22. Critical Care & Fluids/Electrolytes

Question 1

A patient has been receiving 4 days worth of propofol for sedation post-traumatic brain injury. Which of the following statements regarding propofol are correct? (Select ALL that apply.)

A. Hypotension, apnea and elevated triglycerides are likely side effects.
B. This patient may be at risk for developing infections.
C. This medication can cause orange/red urine in rare cases.
D. This agent is generally shorter-acting than lorazepam.
E. Propofol contains significant calories that must be account for in the daily nutrition plan for the patient.

Answer 1

A, B, D, E. Propofol comes as an oil-in-water emulsion that is administered as a continuous infusion for ICU sedation. This formulation can lead to an increased risk of infections and elevated triglycerides that is dose and duration dependent. Use strict aseptic technique when administering. Green urine/hair/nails has been seen in some patients on propofol.

Question 1

A patient in septic shock is unresponsive to repeated doses of epinephrine and his blood pressure continues to decline. The decision is made to initiate an intravenous vasopressin drip. What is the correct receptor pharmacology that explains the utility of vasopressin in the maintenance of blood pressure?

A. Alpha-1 agonist
B. Beta-1 agonist
C. Vasopressin agonist
D. Vasopressin antagonist
E. Dopamine-1 agonist

Answer 1

C. Vasopressin acts on V1a receptors to exert its vasopressor effect. It is also an agonist at V2 receptors which mediates its aquaresis effect.

Question 1

A patient arrives at the emergency department after a severe MVA. The patient’s blood pressure is low and he is in shock. The physician wants to start fluid resuscitation with a colloid on this patient immediately. Which of the following agents are colloids? (Select ALL that apply.)

A. Normal saline
B. Hydroxyethyl starch
C. Lactated Ringer’s
D. Dextran
E. Albumin

Answer 1

B, D, E. Fluid replacement therapy generally consists of crystalloids and/or colloids. Albumin, Hespan, and dextran are colloids.

Question 1

A patient in the ICU with shock is receiving a norepinephrine infusion. What is the purpose of using norepinephrine in this setting?

A. To decrease cardiac output, increase blood flow to vital organs, and increase blood pressure
B. To increase cardiac output, increase blood flow to vital organs, and increase blood pressure
C. To increase cardiac output, decrease blood flow to vital organs, and increase blood pressure
D. To increase cardiac output, increase blood flow to vital organs, and decrease blood pressure
E. To vasodilate in the kidney for nephroprotection, and decrease blood pressure

Answer 1

B. Vasopressors work via vasoconstriction to increase SVR and blood pressure.

Question 2

A patient is admitted with significant hyponatremia (Na = 125). The provider would like to use tolvaptan. Which of the following statements is correct?

A. Tolvaptan is available IV only.
B. Tolvaptan is a first-line agent for treatment of hyponatremia.
C. Sodium should be corrected at a rate of 12 mEq/hr while on tolvaptan.
D. The brand name for tolvaptan is Vaprisol.
E. Tolvaptan use should be limited to 30 days due to potential for hepatotoxicity.

Answer 2

E. Tolvaptan (Samsca) is an oral vasopressin antagonist. It should only be used in refractory cases and close monitoring is required, particularly to avoid raising the Na by more than 12 mEq/L/24h.

Question 2

A patient is in the OR and has received succinylcholine for intubation and is currently receiving inhaled isoflurane (an inhaled anesthetic) during surgery. The rare, but serious side effect this patient is potentially at risk for is:

A. Neuroleptic malignant syndrome
B. Sundowning effect
C. Serotonin syndrome
D. Malignant hyperthermia
E. Acute quadriplegic myopathy syndrome

Answer 2

D. Malignant hyperthermia can be seen with the use of inhaled anesthetics, particularly when combined with succinylcholine.

Question 3

A patient is receiving vecuronium for paralysis. Which of the following medications can potentiate the actions of vecuronium?

