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NAPLEX 2024 > 53. Acute + Critical Care > Flashcards

53. Acute + Critical Care Flashcards

1
Q

D5W, NS, and LR are all examples of what type of fluids?

A

Crystalloids

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2
Q

What are some examples of colloid fluids?

A

Albumin (Albutein, AlbuRx)
Others: Dextran, hydroxyethyl starch (Hespan, Hextend)

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3
Q

Which colloid fluid should only be used if other treatments are unavailable d/t boxed warning for morality, renal injury, and coagulopathy (bleeding)?

A

Hydroxyethyl starch

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4
Q

Hyponatremia (Na < ___) is usually not symptomatic until sodium is <____ unless serum level falls rapidly

A

<135
<120

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5
Q

What are some s/sx of hyponatremia

A

Typical result from cerebral edema and increased intracranial pressure, can range
Mild-moderate: HA, confusion, lethargy, gait disturbances
Severe: seizures, coma, respiratory arrest

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6
Q

Explain hypotonic hypervolemic hyponatremia

A

Caused by fluid overload (e.g. cirrhosis, HF, renal failure)
Diuresis with fluid restriction is preferred treatment

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7
Q

Explain hypotonic isovolemic (euvolemic) hyponatremia

A

Can be caused by SIADH
Treatment includes diuresis, restricting fluids, and stopping drugs that can induce SIADH (demeclocycline can be used off-label for SIADH)

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8
Q

Explain hypotonic hypovolemic hyponatremia

A

Caused by diuretics, salt-wasting syndromes, adrenal insufficiency, blood loss or vomiting/diarrhea
Correct any underlying causes and stop intake of hypotonic solutions

Pts with acute hyponatremia, severe symptoms, and/or Na<120 are candidates for hypertonic (3%) NaCl IV

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9
Q

Correcting sodium more rapidly than _____ can cause osmotic demyelination syndrome (ODS) or central pontine myelinolysis, which can cause ____

A

12 mEq/L/24hrs
paralysis, seizures, and death

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10
Q

____ may be used to treat SIADH and hypervolemic hyponatremia but role is still being determined (more expensive than 3% saline and use beyond 30 days with oral product ___ is not recommended)

A

Arginine vasopressin (AVP) receptor antagonists (conivaptan, and tolvaptan)

Tovaptan

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11
Q

PO arginine vasopressin (AVP) ___ is not recommended to use longer than __ days d/t ___

A

tolvaptan
30 days
hepatotoxicity

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12
Q

Boxed warnings for tolvaptan

A

Should be initiated/re-initiated in the hospital with close monitoring
Overly rapid correction of hyponatremia (12mEq/L/24hrs) can lead to ODS (life-threatening)

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13
Q

Warnings for tolvaptan (Samsca)

A

Hepatotoxicity (Avoid > 30 days duration and in liver disease/cirrhosis)

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14
Q

Side effects for tolvaptan (Samsca)

A

Thirst, nausea, dry mouth, polyuria
Others: weakness, hyperglycemia, hypernatremia

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15
Q

Hypernatremia (Na > ____) is a/w _____

A

145 mEq/L
Water deficit and hypertonicity

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16
Q

Hypovolemic hypernatremia is caused by ___

A

dehydration, vomiting, or diarrhea
treated with fluids

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17
Q

Hypervolemic hypernatremia is caused by ___

A

intake of hypertonic fluids and treated with diuresis

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18
Q

Isovolemic (euvolemic) hypernatremia is frequenty cause by ____

A

Diabetes insipidus (DI) which can decrease antidiuretic hormone (ADH)
Treated with desmopressin

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19
Q

Hypokalemia (K<___) is common occurrence in hospitalized patient. In general a drop of 1 mEq/L in K below 3.5mEq/L represents a total body deficit of ___ mEq

A

K<3.5
100-400mEq

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20
Q

Hypokallemia management

A

treating underlying cause (e.g metabolic alkalosis, overdiuresis, meds (such as amphotericin, insulin)), and administering oral or IV potassium

