Critical Care/Fluids Flashcards
Peripheral nervous system breaks down into what 2 systems?
somatic and autonomic
Somatic nervous system controls ________
vs
autonomic nervous system controls _______
somatic: muscle movement
autonomic: bodily functions (digestion, cardiac output, blood pressure)
Autonomic nervous system breaks down into what different systems?
sympathetic and parasympathetic
Sympathetic or Parasympathetic:
is the “rest and digest” system
parasympathetic
Sympathetic or Parasympathetic:
is known as the fight/flight system
sympathetic
Sympathetic or Parasympathetic:
will release NE and Epi to act on adrenergic receptors
sympathetic
Sympathetic or Parasympathetic:
causes SLUDD
parasympathetic
what does SLUDD stand for
salivation lacrimation urination diarrhea/defecation digestion
Sympathetic or Parasympathetic:
releases Ach to act on muscarinic receptors
parasympathetic
Sympathetic or Parasympathetic:
- will increase glucose production
- will increase bronchodilation
sympathetic
Sympathetic or Parasympathetic:
will increase HR and BP
sympathetic
Muscarinic receptors:
what happens with AGONIST action
increased SLUDD (salivation lacrimation urination diarrhea/defecation digestion)
examples of muscarinic agonists?
pilocarpine
bethanecol
examples of muscarinic antagonists?
atropine
oxybutynin
Alpha 1 receptors:
what happens with AGONIST action
increased vasoCONSTRICTION
increased blood pressure
examples of alpha 1 agonists?
phenylephrine
examples of alpha 1 antagonists?
phentolamine
doxazosin ("alpha blockers")Alpha 1 receptors:
what happens with ANTAGONIST action
increased vasodilation (via smooth muscle relaxation) decreased blood pressure
examples of beta 1 agonists?
dobutamine
examples of beta 1 antagonists?
selective beta blockers and non-selective
Beta 1 receptors:
what happens with ANTAGONIST action
decreased Cardiac output and HR
Beta 1 receptors:
what happens with AGONIST action
increased Cardiac output and HR
Beta 2 receptors:
what happens with AGONIST action
increased bronchodilation
Beta 2 receptors:
what happens with ANTAGONIST action
bronchoCONSTRICTION
increased vasodilation
decreased BP
Examples of beta 2 AGONIST?
albuterol
terbutaline
Examples of beta 2 antagonists?
non-selective beta blockers
Clonidine is a _________ agonist and leads to overall _______
CENTRALLY located alpha 2;
overall DECREASED sympathetic output
Vasopressors:
work by stimulating ______ receptors
cause vaso________
which increased ______ and ______
alpha
vasoconstriction…
increased SVR (systemic vascular resistance)
increased blood pressure
______ is a natural precursor to NE
dopamine
which vasopressor’s MOA (which receptors it hits) is dose dependent?
dopamine
Dopamine is a dopamine-1 agonist at a (low, medium, high) dose which is this dosing range ________
LOW;
1 - 4 mcg/kg/min
Dopamine is a beta-1 agonist at a (low, medium, high) dose which is this dosing range ________
medium;
5 - 10 mcg/kg/min
Dopamine is a alpha-1 agonist at a (low, medium, high) dose which is this dosing range ________
HIGH;
10 - 20 mcg/kg/min
Boxed warning:
All vasopressors are _______ when given ____;
treat with ________
vesicants (cause extravasation); given IV
treat w/ phentolamine
Vasopressors should be given via a ______ line
central line
Monitoring for vasopressors?
CONTINUOUS BP monitoring
HR
MAP
ECG
Epinephrine dosing for IV push?
0.1 mg/mL (1 : 10,000 ratio strength)
Epinephrine dosing for IM injection or compounding IV products?
1 mg/mL (1: 1000 ratio strength)
Examples of vasopressors?
Dopamine Epinephrine Norepinephrine Phenylephrine Vasopressin
Vasopressin — known as ______ and ______
AVP (arginine vasopressin) and ADH (antidiuretic hormone)
Examples of Vasodilators?
Nitroprusside
Nitroglycerin
nesiritide
Which vasodilator is used for MIs/ uncontrolled HTN
nitroglycerin
How long can you use Nitroglycerin?
24 - 48 hours MAX because of tachyphylaxis
Metabolism of which vasodilator will lead to toxicity via thiocynate or cyanide?
nitroprusside
which vasodilator is a recombinant B type natriuretic peptide (will work by binding to vascular smooth muscle and increase cGMP)?
Nesiritide
Which vasodilator requires a non-PVC container
nitroglycerin
Contraindications for nitroglycerin?
SBP < 90 mmHg;
concurrent use of PDE-5 inhibitors or riociguat
Warnings of nitroglycerin?
severe hypotension and increased intracranial pressure
which vasopressor requires light protection during administration?
nitroprusside
Nitroprusside: use only ______ solutions;
a ______ solution indicates degradation to cyanide and you must not use it!!
use CLEAR;
a blue colored solution = cyanide
which vasopressor is not used commonly? (because it has not been found to reduce mortality…)
nesiritide
Inotropes increase what?
contractility of the heart
what are some common inotropes?
