BCCCP || 100% Errorless Answers.
What types of things does the Behavioral Pain Scale (BPS) assess and what score indicates
significant pain? correct answers 1. Facial expression (relaxed vs. grimacing)
2. Upper limbs (no movement vs. permanently retracted)
3. Compliance with ventilation (tolerating movement vs. unable to control ventilation/fighting
vent)
>5
What types of things does the Critical-Care Pain Observation Tool (CPOT) assess and what
score indicates significant pain? correct answers 1. Body movements (absence of movement vs.
restlessness)
2. Muscle tension - flexion/extension of upper extremities (relaxed vs. very tense or rigid)
3. Compliance with ventilator (tolerating vs. fighting) OR vocalization
>=3
Fentanyl metabolic/drug interaction considerations correct answers Major substrate of 3A4
Drug accumulation factors to consider with fentanyl correct answers Hepatic failure, high Vd
Morphine metabolic/drug interaction considerations correct answers Glucuronidation
Morphine major adverse effects correct answers Hypotension, bradycardia (from histamine
release)
Morphine drug accumulation factors correct answers Hepatic failure, active metabolite
accumulates in renal failure
Hydromorphone metabolic/drug interaction considerations correct answers Glucuronidation
Hydromorphone drug accumulation factors correct answers Hepatic failure
Methadone metabolic/drug interaction considerations correct answers 3A4 and 2B6 major
substrates
Methadone significant adverse effects correct answers QTc prolongation, serotonin syndrome
Methadone drug accumulation factors correct answers Long half-life, hepatic and renal failure
will delay clearance
Remifentanyl clearance correct answers blood and tissue esterase (not dependent on organ
function)
Which IV opioids will not cause bradycardia correct answers Hydromorphone, methadone
,Which IV opioid will not cause hypotension correct answers methadone
Which IV opioids carry a risk of serotonin syndrome with other serotinergic agents correct
answers fentanyl, morphine, methadone
Which IV opioids can accumulate with liver failure correct answers fentanyl, morphine,
hydromorphone, methadone
Which IV opioids can accumulate with renal failure correct answers morphine, methadone
How is propofol cleared correct answers Hepatic (caution in patients with hepatic impairment or
cirrhosis)
How many calories and grams of fat does propofol have correct answers 1.1 kcal/mL or 0.1
g/mL
What are some clinical characteristics of PRIS correct answers metabolic acidosis, acute renal
failure, cardiovascular collapse, cardiac arrhythmias, rhabdo, myoglobinuria, hyperkalemia,
hyperTG, elevated CK
Which sedative may have weak opiate-sparing antinociceptive effects correct answers Precedex
Recommended duration of Precedex correct answers Package insert recommends therapy for 24
hours or less, RCTs have used it up to 5-7 days, and safety beyond 7 days is not well established
Lorazepam vs. midazolam clearance and volume of distribution correct answers Lorazepam:
hepatic clearance by conjugation to inactive compounds, moderate to high Vd
Midazolam: hepatic clearance by glucuronidation to an active metabolite which is renally
cleared, large Vd
What to do with sedation and analgesia during an SAT correct answers Hold continuous sedative
and analgesic infusions and bolus opioids for breakthrough pain (continuous opioid infusions
allowed to continue while stopping sedatives if presence of active pain)
What to do with sedation and analgesia if SAT fails correct answers Bolus opioids before
restarting infusion. Re initiate sedative infusion, if necessary, at half the previous dose and titrate
to goal
If a patient is delirious, which classes of medications should be scrutinized for need and
appropriate dosage? correct answers 1. Anticholinergics
2. BZDs
3. Opiates
4. Antipsychotics
5. Antispasmodics
6. Anticonvulsants
,7. Corticosteroids
What are precipitants of delirium to keep in mind and try to treat correct answers 1. Infection
2. Dehydration or malnutrition
3. Sleep deprivation
4. Centrally acting medications (benzodiazepines, opiates, anticholinergics)
5. Lack of exposure to sunlight
6. Lack of personal interaction
7. Physical restraints or insertion of catheters or tubes
Out of the following antipsychotics for delirium (haloperidol, olanzapine, quetiapine,
risperidone, ziprasidone), which:
