CASES ON CRITICAL CARE

LEARNING OBJECTIVES

1. Interpret hemodynamic parameters and acid-base status in critically ill patients.

2. Differentiate between presentation of and treatment strategies for hypovolemic, obstructive, and
distributive shock.
3. Discuss the appropriate use of fluids, vasopressors, antibiotics, and corticosteroids in patients with
sepsis, severe sepsis, or septic shock.
4. Discuss strategies to optimize the safety and efficacy of therapeutic hypothermia for patients after
cardiac arrest.
5. Recommend therapeutic options to minimize delirium and provide optimal analgesia, sedation,
neuromuscular blockade, and nutritional support in critically ill patients.
6. Recommend therapeutic options to prevent stress ulcers, venous thromboembolism, hyperglycemia,
and ventilator-associated pneumonia in critically ill patients.
7. Recommend treatment options for acute intracranial hemorrhage.

CASE 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 a blood pressure (BP) of 85/40 mm Hg and a
heart rate (HR) of 110 beats/minute.

1. Which action is best to improve her acid-base status?

A. 0.9% sodium chloride (NaCl) bolus. B. 5% dextrose (D5W) bolus.
C. Hydrochloric acid infusion. D. Acetazolamide intravenously.

CASE 2
A 21-year-old, 80-kg man 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. On
the
Richmond Agitation-Sedation Scale (RASS), he is rated a +3. 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 −1. He is receiving a
morphine 4- mg/hour infusion for pain control, which has been adequately controlling his pain (pain
scores less than
3 for 24 hours). Vital signs include BP 110/70 mm Hg and HR 110 beats/ minute. His baseline QTc
interval is 480 milliseconds.

2. In addition to nonpharmacologic interventions to treat delirium, 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 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.

CASE 3
A patient is admitted to the ICU after a motor vehicle accident for traumatic brain injury
and several abdominal injuries. He is initiated on propofol, morphine, and vecuronium for
sedation,
analgesia, and neuromuscular blockade to help control his intracranial pressure. On day 3 of
hospitalization, the patient develops peritonitis with severe sepsis and is treated with
vancomycin, piperacillin/tazobactam, and tobramycin. His train-of-four (TOF) is 0/4.
3. Which intervention would be best to recommend at this time?
A. Sedation should be assessed with the RASS.
B. Change tobramycin to levofloxacin because it can enhance the effects of vecuronium.
C. The patient should be initiated on parenteral nutrition.
D. Morphine can be discontinued because the patient is sedated with propofol.

CASE 4
A 62-year-old woman is admitted to your ICU for respiratory dysfunction
necessitating mechanical ventilation. Hermedical history is nonsignificant, and she is taking no
medications at home. Her chest radiograph shows bilateral lower lobeinfiltrates, her white blood cell
count (WBC) is 21 × 103 cells/m3, her temperature is 39.6°C, her BP is 82/45 mm Hg (normal for her is
115/70 mm Hg), and her HR is 110 beats/minute. After she receives a diagnosis of community-
acquired pneumonia, she is empirically initiated on ceftriaxone 2 g/day and levofloxacin 750
mg/day intravenously. After fluid resuscitation with 6 L of lactated Ringer’s solution, her BP is
unchanged. Dopamine is initiated and titrated to 9 mcg/kg/minute, with a resulting BP of 96/58 mm Hg,
and her HR is 138 beats/minute. She has made less than 100 mL of urine during the past 6 hours, and
her creatinine (Cr) has increased from
0.9 mg/dL to 1.3 mg/dL. Her serum albumin concentration is 2.1 g/dL.

4. 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 an MAP greater than 65 mm Hg.
D. Reduce the dopamine infusion to 1 mcg/kg/ minute to maintain urine output of at least
1 mL/kg/hour.

CASE 5
A 92-year-old woman 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
BP is 72/44 mm Hg, central venous pressure (CVP) is 5 mm Hg, HR 120 beats/minute, and
oxygen
saturation 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.

5. Which therapy is most appropriate to initiate next?

A. Norepinephrine 0.05 mcg/kg/minute. B. Lactated Ringer’s 500-mL bolus.
C. Normal saline 500-mL bolus. D. Albumin 5% 500-mL bolus.

CASE 6.
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. He received an additional two shocks of 200 J
with no improvement. Between shocks, the patient received cardiopulmonary resuscitation (CPR).
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 an HR of 100 beats/minute. The patient was then
transported to the hospital,
intubated and unresponsive.

