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BCPS > F.E.N > Flashcards

F.E.N Flashcards

1
Q

Fluids for revascularization

A

NS
LR

Fluid mostly stays in intravascular space, hence ideal for revascularization

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2
Q

Fluids for maintenance

A

Ideal: D5W 1/2NS +/- 20 or 40 mEq K

D5W = free water, will distribute into all areas so not ideal for revascularization

20-40 mL/kg/day

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3
Q

Signs/Symptoms of intravascular volume depletion

A

Tachycardia
Hypotension
Orthostatic changes
BUN/SCr > 20:1
Dry mucous membranes
Decreased skin turgor
Reduced UOP
Dizziness
Improved BP/HR after 500-1000mL bolus

**If pt has these factors, first replete with fluids then address other causes for symptoms

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4
Q

IV fluid dose in sepsis

A

30mL/kg

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5
Q

Colloids

A

5%,25% albumin, hetastarch, packed red blood cells, dextran

Too large to cross capillary membrane, so practically all remains in intravascular space

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6
Q

Why avoid hetastarch and dextran?

A

Coagulopathy and kidney impairment

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7
Q

Albumin 25%

A

hyperoncotic - would cause dehydration if given during revascularization

Beneficial in redistribution of fluid (ascities, pleural effusion)

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8
Q

Possible uses for colloids

A

-failure of crystalloids (after ~4-6L)

-large volume parecentesis in cirrhotic patient

-low albumin concentration who have required large volume resuscitation fluids

-25% albumin + diuretics if significant edema and low albumin (if regular diuretic ineffective)

-

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9
Q

Plasma osmolality range

A

275-290 mOsm/kg

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10
Q

Osmolality

A

measure of osmoles of solute per kg of solvent

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11
Q

Osmolarity

A

measure of osmoles of solute per L of solution

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12
Q

Plasma osmolality estimation

A

(2 * Na) + (glucose/18) + (BUN/2.8)

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13
Q

Change in plasma osmolality

A

Increase: osmotic shift of fluid into plasma (cell dehydration, shrinkage)
Ex: NaCl 3% (hypertonic)

Decrease: osmotic shift of fluid into cell (cell overhydration, swelling)
Ex: NaCl 0.225% (hypotonic)

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14
Q

Uses of hypertonic saline

A

TBI to reduce ICP

Symptomatic hyponatremia

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15
Q

Chronic asymptomatic hyponatremia Tx

A

Ex: SIADH

Fluid restriction (<1000mL/day)

Do NOT use hypertonic saline

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16
Q

Pseudohyponatremia Tx

A

Ex: DKA

Insulin - to correct blood sugar. This will then normalize sodium

NOT hypertonic saline

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17
Q

Corrected sodium equation

A

Serum Na + [(1.6 * (glucose - 100))/100]

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18
Q

Hyponatremia with hypervolemia tx

A

Ex: heart failure

Fluid restriction OR diuresis

NOT hypertonic saline

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19
Q

Hypertonic saline dose for TBI

A

3%: 250mL over 1-15 minutes thru central line (or 2-4 mL/kg)

23.4%: 30mL over 20-30 min thru central line

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20
Q

Na increase goal in symptomatic hyponatremia

A

0.5-1 mEq/L/hr (to max of Na 120 mEq/L)

NO MORE THAN 10-12 MEQ IN 24 HRS!!!!

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21
Q

Hypertonic saline rate in symptomatic hyponatremia

A

IBW * desired rise of sodium/hr (ex:1)

Generally, 1-2 mL/kg/hr

Can do 250mL over 30 min
OR
50 mL bolus every 30 min for 2 doses

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22
Q

Osmotic demyelination syndrome

A

Permanent neurologic damage that can occur due to rapid correction of sodium

More likely in cases of chronic hyponatremia than acute

Prevent by increasing Na no more than 10-12 mEq/L in 24 hrs or 18 mEq/L in 48 hrs.

