Critical care

Question 1

1. A 58-year-old woman remains intubated in the
   intensive care unit (ICU) after a recent abdominal
   operation. In the operating room, she receives
   more than 10 L of fluid and blood products, but has
   received aggressive diuresis with furosemide postoperatively.
   In the past 3 days, she has generated
   12 L of urine output, and her blood urea nitrogen
   (BUN) and serum creatinine (SCr) have steadily
   increased to 40 and 1.5 mg/dL, respectively. Her
   urine chloride (Cl) concentration was 9 mEq/L
   (24 hours after her last dose of furosemide). This
   morning, her arterial blood gas (ABG) reveals pH
   7.50, Paco2 46 mm Hg, and bicarbonate (HCO3
   −)
   34 mEq/L. Her vital signs include blood pressure
   85/40 mm Hg and heart rate 110 beats/minute.
   Which action is best to improve her acid-base status?
   A. 0.9% sodium chloride bolus.
   B. 5% dextrose (D5W) bolus.
   C. Hydrochloric acid infusion.
   D. Acetazolamide intravenously.

Answer 1

1. Answer: A
   Hydrochloric acid infusions are rarely used in practice
   and are typically reserved for more severe alkalosis
   (pH greater than 7.55) that is not responding to conventional
   therapy (Answer C is incorrect). Administering
   D5W will provide hydration but will not correct intravascular
   volume depletion (Answer B is incorrect).
   Acetazolamide (Answer D) would be a consideration
   if the metabolic alkalosis persisted after correcting
   the underlying problem (i.e., volume contraction).
   This patient’s ABG and urine Cl are consistent with a
   saline-responsive metabolic alkalosis. In critically ill
   patients, the most common cause of metabolic alkalosis
   is volume contraction. In this case, the volume contraction
   is probably caused by overly aggressive diuresis.
   In patients receiving diuretics, the urine Cl should be
   measured at least 12–24 hours after the last dose. In
   addition, the patient is hypotensive with an elevated
   heart rate, which probably represents hypovolemia.
   This patient should receive a normal saline infusion
   (Answer A is correct).

Question 2

2. A 21-year-old man (weight 80 kg) admitted 1
   day ago after a gunshot wound to the abdomen
   is receiving mechanical ventilation and is thrashing
   around in bed and pulling at his endotracheal
   tube. His score is +3 on the Richmond Agitation-
   Sedation Scale (RASS). The patient is negative for
   delirium according to the Confusion Assessment
   Method for the ICU (CAM-ICU). His pulmonary
   status precludes extubation, and the attending physician
   estimates that he will remain intubated for at
   least 48 more hours. The medical team has decided
   that his RASS goal should be between 0 and -1.
   He is receiving a fentanyl infusion (150 mcg/hour),
   which has been adequately controlling his pain
   (Critical-Care Pain Observation Tool [CPOT] less
   than 3 for 24 hours). Vital signs include blood pressure
   110/70 mm Hg and heart rate 110 beats/minute.
   His baseline QTc interval is 460 milliseconds.
   Which is the best intervention for achieving this
   patient’s RASS goal?
   A. Initiate a dexmedetomidine 1-mcg/kg loading
   dose over 10 minutes, followed by 0.2 mcg/kg/
   hour.
   B. Initiate a lorazepam 3-mg intravenous load,
   followed by a lorazepam 3-mg/hour infusion.
   C. Initiate propofol at 5 mcg/kg/minute and
   titrate by 5 mcg/kg/minute every 5 minutes as
   needed.
   D. Initiate haloperidol 1 mg intravenously, and
   double the dose every 20 minutes as needed.

Answer 2

2. Answer: C
   If analgesia with fentanyl is adequate, this patient needs
   a sedative to achieve his RASS goal. Propofol is a sedative
   that is easily titrated and cost-effective (Answer C is
   correct). Dexmedetomidine is another safe and effective
   option, even when used for longer than 24 hours, but it
   has not been shown superior to propofol in randomized
   controlled trials (Answer A is incorrect). Furthermore,
   dexmedetomidine is more expensive than propofol, and
   a loading dose is not recommended. Lorazepam should
   be avoided in patients with (or at high risk of) delirium
   and is not a preferred first-line agent in the guidelines
   (Answer B is incorrect). Haloperidol is incorrect
   because the patient is CAM-ICU negative (Answer D is
   incorrect). Haloperidol can cause further prolongation
   of the QTc interval and lead to torsades.

Question 3

3. A 62-year-old woman is admitted to the medical
   ICU for respiratory dysfunction necessitating
   mechanical ventilation. She has no significant
   medical history. Her chest radiograph reveals
   bilateral lower lobe infiltrates, her white blood cell
   count (WBC) is 21 × 103 cells/mm3, lactate is 1.7
   mmol/L, temperature is 103.3°F (39.6°C), blood
   pressure is 82/45 mm Hg (normal for her is 115/70
   mm Hg), heart rate is 110 beats/minute, and respiratory
   rate is 22 breaths/minute. After she is given
   a diagnosis of community-acquired pneumonia,
   she is empirically initiated on ceftriaxone 2 g/day
   and azithromycin 500 mg/day intravenously. After
   fluid resuscitation with 6 L of lactated Ringer solution,
   her blood pressure is unchanged. Dopamine
   is initiated and titrated to 9 mcg/kg/minute, with a
   resulting blood pressure of 96/58 mm Hg, and her heart rate is 138 beats/minute. She has made less
   than 100 mL of urine during the past 6 hours, and
   her SCr has increased from 0.9 mg/dL to 1.3 mg/
   dL. Her serum albumin concentration is 2.7 g/dL.
   Which therapy is best for this patient at this time?
   A. Administer 5% albumin 500 mL intravenously
   over 1 hour and reassess mean arterial
   pressure (MAP).
   B. Initiate hydrocortisone 50 mg intravenously
   every 6 hours.
   C. Change dopamine to norepinephrine 0.01
   mcg/kg/minute to maintain a MAP greater
   than 65 mm Hg.
   D. Reduce the dopamine infusion to 1 mcg/kg/
   minute to maintain a urine output of at least 1
   mL/kg/hour.

