Inpatient Medical Management Flashcards
main conditions to manage
pain
bleeding
nausea / vomiting
anxiety
wound VACs
electrolytes
pain pathway
local mediators - cytokines, prostagladins, in tissue beds initiate electrical impulses by affarent nerve fibers
fibers synapse on root ganglion
follow tract to thalamus
synapse on somatosensory cortex and limbic system
somatic pain
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?
visceral pain
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?
neuropathic pain?
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?
pharmocological agents used in pain management
opioids
NSAIDs
Local Anesthetics
Acetaminophen
Steroids
Opioids - general
analgesic effect vis?
risks?
Mu, kappa, and delta receptors located in dorsal horn, brain stem, thalamus, and somatosensory cortex
analgesic effect via ; decrease CA influx at nerve terminals, increased K efflux and inhibition of GABA transmission at brainstem
risks: respiratory depression, N/V - chemoreceptor trigger zone, decreased GI motility, Arteriolar vasodilation, increased smooth muscle tone, itching (histamine release)
NSAIDs - general as __ inhibitors?
risks?
prevent edema, erythema, hyperalgesia, and inflammation
Cox 1/2 inhibitors - blocking Arachidonic acid from forming prostaglandins
risks: GI bleeding, kidney damage, decreased effectiveness of ACE inhibitors, beta blockers, and diuretics
use of local anesthetics for pain control?
long acting LA’s like marcaine 0.5% w. epi 1:200,000
use of this LA long acting (8-12 hrs) decreases hyperexcitability of CNS and can reduce post-op pain and analgesia
details about acetaminophen - include dosage
AKA tylenol
metabolized extensively by the liver CYP450
good for pain relief
NO anti-inflammatory properties
often combined with opioids
650- 1000 mg q4-6 hrs.
4000 mg daily max
steroids
inhibit phospholipase A2 inhibiting production of arachidonic acid - step above where NSAIDs play a role
eliminate post-op edema via suppression of arachidonic acid production
has antinociceptive properties at spinal cord and is an antiemetic
risks
- can cause GI bleeding if combined with NSAIDs
pre-op and intra-op management ?
include drugs and dosages
Toradol (ketorolac -NSAID) before end of surgery to decrease amount of opioids necessary
- 15-30mg IV q4-6 hrs (120 mg max dose)
if not NO - ibuprofen 400 mg 30 mins prior to surgery can decrease onset and severity of post-op pain
prevents hyperalgesia
bone pain best treated with?
NSAIDs and steroids
dosage and drugs for post-op /inpatient management
Ibuprofen - 600mg PO (3200 mg max)
*using two different analgesics (NSAIDS + opioids) leads to greater efficacy in pain control
Dilaudid (hydromorphone) (0.2-1mg q 2-3 hr) - pt. controlled analgesia
tranexamic acid
antifibrinolytic
blocking plasminogen to plasmin
(plasmin used to break down clots)
surgicel and bone wax
bone wax = paraffin and wax
oxidized cellulose (surgicel) are among the commonly used hemostatic agents for controlling hemorrhage from the surgical site. Bone wax is a sterile mixture of 85-90% white bees’ wax and 10-15% isopropyl palmitate,4 a palm oil-based emollient, moisturizer, thickening and antistatic agent.
The hemostatic action of surgicel is by formation of a gelatinous mass upon saturation with blood, which leads to formation of a stable clot.
risk factors for nausea / vomitting
female
non smoker
hx of PONV or motion sickness
volatile anesthetics
nitrous oxide
opioid use
long anesthesia time
prevention for nausea
include medications
prophylactic antiemetics (only moderate to high risk patients)
propofol induction
hydration
intra-op O2 use
Toradol
NG tube
scopolamine patch - evening prior or 4 hrs prior to conclusion of surgery
dexamethasone (induction) - steroid use
5-10 mg IV
ondansetron (closing) 5-HT seretonin inhibitor
4-8 mg IV
post -op / inpatient managementfor N/V
rule out any local factors
if no prophylaxis was given (ondansetron) - give 4 mg q4hr
if prophy failed - give ondansetron or consider switching antiemetic classes -
promethazine - antihistamine (H1 antagonist)
compazine- dopamine receptor antagonist - also have anticholinergic and antihistaminic blocking effects
droperidol- D2 receptor antagonist in chemoreceptor trigger zone
metoclopramide - inhibits dopamine and serotonin 5-Ht3 receptors in chemo-receptor trigger zone
caution with what when giving antiemetics?
