Exam 3- the killer (cirrosis & vits) Flashcards
what scoring thing is used for dosage adjustments mainly?
child’s-pugh
- as the numbers get higher, the disease is worse)
what scoring thing is used for transplant considerations?
mayo end-stage liver disease score (MELD)
-higher the score, the higher pt is on the list
ascites physical exam
- full, tense + bulging abdomen
- seen via abdominal ultrasound (tells you that there is fluid there but not what the cause is)
tests that can be used to diagnose ascites
- BNP evaluation
- do an ECO
- abdominal paracentesis (this fluid removal is both therapeutic to the patient & helpful for diagnosis
what SAAG level tells you that the ascites is from cirrhosis?
SAAG > 1.1
What are all (5) treatments for ascites?
1- sodium restrict 2- aldosterone antagonists 3- loop diuretics 4- large volume paracentesis 5- last option = TIPS
1- sodium restriction in ascites tx
2g/day: do not wan to make the swelling any worse
-do not fluid restrict!
2- aldosterone antagonists in ascites tx
- spironolactone 50-100mg
- big SE = hyperkalemia
3- loop diuretic in ascites tx
furosemide 40mg
- helps to mobilize a lot of fluid but will decrease the potassium = the 40:100 ratio maintains normal kalemia*
- hold if SBP <90
- do not use thiazides
what happens if a pt is on 40:100 ratio and develops hyponatremia? (< 135)
add midodrine
4- large volume paracentesis in ascites tx
- 4-8L of fluid removed every 2 weeks
- see reduction in BP, Scr can increase & it can reduce mortality
- *if taking out more than 5L: give 8g of 25% albumin IV for every liter of fluid removed
5- LAST option for ascites tx: TIPS
-really good for refractory ascites, pts that cant tolerate a large volume paracentesis & refractory variceal bleeding
Side effects: *pts develop hepatic encephalopathy: livers ability to detoxify albumin us reduced
portal hypertension
-management is really about variceal bleeding prevention, not the development of variceals
portal hypertension diagnosis (2)
- difference in pressure between the portal vein and the hepatic vein → this is super difficult and invasive to measure: SAAG is what we use for diagnosis (SAAG >1.1 = diagnosis of portal hypertension)
- upper endoscopy to look for the presence of these varicies
When we see varicies, how do we treat them?
non- selective beta blockers!
- beta 1 will reduce HR = reduce cardiac output
- beta 2 will block the splanchnic vasodilation
what non-selective beta blockers are used in the tx of portal HTN?
- propranolol 20-40 mg bid
- nadolol 20-40mg qd
- carvedilol 3.125 mg bid (greatest antihypertensive effect)
- want to titrate up the meds till you get to a resting HR of ~60 beats/min
when do you decrease/hold the dose of a BB in portal HTN tx?
- if BP <90/<60
- HR<60
- refractory ascites
- pt has hepatorenal syndrome (lack of blood flow to the kidney)
- pts that have SBP (low bp, septic shock)
what are acute variceal bleeds?
- consequences of portal hypertension
- risk factor for SBP
what are the signs and symptoms to variceal bleeds?
- melema
- hematemesis
- coffee ground vomit
- decreased hemoglibin
treatment of variceal bleeds? (6)
- supportive care
- octreotide
- EVL
- TIPS (if above 2 fail)
- SBP prophylaxis
- non-selective beta blockers
supportive care in variceal bleeds
- IV fluids
- packed RBCs (keep hemoglobin ~8)
- O2 supp therapy
Octreotide in variceal bleed tx
50 mcg bolus then 50 mcg/hr infusion
EVL in variceal bleed treatment
- do an upper endoscopy & see the bleeding vessel and choke it off
- combo of EVL & octreotide is the best
What do you do in variceal bleeding if EVL + octreotide fail?
use TIPS
what is SBP prophylaxis in tx of variceal bleed
- 7 day course of Ceftriaxone IV (or any other 3rd gen cephalosporin)
- after bleeding has stabilized- use non-selective beta blocker to treat that portal hypertension
what gram - bacteria can cause SBP?
- e. coli, k. pneumonia*
- s. pneumonia & s. aureus
how to diagnose SBP?
- symptoms (fever, malaise, elevated WBCs, pain/tenderness in abdomen)
- paracentesis (> 250)
- bacterial culture
absolute polymorphonuclease leukocyte count equation
WBC (% PMN)
how to treat active infection of SBP?
- PMN > 250: cefotaxime or ceftriaxone x 5 days (empiric therapy)
- IV albumin 25% of 1.5 g/kg on day 1 then 1 g/kg on day 3 (ONLY IF they have: Scr >1, BUN > 30 & bili >4)
how to treat SBP prophylaxisly?