A. Tricyclic antidepressants
B. Angiotensin converting enzyme inhibitors
C. Proton pump inhibitors
D. Aminoglycosides
E. Azole antifungals

Answer 3

D. Aminoglycosides can potentiate the effect of NMBAs. If used together, close monitoring for respiratory depression is necessary.

Question 4

A patient picks up a prescription for an Epipen for her son. Which of the following ratio strengths is used for epinephrine given by intramuscular administration?

A. 1:500
B. 1:1,000
C. 1:10,000
D. 1:100,000
E. 1:1,000,000

Answer 4

B. Epinephrine [1:1,000] is used in epinephrine products designed for intramuscular or subcutaneous administration.

IV route Epinephrine [1:10,000]. More dilute than IM.

Question 5

A patient with acute decompensated heart failure is receiving milrinone. Which of the statements concerning milrinone are correct? (Select ALL that apply.)

A. Milrinone is a positive inotrope and increases contractility in the heart.
B. Milrinone is an alpha-2 agonist.
C. Milrinone is a vasodilator.
D. Milrinone is administered IV only.
E. Monitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.

Answer 5

A, C, D, E. Milrinone is a phosphodiesterase inhibitor. Milrinone requires dose adjustment in renal dysfunction.

Question 6

A patient with end-stage alcoholic cirrhosis is admitted to the medical floor. His serum sodium level is 122 mEq/L. On physical exam he has ascites and peripheral edema, but only mild shortness of breath. What is the preferred treatment for this patient’s hyponatremia?

A. Sodium chloride tablets by mouth – start now.
B. 0.9% NaCl – start when serum sodium level drops below 120 mEq/L.
C. Diuresis and fluid restriction – start now.
D. Desmopressin – start when serum sodium drops below 115 mEq/L.
E. Lactated Ringer’s – start now.

Answer 6

C. Hypervolemic hyponatremia is common in patients with cirrhosis, heart failure, and renal failure. Administering fluids to these patients will often worsen the hyponatremia.

Question 7

A patient’s norepinephrine intravenous line extravasated into the surrounding tissue. The nurse quickly starts to give phentolamine to reverse any skin necrosis. What is the mechanism of action of phentolamine?

A. Alpha-adrenergic antagonist
B. Alpha-adrenergic agonist
C. Beta-adrenergic antagonist
D. Beta-adrenergic agonist
E. Calcium channel antagonist

Answer 7

A. Phentolamine is an alpha-adrenergic antagonist that antagonizes the effects of vesicants such as vasopressors.

Question 8

A pharmacist is preparing an IVIG infusion. Which of the following statements is incorrect?

A. If the patient experiences side effects such as nausea or a drop in blood pressure during the infusion, slowing the infusion rate may be helpful.
B. IVIG may come already in solution, or it may come as a powder that is reconstituted with diluent.
C. The IVIG dose is based on the Ideal Body Weight (IBW).
D. If particles are present, the pharmacist should shake well to dissolve the particles prior to the infusion.
E. Certain patients respond to one IVIG brand better than another.

Answer 8

D. Use the IBW to calculate the dose. Do not shake IVIG preparations; this will inactivate the antibodies.

Other drugs that should not be agitated include: alteplase, immune globulins, insulins, rasburicase, zoster vaccine. Quinupristin/dalfopristin (Synercid), etanercept (Enbrel) vials are swirled when reconstituting, which makes foam; do not shake. Wait for foam to dissolve.

Question 9

A pharmacist receives an order for Diprivan. Which of the following is an appropriate generic substitution for Diprivan?

A. Propofol
B. Diltiazem
C. Oxycodone
D. Lorazepam
E. Propantheline

Answer 9

A. The generic name of Diprivan is propofol.

Question 9

A physician wishes to use morphine in a patient with a creatinine clearance of 20 mL/minute. The patient is in severe pain and requires analgesia. Choose the correct statement/s: (Select ALL that apply.)

