FFICM Practice Test Video Answers

1. C
Severe ARDS is defined by the Berlin Definition as a PaO2/FiO2 ratio of ≤100 mmHg with PEEP ≥5 cmH2O. With a PaO2/FiO2 of 85 mmHg, this patient meets criteria for severe ARDS. Mild ARDS is 200-300 mmHg, moderate is 100-200 mmHg. There is no “critical” category in the Berlin Definition.

2. B
The ARDSNet ARMA trial established that a tidal volume of 6-8 mL/kg of predicted body weight (not actual body weight) reduces mortality in ARDS. Predicted body weight is calculated using height and sex, avoiding the overventilation that would occur if actual weight were used in obese patients.

3. B
Prone positioning for more than 12 hours per day has been shown in the PROSEVA trial to reduce mortality in severe ARDS with elevated plateau pressures. While other interventions may be considered, prone positioning directly addresses both oxygenation and lung protection. Simply increasing PEEP may worsen lung overdistension if plateau pressures are already elevated.

4. D
The PROSEVA trial demonstrated mortality benefit with prone positioning for at least 16 hours per day in patients with severe ARDS. This duration allows optimal redistribution of ventilation and recruitment of dorsal lung regions while maintaining consistent prone periods.

5. B
With an ScvO2 of 58% (low, indicating inadequate oxygen delivery relative to consumption) despite adequate MAP, the issue is cardiac output or oxygen-carrying capacity rather than vasoplegia. Dobutamine, an inotrope, would improve cardiac output and oxygen delivery. Vasopressin is used to reduce norepinephrine requirements but would not address the low ScvO2.

6. C
The Surviving Sepsis Campaign recommends an initial target MAP of ≥65 mmHg in septic shock. This target balances organ perfusion against the potential harms of excessive vasopressor use. Individualized targets may be higher in patients with chronic hypertension.

7. C
The STARRT-AKI trial showed that an accelerated (early) strategy of RRT initiation did not reduce 90-day mortality compared to a standard (delayed) strategy. Importantly, 40% of patients in the delayed group never required RRT due to renal recovery, demonstrating that watchful waiting is a reasonable approach.

8. B
The RENAL and ATN trials demonstrated that an effluent dose of 20-25 mL/kg/hour provides equivalent outcomes to higher doses (35 mL/kg/hour) in critically ill patients with AKI. Higher doses do not improve mortality or renal recovery and may increase complications.

9. C
Continuous renal replacement therapy (particularly CVVH) is preferred in patients with acute brain injury due to better hemodynamic stability and lower risk of dialysis disequilibrium syndrome. Intermittent hemodialysis causes more rapid fluid and solute shifts, which can increase intracranial pressure.

10. A
This patient has cardiogenic shock with evidence of low cardiac output (low CI), high filling pressures (elevated PCWP), and hypotension. Adding an inotrope like dobutamine will increase cardiac output and improve tissue perfusion. Additional fluid would worsen pulmonary congestion given the elevated PCWP.

11. B
In the SCAI classification, Stage B represents “beginning” shock with clinical evidence of relative hypotension or tachycardia without evidence of hypoperfusion. Stage C involves hypoperfusion, Stage D represents deterioration, and Stage E represents extremis.

12. B
Current evidence supports that enteral nutrition can be safely initiated in patients on stable vasopressor doses once hemodynamic stability is achieved (typically norepinephrine <0.14-0.3 mcg/kg/min or equivalent). Enteral nutrition is not absolutely contraindicated and is preferred over parenteral nutrition when tolerated.

13. B
The primary benefit of permissive hypercapnia is that it allows the use of lower tidal volumes, thereby reducing ventilator-induced lung injury (volutrauma, barotrauma, and biotrauma). While CO2 may have some anti-inflammatory properties, the mechanical protection from reduced tidal volumes is the main benefit.