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23
Q

Hypotonic solutions

A

Avoid using IV fluid with <150 mOsm/L (can cause hemolysis, patient death)

NEVER USE STERILE WATER ALONE IV

If 0.225% sodium chloride ordered, try to recommend D5W instead, in combo with D5W or at least thru central line

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24
Q

Hypovolemic hyponatremia

A

from fluid loss, renal loss, third spacing, cerebral salt wasting

If Urine Na <20 = nonrenal loss (diarrhea, emesis)
If Urine Na >20 = renal loss

Give fluids or NaCl tabs or fludrocortisone

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25
Q

Euvolemic hyponatremia

A

Dilutional sodium (SIADH, meds)

Urine Na >20, Urine Osmolality >100

fluid restriction, demeclocycline, conivaptan/tolvaptan

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26
Q

Hypervolemic hyponatremia

A

HF, cirrhosis, nephrotic syndrome

Urine Na <20 (HF, cirrhosis)
Urine Na >20 (acute/chronic renal failure)

Na, water restriction, treat underlying cause, conivaptan/tolvaptan, diuretic

27
Q

Meds associated with hyponatremia

A

Thiazide diuretics
Antiepileptics (carbamazepine, oxcarbazepine)
SSRI, TCAs

28
Q

Symptoms of hyponatremia with levels of Na

A

120-125: nausea, malaise

115-120: HA, lethargy, obtundation, unsteadiness, confusion

<115: delirium, seizure, coma, respiratory arrest, death

29
Q

Vasopressin antagonists

A

Conivaptan (IV) tonivaptan (PO)

-use in SIADH or HF, cirrhosis
-Increases sodium but not shown to improve clinical outcomes
-Substrate & inhibitor of CYP3A4. Interactions may increase sodium too rapidly!
-Do not use along with fluid restriction - may increase too rapidly!

30
Q

Hypernatremia symptoms

A

Lethargy, weakness, irritability
>158: severe (twitching, seizures, coma, death)

31
Q

Hypernatremia treatment

A

-reduce by 0.5mEq/L/hr or 12mEq/L/day

-Need to replace free water - do orally or by D5W
-Can use D5W + 0.225% NaCl

32
Q

Estimated water deficit

A

(0.4 * IBW) * ((Serum sodium/140) -1)

33
Q

Hypokalemia causes

A

-Increased intracellular shift of K (alkalosis, insulin/carb load, B-agonism, hypothermia)
-increased GI losses
-Increased urinary losses
-Hypomag

34
Q

Symptoms of hypokalemia

A

Usually occur when K <3.0
-muscle weakness
-ECG changes (flattened T wave, elevated U wave)
-Cardiac arrhythmia
-Digoxin toxicity
-Rhabdomyolysis

35
Q

K 3.0-3.5 Tx

A

PO
40-80 mEq/day
Divide doses > 60 mEq to avoid GI side effect

36
Q

K 2.5-3.0 tx

A

PO : 120 mEq/day in divided doses
Or
IV: 60-80 mEq at 10-20 mEq/hr if s/s

Check K 2 hr post infusion

37
Q

K 2.0-2.5 tx

A

IV KCl 10-20mEq/hr until normalized

Consider continuous ECG

38
Q

K <2.0 tx

A

IV KCl 20-40 mEq/hr until normalized

MUST have continuous ECG monitoring

39
Q

Hyperkalemia causes

A

-Increased intake of K

-Increased exctracellular shift (acidosis, insulin deficiency, B blockade, Digoxin overdose, rewarming after hypothermia, succinylcholine)

-Reduced urinary excretion (K sparing diuretic, ACE/ARB, TMP)

40
Q

Symptoms of hyperkalemia

A

-Muscle weakness or paralysis (If K >8)
-Abnormal ECG (peaked T waves, QRS widening)
-Arrhythmia (initial manifestation can be ventricular fibrillation)

41
Q

Urgent/immediate Treatment of hyperkalemia when

A

K >6.5
Severe muscle weakness
ECG changes

42
Q

Hyperkalemia Treatment

A

1) Normalize ECG
–Calcium gluconate 10mL slowly over 2-10 min, may repeat in 5 min
–Caution w/ digoxin due to risk of hypercalcemia causing sudden death