A. It would be preferable to use MS Contin, crushed and placed into the g-tube
B. Morphine has an active metabolite that can accumulate with renal impairment.
C. Morphine cannot be used with this degree of renal impairment.
D. Meperidine would be a better choice in this patient.
E. The patient will be at an increased risk of respiratory depression versus a patient with normal renal function.

Answer 9

B, E. Morphine is commonly given IV, as well as IM and orally. If a patient is receiving oral long-acting formulations, do not crush.

Question 11

A young man with immune thrombocytopenia recently had transient intravascular hemolysis during intravenous gamma globulin treatment. The hemolysis was mediated by anti-A antibody present in the gamma globulin treatment. What signs and symptoms could indicate hemolysis? (Select ALL that apply.)

A. Negative Direct Coombs test
B. Blood in the stool
C. Positive Direct Coombs test
D. Blood in the urine
E. Positive ANA test

Answer 11

C, D. Blood in the urine could indicate internal bleeding, while blood in the stool would indicate bleeding in the GI tract (or colon cancer or hemorrhoids). The Direct Coombs test is used to test for hemolytic anemia. It is important in pharmacy as certain drugs can cause hemolysis (notably cephalosporins, sulfonamides, methyldopa and others).

Question 12

An ICU patient is receiving dexmedetomidine for sedation. Which of the following statements regarding dexmedetomidine is incorrect:

A. The duration of the infusion should not exceed 72 hours.
B. This agent has a very low risk of causing respiratory depression.
C. Patients are arousable and alert upon stimulation when using this agent.
D. The BP and HR must be monitored.
E. Dexmedetomidine can cause significant blood pressure changes upon initiation of the infusion.

Answer 12

A. The duration of infusion should not exceed 24 hours. Dexmedetomidine causes transient hypertension when the infusion is started, and this may require an initial dose reduction. With continued use, monitor for hypotension, bradycardia, and dry mouth (in addition to BP, HR and sedation).

Question 14

An ICU patient with severe renal impairment requires a neuromuscular blocking agent (NMBA) in order to receive mechanical ventilation. Which of the following statements are correct? (Select ALL that apply.)

A. The medical staff must ensure that the patient is adequately sedated prior to the use of the NMBA.
B. The medical staff must ensure that the patient is receiving appropriate analgesia prior to the use of the NMBA.
C. Succinylcholine binds to the GABA receptor, resulting in activation.
D. ICU sedative agents are monitored via a nerve stimulator.
E. Patients must be mechanically ventilated prior to receiving a NMBA or they will suffocate; they should also be administered eye lubricant.

Answer 14

A, B, E. Succinylcholine binds to the acetylcholine receptor, resulting in desensitization. Succinylcholine is the only available depolarizing agent; the others are non-depolarizing agents. Paralytics (not sedatives) are monitored with a nerve stimulator (train-of-four).

Question 15

Ana has recently been admitted to the intensive care unit after an acute asthma exacerbation. She has been intubated and requires adequate sedation. She has normal renal and liver function. The medical team wants to use the shortest acting benzodiazepine available intravenously for sedation. Which of the following medications would be the best recommendation for Ana?

A. Temazepam
B. Lorazepam
C. Diazepam
D. Clonazepam
E. Midazolam

Answer 15

E. Midazolam is a short acting benzodiazepine that is available intravenously. Triazolam and clonazepam do not come in an intravenous formulation. Midazolam does not accumulate when used for a short period of time in patients with normal renal and liver function.

Question 16

Choose the correct statement concerning neuromuscular blocking agents:

A. Patients do not need to be on mechanical ventilation to receive a neuromuscular blocker.
B. Patients should receive sedation and analgesia prior to the use of neuromuscular blockers.
C. No monitoring is needed when using neuromuscular blockers.
D. The Institute for Safe Medication Practices (ISMP) does not include neuromuscular blockers as medications that can cause significant harm, but they do include opioids.
E. They should be used in the majority of the patients in the ICU.