Answer 3

3. Answer: C
   This patient meets the definition for septic shock.
   Treatment with 5% albumin is unlikely to offer additional
   benefit because the patient’s MAP is at goal (more
   than 65 mm Hg) (Answer A is incorrect). Furthermore,
   colloids are no more effective than crystalloids for fluid
   resuscitation, and a serum albumin concentration does
   not predict the efficacy of albumin administration.Hydrocortisone is incorrect because the patient is not
   persistently hypotensive after receiving fluids and
   vasopressors (Answer B is incorrect). Although this
   patient’s blood pressure is responding to the infusion of
   dopamine, the heart rate has increased. Norepinephrine
   (Answer C) is correct because it has similar efficacy,
   but with fewer tachyarrhythmias than dopamine.
   Dopamine should not be reduced because lower doses
   are not renal protective (Answer D is incorrect).

Question 4

4. A 92-year-old woman (weight 51 kg) is admitted
   to the ICU with urosepsis and septic shock. She
   lives in a long-term care facility and has a medical
   history significant for coronary artery disease
   and hypertension. Her blood pressure is 72/44 mm
   Hg, central venous pressure (CVP) is 5 mm Hg,
   heart rate 120 beats/minute, and oxygen saturation
   (Sao2) is 99%; her laboratory values are normal,
   except for a BUN of 74 mg/dL and Cr of 2.7 mg/dL
   (baseline of 1.5 mg/dL). Her urine output is about
   20 mL/hour. Appropriate empiric antibiotics were
   initiated. Which therapy is most appropriate to initiate
   next?
   A. Norepinephrine 0.05 mcg/kg/minute.
   B. Lactated Ringer solution 1500-mL bolus.
   C. Dopamine 5 mcg/kg/minute.
   D. Albumin 5% 500-mL bolus.

Answer 4

4. Answer: B
   The SSC guidelines recommend adequate fluid resuscitation
   with either crystalloids or colloids before adding
   vasopressor agents in patients with sepsis. This
   patient’s CVP, blood pressure, heart rate, and BUN/
   creatinine ratio indicate that she has intravascular
   volume depletion and needs immediate volume
   replacement. Therefore, intravenous fluids with either
   crystalloid or colloid should be the next therapy added
   to this patient’s regimen. Answers A and C are incorrect
   because fluid resuscitation should be attempted
   before adding vasopressors. No data favor colloids over
   crystalloids, and the substantial increase in cost associated
   with colloids precludes it from being first line;
   therefore, Answer D (albumin) is incorrect. Lactated
   Ringer solution is cost-effective and is a first-line agent
   per current guidelines (Answer B is correct).

Question 5

5. A 46-year-old man had a witnessed cardiac arrest
   in an airport terminal. After about 5 minutes, emergency
   medical services arrived, and defibrillator
   pads were applied. The cardiac monitor showed
   ventricular tachycardia (VT), and the patient had
   no discernible pulse. He was defibrillated with
   200 J without return of spontaneous circulation
   (ROSC). He received an additional two shocks of
   200 J with no improvement. Between shocks, the
   patient received compressions. An intravenous line
   was obtained, and an epinephrine 1-mg intravenous
   push was given; chest compressions and artificial respirations were initiated. Within 1 minute, the
   patient was reassessed. The cardiac monitor still
   showed VT, and he remained pulseless; therefore,
   another shock of 200 J, followed by an amiodarone
   300-mg intravenous push, was administered. After
   this, the patient was converted to a normal sinus
   rhythm with a heart rate of 100 beats/minute. The
   patient was then transported to the hospital, intubated
   and unresponsive. Which recommendation is
   most likely to improve this patient’s outcomes?
   A. Administer sodium bicarbonate 50 mEq
   intravenously.
   B. Administer vasopressin 40 units intravenously.
   C. Administer a continuous infusion of heparin.
   D. Initiate a targeted temperature management
   protocol.

Answer 5

5. Answer: D
   Targeted temperature management (i.e., therapeutic
   hypothermia) improves neurologic recovery and mortality
   in patients who have had a cardiac arrest (Answer
   D is correct). Although the patient probably has a metabolic
   acidosis, administering sodium bicarbonate
   would not improve outcomes (Answer A is incorrect).
   Vasopressin is no longer recommended in the ACLS
   guidelines (Answer B is incorrect). Although acute coronary
   syndrome is a common cause of cardiac arrest,
   anticoagulation with heparin would be a consideration
   after initiating targeted temperature management. A
   continuous infusion of heparin does not improve mortality
   in patients with an acute coronary syndrome
   (Answer C is incorrect). Of note, the induction of hypothermia
   would not necessarily interfere with treatment
   plans for acute coronary syndrome (e.g., percutaneous
   coronary intervention).

