, MD........................................................ 640
260 Do not administer platelets in immune thrombocytopenic
purpura. Laith R. Altaweel, MD......................................... 642
261 Do not administer platelets in type 2 heparin-induced
thrombocytopenia. Laith R. Altaweel, MD........................... 644
262 Remember that reticulocyte count is not accurate after blood
transfusion. Anthony D. Slonim, MD, DrPH......................... 646
263 Consider leukocyte-depleted blood in patients who are
immunosuppressed. Mehmet S. Ozcan, MD and
Praveen Kalra, MD........................................................... 648
264 Administer octreotide in variceal bleeding while waiting for
endoscopy. Madhavi Meka, MD......................................... 650
265 Consider bleeding around a chest tube to be a sign of bleeding in
the chest cavity until proven otherwise.
David J. Caparrelli, MD.................................................... 652
266 Start a proton pump inhibitor infusion for gastric and duodenal
bleeding. Hari Nathan, MD.............................................. 655
267 Remember that bleeding associated with direct thrombin
inhibitors is not correctable with protamine, fresh-frozen plasma,
or platelets. Michael B. Streiff, MD..................................... 657
268 Attempt to decrease phlebotomy. Elliott R. Haut, MD............ 660
269 Consider the use of factor VIIa to treat medical bleeding in a
surgical or trauma patient. Suneel Khetarpal, MD and
Andrew J. Kerwin, MD...................................................... 662
270 Consider angiography as an adjunct in controlling solid-organ
bleeding after damage control surgery.
Michael D. Grossman, MD.................................................. 664
271 Consult surgery emergently if a patient with a bleeding peptic
ulcer rebleeds after endoscopic control. Lee Ann Lau, MD and
Heidi L. Frankel, MD........................................................ 666
272 Call for a Sengstaken-Blakemore or Minnesota tube when a
cirrhotic patient has an upper gastrointestinal bleed.
Anthony D. Slonim, MD, DrPH........................................... 668

IMAGING AND TESTS
273 Treat loss of doppler signals in a free ?ap as a surgical emergency.
Mazen I. Bedri, MD......................................................... 672
274 Remember when reviewing doppler ultrasound results that the
super?cial femoral vein is a component of the deep venous
system. Patrick Schaner, MD............................................. 675
275 Post a sign outside of the door of patients who have received a
tagged white blood cell scan warning of the pregnancy risk.
Tonya N. Walker, MD and
Elizabeth A. Martinez, MD, MHS....................................... 677
276 Obtain an echocardiogram to rule out bacterial endocarditis in
gram-positive bacteremia. Mike J. Faulkner, MD................... 679
277 Diagnose tamponade based on clinical ?ndings and not
echocardiogram. James F. Weller, MD.................................. 682
278 Consider pulsus alternans as a sign of impending tamponade.
Melissa S. Camp, MD ....................................................... 685
279 Do not use a negative focused assessment with sonography for
trauma (FAST) exam to rule out bowel injury or injury to the
retroperitoneum or as the only test in penetrating trauma.
Brendan G. Carr, MD, MA and Patrick K. Kim, MD............... 687
280 Consider using computed tomography reconstructions of the
chest/abdomen/pelvis to rule out thoracic and lumbar fractures
and dislocations. Suneel Khetarpal, MD and
Barbara Haas, MD........................................................... 691
281 Do not rule out cervical spine or spinal cord injury on bony ?lms
or computed tomography alone. Michael D. Grossman, MD..... 693
282 Use the position of the mediastinum as a clue to the diagnosis of
a white-out on chest radiograph.
Nadia N. Hansel, MD, MPH and
Noah Lechtzin, MD, MHS................................................. 695
283 Consider angiography for blunt solid-organ injury.
Suneel Khetarpal, MD and Barbara Haas, MD....................... 697
284 Be alert for compartment syndromes. Frank J. Frassica, MD,
Brett M. Cascio, MD, and Derek Papp, MD............................ 700
285 Be alert for acalculous cholecystitis.
Meredith S. Tinti, MD and Patrick K. Kim, MD..................... 704
286 Avoid giving intravenous contrast dye more often than every
48 hours if possible. Amisha Barochia, MD........................... 706

