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Therapeutics Spring 2015 > Exam 1 Flashcards > Flashcards

Exam 1 Flashcards

1
Q

Vitamin C deficiency

A

Scurvy – connective tissue dysfunction

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2
Q

Vitamin A deficiency

A

Night blindness

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3
Q

Vitamin D deficiency

A

Ricketts or osteomalacia

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4
Q

Thiamin deficiency

A

Beriberi – muscle weakness/atrophy

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5
Q

Riboflavin deficiency

A

Skin breakouts

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6
Q

Niacin deficiency

A

Pellagra (dermatitis, diarrhea, dementia). alcoholics

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7
Q

Pyridoxine (Vit B6) deficiency

A

Mild–mood disorders. Severe – neuropathy/convulsions

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8
Q

Folic acid deficiency

A

Anemia, birth defects, esp pregnant women and alcoholics

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9
Q

Zn deficiency

A

Poor growth, healing, immune response, sexual development

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10
Q

Glucose transporter influenced by insulin

A

GLUT4

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11
Q

Glucose transporter in liver

A

GLUT2

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12
Q

Glucose transporter in brain

A

GLUT3

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13
Q

Caloric intake for preterm infant

A

100-120+ kcal/kg/day

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14
Q

Caloric intake for infant 0-6 mos

A

100-110 kcal/kg/day

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15
Q

Caloric intake for infant 6-12 most

A

90-100 kcal/kg/day

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16
Q

Caloric intake for child 1-7 yrs

A

60-80 kcal/kg/day

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17
Q

Protein intake for preterm infant

A

3.5-4 g/kg/day

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18
Q

Protein intake for infant 0-6 mos

A

2-3 g/kg/day

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19
Q

Protein intake for infant 6-12 mos

A

1.5-2 g/kg/day

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20
Q

Protein intake for child 1-7 yrs

A

1-2 g/kg/day

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21
Q

Fluid requirements for infant 0-3 kg

A

120 mL/kg/day

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22
Q

Fluid requirements for infant 3-10 kg

A

100 mL/kg/day

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23
Q

Fluid requirements for infant 11-20 kg

A

1000 mL/day + 50 mL/kg/day

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24
Q

Fluid requirements for infant >20 kg

A

1500 mL/day + 20 mL/kg/day

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25
Q

Caloric density of breastmilk

A

20 kcal/ounce

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26
Q

Wt loss goal for pt BMI >30 or >25 w comorbidity

A

5-10% over 6 most without regain

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27
Q

Who is bariatric surgery recommended for?

A

Pt BMI >40 or >35 w comorbidity

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28
Q

Noradrenergic agent important points

A

For short-term management, potential for abuse, watch out if cardiovascular issues–tends to aggravate

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29
Q

Orlistat Xenical and Alli important points

A

Causes oily stools through mechanism of action, bad if absorptive issues already, good for T2DM or HLD patients

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30
Q

Lorcaserin (Belviq) important points

A

Suppresses appetite thru serotonin pathways, good tolerability and dosing schedule, lower weight loss

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31
Q

Topiramate/phentermine (Qsymia) important points

A

Titration schedule, greatest weight loss, REMS program because teratogen, avoid if HTN, CVD

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32
Q

Naltrexone/bupropion (Contrave) important points

A

CYP enzyme interactions, titration schedule, avoid if HTN, seizure, opioid addiction, high % nausea

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33
Q

Liraglutide (Saxenda) important points

A

Increase satiety by increasing insulin release, slow gastric emptying, titration, BEST for T2DM, REMS program, high # GI side effects

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34
Q

Putting anything but breastmilk/formula into bottle, giving child under 1 year honey, cow’s milk, choking hazards, or potential allergens – bad idea or good idea?

A

Bad idea

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35
Q

Introducing 1 new food every 4-5 days, increasing serving size gradually, and emphasizing all food groups – bad idea or good idea?

A

Good idea

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36
Q

mEq Na in NS

A

154

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37
Q

NS – maintenance, rehydration, or resuscitation?

