Acute Care Flashcards
Crystalloids
-D5W (free water)
-NS (volume resuscitation)
-LR (volume resuscitation)
Colloids
-large molecules that remain in the intravascular space and increase oncotic pressure
-albumin (edema)
hypotonic hypervolemic hyponatreia
-caused by fluid overload
-diuresis with fluid restriction
hypotonic isovolemic hyponatremia
-caused by SIADH
-diuresis, restricting fluids, and stopping drugs that can cause SIADH
hypotonic hypovolemic hyponatremia
-salt wasting, diuretics, adrenal insufficiency, blood loss, or vomiting/diarrhea
-stop hypotonic solutions
-severe symptoms/Na <120 can use hypertonic (3%) sodium
correcting hyponatremia
-should not be correct too fast (4-8 mEq/L/24h)
-correcting more rapidly than 12 mEq/L/24h can cause osmotic demyelination syndrome or central pontine myelinolysis which can cause paralysis, seizures, and death
Conivaptan and Tolvaptan
can be used to treat SIADH and hypervolemic hyponatremia
Hypernatremia
-associated with a water deficit and hypertonicity
-hypovolemic: loss of fluids > replace with fluids
-hypervolemic: hypertonic fluids > diuresis
-isovolemic: DI > desmopressin
KCl
-peripheral line: max infusion rate < 10 mEq/hr and max concentration of 10 mEq/100 mL
-higher rates/concentration require a central line and cardiac monitoring
-DO NOT IV PUSH
Resistant hypokalemia
-serum magnesium should be checked as magnesium is necessary for potassium uptake
-magnesium should be replaced first when both are present
hypomagnesium
-IV, IM magnesium sulfate
-magnesium oxide (PO)
hypophosphotemia
< 1 mg/dL treat with IV phosphorous
IVIG (Gammagard, Gamunex-C, Octagam, Privigen)
-slower infusion rate in renal and CV disease
-do not freeze, shake or heat
-Boxed Warnings: acute renal dysfunction, thrombosis
-infusion reaction (facial flushing), chest tightness, fever, chills, hypotension
Vasopressors
-most work by stimulating alpha receptors
-causes peripheral vasoconstriction and increasing systemic vascular resistance which in turn increases BP, HR, CO
-all are vesicants when administered IV –> treat extravasation with phentolamine
-arrhythmias, tachycardia, necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)
-all should be administered via central line
Dopamine
-Low (renal) dose: 1-4 mcg/kg/min works at dopamine-1-agonist receptors
-medium dose: 5-10 mcg/kg/min works at beta-1-agonist receptors
-high dose: 10-20 mcg/kg/min works at alpha-1-agonist
epinephrine (Adrenaline)
-alpha-1, beta-1, beta-2 agonist
-IV push is 0.1 mg/mL (1:10,000 ratio strength)
-IM/compounding is 1 mg/mL (1:1,000)
Norepinephrine (Levophed)
alpha-1 agonist activity is > beta-1-agonist
phenylephrine (neosynephrine)
alpha-1 agonist
Vasopressin (Vasostrict)
vasopressin receptor agonist
Nitroprusside (Nipride)
-mixed (equal) arterial and venous vasodilator
-produces cyanide, excessive hypotension
-increased ICP
-headache, tachycardia, thiocyanate/cyanide toxicity (risk increases in renal and hepatic impairment)
-degradation color to blue means cyanide
Nitroglycerin
-low dose: venous vasodilator
-high dose: arterial vasodilator
-Contraindications: SBP < 90 mmHg; PDE-5 inhibitors
-headache, tachycardia, tachyphylaxis
-requires non-PVC container
Inotropes
-increase contractility of the heart
-dobutamine (beta-1 agonist with some beta-2 and alpha-1 agonism)
-milrinone (PDE-3 inhibitor)
Hypovolemic shock
fluid resuscitation with crystalloids (if not caused by hemorrhage)
-then vasopressors after fluid resuscitation
Septic Shock
-target MAP of > 65
-fill the tank: optimize preload with IV crystalloids (LR preferred)
-alpha-1 agonist activity (peripheral vasoconstriction) to incr SVR
-beta-1 agonist activity to increase myocardial contractility and CO
-norepi is the vasopressin of choice
MAP
= [(2 x DBP) + SBP]/3
VAP
pseudomonas (and a few other organisms) thrive in the moist air in the ventilator
indwelling catheter
CAUTI
Cardiogenic shock
pt presented with edema, JVD, or ascites are VOLUME OVERLOADED:
-loop diuretic, vasodilators (NTG, nitroprusside)
Pt with decreased renal fx, AMS, and/or cool extremities have HYPOPERFUSION:
-inotropes (dobutamine, milrinone)
-if hypotensive consider adding a vasopressor (dopamine, norepi, phenylephrine)
Some patients experience BOTH
P.A.D.I.S
-Pain: IV morphine, dilaudid, fentanyl are first line options for analgesia
-Agitation: benzos, propofol, dexmedetomidine
-Delirium: no prevention - use of non-benzos may help reduce the incidence (quetiapine)
[RASS SCORE +4 combative | 0 calm/alert | -5 unarousable]
Dexmedetomidine (Precedex)
-alpha-2 adrenergic agonist
-hypo/hypertension, bradycardia
-does not require refrigeration
-infusion should not exceed 24 hours
-approved for both intubated and not intubated patients`
Propofol
hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS)
-bacterial growth, discard vial and tubing within 12 hours of use
-provides 1.1 kcal/mL
lorazepam (Ativan)
propylene glycol toxicity (acute renal failure and metabolic acidosis)
Stress ulcers
H2RAs and PPIs are recommended to prevent-stress related mucosal damage
-PPIs can increase the risk of GI infections, fractures, nosocomial pneumonia
NMBA: depolarizing
Succinylcholine
NMBA: non-depolarizing
-rocuronium, vecuronium, cisatracurium (hofmann elimination - independent of renal and hepatic function)
-flushing, bradycardia, hypotension, tachyphylaxis
hemostatic agents
-inhibit fibrinolysis and enhancing coagulation
-Tranexamic acid (Cyklokapron inj, Lysteda tab)
-Recombinant Factor VIIa (NovoSeven RT)
