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NAPLEX > Chapter 53: Acute & Critical Care Medicine > Flashcards

Chapter 53: Acute & Critical Care Medicine Flashcards

1
Q

Which fluids are less costly and generally have fewer side adverse reactions - crystalloids or colloids

A

Crystalloids

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2
Q

Colloids are ____ molecules (typically protein or starch) dispersed in solutions that primarily remain in the ______ space and ____ oncotic pressure

A

Large molecules
intravascular space
Increase

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3
Q

Which fluid is used when water is needed intracellularly, as these products contain “free water”

A

Dextrose

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4
Q

Which fluids are the most common drugs used for volume resuscitation in shock states

A

Lactated Ringers and Normal saline

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5
Q

Which fluid is the most commonly used colloid

A

Albumin

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6
Q

When is albumin useful

A

significant edema (e.g., cirrhosis)

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7
Q

Boxed warning for hydroxyethyl starch

A

avoid use in critical illness (including sepsis) due to mortality and renal injury

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8
Q

Which common fluids are crystalloids

A

D5W
Normal saline
Lactated Ringers
Multiple electrolyte injection (i.e., Plasma-Lyte A)

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9
Q

Which common fluids are colloids

A

Albumin 5%, 25% (Albutein, AlbuRx)
Dextran
Hydroxyethyl starch

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10
Q

Hyponatremia is Na below

A

< 135 mEq/L

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11
Q

How do you treat hypotonic hypovolemic hyponatremia

A

administer sodium chloride IV solutions

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12
Q

How do you treat hypotonic hypervolemic hyponatremia

A

Diuresis with fluid restriction (since it is caused by fluid overload)

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13
Q

What drugs/drug class can be used to treat SIADH and hypervolemic hyponatremia

A 
Arginine vasopressin (AVP) receptor antagonists
Conivaptan and tolvaptan
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14
Q

Correcting sodium more rapidly than ___ mEq/L over ___ hrs can cause ______ or _____, which can cause paralysis, seizures, & death

A

12 mEq/L over 24 hrs

osmotic demyelination syndrome (ODS) or central pontine myelinolysis

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15
Q

Tolvaptan brand name

A

Samsca

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16
Q

Tolvaptan is limited to how many days and why

A

less than 30 days due to hepatotoxicity

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17
Q

Where must tolvaptan be initiated and re-initiated

A

In a hospital

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18
Q

Side effects of tolvaptan

A

Thirst, nausea, dry mouth, polyuria

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19
Q

Tolvaptan monitoring

A

Rate of Na increase

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20
Q

Hypernatremia is sodium greater than ____ mEq/L

A

145 mEq/L

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21
Q

Hypokalemia is potassium less than ___ mEq/L

A

3.5 mEq/L

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22
Q

Medications that can cause hypokalemia

A

amphotericin, insulin

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23
Q

A drop of 1 mEq/L in serum K below 3.5 mEq/L represents a total body deficit of ___-___ mEq

A

100-400 mEq

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24
Q

Through a peripheral line, IV potassium replacement includes a max infusion rate of < / = ___ mEq/hr & a max concentration of ___ mEq/___ mL

A

10 mEq/hr

10 mEq/100 mL

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25
Q

IV potassium can be fatal if administered in which ways

A

undiluted or IV push

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26
Q

When hypokalemia is resistant to treatment, what should be checked

A

serum magnesium

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27
Q

What is necessary for potassium uptake

A

Magnesium

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28
Q

When serum Mg is < __ mEq/L with life-threatening symptoms (seizures & arrhythmias), what is recommended

A

< 1 mEq/L

IV magnesium sulfate

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29
Q

When serum Mg is > 1 mEq/L without life-threatening symptoms, what can be used

A

oral magnesium oxide

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30
Q

When is hypophosphatemia considered severe

A

When serum phosphate is < 1 mg/dL

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31
Q

When serum PO4 is < 1 mg/dL, what is used for replacement

A

IV Phosphorous

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32
Q

What does IV immune globulin contain

A

Pooled immunoglobulin (IgG)

