22. Critical Care & Fluids/Electrolytes Flashcards
A patient has been receiving 4 days worth of propofol for sedation post-traumatic brain injury. Which of the following statements regarding propofol are correct? (Select ALL that apply.)
A. Hypotension, apnea and elevated triglycerides are likely side effects.
B. This patient may be at risk for developing infections.
C. This medication can cause orange/red urine in rare cases.
D. This agent is generally shorter-acting than lorazepam.
E. Propofol contains significant calories that must be account for in the daily nutrition plan for the patient.
A, B, D, E. Propofol comes as an oil-in-water emulsion that is administered as a continuous infusion for ICU sedation. This formulation can lead to an increased risk of infections and elevated triglycerides that is dose and duration dependent. Use strict aseptic technique when administering. Green urine/hair/nails has been seen in some patients on propofol.
A patient in septic shock is unresponsive to repeated doses of epinephrine and his blood pressure continues to decline. The decision is made to initiate an intravenous vasopressin drip. What is the correct receptor pharmacology that explains the utility of vasopressin in the maintenance of blood pressure?
A. Alpha-1 agonist
B. Beta-1 agonist
C. Vasopressin agonist
D. Vasopressin antagonist
E. Dopamine-1 agonist
C. Vasopressin acts on V1a receptors to exert its vasopressor effect. It is also an agonist at V2 receptors which mediates its aquaresis effect.
A patient arrives at the emergency department after a severe MVA. The patient’s blood pressure is low and he is in shock. The physician wants to start fluid resuscitation with a colloid on this patient immediately. Which of the following agents are colloids? (Select ALL that apply.)
A. Normal saline
B. Hydroxyethyl starch
C. Lactated Ringer’s
D. Dextran
E. Albumin
B, D, E. Fluid replacement therapy generally consists of crystalloids and/or colloids. Albumin, Hespan, and dextran are colloids.
A patient in the ICU with shock is receiving a norepinephrine infusion. What is the purpose of using norepinephrine in this setting?
A. To decrease cardiac output, increase blood flow to vital organs, and increase blood pressure
B. To increase cardiac output, increase blood flow to vital organs, and increase blood pressure
C. To increase cardiac output, decrease blood flow to vital organs, and increase blood pressure
D. To increase cardiac output, increase blood flow to vital organs, and decrease blood pressure
E. To vasodilate in the kidney for nephroprotection, and decrease blood pressure
B. Vasopressors work via vasoconstriction to increase SVR and blood pressure.
A patient is admitted with significant hyponatremia (Na = 125). The provider would like to use tolvaptan. Which of the following statements is correct?
A. Tolvaptan is available IV only.
B. Tolvaptan is a first-line agent for treatment of hyponatremia.
C. Sodium should be corrected at a rate of 12 mEq/hr while on tolvaptan.
D. The brand name for tolvaptan is Vaprisol.
E. Tolvaptan use should be limited to 30 days due to potential for hepatotoxicity.
E. Tolvaptan (Samsca) is an oral vasopressin antagonist. It should only be used in refractory cases and close monitoring is required, particularly to avoid raising the Na by more than 12 mEq/L/24h.
A patient is in the OR and has received succinylcholine for intubation and is currently receiving inhaled isoflurane (an inhaled anesthetic) during surgery. The rare, but serious side effect this patient is potentially at risk for is:
A. Neuroleptic malignant syndrome
B. Sundowning effect
C. Serotonin syndrome
D. Malignant hyperthermia
E. Acute quadriplegic myopathy syndrome
D. Malignant hyperthermia can be seen with the use of inhaled anesthetics, particularly when combined with succinylcholine.
A patient is receiving vecuronium for paralysis. Which of the following medications can potentiate the actions of vecuronium?
A. Tricyclic antidepressants
B. Angiotensin converting enzyme inhibitors
C. Proton pump inhibitors
D. Aminoglycosides
E. Azole antifungals
D. Aminoglycosides can potentiate the effect of NMBAs. If used together, close monitoring for respiratory depression is necessary.
A patient picks up a prescription for an Epipen for her son. Which of the following ratio strengths is used for epinephrine given by intramuscular administration?
A. 1:500
B. 1:1,000
C. 1:10,000
D. 1:100,000
E. 1:1,000,000
B. Epinephrine [1:1,000] is used in epinephrine products designed for intramuscular or subcutaneous administration.
IV route Epinephrine [1:10,000]. More dilute than IM.
