Block 1 Flashcards
What is inpatient hyperglycemia?
≥140mg/dl
What are the major classes of drugs that cause hyperglycemia?
Corticosteroids
Atypical antipsychotics (Risperidone, Olanzapine, Quetiapine)
Immunosuppressants
Catecholamines
Insulin is given to those with a range of ______ to keep them off of >180mg/dl
140-180
What are the rapid acting insulins?
Aspart, Lispro, Glulisine
How do you determine the dose of insulin experienced and insulin naive patients?
Experienced = take 1/2 to 1/3 of their normal dose
Naive = 0.1u/kg/day (outpatient)
If well controlled or at higher risk of hypoglycemia = 0.2u/kg/day
If poorly controlled = 0.5-0.8u/kg
BUT naive pt use sliding scales but should remain the sole treatment
Which insulin is typically used in ICU patients?
Insulin regular IV bags
When a patient is stable, how do you transition from IV to SQ insulin?
Calculate TDD by taking average rate/hr in the past 6-8hrs
Multiply number by 24 (total IV insulin) then multiplying it by 0.8 (total SC insulin)
SC is given as 50/50 basal and bolus
When should you monitor pt on basal only insulin?
Once daily with morning labs
When should you monitor pt on basal + bolus regimen?
Before each meal and at bedtime
What is hypoglycemia?
Warnings begin at <70 but officially ≤54mg/ml
How do you manage hypoglycemia?
BG checked q15min
D50W 25ml if <70
D50W 50ml if <54
Glucagon if <70 + no IV access
Differentiating pieces of DKA and HHS?
DKA - metabolic acidosis + ketonemia; tachypnea, kussmaul breathing, acetone breath
HHS - high serum osmolality + dehydration; hypotension
How often should you monitor a DKA pt?
Every 2-4 hours
When treating DKA or HHS, what kind of insulin plan do we utilize?
Bolus 0.1u/kg
0.1u/kg/hr continuously IV infusion
DKA BG <200 or HHS BG<300; decrease dose to 0.02-0.05u/kg/hr and switch fluids to D51/2NS
What is the corrected sodium equation?
Measured Na + ((0.016*(glucose-100))
When do we correct potassium during insulin therapy?
<3.3 = hold insulin, give 20-30mEq/hr until potassium is above 3.3
3.3-5.2 = give 20-30mEq/hr in 1L fluid
> 5.2 = dont give potassium and check q2hrs
How do you measure anion gap?
Na - (Cl+HCO3)
Normal <12
How do you manage fluids in DKA/HHS?
Regardless of condition, 1L bolus of NS
If <135 Na, Give NS 250-500ml/hr
If >135 Na, Give 1/2NS 250-500ml/hr
If glucose range is below their targets, just add D5W
DKA is resolved in what criteria?
Glucose <200 and two of the following:
Bicarb≥15
Venous pH>7.3
Anion gap≤12
HHS is resolved in what criteria?
Normal osmolality and normal mental status
Post resolution care, when should you start SQ admin of insulin?
1-2 hrs before stopping IV
What are some complications of DVT and PE?
DVT = swelling and pain, unilaterally
PE = Arrhythmias and death, SOB, chest pain
RF for VTE?
Stasis
ICU
Cancer
Rx (estrogen, vasopressor, ESAs)
Patient-related
Surgery
What is a good thing about using the PADUA prediction score for VTE?
If you score low, it has a 99% value stating that you have a low risk for VTE, it is not specific nor sensitive
Which diagnostic tests are used in DVT vs PE?
DVT = compression ultrasound
PE = CT and ventilation/perfusion scans
Prophylactic dosing of:
Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)
Enoxaparin 40mg daily
Dalteparin 5000u daily
Heparin 5000u q8-12hrs
Fondaparinux 2.5mg daily
DOACs not recommended
MOA of:
Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)
Enoxaparin + Dalteparin + Fondaparinux = Indirect Xa inhibitors
Heparin = indirect IIa and Xa inhibitor
Dose of heparin and lovenox in BMI>40?
Heparin 7500 TID
Lovenox 40mg BID or 0.5mg/kg/day
Dose of heparin and lovenox in low body weight <50kg
Heparin 5000 BID or TID
Lovenox 30mg QD
Dose of heparin and lovenox in renal dysfunction?
Heparin = no change
Lovenox; if CrCl<30 its 30mg QD or switch to heparin
Dose of heparin and lovenox in surgery?
Major orthopedic surgery, then Lovenox 30mg BID
What RF are there for hemorrhages?