PREGNANCY
287 Place pregnant patients with right side elevated 15 degrees.
Glen Tinkoff, MD............................................................. 710
288 Avoid the use of drugs harmful to the fetus if at all possible.
Lee Ann Lau, MD and Heidi L. Frankel, MD......................... 711
289 Strongly consider the use of an electronic fetal monitor in caring
for a patient at greater than 24 weeks’ gestation in the intensive
care unit. Robert K. Michaels, MD, MPH............................. 713
290 Know the normal physiologic changes and associated laboratory
values that occur in pregnancy. Glen Tinkoff, MD.................. 715

BURNS
291 Do not administer prophylactic antimicrobials to burn patients.
Gary T. Marshall, MD and James H. Holmes IV, MD.............. 718
292 Remember that not all fever in the burn patient is due to infection.
Oliver A. Varban, MD and James H. Holmes IV, MD............... 721
293 Never underestimate the severity of an electrical burn.
Travis L. Perry, MD and James H. Holmes IV, MD................. 723
294 Do not use hyperbaric oxygen therapy in burns.
Travis L. Perry, MD and James H. Holmes IV, MD................. 727
295 Do not use parenteral nutrition, if at all possible, in burn patients.
Jeremy W. Pyle, MD and James H. Holmes IV, MD.................. 729
296 Strongly consider escharotomy in circumferential burns.
Richard Wong She, MBChB and James H. Holmes IV, MD........ 732
297 Be aware of the pitfalls in the management of Stevens-Johnson
syndrome and toxic epidermal necrolysis.
Vijay A. Singh, MD and Stephen M. Milner, MD.................... 735
298 Adopt a philosophy of early excision and grafting of burn
wounds. Jeremy W. Pyle, MD and
James H. Holmes IV, MD................................................... 737
299 Be aggressive in mobilizing burn wounds.
Dana Nakamura, OT, CLT, CLMC and
James H. Holmes IV, MD................................................... 740
300 Have a low threshold for intubating a patient with an inhalation
burn injury. Richard Wong She, MBChB and
James H. Holmes IV, MD................................................... 743
301 Do not under-resuscitate a burn patient.
Oliver A. Varban, MD and James H. Holmes IV, MD............... 745
302 Avoid the pitfalls of vascular access in burn patients.
Myron S. Powell, MD and James H. Holmes IV, MD................ 749
303 Know how to estimate burn size and depth.
John Zannis, MD and James H. Holmes IV, MD...................... 751

MISCELLANEOUS
304 Do not talk to families about organ donation.
Matthew J. Weiss, MD....................................................... 756
305 Alert the transplant team emergently if there is an acute decrease
in urine output after a kidney transplant.
Matthew J. Weiss, MD....................................................... 758
306 Remember that cardiac output is not the same thing as ejection
fraction. Frank Rosemeier, MD........................................... 760
307 Do not “rock the pelvis” in a fracture.
J. Christopher DiGiacomo, MD............................................ 762
308 Consider treatment for Heterotopic ossi?cation after trauma.
Constantine A. Demetracopoulos, BS and
Frank J. Frassica, MD....................................................... 767
309 Look for missed extremity fractures in patients with a diagnosed
extremity fracture. William S. Hoff, MD.............................. 771
310 Have a working knowledge of intensive care unit scoring systems.
Ronald W. Pauldine, MD.................................................... 773
311 Have a working knowledge of the Emergency Medical Treatment
and Active Labor Act as it applies to the intensive care unit.
Christian Merlo, MD, MPH and
Nadia N. Hansel, MD, MPH.............................................. 775
312 Know what the basic statistical terms mean.
Peter F. Cronholm, MD, MSCE and
Joseph B. Straton, MD, MCSE............................................ 777
313 Consider emboli when there is a change in mental status after an
invasive procedure. Nirav G. Shah, MD.............................. 784
314 Know the noninfectious causes of fever in the intensive care unit.
Laith R. Altaweel, MD...................................................... 786
315 Cardiovert unstable tachycardias (both narrow and wide
complex). Laith R. Altaweel, MD....................................... 788
316 Be concerned about chest pain even if it is found to be noncardiac
in nature. Laith R. Altaweel, MD........................................ 790
317 Know the difference between mm Hg and cm H2O.
Anthony D. Slonim, MD, DrPh............................................ 793
318 Be alert for lupus ?ares. Anthony D. Slonim, MD, DrPh.
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