6. Which recommendation is most likely to improve this patient’s outcomes?

A. Administer sodium bicarbonate intravenously. B. Administer vasopressin 40 units intravenously.
C. Administer a continuous infusion of heparin. D. Initiate a targeted temperature management protocol.
CASE 7
 A 22-year-old man is admitted to the trauma ICU after a motor vehicle accident. He has several
rib fractures, a ruptured spleen, and a small brain contusion. He is rushed to the operating room for an
emergency splenectomy, and the trauma team places an orogastric feeding tube (OGT) before
returning to the ICU. The patient is unresponsive and mechanically ventilated, with no plans for
extubation.

7. Which is most cost-effective for stress ulcer prophylaxis (SUP)?

A. Pantoprazole intravenous push. B. Famotidine by OGT.
C. Sucralfate by OGT. D. No SUP indicated.

CASE 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 plasmalyte
and 1 L of albumin and is currently receiving norepinephrine 0.15 mcg/kg/minute and vasopressin 0.03
units/minute for hemodynamic support. His current vital signs are BP 85/58 mm Hg, HR 99
beats/minute, and respiratory rate (RR) 18 breaths/minute.

8. Which of the following is the best plan for steroid therapy in this patient?
A. Begin hydrocortisone 50 mg every 6 hours intravenously.
B. Perform a cosyntropin stimulation test and begin 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 begin hydrocortisone 50 mg every 6 hours intravenously if the result is less
than 10 mcg/dL.
D. Steroids are not indicated at this time.

CASE 9
The patient in Case 8 continued to decline and was placed on cisatracurium overnight
for hypoxemia. He is currently on cisatracurium 3 mcg/kg/ minute, fentanyl 500 mcg/hour, propofol 40
mcg/
kg/minute, and ketamine 10 mg/hour. His ABG shows a pH of 7.32, Pco2 of 45 mm Hg, Pao2 of 60 mm
Hg (O2 saturation 93%), and Hco3 of 27 mEq/L on 70% Fio2. All laboratory values are normal except for
a sodium of 148 mEq/L and creatinine of 1.4 mg/dL. His vasopressor doses have increased to
norepinephrine 1 mcg/kg/minute and vasopressin 0.03 units/minute. An Scvo2 is measured and found
to be 45%. His skin is mottled, and urine output has decreased to 0.1 mL/kg/hour for the last 12 hours.
Other pertinent vital signs are BP 100/64 mm Hg, HR 95 beats/minute, and RR 26 breaths/minute.

9. Which of the following is the best recommendation to optimize the patient’s hemodynamics?
A. Start dobutamine 5 mcg/kg/minute.
B. Decrease norepinephrine to 0.5 mcg/kg/minute.
C. Decrease propofol to 20 mcg/kg/minute.
D. Start epinephrine 0.05 mcg/kg/minute.

CASE 10.
A 69-year-old man has a seizure on postoperative day (POD) 0 after four-vessel coronary bypass
and maze procedure. On POD 2, he develops hypotension and an increase in lactate to 3.5 mmol/L. His
pulmonary artery catheter shows a cardiac index of 1.5 L/minute/m2, pulmonary capillary wedge
pressure 34 mm Hg, CVP 24 mm Hg, and systemic vascular resistance of 1240 dynes/s/cm5. Other vital
signs are HR 110 beats/minute and BP 95/45 mm Hg.

10. Which of the following is the best intervention for the patient’s shock?
A. Administer 500 mL of 5% albumin.
B. Start dobutamine 5 mcg/kg/minute.
C. Call surgical attending for immediate pericardiocentesis.
D. Start norepinephrine at 0.05 mcg/kg/minute.

CASE 11.
 A 19-year-old man is admitted to the ICU after ingesting an unknown quantity of acetaminophen.
He is 180 cm tall and weighs 68 kg. After initial resuscitation and treatment with acetylcysteine, the
patient remains unresponsive and intubated. The intensivist would like to start enteral nutrition as
soon as possible.

11. Which of the following is the best way to calculate the patient’s caloric and protein needs?
A. Calculate caloric needs based on the modified Penn State equation and estimate protein needs 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 level to assess protein needs.

CASE 12.
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.

12. Which of the following 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. Always maintain head of bed elevation at 20°.
D. Start chlorhexidine 0.12% oral swabs twice daily.

CASE 13.
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.

13. Which of the following goals should be implemented 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.