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21
Q

Safe recommendations for administration of IV potassium (usually potassium chloride) through a ___ line include a max infusion rate ___ and max conc of ____
More rapid infusions and higher conc may be warranted in severe or symptomatic hypokalemia

A

Peripheral line
≤10 mEq/hr
10m Eq/100mL

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22
Q

T/F: IV potassium can be fatal if administered undiluted or via IV push

A

True

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23
Q

When hypokalemia is resistant to treatment, ___ should be checked

A

Magnesium - necessary for potassium uptake, should be replaced first

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24
Q

Hypomagnesemia (Mg <___) common causes are ____

A

1.3
chronic alcohol use, diuretics, amphotericin B, vomiting, diarrhea

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25
Q

When serum Mg is <1 with life-threatening symptoms (e.g. ___,____), ___ is recommended

A

seizures, arrhythmias
IV magnesium sulfate

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26
Q

Hypophosphatemia is considered severe and is usually symptomatic when serum PO4 is <___

A

1mg/dL

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27
Q

S/sx of hypophosphatemia

A

muscle weakness and respiratory failure

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28
Q

When PO4 < 1mg/DL, ___ is used for replacement

A

IV phosphorus

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29
Q

Patients with hypophosphatemia often have ___ and ___ that will require correction

A

hypokalemia
hypomagnesemia

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30
Q

Incentive spirometry is a technique used to facilitate ____ in patients with ____

A

lung expansion
atelectasis (i.e. completely or partially collapsed lung with reduced lung volume)

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31
Q

What is IVIG used for

A

Immunodeficiency conditions
Off-label indications (e..g MS, MG, Guillain-Barre syndrome)

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32
Q

Note: IVIG treatment can impair the response to ___

A

vaccination

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33
Q

Patients with ___ and ___ should have slower infusion rate or IVIG

A

renal and CV disease

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34
Q

Storage/Handling for IVIG

A

Do NOT freeze, shake, or heat

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35
Q

Boxed warnings for IVIG

A

Acute renal dysfunction, usually within 7 days (more likely with products stabilized with sucrose – use caution in elderly, renal disease, DM, volume depletion, sepsis, paraproteinemia, or taking nephrotoxic meds
Thrombosis

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36
Q

Side effects of IVIG

A

Infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)

Others: HA, nausea, diarrhea, injection site reaction, renal failure, or blood dyscrasias (rare)

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37
Q

Patients should be asked about past IVIG infusions; __ and __ may be needed

A

slower titration and premedication

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38
Q

____ is a scoring tool used to determine prognosis and estimate ICU mortality risk

A

Acute physiologic assessment and chronic health evaluation II (APACHE II)

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39
Q

How do most vasopressors work?

A

Stimulates alpha receptors > peripheral vasoconstriction (“presses down on vasculature”)&raquo_space; increases systemic vascular resistnace (SVR), which increases BP

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40
Q

Dopamine stimulates diff receptors depending on the dose
Low renal dose: 1-4 mcg/kg/min = ____ agonist
Medium dose: 5-10 mcg/kg/min = ____ agonist
High dose: 10-20 mcg/kg/min = ____ agonist

A

Dopamine-1 agonist
Beta-1 agonist
Alpha-1 agonist

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41
Q

MOA epinephrine (Adrenalin)

A

Alpha-1, Beta-1, Beta-2 agonist

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42
Q

MOA norepinephrine (Levophed)

A

Alpha-1 agonist > beta-1 agonist activity

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43
Q

MOA phenylephrine

A

Alpha-1 agonist

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44
Q

MOA vasopressin (Vasostrict) - aka arginine vasopressin (AVP) and antidiuretic hormone (ADH)

A

Vasopressin receptor agonist
Vasoconstrictor, no inotoropic or chronotropic effects