A patient with acute decompensated heart failure is receiving milrinone. Which of the statements concerning milrinone are correct? (Select ALL that apply.)
A. Milrinone is a positive inotrope and increases contractility in the heart.
B. Milrinone is an alpha-2 agonist.
C. Milrinone is a vasodilator.
D. Milrinone is administered IV only.
E. Monitor BP, HR, renal function and ECG (for arrhythmias) when using this agent.
A, C, D, E. Milrinone is a phosphodiesterase inhibitor. Milrinone requires dose adjustment in renal dysfunction.
A patient with end-stage alcoholic cirrhosis is admitted to the medical floor. His serum sodium level is 122 mEq/L. On physical exam he has ascites and peripheral edema, but only mild shortness of breath. What is the preferred treatment for this patient’s hyponatremia?
A. Sodium chloride tablets by mouth – start now.
B. 0.9% NaCl – start when serum sodium level drops below 120 mEq/L.
C. Diuresis and fluid restriction – start now.
D. Desmopressin – start when serum sodium drops below 115 mEq/L.
E. Lactated Ringer’s – start now.
C. Hypervolemic hyponatremia is common in patients with cirrhosis, heart failure, and renal failure. Administering fluids to these patients will often worsen the hyponatremia.
A patient’s norepinephrine intravenous line extravasated into the surrounding tissue. The nurse quickly starts to give phentolamine to reverse any skin necrosis. What is the mechanism of action of phentolamine?
A. Alpha-adrenergic antagonist
B. Alpha-adrenergic agonist
C. Beta-adrenergic antagonist
D. Beta-adrenergic agonist
E. Calcium channel antagonist
A. Phentolamine is an alpha-adrenergic antagonist that antagonizes the effects of vesicants such as vasopressors.
A pharmacist is preparing an IVIG infusion. Which of the following statements is incorrect?
A. If the patient experiences side effects such as nausea or a drop in blood pressure during the infusion, slowing the infusion rate may be helpful.
B. IVIG may come already in solution, or it may come as a powder that is reconstituted with diluent.
C. The IVIG dose is based on the Ideal Body Weight (IBW).
D. If particles are present, the pharmacist should shake well to dissolve the particles prior to the infusion.
E. Certain patients respond to one IVIG brand better than another.
D. Use the IBW to calculate the dose. Do not shake IVIG preparations; this will inactivate the antibodies.
Other drugs that should not be agitated include: alteplase, immune globulins, insulins, rasburicase, zoster vaccine. Quinupristin/dalfopristin (Synercid), etanercept (Enbrel) vials are swirled when reconstituting, which makes foam; do not shake. Wait for foam to dissolve.
A pharmacist receives an order for Diprivan. Which of the following is an appropriate generic substitution for Diprivan?
A. Propofol
B. Diltiazem
C. Oxycodone
D. Lorazepam
E. Propantheline
A. The generic name of Diprivan is propofol.
A physician wishes to use morphine in a patient with a creatinine clearance of 20 mL/minute. The patient is in severe pain and requires analgesia. Choose the correct statement/s: (Select ALL that apply.)
A. It would be preferable to use MS Contin, crushed and placed into the g-tube
B. Morphine has an active metabolite that can accumulate with renal impairment.
C. Morphine cannot be used with this degree of renal impairment.
D. Meperidine would be a better choice in this patient.
E. The patient will be at an increased risk of respiratory depression versus a patient with normal renal function.
B, E. Morphine is commonly given IV, as well as IM and orally. If a patient is receiving oral long-acting formulations, do not crush.
A young man with immune thrombocytopenia recently had transient intravascular hemolysis during intravenous gamma globulin treatment. The hemolysis was mediated by anti-A antibody present in the gamma globulin treatment. What signs and symptoms could indicate hemolysis? (Select ALL that apply.)
A. Negative Direct Coombs test
B. Blood in the stool
C. Positive Direct Coombs test
D. Blood in the urine
E. Positive ANA test
C, D. Blood in the urine could indicate internal bleeding, while blood in the stool would indicate bleeding in the GI tract (or colon cancer or hemorrhoids). The Direct Coombs test is used to test for hemolytic anemia. It is important in pharmacy as certain drugs can cause hemolysis (notably cephalosporins, sulfonamides, methyldopa and others).