1. Have the least anticholinergic effects?
2. Are the most sedating?
3. Have the highest risk of EPS?
4. Have the highest risk of NMS?
5. Have a risk of neuromuscular weakness?
6. Have a risk of orthostatic hypotension?
7. Have a risk of cardiac conduction abnormalities? correct answers 1. Haloperidol, risperidone,
ziprasidone
2. Olanzapine, quetiapine
3. Haloperidol, risperidone
4. All have a low risk of NMS
5. Olanzapine
6. Quetiapine and risperidone
7. Risperidone
When may a short term (<48 hours) NMBA be beneficial? correct answers Severe ARDS
(PaO2/FiO2 < 120 mmHg)
2 classes of NMBA, MOA, and examples correct answers 1. Depolarizing: binds and activates
acetylcholine receptors causing persistent depolarization (succinylcholine)
2. Nondepolarizing: blocks the action of acetylcholine and the neuromuscular junction (all others
- vec, roc, atra, cisatra)
Succinylcholine duration correct answers 4-6 min
Vecuronium:
1. Metabolism
2. Duration correct answers 1. Hepatically metabolized and some renal clearance with an active
metabolite
2. Duration 30 min
Rocuronium
1. Metabolism
2. Duration correct answers 1. Hepatically metabolized
, 2. 30-40 min
Atracurium
1. Metabolism
2. Duration
3. Unique adverse effects correct answers 1. Hofmann elimination to form the toxic metabolite
laudanosine which is then hepatically and renally cleared (may precipate seizure activity)
2. 30-40 min
3. Histamine release may cause cardiovascular adverse effects and bronchospasm
Cisatracurium
1. Differences from atracurium
2. Metabolism
3. Duration correct answers 1. slower onset, no histamine release, produces laudanosine and
much lower levels
2. Hofmann elimination
3. 30-60 min
RIsk factors for stress-related bleeding correct answers 1. Respiratory failure requiring
mechanical ventilation for 48 hours or longer OR
2. Coagulopathy: PLT<50, INR>1.5, aPTT >2x control
Variables associated with the risk of GIB while receiving prophylaxis correct answers Renal
failure/AKI/RRT, age 50 or older, acute respiratory failure, MI, neurologic injury, sepsis, shock,
acute or chronic hepatic failure, coagulopathy
What are other risk factors for stress-related mucosal disease besides the two independent risk
factors? correct answers 1. Spinal cord/head trauma
2. Thermal injury affecting more than 35% of total body surface area
3. History of GIB within the past year
4. Postoperative transplant
5. Ulcerogenic medications (NSAIDs, CS)
Metabolism/drug interactions for all PPIs correct answers All agents hepatically metabolized by
CYP isoenzymes 3A4 and 2C19
What are 4 independent risk factors for ICU-acquired VTE? correct answers 1. Personal or
family history of VTE
2. End stage renal failure
3. Platelet transfusion
4. Vasopressor use
What are other risk factors for VTE correct answers Malignancy
Previous VTE
Immobility
Known thrombophilia
What types of things does the Behavioral Pain Scale (BPS) assess and what score indicates
significant pain? correct answers 1. Facial expression (relaxed vs. grimacing)
2. Upper limbs (no movement vs. permanently retracted)
3. Compliance with ventilation (tolerating movement vs. unable to control ventilation/fighting
vent)
>5
What types of things does the Critical-Care Pain Observation Tool (CPOT) assess and what
score indicates significant pain? correct answers 1. Body movements (absence of movement vs.
restlessness)
2. Muscle tension - flexion/extension of upper extremities (relaxed vs. very tense or rigid)
3. Compliance with ventilator (tolerating vs. fighting) OR vocalization
>=3
Fentanyl metabolic/drug interaction considerations correct answers Major substrate of 3A4
Drug accumulation factors to consider with fentanyl correct answers Hepatic failure, high Vd
Morphine metabolic/drug interaction considerations correct answers Glucuronidation
Morphine major adverse effects correct answers Hypotension, bradycardia (from histamine
release)
Morphine drug accumulation factors correct answers Hepatic failure, active metabolite
accumulates in renal failure
Hydromorphone metabolic/drug interaction considerations correct answers Glucuronidation
Hydromorphone drug accumulation factors correct answers Hepatic failure
Methadone metabolic/drug interaction considerations correct answers 3A4 and 2B6 major
substrates
Methadone significant adverse effects correct answers QTc prolongation, serotonin syndrome
Methadone drug accumulation factors correct answers Long half-life, hepatic and renal failure
will delay clearance
Remifentanyl clearance correct answers blood and tissue esterase (not dependent on organ
function)
Which IV opioids will not cause bradycardia correct answers Hydromorphone, methadone
,Which IV opioid will not cause hypotension correct answers methadone
Which IV opioids carry a risk of serotonin syndrome with other serotinergic agents correct
answers fentanyl, morphine, methadone
Which IV opioids can accumulate with liver failure correct answers fentanyl, morphine,
hydromorphone, methadone
Which IV opioids can accumulate with renal failure correct answers morphine, methadone