Answer 16

B. Neuromuscular blockers paralyze muscles, including the muscles responsible for breathing. Patients must have a secure airway (such as mechanical ventilation) and must have adequate sedation and analgesia before the initiation of a paralytic. These medications can cause significant patient harm if used inappropriately.

Question 17

Hemostatic agents prevent blood loss. Which of the following statements concerning hemostatic agents are correct? (Select ALL that apply.)

A. Newer hemostatic agents are reducing the need for transfusions.
B. The most common adverse events from the use of hemostatic agents are a drop in hemoglobin and anemia.
C. Patients receiving hemostatic agents are at low risk of clotting.
D. Recombinant thrombin (Recothrom) is not associated with the risk of disease transmission (such as Creutzfeld-Jakob disease) and is less immunogenic than previous thrombin formulations.
E. Tranexamic acid is a hemostatic agent used for both heavy menstrual bleeding and hemophilia-associated bleeding; it comes as both an oral and injectable.

Answer 17

A, D, E. The most common adverse events from the use of hemostatic agents are hypersensitivity and thrombosis. Patients receiving thrombin products are at risk of thrombosis (clotting). Recothrom is a topical hemostatic agent.

Question 18

JH is a 55 year old male who will be receiving his third IVIG treatment for autoimmune encephalopathy. He reports that he had been receiving steroid therapy for many years, but was changed to IVIG the previous fall when the symptoms worsened. He has presented to the infusion room. The pharmacist cannot locate the referring doctor’s paperwork and will attempt to conduct a pre-screening prior to the treatment. Which of the following screening questions should the pharmacist ask JH? (Select ALL that apply.)

A. Did you use any medications prior to the treatment to help lessen the side effects?
B. What is the name of the IVIG medication received previously, and are you aware of the dose?
C. Is anyone in the house presently immune-compromised (such as cancer or HIV-infected persons?)
D. Are there any small infants in the house?
E. Did you develop any reactions to the medication, either during the infusion, or afterwards?

Answer 18

A, B, E. The two questions not chosen would apply for certain immunizations, but are not necessary prior to an IVIG infusion.

Question 20

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
The ICU staff will monitor LS for delirium during her stay. Which statement is correct regarding ICU delirium?

A. Delirium is rare in ventilated ICU patients.
B. Haloperidol is recommended for prophylaxis and treatment of ICU delirium.
C. Providing sedation with Ativan as opposed to Precedex may reduce the incidence of delirium.
D. Seroquel may increase duration of delirium.
E. Early mobilization and environmental control are recommended to prevent delirium.

Answer 20

E. There is little evidence to support use of haloperidol. Quetiapine, which is mildly sedating and has little risk for movement disorders can be useful. Providing sedation with dexmedetomidine as opposed to benzodiazepines may decrease incidence of delirium and shorten duration in patients who already have it.

Question 21

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
LS requires fluid resuscitation. Which of the following is the best recommendation?

A. Hespan
B. Dextrose 5%
C. NaCl 0.9%
D. Albumin 25%
E. Dextran 70

Answer 21

C. Crystalloids should be used for fluid resuscitation, when possible. They are less expensive and associated with fewer adverse reactions than colloids. D5W (5% dextrose) should be avoided in this diabetic patient with increased blood glucose. Though the patient’s serum albumin is low, IV albumin is not effective at increasing serum albumin and should not be used for this purpose.

Question 22

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
An order is placed for LS to receive 40 mEq of KCl IV with continuous EKG monitoring. The hospital stocks premixed bags of 20 mEq KCl/100 mL 0.9% NaCl. The pharmacist modifies the order to read “20 mEq KCl/100 mL 0.9% NaCl x 2 doses.” Over what period of time should each 20 mEq KCl bag be infused?