Question 6

6. A 72-year-old man is admitted to the medical ICU
   for post-cardiac arrest care with therapeutic hypothermia.
   His body temperature was maintained
   at 91.4°F (33°C) for 24 hours, and the health care
   team decides it is time to rewarm slowly at 0.5°C
   every hour. Which is most important to consider
   during the rewarming phase?
   A. Frequent laboratory monitoring is necessary
   to guide potassium supplementation because
   of the risk of hypokalemia.
   B. A vecuronium continuous infusion should be
   administered to prevent shivering.
   C. Phenytoin should be administered for seizure
   prophylaxis.
   D. Frequent blood glucose monitoring is necessary,
   given the risk of hypoglycemia.

Answer 6

6. Answer: D
   The cooling phase of therapeutic hypothermia may
   cause an intracellular shift of potassium, leading to
   decreased serum potassium on laboratory results.
   During the rewarming phase, an extracellular shift
   occurs, placing the patient at risk of hyperkalemia
   (Answer A is incorrect). Paralytics are not mandatory
   for shivering prevention during the rewarming phase
   and should be avoided, if possible (Answer B is incorrect).
   The rewarming phase of targeted temperature
   management alone does not place the patient at an
   increased risk of seizures, so prophylaxis with phenytoin
   is not required (Answer C is incorrect). Answer D,
   frequent blood glucose monitoring, is correct.

Question 7

7.A 65-year-old man with a history of hypothyroidism,
heart failure, and myocardial infarction is
admitted to the ICU with severe community-acquired
pneumonia. Six hours after admission, he
develops acute respiratory failure, hypotension,
and acute kidney injury from presumed sepsis. He
is placed on mechanical ventilation, and a nasogastric
tube is placed, with no plans for extubation.
Which is most appropriate for this patient’s stress
ulcer prophylaxis (SUP)?
A. Administer sucralfate 1 g four times daily by
nasogastric tube.
B. Administer magnesium hydroxide 30 mL four
times daily by nasogastric tube.
C. Administer famotidine 20 mg intravenously
daily.
D. No prophylaxis is indicated for this patient
because he has no risk factors for SUP.

Answer 7

7. Answer: C
   Mechanical ventilation for more than 48 hours is an
   independent risk factor for stress ulcers; therefore,
   Answer D is incorrect because the patient has a high
   risk of developing a stress ulcer and should receive
   prophylaxis. Antacids such as magnesium hydroxide
   are not used to prevent stress ulcers because of their
   need for frequent dosing and increased adverse effects
   (Answer B is incorrect). Sucralfate was inferior to H2
   receptor blockers in preventing clinically significant
   bleeding (Answer A is incorrect). Histamine-2 receptor
   blockers and PPIs are the two drug classes commonly
   used to prevent stress ulcers in critically ill patients
   (Answer C is correct).

Question 8

8. A 45-year-old man is admitted to the ICU with
   H1N1 causing respiratory failure. He is intubated
   and sedated with fentanyl 200 mcg/hour and
   propofol 25 mcg/kg/minute. He has received 4 L
   of lactated Ringer solution and 1 L of albumin and
   is currently receiving norepinephrine 0.15 mcg/kg/
   minute and vasopressin 0.03 unit/minute for hemodynamic
   support. His current vital signs are blood
   pressure 85/58 mm Hg, heart rate 99 beats/minute,
   and respiratory rate 18 breaths/minute. Which is
   the best plan for this patient’s steroid therapy?
   A. Initiate hydrocortisone 50 mg every 6 hours
   intravenously.
   B. Perform a cosyntropin stimulation test and
   initiate hydrocortisone 50 mg every 6 hours
   intravenously if the patient does not have an
   increase greater than 9 mcg/dL from baseline.
   C. Check a random cortisol and initiate
   hydrocortisone
   50 mg every 6 hours intravenously
   if the result is less than 10 mcg/dL.
   D. Steroids are not indicated at this time.

Answer 8

8. Answer: A
   The SSC suggests hydrocortisone at a dose of 200 mg
   per day if fluids and vasopressors cannot restore hemodynamic
   stability (Answer A is correct; Answer D is
   incorrect). Although low, random cortisol concentrations
   predict worse outcomes, there are no data supporting
   treatment of low cortisol concentrations (Answer C
   is incorrect). Because of the results of the most recent
   clinical trial and increased health care costs, a cosyntropin
   stimulation test is not recommended for patients
   with septic shock (Answer B is incorrect).

Question 9

9. A 19-year-old man (height 71 inches [180 cm],
   weight 68 kg) is admitted to the ICU after ingesting
   an unknown quantity of acetaminophen. After initial
   resuscitation and treatment with acetylcysteine,
   the patient remains unresponsive and intubated.
   The intensivist would like to start enteral nutrition
   (EN) as soon as possible. Which is the best way to
   calculate the patient’s caloric and protein needs?
   A. Estimate caloric needs at 25 kcal/kg and protein
   at 1.2 g/kg.
   B. Perform indirect calorimetry to estimate
   caloric and protein needs.
   C. Estimate caloric needs at 14 kcal/kg and protein
   at 2 g/kg.
   D. Calculate caloric needs based on the Mifflin
   equation, and order a prealbumin concentration
   to assess protein needs.

Answer 9

9. Answer: A
   There are many ways to estimate nutritional needs in
   critically ill patients. In general, 25 kcal/kg is an appropriate
   goal caloric intake per day. The recommended
   protein intake for medically ill patients in the ICU is
   1.2-1.5 g/kg (Answer A is correct). Indirect calorimetry
   will most closely calculate caloric needs, but it does not provide information on the amount of protein needed
   (Answer B is incorrect). Feeding at 11–14 kcal/kg is recommended
   for patients with obesity, but this patient’s
   BMI is less than 30 kg/m2 (Answer C is incorrect).
   Prealbumin concentrations have not shown good correlation
   with nutritional deficits in critically ill patients
   and are not recommended (Answer D is incorrect).