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45
Q

Boxed warning for dopamine and NE

A

extravasation

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46
Q

All vasopressors are ___ when administered IV; treat with ___

A

vesicants
Treat extravasation with phentolamine

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47
Q

Side effects of vasopressors

A

Arrhythmias, tachycardia (esp dopamine, Epi), necrosis (gargrene), bradycardia (phenylephrine), hyperglycemia (Epi), tachyphylaxis, peripheral and gut ischemia

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48
Q

All vasopressors should be administered via ___ line

A

central IV line

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49
Q

Epinephrine IV push is ___mg/mL (____ ratio strength) while IM injection or compounding IV products is ___ mg/mL(___ ratio strength)

A

0.1mg/mL (1:10,000 ratio strength)
1mg/mL (1:1000 ratio strength)

Note: ratio strength has been removed from labeling per FDA

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50
Q

Extravasation is considered a medical emergency. To reduce risk, vasopressors should be administered via ___. If Vasopressor extravasation occurs, treat with ___

A

central line
Phentolamine (alpha-1 blocker that antagonizes the effects of vasoprsesor)

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51
Q

When vasopressor extravasation occurs, why is phentolamine used?

A

alpha-1 blocker that antagonizes the effects of vasoprsesor

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52
Q

Vasodilators that are administered by continuous IV infusion include ___

A

nitroglycerin and nitroprusside

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53
Q

Monitoring for vasodilators

A

BP (hypotension)

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54
Q

Nitroglycerin is often used when _____ but effectiveness may be limited to 24-48hrs d/t ___

A

MI or uncontrolled HTN
tachyphylaxis (tolerance)

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55
Q

T/F: Both nitroglyceride and nitroprusside are mixed (equal) arterial and venous vasodilator at all doses

A

False - nitroglyceride is dose dependent, nitroprusside is equal at all doses

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56
Q

Which vasodilator has a greater effect on BP: nitrogylcerin vs ntiroprusside

A

Nitroprusside

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57
Q

Which vasodilator should NOT be used in active MI because it can cause blood to be diverted away from diseased coronary arteries (“coronary steal”)

A

Nitroprusside

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58
Q

Metabolism of nitroprusside results in __ and ___ formation, causing toxicity in pts with renal and hepatic insufficiency, respectively

A

Thiocyanate
Cyanide

59
Q

____ can be administered to reduce the risk of thiocyanate toxicity

A

Hydroxocobalamin

60
Q

___ is used for cyanide toxicity

A

Sodium thiosulfate + sodium nitrite (Nithiodote)

61
Q

Nitroglycerin at low doses is a (venous/arterial) vasodilator vs high doses a (venous/arterial) vasodilator

A

Low doses = venous
High doses = arterial

62
Q

Contraindications for nitroglycerin

A

SBP <90
Use with PDE-5i or riociguat

63
Q

Side effects of nitroglycerin

A

HA, tachycardia, tachyphylaxis (within 24-48 hrs of continuous administration), lightheadedness

64
Q

Nitroglycerin packaging notes

A

Requires non-PVC container (eg.. glass, polyolefin); use administration sets (tubing) intended for nitroglycerine

65
Q

Nitroprusside boxed warning

A

Metabolism produces cyanide (use the lowest dose for the shortest duration necessary), excessive hypotension (continuous BP monitoring required), not for direct injection (must be further diluted; D5W preferred)

66
Q

Warnings for nitroprusside (Nipride)

A

icnreased ICP

67
Q

Side effects for nitroprusside (Nipride)

A

HA, tachycardia, thiocyanate/cyanide toxicity (increased risk with renal/hepatic impairment)

68
Q

Nitroprusside packaging notes

A

Require light protection during administration
Use only clear solutions - blue color indicated degradation to cyanide (do NOT use)

69
Q

Effect of inotrops

A

Increases contractility of heart

70
Q

Dobutamine MOA

A

Beta-1 agonist with some beta-2 and alpha-1 agonism
Increases HR and force of myocardial contraction&raquo_space; increases CO

71
Q

Milrinone MOA

A

Selective PDE-3i in cardiac and vascular tissue
Produces inotropic effects with sig vasodilation

72
Q

Dobutamine may turn slightly pink d/t oxidation. Can it still be used?

