A 55-year-old (80 kg) male is admitted to the ICU with severe rhabdomyolysis complicated by acute kidney injury (AKI) (serum creatinine 3.0 mg/dL, estimated CrCl 25 mL/min by Cockcroft–Gault) and oliguria. He has gained 5 kg of fluid over 48 hours, indicating expanded extracellular volume. The team plans to start IV vancomycin for suspected MRSA pneumonia with a target trough of 15–20 mg/L. Considering his increased volume of distribution and reduced renal clearance, which initial dosing strategy is MOST appropriate?

A 45-year-old man is admitted to the ICU with severe rhabdomyolysis after a prolonged crush injury. He develops acute kidney injury with a creatinine of 6.5 mg/dL and oliguria (<0.5 mL/kg/hr for 18 hours). Laboratory tests reveal a potassium level of 6.2 mEq/L despite medical management and a metabolic acidosis with pH 7.18 unresponsive to bicarbonate infusion. The patient is also volume overloaded, exhibiting bilateral crackles on lung auscultation and increasing oxygen requirements despite diuretic therapy. Considering his current clinical status, which of the following is the most compelling indication for initiating renal replacement therapy (RRT)?

A 62-year-old man is admitted to the ICU after prolonged immobility following a fall at home. He is intubated on assist-control ventilation and has a central venous catheter in place. Aggressive IV isotonic saline resuscitation has been initiated per protocol. Initial labs reveal creatine kinase 45,000 U/L, serum creatinine 2.8 mg/dL (baseline 0.9), potassium 5.6 mEq/L, and dark brown urine positive for myoglobin. His home medications include atorvastatin 40 mg daily, lisinopril 10 mg daily, and ibuprofen 400 mg three times daily. Considering his severe rhabdomyolysis complicated by acute kidney injury, which pharmacotherapy adjustment should the critical care pharmacist MOST critically prioritize to prevent further renal injury?

A 45-year-old, 80-kg man is admitted to the ICU after a motor vehicle collision complicated by severe rhabdomyolysis. Over the first 12 hours, he has received 6 L of isotonic crystalloid. He remains hypotensive and oliguric. His blood pressure is 82/45 mmHg (MAP 58 mmHg), central venous pressure 14 mmHg, and physical exam reveals bilateral crackles. Urine output is 20 mL/hr. Laboratory results: serum creatinine 2.2 mg/dL (baseline 1.0), potassium 5.8 mEq/L, bicarbonate 20 mEq/L. Given his hemodynamic status and worsening renal function, which adjunctive pharmacologic intervention should be prioritized to optimize renal perfusion and prevent further kidney injury?

A 45-year-old male is admitted to the critical care unit after being found unresponsive following prolonged immobility. He is intubated on assist-control ventilation and receiving intravenous fluids via a central line. Initial labs show creatine kinase (CK) 55,000 U/L, serum creatinine 1.8 mg/dL (baseline 0.9 mg/dL), potassium 5.8 mEq/L, and dark, tea-colored urine. His blood pressure is 100/60 mmHg, heart rate 110 bpm, and urine output has been 0.3 mL/kg/hr over the last 2 hours despite initial fluid boluses. Considering the patient’s acute presentation and high risk for complications, which of the following is the MOST critical monitoring strategy to prioritize for immediate intervention and prevention of acute kidney injury and life-threatening electrolyte abnormalities?

A 45-year-old man presents 8 hours after prolonged immobilization from a motor vehicle collision. He complains of diffuse muscle pain and notices dark (“tea-colored”) urine. Laboratory studies show creatine kinase 12 000 U/L (normal 24–170 U/L), serum creatinine 2.4 mg/dL (baseline 0.9 mg/dL), potassium 5.2 mEq/L, and bicarbonate 20 mEq/L. He received an initial 2 L isotonic crystalloid bolus followed by maintenance fluids at 200 mL/hr over the past 6 hours. Despite this, his urine output remains 0.3 mL/kg/hr over the past 3 hours. His blood pressure is 90/60 mmHg and heart rate 110 bpm, consistent with ongoing hypovolemia. Which of the following adjunctive therapies should be used with the MOST caution due to the risk of worsening volume depletion and renal hypoperfusion?

A 55-year-old man with severe rhabdomyolysis is admitted to the ICU. He has acute kidney injury (baseline creatinine 1.0 mg/dL now 3.2 mg/dL, BUN 45 mg/dL) and reduced urine output (200 mL over the last 6 hours). Vital signs: BP 145/90 mm Hg, HR 100 bpm, RR 20/min, SpO₂ 98% on room air. Serum potassium is 6.8 mEq/L, and ECG shows peaked T waves. He also has signs of fluid overload (bilateral lower extremity edema, pulmonary crackles) following aggressive IV fluid resuscitation. What is the most appropriate immediate management to stabilize his condition?

A 45-year-old man in the ICU after a motor vehicle accident developed severe rhabdomyolysis (peak CK >150,000 U/L) and acute kidney injury requiring continuous renal replacement therapy (CRRT) for refractory hyperkalemia and volume overload. Over the past 48 hours, urine output has increased from anuria to 1800 mL/day, serum creatinine has fallen from 5.2 to 2.1 mg/dL, potassium remains stable at 4.2 mEq/L, and net fluid balance is –1.5 L over 24 hours. He is hemodynamically stable without vasopressors. As the critical care pharmacist, which is the MOST appropriate next step in managing his recovering kidney function?

A 58-year-old male is recovering in the ICU from severe rhabdomyolysis complicated by acute kidney injury (current CrCl 35 mL/min). He is now hemodynamically stable, off vasopressors, and tolerating continuous enteral nutrition (40 mL/h) via a radiographically confirmed gastric nasogastric tube with minimal residuals (<50 mL). He is receiving the following IV medications: levofloxacin for pneumonia, metoprolol for rate control, pantoprazole for stress ulcer prophylaxis, and furosemide for fluid management. As the critical care pharmacist, you must convert his IV medications to enteral formulations. Considering his clinical status, renal function, gastrointestinal tolerance, and enteral access, which of the following represents the MOST appropriate prioritized plan for converting his IV medications to enteral formulations?

A 45-year-old man, admitted for severe sepsis with multi-organ dysfunction, is on volume-controlled ventilation with a continuous norepinephrine infusion via a right internal jugular central line. During morning rounds, new-onset acute, flaccid limb weakness is noted. Initial lab work reveals a serum creatine kinase (CK) level of 55,000 U/L and dark, tea-colored urine. Nerve conduction studies performed yesterday were reported as near-normal. Based on the expected prognosis for this condition, which rehabilitation strategy is most appropriate?