An ICU patient is receiving dexmedetomidine for sedation. Which of the following statements regarding dexmedetomidine is incorrect:
A. The duration of the infusion should not exceed 72 hours.
B. This agent has a very low risk of causing respiratory depression.
C. Patients are arousable and alert upon stimulation when using this agent.
D. The BP and HR must be monitored.
E. Dexmedetomidine can cause significant blood pressure changes upon initiation of the infusion.
A. The duration of infusion should not exceed 24 hours. Dexmedetomidine causes transient hypertension when the infusion is started, and this may require an initial dose reduction. With continued use, monitor for hypotension, bradycardia, and dry mouth (in addition to BP, HR and sedation).
An ICU patient with severe renal impairment requires a neuromuscular blocking agent (NMBA) in order to receive mechanical ventilation. Which of the following statements are correct? (Select ALL that apply.)
A. The medical staff must ensure that the patient is adequately sedated prior to the use of the NMBA.
B. The medical staff must ensure that the patient is receiving appropriate analgesia prior to the use of the NMBA.
C. Succinylcholine binds to the GABA receptor, resulting in activation.
D. ICU sedative agents are monitored via a nerve stimulator.
E. Patients must be mechanically ventilated prior to receiving a NMBA or they will suffocate; they should also be administered eye lubricant.
A, B, E. Succinylcholine binds to the acetylcholine receptor, resulting in desensitization. Succinylcholine is the only available depolarizing agent; the others are non-depolarizing agents. Paralytics (not sedatives) are monitored with a nerve stimulator (train-of-four).
Ana has recently been admitted to the intensive care unit after an acute asthma exacerbation. She has been intubated and requires adequate sedation. She has normal renal and liver function. The medical team wants to use the shortest acting benzodiazepine available intravenously for sedation. Which of the following medications would be the best recommendation for Ana?
A. Temazepam
B. Lorazepam
C. Diazepam
D. Clonazepam
E. Midazolam
E. Midazolam is a short acting benzodiazepine that is available intravenously. Triazolam and clonazepam do not come in an intravenous formulation. Midazolam does not accumulate when used for a short period of time in patients with normal renal and liver function.
Choose the correct statement concerning neuromuscular blocking agents:
A. Patients do not need to be on mechanical ventilation to receive a neuromuscular blocker.
B. Patients should receive sedation and analgesia prior to the use of neuromuscular blockers.
C. No monitoring is needed when using neuromuscular blockers.
D. The Institute for Safe Medication Practices (ISMP) does not include neuromuscular blockers as medications that can cause significant harm, but they do include opioids.
E. They should be used in the majority of the patients in the ICU.
B. Neuromuscular blockers paralyze muscles, including the muscles responsible for breathing. Patients must have a secure airway (such as mechanical ventilation) and must have adequate sedation and analgesia before the initiation of a paralytic. These medications can cause significant patient harm if used inappropriately.
Hemostatic agents prevent blood loss. Which of the following statements concerning hemostatic agents are correct? (Select ALL that apply.)
A. Newer hemostatic agents are reducing the need for transfusions.
B. The most common adverse events from the use of hemostatic agents are a drop in hemoglobin and anemia.
C. Patients receiving hemostatic agents are at low risk of clotting.
D. Recombinant thrombin (Recothrom) is not associated with the risk of disease transmission (such as Creutzfeld-Jakob disease) and is less immunogenic than previous thrombin formulations.
E. Tranexamic acid is a hemostatic agent used for both heavy menstrual bleeding and hemophilia-associated bleeding; it comes as both an oral and injectable.
A, D, E. The most common adverse events from the use of hemostatic agents are hypersensitivity and thrombosis. Patients receiving thrombin products are at risk of thrombosis (clotting). Recothrom is a topical hemostatic agent.
JH is a 55 year old male who will be receiving his third IVIG treatment for autoimmune encephalopathy. He reports that he had been receiving steroid therapy for many years, but was changed to IVIG the previous fall when the symptoms worsened. He has presented to the infusion room. The pharmacist cannot locate the referring doctor’s paperwork and will attempt to conduct a pre-screening prior to the treatment. Which of the following screening questions should the pharmacist ask JH? (Select ALL that apply.)
A. Did you use any medications prior to the treatment to help lessen the side effects?
B. What is the name of the IVIG medication received previously, and are you aware of the dose?
C. Is anyone in the house presently immune-compromised (such as cancer or HIV-infected persons?)
D. Are there any small infants in the house?
E. Did you develop any reactions to the medication, either during the infusion, or afterwards?
A, B, E. The two questions not chosen would apply for certain immunizations, but are not necessary prior to an IVIG infusion.
LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
The ICU staff will monitor LS for delirium during her stay. Which statement is correct regarding ICU delirium?
A. Delirium is rare in ventilated ICU patients.
B. Haloperidol is recommended for prophylaxis and treatment of ICU delirium.
C. Providing sedation with Ativan as opposed to Precedex may reduce the incidence of delirium.
D. Seroquel may increase duration of delirium.
E. Early mobilization and environmental control are recommended to prevent delirium.
E. There is little evidence to support use of haloperidol. Quetiapine, which is mildly sedating and has little risk for movement disorders can be useful. Providing sedation with dexmedetomidine as opposed to benzodiazepines may decrease incidence of delirium and shorten duration in patients who already have it.
LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
LS requires fluid resuscitation. Which of the following is the best recommendation?
A. Hespan
B. Dextrose 5%
C. NaCl 0.9%
D. Albumin 25%
E. Dextran 70
C. Crystalloids should be used for fluid resuscitation, when possible. They are less expensive and associated with fewer adverse reactions than colloids. D5W (5% dextrose) should be avoided in this diabetic patient with increased blood glucose. Though the patient’s serum albumin is low, IV albumin is not effective at increasing serum albumin and should not be used for this purpose.
LS is a 84 y/o Hispanic female admitted directly to the medical ICU on 12/15/14 because of low blood pressure during evaluation in the ER. She was transferred from her nursing home for confusion, disorientation, and decreased oral intake. Her past medical history includes: hypertension, diabetes, and dementia.
Allergies: NKDA
Medications:
Norvasc 10 mg PO daily
Lasix 40 mg PO daily (started 12/1/14 for lower extremity swelling)
Exelon patch 9.5 mg/24 hr
Namenda 5 mg BID
Lantus 10 units at HS
Novolin R sliding scale PRN (scale not documented on transfer records)
Calcium supplement (dose not documented on transfer records)
Vitals:
Height: 5’2” Weight: 136 pounds
BP: 85/62 mmHg HR: 101 BPM RR: 14 BPM Temp: 101.8°F Pain: 3/10
Labs from Nursing Home on 10/2/14:
Na (mEq/L) = 138 (135 – 145)
K (mEq/L) = 3.6 (3.5 – 5)
Cl (mEq/L) = 100 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 20 (7 – 20)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
Glucose (mg/dL) = 187 (100 – 125)
Ca (mg/dL) = 8.7 (8.5 – 10.5)
Mg (mEq/L) = 1.3 (1.3 – 2.1)
PO4 (mg/dL) = 2.2 (2.3 – 4.7)
A1C (%) = 8.9
Albumin (g/dL) = 3.6 (3.5 – 5)
Labs on Hospital Admission 12/15/14:
Na (mEq/L) = 135 (135 – 145)
K (mEq/L) = 3.1 (3.5 – 5)
Cl (mEq/L) = 99 (95 – 103)
HCO3 (mEq/L) = 27 (24 – 30)
BUN (mg/dL) = 42 (7 – 20)
SCr (mg/dL) = 1.4 (0.6 – 1.3)
Glucose (mg/dL) = 169 (100 – 125)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Mg (mEq/L) = 1.0 (1.3 – 2.1)
PO4 (mg/dL) = 1.9 (2.3 – 4.7)
A1C (%) = 8.8
Albumin (g/dL) = 2.9 (3.5 – 5)
Tests:
EKG: sinus tachycardia, non-specific T wave changes, and prolonged QT interval
Urinalysis and blood cultures are ordered and results are pending.
Question:
An order is placed for LS to receive 40 mEq of KCl IV with continuous EKG monitoring. The hospital stocks premixed bags of 20 mEq KCl/100 mL 0.9% NaCl. The pharmacist modifies the order to read “20 mEq KCl/100 mL 0.9% NaCl x 2 doses.” Over what period of time should each 20 mEq KCl bag be infused?
A. 1-2 minutes
B. 30 minutes
C. 2 hours
D. 6 hours
E. 12 hours
C. Potassium replacement should occur via the oral route when possible. IV replacement may be warranted in cases like this, where EKG changes may be a result of the electrolyte abnormality. IV potassium should be administered no faster than 10-20 mEq/hour with intermittent dosing. Serum potassium can be rechecked between doses when ordered like this to avoid hyperkalemia.
