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GI/Skin Therapeutics > Exam 3- the killer (cirrosis & vits) > Flashcards

Exam 3- the killer (cirrosis & vits) Flashcards

1
Q

what scoring thing is used for dosage adjustments mainly?

A

child’s-pugh

- as the numbers get higher, the disease is worse)

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2
Q

what scoring thing is used for transplant considerations?

A

mayo end-stage liver disease score (MELD)

-higher the score, the higher pt is on the list

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3
Q

ascites physical exam

A
  • full, tense + bulging abdomen

- seen via abdominal ultrasound (tells you that there is fluid there but not what the cause is)

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4
Q

tests that can be used to diagnose ascites

A
  • BNP evaluation
  • do an ECO
  • abdominal paracentesis (this fluid removal is both therapeutic to the patient & helpful for diagnosis
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5
Q

what SAAG level tells you that the ascites is from cirrhosis?

A

SAAG > 1.1

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6
Q

What are all (5) treatments for ascites?

A 
1- sodium restrict 
2- aldosterone antagonists 
3- loop diuretics 
4- large volume paracentesis 
5- last option = TIPS
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7
Q

1- sodium restriction in ascites tx

A

2g/day: do not wan to make the swelling any worse

-do not fluid restrict!

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8
Q

2- aldosterone antagonists in ascites tx

A
  • spironolactone 50-100mg

- big SE = hyperkalemia

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9
Q

3- loop diuretic in ascites tx

A

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
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10
Q

what happens if a pt is on 40:100 ratio and develops hyponatremia? (< 135)

A

add midodrine

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11
Q

4- large volume paracentesis in ascites tx

A
  • 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
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12
Q

5- LAST option for ascites tx: TIPS

A

-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

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13
Q

portal hypertension

A

-management is really about variceal bleeding prevention, not the development of variceals

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14
Q

portal hypertension diagnosis (2)

A
  • 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
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15
Q

When we see varicies, how do we treat them?

A

non- selective beta blockers!

  • beta 1 will reduce HR = reduce cardiac output
  • beta 2 will block the splanchnic vasodilation
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16
Q

what non-selective beta blockers are used in the tx of portal HTN?

A
  • 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
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17
Q

when do you decrease/hold the dose of a BB in portal HTN tx?

A
  • 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)
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18
Q

what are acute variceal bleeds?

A
  • consequences of portal hypertension

- risk factor for SBP

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19
Q

what are the signs and symptoms to variceal bleeds?

A
  • melema
  • hematemesis
  • coffee ground vomit
  • decreased hemoglibin
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20
Q

treatment of variceal bleeds? (6)

A
  • supportive care
  • octreotide
  • EVL
  • TIPS (if above 2 fail)
  • SBP prophylaxis
  • non-selective beta blockers
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21
Q

supportive care in variceal bleeds

A
  • IV fluids
  • packed RBCs (keep hemoglobin ~8)
  • O2 supp therapy
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22
Q

Octreotide in variceal bleed tx

A

50 mcg bolus then 50 mcg/hr infusion

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23
Q

EVL in variceal bleed treatment

A
  • do an upper endoscopy & see the bleeding vessel and choke it off
  • combo of EVL & octreotide is the best
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24
Q

What do you do in variceal bleeding if EVL + octreotide fail?

A

use TIPS

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25
Q

what is SBP prophylaxis in tx of variceal bleed

A
  • 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
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26
Q

what gram - bacteria can cause SBP?

A
  • e. coli, k. pneumonia*

- s. pneumonia & s. aureus

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27
Q

how to diagnose SBP?

A
  • symptoms (fever, malaise, elevated WBCs, pain/tenderness in abdomen)
  • paracentesis (> 250)
  • bacterial culture
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28
Q

absolute polymorphonuclease leukocyte count equation

A

WBC (% PMN)

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29
Q

how to treat active infection of SBP?

A
  • 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)
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30
Q

how to treat SBP prophylaxisly?

A

-anyone with acute variceal bleeding: IV ceftriaxone x 7 days (cipro for them allergies)

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31
Q

Indefinite therapy for SBP:

A

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
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32
Q

what is hepatic encephalopathy?

