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Category: Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders--->Drug Dosing in Renal Failure
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Question 1# Print Question

A 67-year-old man with a history of syringomyelia, benign prostatic hypertrophy, and chronic pain with an intrathecal pump with morphine and baclofen presents with altered mental status. His vitals are:

  • temperature 37.2°C
  • blood pressure (BP) 116/70 mm Hg
  • heart rate (HR) 90 beats/ min
  • respiratory rate 4/min
  • SpO2 92%

His basic laboratory data are:

  • potassium 5.0 mEq/L
  • sodium 142 mEq/L
  • creatinine 2.9 mg/dL
  • glomerular filtration rate 22 mL/min/1.73 m2

On examination, the patient appears somnolent, and his neurological examination is significant for constricted pupils. On further questioning, the patient’s wife states that he has had his intrathecal pump for 12 years with no issues and denies any recent change in the dose of intrathecal medications. You suspect that impaired renal excretion of his intrathecal medications has caused the patient’s altered mental status.

Which of the following is the MOST LIKELY cause for this patient’s clinical presentation?

A. Morphine-6-glucuronide (M6G)
B. Morphine-3-glucuronide (M3G)
C. Normorphine
D. Baclofen

Question 2# Print Question

Which of the following statements is correct with regards to drug dosing in chronic kidney disease (CKD)?

A. The loading dose of vancomycin needs to be decreased in patients with chronic renal failure
B. The induction dose of propofol for intubation in CKD patients must be significantly reduced
C. The dose of tobramycin needs to be reduced in patients with CKD
D. The duration of action of cisatracurium is not prolonged in renal failure because of its Hoffman elimination

Question 3# Print Question

You are called to evaluate a 70-year-old man who underwent cystoscopy and ureteral stent placement under general anesthesia for potential intensive care unit (ICU) admission. The post anesthesia care unit nurse tells you that the patient was shivering in the immediate postoperative period, but now he is exhibiting more pronounced jerky movements of his extremities. He has a past medical history of hypertension, diabetes, CKD, and mild dementia. Laboratory data are:

  • hematocrit 40%
  • platelets 182 000/µL
  • potassium 5.1 mEq/L
  • creatinine 2.7 mg/dL
  • glomerular filtration rate 48 mL/min/1.73 m2

You are told that he has received some medications for his pain and shivering. Suddenly, the patient begins to seize.

Which of the therapies administered to the patient MOST LIKELY explains this outcome?

A. Fentanyl
B. Meperidine
C. Acetaminophen
D. Ondansetron

Question 4# Print Question

A 71-year-old man with a history of diabetes, hypertension, and CKD is in the ICU for septic shock secondary to a urinary tract infection. The patient has a complicated psychiatric and social history that includes posttraumatic stress disorder, depression, and generalized anxiety disorder in the setting of homelessness. He currently complains of severe anxiety to the point that he has not been able to get any rest since being admitted. He says that he takes some medication for his anxiety and sees a psychiatrist for it sporadically. You order a one-time dose of alprazolam 0.5 mg PO. One hour later, the nurse pages you and states that the patient has become overly sedated.

What is the most likely pharmacokinetic explanation for why this medication produced an exaggerated clinical effect in this patient with CKD?

A. With lowered protein binding in CKD, there is an increase in the free fraction of alprazolam, potentiating its clinical effect
B. Secondary to impaired renal excretion, there is a rapid accumulation of the metabolite of alprazolam, causing oversedation
C. Owing to the decrease in volume of distribution found in CKD patients, there is a higher concentration of alprazolam in the plasma, leading to greater clinical effect
D. The metabolism of alprazolam is heavily dependent on the kidneys. In CKD, the decreased metabolism of benzodiazepines can often lead to an overdose of the medication

Question 5# Print Question

A 42-year-old male with history of positive human immunodeficiency virus status with poor compliance to antiretroviral therapy presents to the ICU with altered mental status and severe hypotension, requiring aggressive intravenous fluid resuscitation, vasopressor therapy, and endotracheal intubation with sedation. He has recently been in a skilled nursing facility and was lost to follow-up on discharge. Cultures are drawn, and he is placed on broad-spectrum antimicrobial therapy as further workup is being performed. His basic labs show that he has acute kidney injury with creatinine 2.3 mg/dL with estimated glomerular filtration rate (eGFR) 38 mL/min/1.73 m2 .

Which of the following is FALSE regarding antibiotic treatment in this patient?

A. Checking a trough level for vancomycin is a useful tool to help determine an appropriate dose for the individual patient
B. As many antimicrobial medications are renally excreted, a dose reduction should be considered based on the eGFR to avoid overdose
C. When patients are placed on continuous renal replacement therapy (CRRP), antimicrobials tend to reach supratherapeutic levels because of further decrease in the clearance of these medications
D. There are two main ways to adjust the total dosage of antimicrobials given to the patient—changing the dosing interval and the dose of medication given each time

Category: Critical Care Medicine-Renal, Electrolyte and Acid Base Disorders--->Drug Dosing in Renal Failure
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