Supportive and Preventive Medicine

Answer: C

The FAST-HUG mnemonic can serve as a checklist

for every patient admitted to the ICU. Every patient

should be assessed for a sedation interruption to min-

imize sedative exposure and maintain a light level of

sedation (Answer C is correct). To decrease the risk of

nosocomial pneumonia, each patient should have his or

her head elevated 30–45 degrees above the head of the

bed (Answer C is correct). Enteral nutrition should be

initiated as soon as possible – typically, once the patient

is stabilized; however, thromboprophylaxis should be

initiated in every patient, using pharmacologic agents

preferentially to mechanical prophylaxis (Answer B

is incorrect). Stress ulcer prophylaxis should only be

initiated in patients who have risk factors and should

be discontinued once the risk factors no longer exist

(Answer A is incorrect). Insulin infusions should be

initiated if blood glucose readings exceed 180 mg/dL

(Answer D is incorrect).

Answer: C

Sucralfate forms a protective barrier over the surface

of the stomach, reducing exposure to acidic gastric

contents; therefore, sucralfate does not affect gastric

pH (Answer A is incorrect). Compared with H2RAs,

PPIs appear more effective at reducing gastric acidity,

but no well-conducted trial has shown PPIs superior in

preventing clinically significant bleeding (Answer B is

incorrect). Tolerance to any H2RA may occur, but not to

PPIs (Answer C is correct). Antacids have some effect

on reducing stress ulceration, provided the gastric pH

is kept around 3.5, but frequent dosing (up to every 2

hours) is required to achieve this goal, making their use

impractical (Answer D is incorrect).

Answer: D

The patient has an indication for SUP (cirrhosis). He has

an NGT in place and is tolerating tube feedings, indi-

cating a functioning gut; therefore, intravenous therapy

is not required (Answers A and C are incorrect). The

patient has erosive esophagitis, for which a PPI will

be more effective than an H2RA (Answer B is incor-

rect). Omeprazole suspension is effective in preventing

SRMD; therefore, an omeprazole suspension would be

most appropriate for this patient (Answer D is correct).

Answer: A

Proton pump inhibitors are potent inhibitors of gastric

acid production and are the drug of choice for gastro-

esophageal reflux disease. To date, the only prospective

randomized controlled trial to evaluate CDI risk with PPI

use found no difference between PPI and placebo; how-

ever, this was an underpowered secondary end point,

and several cohort studies have found an association.

(Answer C is incorrect). All published trials assessing

the risk of CDI with PPI use have been limited by the

inconsistent definitions of CDI and the variable infection

control practices (Answer D is incorrect). Gastric juice is

strongly bactericidal for microorganisms. Proton pump

inhibitors are commonly used to increase the gastric

pH; therefore, they act as a potential risk factor for CDI

(Answer A is correct).

Answer: B

Low-dose unfractionated heparin or LMWH should

be initiated for VTE prophylaxis in a critically ill

patient over no prophylaxis (Answer D is incorrect).

Intermittent pneumatic compression devices would be

insufficient prophylaxis in a patient with several risk

factors for VTE (Answer A is incorrect). A continuous

infusion of heparin is inappropriate for preventing VTE

(Answer C is incorrect). Enoxaparin may be used for

VTE prophylaxis in a critically ill patient with stable

renal function (Answer B is correct).

Answer: A

This patient had a closed-head injury, placing her at

high risk of VTE (Answer D is incorrect). She is at high

risk of major bleeding and acute kidney injury; there-

fore, a LMWH or a factor Xa inhibitor would not be best

for her (Answers B and C are incorrect). Mechanical

prophylaxis with intermittent pneumatic compression

devices is preferred to no prophylaxis in the absence of

lower-extremity injury until the bleeding risk is no lon-

ger present (Answer A is correct).

Answer: D

Clinical assessment is essential in diagnosing HIT

because of the immediate need for treatment and the

delay in laboratory testing. Although this patient’s Plt

did decrease by 50%, the characteristic onset of the Plt

decrease in HIT is 5–10 days after heparin initiation.