- Na < 135 mEq/L - Hypovolemic - administer NS - Hypervolemic - diuresis with fluid restriction - Don't correct Na more than 12 mEq/d = risk for osmotic demyelination syndrome or central pontine myelinolysis - If treating SIADH (isovolemic) or hypervolemic hypoNa - AVP antagonists, conivaptan and tolvaptan, can be used to increase free water excretion

- Tolvaptan, AVP (arginine vasopressin) receptor antagonists - Box Warnings: initiate/reinitiate at hospital with close Na monitoring, don't overcorrect Na (>12 mEq/d) - Warning: hepatotoxicity - SE: Thirst, nausea, dry mouth, polyuria

- Na > 145 mEq/L - Hypovolemic - fluids - Hypervolemic - diuresis - Isovolemic - often due to diabetes insipidus, treat with desmopressin (ADH analog)

- K < 3.5 - Amphotericin and insulin can lower K - 1 mEq below 3.5 ~ 100-400 mEq body deficit - Max peripheral infusion = 10 mEq/hr and max [10mEq/100mL] - If resistant to replenishment, check magnesium (Mg needed for K uptake) - IV K+ can be fatal is given undiluted or by IV push

- Mg IV replenish - Magnesium sulfate used for IV, magnesium oxide for PO (Use when 1 < Mg < 1.5) - Replenish for 5 days to replace body stores

- Considered severe and is symptomatic when Phos <1 - When < 1 use IV phosphorous for replacement - If less severe, PO formulations can be used - Often will need Mg and K corrected as well - Replenishment often takes a week or longer

- Box warning: acute renal dysfunction (especially in products with sucrose), thrombosis (w/o risk factors) - SE: HA, N/D, injection site rxn, infusion rxn (flush/fever/hypotension - slow/stop infusion)

- Low (renal) dose: 1-4 mcg/kg/min => dopamine agonist - Medium dose: 5-10 mcg/kg/min => beta-1 agonist - High doses: 10-20 mcg/kg/min => alpha-1 agonist (vasopressor)

- Vasopressor - Alpha-1, beta-1, and beta-2 agonist - Causes hyperglycemia - IV push is 0.1 mg/mL (1:10,000) while IM injection is 1mg/mL (1:1000) - Ratio strengths have been removed from labeling per FDA

- Vasopressor - Alpha-1 and beta-1 agonist (more alpha than beta)

- Vasopressor - Alpha-1 agonist - Causes bradycardia

- Vasopressor - Arginine vasopressor (AVP) + ADH

- Used when active MI or uncontrolled HTN - Effectiveness usually limited to 24-48 hours due to tachyphylaxis (tolerance) - Low doses => venous vasodilator; high doses => arterial vasodilator

- CI: SBP < 90 or use with PDE5i - SE: HA, tachycardia, tachyphylaxis - Requires non-PVC container (glass, polyolefin)

- Nitroprusside - Mixed arterial and venous vasodilator (equal) - DON'T use in active MI, can cause "coronary steal" - Metabolites are toxic, thiocyanate and cyanide - Hydroxocobalamin = used to reduce thiocyanate toxicity - Sodium thiosulfate = used for cyanide toxicity

- Inotrope, beta-1 agonist - Weak beta-2 and alpha-1 agonism - May turn slightly pink due to oxidation, potency not lost

Acute/Critical Care Flashcards by Rachel Crusius

Hyponatremia Tx

Na < 135 mEq/L
Hypovolemic - administer NS
Hypervolemic - diuresis with fluid restriction
Don’t correct Na more than 12 mEq/d = risk for osmotic demyelination syndrome or central pontine myelinolysis
If treating SIADH (isovolemic) or hypervolemic hypoNa - AVP antagonists, conivaptan and tolvaptan, can be used to increase free water excretion

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Samsca

Tolvaptan, AVP (arginine vasopressin) receptor antagonists
Box Warnings: initiate/reinitiate at hospital with close Na monitoring, don’t overcorrect Na (>12 mEq/d)
Warning: hepatotoxicity
SE: Thirst, nausea, dry mouth, polyuria

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Hypernatremia

Na > 145 mEq/L
Hypovolemic - fluids
Hypervolemic - diuresis
Isovolemic - often due to diabetes insipidus, treat with desmopressin (ADH analog)