DOBUTamine
Milrinone
Which inotrope MUST be dose reduced in renal impairment?
Milrinone
which inotrope might turn pink due to oxidation (but is still ok to use if it does turn pink?)
DOBUTamine
what color may dobuatmine may turn due to oxidation
pink
Shock = hypoperfusion usually due to hypotension
defined as
SBP < _____ mmHg
or
MAP < _____mmHg
SBP < 90
MAP < 70
4 main types of shock?
hypovolemic
distributive
cardiogenic
obstructive
1st line treatment for hypovolemic shock that is not caused by hemorrhage?
crystalloids
Blood products for shock should be used when?
if Hgb < 7 (< 10 if CV pt)
or if significant active bleed
Shock treatment principles (what 3 steps?)
Fill the tank: IV crystalloids
Squeeze the pipes: vasopressors - alpha agonist to cause vasoconstriction and thus increase SVR
Kick the pump: beta 1 agonist to increase myocardial contractility/cardiac output
what is the only sedative approved for intubated AND non intubated patients
dexmedetomidine
possible ways to decrease the incidence of delirium?
sedate with NON benzos
and/or shorten the duration in patients who already have it
is it recommended to use haloperidol for delirium in ICU pts?
not recommended – very little evidence
caution with injectable lorazepam??
formulated in propylene glycol — therefor risk for propylene glycol toxicity
what is PRIS
propofol related infusion syndrome – rare but fatal
propofol can cause which metabolic change?
high triglycerides….
monitor if used for more than 2 days
Administration notes for Propofol:
Do not use filter < ______
5 micron
Administration notes for Propofol:
Discard vial/tubing after _______
12 hours
Administration notes for Propofol:
is a _____ in a _____ emulsion
oil in water
Which sedative provides 1.1 kcal/mL?
propofol
Dexmedetomidine:
do not exceed infusion > ______
24 hours
MOA of dexmedetomidine?
alpha 2 adrenergic agonist
risk factors for stress ulcer?
**mechanical ventilation coagulopathy** sepsis traumatic brain injury burn patients acute renal failure high dose systemic steroids
what are the different types of anesthetics?
local
regional
general
what type of anesthetic will cause malignant hyperthermia
inhaled anesthetics
examples of local anesthetics
lidocaine
benzocaine
LIPOSOMAL bupivacaine
examples of inhaled anesthetics
desflurane
sevoflurane
nitrous oxide
isoflurane
brand of desflurane?
Suprane
brand of sevoflurane?
Ultane
examples of injectable anesthetics?
bupivacaine
ropivacaine
lidocaine
Bupivacaine (which is commonly found in ______) is FATAL if administered ______
found in epidurals;
fatal if administered IV
Lidocaine (should or should not) be given dual routes (IV and topical)
should NOT
Lidocaine and _______ are typically used together to keep lidocaine localized
epinephrine (causes vasoconstriction)
what does NMBA stand for
neuromuscular blocking agent
NMBAs cause _______ of _______
paralysis of skeletal muscle
T or F: NMBAs help with pain AND sedation
false; it helps with NEITHER pain or sedation
patients must get adequate sedation/analgesia prior to NMBA
NMBAs:
T or F: patients need mechanically ventilated
TRUE!
NMBAs cause diaphragm paralysis
All NMBAs need a label that say ______ (per ISMP)
WARNING: PARALYZING AGENT
types of NMBAs
depolarizing and polarizing
Options for depolarizing NMBA?
only thing available = succinylcholine
MOA of succinylcholine:
Resembles _______
binds to and activates _______ receptors which ________ them
resembles acetylcholine;
activates acetylcholine receptors;
desensitizes them
Patients on NMBAs cannot move, blink, or breath…
can use _______ to reduce secretions
glycopyrrolate (anticholinergic
what drugs can be used to reverse NMBAs?
neostigmine methylsulfate and sugammadex
brand for neostigmine methylsulfate
Bloxiverz
brand for sugammadex
Bridion
neostigmine methylsulfate or sugammadex?
is an acetylcholinesterase inhibitor
neostigmine
neostigmine methylsulfate and sugammadex?
reverses rocuronium or vercuronium (aka only reverses non-depolarizing agents)
sugammadex
Examples of hemostatic drugs
Tranexamic Acid
Recombinant Factor VIIa
Aminocaproic Acid
Topical hemostatic drugs are usually used in surgery:
It is usually _______ in a bunch of different dosage forms
thrombin
Drug name examples for topical thrombin products
Recothrom
IVIG stands for ?
intravenous immunoglobulin (IgG)
Possible indications for IVIG?
immunodeficiency conditions, guillan barre, MS, myasthenia gravis
(look at products for specific indications)
Some brand names for IVIG?