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33
Q

What are some off-label uses for IVIG

A

MS, myasthenia gravis, Guillain-Barre

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34
Q

IVIG brand names

A

Carimune NF, Flebogamma DIF, Gamunex-C, Octagam, Privigen

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35
Q

When should a slower infusion rate be used with IVIG

A

In renal and CV disease

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36
Q

IVIG boxed warnings

A
  • Acute renal dysfunction - rare, but fatal (more likely with products stabilized with sucrose)
  • Thrombosis (even without risk factors)
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37
Q

IVIG boxed warnings

A

HA, nausea, diarrhea, injection site reaction, infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)

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38
Q

What is the scoring tool used to determine prognosis and estimate ICU mortality risk

A

The Acute Physiologic Assessment & Chronic Health Evaluation II (APACHE II)

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39
Q

Most vasopressors work by stimulating alpha receptors, which causes _______ & (increases/decreases) systemic vascular resistance (SVR), which increases ____

A

Vasoconstriction (think vasopressor PRESSES down on the vasculature)
Increases
BP

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40
Q

_____ is a natural precursor of NE and is recommended for use in symptomatic bradycardia

A

Dopamine

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41
Q

Low (renal) dopamine dose (DA-1 agonist)?

A

1-4 mcg/kg/min

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42
Q

Medium dopamine dose (beta-1 agonist)?

A

5-10 mcg/kg/min

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43
Q

High dopamine dose (alpha-1 agonist)?

A

10-20 mcg/kg/min

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44
Q

Epinephrine MOA

A

Alpha-1, beta-1, beta-2 agonist

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45
Q

Norepinephrine brand name

A

Levophed

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46
Q

Norepinephrine MOA

A

Alpha-1 agonist > beta-1 agonist

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47
Q

Phenylephrine MOA

A

Alpha-1 agonist

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48
Q

What are the other names for vasopressin

A

ADH and arginine vasopressin (AVP)

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49
Q

All vasopressors are ____ when administered IV

A

Vesicants

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50
Q

How should vasoconstrictor extravasation be treated

A

phentolamine

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51
Q

Vasopressor side effects

A

Arrhythmias, tachycardia (esp DA, Epi, and vasopressin), necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)

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52
Q

What should be monitored with all vasopressors

A

BP

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53
Q

How should all vasopressors be administered

A

central IV line

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54
Q

Dose of epinephrine used for IV push

A

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

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55
Q

Dose of epinephrine used for IM injection

A

1 mg/mL (1:1,000 ratio strength)

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56
Q

Phentolamine MOA

A

alpha-1 blocker

57
Q

When is nitroglycerin often used

A

When there is severe myocardial ischemia or uncontrolled HTN

58
Q

Effectiveness of nitroglycerin may be limited after __-__ hrs due to ____

A

24-48 hrs due to tachyphylaxis (tolerance)

59
Q

Nitroprusside MOA

A

mixed (equal) arterial and venous vasodilator at all doses

60
Q

When should nitroprusside NOT be used

A

active myocardial ischemia (can cause blood to be diverted away from the diseased coronary arteries - “coronary steal”)

61
Q

Metabolism of nitroprusside results in:

A

formation of thiocyanate and cyanide (both can cause toxicity)

62
Q

What can be administered to reduce the risk of thiocyanate toxicity with use of nitroprusside

A

Hydroxycobalamin

63
Q

What can be administered to reduce the risk of cyanide toxicity with use of nitroprusside

A

Sodium thiosulfate

64
Q

Nesiritide MOA

A

recombinant B-type natriuretic peptide that binds to vascular smooth muscle and increases cGMP, resulting in vasodilation