Increasing doses of anticoagulation, concomitant antiplatelet therapy
Low body weight (<50kg)
Malignancy, HF, renal failure
h/o bleed
What is a major bleed?
Fatal bleed
Symptomatic bleed in critical organ
Bleeding causing Hgb >=2g/dl
Transfusion w/ 2+ units of blood
What is a life-threatening bleed?
Symptomatic intracranial bleed
Bleeding causing Hgb >=5g/dl
Transfusion w/ 4+ units of blood
Bleed associated w/ hypotension
What do they inactive:
Protamine
Protamine - UFH + LMWH
1mg Protamine neutralizes ____ units of UFH
100
Utilize the last _____ hours of heparin administered when using protamine
2-3
Max dose of protamine = ___ mg
50
Max infusion rate of protamine = ____mg/min
5
IV vs SQ heparin reversal, how do you administer protamine?
IV = just give protamine infusion rate of 5mg/ml
SQ = bolus dose protamine of 25mg, then remaining dose of IV over 8hours
When administering protamine for heparin, how much does it reverse LMWH?
Only 60%
Protamine dosing for LMWH?
Time since last dose:
<8hrs = 1mg (100u) / 1mgLMWH
8-12hrs = 0.5 (50u) / 1mg LMWH
> 12hrs = n/a
Max dose of protamine = 50mg
How is protamine administered for LMWH?
SQ only
What intervention is needed with warfarin if INR is supratherapeutic but <4.5 and NO bleed?
Hold 1-2 doses OR reduce warfarin dose
What intervention is needed with warfarin if INR is 4.5-9.9 and NO bleed?
Hold doses
What intervention is needed with warfarin if INR is >10 and NO bleed?
Hold dose AND give Vit. K PO 1-2.5mg
What intervention is needed with warfarin at any INR with major/life-threatening/emergency bleed?
Hold dose AND give 4-factor PCC and Vit. K IV 5-10mg
Recheck INR 30-60 min after 4-factor PCC, then every 6 hours
What is fresh frozen plasma used to reverse? Dose and considerations?
Warfarin reversal
15ml/kg
Time consuming (90min from order to admin), must find ABO blood type match and thawing process, volume overload
Kcentra is dosed based on ______
Factor IX/kg (actual body weight)
What is recombinant factor VIIa used for?
Warfarin reversal
BBW of serious thrombotic events
What is andexant alfa used for?
Rivaroxaban and apixaban reversal
Andexant alfa dose?
400-800mg IV bolus then 4-8mg/min infusion for 2 hours
What is idarucizumab used for?
Dabigatran reversal
Idarucizumab dose?
50mg/kg IV *max dose of 5000u. Typically uses 2 separate 2.5g vials 15 min apart
What is the metabolism of critical ill patients?
Carbs
Lipids
Protein
Carbs = increased glucose production + insulin resistance = hyperglycemia
Lipids = increased lipolysis
Protein catabolism > protein synthesis
Net effect = decreased lean body mass
Which lab values should not be included for nutrition screening?
Albumin, transferrin, prealbumin
What NRS-2002 score indicates nutritionally at-risk?
Anything greater than 2
What mNUTRIC score indicates worse clinical outcome AND likely to benefit from aggressive nutrition therapy?
Anything greater than 4
What are the weights to measure calories needed for patients? Some cons?
Indirect Calorimetry**gold standard
Predictive equations **not super accurate, less accurate in pt w/ obesity or are underweight
Simplistic weight-based estimation
Indirect calorimetry info?
Gold standard
Estimates energy expenditure from measures of CO2 production and O2 consumption
Uses respiratory quotient (normal = 0.8-0.85)
Can provide resting energy expenditure
What is the most “important” macronutrient? Who needs more of them?
Protein, generally higher amount in ICU patients
Dont reduce protein need in acute kidney or hepatic failure
What is used to measure adequacy or protein administration?
Weekly urine urea nitrogen
High dose protein should be given to which specific patients?
Burn or multitrauma
Obese + critical patient, what kind of feeding should they get?
Early EN within 24-48hrs
High protein + hypocaloric
Those w/ HD or CRRT, how is protein intake adjusted?
Increases protein to 2.5g/kg/day
Nutritionally needs for those w/ respiratory failure?
If they have the condition for >72hrs, low/moderate risk get trophic fee for 6 days and high risk gets for 2-3 days
Low/moderate risk get PN on top of EN after a week of EN
High risk gets PN ASAP on top of EN
EN complications?
