Icu 1

1. A 70-kg patient is to receive a continuous infusion of dopamine for BP support.
The nurse
has a 250-mL
bag of D5W containing 400 mg of dopamine. At which one of the following rates should the
dopamine drip
be given to provide the patient with a dose of 5 mcg/kg/minute?
A. 13 mL/hour.
B. 13 mL/minute.
C. 22 mL/hour.
D. 22 mL/minute
5. Answer: A
Calculating an infusion rate is a very important role for
the pharmacist in code situations. The infusion pump is
set to run in milliliters per hour, so your answer should
always be in these units. To determine the rate (in milliliters
per hour) needed to achieve a 5-mcg/kg/minute
dose, use the following calculation:
concentration of dopamine drip: 400 mg/250 mL = 1.6
mg/mL or 1600 mcg/mL. Therefore, 70 kg × 5 mcg/
kg/minute × 60 minutes/1 hour × 1 mL/1600 mcg = 13
mL/hour
2. A 42-year-old man was found unresponsive at his group home covered in vomit. He was
intubated by the
paramedics. On arrival to the emergency department, his BP is 72/30 mm Hg and HR is 122
beats/minute.
During the next couple of hours, he receives 5 L of normal saline, 500 mL of 5% albumin, and
norepinephrine
infusing at 40 mcg/minute. With these interventions, his BP is 87/56 mm Hg and HR is 100
beats/
minute. Pertinent laboratory values include a WBC of 20,000 cells/mm3, lactic acid 15 mmol/L,
AST 78,
creatinine 2 (baseline 1) mg/dL, platelet count 118,000, and urine output of about 15 mL/hour.
The patient
is started piperacillin/tazobactam to cover for presumed aspiration pneumonia and initiated on
an infusion
of drotrecogin alfa 24 mcg/kg/hour. Which one of the following is most appropriate?
A. Add hydrocortisone 50 mg intravenously every 6 hours.
B. Check a random cortisol concentration to determine whether hydrocortisone is indicated.
C. Check the aPTT and adjust drotrecogin alfa to maintain aPTT in a therapeutic range.
D. Add low-dose dopamine.
E. Add enoxaparin 40 mg subcutaneously daily.
6. Answer: E
3. This patient is at risk of developing a VTE and should

receive prophylaxis with either enoxaparin (Answer E)
or unfractionated heparin. Either can be used in prophylactic
doses in patients who receive drotrecogin alfa.
Hydrocortisone (Answer A) is not necessary in this case
because the patient is responding to fluid resuscitation
and the infusion of norepinephrine, as evidenced by the
increase in MAP from 44 mm Hg on arrival to the emergency
department to 66 mm Hg after initial resuscitation.
The addition of dopamine (Answer D) is not necessary
at this time because MAP is greater than 65 mm
Hg, thus allowing global organ perfusion. In addition, there is no evidence that a low dose of
dopamine will
prevent acute kidney injury, and it has been shown to
increase the risk of arrhythmias compared with norepinephrine.
A random cortisol concentration (Answer B)
is not recommended because it does not predict patient
responsiveness to corticosteroids. Monitoring aPTT
(Answer C) is also not needed for use with drotrecogin
alfa because the dose does not need to be adjusted on
the basis of aPTT.
4. A 51-year-old woman collapsed in front of her family, who called 911 and began CPR. The
paramedics
arrive and find the victim unresponsive with an electrocardiogram showing bradycardia and an
HR of 20
beats/minute. In the emergency department, the patient's MAP is 68 mm Hg after fluids and
norepinephrine,
but the patient remains unresponsive. She is started on the hypothermia protocol. After 24
hours of
hypothermia (temperature 33°C), the patient is in the ICU, and the rewarming process has
recently begun.
The pharmacist arrives in the ICU about 30 minutes into the rewarming process. The patient
has been receiving
a continuous infusion of insulin throughout the period of hypothermia at an average rate of 15
units/
hour, with blood glucose testing every 6 hours. The patient has been sedated with a continuous
infusion of
propofol and is paralyzed with a continuous infusion of cisatracurium. The patient's vital signs
are stable,
and her laboratory values are normal. Which one of the following pharmacist recommendations
is appropriate
at this time?
A. Increase blood glucose testing to now and every 1-2 hours during rewarming.
B. Adjust cisatracurium to achieve a train-of-four of zero out of four impulses.
C. Discontinue propofol to facilitate extubation.
D. Increase insulin infusion to prevent hyperkalemia.
7. Answer: A
During rewarming, patients can become hypoglycemic.

Therefore, a reduction in the insulin infusion is likely,
and the blood glucose should be monitored more often
(Answer A). Paralysis is generally only needed during
the cooling process if other measures fail to prevent
shivering. Once the patient is at goal temperature, and
during the rewarming process, continued use of a paralytic
agent should be reassessed. Paralytic assessment
can include titrating to a TOF goal; however, a more applicable
goal would be the presence of shivering in this
patient when the paralytic is briefly interrupted. If the
patient is not shivering, consideration should be given
to discontinuing the paralytic. Of note, the TOF goal is
2/4 twitches, rather than 0/4 (Answer B), to avoid overparalysis.
Although discontinuing propofol (Answer C)
can facilitate extubation, this should not be done until
the patient is at a normal body temperature and ready
for ventilator weaning. Finally, although rewarming
can cause hyperkalemia, it is appropriate to monitor
potassium concentrations and treat as needed. It is not
appropriate to increase the infusion of insulin (Answer
D) to prevent hyperkalemia because this could precipitate
hypoglycemia during the rewarming process.

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1. A 70-kg patient is to receive a continuous infusion of dopamine for BP support.

3. This patient is at risk of developing a VTE and should

During rewarming, patients can become hypoglycemic.

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