Drug X is highly protein bound. Your patient’s albumin has decreased acutely due to a septic process. You are concerned since hypoalbuminemia will generally increase the concentration of free/unbound Drug X and increase its volume of distribution (Vd). Which of the following concomitant changes might counter your concern?
Increasing free/unbound Drug X will decrease Drug X efficacy.
Your patient will lose muscle mass due to catabolism and decrease Vd.
An increase in inflammatory mediators/globulins will bind Drug X.
Increasing free/unbound Drug X will increase its metabolism and clearance.
Increasing free/unbound Drug X will increase its metabolism and clearance.
For effective analgesia, it is generally recommended to administer opioids parenterally. Which mechanism of the metabolism of opioids is this recommendation meant to avoid?
Metabolism by intestinal epithelial cells
First pass metabolism by the liver
Metabolism by phase II conjugation
Inhibition of cytochrome P450 mediated metabolism
First pass metabolism by the liver
Which of the following is a pharmacodynamic factor that explains drug tolerance?
Increased renal excretion
Increased production of cAMP
Decreased drug receptor affinity
Decreased drug absorption
Decreased drug receptor affinity
In systemic inflammation, cytokines trigger coagulation through the binding of which coagulation factor?
Factor II
Factor VII
Factor VIII
Factor X
Factor VII
Activation of pattern recognition receptor, such as Toll Like Receptors, initiates signaling cascades through which transcription regulator?
Nuclear Factor Kappa B (NFkB)
Tissue Factor (TF)
High-mobility group box 1 (HMGB1)
Complement activation
Nuclear Factor Kappa B (NFkB)
Ineffective cellular oxygen utilization is a contributing factor to the development of multiple organ dysfunction syndrome by which mechanism?
Increased reactive oxygen species through upregulation of eNOS-generated nitric oxide.
Interlukin-1 can directly inhibit electron transport chain complexes III, IV and V.
Reactive oxygen species damage leads to release of cytochrome c into cytosol triggering apoptotic death.
Released mitochondrial DNA, acts as a PAMP, triggering cytokine generation via TLR-9.
Reactive oxygen species damage leads to release of cytochrome c into cytosol triggering apoptotic death
You have a 40 kg septic patient with an albumin of 1.6 g/dL (16 g/L), and you desire to give a transfusion to raise their albumin to 2.5 g/dL (25 g/L). What is the albumin deficit in grams?
= 162 grams
= 324 grams
= 216 grams
= 120 grams
= 120 grams
Albumin synthesis is under the influence of:
thyroxine.
insulin.
vasopressin.
epinephrine.
thyroxine
Hypoalbuminemia may potentiate the toxicity of which of the following medications?
theophylline
salicylates
diazepam
vancomycin
diazepam
Glycine is a neurotransmitter with both excitatory and inhibitory effects in the central nervous system. Similar to GABA, glycine exerts inhibitory effects by increasing ______________ ion conductance.
calcium
sodium
chloride
potassium
chloride
Which of the following is the mechanism of action of levetiracetam?
Enhancement of responsiveness to the inhibitory postsynaptic effects of GABA.
Modulating voltage-gated calcium-dependent neurotransmitter release.
Inhibit neuronal voltage-dependent sodium and T-type calcium channels.
Hyperpolarization of the neuronal cell membrane via the chloride channel.
Modulating voltage-gated calcium-dependent neurotransmitter release.
Which of the following statements is NOT a true statement regarding N-methyl-D-aspartate (NMDA) receptors?
Glutamate and aspartate are major agonists for the NMDA receptor.
Glycine is a co-agonists of NMDA receptors.
Activated NMDA channels permit the influx of Na+ and Ca2+ into the cell and K+ out.
At normal membrane potentials, the NMDA channels are blocked by extracellular Na+.
At normal membrane potentials, the NMDA channels are blocked by extracellular Na+.