A

Yes, potency is not lost

73
Q

Shock is a medical emergency common in ICU patients. It is characterized by ____

A

hypoperfusion, usually in the setting of hypotension (SBP <90 or MAP <70)

74
Q

What are the 4 types of shock?

A

Hypovolemic (e.g. hemorrhagic)
Distributive (e.g septic, anaphylactic)
Cardiogenic (e.g. post-MI)
Obstructive (e.g. massive PE)

75
Q

What is recommended as first-line for hypovolemic shock?

A

Fluid resuscitation with crystalloids if not caused by hemorrhage
Blood products should be administered if caused by hemorrhage

76
Q

____ will not be effective in hypovolemic shock unless intravascular volume is adequate

A

Vasopressors

77
Q

What may be indicated if hypovolemic shock pt does not respond to first line therapy

A

Vasopressors

78
Q

Distributive shock is characterized by ___

A

low SVR and initially high CO followed by low or normal CO
Sepsis is an example

79
Q

Sepsis is defined as

A

life-threatening organ dysfunction caused by dysregulated host response to infection

80
Q

MAP formula

A

[(2*DBP)+SBP]/3 OR
2/3 DBP + 1/3 SBP

81
Q

General principles for treating septic shock

A

Target MAP ≥65mmHg
Fill the tank - optimize preload with IV crystalloids (LR preferred)
Squeeze the pipe and kick the pump - Alpha-1 agonist to increase SVR // beta-1 agonist to increase myocardial contractility and CO

82
Q

2 common causes of ICU infections

A

Mechanical ventilation (increase time on ventilator = increased risk of infection, including lung)
Indwelling urinary catheter (increased time with Foley catheter = increased risk of bladder infection)

83
Q

Septic shock is sepsis with ____

A

persistent hypotension requiring vasopressor to maintain MAP ≥65 and serum lactate level ≥2 mEq/L despite adequate fluid resuscitation

84
Q

____ is considered the vasopressor of choice in septic shock

A

Norepinephrine

85
Q

Septic shock interventions include early administration of ___ and ___

A

Broad spectrum abx and fluid resuscitation with IV crystalloids

86
Q

What is acute decompensated HF (ADHF)?

A

Worsening HF symptoms (sudden weight gain, an inability to life flat w/o becoming SOB, decreasing functionality, increasing SOB and fatigue)

87
Q

When ___ and ___ are also present with acute decompensated HF, it is called cardiogenic shock

A

Hypotension
Hypoperfusion

88
Q

Some ADHF pts require invasive monitoring with a catheter that is called ___

A

Swan-Ganz or pulmonary artery catheter

89
Q

Why is a Swan-Ganz (or pulmonary artery catheter) used?

A

Provides hemodynamic measurements of congestion (pulmonary capillary wedge pressure or PCWP), hypoperfusion (cardiac output) and other measurements (e.g. SVR, CVP) useful to guiding treatment

90
Q

Treatment of ADHF generally consists of _____ used in various combinations depending on patient symptoms

A

diuretics, inotropes, and vasodilators

91
Q

____ should only be stopped in an ADHF episode if hypotension or hypoperfusion is present

A

Beta-blockers

92
Q

ADHF pt is volume overloaded(edema, jugular venous distention (JVR), and/or ascites). What are the treatment options?

A

Loop diuretics
Vasodilators can be added (NTG, nitroprusside)

93
Q

ADHF pt is hypoperfused (decreased renal fxn, altered mental status, and/or cool extremities). What are the treatment options?

A

Inotropes (dobutamine, milrinone)
If pt becomes hypotensive, consider vasopressor (dopamine, NE, phenylephrine)

94
Q

ADHF pt is both volume overloaded and hypoperfused. What are the treatment options?

