ABA Critical Care & Pain Medicine 3 — Questions and Answers
Question 1: Which vasopressor is recommended as the FIRST-LINE agent in septic shock according to current guidelines?
- Epinephrine
- Vasopressin
- Norepinephrine (Correct answer)
- Dopamine
Correct answer: Norepinephrine
Norepinephrine is the first-line vasopressor for septic shock due to its potent alpha-adrenergic effects with less tachycardia compared to dopamine.
Question 2: A chronic pain patient on 90 MME/day of oral oxycodone requires conversion to IV morphine infusion. Using standard equianalgesic ratios, what is the appropriate starting IV morphine dose per day?
- 15 mg/day IV morphine
- 30 mg/day IV morphine (Correct answer)
- 45 mg/day IV morphine
- 60 mg/day IV morphine
Correct answer: 30 mg/day IV morphine
Oral oxycodone 90 MME converts to 30 mg/day IV morphine using the equianalgesic ratio (oxycodone oral:morphine IV = 3:1), with clinical titration as needed.
Question 3: A patient develops ventilator-associated pneumonia (VAP). Which bundle element has the STRONGEST evidence for prevention?
- Routine endotracheal tube changes every 72 hours
- Subglottic secretion drainage with specialized ETT (Correct answer)
- Prophylactic systemic antifungals
- Supine positioning at 0 degrees
Correct answer: Subglottic secretion drainage with specialized ETT
Subglottic secretion drainage using specialized endotracheal tubes significantly reduces VAP incidence by preventing aspiration of oropharyngeal secretions.
Question 4: In neuraxial pain management, which complication is MOST specific to intrathecal opioid administration (versus epidural)?
- Pruritus
- Nausea and vomiting
- Urinary retention
- Delayed respiratory depression up to 24 hours later (Correct answer)
Correct answer: Delayed respiratory depression up to 24 hours later
Intrathecal hydrophilic opioids (e.g., morphine) can cause delayed respiratory depression up to 24 hours post-administration due to cephalad CSF spread to respiratory centers.
Question 5: Which parameter BEST guides the decision to discontinue vasopressors in a recovering septic shock patient?
- CVP normalization above 8 mmHg
- Lactate clearance >10% and MAP >65 mmHg on decreasing doses (Correct answer)
- Urine output >1 mL/kg/hr for 2 hours
- Heart rate below 100 bpm
Correct answer: Lactate clearance >10% and MAP >65 mmHg on decreasing doses
Serial lactate measurements demonstrating clearance combined with hemodynamic stability on tapering vasopressor doses indicate adequate perfusion restoration.
Question 6: A patient with postherpetic neuralgia fails gabapentin. Which medication class is the MOST appropriate next-line pharmacological option?
- COX-2 inhibitors
- Tricyclic antidepressants (e.g., amitriptyline) (Correct answer)
- Strong mu-opioids as monotherapy
- Muscle relaxants (e.g., cyclobenzaprine)
Correct answer: Tricyclic antidepressants (e.g., amitriptyline)
Tricyclic antidepressants have robust evidence for postherpetic neuralgia and are a recommended second-line therapy when gabapentinoids are insufficient or not tolerated.
Question 7: In ICU patients requiring sedation, which strategy is associated with reduced duration of mechanical ventilation and ICU length of stay?
- Deep continuous sedation targeting RASS -4 to -5
- Daily sedation interruption (spontaneous awakening trials) (Correct answer)
- Benzodiazepine-based continuous infusion protocols
- Neuromuscular blockade without sedation monitoring
Correct answer: Daily sedation interruption (spontaneous awakening trials)
Daily sedation interruption (spontaneous awakening trials) paired with spontaneous breathing trials reduces mechanical ventilation duration and ICU length of stay per the ABC trial.
ABA Critical Care & Pain Medicine 3
Which vasopressor is recommended as the FIRST-LINE agent in septic shock according to current guidelines?