BCCCP: Acute Upper Gastrointestinal Bleeding Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old man is admitted to the intensive care unit for severe pneumonia complicated by acute respiratory distress syndrome. He has required intubation and has been on mechanical ventilation (assist-control mode, PEEP 10 cm H₂O) for the past 3 days. He remains hemodynamically unstable, receiving a continuous norepinephrine infusion via a central line to maintain a mean arterial pressure >65 mmHg. He is NPO with a nasogastric tube in place. He has no history of gastrointestinal bleeding or liver disease. Platelet count is 180,000/µL and INR is 1.1. According to evidence-based guidelines, which of the following is the most appropriate agent to initiate for stress ulcer prophylaxis?

Intravenous pantoprazole 40 mg once daily
Enteral omeprazole 40 mg once daily via nasogastric tube
Intravenous famotidine 20 mg every 12 hours
Sucralfate suspension 1 g every 6 hours via nasogastric tube

Question 2 of 10

2. Question

A 65-year-old man is admitted to the ICU for severe sepsis secondary to pneumonia. He is intubated on assist-control ventilation and receiving a norepinephrine infusion at 0.1 mcg/kg/min through a central line. Early enteral nutrition via a nasogastric tube has been running at goal rate for 24 hours. He is not currently receiving any acid-suppressive stress ulcer prophylaxis. During morning rounds, a single guaiac-positive gastric aspirate is noted. His vital signs are stable: HR 88 bpm, BP 118/72 mmHg, SpO₂ 96%. His hemoglobin 6 hours ago was 10.2 g/dL (admission 24 hours ago 10.5 g/dL). He has no history of peptic ulcer disease or coagulopathy. Which of the following is the most appropriate next step?

Initiate intravenous proton pump inhibitor stress ulcer prophylaxis.
Start a histamine-2 receptor antagonist infusion for prophylaxis.
Continue current management with enteral nutrition and monitor clinically.
Hold enteral feeding and switch to total parenteral nutrition.

Question 3 of 10

3. Question

In critically ill patients receiving hydrophilic medications, which of the following pharmacokinetic or pharmacodynamic changes most commonly necessitates an increased initial loading dose?

Expanded volume of distribution due to fluid resuscitation and capillary leak, lowering peak concentrations of hydrophilic drugs.
Hypoalbuminemia increasing the free fraction of highly protein-bound drugs, primarily affecting maintenance dosing.
Reduced hepatic metabolism prolonging elimination half-life, often requiring lower maintenance doses to prevent accumulation.
Altered receptor sensitivity modifying drug response, influencing maintenance therapy rather than initial dosing.

Question 4 of 10

4. Question

A 65-year-old man with septic shock secondary to community-acquired pneumonia is admitted to the ICU. He develops acute kidney injury (serum creatinine 3.2 mg/dL, estimated GFR ≈20 mL/min/1.73 m2) and is started on continuous veno-venous hemodiafiltration (CVVHDF). He requires initiation of vancomycin, an antibiotic that is primarily renally cleared. Which of the following dosing strategies is most appropriate to minimize drug accumulation while maintaining efficacy?

No dosing adjustments are required; administer the standard vancomycin dose every 12 hours.
Increase the dose of vancomycin to overcome enhanced clearance by CRRT.
Reduce the individual vancomycin dose or extend the dosing interval to avoid accumulation.
Discontinue all nephrotoxic drugs, including vancomycin, regardless of infection severity.

Question 5 of 10

5. Question

A 65-year-old man in the medical ICU with ventilator-associated MRSA pneumonia is started on intravenous vancomycin. He has fluctuating renal function (baseline creatinine 1.2 mg/dL, peak 1.8 mg/dL) and is on a continuous infusion protocol with Bayesian software support. According to the 2020 IDSA/ASHP/PIDS/SIDP consensus guidelines, which monitoring strategy is most appropriate to optimize efficacy and minimize toxicity in this patient?