Question 10

10. A 57-year-old woman is admitted to the ICU with
    injuries sustained after a fall from 12 feet. She has
    traumatic brain injury and has been intubated for
    airway protection. What is the best intervention
    to prevent ventilator-associated pneumonia in this
    patient?
    A. Initiate pantoprazole 40 mg intravenously daily.
    B. Perform selective digestive decontamination
    with enteral polymyxin B sulfate, neomycin
    sulfate, and vancomycin hydrochloride.
    C. Maintain head of bed elevation at 20 degrees
    at all times.
    D. Start chlorhexidine 0.12% oral swabs twice
    daily.

Answer 10

10. Answer: D
    Proton pump inhibitors have been associated with
    an increase in ventilator-associated pneumonia
    (Answer A is incorrect). Selective digestive decontamination
    is effective, but because of its adverse
    effects and increases in resistant bacteria, it is not
    in widespread use and is not part of the Institute for
    Healthcare Improvement ventilator bundle (Answer
    B is incorrect). Head elevation prevents ventilatorassociated
    pneumonia, but it should be 30–45 degrees
    (Answer C is incorrect). Chlorhexidine is inexpensive,
    carries few adverse effects, is easy to administer, and
    is effective in the prevention of ventilator-associated
    pneumonia (Answer D).

Question 11

11. You are the critical care pharmacist for a 300-bed
    hospital. The critical care committee wants to
    institute an evidence-based glucose control protocol
    for the ICU. What is the best goal to implement
    for patients who present with septic shock?
    A. Check blood glucose every 6 hours and treat
    with sliding scale protocol when greater than
    180 mg/dL.
    B. Initiate insulin infusion with a target of
    110–140 mg/dL for two blood glucose values
    greater than 140 mg/dL.
    C. Initiate insulin infusion with a target of
    110–180 mg/dL for two blood glucose values
    greater than 180 mg/dL.
    D. Initiate insulin infusion with a target blood
    glucose of 80–110 mg/dL for two blood glucose
    values greater than 150 mg/dL.

Answer 11

11. Answer: C
    A sliding-scale protocol is inappropriate as the sole
    therapy for hyperglycemia in the ICU (Answer A is
    incorrect). The SSC and SCCM guidelines recommend
    an insulin infusion for two blood glucose values
    greater than 180 mg/dL (Answer B is incorrect). The
    ideal blood glucose range for critically ill adults has yet
    to be determined, but a goal of 80–110 mg/dL will not
    improve outcomes and may increase mortality (Answer
    D is incorrect). A target of 110–180 mg/dL prevents
    hyperglycemia but without an excess risk of hypoglycemia
    (Answer C is correct).

Question 12

12. Which is the most appropriate therapy to reduce
    the risk of delayed ischemia and improve neurologic
    outcomes after an aneurysmal subarachnoid
    hemorrhage (SAH)?
    A. Clevidipine continuous infusion titrated to
    maintain a systolic blood pressure (SBP) less
    than 160 mm Hg.
    B. Nimodipine 60 mg orally every 4 hours for 21
    days.
    C. Norepinephrine continuous infusion titrated
    to maintain an SBP greater than 160 mm Hg.
    D. Amlodipine 10 mg orally every 24 hours for 21
    days.

Answer 12

12. Answer: B
    Nimodipine should be administered in all patients with
    an aneurysmal SAH for 21 days to reduce the risk of
    delayed cerebral ischemia and improve neurologic outcomes
    (Answer B is correct). Blood pressure control
    is important, and the guidelines recommend using a
    titratable agent such as clevidipine to maintain a goal
    systolic blood pressure less than 160 mm Hg (Answer
    C is incorrect). The value of calcium antagonists other
    than nimodipine for vasospasm remains uncertain
    (Answers A and D are incorrect).

Question 13

Patient Cases
1. A 62-year-old woman has been hospitalized in the ICU for several weeks. Her hospital stay has been complicated
by aspiration pneumonia and sepsis, necessitating prolonged courses of antibiotics. For the past few
days, she has been having high temperatures, and her stool output has increased dramatically. Her most recent
stool samples have tested positive for Clostridioides difficile toxin, and her laboratory tests show serum sodium
138 mEq/L, K 3.5 mEq/L, Cl 115 mEq/L, HCO3
− 15 mEq/L, albumin 4.4 g/dL, pH 7.32, and Paco2 30 mm Hg.
Which is most consistent with this patient’s primary acid-base disturbance?
A. AG metabolic acidosis.
B. Non-AG metabolic acidosis.
C. Chloride-responsive metabolic alkalosis.
D. Acute respiratory acidosis.

Answer 13

1. Answer: B
   This patient’s ABG is consistent with metabolic acidosis.
   The pH is less than 7.40, indicating primary acidosis
   (Answer C is incorrect). The HCO3
   − and Paco2 are
   lower than normal, indicating this is metabolic in origin
   (Answer D is incorrect). In metabolic acidosis, the
   decrease in HCO3
   − is the primary disorder. When metabolic
   acidosis is present, the AG should be calculated
   to provide additional insight about the potential cause
   of the disorder. The AG is calculated by subtracting the
   sum of measured anions (Cl− and HCO3
   −) from cations
   (Na+). This patient’s AG (8 mEq/L) is within the normal
   reference range of 6–12 mEq/L; therefore, it is called
   a normal AG metabolic acidosis or non-AG metabolic
   acidosis (Answer B is correct; Answer A is incorrect).
   C. difficile–induced diarrhea is the most likely cause of
   this patient’s acid-base disorder.

