Acute Care and Critical Care Medicine Flashcards
Crystaloids vs colloids
Crystalloids:
- less costly
- fewer adverse reactions
Colloids:
- large molecules
- remain in the intervascular space and increase oncotic pressure
- more expensive and do not show clear clinical benefit
Crystalloids examples
5% dextrose (D5W)
0.9% NaCl (normal saline, NS)
Lactated Ringers (LR)
Plasma Lyte
Colloid examples
Albumin 5, 25%
When are dextrose crystalloids used?
When water is needed intracellularly since they contain free water
When are Lactated Ringers and normal saline used?
For volume resuscitation in shock states
when is the colloid albumin used
when there is significant edema (cirrhosis)
Why is the hydroxyethyl startch use limited
boxed warning in critical illness due to mortality
what is the cutoff for hyponaturemia
Na <135
what is the tx for hypovolemic hyponatremia
administer sodium chloride IV
What is the tx for hypervolemic hyponatremia
diuresis with fluid restriction
What is arginine vasopressin receptor (AVP) antagonists (conivaptan or tolvaptan) used to treat
SIADH and hypervolemic hyponaturemia
What is too rapid for sodium correction and what can happen?
12 meq/L over 24 hours to cause osmotic demyelination syndrome (ODS) or central pontine myelinolysis which can cause seizures and death
Samsca
Tolvaptan
What are the arginine vasopressin receptor antagonists
Conivaptan (Vapristol) and Tolvaptan (Samsca)
Why is Tolvaptan limited to greater than 30 days
hepatotoxicity
How should tolvaptan be administered
in a hospital
Side effects of tolvaptan
thirst, nausea, dry mouth, polyuria
monitoring for tolvaptan
rate of na increase
what is the cutoff for hypernaturemia
Na > 145 mEq/L
what are medications that cancause hypokalemia
amphotercin, insulin
What does a drop of 1meq/L represent in body defecit
100-300meQ
What can you NEVER administer potassium via
undiluted of via IV push
What needs to be given to incrtease potassium uptake
magensium
what is the max infusion rate and concentration of potassium
<10meq/100mL infusion rate and concentration of 10meq/100ml
what form of magnesium is orally replaced
magnesium oxide
what form of magnesium is replaced via IV
magnesium sulfate
when is IV magnesium recommended
When serum MG is <1 with life threatening symotins (seizures or arrhytmias)
When is hypophosphatemia considered severe? How to tx?
Less than 1mg/dL - tx by giving IV phos
carimune nf, flebogamma DIF, gammagard, gamumex c, octogam, privigen
intravenous immunoglobulin
when do you give slower infusion of iv immunoglobulin
in renal and CV disease
boxed warning of IV immunuglob
acute renal dysfunction (more likely in products stabilized with sucrose) and thrombosis
what are the side effects of iv immunoglobulin
headache, nausea, diarrhea, injection site reacion, infusion reacition (facial flushing, chest tightness, fever, chils, hypotension - slow, stop infusion)
what tool is used to estimate ICU mortality risk
APACHE II
Dosing for dopamine and receptors
Low (renal) dose 1-4 mcg/kg/min - Dopamine 1 agonist
Medium dose 5-10 mcg/kg/min beta 1 agonist
High dose 10-20 mcg/kg/min alpha 1 agonist
what does stimulating alpha receptors do
vasoconstriciton and increasing svr which increases BP
what is dopamine a precursor of
norephinephrine
epinephrine hits what receptors
alpha 1, beta 1, beta 2
levophed
norepinephrine
norepinephrine
alpha 1 > beta 1 agonist
phenylephrine moa
alpha 1 agonist
vasopressin known as
arginine vasopressin and antidiuretic hormone
boxed warning for vasopressor
vesicants when administered IV; treat extravasation with phentolamine
Side effects of vasopressors
arrhythmias, tachycardia, necrosis (gangrene), bradycardia (for phenylephrine), hyperglycemia (epinephrine)
monitoring for vasopressor
continuous BP
dosing for epinephrine push
0.1 mg/mL for IV and 1 mg/mL for IM
how to treat vasopressor extravasation
phentolamine which is an alpha 1 blocker that antagonizes the effects of the vasopressor
nitropres
nitroprusside
Nipride
Nitroprusside
contraindication to nitroglycerin
SBP < 90 mm hg or use with a PDE-5 inhibitor
What is nitroglycerin at low vs high dose vs nitroprosside
Nitroglycerin:
- low dose: venous vasodilator
- High dose: arterial
Nitroprusside: mixed arterial and venous
metabolism warning for nitroprusside
produces cyanide, excessive hypotension, not for direct injection (diluted D5w preferred)
