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A collet is typically used to:

Explain why enzymes do not function properly in low pH or extremely high temperatures. What happens?

Before powering the machine off, you should:

What initial blood pressure goal do you recommend for PJ?

Throughout the day, PJ is still having trouble syncing with the ventilator, even with control of pain and sedation within goals with as needed boluses of fentanyl (no matter what you chose in question #12).  The team wants to paralyze PJ, to get him to synchronize with the ventilator and improve oxygenation.  The team orders a vecuronium infusion.  What is your response to the team’s choice of paralytic?

Nephrology decides to start continuous renal replacement therapy.  Would you expect the following medications to be cleared by CRRT? (0.5 points each)  –> A medication with a volume of distribution (Vd) = 0.3 L/kg?

PJ is a 53-year-old male (92 kg, BMI 32) with a history of Duchenne muscular dystrophy, diabetes mellitus, and hypertension who resides in a skilled nursing facility.  He is brought to the hospital with confusion, shortness of breath, cough, and increased sputum production consistent with pneumonia.  One month prior to presentation he received a 10 day course of ciprofloxacin for a suspected urinary tract infection.  Vitals/labs on arrival include BP 71/48 (MAP 58), HR 127 beats/min, SCr 4.9 (baseline ~0.6), estimated CrCl = 21 ml/min, urine output 78 ml in last 4 hours, K = 5 (normal range = 3.5-5.1), RR 32 breaths/min, PaO2 = 54 on Room Air (PaO2/FiO2 ratio = 257), Glasgow Coma Scale (GCS) = 9, T 39.0 C, WBC 13.8 (normal range = 3.8-10.5), plt 350 (normal range = 160-370), ALT = 182 (normal range = 13-59), AST = 121 (normal range = 0-40), bilirubin = 1.4 (normal range = 0-1.4).    Use Case 1 for questions 1-36

DF is a 32-year-old female (100 kg) who is brought into the emergency department after slipping on her icy driveway and hitting her head.  She is currently confused, only answering “yes” or “no” to questions and complaining of a severe headache.  She is known to be dialysis-dependent and has a mechanical valve for which she is on warfarin.  Her INR on admit is 2.5, and her blood pressure is 216/128 mmHg.  Her pregnancy test is currently pending.  A head CT shows a large subdural hematoma and a smaller subarachnoid hemorrhage, with brain swelling.  A peripheral line is placed for medication administration.    Use Case 2 for questions 37-47

PJ is syncing much better with the ventilator after the paralytic is started.  Six hours after the paralytic was started, the team asks the nurse to measure a train-of-four, which is 0/4.  What do you recommend?

This 2024 Society of Critical Care Medicine Guidelines on Glycemic control recommends initiating insulin therapy when blood glucose is: