Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Cardiovascular Disorders--->Shock States
Page: 2

Question 6#Print Question

A 54-year-old man with ischemic cardiomyopathy (last known ejection fraction 0.4) and coronary artery disease status post prior three-vessel coronary artery bypass grafting presents to his primary care doctor with fatigue and is found to be hypotensive with BP 85/55 mm Hg. He is triaged to the emergency department where he remains hypotensive with initial BP 90/48 mm Hg and is found to be febrile with temperature 39°C with HR 110 beats per minute. He reports fevers at home over the last 48 hours with one episode of rigors. He receives 2 L of IV fluids and is started on norepinephrine.

Which of the following is most accurate regarding placement of a pulmonary artery (PA) catheter in this patient?

a. Use of PA catheters is associated with improved outcomes in cardiogenic shock
b. Use of PA catheters is associated with improved outcomes in septic shock
c. PA catheters are demonstrated to be useful in early goal-directed therapy for sepsis
d. PA catheters are useful in distinguishing cardiogenic shock and vasodilatory shock
e. The most frequent complication of PA catheters is significant bleeding

Question 7#Print Question

A 23-year-old man is transferred from another hospital with refractory cardiogenic shock and a diagnosis of fulminant viral myocarditis with an echocardiogram that demonstrated biventricular systolic dysfunction with estimated ejection fraction of 0.15. On arrival to the ICU, he has a PA catheter in place with PA pressures 54/30 mm Hg, a pulmonary capillary wedge pressure of 30 mm Hg, cardiac index 1.8 L/min/m2 , and mixed venous saturation (MVO2 ) of 40%. He has been treated with inotropic support with dobutamine up to a dose of 20 µg/kg/min and diuresis with a continuous high-dose IV furosemide infusion without improvement. His labs are significant for a lactate of 4 mmol/L and a creatinine that has increased from a baseline of 0.8 to 2.6 mg/dL. On examination, his extremities are cold and mottled.

Which of the following is the next best step in managing this patient?

a. Addition of milrinone infusion
b. Placement of a percutaneous mechanical circulatory support device
c. Initiation of a workup for a heart transplant
d. Transition from furosemide to bumetanide
e. Addition of neosynephrine infusion

Question 8#Print Question

A 34-year-old with quadriplegia secondary to a motor vehicle accident that has been complicated by neurogenic bladder and recurrent urinary tract infections presents to the emergency department with fever, chills, and purulent urine with intermittent straight cath. He is found on presentation to have:

  • T 38.8 C
  • HR 124 beats per minute
  • BP 88/54 mm Hg
  • respiratory rate 18 breaths per minute

He receives a total of 2500 mL of IV fluids (30 mL/kg) but remains hypotensive. His laboratory tests are notable for a leukocytosis to 18 000/µL with 70% neutrophils and 15% bands. Blood and urine cultures are ordered.

Which of the following is most accurate regarding management of his septic shock?

a. IV fluids should be given to a target central venous pressure of 8 to 12 cm H2O
b. A central venous catheter should be placed to guide further management
c. Lactate should be drawn within 3 hours of presentation
d. Antibiotics should be given immediately
e. He should receive an additional 2500 mL of IV fluid

Question 9#Print Question

A 40-year-old woman with idiopathic pulmonary arterial hypertension on continuous treprostinil has worsening shortness of breath and weight gain of 8 kg in the setting of nonadherence to her home diuretic regimen. On evaluation in the emergency department, she is found to have:

  • T 37°C
  • BP 90/62 mm Hg
  • HR 126 beats per minute
  • respiratory rate 40 breaths per minute
  • SpO2 74% that improves to 84% on high-flow nasal cannula at 60 L/min and FiO2 0.6

While undergoing other workup, the patient’s respiratory status worsens and the decision is made to intubate her.

Which of the following is most accurate regarding her physiology?

a. She should receive an IV fluid bolus before induction to maintain preload
b. Vasopressin may help preserve right ventricular systolic function during intubation
c. She should receive high minute ventilation with a high positive end-expiratory pressure to maintain her oxygenation during intubation
d. There is evidence that norepinephrine is the best medication for hemodynamic support in this situation
e. Propofol is the preferred agent for induction in this patient

Question 10#Print Question

A 68-year-old woman with hypertension and hyperlipidemia is admitted with septic shock due to urinary tract infection and gramnegative rod bacteremia. She is treated with 6 L of IV fluids, antibiotics, and norepinephrine up to a dose of 1.5 µg/kg/min. She develops worsening end-organ dysfunction including acute kidney injury requiring renal replacement therapy, acute respiratory failure with hypoxemia requiring intubation, and disseminated intravascular coagulation. On day 3 of her critical illness, she remains on high-dose norepinephrine and mean arterial pressure of 55 mm Hg. In addition to ensuring adequate source control, what is the next best step in her management?

a. Addition of continuous vasopressin infusion
b. A cosyntropin stimulation test to determine if she has adrenal insufficiency
c. Volume resuscitation with 30 mL/kg of IV fluids
d. Early initiation of parenteral nutrition
e. Liberal tidal volumes to allow her to regulate her acid-base status

Category: Critical Care Medicine-Cardiovascular Disorders--->Shock States
Page: 2 of 2