BCCCP: Intravenous Fluid Therapy and Resuscitation

Question 1 of 10

1. Question

A 62-year-old man (70 kg) with severe sepsis is admitted to the ICU on mechanical ventilation and a norepinephrine infusion. He has already received 2 L of fluid in the ED and remains hypotensive (85/50 mmHg) with a lactate of 4.2 mmol/L. You must choose an initial resuscitation fluid based on both acquisition cost and the potential downstream costs from fluid-related complications. Which of the following is the most pharmacoeconomically sound initial resuscitation fluid for this patient?

Lactated Ringer’s solution
0.9% Sodium Chloride (normal saline)
5% Human Albumin
PlasmaLyte A (balanced crystalloid)

Question 2 of 10

2. Question

A 62-year-old, 75 kg male with severe septic shock is admitted to the ICU. Despite 5 L of crystalloid and escalating norepinephrine (0.3 mcg/kg/min), his mean arterial pressure remains <65 mmHg and lactate is rising. He has active melena, thrombocytopenia (platelets 55 ×10^9/L), and his hemoglobin has dropped from 9.5 to 7.2 g/dL over 6 hours. Which of the following adjunctive resuscitation therapies should be prioritized to optimize his hemodynamic status and oxygen delivery?

Administer 20% albumin 250 mL IV over 30 minutes
Administer 3% hypertonic saline 100 mL IV bolus
Administer an additional 500 mL bolus of lactated Ringer’s solution
Transfuse 2 units of packed red blood cells

Question 3 of 10

3. Question

A 65-year-old male patient is admitted to the ICU with septic shock secondary to pneumonia. He is receiving aggressive fluid resuscitation to maintain adequate tissue perfusion. As the critical care pharmacist, you are asked to prioritize the most essential components of a comprehensive monitoring plan to assess the efficacy and potential complications of ongoing fluid therapy in this patient. Which of the following combinations represents the MOST critical elements to monitor serially for ongoing fluid therapy?

Lactate clearance, mean arterial pressure, and capillary refill time
Hourly urine output, daily weight, and central venous pressure
Serial fluid balance, electrolyte panels, and acid-base status
Blood urea nitrogen, serum creatinine, and BUN-to-creatinine ratio

Question 4 of 10

4. Question

A 62-year-old male is admitted to the ICU, mechanically ventilated for acute respiratory distress syndrome secondary to severe sepsis. He is receiving norepinephrine to maintain a mean arterial pressure (MAP) above 65 mmHg. Despite treatment, his MAP has dropped to 62 mmHg, urine output is decreasing, and lactate levels are elevated, indicating ongoing hypoperfusion. The clinical team plans immediate fluid resuscitation. Considering his condition and current evidence-based guidelines, which intravenous fluid should be prioritized as the first-line choice for initial resuscitation?

0.9% Sodium Chloride
Lactated Ringer’s solution
5% Albumin
Hydroxyethyl Starch

Question 5 of 10

5. Question

A 68-year-old man with a history of diabetic nephropathy is admitted to the ICU with septic shock secondary to pneumonia. He is receiving norepinephrine at 0.1 µg/kg/min and a 0.9% sodium chloride infusion at 150 mL/hour. His laboratory values are: serum potassium 6.5 mEq/L, creatinine 3.2 mg/dL, BUN 60 mg/dL, pH 7.30, and bicarbonate 18 mEq/L. A 12-lead ECG shows peaked T waves and a widened QRS complex. Considering this patient’s current clinical status and laboratory findings, which intervention should be prioritized by the critical care pharmacist to address the most immediate life-threatening complication?

Administer intravenous furosemide 40 mg and switch maintenance fluids to lactated Ringer’s solution.
Administer intravenous calcium gluconate 1 g over 5 minutes and initiate an insulin-glucose infusion (10 units regular insulin with 25 g dextrose).
Discontinue the 0.9% sodium chloride infusion and prepare for continuous renal replacement therapy (CRRT).
Increase the norepinephrine infusion rate to improve blood pressure and administer intravenous sodium bicarbonate.

Question 6 of 10

6. Question

A 68-year-old patient is admitted to the ICU with septic shock secondary to pneumonia. Despite 30 mL/kg crystalloid resuscitation and vasopressor support with norepinephrine at 0.3 mcg/kg/min plus vasopressin at 0.03 U/min, the patient remains hypotensive with a mean arterial pressure of 55 mm Hg and lactate of 4.5 mmol/L, with cool extremities and oliguria. The family expresses significant concern about the patient’s prognosis and the burdens of ongoing treatment. As the critical care pharmacist on the multidisciplinary team, what is the MOST appropriate next step to advocate for in the care plan?