warning for nitroprosside
increased ICP
pneumonic for light protection
protect every necessary med from daylight
nitroprusside - protect from light, if blue a no go
What are the pros and cons of using PPIS in the ICU
pros: stress ulcer prophylaxis
xons: risk of GI, fractures, nosocomial pneumonia
what are the risk factors for stress ulcers
mechanical ventilation > 48h and coagulapathy
What characterizes shock
hypoperfusion in the setting of hypotension
tx for shock
1) fill the tank - IV crystaloid bous as needed to optomize preload
2) squeeze the pipes - peripheral vasoconstrictor (alpa 1 agonist) to increase SVR
3) kick the pump - beta 1 agonist to increase myocardial contractility and cardiac output
What are two common cause of ICU infections
1) mechanical ventillator
2) foley catheters
vasopressor of choice in septic shock
norpinephrine
cardiogenic shock and acute decompensated heart failure meaning
ADHF is the worsening symptoms of HF and cardiogenic shock is when hypotension and hypoperfusion is present
when should be stopped in heart failures
beta-blockers only if hypotension or hypoperfusion is present
how is ADHF monitored
via a catheter called a swan ganz that provides pulmonary capillary wedge pressure
volume overload treatment
loop diuretics +/- vasodilators (NTG, nitroprusside, nesiritide)
hypoperfusion tx (cool extremities, altered mental status, decreased renal function)
ionotropes (dobutamine, milrinone) and maybe a vasopressor if hypotensive (dopamine, norepipenphrine, phenylephrine)
What are sedatives used
to prevent bucking the vasodilator
what is preferred in sedation and what are the risks with it
propofol and dexpedetodomine (precedex) due to improved outcomes and decreased chance of delerium
Sublimaze
fentanyl
Dilaudid
Hydromorphone
Duramorph
Morphine
Infumorph
Morphine
Precedex
Dexmedetomidine
MOA of precedex (dexmedetomine)
alpha 2 adrenergic agonist
Warnings with dexamethadone (precedex)
hypotension, bradycardia
max duration of precedex infusion and max use of vial
24 hours
12 hours for vial
only sedative also approved for non intubated patients
precedex (dexmedetomadine)
Diprivan
Propofol
What are contraindications to propofol (Diprivan), what do you monitor, how much energy does it provide
egg, soy
monitor triglycerides, equivimlent to 10% sln
What color can propofol turn urine
Green
Side effects of propofol
Hypotension, apnea
Ativan
Lorazepam
What is Ativan/Propofol formulated in and what can it cause
propylene glycol which can cause acute renal failure and metabolic acidosis
Versed
Midazolam
Versed/Midazolam contraindications and warnings
Contraindicated with use in CYP3A4 inhibitors (PACMANG) and canaccumulate in renal impairment due to active metabolite
What do you monitor for in Etomidate (Amidate)
adrenal insufficiency
Ketamine warnings
Emergence reactons
Haldol
Haloperidol
Seroquel
Quetiapine
Xylocaine
Lidocaine
Suprane
Desflurane (inhaled)
buvicane and ropicivane are what
injectible anesthetics
Overdose of inhaled anastetics can cause what
malignant hyperthermia
Bupivacaine for epidurals are fatal if administered
intravaneously
purpose of giving epinephrine with lidocaine
epinephrine vasoconstricts
Nimbex
Cisatracurium
How is Nimbex (Cisatracurium) metabolized
by Hoffman elimination independant of hepatic and renal function
Succinylcholine is what
A depolarizing NMBA (neuromuscular blocking agent) typically used for intubationj
Non depolarizing NMBAs can cause what side effects
eg atracurium, cistracurium (nimbex) and can cause flushing, bradycardia, hypotension, tachyphylaxis
labeling and use of NMBDA
must be labled with warning paralyzing agents, must be used with ventilator since paranyzes diapragm, usually used to faciltate mechanical ventilation, manage inctreased increased intractranial pressure, and treat muscle spasms
What special care must be taken while giving NMBAs
protect the skin, lubricate the eyes and suction the airway. Glycopyrrolate is an anticholinergic drug that can be used to reduce secretions
how do systemic hemostatic drugs work
inhibit fibrinolysis or enhance coagulation to stop bleeding
recothrom and thrombin JMI are what
topical hemostatic agents
Cyklokapron
Tranexamic acid
Lysteda
Tranexamic acid
What is Lysteda Tranexamic acid approved for
heavy menstrual bleeding (menorrhagia)
NovosevenRT
Recombinant Factor VIIa
