BCCCP: Mechanical Ventilation Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old, 70 kg male with severe pneumonia has been intubated for 10 days and ventilated on pressure support of 8 cm H₂O, PEEP 5 cm H₂O, FiO₂ 40%. He is on a fentanyl infusion at 2 mcg/kg/hr and low-dose norepinephrine (4 mcg/min). He was difficult to intubate requiring three attempts. Over 24 hours he has become more awake but intermittently agitated (RASS +3) and disoriented. His spontaneous breathing trial was successful, and the team plans extubation within 12 hours. He remains on propofol at 10 mcg/kg/min, but agitation and ventilator dyssynchrony persist.

Which pharmacologic strategy should be prioritized to facilitate ventilator liberation and minimize post-extubation stridor?

Transition propofol to a dexmedetomidine infusion at 0.2–1.4 mcg/kg/hr and initiate methylprednisolone 40 mg IV every 6 hours starting 12 hours before extubation for 48 hours.
Increase propofol infusion to 50 mcg/kg/min to achieve RASS –2 and give a single dose of dexamethasone 8 mg IV just prior to extubation.
Discontinue propofol and start a continuous midazolam infusion at 0.02–0.1 mg/kg/hr, while monitoring for post-extubation stridor.
Administer a fentanyl bolus of 1 mcg/kg for agitation and continue propofol at the current rate.

Question 2 of 10

2. Question

A 62-year-old mechanically ventilated ICU patient is exhibiting agitation despite receiving moderate sedation with a continuous propofol infusion. The patient’s heart rate and blood pressure are elevated, but no recent pain assessment has been documented. As the critical care pharmacist, which intervention should you prioritize to align with analgesia-first sedation principles and the ABCDEF bundle?

Increase the continuous propofol infusion to achieve a deeper sedation target of RASS -4.
Initiate a continuous fentanyl infusion at 50 mcg/hour to treat presumed pain.
Implement a structured protocol for routine pain assessment using validated tools (e.g., Behavioral Pain Scale, Critical-Care Pain Observation Tool) and address identified pain before adjusting sedation.
Add a continuous midazolam infusion to the current propofol regimen for additional sedation.

Question 3 of 10

3. Question

A 62-year-old male with moderate ARDS is receiving mechanical ventilation via assist-control mode and a continuous propofol infusion. He has been on dexamethasone 6 mg daily for 7 days. His oxygenation has improved, and he is hemodynamically stable without vasopressors. The physical therapy team plans to initiate in-bed cycling and progressive mobilization. Despite attempts to lighten sedation from a RASS of –4 to a target of –2, the patient exhibits generalized weakness and poor participation. Given the goal of promoting early mobilization, which pharmacologic intervention should be prioritized?

Taper and discontinue dexamethasone to reduce corticosteroid-induced muscle weakness.
Initiate a continuous theophylline infusion to augment respiratory drive.
Increase the propofol infusion rate to maintain deeper sedation during therapy sessions.
Administer a short course of neuromuscular blocking agents to improve ventilator synchrony.

Question 4 of 10

4. Question

A 68-year-old man is admitted to the ICU with septic shock secondary to community-acquired pneumonia. Despite aggressive fluid resuscitation (30 mL/kg crystalloid) and norepinephrine infusion at 0.5 µg/kg/min, his mean arterial pressure remains 60 mm Hg and heart rate is 110 bpm. He has no significant cardiac arrhythmias. Which of the following is the most appropriate next step in management?

Increase the norepinephrine infusion by 0.2 µg/kg/min
Add a fixed-rate vasopressin infusion at 0.03 units/min
Add a low-dose epinephrine infusion at 0.05 µg/kg/min
Add a phenylephrine infusion at 0.5 µg/kg/min

Question 5 of 10

5. Question

A 58-year-old man with severe acute respiratory distress syndrome (ARDS) secondary to pneumonia is admitted to the ICU. He is mechanically ventilated with a PEEP of 15 cm H₂O and FiO₂ of 0.9. Despite deep sedation, he exhibits significant patient–ventilator dyssynchrony, variable tidal volumes, and elevated peak inspiratory pressures. His PaO₂ remains 60 mm Hg. Given these findings, which of the following is the MOST compelling reason to initiate a neuromuscular blocking agent (NMBA)?

To facilitate prone positioning by eliminating spontaneous movements and ensuring endotracheal tube stability.
To optimize lung-protective ventilation by abolishing spontaneous efforts in severe ARDS with refractory hypoxemia and ventilator dyssynchrony.
To control elevated intracranial pressure by abolishing coughing and straining during mechanical ventilation.
To reduce oxygen consumption in a hypermetabolic septic patient through complete neuromuscular paralysis.