Question 14

2. A 32-year-old man with no pertinent medical history is admitted to the hospital after being “found down” in
   his home with an empty bottle of alprazolam by his side. On arrival at the emergency department, he was neurologically
   unresponsive, with the following ABG values: pH 7.21, Paco2 58 mm Hg, Pao2 90 mm Hg, HCO3−
   24 mEq/L, and Sao2 86% on 2 L/minute of oxygen by nasal cannula. Which action is most appropriate?
   A. Administer acetazolamide 500 mg intravenous push.
   B. Administer 100% oxygen by face mask.
   C. Give sodium bicarbonate 100 mEq intravenous push.
   D. Provide urgent intubation.

Answer 14

2. Answer: D
   In patients without chronic obstructive pulmonary
   disease, a Paco2 greater than 50 mm Hg is usually an
   indication for mechanical ventilation, regardless of
   oxygenation status. Oxygen therapy alone is unlikely
   to correct this patient’s cause of respiratory failure
   (hypoventilation) (Answer B is incorrect). Similarly,
   his acid-base disturbance is consistent with a pure acute
   respiratory acidosis (elevated Paco2, normal HCO3-)
   and is therefore unlikely to respond to HCO3- (Answer
   C is incorrect). Acetazolamide is used for metabolic
   alkalosis (Answer A is incorrect). Given this patient’s
   neurologic status and elevated Paco2, he should be intubated
   and transferred to the ICU (Answer D is correct).

Question 15

3. A 55-year-old woman is admitted to the hospital after several days of worsening shortness of breath. Recently,
   she was discharged from the hospital after a similar episode and was doing fine until 3 days before admission,
   when she developed a productive cough, necessitating an increase in her home oxygen and more frequent use
   of her metered dose inhalers. On admission to the medical ICU, she was anxious and markedly distressed, with
   rapid, shallow breaths. She was hypertensive (160/80 mm Hg), tachycardic (140 beats/minute), and tachypneic
   (respiratory rate 28 breaths/minute). Her ABG showed pH 7.30, Paco2 59 mm Hg, Pao2 50 mm Hg, HCO3− 28
   mEq/L, and Sao2 83% on 6 L/minute of oxygen by face mask, and she was immediately intubated. Her most
   recent laboratory tests show serum sodium 142 mEq/L, K 3.8 mEq/L, Cl 109 mEq/L, HCO3− 28 mEq/L, and
   albumin 4.1 g/dL. Which primary acid-base disturbance is most consistent with this patient’s presentation and
   laboratory data?
   A. AG metabolic acidosis.
   B. Non-AG metabolic acidosis
   C. Respiratory acidosis.
   D. Respiratory alkalosis.

Answer 15

3. Answer: C
   This patient’s ABG is consistent with respiratory acidosis.
   The pH is below 7.40, indicating acidosis (Answer
   D is incorrect). The Paco2 is higher than normal (about
   40 mm Hg). In chronic respiratory acidosis, the kidneys
   conserve HCO3- (a base) to maintain a normal pH. This
   patient’s compensatory metabolic alkalosis is obvious,
   given that her serum HCO3- is 28 mEq/L (which
   is about 4 mEq/L higher than normal). This patient’s
   elevated HCO- concentration confirms the diagnosis
   of
   respiratory acidosis (because the HCO3- would be less
   than 24 mEq/L if the acidemia were attributable to a
   metabolic cause) (Answer C is correct; Answers A and
   B are incorrect).

Question 16

Patient Cases (Cont’d)
4. A 65-year-old woman is admitted to cardiac surgery ICU after an aortic valve replacement. On hospital day 4,
she is hypotensive (blood pressure 80/50 mm Hg), tachycardic (heart rate 125 beats/minute), tachypneic (respiratory
rate 30 breaths/minute), hypoxemic (Pao2 40 mm Hg), febrile (temperature 103.1°F [39.5°C]), and confused.
The patient is given adequate boluses of lactated Ringer solution and is then reintubated and initiated
on piperacillin/
tazobactam and vancomycin for possible nosocomial pneumonia. After fluid boluses fail to
improve her hemodynamic and clinical status, a pulmonary artery catheter is placed, which reveals a PCWP
of 18 mm Hg, CI of 3.3 L/minute/m2 and SVR of 515 dynes/second/cm5. Her chest radiograph reveals a left
lower lobe consolidation, and she still needs 100% fraction of inspired oxygen (Fio2). Which action is best?
A. Administer angiotensin II infusion titrated to achieve a MAP of at least 65 mm Hg.
B. Administer a dobutamine infusion titrated to achieve a MAP of at least 65 mm Hg.
C. Administer a norepinephrine infusion titrated to achieve a MAP of at least 65 mm Hg.
D. Administer a dopamine infusion titrated to achieve a MAP of at least 65 mm Hg.

Answer 16

4. Answer: C
   This patient’s hemodynamic profile is most consistent
   with sepsis (i.e., high CI, low SVR). Her PCWP is consistent
   with an adequate volume challenge. Because
   she remains hypotensive despite receiving an adequate
   fluid load, norepinephrine
   should be initiated because
   it is the initial vasopressor of choice in septic shock
   (Answer C is correct). Dobutamine is an inotropic
   agent that increases CI, which is adequate in this patient
   (Answer B is incorrect). If the patient continues to be
   hypotensive despite adequate fluid resuscitation and
   use of norepinephrine, angiotensin II can be considered
   (Answer A is incorrect). Dopamine is an alternative
   to norepinephrine, but it is not preferred because it is
   associated with a higher incidence of arrhythmias than
   norepinephrine (Answer D is incorrect).

