Intensive Care Medicine Module 2

Which of the following conditions is NOT associated with the presence of giant or cannon a waves in the context of atrioventricular dissociation?

Atrial fibrillation

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Ventricular tachycardia

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Complete heart block

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AV nodal tachycardia

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Tricuspid stenosis

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What does the v wave in the right atrial (RA) waveform primarily represent?

Ventricular systole and passive atrial filling

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Atrial systole

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Closure of the tricuspid valve

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Opening of the tricuspid valve

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Fall in RA pressure following atrial contraction

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Which condition is LEAST likely to cause a raised pulmonary capillary wedged pressure (PCWP)?

Pulmonary veno-occlusive disease

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Left ventricular systolic heart failure

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Hypertrophic cardiomyopathy

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Large right-to-left shunts

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Cardiac tamponade

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A 55-year-old patient is undergoing cardiac catheterization to evaluate pulmonary hypertension. The following measurements are obtained: mean pulmonary artery pressure (mPAP) = 35 mmHg, left atrial pressure (LAP) = 10 mmHg, and cardiac output (CO) = 4 L/min.

What is the calculated pulmonary vascular resistance (PVR) in dyn·s/cm⁵?

500 dyn·s/cm⁵

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400 dyn·s/cm⁵

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800 dyn·s/cm⁵

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1000 dyn·s/cm⁵

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1200 dyn·s/cm⁵

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What is the recommended timing for measuring Pulmonary Capillary Wedge Pressure (PCWP) to avoid the effects of respiration on measurements?

At end-expiration, regardless of the mode of ventilation

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At the peak of inspiration

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At the trough of expiration

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During the plateau phase of positive pressure ventilation

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At the onset of spontaneous breathing

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A 53-year-old woman with a history of chronic dyspnea undergoes a right heart catheter study. The results are as follows:

Mean pulmonary artery pressure (mPAP): 28 mmHg
Pulmonary capillary wedge pressure (PCWP): 12 mmHg
Pulmonary vascular resistance (PVR): 320 dyn·s/cm⁵

Based on these findings, what is the most likely diagnosis?

Pulmonary arterial hypertension (PAH) of unclear aetiology

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Pulmonary arterial hypertension (PAH) due to left heart disease

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Chronic thromboembolic pulmonary hypertension (CTEPH)

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Pulmonary hypertension due to chronic lung disease

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Elevated pulmonary pressures due to acute hypoxemic-induced vasoconstriction

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A 55-year-old critically ill patient requires increasing doses of norepinephrine to maintain blood pressure.

Which of the following mechanisms is most likely responsible for the development of tachyphylaxis to vasopressors in this patient?

Downregulation of adrenergic receptors

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Increased production of nitric oxide

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Enhanced activity of phosphodiesterase enzymes

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Depletion of vasopressin stores

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Increased vascular smooth muscle sensitivity to vasodilators

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A 65-year-old patient is admitted to the ICU with cardiogenic shock. The patient’s mean arterial pressure (MAP) is 50 mmHg, and the decision is made to start vasopressors to increase MAP.

Which of the following is the primary rationale for avoiding excessive increases in systemic vascular resistance (SVR) when using vasopressors in this patient?

To prevent excessive afterload and potential decrease in cardiac output

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To minimize the risk of cardiac arrhythmias

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To maintain a supraphysiologic cardiac index of >4 to 4.5 L/minute per m2

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To avoid the need for inotropic agents

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To prevent vasodilation and decreased blood pressure

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A 50-year-old critically ill patient is receiving norepinephrine at 0.5 mcg/kg per minute for blood pressure support. The patient is also receiving subcutaneous low molecular weight heparin (LMWH) for deep vein thrombosis prophylaxis.

Which of the following statements is most accurate regarding the patient’s LMWH therapy?

The patient's LMWH dose should be increased due to decreased bioavailability.

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The patient's LMWH dose should be decreased due to increased bioavailability.

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The patient's LMWH therapy should be switched to an oral anticoagulant.

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The patient's LMWH therapy is unaffected by the use of norepinephrine.

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The patient's LMWH therapy should be discontinued due to the risk of bleeding.

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What is the primary mechanism of action of Norepinephrine?

Activation of alpha-1 adrenergic receptors to induce vasoconstriction

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Stimulation of beta-1 adrenergic receptors to increase inotropy and chronotropy

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Stimulation of angiotensin receptors to increase cytosolic calcium concentration and mediate vasoconstriction

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Increase in the sensitivity of the myocardial contractile apparatus to calcium

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Stimulation of dopamine receptors to induce vasodilation

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A 65-year-old patient with heart failure is started on a Dobutamine infusion. Shortly after initiation, the patient’s blood pressure drops from 120/80 mmHg to 90/60 mmHg.

Which of the following best explains this observation?

Dobutamine has increased cardiac output, but also caused vasodilation through beta-2 adrenergic receptor activation.

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Dobutamine has decreased cardiac output, leading to hypotension.