14. B
Hypoglycemia is a critical and potentially fatal complication of acute liver failure due to impaired gluconeogenesis and glycogenolysis. The FFICM examination examiners have specifically noted that hypoglycemia is often overlooked in acute liver failure cases.

15. A
In HHS, serum sodium should be corrected slowly at a rate of 0.5-1 mmol/L per hour to prevent cerebral edema. Rapid correction can cause osmotic shifts leading to neurological deterioration.

16. C
Static compliance = Tidal Volume / (Plateau Pressure – PEEP) = 500 / (25 – 5) = 500 / 20 = 25 mL/cmH2O. This calculation uses plateau pressure (reflecting static conditions) rather than peak inspiratory pressure.

17. B
Pulse pressure variation (PPV) is the most reliable predictor of fluid responsiveness in mechanically ventilated patients with sinus rhythm. A PPV >12-13% predicts fluid responsiveness with high sensitivity and specificity. CVP and PAOP are static measures with poor predictive value.

18. B
Awake prone positioning in non-intubated patients with COVID-19 pneumonia has been shown to improve oxygenation and may reduce the need for intubation. It can be used with high-flow nasal cannula and sessions typically last several hours for maximum benefit.

19. C
The ACURASYS trial showed that early neuromuscular blockade with cisatracurium reduced 90-day mortality in patients with severe ARDS (PaO2/FiO2 <150). However, this benefit was not confirmed in the larger ROSE trial, and current guidelines suggest considering NMBAs only in specific circumstances for severe ARDS.

20. B
A plateau pressure of ≤30 cmH2O is recommended to minimize ventilator-induced lung injury in ARDS. This limit balances adequate ventilation against the risk of overdistension and barotrauma.

21. A
The Surviving Sepsis Campaign recommends guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion. A 10% reduction in lactate within 2-4 hours is associated with improved outcomes.

22. B
Brain stem death testing requires absence of brain stem reflexes including corneal, pupillary, oculocephalic (doll’s eye), oculovestibular (caloric), gag, and cough reflexes. Spinal reflexes (Babinski, deep tendon reflexes, cremasteric) may persist after brain death as they are mediated at the spinal cord level.

23. A
CPP = MAP – ICP = 85 – 28 = 57 mmHg. Target CPP is typically 60-70 mmHg. A CPP of 57 mmHg is below target and intervention is required, either by reducing ICP or increasing MAP.

24. B
According to KDIGO, Stage 2 AKI is defined as a serum creatinine increase of 2.0-2.9 times from baseline. Stage 1 is 1.5-1.9 times, and Stage 3 is ≥3.0 times baseline or creatinine ≥4.0 mg/dL.

25. C
The femoral vein has the lowest risk of immediate mechanical complications (pneumothorax, hemothorax, arterial puncture requiring compression) during insertion. However, it has higher infection rates with prolonged use. Internal jugular access under ultrasound guidance is often preferred for longer-term access.

26. C
pH is the most important parameter to monitor in COPD exacerbation as it indicates acute respiratory acidosis severity and response to NIV. PaCO2 may be chronically elevated in COPD patients, so the pH (reflecting acute-on-chronic changes) is more clinically relevant.

27. B
The combination of sudden hypotension, high airway pressures, absent breath sounds on one side, and contralateral tracheal deviation is classic for tension pneumothorax. This is a clinical diagnosis requiring immediate needle decompression followed by chest tube insertion.

28. A
Vancomycin is significantly removed by CRRT due to its water solubility and moderate protein binding. Standard dosing may result in subtherapeutic levels, requiring therapeutic drug monitoring and dose adjustment. Propofol, fentanyl, and midazolam are highly lipophilic and protein-bound, with minimal removal by CRRT.

29. C
Initial management of abdominal compartment syndrome includes medical optimization: evacuating intraluminal contents, removing fluid collections, optimizing abdominal wall compliance (with neuromuscular blockade), and optimizing fluid administration. Surgical decompression is reserved for refractory cases.

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