A. 1-2 minutes
B. 30 minutes
C. 2 hours
D. 6 hours
E. 12 hours

Answer 22

C. Potassium replacement should occur via the oral route when possible. IV replacement may be warranted in cases like this, where EKG changes may be a result of the electrolyte abnormality. IV potassium should be administered no faster than 10-20 mEq/hour with intermittent dosing. Serum potassium can be rechecked between doses when ordered like this to avoid hyperkalemia.

Question 23

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
Which statement is correct regarding LS’s electrolyte abnormalities on 12/15/14? (Select ALL that apply.)

A. Lasix may have caused the hypokalemia and hypomagnesemia.
B. Replacement of LS’s body stores of magnesium will be complete after one dose of IV magnesium sulfate.
C. Hypophosphatemia is considered severe and usually symptomatic when the serum phosphorus level is < 2 mg/dL.
D. Hypomagnesemia should be treated IV when serum magnesium level is < 1 mEq/L with seizures or arrhythmias.
E. A drop of 1 mEq/L in serum potassium (below 3.5 mEq/L) represents a total body deficit of 100 – 400 mEq.

Answer 23

A, D, E.

Question 24

MD is an elderly patient admitted for altered mental status. His admission serum sodium is 115 mEq/L. MD is started on Vaprisol (loading dose and continuous infusion). The next day his serum sodium is 129 mEq/L. MD is at risk for which of the following adverse effects?

A. Progressive multifocal leukoencephalopathy (PML)
B. Acute quadriplegic myopathy syndrome (AQMS)
C. Diabetes insipidus (DI)
D. Osmotic demyelination syndrome (ODS)
E. Disseminated intravascular coagulation (DIC)

Answer 24

D. Osmotic demyelination syndrome (ODS) or central pontine myelinolysis can be caused by overly rapid correction of hyponatremia (> 12 mEq/L/24 hours). ODS can cause paralysis, seizures and death. Monitor serum sodium frequently during correction of hyponatremia.

Question 24

LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
A dopamine drip is ordered for LS. Which of the following represents the correct combination of dose-effect relationships for dopamine?

A. Low dose → vasopressor effects, medium dose → positive inotropic effect, and high dose → renal vasodilation
B. Low dose → positive inotropic effect, medium dose → renal vasodilation, and high dose → vasopressor effects
C. Low dose → vasopressor effects, medium dose → renal vasodilation, and high dose → positive inotropic effect
D. Low dose → positive inotropic effect, medium dose → vasopressor effects, and high dose → renal vasodilation
E. Low dose → renal vasodilation, medium dose → positive inotropic effect, and high dose → vasopressor effects

Answer 24

E. Dopamine has dose dependent effect. Low dose: D1 agonist. Med dose: Beta-1 agonist. High dose: Alpha-1 agonist.

Question 25

Nina is a 32 year-old female who is in the coronary care unit after a sudden drop in blood pressure following her cardiac catheterization procedure earlier this morning. Her blood pressure remained stable for the past two hours without the use of medications. She is sitting up in bed and eating her lunch. The medical team is anticipating sending her home by this evening or early tomorrow morning. Is Nina a candidate for stress ulcer prophylaxis?

A. Yes, since she is in the coronary care unit.
B. Yes, since she has had a stressful event.
C. No, since she does not have any risk factors.
D. No, since she is sitting up in bed.
E. There is not enough information given.

Answer 25

C. She does not have any risk factors warranting stress ulcer prophylaxis.

Risk factors: mechanical ventilation, coagulopathy, sepsis, traumatic brain injury, burn patients, acute renal failure, high dose corticorsteroid.

Question 27

Sam presented to the ED with severe dehydration. He was out hiking in the Arizona sun and forgot to bring water. He got lost and a 1 hour hike turned into a 6 hour hike. He is lethargic and nauseous. The Chem-7 just came back and his serum sodium level is 128. He has no evidence of seizure activity presently. Which of the following represents the best initial therapeutic option to correct Sam’s sodium?

