ABA Critical Care common mistakes
ABA Critical Care · Understand the traps and how to avoid them.
Sets tidal volume by actual body weight and titrates PEEP to SpO2 alone without measuring plateau pressure or driving pressure in a patient with ARDS.
Operating-room ventilation habits and reliance on pulse oximetry persist under exam pressure; plateau pressure is not displayed unless an inspiratory hold is performed, so it is easy to omit.
What to do instead
Calculate predicted body weight, start at 6 mL/kg predicted body weight, perform an inspiratory hold to keep plateau pressure ≤30 cm H2O and driving pressure ≤15 cm H2O, and reassess after every ventilator change.
Treats a single CVP or PCWP value as a reliable measure of preload and gives repeated fluid boluses until the number reaches a target.
Static filling pressures are easy to obtain and are still mentally linked to volume status; their poor correlation with fluid responsiveness is underappreciated during rapid exam decision-making.
What to do instead
Interpret filling pressures only in clinical context and assess fluid responsiveness with passive leg raise, stroke volume variation, or a small fluid challenge with a predefined hemodynamic endpoint.
Attributes persistent coma after cardiac arrest or sedation cessation to residual sedation and delays EEG, missing nonconvulsive status epilepticus.
Sedative effects are assumed to explain depressed consciousness, and EEG is treated as a second-line test rather than part of the early coma workup.
What to do instead
Obtain continuous or routine EEG early in unexplained coma, especially after cardiac arrest or when subtle facial or eye twitching is present, and treat electrographic seizures promptly.
Gives repeated fluid boluses for oliguria without assessing volume status, urine electrolytes, or bladder scan, and labels all acute kidney injury as prerenal.
Oliguria is reflexively equated with hypovolemia, and bedside bladder scanning and urine electrolyte interpretation are often skipped under time pressure.
What to do instead
Check a bladder scan, review nephrotoxins and hemodynamics, calculate urine sodium or FEUrea when appropriate, and use dynamic measures of fluid responsiveness before giving more fluid.
Waits for blood cultures before giving antibiotics in septic shock and delays vasopressors until central venous access is obtained.
The cultures-before-antibiotics principle is overapplied, peripheral vasopressors are perceived as unsafe, and the one-hour sepsis bundle is not prioritized.
What to do instead
Give broad-spectrum antibiotics within one hour, draw cultures first only if this causes no delay, and start vasopressors peripherally while central access is being obtained.
Transfuses fresh frozen plasma or platelets for an abnormal INR or platelet count in a nonbleeding patient, and misses heparin-induced thrombocytopenia when platelets fall.
Laboratory abnormalities are treated rather than the patient, and heparin-induced thrombocytopenia is mistaken for sepsis or disseminated intravascular coagulation.
What to do instead
Reserve plasma and platelets for active bleeding or invasive procedures using specified thresholds; calculate the 4Ts score when platelets fall and stop heparin if heparin-induced thrombocytopenia is suspected.
Stops the insulin infusion in diabetic ketoacidosis before ketosis resolves, gives bicarbonate routinely for pH above 7.0, and misses adrenal insufficiency in vasopressor-dependent shock.
Glucose normalization is mistaken for resolution of ketoacidosis, bicarbonate is used cosmetically, and adrenal crisis remains low on the differential.
What to do instead
Continue insulin until the anion gap normalizes and ketones clear, use bicarbonate only for pH below 6.9, and check a random cortisol with consideration of hydrocortisone in refractory shock.
Attributes hypotension in a trauma or postoperative patient to sedation or residual anesthesia and does not exclude bleeding, tension pneumothorax, or abdominal compartment syndrome.
The most recent intervention is blamed first, and structured physical examination, bladder pressure measurement, and bedside ultrasound are omitted.
What to do instead
Run a structured shock survey for bleeding, pneumothorax, tamponade, and abdominal compartment syndrome, measure bladder pressure when indicated, and use bedside ultrasound early.
Starts full-calorie enteral nutrition in a malnourished patient without checking electrolytes and misses refeeding syndrome, or gives activated charcoal without protecting the airway.
Nutrition is viewed as purely supportive rather than as a cause of dangerous electrolyte shifts, and the aspiration risk of charcoal is underestimated.
What to do instead
Identify high-risk patients, start low and advance slowly, recheck phosphate, potassium, and magnesium, and avoid charcoal when consciousness is altered or the airway is unprotected.
Conflates withholding and withdrawing life-sustaining treatment, or defers a goals-of-care conversation until the patient is actively dying, and documents the discussion poorly.
The ethical equivalence of withholding and withdrawing is not internalized, clinicians wait for certainty, and conflict avoidance delays family meetings.
What to do instead
State explicitly that withholding and withdrawing are ethically equivalent, hold early family meetings that identify the surrogate and document goals, and involve palliative care consultation when conflict or uncertainty persists.