A

accumulation of toxins from declining hepatic function (reduced # of functional hepatocytes) + systemic shunting (less blood going into liver)

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33
Q

what toxin are we looking for in HE and what do we monitor?

A
  • we can measure ammonia levels but they do not correlate with severity
  • monitor mental status!
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34
Q

Treatment of HE

A

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

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35
Q

Lactulose treatment in HE

A
  • 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
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36
Q

what is hepatorenal syndrome?

A
  • 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
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37
Q

diagnosis of hepatorenal syndrome:

A

-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)

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38
Q

therapies for hepatorenal syndrome:

A
  • 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
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39
Q

PKPd changes in cirrhosis

A

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)

40
Q

how are energy requirements estimated?

A
  • kcal/kg/day

- harris-benedict

41
Q

how are protein requirements estimated?

A
  • g/kg/day

- 24hr urine nitrogen collection

42
Q

indications for TPN (7)

A
  • 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
43
Q

when is peripheral TPN appropriate?

A

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
44
Q

in refeeding syndrome what 3 things are depleted?

A
  • potassium
  • magnesium
  • phosphate
45
Q

how is refeeding syndrome treated?

A

-mandates aggressive supplementation of lytes + thiamine (50-100 mg/day)

46
Q

what are some facts to know about lipids IVFE?

A
  • 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
47
Q

factors interfering in calcium phosphate compatibility

A
  • add phosphate BEFORE calcium
  • increase in ph & temp = decrease in solubility
  • decrease in ph = increase in solubility
48
Q

what medication cannot be adminsitered jejunally?

A

cipro/ fluoroquinolones

49
Q

amiodorone and drug adminstration

A
  • absorption is improved with food

- gastric administration is required!*

50
Q

Rivaroxaban things

A
  • MUST BE ADMINSTERED WITH ENTERAL FEEDS- for the 15 & 20 mg tablets
  • crush and mix in 50ml water
  • avoid administration distal to the stomach
51
Q

Apixaban things

A
  • crush & mix in 60ml water or D5W

- mixture stable for 4 hours

52
Q

Dabigatran things

A

CANNOT be crushed

53
Q

Edoxaban things

A
  • crush and mix in 60-90 ml water

- administer immediately

54
Q

meds with limited-mo impact on F when given En

A
  • atoaquone
  • azole antifungals
  • lenezolid
  • metronidazole
  • H2 receptor blockers
  • levetiracetam
  • pantoprazole
  • tacrolimus
55
Q

water soluble vitamins

A
  • thaimine
  • riboflavin
  • niacin
  • biotin
  • pantothenic acid
  • B6
  • B12
  • folate
  • absorbic acid (vit C)
56
Q

fat soluble vitamins

A

A D E K

57
Q

thiamine facts

A
  • deficiency in alcoholics
  • neurologic sequale, wernickes encephalopathy (percipitated by glucose administration - 50-100mg thiamin), korsakoff’s psychosis
58
Q

riboflavin facts- b2

A

-produces yellow pee when taken in access

59
Q

niacin

A

pellagra is the deficiency state = Dermatitis, Diarrhea, Dementia

60
Q

pyridoxine

A

-DDIs with levadopa, phenobarbital and phenytoin

61
Q

cyanocobalamin (B12)

A

-essential for cell growth & replication

Deficiency: seen in older > 50yrs have decreased absorption, macrocytic anemia, irreversible nervous system damage

62
Q

Folic acid (B9)

A
  • *DNA synthesis and hematopoiesis (with B12/cyano)

- pregnant women need

63
Q

drugs that may induce deficiency in folic acid

A

methotrexate, trimethoprim, phenytoin, oral contraceptives

64
Q

vitamin C facts

A

-required for collagen synthesis/wound healing
-smokers and burned hoes may need increased requirements
deficiency = scurvy

65
Q

vitamin A things

A
  • essential in retinal function
  • bone growth, reproduction & embryonic development ( doses at > 25000 = teratogenic)
  • leading cause of blindness
66
Q

vitamin E things

A
  • antioxidant

- enhances vit A absorption, may protect against symptoms of hypervitamintosis A

67
Q

toxic times: cancer and cardiovascular

A

-NO beta-carotene, vitamin E, selenium, vitamin C or folic acid

68
Q

toxic times: anticoagulant therapy

A

-vitamin E associated with excessive bleeding

69
Q

toxic times: smokers

A

vitamin A increases mortality

70
Q

which point from admission should TPN be initiated assuming EN. can not be implemented?