-anyone with acute variceal bleeding: IV ceftriaxone x 7 days (cipro for them allergies)
Indefinite therapy for SBP:
use if: pt has previous hx,
- ascitic protein <1.5 and 1 of these: Scr > 1.2, BUN > 25, Na+ < 130, CP score > 9 and bili > 3
- cipro 250-500mg daily
- bactrim DS tab daily
what is hepatic encephalopathy?
accumulation of toxins from declining hepatic function (reduced # of functional hepatocytes) + systemic shunting (less blood going into liver)
what toxin are we looking for in HE and what do we monitor?
- we can measure ammonia levels but they do not correlate with severity
- monitor mental status!
Treatment of HE
1- remove precipitating factors: opioids and benzos
2- effective dietary protein: switch pts to dairy or veggie protein sources
3- dealing with ammonia in the GI tract: lactulose
Lactulose treatment in HE
- acute HE (seeing things/hallucinating): 25 ml PO q1-2 hrs until 2 loose stools or retention enema for 1 hr given every 6-12 hours
- prevention of HE: 15-60ml 1 6-12 hours, titrate up until 2-3 soft bowel movements/day
- Rifaximin (as an add on);
- -> acute: 400mg q 8h
- -> maintenance: 550mg po BID
what is hepatorenal syndrome?
- due to that splanchic vasodilation secondary to portal hypertension = reduced circulating volume or intravenous volume = reduced renal perfusion
- high mortality rate, 2-4 weeks and the pt dies
diagnosis of hepatorenal syndrome:
-cirrhosis with ascites
-Scr > .3 mg in 48 hrs or > 50% increase in baseline in the last 7 days
(if there is not improvement in Scr after 2 days of diuretic cessation & IV albumin @ 1g/kg/day = HS)
therapies for hepatorenal syndrome:
- IV norepinephrine + IV albumin 1 g/kg/day
- -> response to this would show Scr decrease to <1.5 mg/dl or return within 0.3 mg/dL of baseline over a max of 2 weeks
- if after 4 days, Scr remains high- d/c, a bish finna die
PKPd changes in cirrhosis
1- decrease in liver blood flow due to portal hypertension (propranolol, morphine, carvedilol/coreg)
2- loss of hepatocyte function ( lorazepam > diazepam)
3- decreased albumin production = more therapeutic effect
4- reduced renal function in the setting of increased Scr
5- increased therapeutic response: BBB has increased permeability (benzos and opioids)
how are energy requirements estimated?
- kcal/kg/day
- harris-benedict
how are protein requirements estimated?
- g/kg/day
- 24hr urine nitrogen collection
indications for TPN (7)
- GI dysfunction (obstruction etc)
- adjunctive treatment for cancer
- pancreatitis
- critically ill
- per-operative: post op is unable to provide EN within 7-14 days
- hyperemesis
- eating disorder
when is peripheral TPN appropriate?
in pts who:
- do not have significant malnutrition
- have good peripheral vascular access
- can tolerate large volumes of fluid (2.5-3 L/day) **
- need 5-14 days of parenteral nutrition support
in refeeding syndrome what 3 things are depleted?
- potassium
- magnesium
- phosphate
how is refeeding syndrome treated?
-mandates aggressive supplementation of lytes + thiamine (50-100 mg/day)
what are some facts to know about lipids IVFE?
- should not be administered within first 7 days in the ICU
- should be avoided in pts with an egg allergy
- hepatotoxicity is related to their phytosterol content
factors interfering in calcium phosphate compatibility
- add phosphate BEFORE calcium
- increase in ph & temp = decrease in solubility
- decrease in ph = increase in solubility
what medication cannot be adminsitered jejunally?