A

A combination of loop diuretics, vasodilators, inotropes

95
Q

Why should vasodilators be avoided when treating ADHF?

A

Can decrease BP and worsen hypoperfusion

96
Q

The vasodilatory and inotropic properties of ___ and ___ make them uniquely suited to treat ADHF in pts with adequate BP and symptoms of both congestion and hypoperfusion.
If BP is inadequate, inotropes will often be used in combination with ____

A

dobutamine and milrinone
Vasopressors

97
Q

ICU Pain first line options

A

IV opioids (e.g. morphine, hydromorphone, fentanyl)

98
Q

Agitation in ICU is managed with ____

A

benzodiazepines (lorazepam, midazolam) and/or non-BZD hypnotics (propofol, dexmedetomidine)

99
Q

____ are preferred for sedation and a/w improved ICU outcomes, shorter mechanical ventilation duration and decrease length of stay

A

Non-BZD (propofol, dexmedetomidine)

100
Q

____ is the only sedative approved for use in intubated and non-intubated patients

A

Dexmedetomidine (Precedex)

101
Q

_____ have an important role in sedation in the presence of seizures or alcohol/BZD withdrawal

A

BZD

102
Q

Sedatives are used with validated sedation scales that allow for titration to light sedation (preferred) or deep sedation. What are some common sedation scales used?

A

Richmond Agitation Sedation Scale (RASS)
Ramsay Agitation scale (RAS)
Riker Sedation-Agitation Scale (SAS)

103
Q

How often are “sedation vacations” used to asses readiness to wean off/stop sedative?

A

Daily

104
Q

Providing sedation with ____ may reduce the incidence of delirium and/or shorten duration in pts who already have it

A

Non-BZD

105
Q

Atypical antipsychotics, primarily ___, which is mildly sedating and has little risk for movement disorders, can be useful in delirium

A

Quetiapine

106
Q

MOA dexmedetomidine (Precedex)

A

Alpha-2 adrenergic agonist

107
Q

Side effects of dexmedetomidine (Precedex)

A

hypo/hypertension, bradycardia, dry mouth, nausea, constipation

108
Q

T/F: dexmedetomidine (Precedex) needs to be refrigerated

A

False

109
Q

Duration of infusion of dexmedetomidine should not exceed ___ per FDA labeling

A

24 hrs

110
Q

Contraindiications for propofol (Diprivan)

A

Hypersenstivity to egg or soy (or egg/soy products)

111
Q

Side effects of propofol (Diprivan)

A

Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare, but can be fatal)
Others: myoclonus, pancreatitis, pain on injection (particularly peripheral vein), QT prolongation

112
Q

If pt is on propofol for longer than 2 days, make sure you monitor ____

A

triglycerides

113
Q

When using propofol, use strict aseptic technique d/t potential of bacterial growth; discard vial and tubing within ____ of use

A

12 hrs

114
Q

What type of emulsion is propofol?

A

Oil in water emulsion (opaque, white solution)
Provides 1.1 kcal/mL

115
Q

Lorazepam TDD as low as ____ can cause propylene glycol toxicity (acute renal failure and metabolic acidosis)

A

1 mg/kg/day

116
Q

Contraindications for midazolam (Versed, Nayzilam)

A

Do NOT use with potent CYP3A4 inhibitors
Intrathecal or epidural administration (benzyl alcohol in formulation) , acute narrow-angle glaucoma

117
Q

What is the concern of using midazolam in obese patients and renal impairment

A

Accumulation
Obese pts - highly lipophilic
Renal impairment - active metabolite

118
Q

Monitoring for etomidate

A

S/sx adrenal insufficiency (hypotension, hyperkalemia)

119
Q

Warnings for ketamine (Ketalar)

A

Emergence reactions (vivid dreams, hallucinations, delirium) CSF pressure elevation, respiratory depression/apnea, dependence/tolerance

120
Q

Risk factors for development of stress ulcers

A

Mechanical ventilation > 48h
Coagulopathy
Others: sepsis, traumatic brain injury, major burns, acute renal failure, high dose systemic steroids

121
Q

What meds are recommended to prevent stress-related mucosal damage in pts with risk factors for stress ulcers?