A

7 days

71
Q

Calcium-phosphate solubility in a parenteral nutrition solution is INCREASED when the _____

A
  • phosphate is added to the solution before the calcium

- solution pH is decreased

72
Q

an ideal candidate for peripherally administered parenteral nutrition should meet:

A
  • do not have significant malnutrition
  • good peripheral access
  • can tolerate large volumes (2.3-5L)
  • needs 5-14 days of support
73
Q

what are the methods for determining protein requirements?

A
  • urine for urea nitrogen

- gm/kg/day

74
Q

what are the methods for determining energy requirements?

A
  • kcal/g/day
  • harris-beneduct
  • indirect calorimetry
75
Q

what is true regarding IVFE?

A
  • 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
76
Q

what electrolytes should be closely monitored in a pt at risk for developing refeeding syndrome?

A
  • potassium
  • magnesium
  • phosphate
77
Q

what vitamins are adequate for hematopoesis?

A
  • cyanocobalamin (b12)

- folic acid (B9)

78
Q

what to tell a prego bitch about vitamins

A
  • 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
79
Q

what is true regarding administration of medication via feeding tube?

A

judicious flushing of the feeding tube with water is necessary to maintain potency

80
Q

alcoholic with bloody butt hole- what would you recommend in conjunction with administration of the glucose-containing fluid

A
  • monitor electrolytes frequently (PMP)
  • thiamine IV 50-100mg before and daily during glucose administration
  • monitor for ataxia, nystagmus, and confusion
81
Q

which of the following conditions would you advise AGAINST the corresponding vitamin supp b/c of an increased risk?

A
  • smokers and beta carotene (vit A)
  • CVD prevention and folic acid
  • CVD prevention and vitmain E
82
Q

Bish got non-occlusive bowel necrosis: what is associated with this development?

A
  • utilization of a fiber-containing formula
  • feeding into the jejunum
  • enteral feeding without adequate volume resuscitation
83
Q

what can contribute to the development of diarrhea in a tube-fed pt?

A
  • metoclopramide
  • antimicrobials
  • magnesium
84
Q

which medication MUST be administered with enteral feeding?

A

Rivaroxaban

85
Q

which medication may increase the risk of developing a folic acid deficiency?

A
  • trimethoprim
  • methotrexate
  • oral contraceptives
86
Q

which of the following is true concerning evaluation of vitamin D

A
  • 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
87
Q

which of the following are potential complications of both parenteral and enteral nutrition?

A

-electrolyte abnormalities

88
Q

for which of the following conditions would you advise the corresponding supplementation?

A

-gastrectomy- vitamin B12

89
Q

what lab value is evaluated in cirrhosis about bleeding during the puncture?

A

PT/INR

90
Q

hepatorenal syndrome therapies are targeted to do?

A
  • increase intravascular volume

- reduce splanchnic vasodilation

91
Q

if a pt has SBP, they should recieve a 3rd gen cepalo for how long?

A

5 days

92
Q

the benefits of non-selective BBS in portal hypertension include all EXCEPT

A

prevent varix development

93
Q

in a pt with cirrhosis, what phenytoin change in dosage would be needed

A

-decrease the dose

94
Q

what side effect usually occurs in pts who get TIPs?

A

heptic encephalopathy

95
Q

a cirrhotic pt has 6L of paracentesis removed: what meds should they be given?

A
  • spirnolactone
  • furosemide
  • albumin
96
Q

an abdominal paracentesis can be used for which of the following?

A
  • SBP diagnosis
  • portal hypertension diagnosis
  • therapeutic removal of ascitic fluid

GI/Skin Therapeutics (3 decks)

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