Question 17

5. A patient (weight 75 kg) is to be initiated on a continuous infusion of norepinephrine for blood pressure support
   because of septic shock. The nurse has a 250-mL bag of normal saline containing 4 mg of norepinephrine.
   Which rate is most appropriate to infuse the norepinephrine drip at a dose of 0.05 mcg/kg/minute?
   A. 7 mL/hour.
   B. 14 mL/hour.
   C. 31.5 mL/hour.
   D. 79 mL/hour.

Answer 17

5. Answer: B
   Calculating an infusion rate is an important role for the
   pharmacist in code situations. The infusion pump is
   set to run in milliliters per hour; therefore, the answer
   should always be in these units. To determine the rate
   (in milliliters per hour) needed to achieve a 0.05-mcg/
   kg/minute dose, use the following calculation: concentration
   of norepinephrine drip: 4 mg/250 mL = 0.016
   mg/mL or 16 mcg/mL. Therefore, 75 kg × 0.05 mcg/kg/
   minute × 60 minutes/1 hour × 1 mL/16 mcg = 14.0625
   mL/hour, which is then rounded to 14 mL/hour (Answer
   B is correct; Answers A, C, and D are incorrect).

Question 18

6. A 42-year-old man was found unresponsive at his group home covered in vomit. He was intubated by the
   paramedics. On arrival at the emergency department, his blood pressure is 72/30 mm Hg and heart rate is 95
   beats/minute. During the next few hours, he receives 5 L of lactated Ringer solution, 500 mL of 5% albumin,
   and norepinephrine infusing at 0.5 mcg/kg/minute. With these interventions, his blood pressure is 87/56 mm
   Hg and heart rate is 148 beats/minute. Pertinent laboratory values include WBC 20 × 103 cells/mm3, lactic acid
   1.5 mmol/L, aspartate aminotransferase 78 units/L, SCr 2.2 (baseline 1) mg/dL, platelet count 118,000 cells/
   mm3, international normalized ratio (INR) 1.4, and urine output about 45 mL/hour since arrival. Which is the
   most appropriate intervention at this time?
   A. Add hydrocortisone 50 mg intravenously every 6 hours.
   B. Change norepinephrine infusion to phenylephrine infusion.
   C. Change norepinephrine infusion to dopamine infusion.
   D. Administer 1 L of lactated Ringer solution.

Answer 18

6. Answer: B
   The patient received adequate fluid resuscitation over
   several hours, and additional fluids are not needed at
   this time (Answer D is incorrect). Hydrocortisone is not
   necessary in this case because the patient is responding
   to fluid resuscitation and the infusion of norepinephrine,
   as evidenced by the increase in MAP from 44 mm
   Hg on arrival at the emergency department to 66 mm
   Hg after initial resuscitation (Answer A is incorrect).
   Changing to dopamine is not necessary at this time
   because the MAP is greater than 65 mm Hg, thus allowing
   global organ perfusion (Answer C is incorrect). In
   addition, there is no evidence that a low dose of dopamine
   will prevent acute kidney injury, and it increases
   the risk of arrhythmias compared with norepinephrine.
   The patient’s heart rate increased significantly
   to 148 beats/minute while receiving norepinephrine.Phenylephrine is an alternative to consider in patients
   with vasopressor-induced tachyarrhythmias (Answer B
   is correct).

Question 19

Patient Case
7. A 61-year-old woman collapses in front of her family members, who call 9-1-1 and begin CPR. The paramedics
arrive and find the victim unresponsive, with an electrocardiogram revealing ventricular fibrillation,
and administer two additional rounds of CPR and two defibrillations, which are successful. In the emergency
department, the patient’s MAP is 68 mm Hg after fluids and norepinephrine, but the patient remains unresponsive.
She is initiated on the hypothermia protocol. After 24 hours of hypothermia (body temperature 33°C),
the patient is in the ICU, and the rewarming process has recently begun. The pharmacist arrives in the ICU
about 30 minutes into the rewarming process. The patient has been receiving a continuous infusion of insulin
throughout the period of hypothermia at an average rate of 4 units/hour, with blood glucose testing every
3 hours. The patient has been sedated with a continuous infusion of propofol and fentanyl and is receiving
cisatracurium for neuromuscular blockade. The patient’s vital signs are stable, and her laboratory values are
normal. Which pharmacist recommendation is most appropriate at this time?
A. Increase blood glucose testing to now and every 1–2 hours during rewarming.
B. Adjust cisatracurium infusion to achieve a TOF of 0/4 impulses.
C. Discontinue propofol infusion to facilitate extubation.
D. Increase insulin infusion to prevent hyperkalemia

Answer 19

7. Answer: A
   During rewarming, patients can become hypoglycemic.
   Therefore, a reduction in the insulin infusion is likely,
   and blood glucose should be monitored more often
   (Answer A is correct). Neuromuscular blockade assessment
   can include titrating to a TOF goal; however, a
   more applicable goal would be the absence of shivering
   in this patient when the paralytic is briefly interrupted.
   If the patient is not shivering, consideration should be
   given to discontinuing the paralytic. Of note, the TOF
   goal is 2/4 twitches, rather than 0/4, to avoid overparalysis
   (Answer B is incorrect). Although discontinuing
   propofol can facilitate extubation, this
   should not be done until the patient is no longer paralyzed,
   is at a normal body temperature, and is
   ready for ventilator weaning (Answer C is incorrect).
   Finally, although rewarming can cause hyperkalemia,
   it is appropriate to monitor K concentrations and
   treat as needed. It is not appropriate to increase the
   insulin infusion to prevent hyperkalemia because this
   could precipitate hypoglycemia during rewarming
   (Answer D is incorrect).