Question 6 of 10

6. Question

A 62-year-old (80 kg) male with severe ARDS on mechanical ventilation exhibits significant patient–ventilator dyssynchrony despite optimal ventilator settings. He is currently receiving propofol at 50 mcg/kg/min and fentanyl at 100 mcg/hr, with a RASS score of –4 and a CPOT score of 2. The critical care team plans to initiate a continuous neuromuscular blocking agent (NMBA) infusion to improve synchrony. Which action should the critical care pharmacist prioritize before starting the NMBA?

Increase the propofol infusion to 60 mcg/kg/min and fentanyl to 150 mcg/hr to achieve a target RASS of –5 and CPOT of 0–1.
Confirm availability and set up train-of-four monitoring to assess neuromuscular function before NMBA initiation.
Initiate a cisatracurium infusion at 2 mcg/kg/min without adjusting current sedation or analgesia.
Add a continuous midazolam infusion to achieve a target RASS of –5 prior to NMBA initiation.

Question 7 of 10

7. Question

A 58-year-old male (weight 85 kg, BMI 27.5 kg/m2) with severe acute respiratory distress syndrome is receiving lung-protective mechanical ventilation in the ICU. He has been on a continuous cisatracurium infusion at 2 mcg/kg/min for 48 hours. Sedation is maintained with propofol 50 mcg/kg/min and fentanyl 2 mcg/kg/h. Peripheral nerve stimulator monitoring shows a persistent train-of-four (TOF) count of 0/4 for the past 24 hours. The patient remains deeply paralyzed with no spontaneous movement. The critical care pharmacist is consulted to prevent complications such as ICU-acquired weakness, prolonged paralysis, and corneal injury. Which of the following is the MOST critical immediate action?

Initiate aggressive physical therapy and early mobilization protocols.
Decrease the cisatracurium infusion rate to target a TOF count of 1–2/4.
Administer artificial tears and apply protective eye patches.
Order daily serum creatinine and liver function tests to assess organ dysfunction.

Question 8 of 10

8. Question

A 62-year-old male (weight 85 kg, BMI 26 kg/m2, serum creatinine 1.0 mg/dL) is admitted to the intensive care unit 12 hours after a severe ischemic stroke. He is intubated, sedated with propofol, and receiving volume-controlled ventilation. Head CT shows no hemorrhagic conversion. Laboratory tests reveal a platelet count of 250,000/mm3, INR 1.1, and aPTT 30 seconds. According to current acute ischemic stroke guidelines, which of the following is the MOST appropriate early strategy for venous thromboembolism (VTE) prevention in this patient?

Initiate unfractionated heparin (UFH) 5,000 units subcutaneously every 8 hours.
Initiate enoxaparin 40 mg subcutaneously once daily.
Use intermittent pneumatic compression devices alone.
Initiate unfractionated heparin (UFH) 5,000 units subcutaneously every 12 hours.

Question 9 of 10

9. Question

A 58-year-old man with severe acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation with lung-protective strategies. Because of severe hypoxemia and ventilator dyssynchrony, neuromuscular blockade has been initiated. Deep sedation targeting a Richmond Agitation-Sedation Scale (RASS) score of –4 to –5 is required to facilitate ventilation and paralysis. The patient is hemodynamically stable and has a history of hypertension. Which of the following is the most appropriate initial sedative regimen?

Initiate a continuous infusion of propofol, titrating to a RASS score of –4 to –5.
Initiate a continuous infusion of dexmedetomidine, titrating to a RASS score of –4 to –5.
Initiate a continuous infusion of midazolam, titrating to a RASS score of –4 to –5.
Initiate a continuous infusion of ketamine, titrating to a RASS score of –4 to –5.

Question 10 of 10

10. Question

A 62-year-old male on mechanical ventilation via an endotracheal tube is receiving a continuous propofol infusion at 50 mcg/kg/min. He initially required deep sedation and paralysis for severe ARDS, but neuromuscular blockade was discontinued 12 hours ago and he now has spontaneous movements. The critical care team aims to transition him to light sedation (Richmond Agitation-Sedation Scale [RASS] –1 to 0) to facilitate ventilator liberation. However, the nurse reports difficulty in accurately assessing sedation level due to fluctuating responsiveness and occasional purposeful movements. Vital signs are stable.

Given the patient’s current status and the goal of achieving light sedation (RASS –1 to 0), which of the following is the most appropriate strategy for assessing and titrating his sedation using validated assessment tools?

Continue propofol at the current rate and rely solely on the Bispectral Index (BIS) monitor to maintain a target BIS of 60–80.
Discontinue propofol for a spontaneous awakening trial and proceed with extubation if the patient remains alert, without using a structured sedation scale.
Gradually titrate the propofol infusion down while frequently assessing sedation level with validated tools such as the RASS or Sedation-Agitation Scale (SAS).
Switch sedation to a continuous midazolam infusion and titrate midazolam dosing based on the Sedation-Agitation Scale targeting a SAS score correlating with light sedation.