pulse oximetry 94% on 2L oxygen via nasal cannula, and she rates her pain on a 0–10 scale as 6.Which one of the following analgesics for postoperative pain management is the best choice for this patient?TramadolOfirmevOxycodoneMorphineCelebrexAcetaminophen injection (Ofirmev®) is indicated for the management of mild‐to‐moderate pain and as an adjunct to opioid analgesics and other agents. Acetaminophen in metabolized by the liver and does not require adjustment in end‐stage renal disease (ESRD). Patients report better pain control than with oral acetaminophen. Tramadol is metabolized to an active metabolite O‐demethyl tramadol, which is excreted by the kidneys. Its elimination half‐life is prolonged 2 times in patients with decreased glomerular filtration rate (GFR). Tramadol may be epileptogenic, especially with associated conditions that lower seizure threshold, such as with uremia. Respiratory depression is also described in patients with chronic kidney disease. Morphine should be used cautiously as morphine metabolites can accumulate, increasing therapeutic and adverse effects in patients with renal failure. Morphine and its metabolite can be removed with dialysis. Oxycodone should not be used in patients with renal failure. Oxycodone and its metabolites can accumulate causing toxic and CNS‐depressant effects. There is no data on oxycodone and its metabolites removal with dialysis; however, oxycodone’s half‐life is significantly prolonged in ESRD. Celebrex is a nonsteroidal anti‐inflammatory drug (NSAIDs), specifically a COX2 inhibitor, used to treat pain and inflammation. NSAIDs may lead to reversible reduction in GFR. COX2 is constitutively expressed in the kidney and has an important role in maintaining renal hemodynamics. Although potentially advantageous for patients at risk of bleeding, COX2 inhibitors appear to exert similar effects on the kidney compared with traditional NSAIDs.Answer: BDavison SN . Pain in hemodialysis patients: prevalence, cause, severity, and management. Am J Kid Dis. 2003; 42 : 1239–1247.Foral PA, Ineck JR, Nystrom KK . Oxycodone accumulation in a hemodialysis patient. South Med Journal. 2007; 100 : 212–214.Kurella M . Analgesia in patients with ESRD: a review of available evidence. Am J Kid Dis. 2003; 42 : 217–228.Golembiewski J Intravenous acetaminophen. J. Perianesth Nurs. 2017; 32 (2):151–55.
3 A 36‐year‐old man is involved in high‐speed motor vehicle collision and was intubated in the field for a Glasgow Coma Scale (GCS) score of 4. His injuries include a severe traumatic brain injury with multiple intraparenchymal and intraventricular hemorrhages, multiple rib fractures bilaterally, bilateral pulmonary contusions, and a right femur fracture that is now in traction. Due to elevated intracranial pressures that have not been controlled, the patient is placed on a cisatracurium drip. Which statement is true regarding cisatracurium?Primarily renally cleared.Cheaper cost compared to vecuronium.Is an aminosteroid‐based neuromuscular blocking agent, similar to rocuronium.Associated with better outcomes in acute respiratory distress and traumatic brain injury.Fast onset of action and used for emergency airway management.Cisatracurium is a widely used nondepolarizing neuromuscular blocking agent (NMBA). Cisatracurium, an isomer of atracurium, undergoes spontaneous chemical degradation (not an enzymatic process) in a process known as Hofmann elimination. The cost of cisatracurium is substantially higher compared to other NMBA. Other NMBAs like pancuronium, rocuronium, and vecuronium are aminosteroid based and their elimination can be affected by hepatic or renal dysfunction. There are three randomized trials that have shown improvement with oxygenation in ARDS patients using cisatracurium. Two additional randomized trials found no decrease in intracranial pressure, mean arterial pressure, cerebral perfusion pressure, or cerebral blood flow velocity with cisatracurium. With atracurium, these parameters decreased and a subsequent rebound in elevated intracranial pressure was noted. Cisatracurium has a relatively slow onset, and should not be used for emergency airway management. Cisatracurium is often the paralytic of choice in patients with severe hepatic and renal dysfunction. Hofmann elimination is a temperature‐ and pH‐dependent process, and therefore the rate of degradation is highly influenced by body pH and temperature; an increase in body pH favors the elimination process, whereas a decrease in temperature slows down the process.Answer: DSzakmany T, Minerva WT . Use of cisatracurium in critical care: a review of the literature. Anestesiol. 2015; 81 (4):450–60. Epub 2014 Apr 10.Sparr HJ, Beaufort TM, Fuchs‐Buder T . Newer neuromuscular blocking agents: how they compare with established agents? Drugs. 2001; 61 :919–942.