Question 20

Patient Cases
8. An older woman is admitted to the ICU for acute decompensated heart failure and acute kidney injury with
an ejection fraction of less than 30%. She is administered a continuous infusion of bumetanide; however, the
benefit is limited because of her acute-on-chronic kidney disease. She is intubated on ICU day 2 because of
worsening pulmonary edema and hypoxia. After intubation, her RASS score is 0, her CAM-ICU is negative,
and her CPOT score is 4. Her blood pressure is 120/70 mm Hg and heart rate is 88 beats/minute. Which is the
best recommendation for achieving her analgesia, sedation, and delirium goals?
A. Initiate propofol at 5 mcg/kg/minute and titrate as needed.
B. Administer haloperidol 5 mg intravenously as needed.
C. Administer fentanyl 25 mcg intravenously every hour as needed.
D. Initiate lorazepam 2 mg/hour and titrate as needed.

Answer 20

8. Answer: C
   Propofol is an effective sedative that does not worsen
   delirium, but a sedative is not needed in this patient
   whose RASS score is 0 (alert and calm; Answer A is
   incorrect). Haloperidol is an option for delirium; however,
   her CAM-ICU is negative, so pharmacologic
   treatment is not indicated at this time (Answer B is
   incorrect). Benzodiazepines are not indicated with
   a RASS score of 0 and should be avoided, when possible,
   to prevent adverse outcomes such as prolonged
   mechanical ventilation, increased ICU length of stay,
   and development of delirium (Answer D is incorrect).
   Fentanyl intravenous boluses as needed would be an
   appropriate analgesic for the patient’s pain, given that
   her CPOT is elevated (Answer C is correct).

Question 21

Questions 9–11 pertain to the following case.
A 42-year-old woman with ARDS and a significant history of alcohol and tobacco abuse is transferred to the medical
ICU from an outside hospital. She presented to the outside hospital after 1 week of productive cough, fever,
chills, and increased shortness of breath. On admission to the medical ICU, she is hypotensive (80/60 mm Hg),
tachycardic (130 beats/minute), and febrile (body temperature 102.2°F [39.0°C]). Her ABG shows pH 7.1, Paco2
56 mm Hg, Pao2 49 mm Hg, HCO3− 16 mEq/L, and Sao2 76% on 100% Fio2. The only other significant laboratory
results are SCr 2.1 mg/dL and WBC 16 × 103 cells/mm3. She is achieving her sedation goals with continuous infusions
of propofol 20 mcg/kg/minute and fentanyl 200 mcg/hour.
9. After several nonpharmacologic attempts to improve her oxygenation fail, she is paralyzed, and her ventilator
settings are adjusted accordingly. Which statement about neuromuscular blockade in this patient is most
appropriate?
A. Opioids should be discontinued to avoid prolonged neuromuscular weakness.
B. Vecuronium is the agent of choice.
C. Sedatives should be titrated to maintain a RASS goal of 0 to –2 during neuromuscular blockade.
D. Neuromuscular blockers should be titrated to the minimal dose necessary to achieve ventilator synchrony

Answer 21

9. Answer: D
   Neuromuscular blocking agents should be titrated to the
   minimal effective dose. Although a peripheral nerve
   stimulator may provide information on the level of
   blockade, the true therapeutic endpoint in all patients is
   ventilator synchrony (Answer D is correct). Clinicians must recognize that neuromuscular blocking agents do
   not cross the blood-brain barrier and are not useful as
   sedatives or analgesics. For this reason, sedatives and
   analgesics should be optimized before initiating neuromuscular
   blockade, because titrating to an RASS goal
   while using neuromuscular blockers is not possible
   (Answer C is incorrect). Adequate sedation and analgesia
   must be achieved before initiating a neuromuscular
   blocker and should continue throughout the treatment.
   Vecuronium, though inexpensive, accumulates in renal
   disease and should be avoided (Answer B is incorrect).
   Analgesics and sedatives should be continued during
   paralysis (Answer A is incorrect).

Question 22

10. The patient was initiated on neuromuscular blockade as instructed and synchronous with the ventilator, but
    about 8 hours later, she began to move around violently in her bed. At this time, she was tachycardic (heart
    rate 120 beats/minute) and appeared agitated; her Sao2 dropped to 80%. Which action is best?
    A. Double the rate of the neuromuscular blocker every 5 minutes as needed until the patient stops moving.
    B. Increase the propofol infusion rate as needed to achieve sedation goals.
    C. Initiate a dexmedetomidine infusion.
    D. Check the TOF.

Answer 22

10. Answer: B
    Although this patient is no longer paralyzed, it would
    be inappropriate to re-paralyze an obviously agitated
    patient (Answer A is incorrect) because he or she
    should first be adequately sedated. Similarly, performing
    TOF using a peripheral nerve stimulator is
    unnecessary because it is obvious from the patient’s
    movement that she is not adequately blocked (Answer
    D is incorrect). It is possible that the patient is agitated
    and tachycardic because she received neuromuscular
    agents without adequate sedation or analgesia. Before
    the paralytic is adjusted, the patient should be given
    an increased dose of sedation (Answer B is correct). In
    patients with neuromuscular blockade, it is generally
    better to err on the side of over-sedation than undersedation.
    Dexmedetomidine does not provide the
    depth of sedation required for neuromuscular blockade
    (Answer C is incorrect).