A

Resuscitation

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38
Q

LR – maintenance, rehydration, or resuscitation?

A

Resuscitation

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39
Q

1/2 NS – maintenance, rehydration, or resuscitation?

A

Maintenance

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40
Q

D5W – maintenance, rehydration, or resuscitation?

A

Rehydration

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41
Q

Most common MIVF

A

1/2NS + D5W + 20mEq KCl

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42
Q

Which is for fluid restricted patients – Albumin 5% or Albumin 25%?

A

Albumin 25%

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43
Q

Which are used for fluid expansion – crystalloids or colloids?

A

Colloids

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44
Q

List specific monitoring parameters to assess fluid balance

A

UOP, HR, BP, CVP, MAP, wt, I/O, BUN/SCr ratio

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45
Q

What is the most common cause of hypertonic hyponatremia?

A

Elevated blood glucose

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46
Q

What is the most common cause of pseudohyponatremia?

A

High proteins/lipids causing increased plasma volume, falsely diluting Na

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47
Q

What are the characteristic symptoms of hypervolemic hypotonic hyponatremia?

A

Edema and weight gain

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48
Q

What do you always use to treat hypervolemic hypotonic hyponatremia?

A

Furosemide (3% saline only if symptomatic)

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49
Q

What is a common cause of isovolemic hypotonic hyponatremia?

A

SIADH

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50
Q

What treatment is usually enough for isovolemic hypotonic hyponatremia?

A

Water restriction with NS. If symptomatic, treat like hypervolemic hypotonic hyponatremia.

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51
Q

What needs to be done for patients with hypovolemic hypotonic hyponatremia?

A

Restore volume deficit. If symptomatic, 3% NaCl first.

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52
Q

What general category of causes can lead to hypovolemic hypotonic hyponatremia?

A

Fluid losses – blood, GI fluid, loss from skin (burn)

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53
Q

What do you treat first in hypovolemic hypernatremia?

A

Volume status if needed – use NS. Then restore free water deficit.

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54
Q

What synthetic hormone is the treatment for isovolemic hypernatremia?

A

Vasopressin (synthetic ADH)

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55
Q

What treatment is usually enough to correct hypervolemic hypernatremia?

A

Stop hypertonic fluids or other cause. Diuretic only if needed.

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56
Q

What major symptom do we worry about in potassium disorders?

A

Cardiac arrhythmias or changes in function

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57
Q

If a patient has asymptomatic hypokalemia, what should they be given to treat it?

A

PO potassium – liquid, powder, tablets, etc.

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58
Q

Under what situations should a hypokalemic patient receive IV potassium?

A

If K <2.5 or 3, cannot tolerate PO, or if S/Sx present (change in ECG/spasms)

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59
Q

At what rate can you administer IV potassium?

A

Without cardiac monitoring, 10 mEq/hr. With continuous cardiac monitoring, 20 mEq/hr. If emergent with severe hypokalemia, 40-60 mEq/hr.

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60
Q

What is a signature symptom of hyperkalemia?

A

Peaked T wave

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61
Q

What do you use to treat hyperkalemia? (Correct order necessary)

A
  1. CaCl2, IVP2. Insulin with D50W or NaHCO3 or albuterol3. (If needed) Furosemide or hemodialysis or Kayexalate (only if GI intact)
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62
Q

What other electrolyte disturbances are magnesium disturbances related to?

A

Potassium and calcium

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63
Q

If PO magnesium cannot be given to a hypomagnesemic patient, how much Mg be administered IV?

A

0.5 mEq/kg if Mg is 1-2 mg/dL or 1 mEq/kg if Mg is <1 mEq/dL at a rate of 1 gm/hr

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64
Q

What is ratio of mEq of Mg to grams of Mg?

A

8 mEq = 1 gm

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65
Q

What is the normal range for ionized calcium?

A

4.6 - 5.1 mg/dL

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66
Q

What equivalents do we use when replacing calcium?

A

1 gram CaCl2 = 3 grams Ca gluconate = 270 mg elemental calcium

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67
Q

When should calcium gluconate be used?