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Dobutamine has caused vasoconstriction, increasing peripheral resistance.

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Dobutamine has had no effect on cardiac output, but has caused a decrease in preload.

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Dobutamine has caused an allergic reaction, leading to anaphylactic shock.

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A 60-year-old patient is in shock and requires vasopressor support. Dopamine is initiated at a dose of 5 mcg/kg per minute and gradually increased to 15 mcg/kg per minute.

Which of the following is most likely to occur as a result of this dose increase?

Shift from predominantly beta-1 adrenergic receptor activation to alpha-adrenergic receptor activation

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Increased activation of beta-2 adrenergic receptors

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Decreased activation of alpha-adrenergic receptors

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Increased activation of beta-1 adrenergic receptors only

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No change in receptor activation

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A 65-year-old patient in the ICU is experiencing severe hypotension due to septic shock. The Intensivist orders a norepinephrine infusion to increase the patient’s blood pressure.

The nurse notes that the patient’s heart rate prior to the infusion was 90 beats per minute. After the norepinephrine infusion is started, the patient’s mean arterial pressure (MAP) increases significantly.

What is the most likely effect on the patient’s heart rate?

The heart rate will remain relatively stable or decrease slightly

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The heart rate will increase significantly to 120 beats per minute or more

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The heart rate will decrease significantly to 60 beats per minute or less

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The heart rate will not change due to equal opposing effects

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The heart rate will initially increase and then decrease

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What is the recommended approach for drawing blood cultures in patients with suspected infection?

Draw at least two blood cultures through an indwelling or central intravascular catheter before antimicrobial administration.

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Draw blood cultures from at least two different peripheral venipuncture sites before antimicrobial administration.

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Draw a single blood culture through an indwelling or central intravascular catheter.

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Draw blood cultures from a peripheral venipuncture site only after antimicrobial administration.

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Draw blood cultures from a single peripheral venipuncture site and then through an indwelling or central intravascular catheter.

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A 45-year-old patient is admitted to the ICU with severe sepsis and requires large volume fluid resuscitation.

To minimize the risk of developing hyperchloremic metabolic acidosis, which of the following crystalloids would be the most suitable choice?

Lactated Ringer solution (Hartmann’s solution).

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0.9% saline

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0.45% saline solution

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3% saline solution

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Dextrose 5% in water

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Which of the following is a potential indication for the use of colloid-containing solutions, such as albumin, in the management of non-hemorrhagic hypovolemia and hypovolemic shock?

In patients with a limited response to crystalloid solutions

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As a first-line resuscitative fluid for all patients

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In patients with a known allergy to crystalloid solutions

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In patients with severe hypernatremia

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In patients with acute kidney injury

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A 55-year-old man is admitted to the ICU with septic shock due to pneumonia. His past medical history includes a recent course of etomidate for sedation during a surgical procedure.

Which of the following mechanisms is most likely contributing to his potential adrenal insufficiency in the context of sepsis?

Impairment of the HPA axis due to previous etomidate therapy

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Reduced cortisol breakdown due to altered metabolism

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Increased glucocorticoid receptor affinity for cortisol

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Glucocorticoid resistance due to increased expression of the alpha-isoform of the glucocorticoid receptor

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Decreased peripheral conversion of precursors to cortisol

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Which of the following conditions is NOT an appropriate indication for glucocorticoid therapy in sepsis?

Severe influenza

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Acute eosinophilic pneumonia

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Hemophagocytic lymphohistiocytosis

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Severe COVID-19

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Severe community-acquired pneumonia

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What is the primary benefit of using procalcitonin-guided therapy in patients with sepsis, particularly those with pneumonia or respiratory tract infections?

Reduced duration of antibiotic use

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Reduced mortality rates

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Reduced duration of hospital stay

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Improved diagnostic accuracy of sepsis

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Reduced duration of illness

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What is the rationale for using empiric antibiotic therapy in patients with sepsis?

To provide coverage for the most common organisms causing sepsis in specific patient populations

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To cover all possible bacterial pathogens

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To treat fungal infections

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To reduce the risk of antibiotic resistance

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To minimize the duration of antibiotic therapy

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What is the most notable characteristic of propofol’s pharmacological profile?

It has amnesic, anxiolytic, and anticonvulsant effects, but no analgesic effects.

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It has potent analgesic effects, making it suitable for pain management.

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It has a direct mechanism of action on opioid receptors, producing analgesia.

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It is a bronchoconstrictor, making it contraindicated in patients with asthma.

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It has a primary mechanism of action through activation of peripheral GABA receptors.

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A 35-year-old male patient with severe head injury is mechanically ventilated and sedated with propofol at a dose of 5 mg/kg/hour for 72 hours.

Suddenly, he develops acute refractory bradycardia with a heart rate of 30 beats per minute, despite receiving dopamine and norepinephrine infusions.

His electrocardiogram (ECG) shows a widened QRS complex and a prolonged QT interval.

