EDAIC - European Diploma in Anesthesiology and Intensive Care Intensive Care and Emergency Medicine Questions and Answers — Questions and Answers
Question 1: A 55-year-old patient with sepsis develops moderate-to-severe ARDS, with a PaO2/FiO2 ratio of 110 mmHg. The patient is ventilated according to a lung-protective strategy (6 mL/kg predicted body weight, plateau pressure < 30 cmH2O). Which of the following adjunctive therapies has demonstrated the most significant mortality benefit in this patient population?
- High-frequency oscillatory ventilation (HFOV)
- Inhaled nitric oxide
- Prone positioning for at least 16 hours per day (Correct answer)
- Routine administration of high-dose corticosteroids
Correct answer: Prone positioning for at least 16 hours per day
The PROSEVA trial demonstrated a significant reduction in both 28-day and 90-day mortality when prone positioning, for at least 16 hours per day, was applied early to patients with severe ARDS (PaO2/FiO2 < 150 mmHg). [7, 23, 28] Other interventions like HFOV and inhaled nitric oxide have not consistently shown a mortality benefit, and routine high-dose corticosteroids are not recommended for most ARDS patients.
Question 2: According to the 2021 Surviving Sepsis Campaign guidelines, what is the recommended initial target for mean arterial pressure (MAP) during vasopressor therapy for an adult patient with septic shock?
- A MAP sufficient to achieve a urine output > 0.5 mL/kg/hr
- ≥ 65 mmHg (Correct answer)
- 75-85 mmHg
- A MAP that normalizes the serum lactate level
Correct answer: ≥ 65 mmHg
The Surviving Sepsis Campaign international guidelines strongly recommend an initial target MAP of 65 mmHg in adult patients with septic shock who require vasopressors. [2, 8, 19, 29] While other parameters like urine output and lactate are crucial markers of perfusion, 65 mmHg is the specific initial blood pressure target. Higher targets have not shown a mortality benefit and may increase the risk of adverse events like arrhythmias. [19]
Question 3: A 68-year-old patient in the ICU with septic shock is anuric and requires vasopressors to maintain a MAP of 65 mmHg. Laboratory results show severe metabolic acidosis and life-threatening hyperkalemia. Renal replacement therapy is indicated. What is the primary advantage of initiating Continuous Renal Replacement Therapy (CRRT) over intermittent hemodialysis (IHD) for this patient?
- More rapid correction of hyperkalemia
- Lower anticoagulation requirement
- Improved hemodynamic stability (Correct answer)
- Significantly lower cost and complexity
Correct answer: Improved hemodynamic stability
In hemodynamically unstable patients, such as those with septic shock on vasopressors, CRRT is generally preferred because it removes fluid and solutes slowly and continuously. [17, 25, 31] This gradual process leads to greater hemodynamic stability and avoids the large, rapid fluid shifts that can cause hypotension during intermittent hemodialysis. While IHD can correct hyperkalemia more rapidly, the risk of worsening hypotension often outweighs this benefit in unstable patients.
Question 4: A trauma patient with uncontrolled hemorrhage arrives in the emergency department, and the Massive Transfusion Protocol (MTP) is activated. To prevent dilutional coagulopathy and mimic the replacement of whole blood, what is the most widely recommended initial ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets (PLTs)?
- 4:2:1
- 1:1:1 (Correct answer)
- 5:1:1
- 10:1:0
Correct answer: 1:1:1
Modern massive transfusion protocols advocate for a balanced resuscitation approach to treat and prevent the coagulopathy of trauma. The most commonly recommended ratio is 1:1:1 for units of PRBCs, FFP, and platelets (one apheresis unit or a pool of 5-6 whole-blood-derived units). [1, 6, 11, 24] This strategy aims to replace all components of lost whole blood, thereby maintaining hemostatic potential.
Question 5: The Confusion Assessment Method for the ICU (CAM-ICU) is used to diagnose delirium. A positive diagnosis requires the presence of an acute onset or fluctuating course (Feature 1) and inattention (Feature 2). Which of the following is one of the two additional features, where the presence of either one would confirm the diagnosis?
- Disorganized thinking (Correct answer)
- Sleep-wake cycle disturbance
- Psychomotor agitation
- Hallucinations or delusions
Correct answer: Disorganized thinking
The CAM-ICU algorithm requires four features to be assessed. A diagnosis of delirium is made if the patient demonstrates (1) an acute onset or fluctuating course AND (2) inattention, PLUS EITHER (3) disorganized thinking OR (4) an altered level of consciousness. [13, 21, 26] While sleep disturbances, psychomotor changes, and hallucinations are common symptoms of delirium, they are not the specific diagnostic features used in the final step of the CAM-ICU tool.
Question 6: A 29-year-old patient presents with severe hypotension and bradycardia following an intentional overdose of metoprolol. The condition is refractory to intravenous fluids and atropine. Which of the following therapies should be considered the first-line antidote?
- Sodium bicarbonate
- Intravenous lipid emulsion (ILE)
- High-dose insulin euglycemic therapy (HIET)
- Glucagon (Correct answer)
Correct answer: Glucagon
Glucagon is traditionally considered the first-line antidote for significant beta-blocker toxicity. [3, 9, 12] It acts by stimulating adenylate cyclase at a site independent of the beta-receptor, thereby increasing intracellular cAMP and leading to increased heart rate and contractility. While high-dose insulin therapy is also a critical treatment, especially for refractory shock, glucagon is typically the initial antidote administered. Sodium bicarbonate is for TCA overdose, and ILE is for toxicity from lipophilic drugs.
EDAIC - European Diploma in Anesthesiology and Intensive Care Intensive Care and Emergency Medicine Questions and Answers
A 55-year-old patient with sepsis develops moderate-to-severe ARDS, with a PaO2/FiO2 ratio of 110 mmHg.
The patient is ventilated according to a lung-protective strategy (6 mL/kg predicted body weight, plateau pressure < 30 cmH2O).
Which of the following adjunctive therapies has demonstrated the most significant mortality benefit in this patient population?