cipro/ fluoroquinolones
amiodorone and drug adminstration
- absorption is improved with food
- gastric administration is required!*
Rivaroxaban things
- MUST BE ADMINSTERED WITH ENTERAL FEEDS- for the 15 & 20 mg tablets
- crush and mix in 50ml water
- avoid administration distal to the stomach
Apixaban things
- crush & mix in 60ml water or D5W
- mixture stable for 4 hours
Dabigatran things
CANNOT be crushed
Edoxaban things
- crush and mix in 60-90 ml water
- administer immediately
meds with limited-mo impact on F when given En
- atoaquone
- azole antifungals
- lenezolid
- metronidazole
- H2 receptor blockers
- levetiracetam
- pantoprazole
- tacrolimus
water soluble vitamins
- thaimine
- riboflavin
- niacin
- biotin
- pantothenic acid
- B6
- B12
- folate
- absorbic acid (vit C)
fat soluble vitamins
A D E K
thiamine facts
- deficiency in alcoholics
- neurologic sequale, wernickes encephalopathy (percipitated by glucose administration - 50-100mg thiamin), korsakoff’s psychosis
riboflavin facts- b2
-produces yellow pee when taken in access
niacin
pellagra is the deficiency state = Dermatitis, Diarrhea, Dementia
pyridoxine
-DDIs with levadopa, phenobarbital and phenytoin
cyanocobalamin (B12)
-essential for cell growth & replication
Deficiency: seen in older > 50yrs have decreased absorption, macrocytic anemia, irreversible nervous system damage
Folic acid (B9)
- *DNA synthesis and hematopoiesis (with B12/cyano)
- pregnant women need
drugs that may induce deficiency in folic acid
methotrexate, trimethoprim, phenytoin, oral contraceptives
vitamin C facts
-required for collagen synthesis/wound healing
-smokers and burned hoes may need increased requirements
deficiency = scurvy
vitamin A things
- essential in retinal function
- bone growth, reproduction & embryonic development ( doses at > 25000 = teratogenic)
- leading cause of blindness
vitamin E things
- antioxidant
- enhances vit A absorption, may protect against symptoms of hypervitamintosis A
toxic times: cancer and cardiovascular
-NO beta-carotene, vitamin E, selenium, vitamin C or folic acid
toxic times: anticoagulant therapy
-vitamin E associated with excessive bleeding
toxic times: smokers
vitamin A increases mortality
which point from admission should TPN be initiated assuming EN. can not be implemented?
7 days
Calcium-phosphate solubility in a parenteral nutrition solution is INCREASED when the _____
- phosphate is added to the solution before the calcium
- solution pH is decreased
an ideal candidate for peripherally administered parenteral nutrition should meet:
- do not have significant malnutrition
- good peripheral access
- can tolerate large volumes (2.3-5L)
- needs 5-14 days of support
what are the methods for determining protein requirements?
- urine for urea nitrogen
- gm/kg/day
what are the methods for determining energy requirements?
- kcal/g/day
- harris-beneduct
- indirect calorimetry
what is true regarding IVFE?
- should not be adminstered within the first 7 days in the ICU
- should be avoided in pts with an egg allergy
- hepatotoxicity is related to their phytosterol contentn
what electrolytes should be closely monitored in a pt at risk for developing refeeding syndrome?
- potassium
- magnesium
- phosphate
what vitamins are adequate for hematopoesis?
- cyanocobalamin (b12)
- folic acid (B9)
what to tell a prego bitch about vitamins
- folic acid is necessary to prevent serious birth defects
- adequate calcium and vitamin D support bone development
- dietry sources of iron may be used for supplementation
what is true regarding administration of medication via feeding tube?
judicious flushing of the feeding tube with water is necessary to maintain potency
alcoholic with bloody butt hole- what would you recommend in conjunction with administration of the glucose-containing fluid
- monitor electrolytes frequently (PMP)
- thiamine IV 50-100mg before and daily during glucose administration
- monitor for ataxia, nystagmus, and confusion
which of the following conditions would you advise AGAINST the corresponding vitamin supp b/c of an increased risk?
- smokers and beta carotene (vit A)
- CVD prevention and folic acid
- CVD prevention and vitmain E
Bish got non-occlusive bowel necrosis: what is associated with this development?
- utilization of a fiber-containing formula
- feeding into the jejunum
- enteral feeding without adequate volume resuscitation
what can contribute to the development of diarrhea in a tube-fed pt?
- metoclopramide
- antimicrobials
- magnesium
which medication MUST be administered with enteral feeding?
Rivaroxaban
which medication may increase the risk of developing a folic acid deficiency?
- trimethoprim
- methotrexate
- oral contraceptives
which of the following is true concerning evaluation of vitamin D
- 1,25 OH2D has a circulating half-life of 15 hours
- 25 OH2D represents vitamin D produced by the skin and intake from diet and supplements
- 25OhD is the best measure of vitamin D exposure
which of the following are potential complications of both parenteral and enteral nutrition?
-electrolyte abnormalities
for which of the following conditions would you advise the corresponding supplementation?
-gastrectomy- vitamin B12
what lab value is evaluated in cirrhosis about bleeding during the puncture?
PT/INR
hepatorenal syndrome therapies are targeted to do?
- increase intravascular volume
- reduce splanchnic vasodilation
if a pt has SBP, they should recieve a 3rd gen cepalo for how long?
5 days
the benefits of non-selective BBS in portal hypertension include all EXCEPT
prevent varix development
in a pt with cirrhosis, what phenytoin change in dosage would be needed
-decrease the dose
what side effect usually occurs in pts who get TIPs?
heptic encephalopathy
a cirrhotic pt has 6L of paracentesis removed: what meds should they be given?
- spirnolactone
- furosemide
- albumin
an abdominal paracentesis can be used for which of the following?
- SBP diagnosis
- portal hypertension diagnosis
- therapeutic removal of ascitic fluid