A

PPIs and H2RAs

122
Q

What med used for stress ulcers can cause thrombocytopenia and mental status changes in elderly or renal impairment?

A

H2RAs

123
Q

Which med used for stress ulcers is a/w increased risk of GI infections (C.diff), fractures, and nosocomial pneumonia?

A

PPIs

124
Q

What formulation of anesthetics can cause malignant hyperthermia?

A

Inhaled anesthetics

125
Q

____, commonly used anesthetic for epidurals, can be fatal if administered ____

A

Bupivacaine
Intravenously

126
Q

Why is lidocaine/epinephrine combination products used for some local procedures?

A

Epinephrine is added for vasoconstriction which keeps lidocaine localized to the area where numbing is needed
Note: deaths have occurred d/t mix ups with Epi products and lidocaine/epinephrine products

127
Q

Which anesthetic should NOT be given by dual routes of administration (e.g. IV and topical)

A

Lidocaine

128
Q

What are some commonly used local anesthetics for?

A

Lidocaine (Xylocaine)
Others: benzocaine, liposomal bupivacaine (Exparel)

129
Q

What are some commonly used inhaled anesthetics?

A

Desflurane (Suprane), sevoflurane (Ultane)
Others: isoflurane (Forane), nitrous oxide

130
Q

What are some commonly used injectable anesthetics?

A

Bupivacaine (Marcaine, Sensorcaine)
Lidocaine (Xylocaine)
Ropivacaine (Naropin)

131
Q

Why are neuromuscular blocking agents (NMBA) sometimes used in surgery?

A

Facilitate mechanical ventilation or treat muscle spasms (tetany)

132
Q

Why do patients on neuromuscular blocking agents (NMBA) have to be mechanically ventilated?

A

NMBAs cause paralysis of skeletal muscle, even those needed for respiration (e.g. diaphragm)

133
Q

There are 2 types of NMBAs: depolarizing and non-depolarizing. ____ is the only available depolarizing agent

A

Succhinylcholine

134
Q

How is succhinylcholine similar to ACh?

A

Resembles ACh, binds to and activates the ACh receptors and desensitizes them

135
Q

Succinylcholine is typically reserved for ___ and not used for continuous neuromuscular blockade

A

Intubation

136
Q

Which neuromuscular blocking agent is a/w malignant hyperthermia particularly when used with inhaled anesthetics?

A

Succinylcholine

137
Q

How do non-depolarizing NMBAs work?

A

Bind to ACh receptor, blocking actions of endogenous ACh.

138
Q

What extra care must be taken for pts who are receiving NMBAs?

A

Protect the skin, lubricate eyes, and suction airway frequently (these pts are unable to breathe, move, blink, cough)

139
Q

____ is an anticholinergic drug that can be used to reduce secretions in pts using NMBAs

A

Glycopyrrolate

140
Q

What are some examples of meds that can enhance neuromuscular blocking activities of NMBAs (leading to toxicity)

A

Aminoglycosides, polymyxins
Others: CCBs, cyclosporine, inhaled anesthetics, lithium, quinidine, vancomycin

141
Q

Side effects of all non-depolarizing NMBAs

A

flushing, bradycardia, hypotension, tachyphylaxis, acute quadriplegic myopathy syndrome (long-term use)

142
Q

Which non-depolarizing NMBA is metabolized by Hofmann elimination (independent of renal and hepatic function)?

A

Cisatracurium (Nimbex)

143
Q

Which non-depolarizing NMBA is long-acting and has the risk of accumulation in renal/hepatic dysfunction?

A

Pancuronium

NAPLEX 2024 (74 decks)

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