65
Q

MOA of NTG at low doses

A

venous vasodilator

66
Q

MOA of NTG at high doses

A

arterial vasodilator

67
Q

NTG contraindications

A

SBP < 90 mmHg

Use with a PDE-5 inhibitor or riociguat

68
Q

Side effects of NTG

A

HA, tachycardia, tachyphylaxis

69
Q

What kind of container does NTG require

A

non-PVC container (e.g., glass, polyolefin)

70
Q

Nitroprusside brand names

A

Nitropress, Nipride

71
Q

Nitroprusside is not for direct injection & must be diluted with

A

D5W

72
Q

Nitrprusside can cause increased:

A

Intracranial pressure

73
Q

If nitroprusside turns this color, it indicates degradation to cyanide

A

Blue

74
Q

Inotropes increase:

A

contractility of the heart

75
Q

Dobutamine MOA

A

Beta-1 agonist

76
Q

Milrinone MOA

A

PDE-3 inhibitor

77
Q

Which drugs are inotropes

A

Dobutamine & milrinone

78
Q

Dobutamine may turn what color due to oxidation, but it does not indicate potency has been lost

A

Slightly pink

79
Q

How is shock characterized

A

Hypoperfusion usually in the setting of hypotension

80
Q

General principles of treating shock

A
  • Optimize preload with IV crystalloid bolus (PRN)
  • Peripheral vasoconstrictor (alpha-1 agonist) to increase systemic vascular resistance (SVR)
  • Beta-1 agonist to increase myocardial contractility & CO
81
Q

First-line therapy for hypovolemic shock that is not caused by hemorrhage

A

Fluid resuscitation with Crystalloids

82
Q

If the patient does not respond to initial crystalloid therapy in hypovolemic shock, vasopressors may be indicated, but they will not be effective unless:

A

Intravascular volume is adequate

83
Q

Example of distributive shock

A

Sepsis

84
Q

Two common causes of ICU infections

A
  • Mechanical ventilation pushes air into the lungs for pts who cannot breathe on their own
  • Foley catheters
85
Q

Bundles to reduce mortality from sepsis and septic shock includes

A

Early administration of broad-spectrum abx & IV fluid resuscitation with IV crystalloids

86
Q

If adequate perfusion cannot be maintained with IV crystalloids in septic shock, what is the vasopressor of choice that can be used

A

Norepinephrine

87
Q

Sudden weight gain, inability to lie flat without becoming SOB, decreasing functionality, increasing SOB and fatigue is called acute decompensated HF & when hypotension and hypoperfusion are also present it is called

A

Cardiogenic shock

88
Q

Beta-blockers should only be stopped in an acute decompensated HF episode if:

A

hypotension or hypoperfusion is present

89
Q

What is the name of the catheter that some patients with acute decompensated HF require

A

Swan-Ganz catheter

90
Q

What does the Swan-Ganz catheter measure in acute decompensated HF

A

pulmonary capillary wedge pressure (for congestion)

91
Q

What treatments are used for volume overload in acute decompensated HF

A

Loop diuretics

Vasodilators can be added (NTG, nitroprusside, nesiritide)

92
Q

What treatments are used for hypoperfusion in acute decompensated HF

A

Inotropes (dobutamine, milrinone)
If the pt becomes hypotensive, consider adding a vasopressor
*avoid vasodilators since they can ↓ BP and worsen hypoperfusion

93
Q

First-line for analgesia in the ICU

A

Opioids given IV like morphine, hydromorphone and fentanyl

94
Q

____ are preferred for sedation and are associated with improved ICU outcomes

A

Non-BZDs like propofol and dexmedetomidine

95
Q

dexmedetomidine brand name

A

Precedex

96
Q

What is the only sedative approved for use in intubated and non-intubated pts

A

dexmedetomidine

97
Q

Which atypical antipsychotic may be beneficial in delerium

A

Quetiapine

98
Q

Fentanyl brand name for ICU

A

Sublimaze

99
Q

dexmedetomidine MOA

A

Alpha-2 adrenergic agonist

100
Q

dexmedetomidine side effects

A

Hypo/hypertension, bradycardia

101
Q

Duration of infusion for dexmedetomidine should not exceed ____ hrs per FDA labeling

