Study guide
25.1 Solid Organ Transplant Recipients & Deceased Donor Management
ABIM Critical Care Medicine Study Guide Exam
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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy
1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy
2 Chapter 2: Acute Respiratory Failure & ARDS
2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO
3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies
3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage
4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies
4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome
5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation
5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support
6 Chapter 6: Shock Syndromes & Hemodynamic Principles
6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets
7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support
7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication
8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy
8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI
9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies
9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis
10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders
10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency
11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias
11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing
12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies
12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes
13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies
13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm
14 Chapter 14: Sepsis & Systemic Infectious Diseases
14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU
15 Chapter 15: ICU-Acquired & Severe Focal Infections
15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections
16 Chapter 16: Focal, Special-Host & Systemic Infections
16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses
17 Chapter 17: Neurocritical Care & Coma
17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage
18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States
18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy
19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness
19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination
20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis
20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis
21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies
21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia
22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis
22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes
23 Chapter 23: Trauma, Burns & Perioperative Critical Care
23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients
24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care
24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy
25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care
25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia
26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation
26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics
27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders
27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity
28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings
28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia
29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound
29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound
25.1 Solid Organ Transplant Recipients & Deceased Donor Management
Key Takeaways Explain This Topic AI
Azoles, macrolides, and non-dihydropyridine calcium-channel blockers raise calcineurin inhibitor levels sharply, while rifampin and phenytoin lower them, so levels must be rechecked whenever such drugs change.
Hyperacute hepatic artery thrombosis after liver transplantation presents with rapidly rising transaminases and is diagnosed with urgent Doppler ultrasound.
Primary graft dysfunction after lung transplantation presents within 72 hours as diffuse infiltrates with hypoxemia and is managed with lung-protective ventilation and ECMO when needed.
Donor management after brain death targets a mean arterial pressure of at least 60 to 65 mmHg with vasopressin for diabetes insipidus and hormone replacement including levothyroxine and methylprednisolone.
After withdrawal in donation after circulatory death, death is declared following a 2 to 5 minute observation period of absent circulation, and procurement begins only after that interval.
Last updated: October 2026
Immunosuppression: What Drives ICU Problems
Agent Key toxicity Interactions
Tacrolimus and cyclosporine (calcineurin inhibitors) Nephrotoxicity, hypertension, hyperkalemia with a low bicarbonate , hypomagnesemia, tremor, seizures, PRES, thrombotic microangiopathy, diabetes Raised by azoles, macrolides, diltiazem and verapamil, protease inhibitors, grapefruit; lowered by rifampin, phenytoin, carbamazepine
- Mycophenolate Myelosuppression, diarrhea Reduced by antacids and cholestyramine
- Azathioprine Myelosuppression Allopurinol and febuxostat cause life-threatening marrow suppression
Sirolimus and everolimus Impaired wound healing, pneumonitis, proteinuria, mouth ulcers, thrombocytopenia CYP3A4 interactions
- Corticosteroids Hyperglycemia, infection, myopathy, psychiatric effects Adrenal suppression: stress dosing
- Belatacept Post-transplant lymphoproliferative disease in EBV-naive patients
- Antithymocyte globulin and alemtuzumab Cytokine release, prolonged lymphopenia
Rule : whenever a critically ill transplant recipient starts or stops an azole, macrolide, rifamycin, or anticonvulsant, recheck the calcineurin inhibitor level within a day or two. Never stop immunosuppression abruptly without transplant team input, even in severe sepsis; it is usually reduced rather than stopped.