Aspiration pneumonia
Diarrhea
How many kcal/gram does dextrose contain and what should the rate be?
3.4kcal/gram
Limit to <4mg/kg/min to prevent hyperglycemia
What is SMOF?
Lipid emulsion (non-soybean oil) even though it has some soybean :/
30% soybean oil
30% median chain TG
25% Olive oil
15% fish oil
What factors affect the activity of the Na-K ATPase pump, the rate-limiting step in for potassium entry into cells?
Several factors affect the activity of this pump,
including insulin, glucagon, catecholamines, aldosterone, acid-base status, plasma osmolality, and intracellular potassium levels.
What are some examples of symptoms of hypokalemia
Signs and symptoms of hypokalemia include nausea, vomiting, weakness, constipation, paralysis, respiratory compromise, and rhabdomyolysis
Severe - ECG changes
What ECG changes might you see due to hypokalemia?
ST-segment depression
T-wave flattening
T-wave inversion
U waves
What drugs cause an intracellular shift of potassium?
Beta agonists
Insulin
Theophylline
Caffeine
What drugs/conditions cause potassium loss?
Loop and thiazide diuretics
SPS
Corticosteroids (especially mineralocorticoids
such as fludrocortisone)
Aminoglycosides
Amphotericin B
Magnesium depletion
HD, CRRT, etc
GI losses (e.g., diarrhea, nasogastric suctioning)
Which IV fluid will worsen hypokalemia?
Dextrose, it will stimulate insulin release
What will happen if you inject potassium peripherally?
Potassium infusion via a peripheral vein may cause burning pain
and phlebitis at the infusion site.
What can you do to minimize pain associated with injecting potassium peripherally? Any issues?
Adding 1 mL of 1% lidocaine to a potassium solution of 10–20 meq/100 mL may minimize the pain at the infusion site. However, this could mask a sign of underlying venous
damage.
How do you treat hyperkalemia? AE of drugs?
Calcium gluconate (antagonizes cardiac complications)
Bicarb (be careful in HF or liver issue, it has sodium in it)
Insulin
Dextrose
Furosemide
SPS (be careful in HF or liver issue, it has sodium in it, GI tract necrosis)
Albuterol
Hemodialysis (removes potassium from plasma)
Issues with hypophosphatemia?
Respiratory, cardiac, neurologic issues
What conditions predispose pt to hypophosphatemia?
Malnutrition
Inadequate body phosphorus stores or inadequate phosphate administration
Alkalosis [respiratory and metabolic]
DKA
Alcoholism
Vomiting
Which medications can cause hypophosphatemia?
CRRT
Insulin
Diuretics
Antacids
Sucralfate,
Administration of carbohydrate loads
What can cause hyperphosphatemia? Treatment?
Hypocalcemia
Correct calcium levels (calcium x phosphorus must be <60)
Drugs:
Calcium acetate Calcium carbonate Aluminum hydroxide Magnesium hydroxide Sevelamer
Why do we calculate a corrected calcium level? Formula?
Calcium is bound to albumin, therefore patients with hypoalbuminemia will have a “low” level
Calcium + ((0.8(4-albumin))
What causes hypocalcemia?
Hypoalbuminemia.
Hypomagnesemia
Hyperphosphatemia,
Sepsis, pancreatitis, renal insufficiency, hypoparathyroidism, and administration of blood preserved with citrate
The hallmark sign of severe acute hypocalcemia is tetany
S/Sx of hypocalcemia?
Brittle and grooved nails, hair loss, dermatitis,
and eczema
Differences between calcium gluconate and calcium chloride?
Calcium chloride provides three times more
elemental calcium than an equivalent
amount of calcium gluconate
When is calcium gluconate preferred over calcium chloride?
Calcium gluconate should be used as the preferred
salt for routine calcium maintenance and supplementation
Calcium chloride for emergency use
What causes hypercalcemia?
The primary causes of hypercalcemia are malignancy and
primary hyperparathyroidism
How do you treat hypercalcemia?
NS
Lasix
HD if severe or renally impaired
Bisphosphonates
Etidronate disodium
Hypomagnesemia can impact which other electrolytes?
Hypokalemia and hypocalcemia
What drugs can cause hypomagnesemia?
Loop and thiazide diuretics
Aminoglycosides
Amphotericin B
Cisplatin
Cyclosporine
Digoxin
Why must IV admin of magnesium go slowly?
It distributes into tissues slowly, but is renally excreted quickly
How do you treat hypermagnesemia?
IV calcium