A

If only line in is peripheral and in non-acute/non-emergent situations

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68
Q

When should calcium chloride be used?

A

When administering into central line or during a code

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69
Q

At what rate should calcium be replaced?

A

1 gram of calcium product per hour

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70
Q

What other disorder is it important to watch out for in calcium disorders?

A

Magnesium disorders

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71
Q

Which types of patients are more prone to hypercalcemia?

A

Cancer patients – treatments also more chronic

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72
Q

What electrolyte besides calcium is regulated by vitamin D and parathyroid hormone?

A

Phosphate

73
Q

In asymptomatic hypophosphatemic patients, are there PO products available?

A

Yes – administer in divided doses

74
Q

Under which situations should you choose KPhos for IV replacement over NaPhos?

A

If K <4 mEq/L

75
Q

What is the mMol to mEq equivalent for NaPhos?

A

1 mMol NaPhos = 1.33 mEq each Na and PO4

76
Q

What is the mMol to mEq equivalent for KPhos?

A

1 mMol KPhos = 1.47 mEq each K and PO4

77
Q

What rate should you not exceed when replacing phosphate?

A

NMT 7 mMol/hr

78
Q

What amount of phosphate should you give if a patient’s phosphate is <1.6?

A

1 mMol/kg

79
Q

What amount of phosphate should you give if a patient’s phosphate is 1.6 - 2.2?

A

0.64 mMol/kg

80
Q

What is used to treat hyperphosphatemia?

A

IV calcium

81
Q

How fast should a patient’s sodium deficit be replaced?

A

1/2 over 1st 8 hours, then next half over next 16 hours

82
Q

How fast should a patient’s free water deficit be replaced?

A

1/2 over 1st day, then next half over next day or two

83
Q

What are the short term routes of enteral nutrition?

A

Nasogastric, nasoenteric, and jejunal tubes

84
Q

What are the long term routes of enteral nutrition?

A

Jejunostomy, gastrostomy, PEG

85
Q

What are the two routes of parenteral nutrition?

A

Peripheral parenteral nutrition and central parenteral nutrition

86
Q

True or false: Most hospitalized patients suffer from acute malnutrition

A

False – most hospitalized patients are somewhere between acute and chronic malnutrition

87
Q

What are patients at risk for if they suffered weight loss of 5-10% body weight in 6 months, had abnormal dietary intake for 1 month, or had anorexia, nausea, vomiting, or diarrhea for a few days?

A

Moderate malnutrition

88
Q

Which type of malnutrition usually develops over months to years?

A

Marasmus – protein/calorie malnutrition

89
Q

True or false: Albumin responds quickly to changes in nutrition

A

False – Prealbumin is a better indicator of protein and calorie intake

90
Q

Is urine the only way we lose nitrogen?

A

No. Also sweat, feces, respirations, GI fistula, wound drainage, burns, etc.

91
Q

What is the goal nitrogen balance for a hospitalized patient?

A

+4 grams (but 0 for maintenance)

92
Q

How many calories does propofol provide?

A

1.1 kcal/mL

93
Q

What ions should monitor to look for refeeding syndrome?

A

Mg, Phos, and K

94
Q

Accelerated proteolysis, glycogenolysis, lipolysis, gluconeogenesis, insulin resistance, (-) nitrogen balance, and hypertriglyceridemia are metabolic responses to what?

A

Stress (could include sepsis, major surgery, major burns, etc.)

95
Q

True or false: If you have correctly calculated a patient’s nutrition requirements, there is no need to watch them for overfeeding or underfeeding.

A

False – patient’s response to nutrition support should be monitored closely – treat the patient, not the number

96
Q

Which value is higher – BEE, REE, or TEE?

A

TEE (total energy expenditure) because TEE = BEE*activity factor. BEE just metabolic activity required to maintain life if no activity

97
Q

Under what circumstances should you use a nutrition body weight?

A

If actual bw is between 130% and 150% of IBW.

98
Q

If a patient’s body weight is >150% IBW, what weight should you use?

A

IBW (permissive underfeeding)

99
Q

What is your goal daily calorie range for a non-stressed, non-depleted patient?