4 A 37‐year‐old man is involved in an all‐terrain vehicle (ATV) collision and has multiple left rib fractures, a left humerus fracture, and a grade II splenic laceration. Prior to his crash, he was taking alprazolam 2 mg three times a day. On post‐trauma day 3, the patient is restless, shaking, tachycardic, diaphoretic, and having auditory hallucinations. Which is true regarding alprazolam withdrawal?Alprazolam withdrawal is typically less severe compared to other benzodiazepines.Due to the long half‐life, the abuse potential is lower compared to other benzodiazepines.Alprazolam has a slow absorption and high lipophilicity.Alprazolam uniquely affects dopaminergic function in the brain.Rebound anxiety is more commonly seen with diazepam withdrawal than with alprazolam withdrawal.Alprazolam has a high misuse potential and more severe withdrawal symptoms compared to other benzodiazepines. Alprazolam has unique pharmacokinetic properties since it is less protein‐bound compared to other benzodiazepines resulting in rapid absorption, low lipophilicity, and short half‐life. The half‐life for alprazolam is 8–16 hours, while the half‐life of diazepam is 22–72 hours (assuming healthy adult). In addition, alprazolam does not accumulate oxidative metabolites. Diazepam and its metabolites accumulate in the body and after discontinuation, there is a slow washout leading to less severe withdrawal symptoms. Alprazolam also crosses the blood‐brain barrier and affects the dopaminergic function in the striatum leading to increased serotonin levels, thus, making it higher risk for abuse and misuse. Alprazolam withdrawal is more complicated and has a unique rebound anxiety associated with it.Answer: DAit‐Daoud N, Hamby AS, Sharma S, et al. A review of alprazolam use, misuse, and withdrawal. J Addict Med. 2018; 12 (1):4–10.
5 A 38‐year‐old woman was involved in motorcycle crash and sustains a small subdural hematoma, an intraparenchymal hemorrhage, multiple right‐sided rib fractures, right tibia and fibula fractures, and significant skin abrasions along right side of her body. She is intubated and sedated with dexmedetomidine drip in the ICU secondary to a Glasgow Coma Scale (GCS) score of 8. What is true regarding dexmedetomidine?It works on GABA receptors, like propofol.Side effects are mostly hemodynamic alterations such as hypotension, bradycardia, and hypertension.It is mainly eliminated via the kidneys and abnormal renal function can affect elimination.It has a long half‐life, usually about 12 hours in healthy adults.In the ICU, it can be used for deep sedation and with paralytics.Dexmedetomidine is a selective α2 adrenoceptor agonist that is used for its anxiolytic, sedative, and analgesic properties. Propofol and benzodiazepines both act on GABA receptors (Answer A). The side effects of dexmedetomidine are mainly hemodynamic changes, to include hypotension, sometimes hypertension, and bradycardia (Answer B). It is mainly hepatically eliminated and elimination can be impacted by hypoalbuminemia and liver failure. The half‐life of dexmedetomidine is 2–3 hours in healthy adults and 2.2–3.7 hours in ICU patients (Answer D). It is approved for light to moderate sedation, not for deep sedation. It should not be used with paralytics in the ICU as it does not provide adequate sedation and cannot achieve the Richmond Agitation Sedation Score (RASS) of ‐4 or ‐5 that is recommended for paralytics (Answer E).Answer: BWeerink MAS, Struys MMRF, Hannivoort LN, et al. Clinical pharma‐cokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017; 56 (8):893–913.Oddo M, Crippa IA, Mehta S, et al. Optimizing sedation in patients with acute brain injury. Crit Care. 2016; 20 (1):128.
6 A 63‐year‐old man weighing 110 kg has a history of multiple pulmonary embolisms and is currently receiving warfarin therapy, presents with 3 hours of hematemesis. His vital signs are BP 86/45 mmHg, HR 121 beats/min, RR 22 breaths/min, and his temperature is 98.9°F. A nasogastric tube is placed with a large amount of bright red blood returned. His hemoglobin is 5.2 g/dL and his INR is 9.2. What is the most effective immediate reversal of his warfarin?Phytonadione 10 mg orally once.Four‐factor prothrombin complex concentrate (PCC) 50 units/kg IV infused over 30 min.Tranexamic acid 1 gm IV over 10 minutes and followed by 1 gm IV over 8 hours.Fresh frozen plasma 15 mL/kg and repeat if INR > 3 on post‐transfusion laboratory.Phytonadione 10 mg IV infusion daily for three days.This patient has an acute gastrointestinal hemorrhage complicated by supratherapeutic warfarin and hemodynamic instability. Reversal should be with four‐factor PCC (Kcentra). Four‐factor PCC contains factors IIa, VIIa, IXa, and Xa;