QT interval prolonging
consult with attending before
anxiety managment - medication and dosage
Ativan - Lorazopam
Benzo
lowers anxiety and potentiates effect of opiods
muscle relaxant at low doses
2mg q6-12 hrs (30mg max in 8 hrs)
Lorazepam binds to benzodiazepine receptors on the postsynaptic GABA-A ligand-gated chloride channel neuron at several sites within the central nervous system (CNS). It enhances the inhibitory effects of GABA, which increases the conductance of chloride ions in the cell.
caution with opioid use due to respiratory depression risk
MOA of wound vacs
four principal components?
decreased pressure on wound allows for rapid healing
- pulls fluid from wound
- reduces swelling
- pulls wound edges together
- stimulates growth of new tissue
- reduces bacterial load
four principal components
1. macrodeformation
2. microdeformaion
3. stabilization
4. fluid removal
indication for wound VAC use?
chronic non healing wounds
large wounds
skin grafts
initial application of wound vac steps?
Window Paning: protects peri-wound surface, improves seal
Cut and Shape Foam
Place in Wound: height at top of wound, do not extend past wound margins
Cover with Drape: extend to peri-wound reach by half an inch circumferentially
Cut 2 cm Hole in Drape: must be placed above foam
Apply Vacuum Tubing
Connect Tubing to VAC Suction Canister
Activate Canister: perform leak check
VAC changes occur?
every 24-72 hours
measure wound size and follow steps for initial application to re-apply
cardiac electrolyte imbalances
hypo Mg?
hypo K?
Hypo Ca?
Hypo P?
seizures can occur with?
hypo Mg –> Torsades de pointes –> vFib
hypo K –> ST depression, T wave inversion, U waves
hypo Ca: QT prolongation
Hypo P: Hypertrophic cardiomyopathy - eventual CHF
Seizures with Na, Ca, Mg
normal range for electrolytes:
potassium
phosphorus
magnesium
calcium
sodium
potassium : 3.6-5.5
sever hypo : below 2.5 sever hyper: 6.5-7 mmol/L
phosphorus: 3mg/dL
less than 2.5 , greater than 4.5
magnesium: 2 mEq
1.38-2.68
calcium : 8-10
sodium: 135-145 mmol/L
how to replete following electrolyte imbalances
potassium
phosphorus
magnesium
calcium
provide target goal (this is the general card need to know)
potassium : 3-5 - want around 4 mEq –> 10 mEq over 1 hour each for 0.1 raise
phosphorus: target for 3 mg/dL –> 15 mmol potassium phosphate over 4 hours
magnesium: target 2
2mEq–> 2g mag sulfate over 1 hr.
calcium : target 8-10
2g Ca Gluconate over 1 hour
potassium replacement protocol – IV*
in general at what value to start to replenish?
less than 3.6
goal is 10 mEq/ hour
maximum is 20 mEq/hr with continuous EKG monitoring
standard concentrations: 10mEg/50ml or 10/100ml 20 mEq/50ml or 20mEq.100ml
max concentration for CENTRL line is 20mEq/ 50mL
max concentration for PERIPHERAL line is 10mEq/50mL
potassium replacement protocol for oral or enteral repletion
standard dosage forms: KCl 20mEQ tablet or KCl 10% solution (20mEq/15mL)m
magnesium replacement protocol – IV*
in general at what value to start to replenish?
goal is 2 mEq/L
if less than 1.5
1gm of magnesium sulfate every 30 mins.
standard concentrations of 1gm/ 100mL and 2gm/50mL
*infusions should be no faster than
calcium replacement protocol – IV* (clarify central vs peripheral)
in general at what value to start to replenish?
must specify what?
goal 8-10 mg/dL (1 deciliter is 100 ml)
specify the salt form ; calcium chloride or calcium gluconate
calcium chloride – must be administered via central line and reserved for level 1 areas only
target of: 2 g calcium gluconate over 1 hr.
standard concentrations: 1 gm / 50 mL
maximum rate of 3 gm IV over 10 mins
phosphorus replacement protocol – IV*
in general at what value to start to replenish?
start infusion if lower than 2 and order must be placed in mmol of phosphorus
goal: 3 mg/dL–> 15 mmol potassium phosphate over 4 hours
recommended rate 3mmol/hr (4.4 mEq/h of K)
use SODIUM phosphate for patients with serum potassium over 4.5 mEq/L and serum sodium less than 145
(think about normal ranges of potassium and sodium we want for patients, 4 for K and 135-145 for sodium)