A

20 - 25 kcal/kg/day

100
Q

What is your goal daily calorie range for a trauma/surgery/stressed patient?

A

25 - 30 kcal/kg/day

101
Q

What is your goal daily calorie range for a major burn patient?

A

35 - 40 kcal/kg/day

102
Q

What is your goal daily calorie range for a for an obese patient?

A

22 - 25 kcal/kg/day times IBW (kg) permissive underfeeding

103
Q

What is your goal daily protein range for a non-hospitalized patient?

A

0.8 - 1 g/kg/day

104
Q

What is your goal daily protein range for a mild to moderately stressed patient (medical floor/repletion)?

A

1 - 1.5 g/kg/day

105
Q

What is your goal daily protein range for a moderate to severely stressed patient (trauma/surgery/ICU)?

A

1.5 - 2 g/kg/day

106
Q

What is your goal daily protein range for a burn patient?

A

2 - 2.5 g/kg/day

107
Q

What is your goal daily protein range for an obese patient?

A

2 g/kg/day times IBW

108
Q

What component of a TPN should be eliminated if a patient has an infection or sepsis?

A

Fat

109
Q

What is a goal respiratory quotient (RQ)?

A

0.85 - 0.95 (>1 indicates overfeeding)

110
Q

True or false: Parenteral nutrition is safer, less costly, better for the GI tract, and less wasteful than enteral nutrition.

A

False – all of these benefits are true for enteral nutrition.

111
Q

Dysphagia, dementia, head and neck surgery, esophageal obstruction, and trauma/burn are all indications for what type of nutrition?

A

Enteral nutrition

112
Q

Acute pancreatitis, high output proximal fistulas, intractable vomiting and diarrhea, GI ischemia, ileum, and nutrition need less than 7 days are all contraindications for what type of nutrition?

A

Parenteral nutrition

113
Q

What administration frequency of enteral nutrition is best tolerated?

A

Continuous administration

114
Q

What is the caloric density of enteral formulations for normal patients? For fluid restricted patients?

A

1 kcal/mL normally; 2 kcal/mL for fluid restriction

115
Q

Which of the following complications applies to enteral nutrition? Aspiration, GERD, pneumothorax, CVC infection, diarrhea, constipation, infusion pump failure, tube clogging

A

Aspiration, GERD, diarrhea, constipation, and tube clogging are all risks of enteral nutrition

116
Q

Does administration of drugs with enteral nutrition tend to increase or decrease bioavailability and pharmacologic effect?

A

Tends to decrease efficacy – must interrupt continuous feed for a few hours to give meds.

117
Q

In what form are the three macronutrients given in parenteral nutrition?

A

Protein – crystalline amino acids (4 kcal/g)Carbs – dextrose (3.4 kcal/g)Fat – emulsion with glycerol (10 kcal/g)

118
Q

What do 3-in-1 TPNs have that 2-in-1 TPNs do not?

A

Fat

119
Q

If a patient is in severe stress, malnutrition, has large caloric requirements, or will need PN >5 days, what kind of parenteral nutrition should he receive?

A

Central PN – via central line or PICC (peripherally inserted central catheter – good for 2-6 weeks)

120
Q

If a patient has bowel ischemia, intractable vomiting/diarrhea, morning sickness, GI obstruction, ileus, inflammatory bowel disease, severe pancreatitis, NPO course >7 days, or short bowel syndrome, what type of nutrition is indicated?

A

Parenteral nutrition

121
Q

What is a typical maximum carbohydrate utilization rate?

A

4 - 5 mg/kg/minute (up to 7 if trauma/burn)

122
Q

If a patient has an egg allergy, what part of a TPN might they react to?

A

Egg yolk phospholipid – fat part

123
Q

What value should daily lipid intake not exceed?

A

2.5 g/kg/day – no more than 60% daily caloric intake

124
Q

In choosing whether to use chloride or acetate salts to administer cationic electrolytes, what ratio should you initially formulate them at?