A. Conivaptan
B. 3% NaCl
C. D5W
D. 0.9% NaCl
E. Hydroxyethyl starch

Answer 27

D. Normal saline is the recommended first-line option to correct hypovolemic hyponatremia. 3% NaCl (a high-risk medication) should be reserved for refarctory cases in which the patient is having significant complications such as seizures or coma.

Question 28

Select the correct concentration of epinephrine that should be used to mix solutions intended for intravenous administration:

A. 1:2,500
B. 1:1000
C. 1:10,000
D. 1:100,000
E. 1:1,000,000

Answer 28

C. Epinephrine [1:10,000] should be used to mix solutions intended for intravenous administration.

Epinephrine [1:1,000] is used for EpiPen. Higher concentration for IM injections.

Question 29

The boxed warning for IVIG products contains the following warning: Associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death. Administer IV at minimum concentration available and minimum rate of infusion in patients predisposed to acute renal failure; IVIG products containing sucrose as a stabilizer account for a disproportionate share of case reports involving renal failure. Choose the correct statements. (Select ALL that apply.)

A. Most cases of renal damage with IVIG therapy have been with IVIG products that contain sucrose.
B. Patients who have diabetes, are elderly, or have pre-existing renal damage are at higher risk for renal damage.
C. Avoid concurrent use of gentamicin therapy, if possible.
D. In patients with renal disease, use a lower rate of infusion, and consider a lower dosage.
E. Avoid concurrent use of vancomycin therapy, if possible.

Answer 29

A, B, C, D, E. The majority of renal adverse events (acute renal failure, osmotic nephritis) associated with IVIG therapy have occurred with products stabilized with sucrose, although all carbohydrate-containing IVIG products carry a boxed warning for renal damage. Almost all of these patients had pre-existing risk for renal damage (mostly either existing renal damage, or diabetes.) Avoid concurrent nephrotoxic drugs if possible, including aminoglycosides and vancomycin.

Question 30

The pharmacist receives an order for Precedex. Which of the following is an appropriate generic substitution for Precedex?

A. Cisatracurium
B. Ketamine
C. Dexmedetomidine
D. Propofol
E. Dexamethasone

Answer 30

C. The generic name of Precedex is dexmedetomidine.

cisatracurium (Nimbex)

ketamine (Ketalar)

propofol (Diprivan)

dexamethasone (Decadron)

Question 31

What are the risks associated with providing intravenous H2RA or PPI therapy to patients who do not require stress ulcer prophylaxis? (Select ALL that apply.)

A. Increased infection risk by increasing gastric pH and allowing bacteria overgrowth in the GI tract and airways.
B. Increased risk of contracting hospital-acquired pneumonia.
C. Increased risk of developing Clostridium difficile diarrhea.
D. Increased risk of GI bleeding.
E. Increased risk of VTE.

Answer 31

A, B, C. Both H2RAs and PPIs should not be over-used in hospitalized patients. Appropriate use is for prevention of GI bleeding in high risk patients (generally ventilated ICU patients), or if a medical floor patient has a history of reflux or GI bleeding. Discontinue most PPI orders when patients leave the ICU.

Question 32

What is the correct definition and rationale for using an inotropic agent in a patient with shock syndrome?

A. To increase cardiac contraction, to increase blood flow out of the heart (CO).
B. To decrease cardiac contraction, in order to provide rest to a failing heart.
C. To increase the heart rate, in order to reverse bradycardia.
D. To decrease the heart rate, in order to reverse tachycardia.
E. To increase systemic vascular resistance, to decrease or reverse tachypnea

Answer 32

A. Agents that increase cardiac contractility, and therefore cardiac index, are considered inotropes.

Question 33

Which of the following agents are used as ICU sedatives? (Select ALL that apply.)

A. Precedex
B. Midazolam
C. Ativan
D. Diprivan
E. Levophed

Answer 33

A, B, C, D. Norepinephrine (Levophed) is used as a vasopressor in shock.