His blood work-up shows the following abnormality:

Severe anion gap metabolic acidosis with a pH of 7.0, a lactate level of 10 mmol/L, and a base deficit of -15 mmol/L.
Raised serum creatinine of 250 mmol/L
Raised serum creatine kinase (CK) level of 10,000 U/L.
Raised serum potassium level of 6.5 mmol/L
Reduced serum phosphate level to 1.5 mmol/L.
Elevated liver enzymes with an alanine transaminase (ALT) of 500 U/L and an aspartate transaminase (AST) of 700 U/L.

The patient’s cardiovascular status deteriorates rapidly, with a decrease in blood pressure to 60/30 mmHg, despite aggressive fluid resuscitation and vasopressor support. His central venous oxygen saturation (ScvO2) is 40%, indicating inadequate oxygen delivery to his tissues. Urine output decreases to 10 mL/hour.

Given the patient’s clinical presentation, what is the next step in management?

Immediately discontinue propofol infusion and provide supportive care.

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Continue propofol infusion at a lower dose

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Administer sodium bicarbonate to correct acidosis

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Initiate hemodialysis to remove propofol

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Administer a beta-blocker to control heart rate

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A 65-year-old patient is admitted to the ICU with a diagnosis of sepsis. The patient is intubated and mechanically ventilated. Dexmedetomidine is started for sedation.

The patient is also receiving metoprolol for hypertension. Suddenly, the patient’s heart rate drops to 40 beats per minute.

Which of the following is the most likely explanation for this finding?

Synergistic effect of dexmedetomidine and metoprolol on heart rate

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Dexmedetomidine-induced hypotension

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Metoprolol-induced bradycardia

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Dexmedetomidine-induced anaphylaxis

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Iatrogenic overdose of dexmedetomidine

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What is the primary reason to avoid using ketamine as an induction agent for rapid sequence intubation (RSI) in a patient with status epilepticus?

Stimulant effects on the brain

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Risk of hypotension

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Potential for cerebral herniation

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Concern for adrenal insufficiency

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Likelihood of inducing hyperkalemia

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A 45-year-old man with a severe head injury is brought to the emergency department with a mean arterial pressure (MAP) of 140 mmHg. He requires rapid sequence intubation (RSI) for airway management.

Which of the following induction agents is most suitable for this patient?

Etomidate

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Ketamine

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Midazolam

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Propofol

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Dexmedetomidine

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In which of the following conditions should succinylcholine be avoided due to the risk of a life-threatening complication?

Personal history of malignant hyperthermia

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Myasthenia gravis

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Recent myocardial infarction

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Chronic obstructive pulmonary disease (COPD)

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Severe hypokalemia

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A 35-year-old male patient is undergoing rapid sequence intubation (RSI) in the emergency department. He has been pre-sedated with remifentanil 2 minutes prior to the administration of rocuronium. The anesthesiologist notices that the patient’s paralysis is taking longer than expected to set in.

Which of the following is the most likely explanation for this delayed effect?

Remifentanil has delayed the onset of paralysis by approximately 30-45 seconds

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The patient has a history of malignant hyperthermia

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The rocuronium dose was inadequate

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The patient has a pre-existing neuromuscular disorder

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The lidocaine administered earlier has altered the duration of paralysis

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Which of the following patient groups is generally not suitable for acute peritoneal dialysis?

Patients who have undergone recent abdominal surgery

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Patients with heart failure refractory to medical management and who require dialysis for AKI

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Patients who are at a high risk for bleeding with anticoagulation

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Patients with cirrhosis and ascites

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Patients with pulmonary edema

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What is the evidence-based minimum delivered dose of continuous kidney replacement therapy (CKRT) required to mitigate the risk of increased mortality in critically ill patients?

13-15 mL/kg/hr

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10 mL/kg/hr

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18 mL/kg/hr

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20 mL/kg/hr

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25 mL/kg/hr

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A 45-year-old male patient is admitted to the ICU with acute kidney injury (AKI) secondary to sepsis. His laboratory results show a plasma potassium concentration of 7.2 mEq/L, which has increased from 5.5 mEq/L over the past 6 hours despite medical management. His arterial blood gas shows a metabolic acidosis with a pH of 7.2. His phosphate level is elevated at 5 mg/dL. He is also experiencing worsening shortness of breath due to fluid overload and appears mildly confused and disoriented.

Which of the following is the most urgent indication for initiating acute dialysis in this patient?

Rapidly rising potassium levels with a current plasma potassium concentration of 7.2 mEq/L

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Fluid overload

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Severe metabolic acidosis with a pH of 7.2

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An altered mental state

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Severe hyperphosphatemia

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What is a predictor of incident sepsis after acute kidney injury (AKI) in critically ill patients?

Prolonged oliguria of more than 3 days.

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Diuretic use

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Early initiation of antibiotics

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Low severity of illness

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A cumulative fluid balance of less than 10 % of body weight

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Intensive Care Medicine Module 2

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