BCCCP: RRT Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old male is admitted to the ICU with severe sepsis secondary to suspected gram-negative pneumonia and acute kidney injury requiring continuous venovenous hemofiltration (CVVH). He weighs 70 kg and is anuric (<50 mL urine/day). CVVH is running with an effluent rate of 25 mL/kg/hr (1.75 L/hr) and meropenem sieving coefficient is approximately 0.95. The team plans to start meropenem infused over 30 minutes. Which dosing regimen is MOST appropriate to optimize efficacy and minimize toxicity?

Meropenem 1 g IV every 8 hours over 30 minutes
Meropenem 500 mg IV every 12 hours over 30 minutes
Meropenem 1 g IV every 12 hours over 30 minutes
Meropenem 500 mg IV every 24 hours over 30 minutes

Question 2 of 10

2. Question

An 80-kg, 55-year-old man with septic shock secondary to ventilator-associated pneumonia is empirically receiving vancomycin for MRSA coverage and meropenem for Pseudomonas aeruginosa (MIC 2 mg/L). He has developed acute kidney injury and is receiving continuous venovenous hemodiafiltration (CVVHDF) with an effluent flow rate of 25 mL/kg/h and a blood flow rate of 150 mL/min. Liver function is normal, and albumin is 3.0 g/dL. Considering his clinical status, the pharmacokinetics of vancomycin and meropenem, and the continuous nature of CVVHDF, which of the following is the MOST appropriate strategy for initial antimicrobial dosing and monitoring?

Vancomycin: administer a loading dose of 25 mg/kg (2 g IV), then continuous infusion at 20 mg/kg/day, with therapeutic drug monitoring targeting trough concentrations of 15–20 mg/L. Meropenem: administer a loading dose of 2 g IV, then continuous infusion of 3 g over 24 hours (dose adjusted for CRRT clearance) to maximize time above MIC.
Vancomycin: administer a loading dose of 25 mg/kg, then intermittent dosing of 15 mg/kg IV every 24 hours, with trough monitoring targeting 15–20 mg/L. Meropenem: administer 1 g IV every 8 hours over 30 minutes, without any dose adjustment for CRRT.
Vancomycin: administer a loading dose of 25 mg/kg, then continuous infusion at 20 mg/kg/day without routine therapeutic drug monitoring. Meropenem: administer a loading dose of 2 g IV, then intermittent extended infusion of 2 g over 3 hours every 8 hours, with dosing adjusted for CRRT.
Vancomycin: administer a loading dose of 25 mg/kg, then continuous infusion at 15 mg/kg/day, monitoring only peak concentrations. Meropenem: administer 500 mg IV every 6 hours over 30 minutes, with adjustment for CRRT clearance.

Question 3 of 10

3. Question

A 72-year-old man with bipolar disorder is evaluated in the ICU for altered mental status. He presents with lethargy, disorientation, and coarse tremors after reportedly ingesting excess lithium. Vital signs: blood pressure 110/70 mmHg, heart rate 90 beats per minute, respiratory rate 16 breaths per minute, temperature 36.8°C. Laboratory studies show serum lithium 4.8 mEq/L, creatinine 2.5 mg/dL (baseline 1.0 mg/dL), BUN 60 mg/dL, and urine output has declined over the past 12 hours. Which of the following is the most appropriate immediate management strategy?

Initiate intermittent hemodialysis and continue until serum lithium falls below 1.0 mEq/L and neurological status improves.
Administer aggressive intravenous isotonic saline with loop diuretics to enhance renal lithium excretion and reassess levels in 6 hours.
Initiate continuous renal replacement therapy (CRRT) and monitor for clinical and laboratory improvement.
Start peritoneal dialysis to increase lithium clearance over the next 24–48 hours.

Question 4 of 10

4. Question

A 65-year-old man (80 kg) in the ICU with acute kidney injury (baseline Scr 1.0 mg/dL; current Scr 3.5 mg/dL, BUN 70 mg/dL, albumin 3.0 g/dL) is receiving CVVHDF (effluent 25 mL/kg/h; blood flow 150 mL/min). His current regimen includes warfarin 5 mg PO daily, vancomycin 1 g IV q12h (trough 15 µg/mL), meropenem 1 g IV q8h, and levofloxacin 750 mg IV daily. As the critical care pharmacist, which of the following medication management strategies is MOST appropriate given the impact of CVVHDF on drug clearance?

Continue warfarin 5 mg PO daily and monitor INR per standard protocol.
Reduce vancomycin to 750 mg IV every 48 hours to compensate for CVVHDF removal.
Switch meropenem to 1 g IV q12h as a 30-minute infusion.
Decrease levofloxacin to 250 mg IV daily due to reduced clearance.

Question 5 of 10

5. Question

A 65-year-old man on continuous venovenous hemodiafiltration (CVVHDF) for acute kidney injury and septic shock develops hospital-acquired pneumonia due to methicillin-resistant Staphylococcus aureus. He is anuric, weighs 80 kg, and has a current serum creatinine of 2.5 mg/dL. Which strategy is most appropriate to optimize vancomycin therapy in this patient?

Administer a weight-based loading dose followed by fixed empiric maintenance doses without therapeutic drug monitoring.
Initiate vancomycin at a reduced maintenance dose based on serum creatinine and monitor clinical response only.
Administer a weight-based loading dose, then individualize maintenance dosing using frequent TDM guided by CRRT clearance parameters.
Discontinue vancomycin and switch to linezolid, which does not require TDM or renal adjustments.