A

24 hrs

102
Q

Propofol brand name

A

Diprivan

103
Q

Propofol contraindications

A

Hypersensitivity to egg & soy

104
Q

Propofol side effects

A

Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare but can be fatal)

105
Q

Propofol vial & tubing should be discarded within how many hours of use due to bacterial growth

A

12 hrs

106
Q

Propofol oil-in-water emulsion provides ___ kcal/mL

A

1.1

107
Q

Lorazepam injection can cause

A

propylene glycol toxicity (acute renal failure and metabolic acidosis)

108
Q

Midazolam brand name

A

Versed

109
Q

Midazolam contraindications

A

Use with potent 3A4 inhibitors

110
Q

Midazolam can accumulate in

A

renal impairment (active metabolite)

111
Q

Etomadite monitoring

A

Adrenal insufficiency

112
Q

Ketamine warnings

A

Emergence reactions (vivid dreams, hallucinations, delirium)

113
Q

What are the recommended agents for prevention of stress ulcers

A

H2RAs and PPIs

114
Q

PPIs have been associated with an increased risk of

A

GI infections (C.diff), fractures and nosocomial pneumonia

115
Q

Which risk factors in the ICU is associated with the development of stress ulcers

A

Mechanical ventilation > 48 hrs

Coagulopathy

116
Q

Inhaled anesthetics can rarely cause

A

malignancy hyperthermia

117
Q

Which anesthetic commonly used in epidurals can be fatal if administered IV

A

Bupivacaine

118
Q

Local anesthetic

A

Lidocaine (Xylocaine)

119
Q

Inhaled anesthetics

A

desflurane (Suprane), sevoflurane

120
Q

Injectable anesthetics

A

Bupivacaine, ropivacaine

121
Q

Neuromuscular blocking agents can cause

A

paralysis of the skeletal muscle

122
Q

Patients can require the use of a NMBA agent in surgery for what reasons:

A

to facilitate mechanical ventilation
to manage increased intracranial pressure
to treat muscle spasms (tetany)

123
Q

Patients should receive adequate what before starting and NMBA

A

Sedation and analgesia

124
Q

Patients must be ______ while on NMBAs since they can paralyze the diaphragm

A

mechanically ventilated

125
Q

All NMBAs must be labeled with a colored auxiliary label stating:

A

“WARNING, PARALYZING AGENT”

126
Q

What is the only available depolarizing NMBA

A

Succinylcholine

127
Q

Succinocholine is typically reserved for

A

intubation

128
Q

Special care when using NMBAs includes

A

protecting the skin, lubricating the eyes and suction the airway frequently to clear secretions

129
Q

Which anticholinergic drug can be used to reduce secretions when using NMBAs

A

Glycopyrrolate

130
Q

Which drug is a non-depolarizing NMBA

A

Cisatracurium

131
Q

Cisatracurium brand name

A

Nimbex

132
Q

Side effects for all non-depolarizing NMBAs

A

Flushing, bradycardia, hypotension, tachyphylaxis

133
Q

How is Cisatracurium metabolized

A

Hofmann elimination (independent of renal and hepatic function)

134
Q

Which non-depolarizing NMBA is long-acting

A

Pancuronium

135
Q

How do systemic hemostatic drugs work

A

They inhibit fibrinolysis or enhance coagulation

136
Q

Tranexamic acid injection brand name

A

Cyklokapron

137
Q

Tranexamic acid tablet brand name

A

Lysteda

138
Q

Recombinant Factor VIIa brand name

A

NovoSeven RT

139
Q

Lysteda (tranexamic acid tablet) is approved for

A

Heavy menstrual bleeding

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