Increasing severity levels of critical illness can result in what changes to a patient’s volume of distribution. Which of the following statements is the most correct?
Increased volume of distribution, resulting in reduced antimicrobial exposure at their site of infection.
Decreased volume of distribution, resulting in reduced antimicrobial exposure at their site of infection.
Increased volume of distribution, resulting in increased antimicrobial exposure at their site of infection.
Decreased volume of distribution, resulting in increased antimicrobial exposure at their site of infection.
Increased volume of distribution, resulting in reduced antimicrobial exposure at their site of infection.
Multi-drug resistance is present when bacteria are resistant to:
a. 1 agent in > 2 separate antimicrobial categories. b. 1 agent in ≥ 3 separate antimicrobial categories. c. 3 agents in > 2 separate antimicrobial categories. d. 3 agents in > 3 separate antimicrobial categories.
1 agent in ≥ 3 separate antimicrobial categories.
With concentration-dependent antimicrobials, it has been demonstrated that maximal bacterial killing is achieved when antimicrobial concentrations are maintained at _________ the MIC of the infecting pathogen.
a. 1 - 2 times b. 2 - 4 times c. 4 – 6 times d. 8 - 10 times
8 - 10 times
What is the corticosteroid of choice for critical illness-related corticosteroid insufficiency?
Dexamethasone
Fludrocortisone
Hydrocortisone
Prednisone
Hydrocortisone
Under which conditions are corticosteroids recommended in septic shock, by the Surviving Sepsis Campaign International Guidelines published in 2016?
Fluid-loaded, vasopressor resistant
Severe vasculitis, non-vasopressor dependent
Extra-pulmonary sepsis, vasopressor dependent
Post fluid resuscitation, prior to use of albumin
Fluid-loaded, vasopressor resistant
Which of the following can cause a Type A hyperlactatemia?
Hyperthyroidism
Muscle tremors
Thiamine deficiency
Malignancy
Muscle tremors
According to the Stewart approach to acid-base analysis, the following were identified as determinants of acid-base balance:
PCO2, HCO3-, and ATOT
PCO2, SID, and ATOT
SID, HCO3-, and ATOT
PCO2, SID, and pH
PCO2, SID, and ATOT
You obtain the following blood gas on your patient.
Test Variable
Result
Reference Range
pH
7.189
7.34 – 7.38
pvCO2
24.7
40 – 46 mmHg
pvO2
88.6
49 – 67 mmHg
HCO3-
9.5
22 – 26 mmol/L
Na+
148.9
140 – 157 mmol/L
K+
3.75
3.5 – 4.9 mmol/L
Cl-
110.2
109 – 120 mmol/L
iCa2+
1.16
1.25 – 1.5 mmol/L
iMg2+
0.68
0.43 – 0.7 mmol/L
Glucose
575
80 – 120 mg/dl
Lactate
2.4
< 2.5 mmol/L
BUN
29
16 – 36 mg/dL
Creatinine
2.0
0.8 – 2.4 mg/dL
What is the calculated serum osmolality?
301.4 mOsm/kg
320.6 mOsm/kg
338.8 mOsm/kg
347.6 mOsm/kg
347.6 mOsm/kg
The formula for calculating free water loss in a patient is: Free water deficit = ([Na+]p ÷ normal [Na+]p] – 1) x (0.6 x BWkg). What does the “0.6” in bold represent?
Intracellular water
Plasma volume
Total body water
Interstitial water
Total body water
The duration of local anesthetic action is primarily determined by:
Lipid solubility
Protein binding
High pKa
Low pKa
Protein binding
The potency of local anesthetics is primarily determined by:
Lipid solubility
Protein binding
High pKa
Low pKa
Lipid solubility
Local anesthetics act by binding reversibly to a target receptor in the voltage-gated _____________ channel of nerves, preventing the conduction of the action potential in any nerve fiber.
potassium
sodium
calcium
chloride
sodium