A

2/3 salts chloride, 1/3 acetate. (May depend on pt acid/base balance)

125
Q

What protein should never be added to TPN?

A

Albumin (high microbial growth potential)

126
Q

What size filter should be used for 3-in-1 TPN? 2-in-1 TPN?

A

1.2 micron for 3-in-1 or 0.22 for 2-in-1 (2 in 1 lacks fat so filter won’t disrupt emulsion)

127
Q

BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, P, AST, ALT

A

1 - 2 times a week

128
Q

BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, and P should all be measured ____ in an unstable patient.

A

Daily

129
Q

What can an elevated INR indicate?

A

Long-term malnutrition

130
Q

What patients are high risk for refeeding syndrome?

A

Malnourished patients

131
Q

To avoid refeeding syndrome, at what rate should you initiate TPN?

A

At half of the rate you calculated. In malnourished patients, consider initial rate of a quarter of calculation.

132
Q

Which should come first – electrolyte correction or nutrition support?

A

Electrolyte correction

133
Q

What is the biggest disadvantage of using 3-in-1 TPN over 2-in-1 TPN?

A

In 3-in-1 TPN, you cannot visibly detect problems with the mix (such as CaPO4 crystallization) because of the cloudiness caused by the fat emulsion.

134
Q

Trissel’s manual is an especially good reference for determining what kind of interaction?

A

Medication-TPN interactions

135
Q

What is always the first step in writing TPN for a patient?

A

Determining the correct weight to use

136
Q

For making TPN, what is the standard stock concentration for dextrose? Fat? Protein?

A

Dextrose – 70%Fat – 20% Protein – 10%

137
Q

How much “TPN space” do electrolytes usually take up?

A

~150 mL

138
Q

True or false: Once a patient is ready to be discharged, TPN can be discontinued immediately. The patient’s GI tract is functional so he can just switch to food.

A

False – TPN must be tapered down by 1/2 every 2 hours.

139
Q

What changes to TPN should be considered in patients with short bowel syndrome?

A

High-carb, low-fat diet with vitamin B12 supplementation prn

140
Q

What changes to TPN should be considered in patients with diabetes?

A

30% of total kcal given as fat, be sure to monitor blood glucose

141
Q

What changes to TPN should be considered in patients with cardiac disease?

A

Fluid restriction (check minimal volume), avoid overfeeding

142
Q

What changes to TPN should be considered in patients with renal disease?

A

Fluid restriction. If pre-dialysis, give low protein. If receiving dialysis, give standard protein.

143
Q

What changes to TPN should be considered in patients with pulmonary failure?

A

Give 30% - 50% of total kcal as fat, protein 1 - 2 g/kg, limit carbohydrates (think about RQ)

144
Q

What changes to TPN should be considered in patients with hepatic disease?

A

High calorie intake (35 kcal/kg/day), protein restriction if encephalopathy, sodium restriction if ascites or edema

145
Q

What is a normal pH range?

A

7.35 - 7.45

146
Q

What blood gas do metabolic disorders involve?

A

Bicarbonate (HCO3-)

147
Q

What blood gas do respiratory disorders involve?

A

CO2

148
Q

What is the henderson-hasselbach equation specified for our physiological bicarbonate buffer?

A

pH = 6.1 + log (HCO3-/0.03xpCO2)

149
Q

What is a normal pCO2?

A

40

150
Q

What is a normal HCO3-?

A

24

151
Q

Are decreased cardiac output and contractility, hyperkalemia, insulin resistance, inhibited anaerobic glycolysis, and coma signs of acidemia or alkalemia?

A

Acidemia

152
Q

Are decreased coronary and cerebral blood flow, increased angina, stimulation of anaerobic glycolysis, and seizures signs of academia or alkalemia?

A

Alkalemia

153
Q

What are our three buffers and which is the most prevalent?

A

Bicarbonate/carbonic acid, phosphate, and protein. Principal buffer = bicarbonate.

154
Q

What are the four systems that regulate acid/base balance?

A

Buffers, kidneys, lungs, and some liver.

155
Q

What are the two main ways that the kidney regulates acid base balance?