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Hypokalemia

K < 3.5
Amphotericin and insulin can lower K
1 mEq below 3.5 ~ 100-400 mEq body deficit
Max peripheral infusion = 10 mEq/hr and max [10mEq/100mL]
If resistant to replenishment, check magnesium (Mg needed for K uptake)
IV K+ can be fatal is given undiluted or by IV push

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Hypomagnesemia

Mg < 1.3
Mg < 1 usually related to life-threatening sxs like seizure and arrhythmias => IV replenish
Magnesium sulfate used for IV, magnesium oxide for PO (Use when 1 < Mg < 1.5)
Replenish for 5 days to replace body stores

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Hypophosphatemia

Considered severe and is symptomatic when Phos <1
When < 1 use IV phosphorous for replacement
If less severe, PO formulations can be used
Often will need Mg and K corrected as well
Replenishment often takes a week or longer

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Privigen/Octagam/Gammagard/Carimune NF

IVIG
Extracted for the plasma of thousands of blood donors
Originally only for immunodeficiency conditions, now many off-label conditions as well (MS, myasthenia gravis, Guillain-Barre syndrome)
Can impair response to vaccination
Slower infusion rates needed in CV and renal disease

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IVIG Information

Box warning: acute renal dysfunction (especially in products with sucrose), thrombosis (w/o risk factors)
SE: HA, N/D, injection site rxn, infusion rxn (flush/fever/hypotension - slow/stop infusion)

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Dopamine Dosing/MoA

Low (renal) dose: 1-4 mcg/kg/min => dopamine agonist
Medium dose: 5-10 mcg/kg/min => beta-1 agonist
High doses: 10-20 mcg/kg/min => alpha-1 agonist (vasopressor)

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Epi MoA

Vasopressor
Alpha-1, beta-1, and beta-2 agonist
Causes hyperglycemia
IV push is 0.1 mg/mL (1:10,000) while IM injection is 1mg/mL (1:1000)
Ratio strengths have been removed from labeling per FDA

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NE MoA

Vasopressor

- Alpha-1 and beta-1 agonist (more alpha than beta)

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Phenylephrine MoA

Vasopressor
Alpha-1 agonist
Causes bradycardia

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Vasopressin

Vasopressor

- Arginine vasopressor (AVP) + ADH

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Vasopressor Information

Box warning: all vesicants, treat extravasation with phentolamine (alpha-1 blocker)
SE: Arrhythmia, tachycardia, necrosis
Continuously monitor BP
Don’t use if discolored or contain precipitate
Administer via central line

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NTG

Used when active MI or uncontrolled HTN
Effectiveness usually limited to 24-48 hours due to tachyphylaxis (tolerance)
Low doses => venous vasodilator; high doses => arterial vasodilator

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NTG Information

CI: SBP < 90 or use with PDE5i
SE: HA, tachycardia, tachyphylaxis
Requires non-PVC container (glass, polyolefin)

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Nitropress/Nipride

Nitroprusside
Mixed arterial and venous vasodilator (equal)
DON’T use in active MI, can cause “coronary steal”
Metabolites are toxic, thiocyanate and cyanide
Hydroxocobalamin = used to reduce thiocyanate toxicity
Sodium thiosulfate = used for cyanide toxicity

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Nitroprusside Information

Box warning: metabolism produces cyanide, excessive hypotension, diluted with D5W (preferably) for injection
Warning: increases ICP
SE: HA, tachycardia, thiocyanate/cyanide toxicity (increased risk in renal/hepatic impairment)
Requires light protection
If blue color, it has degraded to cyanide, do not use

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Dobutamine

Inotrope, beta-1 agonist
Weak beta-2 and alpha-1 agonism
May turn slightly pink due to oxidation, potency not lost

Milirinone

Inotrope

- PDE3i

Hypovolemic Shock

Ex: hemorrhagic
First-line: crystalloid fluid resuscitation if NOT hemorrhagic
Use blood products if related to bleeding
If patients fail their fluid challenge (don’t meet MAP goal), then use vasopressors
*Vasopressors are not effective unless intravascular volume is adequate**

Distributive shock

Includes anaphylactic and septic shock
Sepsis: life-threatening organ dysfunction caused by dysregulated host response to infection
Quick sxs check (qSOFA): altered mental status, SBP =< 100, RR >= 22