How is propofol cleared correct answers Hepatic (caution in patients with hepatic impairment or
cirrhosis)
How many calories and grams of fat does propofol have correct answers 1.1 kcal/mL or 0.1
g/mL
What are some clinical characteristics of PRIS correct answers metabolic acidosis, acute renal
failure, cardiovascular collapse, cardiac arrhythmias, rhabdo, myoglobinuria, hyperkalemia,
hyperTG, elevated CK
Which sedative may have weak opiate-sparing antinociceptive effects correct answers Precedex
Recommended duration of Precedex correct answers Package insert recommends therapy for 24
hours or less, RCTs have used it up to 5-7 days, and safety beyond 7 days is not well established
Lorazepam vs. midazolam clearance and volume of distribution correct answers Lorazepam:
hepatic clearance by conjugation to inactive compounds, moderate to high Vd
Midazolam: hepatic clearance by glucuronidation to an active metabolite which is renally
cleared, large Vd
What to do with sedation and analgesia during an SAT correct answers Hold continuous sedative
and analgesic infusions and bolus opioids for breakthrough pain (continuous opioid infusions
allowed to continue while stopping sedatives if presence of active pain)
What to do with sedation and analgesia if SAT fails correct answers Bolus opioids before
restarting infusion. Re initiate sedative infusion, if necessary, at half the previous dose and titrate
to goal
If a patient is delirious, which classes of medications should be scrutinized for need and
appropriate dosage? correct answers 1. Anticholinergics
2. BZDs
3. Opiates
4. Antipsychotics
5. Antispasmodics
6. Anticonvulsants
,7. Corticosteroids
What are precipitants of delirium to keep in mind and try to treat correct answers 1. Infection
2. Dehydration or malnutrition
3. Sleep deprivation
4. Centrally acting medications (benzodiazepines, opiates, anticholinergics)
5. Lack of exposure to sunlight
6. Lack of personal interaction
7. Physical restraints or insertion of catheters or tubes
Out of the following antipsychotics for delirium (haloperidol, olanzapine, quetiapine,
risperidone, ziprasidone), which:
1. Have the least anticholinergic effects?
2. Are the most sedating?
3. Have the highest risk of EPS?
4. Have the highest risk of NMS?
5. Have a risk of neuromuscular weakness?
6. Have a risk of orthostatic hypotension?
7. Have a risk of cardiac conduction abnormalities? correct answers 1. Haloperidol, risperidone,
ziprasidone
2. Olanzapine, quetiapine
3. Haloperidol, risperidone
4. All have a low risk of NMS
5. Olanzapine
6. Quetiapine and risperidone
7. Risperidone
When may a short term (<48 hours) NMBA be beneficial? correct answers Severe ARDS
(PaO2/FiO2 < 120 mmHg)
2 classes of NMBA, MOA, and examples correct answers 1. Depolarizing: binds and activates
acetylcholine receptors causing persistent depolarization (succinylcholine)
2. Nondepolarizing: blocks the action of acetylcholine and the neuromuscular junction (all others
- vec, roc, atra, cisatra)
Succinylcholine duration correct answers 4-6 min
Vecuronium:
1. Metabolism
2. Duration correct answers 1. Hepatically metabolized and some renal clearance with an active
metabolite
2. Duration 30 min
Rocuronium
1. Metabolism
2. Duration correct answers 1. Hepatically metabolized
, 2. 30-40 min
Atracurium
1. Metabolism
2. Duration
3. Unique adverse effects correct answers 1. Hofmann elimination to form the toxic metabolite
laudanosine which is then hepatically and renally cleared (may precipate seizure activity)
2. 30-40 min
3. Histamine release may cause cardiovascular adverse effects and bronchospasm
Cisatracurium
1. Differences from atracurium
2. Metabolism
3. Duration correct answers 1. slower onset, no histamine release, produces laudanosine and
much lower levels
2. Hofmann elimination
3. 30-60 min
RIsk factors for stress-related bleeding correct answers 1. Respiratory failure requiring
mechanical ventilation for 48 hours or longer OR
2. Coagulopathy: PLT<50, INR>1.5, aPTT >2x control
Variables associated with the risk of GIB while receiving prophylaxis correct answers Renal
failure/AKI/RRT, age 50 or older, acute respiratory failure, MI, neurologic injury, sepsis, shock,
acute or chronic hepatic failure, coagulopathy
What are other risk factors for stress-related mucosal disease besides the two independent risk
factors? correct answers 1. Spinal cord/head trauma
2. Thermal injury affecting more than 35% of total body surface area
3. History of GIB within the past year
4. Postoperative transplant
5. Ulcerogenic medications (NSAIDs, CS)
Metabolism/drug interactions for all PPIs correct answers All agents hepatically metabolized by
CYP isoenzymes 3A4 and 2C19
What are 4 independent risk factors for ICU-acquired VTE? correct answers 1. Personal or
family history of VTE
2. End stage renal failure
3. Platelet transfusion
4. Vasopressor use
What are other risk factors for VTE correct answers Malignancy
Previous VTE
Immobility
Known thrombophilia
