Supportive and Preventive Medicine

Answer: A

The mnemonic FAST-HUG stands for Feeding,

Analgesia, Sedation, Thromboembolic prophylaxis,

Head of bed elevation, stress Ulcer prophylaxis, and

Glycemic control. Using this mnemonic as a checklist

every day for each critically ill patient will help maxi-

mize therapeutic interventions and promote patient

safety. This patient would benefit from receiving enteral

nutrition (an NGT is already placed and he has a working

GI tract), interrupting the sedative (current RASS score

is above the designated goal), and adding SUP (risk fac-

tors include cirrhosis) (Answer A is correct). Critically

ill patients with risk factors for VTE should remain

on VTE prophylaxis (Answers B and D are incorrect);

moreover, sliding-scale insulin should be initiated when

the patient is not critically ill and once the glucose is

stable (less than 180 mg/dL), adding another reason why

Answer B is incorrect and making Answer C incorrect.

Answer: B

Factors placing critically ill patients at risk of clinically

important stress-related bleeding are shock, chronic

liver disease, or coagulopathy (Plt less than 50 × 103/

μL, INR greater than 1.5, or aPTT greater than 2 times

the control). This patient has coagulopathy as well as

septic shock, as evidenced by end-organ dysfunction

and acute kidney injury (Answer A is incorrect; Answer

B is correct). Answers C and D are incorrect because

mechanical ventilation is no longer considered a risk

factor for stress-related upper GI bleeding.

Answer: D

Antacids are not recommended for routine use because

of their frequency of administration, adverse effects,

and interactions (Answer B is incorrect). In a large

randomized controlled trial, sucralfate was inferior to

H2RAs in preventing clinically significant bleeding

from SRMD and is generally not recommended because

of its adverse effect profile (Answer A is incorrect).

Proton pump inhibitors are no better than H2RAs in pre-

venting SRMD and may be associated with increased

infectious complications, including CDI (Answer D is

correct). Meta-analyses have favored PPIs to H2RAs

for GI bleeding; however, the individual trials included

lacked methodological quality (Answer C is incorrect).

Answer: C

Once the risk factors are no longer present, SUP should

promptly be discontinued (Answer C is correct). This

patient no longer has risk factors (coagulopathy, shock,

or chronic liver disease). In addition, there is no evi-

dence that SUP should be continued until hospital or

ICU discharge or when antimicrobial therapy is com-

plete (Answers A, B, and D are incorrect).

Answer: C

This patient has several risk factors for VTE, includ-

ing immobility and respiratory failure, making heparin

5000 units subcutaneously twice daily appropriate for

VTE prophylaxis (Answer C is correct). Neither enoxa-

parin nor fondaparinux is appropriate for this patient,

who has acute kidney injury with an estimated CrCl

of less than 20 mL/minute/1.73 m2 (Answers B and D

are incorrect). Additionally, VTE prophylaxis with

fondaparinux is contraindicated in patients less than

50 kg. Intermittent pneumatic compression would be

insufficient in a patient with no contraindication to phar-

macologic prophylaxis (Answer A is incorrect).

Answer: A

Diagnosing HIT is difficult in a critically ill patient

because there are many alternative causes of thrombo-

cytopenia. Clinical assessment is essential in diagnosing

HIT because of the immediate need for treatment and

the delay in laboratory testing (Answers B and D are

incorrect). Clinically, this patient has had a greater than

50% decrease in Plt within 5 days of receiving heparin.

The calculated 4Ts score is 5 (2 points for Plt decrease

by greater than 50%, 2 points for a clear onset at days

5–10, and 1 point for other possible causes of throm-

bocytopenia. This score is an intermediate probability

for HIT. In managing suspected HIT, first ensure that

all forms of heparin are discontinued, including flushes

and heparin-coated catheters. Next, initiate an alterna-

tive form of anticoagulation. Direct thrombin inhibitors

are the agents of choice for anticoagulation in acute

HIT because they have no cross-reactivity with heparin

(Answer A is correct). Factor Xa inhibitors have been

used to manage HIT; however, they would not be best

in this patient, who has acute kidney injury (Answer C

is incorrect).