Question 6 of 10

6. Question

A 62-year-old man is admitted to the intensive care unit with septic shock secondary to pneumonia. Despite receiving broad-spectrum antibiotics, aggressive fluid resuscitation, and vasopressor support, his hemodynamics remain unstable. The critical care team considers adjunctive therapies to modulate the inflammatory response. Hemoadsorptive and hemoperfusion devices such as CytoSorb and polymyxin-B columns are discussed as potential options. Based on current evidence and guideline recommendations, which of the following best describes the role and limitation of these extracorporeal devices in managing refractory septic shock?

They are considered first-line therapy for all patients with septic shock unresponsive to initial vasopressors.
They consistently demonstrate a significant mortality benefit in large, randomized controlled trials.
They are primarily used as adjunctive therapy and do not replace standard sepsis management.
They are contraindicated in patients already receiving conventional renal replacement therapy for acute kidney injury.

Question 7 of 10

7. Question

A 65-year-old critically ill patient with acute kidney injury is receiving continuous renal replacement therapy (CRRT). Laboratory results reveal hypokalemia (serum K⁺ 2.9 mEq/L), hypomagnesemia (Mg²⁺ 1.1 mg/dL), and hypophosphatemia (PO₄³⁻ 1.8 mg/dL). The ICU team is concerned about ongoing electrolyte losses due to CRRT and wants to implement a comprehensive plan to correct current deficits and prevent further derangements. Which of the following represents the MOST appropriate comprehensive management plan?

Initiate intravenous potassium, magnesium, and phosphate supplementation to correct acute deficits; adjust the CRRT replacement fluid or dialysate to include higher concentrations of these electrolytes; and monitor serum levels every 6–8 hours with clinical vigilance for cardiac and neuromuscular signs.
Administer oral potassium, magnesium, and phosphate supplements as tolerated, modestly increase dialysate electrolyte concentrations, and recheck serum electrolytes every 12–24 hours.
Increase the CRRT dialysate flow rate to enhance removal of uremic toxins, and provide bolus intravenous electrolyte replacement as needed.
Reduce CRRT ultrafiltration and dialysate flow rates to minimize electrolyte clearance, supplement electrolytes intermittently, and resume standard CRRT settings once levels normalize.

Question 8 of 10

8. Question

A 68-year-old man with acute liver failure and septic shock has been on continuous venovenous hemodiafiltration (CVVHDF) with regional citrate anticoagulation for 18 hours. Citrate is infused at 4 mmol per liter of blood flow with calcium-free dialysate. Over the past 12 hours, his anion gap has risen from 10 to 15 mEq/L, and he remains hypocalcemic despite calcium replacement. Current labs: arterial blood gas pH 7.25, bicarbonate 14 mEq/L; total serum calcium 2.4 mmol/L (normal 2.2–2.6), ionized calcium 0.88 mmol/L (1.12–1.32), total/ionized calcium ratio 2.7. Liver enzymes are ALT 650 U/L and AST 720 U/L. Which of the following is the MOST appropriate immediate action to address his metabolic complication?

Increase the citrate infusion rate and administer intravenous sodium bicarbonate.
Decrease the citrate infusion rate and increase the intravenous calcium infusion rate.
Discontinue citrate anticoagulation, initiate unfractionated heparin, and administer intravenous calcium gluconate.
Increase dialysate flow rate to enhance citrate clearance while maintaining the current citrate and calcium infusion rates.

Question 9 of 10

9. Question

A 65-year-old, 75-kg man with septic shock secondary to pneumonia is receiving intermittent hemodialysis three times weekly for acute kidney injury. He is on continuous norepinephrine 0.15 mcg/kg/min to maintain a baseline mean arterial pressure (MAP) of 75 mmHg. During a scheduled 4-hour session, the dialysate temperature is 37 °C and ultrafiltration is set at 1.0 L/hr (total fluid removal goal 4.0 L). Despite a 250 mL 0.9% saline bolus, his MAP acutely drops to 55 mmHg. Considering his ongoing vasopressor support and acute intradialytic hypotension, which of the following initial interventions best addresses the underlying pathophysiology while minimizing further complications?

Increase norepinephrine infusion by 0.05 mcg/kg/min and administer a 500 mL 0.9% saline bolus, continuing current dialysis settings.
Administer a 250 mL bolus of 3% saline over 10 minutes and reduce ultrafiltration rate to 0.75 L/hr.
Decrease dialysate temperature to 35 °C, reduce ultrafiltration rate to 0.5 L/hr, and extend the dialysis session by 60 minutes.
Maintain dialysate temperature at 37 °C, reduce ultrafiltration rate to 0.5 L/hr, and add sodium profiling to the dialysate.

Question 10 of 10

10. Question

A 65-year-old man with acute kidney injury is receiving continuous renal replacement therapy (CRRT) on a medical ward. During routine monitoring, nursing staff note air bubbles in the arterial line of the CRRT circuit, and the patient suddenly becomes hypotensive and dyspneic. What is the MOST appropriate immediate management?

Administer an intravenous bolus of isotonic crystalloid.
Clamp the arterial line and attempt to withdraw the visible air using a syringe.
Stop the CRRT blood pump and position the patient in left lateral decubitus and Trendelenburg.
Administer an intravenous bolus of norepinephrine to support blood pressure.

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