BCPS / Special populations

Answer D. The following 5 elements are part of the Institute of Healthcare Improvement VAP bundle: oral care with Chlorhexidine, head of bed elevation, DVT prophylaxis, SUP, and daily sedation assessment and spontaneous breathing trials. Other suggested measures for VAP prophylaxis are small bowel feeding instead of gastric feeding, prophylactic probiotics, alcohol based hand washing policy, early discontinuation of invasive devices, early tracheostomy, and reducing reintubation rates. Giving prophylaxis antibiotic is not recommended. Reference: Kalanuria AA, Zai W, Mirski M. Ventilator-associated pneumonia in the ICU. Critical Care. 2014;18(2):208. doi:10.1186/cc13775.

Answer A. Thiamine should be administered to prevent Wernicke’s encephalopathy. Reference: Management of moderate and severe alcohol withdrawal syndromes. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016.

Answer B. Benzodiazepines are the most studied drugs for alcohol withdrawal treatment. Long-acting agents such as Diazepam and Chlordiazepoxide may be used. Antipsychotics are not recommended to treat alcohol withdrawal. Haloperidol is an antipsychotic, an inappropriate choice. Reference: 1) Kosten T, O’Connor P. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786- 95. A good general review of the management of the most common syndromes.
2) Management of moderate and severe alcohol withdrawal syndromes. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016

Answer A. Acamprosate is indicated for ethanol dependence, but only in patients who have become abstinent. Diazepam is not indicated for ethanol dependence but for acute alcohol withdrawal. Metronidazole may interfere with the metabolism of ethanol, resulting in disulfiram-like effects, not indicated for alcohol withdrawal. Patients should try to avoid ethanol ingestion to avoid the risk of undesirable side effects while on Metronidazole. Duloxetine is not indicated to treat alcohol withdrawal. Reference: 1) Doering P, Boothby L. Substance-related disorders: overview and depressants, stimulants, and halluci¬nogens. In: DiPiro J, Talbert R, Yee G, et al., eds. Pharmacotherapy. A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008.
2) Gold Standard, Inc. Acamprosate (Indications/Dosage). https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=2097&sec=monindi&t=0. Accessed May 24, 2016.

Answer C. Surgery, trauma (major trauma or lower-extremity injury), immobility, lower-extremity paresis, cancer (active or occult), cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy), venous compression (tumor, hematoma, arterial abnormality), previous VTE, increasing age, pregnancy and the postpartum period, estrogen-containing oral contraceptives or hormone replacement therapy, selective estrogen receptor modulators, erythropoiesis-stimulating agents, acute medical illness, inflammatory bowel disease, nephrotic syndrome, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, obesity, central venous catheterization, and inherited or acquired thrombophilia. Reference: Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6_suppl):381S.

Answer D. SUP is indicated for patients who have coagulopathy, a requirement for mechanical ventilation for over 48 hours, a history of GI ulceration or bleeding within one year before admission, and in patients with at least two of the following: ICU stay of more than one week, sepsis, use of high-dose corticosteroids (>250 mg of hydrocortisone or the equivalent per day) and occult bleeding lasting six days or more. Reference: ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;56(4):347-379.