A

Reabsorbing bicarb and secreting H+

156
Q

Is the distal tubule responsible for reabsorbing bicarb or creating bicarb?

A

Creating bicarb – this is where H+ excretion mainly takes place and this is essential for bicarb synthesis.

157
Q

In bicarbonate reabsorption, what is the net change in bicarbonate and H+?

A

One filtered HCO3 reabsorbed, no change in H+

158
Q

What ion is hydrogen exchanged for when it is secreted?

A

Na+

159
Q

What is the end result of carbonic anhydrase inhibitor therapy?

A

Prevents bicarb reabsorption – urinate it out. Can cause metabolic acidosis or correct metabolic alkalosis.

160
Q

What type of bicarb generation has the highest capacity?

A

Ammonium excretion/ammoniagenesis – instead of the excreted H+ binding with HCO3 to reabsorb it, it binds with ammonia, so the bicarbonate that was made in the cell is essentially new bicarb that is absorbed into the capillary

161
Q

What ion does the secreted H+ bind with in titratable acidity?

A

Phosphate. Lower capacity because phosphate harder to access.

162
Q

What type of bicarb generation relies on ATP?

A

Distal tubular hydrogen ion secretion – H+ is transported into lumen by ATPase and HCO3 freely enters peritubular capillary

163
Q

What gas do chemoreceptors detect for ventilatory regulation?

A

PaCO2

164
Q

Where are the chemoreceptors for ventilatory regulation located?

A

Carotid artery, aorta, medulla

165
Q

What is hepatic regulation of acid/base balance based on?

A

Urea synthesis because 2 bicarb and 2 ammonium are needed to create urea. An increase in urea synthesis decreases the amount of bicarb.

166
Q

What disorder is characterized by low pH, low pCO2, and low HCO3?

A

Metabolic acidosis

167
Q

In what disorder is it always necessary to calculate an anion gap?

A

Metabolic acidosis

168
Q

What is a normal anion gap?

A

3 - 11 mEq/L

169
Q

When loss of plasma HCO3 is replaced by chloride, what kind of metabolic acidosis is this?

A

Non-anion gap acidosis. If HCO3 loss is replaced by something else, this is anion gap acidosis.

170
Q

GI bicarbonate loss, pancreatic fistulas/biliary drainage, renal bicarbonate loss (RTAs), TPN administration and chronic renal failure can all cause what acid/base disorder?

A

Non-anion gap metabolic acidosis

171
Q

What does MULEPAKS stand for?

A

Methanol intoxication, uremia, lactic acidosis, ethylene glycol, paraldehyde ingestion, aspirin (salicylates), ketoacidosis, sepsis

172
Q

Which acid/base disorder is MULEPAKS associated with?

A

Anion gap metabolic acidosis – HCO3 losses replaced by something other than Cl

173
Q

Shock, seizures, leukemia, hepatic/renal failure, DM, malnutrition, rhabdomyolysis, alcohol, metformin, NRTIs, propofol, and propylene glycol can all cause which of the causes in MULEPAKS?

A

Lactic acidosis

174
Q

Which acid/base disorders can be caused by salicylate toxicity?

A

Respiratory alkalosis from stimulation of breathing or metabolic acidosis from accumulation of organic acids.

175
Q

When should you treat metabolic acidosis with bicarb?

A

If pH < 7.10 - 7.15, hyperkalemia, overdoses, and in cardiac arrest if defibrillation, ventilation, and meds have already been used

176
Q

What is the calculation for dosing bicarb?

A

Dose (mEq) = (0.5 L/kg)(IBW)(12 mEq/L - actual HCO3) Give 1/3 to 1/2 calculated dose and monitor ABG~1 mEq/kg may be given in cardiac arrest

177
Q

What are the risks associated with bicarb therapy?

A

Overalkanization impairing O2 release, hypernatremia, hyperosmolality, CSF acidosis, electrolyte shifts (hypokalemia, hypocalcemia)

178
Q

Citrate and acetate are metabolized to…

A

bicarb.

Therapeutics Spring 2015 (12 decks)

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