Question 23

11. After that event, the patient did poorly the rest of the night. The patient was initiated on a norepinephrine
    infusion at 0.02 mcg/kg/minute to maintain an adequate blood pressure. Other medications initiated overnight
    included piperacillin/tazobactam, vancomycin, and gentamicin. By morning, her SCr has increased to
    2.8 mg/dL, and the night shift nurse reports that the patient has had 0/4 twitches on TOF for the past 8 hours.
    Pertinent electrolyte values include K+ 4.9 mEq/L, calcium 9 mg/dL, and magnesium 2 mg/dL. What is most
    likely to potentiate the effects of the neuromuscular blocker?
    A. Piperacillin/tazobactam.
    B. Gentamicin.
    C. Norepinephrine.
    D. Potassium concentration

Answer 23

11. Answer: B
    Gentamicin has pharmacodynamic effects (i.e.,
    inhibits the release of acetylcholine at the nicotinic
    receptor), which may potentiate the action of neuromuscular-
    blocking agents (Answer B is correct).
    Piperacillin/tazobactam and norepinephrine will not
    prolong the effects of neuromuscular blocking agents
    (Answers A and C are incorrect). Although hypokalemia
    can prolong the effects of neuromuscular blocking
    agents, potassium concentration will not (Answer D is
    incorrect).

Question 24

Patient Case
Questions 12 and 13 pertain to the following case.
A 73-year-old woman (weight 84 kg) is admitted to the ICU after a pneumonectomy. Her blood pressure is 104/65
mm Hg, heart rate is 88 beats/minute, and Sao2 values are 98% on 40% Fio2 and positive end-expiratory pressure
5 cm H2O; her Glasgow Coma Scale score is 11. Her other laboratory values are normal. Her medications include
simvastatin 20 mg every night, aspirin 81 mg/ day, metoprolol 25 mg twice daily, heparin 5000 units subcutaneously
every 8 hours, and 0.9% sodium chloride intravenously at 75 mL/hour.
12. The surgeon would like to initiate SUP. Which is the best recommendation for this patient?
A. Administer famotidine 20 mg per tube every 12 hours.
B. Administer magnesium hydroxide 30 mL per tube four times daily.
C. Administer sucralfate 1 g per tube four times daily.
D. SUP is not indicated.

Answer 24

12. Answer: A
    Given that the patient is mechanically ventilated,
    SUP should be administered (Answer D is incorrect).
    Antacids such as magnesium hydroxide are not used to prevent stress ulcers (Answer B is incorrect). Sucralfate
    has been shown inferior to histamine receptor antagonists
    (Answer C is incorrect). Efficacy of histamine
    receptor blockers has been shown in several clinical trials,
    and famotidine would be appropriate to add for this
    patient (Answer A is correct).

Question 25

13. One week later, the patient is extubated but still in the ICU. Her Glasgow Coma Scale score is 15, blood pressure is 112/70 mm Hg, and heart rate is 75 beats/minute, but her appetite is poor. Which statement is most appropriate regarding SUP for this patient? A. SUP should continue until the patient is discharged from the ICU. B. SUP should be discontinued now. C. Continue SUP until patient is eating. D. SUP should be discontinued at hospital discharge.

Answer 25

13. Answer: B This patient’s risk factors for SUP (mechanical ventilation and hypoperfusion) are no longer present; therefore, SUP should be discontinued (Answer B is correct). There is no reason to continue SUP until ICU or hospital discharge, and this practice just increases the risk of continuing the SUP in an outpatient without an appropriate indication (Answers A and D are incorrect). A poor appetite is not a risk factor for developing stress-related mucosal disease (Answer C is incorrect).

Question 26

Patient Case Questions 14 and 15 pertain to the following case. A 75-year-old woman (height 65 inches [165 cm], weight 68 kg) who is intubated needs mechanical ventilation for an acute exacerbation of chronic obstructive pulmonary disease. She has a medical history of heart failure and hypertension. Her laboratory values are normal except for a creatinine level of 1.9 mg/dL. 14. Which is the most appropriate recommendation to prevent VTE in this patient? A. Initiate intermittent pneumatic compression. B. Administer fondaparinux 2.5 mg subcutaneously once daily. C. Administer enoxaparin 30 mg subcutaneously twice daily. D. Administer heparin 5000 units subcutaneously three times daily.

Answer 26

14. Answer: D This patient has several risk factors for VTE, including age, respiratory failure, and a history of heart failure. For this reason, intermittent pneumatic compression is insufficient prophylaxis (Answer A is incorrect). Fondaparinux is contraindicated in patients with an estimated CrCl less than 30 mL/minute/1.73 m2 (Answer B is incorrect). Enoxaparin 30 mg subcutaneously twice daily is not an appropriate dose for this patient, considering her reduced kidney function (Answer C is incorrect). Heparin is appropriate for preventing a VTE in high-risk patients with renal dysfunction (Answer D is correct).

Question 27

15. Three days later, the patient continues to need mechanical ventilation. Enteral nutrition has been initiated through her nasogastric feeding tube and has gradually been increased to her goal of 45 mL/hour. Over the past day, her gastric residuals are consistently 300–350 mL. Which statement is most appropriate to optimize this patient’s nutrition support? A. Change to PN. B. Add metoclopramide 5 mg intravenously every 6 hours. C. Change feeds to a more concentrated formula. D. Decrease tube feeds to 10 mL/hour.