Carimune NF Flebogamma DIF Gammagard Gamunex-C Octagam Privigen
How to dose IVIG?
use IBW!!
Use a slower infusion rate for IVIG for what patients?
renal and cardiovascular disease patients
Contraindication to using IVIG?
IgA deficiency
Boxed Warnings for IVIG:
Acute _______; more common with products stabilized in _______
Acute renal dysfunction;
sucrose
Boxed Warnings for IVIG:
Use with caution (because of acute renal issues) in what patients?
pts with…
- renal disease
- diabetes
- volume depletion
- sepsis
- paraproteinemia
- nephrotoxic medications
Boxed Warnings for IVIG:
Can cause _______ even when no risk factors
thrombosis
Monitoring for IVIG?
renal function
urine output
volume status
Hyponatremia:
Considered < _____ mEq/L
but not symptomatic until ______ usually
< 135;
Symptomatic: < 120
Hypotonic Hypovolemic Hyponatremia:
usually caused by?
diuretics salt wasting syndromes adrenal insufficiency blood loss vomiting/diarrhea
Hypotonic Hypovolemic Hyponatremia:
usually treated with
treat underlying cause… and sodium chloride solutions
Hypotonic Hypervolemic Hyponatremia:
usually caused by?
fluid overload (because of cirrhosis, heart failure, or renal failure usually)
Hypotonic Hypervolemic Hyponatremia:
usually treated with?
diuretics and fluid restriction
Hypotonic Isovolemic Hyponatremia:
usually caused by?
SIADH (syndrome of inappropriate antidiuretic hormone)
Arginine vasopression (AVP) receptor antagonists examples?
conivaptan or tolvaptan
Arginine vasopression (AVP) receptor antagonists are usually used to treat what?
SIADH and hypervolemic hyponatremia
Arginine vasopression (AVP) receptor antagonists are useful because they cause ______ excretion but while maintaining _______
water excretion;
maintain sodium
Arginine vasopression (AVP) receptor antagonists aren’t used that much because they are a lot more expensive than ________
3% saline
Correcting sodium more than _____mEq/L over ____ hours can cause issues
12 mEq/L over 24 hours
what issues can happen if sodium is corrected too quickly
ODS (osmotic demyelination syndrome) or CPM (Central pontine myelination) or paralysis/seizures/death
Contraindication to Conivaptan?
hypovolemic hyponatremia
anuria
ADEs of Conivaptan?
orthostatic hypotension
fever
hypokalemia
infusion site reaction (very common)
How is Conivaptan and Tolvaptan given?
Coni: IV
Tolva: PO - tablet
Conivaptan or Tolvaptan?
which one is limited to less than 30 days for use due to hepatoxicity
Tolvaptan
Contraindication to Tolvaptan?
- people who cannot respond/sense response to thirst
- if Na needs to increase quickly
- anuria
Warnings for Tolvaptan?
hepatoxicity
ADEs for Tolvaptan?
thirst nausea dry mouth polyuria weakness
Hypernatremia is > _____mEq/L
145
Cause of hypovolemic hypernatremia - and how to treat???
dehydration
vomiting/diarrhea
tx w/ fluids
Cause of hypervolemic hypernatremia - and how to treat???
caused by intake of hypertonic fluids
treated with diuresis
Cause of Isovolemic (euvolemic) hypernatremia - and how to treat???
caused: by diabetes insipidus - which decreases ADH
tx with desmopressin
Hypokalemia is < ____mEq/L
3.5
Potassium:
A drop of 1 mEq/L in serum K+ = about a total body deficit of ____ - ____ mEq
100 - 400
Potassium Replacement: (for safest replacement)
- give thru a _____ line
- infusion rate should be < _____ mEq/HOUR
peripheral
be < 10 mEq/hour
Potassium Replacement:
if want to infuse K+ faster than 10 mEq/hour — what 2 things must you do
use CENTRAL line and have cardiac monitoring
Maximum concentration of Potassium??
Max is 10 mEq/100 mL
IV potassium can be fatal if given _______ or _______
given UNDILUTED or IV Push
If hypokalemia is being resistant to treatment;
check serum ________ (it is needed for K+ uptake)
magnesium
Hypomagnesium is < ___mEq/L
1.3
When serum magnesium is less than _____ mEq/L there are life threatening symptoms that include what???
treat this how??
< 1 mEq/L
seizures and arrhythmias
IV magnesium SULFATE recommended here
Magnesium replacement should continue for how long to fully replace body stores???
5 days
Hypophosphotemia:
usually < ____ mg/dL
is it (usually asymptomatic/not life threatening) or is it (severe and symptomatic)
treat how??
1 mg/dL
severe and symptomatic
IV phosphorous
Less severe hypophosphotemia can be treated orally — full replacement takes how long?
1 week or longer