2) Shift K intracellulary
–Insulin and glucose
–Sodium bicarb 50mEq slowly over 5 min
–Albuterol 10-20 mg neb over 10 min

3) Increase K excretion
–Diuretic
–Patiromer or sodium zirconium cyclosilicate > sodium polysterene sufonate
–Dialysis as last line

43
Q

Magnesium concentration

A

1.7-2.3

44
Q

Rate of magnesium IV

A

1g/hr to avoid hypotension & increased renal excretion due to rapid administration

45
Q

Phosphorus concentration

A

2.5-4.5

46
Q

Hypomagnesemia causes

A

-impaired intestinal absorption (UC, diarrhea, pancreatitis, laxative abuse)
-inadequate intake
-hypokalemia
-increased renal excretion
-alcoholism, delirium tremens

47
Q

Hypophosphatemia causes

A

-Increased renal excretion (diuretic, glucocorticoid, sodium bicarb)

-refeeding syndrome

-respiratory alkalosis

-DKA treatment

48
Q

Max rate of phosphate infusion

A

7.5mmol/hr (usually given over 3-6 hours)

49
Q

Calcium concentration

A

8.5-10.5

50
Q

Corrected Ca equation =

A

serum Ca + 0.8 (4-albumin)

51
Q

Administration of calcium IV concerns

A

Calcium chloride: must be central line due to risk of limb ischemia

Calcium gluconate: may be given peripherally

Rate: no faster than 60mg/min due to risk of hypotension, bradycardia, asystole
Usually give over 1-2 hours

52
Q

Water needs while on EN

A

30 mL/kg/day of water

53
Q

Macro kcal/g

A

Dextrose: 3.4 kcal/g

Lipid: 10 kcal/g

AA: 4 kcal/g

54
Q

PN Caloric requirements

A

BMI <30: 25-35 kcal/kg/day based on ABW

BMI > 30: 11-14 kcal/kg based on ABW or 22-25kcal/kg based on IBW

55
Q

PN fluid requirements

A

30-35 mL/kg/day
OR
2500-3500 mL/day

Maintain UOP 0.5-2 mL/kg/hr

56
Q

PN AA requirements

A

0.8-2 g/kg/day on ABW

Maintenance: 0.8-1 g/kg/day
Moderate stress: 1.3-1.5 g/kg/day
Severe stress: 1.5-2 g/kg/day

Higher requirements ok for BMI >30

CKD: may need protein restriction

57
Q

PN lipid reqiurements

A

After figuring out protein needs, subtract protein kcal from total kcal. 20-30% of that is kcal of lipid needed

58
Q

PN dextrose requirements

A

kcal will be the remainder after figuring out protein & lipid

Usually around 150-200 g/day

59
Q

PN Maintenance electrolyte needs

A

Na: 1-2 mEq/kg/day
K: 1 mEq/kg/day
Phos: 10-40 mmol/day
Ca: 10-15 mEq/day
Mg: 8-20 mEq/day

60
Q

Concentration of Ca, phos to prevent precipitation

A

Ca: 6mEq/L or less

Phos: 30 mmol/L or less

61
Q

Refeeding syndrome

A

Risk: anorexia, alcohol use disorder, cancer, chronically ill, poor nutritional intake for 1-2 weeks, malabsorption, unintentional weight loss)

Hypophosphatemia, hypokalemia, hypomagnesemia

Prevent by providing 1/2 strength, monitoring, increasing prn

Replace prior to initiating PN

62
Q

Prealbumin

A

use to monitor nutritional status, preferred over albumin.

normal 16-40

63
Q

PN acid-base imbalances

A

Metabolic alkalosis: change Na / K to chloride

Metabolic acidosis: change Na / K to acetate

Respiratory: address underlying cause (hypercapnia = overfeeding)

64
Q

When to withhold lipids in PN

A

Trig > 400

BCPS (9 decks)

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