With respect to iatrogenic drug withdrawal (IDW) of medicines prescribed as part of intensive care management:
a) Explain why critically ill patients are vulnerable to IDW (4 marks)
b) Outline the clinical presentation (2 marks)
c) Outline the management and prevention of IDW (4 marks)
Syllabus topic/section: 2.1.21 Applied Pharmacology in Intensive care
Discussion:
The responses to this question varied. Those candidates who could recognise and describe IDW with regards to ICU prescribed drugs (eg opioids and benzodiazepines) generally scored at or above the minimum standard, with those able to describe this in-depth scoring more highly. Part A required both patient and drug factors to be addressed and those candidates who could do so scored well. The candidates who provided a below standard answer did so mainly because they did not follow the directions of the stem. Medications prescribed as part of intensive care management are not drugs of chronic disease therapy or withdrawal states from drugs of abuse. Answers concentrating on these drugs did not gain marks.
Less successful responses included those which focused on pre-ICU medications being withheld or discontinued, or withdrawal/intoxication states resulting from pre-ICU drugs of abuse. This was not what the question was asking, and candidates are reminded to read the question carefully. Answers that were overly narrow in scope or else did not focus on the correct definitions also did not score well. Part B was generally answered to a minimum standard, but few candidates were able to expand beyond opioids and benzodiazepines. Also, some candidates listed a variety of potential withdrawal side effects without reference to the culprit medications.
In Part C, the management was often poorly structured with some relevant points but a lack of coherent structure and detail.
The rubric is provided to aid the candidate's future study.
Rubric
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Below standard |
At standard |
Above standard |
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a) Explain why critically ill patients are vulnerable to IDW (4 marks) |
Poorly structured answer Nil or very superficial mention of patient factors or drug factors including dose/duration AND/OR Opioids and benzo not specifically mentioned Note: Question is about ICU prescribed drugs, so candidates should not receive additional marks for discussion about omission of chronic outpatient medication 0-1.5 marks |
Both patient and drug specific factors required Patient factors
Drug factors
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At standard PLUS Patient
Drugs
medication |
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b) Outline the clinical presentation of IDW (2 marks) |
Failure to describe clinical signs consistent with opioid or benzo withdrawal OR Signs appropriate, but only physical (CVS/GI) OR psychological (CNS) described |
Discussion regarding delayed presentation, lack of specific signs and that the condition mimics other conditions (sepsis, delirium, GI pathology) Opioid and/or benzos should be described as a minimum Multiple (>1) organ system effects correctly described. |
at standard PLUS Description extends beyond opioid and benzo (higher marks for depth AND breadth of pharmacopeia described) And/or Relation to drug dose, pharmacology and withdrawal rate discussed in detail |
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Consider above standard if some minor at standard omissions but provides detailed description of non-opioid/benzo withdrawal |
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0 - 0.5 marks |
1 mark |
1.5 - 2.0 marks |
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c) |
Poorly structured answer |
Answers should cover the following domains |
at standard PLUS |
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Outline the management and prevention of IDW (4 marks) |
Incorrect or superficial answers Fails to mention more than one of the 4 domains in the ‘at standard’ column |
description of key drugs prescribed to treat or prevent IDW (dexmed etc)Use discretion for answers which omit or only superficially touch onone of the above domains but otherwise demonstrate an excellent overall plan |
Detailed description in each of the four domains or covers the content without specific headings Good articulation of a proactive prevention (weaning) and treatment plan with some description of drugs used. Use discretion for answers which only superficially cover one of the domains but otherwise demonstrate an excellent overall plan |
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0-1.5 marks |
2.0-2.5 marks |
3.0-4.0 marks |