BCCCP: Withdrawal Syndromes Critical Care Questions

Question 1 of 10

1. Question

A 65-year-old critically ill patient in the ICU develops acute kidney injury after being started on multiple medications, including vancomycin and piperacillin-tazobactam. What is the best initial step in managing this drug-induced acute kidney injury?

Continue the current antibiotic regimen, adjust doses based on creatinine clearance, and monitor renal function closely.
Immediately discontinue all nephrotoxic medications and initiate renal replacement therapy.
Review and identify offending agents, adjust dosages or discontinue specific nephrotoxic drugs, optimize hydration, and monitor renal function.
Obtain a renal ultrasound to exclude post-renal obstruction before changing the antibiotic regimen.

Question 2 of 10

2. Question

A 60-year-old patient with acute kidney injury is receiving continuous renal replacement therapy (CRRT). Which of the following best describes the optimal approach to dosing adjustments for renally cleared medications in this setting?

Use a predefined dosing nomogram based on estimated creatinine clearance without accounting for RRT modality.
Adjust drug doses by empirically reducing 30–40% for all RRT patients, irrespective of modality or residual renal function.
Individualize dosing based on drug pharmacokinetics, RRT modality and intensity, residual renal function, and clinical status.
Refer to published RRT drug removal tables to increase initial doses for drugs known to be cleared by CRRT without further individual adjustment.

Question 3 of 10

3. Question

Select the most appropriate first-line pharmacologic agent for managing alcohol withdrawal in critically ill patients based on current evidence-based guidelines.

Benzodiazepines (e.g., diazepam, chlordiazepoxide)
Methadone for opioid withdrawal
Buprenorphine for opioid withdrawal
Clonidine for opioid withdrawal

Question 4 of 10

4. Question

A 68-year-old man is transferring from the ICU to a step-down unit following treatment for septic shock. His ICU regimen included norepinephrine, broad-spectrum antibiotics, and stress ulcer prophylaxis. Before handoff, the ICU pharmacist is tasked with developing a medication reconciliation and discharge counseling plan. Which step should the pharmacist prioritize first to minimize the risk of medication errors during this transition?

Obtain and verify a complete list of the patient’s pre-ICU home medications, including doses and schedules.
Confirm and document all new ICU-initiated medications with indications and doses.
Provide the patient and family with counseling on medication changes and potential side effects.
Coordinate outpatient follow-up appointments and ensure continuity with the primary care provider.

Question 5 of 10

5. Question

A 62-year-old, 70-kg man with severe sepsis and multi-organ dysfunction is mechanically ventilated on an assist-control setting. He is receiving a propofol infusion at 20 mcg/kg/min and a fentanyl infusion at 50 mcg/hr via a central venous catheter. Over the past 48 hours, his vasopressor requirements have decreased, and he is now hemodynamically stable on minimal norepinephrine. His Richmond Agitation-Sedation Scale (RASS) score is consistently –2, and he follows simple commands. A spontaneous breathing trial (SBT) is planned for the morning. A de-escalation of sedation and analgesia is being considered, with a goal of transitioning to enteral administration via his percutaneous endoscopic gastrostomy (PEG) tube. Which of the following is the most appropriate initial strategy for de-escalating this patient’s sedation and analgesia?

Immediately discontinue both propofol and fentanyl infusions and initiate scheduled enteral lorazepam and oxycodone via the PEG tube.
Gradually wean the propofol infusion, convert the fentanyl infusion to an equivalent dose of scheduled enteral opioid, and monitor for withdrawal using a validated scale.
Convert propofol to intermittent IV boluses and fentanyl to as-needed IV boluses, then transition to enteral medications once the patient is extubated.
Discontinue propofol and switch to a dexmedetomidine infusion while continuing the fentanyl infusion until the patient is fully awake and interactive.

Question 6 of 10

6. Question

A 45-year-old man is in the medical ICU for severe sepsis and acute respiratory distress syndrome. He has been mechanically ventilated and sedated with propofol at 30 mcg/kg/min and fentanyl at 2 mcg/kg/h via a central venous catheter for the past 7 days. He is now hemodynamically stable, afebrile, and his oxygenation has improved (PaO2/FiO2 ratio 250). The intensivist team plans to de-escalate sedation and analgesia. His Richmond Agitation-Sedation Scale (RASS) score has been −3 to −4, and nursing assessments confirm adequate pain control. Which of the following is the most essential component of a protocol for safely tapering sedation and analgesia in this patient?

Abruptly discontinuing all sedative and analgesic infusions once the patient is extubated to accelerate mobilization.
Implementing a fixed-dose, time-based tapering schedule for propofol and fentanyl regardless of the patient’s daily assessments.
Prophylactically initiating high-dose oral benzodiazepines in all patients undergoing sedative weaning to prevent withdrawal.
Establishing a multidisciplinary, protocol-driven approach utilizing daily assessment with validated scales (e.g., RASS, CPOT) and gradual, agent-specific titration.

Question 7 of 10

7. Question

A 45-year-old man is in the medical ICU on day 3 of hospitalization for a traumatic injury. He is intubated and mechanically ventilated. He developed severe alcohol withdrawal syndrome and is receiving a continuous intravenous lorazepam infusion at 10 mg/hour. Despite this, he remains agitated (RASS +2 to +3). Which of the following is the most critical monitoring parameter to guide therapeutic adjustments?

Daily assessment of liver function tests and bilirubin
Continuous monitoring of heart rate and blood pressure
Frequent, protocolized assessment of a validated sedation–agitation scale such as RASS or SAS
Daily electrolyte panel, particularly magnesium and phosphate

Question 8 of 10

8. Question

A 45-year-old woman presents to the ICU with septic shock secondary to pneumonia. Her blood pressure is 85/50 mmHg despite adequate initial fluid resuscitation, and she requires vasopressor support. Based on the recent network meta-analysis by Long et al. (2025) involving 8,770 patients, which fluid type should be prioritized for ongoing resuscitation to optimize mortality and renal outcomes?

Balanced crystalloids (e.g., lactated Ringer's)
Normal saline (0.9% sodium chloride)
High molecular weight hydroxyethyl starch
Hyperoncotic albumin (25%)

Question 9 of 10

9. Question

A 62-year-old man is in the ICU for severe ARDS. He has been intubated and on continuous infusions of midazolam and fentanyl for 10 days. With improved respiratory status and risk factors for withdrawal, which is the most appropriate initial strategy for sedation de-escalation?

Transition midazolam to intermittent boluses and rapidly taper fentanyl to expedite extubation.
Initiate a continuous infusion of propofol and titrate to light sedation to replace midazolam.
Utilize a protocol-directed sedation weaning strategy, including daily sedation interruptions and frequent assessment using validated scales, to guide gradual dose reduction.
Discontinue all sedative infusions immediately and closely monitor for signs of withdrawal, treating symptoms as they arise.

Question 10 of 10

10. Question

A 55-year-old man with chronic alcohol use has refractory alcohol withdrawal with seizures despite high-dose intravenous lorazepam. Which adjunctive agent is most appropriate?

Phenobarbital
Dexmedetomidine
Intravenous clonidine infusion at 0.2 mcg/kg/h
Initiate lorazepam continuous infusion at 2 mg/h and titrate to RASS 0 to –1

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