Graft-Specific Emergencies
Organ Early complications Clues and management
Kidney Renal artery or vein thrombosis, urine leak, ureteral obstruction, lymphocele, acute rejection, calcineurin toxicity, BK nephropathy Sudden anuria with graft tenderness suggests vascular thrombosis: urgent Doppler ultrasound and surgical exploration. Biopsy distinguishes rejection from toxicity
Liver Hepatic artery thrombosis (rapidly rising transaminases, needing urgent Doppler and revascularization or retransplantation), portal vein thrombosis, biliary leak or stricture, primary nonfunction, small-for-size syndrome Postoperative coagulopathy, hypoglycemia, and encephalopathy point to graft failure
Lung Primary graft dysfunction within 72 hours (diffuse infiltrates with hypoxemia, graded like ARDS), airway anastomotic dehiscence, phrenic nerve injury, pleural complications, hyperacute and acute rejection, CMV and Aspergillus infection Lung-protective ventilation, conservative fluids, ECMO for severe dysfunction; bronchoscopy for anastomotic assessment and for diagnosis of rejection
Heart Right ventricular failure from donor-recipient mismatch or pulmonary hypertension, bradyarrhythmia (denervated heart), acute rejection, tamponade The denervated heart does not respond to atropine : use isoproterenol, dobutamine, or pacing; inhaled pulmonary vasodilators and inotropes for RV failure
Pancreas and intestine Graft thrombosis, anastomotic leak, rejection with high rejection rates for intestine Monitor glucose for pancreas graft function; endoscopy for intestinal rejection
Distinguishing rejection from infection is the central ICU problem: both cause fever and graft dysfunction, and the treatments are opposite. Biopsy and pathogen testing (including CMV PCR, respiratory viral panels, galactomannan, and beta-D-glucan) should be pursued before committing to escalating immunosuppression.
Post-Transplant Infection and Malignancy
Follow the timeline framework (see the immunocompromised host section): nosocomial in the first month, opportunistic from 1 to 6 months, and community-acquired beyond 6 months, modified by prophylaxis and net immunosuppression.
Prophylaxis typically includes trimethoprim-sulfamethoxazole for Pneumocystis , valganciclovir for CMV in at-risk pairings, and antifungal prophylaxis in lung and liver recipients.
Post-transplant lymphoproliferative disease : EBV-driven, presenting with fever, adenopathy, and organ masses; reduce immunosuppression and give rituximab-based therapy.
Hemophagocytic lymphohistiocytosis and thrombotic microangiopathy are immunosuppression-associated syndromes that mimic sepsis.
Deceased Donor Management After Brain Death
Once death by neurologic criteria is declared and authorization obtained, the goal shifts to organ preservation . The organ procurement organization directs management, often with "rule of 100s" style targets.
Problem Target and therapy
Hemodynamics Mean arterial pressure at least 60 to 65 mmHg; volume repletion first, then vasopressin (which also treats diabetes insipidus) and norepinephrine; avoid excessive catecholamines, which harm the heart graft
Diabetes insipidus Occurs in most donors: desmopressin or a vasopressin infusion, with free water replacement; keep sodium below about 155 mEq/L to protect liver grafts
Hormone replacement Methylprednisolone (which improves lung and other graft outcomes), levothyroxine for hemodynamic instability, insulin for glucose 140 to 180 mg/dL
Lungs Lung-protective ventilation with PEEP, recruitment, head elevation, aspiration prevention, and bronchoscopy; a conservative fluid strategy
Temperature Normothermia; poikilothermia is common. Therapeutic mild hypothermia (34 to 35 °C) in donors reduced delayed graft function in kidney recipients
- Coagulopathy and anemia Transfuse to maintain oxygen delivery; correct coagulopathy for procurement
- Monitoring Arterial line, central access, echocardiography for cardiac assessment, serial laboratory tests
Family support and clear separation of the clinical team from the donation request remain essential (see the ethics section).
Donation After Circulatory Death (DCD)
Setting : a patient with devastating, non-survivable illness who does not meet neurologic criteria for death, whose surrogate has independently decided to withdraw life-sustaining treatment.
Process :
The decision to withdraw is made first and independently of donation.
Withdrawal occurs in a setting (operating room or ICU) that allows timely procurement, with comfort-focused care provided throughout.
After circulation ceases, a hands-off observation period of 2 to 5 minutes (program-specific) elapses before death is declared. Procurement begins only afterward.
If death does not occur within a predefined window (commonly 60 to 120 minutes), donation is cancelled and the patient continues to receive comfort care.
Premortem interventions (such as heparin or cannula placement) require consent and are governed by local policy.
Normothermic regional perfusion (NRP) restores circulation to abdominal or thoracoabdominal organs after death is declared, with the cerebral circulation excluded by aortic arch vessel occlusion or clamping. It improves graft function, and the ethical debate centers on whether restoring circulation is consistent with the permanence standard of death; practice and policy vary by jurisdiction and institution.
Machine perfusion (hypothermic and normothermic ex situ) is increasingly used to assess and improve marginal grafts, including after DCD.