ADHF/Cardiogenic Shock

ADHF: Episodes of worsening sxs in HF patients
Ex: weight gain, inability to lie down w/o SOB, decreased functionality
If coupled with hypotension and hypoperfusion => cardiogenic shock
*Only stop B-blockers if Cardiogenic shock is occurring**
May require invasive monitoring with Swan-Ganz catheter to measure PCWP

ADHF + Volume Overload Tx

Ex: edema, JV, ascites
Loop diuretics
Vasodilators (NTG, nitroprusside)

ADHF + Hypoperfusion Tx

- Ex: Decreased renal fxn, altered mental status, cool extremities - Inotropes (dobutamine, milrinone - If hypotension occurs => vasopressor (avoid when possible, can worsen BP)

Non-BZD Sedatives

- Dexmedetomidine (Precedex) and propofol - Preferred for sedation with improved ICU outcomes - Precedex is ONLY agent approved for intubated and non-intubated patients - Light sedation is preferred and validated with sedation scales - Daily interruptions of continuous infusions of sedatives are used to assess pt. readiness ("sedation vacations")

Precedex

- Dexmedetomidine - Alpha-2 adrenergic agonist - SE: Hypo/HTN, bradycardia - Doesn't need refrigeration - Don't exceed 24 hours for duration of infusion

Diprivan

- Propofol - Short-acting general anesthetic - CI: allergic to eggs or soy - SE: Hypotension, apnea, Hyper-TG, green urine/hair/nail beds, PRIS (infusion syndrome, rare but fatal) - Monitor: TG - Strict aseptic technique, discard vial/tubing within 12 hours of use - Oil-in-water emulsion, provides 1.1 kcal/mL

Ativan

- Lorazepam - BZD used for agitation - Can cause propylene glycol toxicity (acute renal failure + metabolic acidosis)

Versed

- Midazolam - BZD used for sedation, shorted duration - CI: Use with potent CYP3A4 inhibitors - Can accumulate in obese and renally impaired patients - use with caution

Amidate

- Etomidate - Non-barbiturate hypnotic - Monitor for s/sxs of adrenal insufficiency

Ketalar

- Ketamine - NMDA receptor antagonist - Can cause emergence rxns (vivid dreams, hallucinations, delirium)

Risk Factors for Stress Ulcers

- Mechanical ventilation > 48 hours - Coagulopathy - Sepsis - TBI - Major burns

Stress Ulcer Prevention Agents

- H2RAs and PPIs - Both have their own risk factors - PPIs: risk of GI infections, fractures, and nosocomial pneumonia

Xylocaine

- Lidocaine - Common local anesthetic - Can be combined with epi to help keep lidocaine localized - Deaths have occurs due to mix ups with Epi and Lido/epi products

Suprane

- Desflurane - Commonly inhaled anesthetic - Can cause malignant hyperthermia

Ultane

- Sevoflurane - Commonly inhaled anesthetic - Can cause malignant hyperthermia

Marvaine/Sensorcaine

- Bupivacaine - Common injected anesthetic - Used in epidurals but can be fatal if given IV

Naropin

- Ropivacaine | - Commonly used injected anesthetic

NMBA

- Neuromuscular blocking agents - Cause paralysis of skeletal muscle which can help with mech. ventilation to stop tetany in intubated/surgery pts - Patients should receive adequate sedation BEFORE NMBAs since they don't provide any themselves - "WARNING: PARALYSIS AGENT" - Protect patient's skin, lubricate eyes, and suction airway - Glycopyrrolate can be used to reduce secretions (anticholinergic)

Succinylcholine

- Only available depolarizing NMBA - Used for intubation - Short-acting/quick onset - Risk for malignant hyperthermia

Nimbex

- Cisatracurium - Non-depolarizing NMBA - Metabolized by Hoffman elimination (independent or renal/hepatic fxn)

Pancuronium

- Non-depolarizing NMBA | - Long acting

All Non-depolarizing NMBA

SE - Flushing - Bradycardia - Hypotension - Tachyphylaxis

Hemostatic Agents

- Agents that stop bleeding - Systemic drugs work by inhibiting fibrinolysis or enhancing coagulation (ex: Recombinant Factor VIIa, Brand name: NovoSeven RT) - Topical agents are also available (Ex: Recothrom, Thrombin-JMI)

Cyklokapron

- Injection formulation of tranexamic acid | - Lysteda is a tablet form that can be used for menorrhagia (heavy periods)