Question 35

Which of the following agents is a depolarizing neuromuscular blocking agent?

A. Succinylcholine
B. Cisatracurium
C. Pancuronium
D. Vecuronium
E. Atracurium

Answer 35

A. Succinylcholine is the only available depolarizing neuromuscular blocking agent. It is not used long-term in the ICU, but generally reserved for intubations.

Question 36

Which of the following are crystalloids? (Select ALL that apply.)

A. Sodium chloride
B. 5% Albumin
C. Lactated Ringer’s
D. Dextrose
E. Dextran

Answer 36

A, C, D. Sodium chloride, dextrose, and lactated ringer’s are crystalloids.

Question 37

Which of the following drugs is formulated in a lipid emulsion?

A. Precedex
B. Valium
C. Fentanyl
D. Diprivan
E. Ativan

Answer 37

D. Monitor triglycerides if Diprivan is used long-term. Usually, triglyceride monitoring begins on day 3 of therapy.

Question 38

Which of the following is not an IV hemostatic agent?

A. Amicar
B. Kcentra
C. Profilnine SD
D. NovoSeven
E. Amidate

Answer 38

E. Etomidate (Amidate) is used for agitation or sedation in the ICU.

Amicar (aminocaproic acid)

Kcentra (prothrombin complex concentrate or PCC)

Profilnine SD (factor IX complex)

NovoSeven (recombinant factor VIIa)

Question 39

Which of the following medications is a vasopressor?

A. Duloxetine
B. Phenylephrine
C. NovoSeven
D. Amiodarone
E. Adenosine

Answer 39

B. A vasopressor causes vasoconstriction which leads to increases in blood pressure. Phenylephrine is a pure alpha agonist, causing vasoconstriction.

Question 40

Which of the following represent risks associated with IVIG therapy? (Select ALL that apply.)

A. Acute renal damage
B. Infusion reactions
C. Acute liver damage
D. Fever
E. Pulmonary fibrosis

Answer 40

A, B, D. Acute renal damage, infusion reactions, and fever are among the potential risks associated with IVIG therapy.

Question 42

Which of the following statements concerning IVIG is correct?

A. IVIG is now available as inexpensive generic formulations.
B. IVIG is a form of active immunity.
C. Antibodies recognize antigens on foreign targets, such as bacteria.
D. It takes 10 human donors to make one dose of IVIG.
E. Intravenous immunoglobulins contain a mixture of approximately 50% IgG and 50% IgM.

Answer 42

C. IVIG is nearly all IgG; small amounts of other antibodies may be present. IVIG is obtained from human donors only. The patient is receiving passive immunity (the transfer or human antibodies from another person, or persons, to the patient). IVIG is expensive.

Question 43

Which of the following statements concerning rocuronium, vecuronium and cisatracurium is incorrect?

A. According to ISMP, these are all classified as “HIGH-RISK” medications.
B. These agents are paralytics, or neuromuscular blocking agents (NMBAs).
C. These drugs provide a high degree of sedation.
D. These agents should have a warning applied to the bag, such as: WARNING: PARALYZING AGENT.
E. The non-depolarizing neuromuscular blockers bind to the acetylcholine receptor and block the action of acetylcholine.

Answer 43

C. These drugs do not provide sedation or analgesia. These are all non-depolarizing NMBAs. Succinylcholine is the only depolarizing NMBA. Flushing, bradycardia, hypotension, tachyphylaxis are common side effects.

Question 44

Which of the following statements is true of colloids and crystalloids?

A. Crystalloids cause more adverse reactions than colloids.
B. Colloids improve mortality in shock when compared to crystalloids.
C. Colloids are commonly used for maintenance hydration and to replace fluid losses.
D. Colloids are more expensive than crystalloids.
E. Crystalloids are large molecules that primarily remain in the intravascular space.

Answer 44

D. Colloids are more expensive and provide questionable clinical benefit over crystalloids.