BCCCP STUDY EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS

What types of things does the Behavioral Pain Scale (BPS) assess and what score indicates significant pain? correct answer: 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 answer: 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 answer: Major substrate of 3A4 Drug accumulation factors to consider with fentanyl correct answer: Hepatic failure, high Vd Morphine metabolic/drug interaction considerations correct answer: Glucuronidation Morphine major adverse effects correct answer: Hypotension, bradycardia (from histamine release) Morphine drug accumulation factors correct answer: Hepatic failure, active metabolite accumulates in renal failure Hydromorphone metabolic/drug interaction considerations correct answer: Glucuronidation Hydromorphone drug accumulation factors correct answer: Hepatic failure Methadone metabolic/drug interaction considerations correct answer: 3A4 and 2B6 major substrates Methadone significant adverse effects correct answer: QTc prolongation, serotonin syndrome Methadone drug accumulation factors correct answer: Long half-life, hepatic and renal failure will delay clearance Remifentanyl clearance correct answer: blood and tissue esterase (not dependent on organ function) Which IV opioids will not cause bradycardia correct answer: Hydromorphone, methadone Which IV opioid will not cause hypotension correct answer: methadone Which IV opioids carry a risk of serotonin syndrome with other serotinergic agents correct answer: fentanyl, morphine, methadone Which IV opioids can accumulate with liver failure correct answer: fentanyl, morphine, hydromorphone, methadone Which IV opioids can accumulate with renal failure correct answer: morphine, methadone How is propofol cleared correct answer: Hepatic (caution in patients with hepatic impairment or cirrhosis) How many calories and grams of fat does propofol have correct answer: 1.1 kcal/mL or 0.1 g/mL What are some clinical characteristics of PRIS correct answer: 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 answer: Precedex Recommended duration of Precedex correct answer: 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 answer: 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 answer: 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 answer: 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 answer: 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 answer: 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 answer: 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 answer: Severe ARDS (PaO2/FiO2 < 120 mmHg) 2 classes of NMBA, MOA, and examples correct answer: 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 answer: 4-6 min