Initiate an immediate multidisciplinary goals-of-care discussion with the patient’s family and ICU team, focusing on prognosis, patient values, and the potential burdens versus benefits of continued aggressive interventions.
Advocate for further escalation of vasopressor support by increasing norepinephrine above 0.3 mcg/kg/min and adding vasopressin at 0.04 U/min to target a mean arterial pressure ≥ 80 mm Hg.
Recommend administering an additional 500 mL crystalloid bolus to optimize preload, then re-evaluating mean arterial pressure and lactate in 2 hours.
Advise ordering a comprehensive infectious disease workup, including repeat blood cultures, procalcitonin measurement, and advanced microbiology testing to identify resistant organisms and guide antibiotic optimization.

Question 7 of 10

7. Question

A 65-year-old man with severe sepsis. Laboratory studies show thrombocytopenia (platelets 40,000/µL) and an elevated INR of 1.8. He is receiving enoxaparin 40 mg subcutaneously daily for venous thromboembolism (VTE) prophylaxis and pantoprazole 40 mg daily for stress ulcer prophylaxis. A central venous catheter was placed 3 days ago. As the critical care pharmacist during ICU rounds, which intervention requires the highest priority action to balance bleeding and thrombosis risks?

Discontinue enoxaparin and initiate intermittent pneumatic compression for VTE prophylaxis
Continue pantoprazole 40 mg daily; no dose adjustment is necessary
Ensure adherence to central line maintenance bundles and assess catheter necessity daily
Avoid fresh frozen plasma transfusion solely to normalize INR in the absence of active bleeding

Question 8 of 10

8. Question

A 62-year-old man with septic shock secondary to pneumonia is mechanically ventilated and receiving aggressive fluid resuscitation (6 L of balanced crystalloids) and a norepinephrine infusion at 0.2 µg/kg/min. Despite these measures, his mean arterial pressure remains 58 mmHg. He is on volume-controlled ventilation with tidal volume 6 mL/kg predicted body weight, PEEP 12 cm H₂O, plateau pressure 28 cm H₂O, and FiO₂ 0.8. He has worsening pulmonary infiltrates on chest radiograph, increased abdominal girth, and an intra-abdominal pressure of 18 mmHg. Which of the following is the next best step in management?

Increase the norepinephrine infusion to achieve MAP ≥ 65 mmHg and add vasopressin as an adjunct.
Administer a 1 L bolus of balanced crystalloids to further optimize preload and improve urine output.
Initiate a continuous furosemide infusion to reduce fluid overload and improve oxygenation.
Decrease PEEP to 5 cm H₂O to lower intrathoracic pressure and improve venous return.

Question 9 of 10

9. Question

Formulate a plan for converting from IV to enteral fluid and electrolyte management, including considerations for patients with enteral access devices.

Start enteral fluids at full maintenance rate immediately and stop IV fluids.
Gradually taper IV fluids while initiating enteral fluids at a low rate, monitoring electrolytes and fluid balance.
Discontinue all IV fluids and replace immediately with enteral fluids at double the normal rate.
Maintain IV fluids and enteral fluids simultaneously without monitoring until the patient is fully on enteral feeds.

Question 10 of 10

10. Question

A 62-year-old man with severe sepsis. He received initial fluid resuscitation (30 mL/kg of balanced crystalloids), but now has hypoalbuminemia (serum albumin 2.1 g/dL) and clinical signs of third-spacing (peripheral edema, mild pulmonary congestion). His mean arterial pressure (MAP) remains borderline low despite the initial bolus. You have access to dynamic fluid responsiveness monitoring (e.g., passive leg raise, stroke volume variation). Considering altered volume of distribution from capillary leak and low oncotic pressure, which fluid management strategy best balances the need for further resuscitation while minimizing fluid overload?

Administer repeated boluses of 0.9% sodium chloride until MAP ≥65 mm Hg, then switch to a maintenance infusion.
Start a continuous infusion of 5% albumin to raise oncotic pressure and draw fluid back into the intravascular space.
Adopt a conservative fluid approach by limiting additional boluses and escalating vasopressors if MAP remains low.
Give further boluses of balanced crystalloids, titrated to dynamic fluid responsiveness assessments, with higher volumes if indicated by capillary leak.

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