BCCCP COMPREHENSIVE EXAM UPDATED QUESTIONS AND
SOLUTIONS RATED A+
✔✔What to do with sedation and analgesia during an SAT - ✔✔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 - ✔✔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? - ✔✔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 - ✔✔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? - ✔✔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? - ✔✔Severe ARDS
(PaO2/FiO2 < 120 mmHg)
✔✔2 classes of NMBA, MOA, and examples - ✔✔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 - ✔✔4-6 min
✔✔Vecuronium:
1. Metabolism
2. Duration - ✔✔1. Hepatically metabolized and some renal clearance with an active
metabolite
2. Duration 30 min
✔✔Rocuronium
1. Metabolism
2. Duration - ✔✔1. Hepatically metabolized
2. 30-40 min
✔✔Atracurium
1. Metabolism
2. Duration
3. Unique adverse effects - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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? - ✔✔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 - ✔✔All agents hepatically metabolized by
CYP isoenzymes 3A4 and 2C19
✔✔What are 4 independent risk factors for ICU-acquired VTE? - ✔✔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 - ✔✔Malignancy
Previous VTE
Immobility
Known thrombophilia
Recent (1 month or less) surgery or trauma
70 years of age or older
Heart or respiratory failure
Sepsis
Obesity (BMI >30)
Pregnancy
ESA use w/ hgb 12 or greater
Hormonal therapy
Recent transfusion of concentrated clotting factors
Central venous lines
Long-distance travel
✔✔Dose of fondaparinux for VTE ppx - ✔✔2.5 mg once daily for patients weighing 50
kg or more
✔✔4T score: thrombocytopenia - ✔✔2 points: >50% platelet fall to nadir >20
1 point: 30-50% platelet fall, or nadir 10-19
0 points: <30% platelet fall, or nadir <10
✔✔4T score: Timing - ✔✔2 points: Days 5-10, or <1 day with recent heparin exposure
(past 30 days)
, 1 point: >10 days of timing unclear, or <1 day with recent heparin exposure (past 31-
100 days)
0 points: <day 4 with no recent heparin exposure
✔✔4T score: thrombosis - ✔✔2 points: proven new thrombosis, skin necrosis, or acute
systemic reaction after IV UFH bolus
1 point: progressive or recurrent thrombosis or suspected thrombosis
0 points: no thrombosis
✔✔4T score: other causes of platelet fall - ✔✔2 points: none evident
1 point: possible
0 points: definite
✔✔4T score: pretest probability scores - ✔✔Low positive predictive value:
High: 6-8 points
Intermediate: 4-5 points
High negative predictive value:
Low: 0-3 points
✔✔What is a positive HIT antibody value and what is the predictive value of this test? -
✔✔OD of 0.4 or greater
High sensitivity (>90%) and low to moderate specificity
✔✔What is the predictive value of the SRA test - ✔✔High sensitivity and specificity
✔✔When can you start warfarin hen patient is being treated for HIT with a DTI -
✔✔Once platelet count has recovered to at least 150 and at least 5 days of therapy with
the DTI
✔✔What are the 3 big risks we think of with PPIs (significantly higher than with H2RAs)
- ✔✔1. Increased risk of fractures (hip, waist, and spine)
2. CDI (definitive cause-effect relationship is not well established, but the increased risk
is there)
3. Risk of nosocomial pneumonia
✔✔Summarize the PPI vs. H2RA data - ✔✔Some meta-analyses favor PPIs to H2RAs
for GIB and one retrospective cohort found the OR of GIB greater with PPI than H2RAs
✔✔A course or plan of action which establishes standards of practice or
quality/compliance measures and protects against error - ✔✔Policy
SOLUTIONS RATED A+
✔✔What to do with sedation and analgesia during an SAT - ✔✔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 - ✔✔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? - ✔✔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 - ✔✔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? - ✔✔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? - ✔✔Severe ARDS
(PaO2/FiO2 < 120 mmHg)
✔✔2 classes of NMBA, MOA, and examples - ✔✔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 - ✔✔4-6 min
✔✔Vecuronium:
1. Metabolism
2. Duration - ✔✔1. Hepatically metabolized and some renal clearance with an active
metabolite
2. Duration 30 min
✔✔Rocuronium
1. Metabolism
2. Duration - ✔✔1. Hepatically metabolized
2. 30-40 min
✔✔Atracurium
1. Metabolism
2. Duration
3. Unique adverse effects - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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? - ✔✔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 - ✔✔All agents hepatically metabolized by
CYP isoenzymes 3A4 and 2C19
✔✔What are 4 independent risk factors for ICU-acquired VTE? - ✔✔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 - ✔✔Malignancy
Previous VTE
Immobility
Known thrombophilia
Recent (1 month or less) surgery or trauma
70 years of age or older
Heart or respiratory failure
Sepsis
Obesity (BMI >30)
Pregnancy
ESA use w/ hgb 12 or greater
Hormonal therapy
Recent transfusion of concentrated clotting factors
Central venous lines
Long-distance travel
✔✔Dose of fondaparinux for VTE ppx - ✔✔2.5 mg once daily for patients weighing 50
kg or more
✔✔4T score: thrombocytopenia - ✔✔2 points: >50% platelet fall to nadir >20
1 point: 30-50% platelet fall, or nadir 10-19
0 points: <30% platelet fall, or nadir <10
✔✔4T score: Timing - ✔✔2 points: Days 5-10, or <1 day with recent heparin exposure
(past 30 days)
, 1 point: >10 days of timing unclear, or <1 day with recent heparin exposure (past 31-
100 days)
0 points: <day 4 with no recent heparin exposure
✔✔4T score: thrombosis - ✔✔2 points: proven new thrombosis, skin necrosis, or acute
systemic reaction after IV UFH bolus
1 point: progressive or recurrent thrombosis or suspected thrombosis
0 points: no thrombosis
✔✔4T score: other causes of platelet fall - ✔✔2 points: none evident
1 point: possible
0 points: definite
✔✔4T score: pretest probability scores - ✔✔Low positive predictive value:
High: 6-8 points
Intermediate: 4-5 points
High negative predictive value:
Low: 0-3 points
✔✔What is a positive HIT antibody value and what is the predictive value of this test? -
✔✔OD of 0.4 or greater
High sensitivity (>90%) and low to moderate specificity
✔✔What is the predictive value of the SRA test - ✔✔High sensitivity and specificity
✔✔When can you start warfarin hen patient is being treated for HIT with a DTI -
✔✔Once platelet count has recovered to at least 150 and at least 5 days of therapy with
the DTI
✔✔What are the 3 big risks we think of with PPIs (significantly higher than with H2RAs)
- ✔✔1. Increased risk of fractures (hip, waist, and spine)
2. CDI (definitive cause-effect relationship is not well established, but the increased risk
is there)
3. Risk of nosocomial pneumonia
✔✔Summarize the PPI vs. H2RA data - ✔✔Some meta-analyses favor PPIs to H2RAs
for GIB and one retrospective cohort found the OR of GIB greater with PPI than H2RAs
✔✔A course or plan of action which establishes standards of practice or
quality/compliance measures and protects against error - ✔✔Policy
