Reviewed by: 2018 Clinical Pharmacy Challenge Exam Review Panel
History of Present Illness: A 39-year-old woman (actual body weight 72 kg) presents to the hospital with altered mental status, hypercapnic respiratory failure, and elevated blood glucose values. The patient’s husband reports that the patient has been adherent to all of her home medications (insulin glargine, aspirin) but had been feeling ill for about 2 days before her hospital presentation.
Past Medical History: Unable to provide
Social History: Unable to provide
Current Medications: Ascorbic acid intravenous piggyback 1.5 g every 6 hours, cefepime intravenous piggyback 2 g every 8 hours, dexmedetomidine infusion 0.4 mcg/kg/hour, famotidine oral tablet 20 mg every 24 hours, fentanyl intravenous push 50 mg every 2 hours as needed, hydrocortisone subcutaneous injection 50 mg every 6 hours, insulin regular infusion 2 units/hour, linezolid oral tablet 600 mg every 12 hours, norepinephrine infusion 15 mcg/minute, oseltamivir oral suspension 75 mg every 24 hours, and thiamine intravenous piggyback 200 mg every 12 hours
Allergies: NKDA
Vital Signs: MAP 66 mm Hg, HR 90 beats/minute, RR 20 breaths/minute, Temp 38.2°C
Lab Values: SCr 3.1 mg/dL (SI 274 micromol/L), INR 2.1, AST 800 unit/L (SI 13.3 microkat/L), ALT 750 IU/L (SI 12.5 microkat/L), blood glucose 1050 mg/dL (SI 58.3 mmol/L), pH 7.12, anion gap 24, WBC 21 x 103 cells/mm3 (SI 21 x 109/L), troponin 0.1 ng/mL (SI 0.1 mcg/L)
Procedure Data: Not applicable
Other Data: Patient is currently intubated and receiving mechanical ventilation (high PEEP and Fio2, low tidal volume [6 mL/kg]) for acute respiratory distress syndrome (ARDS)
Urinary output over the past 6 hours = 50 mL
Cultures (two of two) from tracheal aspirate growing gram-positive cocci in clusters
Influenza PCR positive for influenza A
Question 1
Which is the most likely etiology of the patient’s diabetic ketoacidosis?
- Acute infection
- Medication nonadherence
- Myocardial infarction
- New diabetes diagnosis
Question 2
Which pharmacologic and/or nonpharmacologic intervention should be provided to prevent the development of venous thromboembolism?
- Enoxaparin 30 mg subcutaneously every 12 hours
- Heparin 5000 units subcutaneously every 8 hours
- Sequential compression devices
- No intervention; the patient’s INR is 2.1
Question 3
For which of this patient’s medications is it most appropriate to reduce the daily dosage?
- Cefepime
- Hydrocortisone
- Norepinephrine
- Thiamine
Question 4
It is day 2 of this patient’s care. Which therapy is most likely to increase the patient’s risk of mortality?
- Cisatracurium continuous infusion
- High-frequency oscillating ventilation
- Inhaled epoprostenol
- Methylprednisolone 1–2 mg/kg/day
Question 5
The patient has become fluid overloaded. Which is the most appropriate treatment strategy, given her acute respiratory distress syndrome?
- Bumetanide 8 mg orally and chlorothiazide 500-mg intravenous push
- Dopamine 2.5 mcg/kg/minute
- Furosemide 3-mg/hour continuous infusion
- Nitroglycerin intravenous infusion 50 mcg/minute
ANSWERS
Question 1
Which is the most likely etiology of the patient’s diabetic ketoacidosis?
- Acute infection
- Medication nonadherence
- Myocardial infarction
- New diabetes diagnosis
Rationale: Answer 1, acute infection, is correct. The patient has two acute infections (bacterial pneumonia and influenza pneumonia). The patient has been adherent to her home insulin glargine, making Answer 2 incorrect. The patient has no symptoms or signs of an acute myocardial infarction (other than a mildly elevated troponin, which can be attributed to hypoperfusion from sepsis), making Answer 3 incorrect. The patient takes insulin glargine at home, so diabetes has already been diagnosed, making Answer 4 incorrect.
Citation: Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006;29:2739-48.
Question 2
Which pharmacologic and/or nonpharmacologic intervention should be provided to prevent the development of venous thromboembolism?
- Enoxaparin 30 mg subcutaneously every 12 hours
- Heparin 5000 units subcutaneously every 8 hours
- Sequential compression devices
- No intervention; the patient’s INR is 2.1
Rationale: Answer 2 is correct because the patient has a reduced creatinine clearance (calculated as 28 mL/minute/1.73 m2 but likely less than this because of greatly reduced urinary output), and the INR of 2.1 is from acute liver failure and does not represent an anticoagulated state. Answer 1 is incorrect because the enoxaparin dosing is too high for this patient’s renal function. Answer 3 is incorrect because chemical thromboprophylaxis is more effective than mechanical thromboprophylaxis. Answer 4 is incorrect because the INR of 2.1 is from acute liver failure and does not represent an anticoagulated state.
Citation: Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 suppl):e195S-e226S.
Question 3
For which of this patient’s medications is it most appropriate to reduce the daily dosage?
- Cefepime
- Hydrocortisone
- Norepinephrine
- Thiamine
Rationale: Answer 1 is correct. Cefepime can accumulate at standard dosing in patients with acute kidney injury and lead to seizure development. Answers 2, 3, and 4 do not require dosage adjustments in kidney or liver dysfunction.
Citation: Fugate JE, Kalimullah EA, Hocker SE, et al. Cefepime neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy. Crit Care 2013;17:R264.
Question 4
It is day 2 of this patient’s care. Which therapy is most likely to increase the patient’s risk of mortality?
- Cisatracurium continuous infusion
- High-frequency oscillating ventilation
- Inhaled epoprostenol
- Methylprednisolone 1–2 mg/kg/day
Rationale: Answer 2 is correct. High-frequency oscillating ventilation increased mortality in patients with ARDS in the OSCILLATE trial and showed no difference in mortality in the OSCAR trial. Answer 1 is incorrect because early (within 72 hours) initiation of cisatracurium continuous infusion reduces mortality in ARDS. Answer 3 is incorrect because inhaled epoprostenol improves hemodynamics without changing mortality. Answer 4 is incorrect because early (within 7 days) initiation of methylprednisolone 1–2 mg/kg/day reduces mortality in ARDS.
Citation: Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013;368:795-805.
Question 5
The patient has become fluid overloaded. Which is the most appropriate treatment strategy, given her acute respiratory distress syndrome?
- Bumetanide 8 mg orally and chlorothiazide 500-mg intravenous push
- Dopamine 2.5 mcg/kg/minute
- Furosemide 3-mg/hour continuous infusion
- Nitroglycerin intravenous infusion 50 mcg/minute
Rationale: Answer 3 is correct. According to the FACTT Lite fluid management protocol, furosemide 20 mg intravenously or a 3-mg/hour continuous infusion should be provided to achieve a central venous pressure of less than 4 mm Hg or a pulmonary artery occlusion pressure of less than 8 mm Hg. Answer 1 has too high of an initial dose of bumetanide, bumetanide is oral instead of intravenous, and a thiazide-type diuretic should not be added to the initial therapy. Answer 2 is not a recommended use of dopamine. Answer 4 is not a recommended use of nitroglycerin.
Citation: Grisson CK, Hirshberg EL, Dickerson JB, et al. Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome. Crit Care Med 2015;43:288-95.