Use Bayesian-derived AUC/MIC monitoring to target an AUC0–24/MIC of 400–600 mg·h/L.
Measure vancomycin trough levels daily and adjust to maintain 15–20 µg/mL.
Obtain peak and trough levels every 3 days, targeting a peak of 30 µg/mL.
Monitor liver function tests twice weekly to detect hepatotoxicity.

Question 6 of 10

6. Question

In critically ill adult patients with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections, which of the following intravenous anti-MRSA agents does NOT require routine serum drug level (therapeutic drug) monitoring?

Vancomycin
Linezolid
Daptomycin
Teicoplanin

Question 7 of 10

7. Question

A 45-year-old man is admitted to the intensive care unit following elective spinal surgery. He is receiving continuous enteral nutrition via a nasogastric tube at goal rate. He was extubated on postoperative day 1 and has not required mechanical ventilation for more than 48 hours. His current medications include pantoprazole 40 mg IV daily, initiated on admission. He has no history of gastrointestinal bleeding or coagulopathy, and his hemoglobin is 13.8 g/dL. Based on this patient’s clinical presentation, what is the most appropriate management of his pantoprazole therapy?

Continue pantoprazole 40 mg IV daily to prevent stress-related mucosal bleeding.
Switch pantoprazole to ranitidine 50 mg IV every 12 hours to reduce potential adverse effects.
Discontinue pantoprazole, as the patient is at low risk for clinically significant gastrointestinal bleeding.
Change therapy to sucralfate 1 g orally four times daily to provide mucosal protection.

Question 8 of 10

8. Question

A 67-year-old man in the ICU is being treated for hospital-acquired pneumonia with vancomycin and piperacillin–tazobactam. Over the past 48 hours, his serum creatinine has risen from 1.0 to 2.5 mg/dL, he is oliguric, and shows signs of fluid overload. Blood cultures remain negative. What is the most appropriate next step in management of his suspected drug-induced acute kidney injury?

Discontinue the offending antibiotics and provide supportive measures for renal function, including consideration of renal replacement therapy.
Continue both antibiotics at current doses and monitor renal function for spontaneous improvement.
Add prophylactic broad-spectrum antibiotics to prevent secondary infections associated with acute kidney injury.
Increase the dose of vancomycin to achieve higher tissue concentrations and overcome presumed microbial resistance.

Question 9 of 10

9. Question

A 75-year-old woman with end-stage heart failure and chronic kidney disease is admitted to the ICU with acute decompensation. Her prognosis is poor despite maximal medical therapy, and the ICU team is considering initiation of continuous renal replacement therapy (CRRT) and advanced mechanical ventilation. Which of the following best describes the primary purpose of a multidisciplinary goals-of-care discussion in this scenario?

To ensure that proposed invasive therapies align with the patient’s values, goals, and preferences through shared decision-making among the patient (or surrogate), family, and interdisciplinary team.
To complete required procedural consent documents without necessarily incorporating the patient’s personal values or long-term goals.
To facilitate decision-making led solely by the primary ICU physician, without systematic input from nursing, social work, or palliative care specialists.
To streamline ICU workflow and provider schedules, improving efficiency rather than guiding patient-centered treatment decisions.

Question 10 of 10

10. Question

A 62-year-old man was admitted 5 days ago with severe septic shock requiring mechanical ventilation and a continuous norepinephrine infusion via a central line. He was started on pantoprazole 40 mg IV daily for stress ulcer prophylaxis on admission. This morning he was successfully extubated, norepinephrine has been discontinued for 24 hours, and he is tolerating continuous enteral nutrition at goal rate. His vital signs and hemoglobin (12.5 g/dL) are stable. What is the most appropriate next step in managing his stress ulcer prophylaxis?

Continue pantoprazole 40 mg IV daily until ICU discharge.
Discontinue pantoprazole, as his stress ulcer risk factors have resolved.
Convert pantoprazole to enteral (oral) 40 mg daily via feeding tube.
Switch to oral famotidine 20 mg twice daily for ongoing prophylaxis.