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MLA - Pharmacology Revision > IV Fluids and Bloods > Flashcards

IV Fluids and Bloods Flashcards

1
Q

What are clinical signs of dehydration?

A

Dry mucous membranes
Loss of skin turgor

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2
Q

What are the following indicators for fluid resuscitation?

SBP
Pulse
Capillary Refill Time
Respiratory Rate
NEWS Score
JVP
Urine Output
Acid-base levels
Serum U&Es
Serum Osmolality

A

SBP <100 mmHg
Pulse >90
Capillary refill time >2 secs +/- cold peripheries
Respiratory rate >20 breaths
News 5+
JVP - raised if fluid overload
Urine output - decreased if dehydrated
Acid-base - disturbances occur in extremes of fluid states
Serum U&Es - will be raised in dehydration
Serum osmolality - will be increased in dehydration

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3
Q

How is passive leg raising used in terms of fluids?

A

If BP improves when legs are raised rather than legs down, it suggests fluid responsiveness.

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4
Q

What are the routine maintenance average requirements of a normal patient?

A

25-30ml/kg/day water
1 mmol/kg/day K, Na & Cl
50-100g /day glucose

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5
Q

How much water should be prescribed to a patient who more vulnerable (e.g. older, frailer, renal impairment, cardiac failure, malnourished or at risk of refeeding)?

A

20-25 ml/kg/day

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6
Q

Most patients don’t require more than how many litres per 24 hours?

A

Most patients do not require more than 3L fluid in 24 hours

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7
Q

What is refeeding syndrome?

A

Starvation - then food reintroduced - have low serum K, Mg and P as the cells pump these ions intracellularly along with glucose. Can cause pulmonary and neuro symptoms and can be fatal.

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8
Q

When a patient has severe oedema, how much of the fluid that you give a P will be lost to the interstitial area?

A

1/3 at least

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9
Q

Of fluids given to a sceptic patient, how much fluid will be lost into the EC space?

A

1/3 at least

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10
Q

Hypo and hypernatremia - how do these affect fluid levels?

A

Hyponatremia - means that the water will move intracellularly
Hypernatremia - the water will stay extracellularly in the intravascular space

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11
Q

For resuscitation - what volume of fluid should be given to patients in a bolus?

How should this be altered if they are older or have heart failure?

A

500ml over 15 mins

If older / CHF - this should be reduced to 250ml

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12
Q

When should you seek help with a patient in terms of amount of fluid given in a bolus?

A

When you have given 2L to a patient OR 1L if they are older Ps

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13
Q

What are the contents of 0.9% saline?

A

Sodium and Chloride

154 mmol/L Na
154 mmol/L Cl
308 Osmolarity

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14
Q

What are the contents of 5% glucose?

A

Water and sugar

277 mmol/L glucose
Osmolarity 278

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15
Q

What are the contents of Hartmann’s?

A

Na, K, Cl, Ca, HCO3

Na - 131 mmol/L
K - 5 mmol/L
Cl - 111 mmol/L
Ca - <0.5 mmol/L

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16
Q

What are the benefits and negatives of 0.9% saline solution?

A

Similar osmolarity to plasma - doesn’t rupture or dehydrate RBCs

Very salty - can cause. significant acid base abnormalities

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17
Q

What are the benefits of 5% glucose?

A

Glucose is metabolised to H20 and CO2 - so therefore you give the P pure water.

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18
Q

Which solution is the closest physiologically to blood?

A

Hartmann’s

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19
Q

What alternatives can be used to blood transfusion?

A

Erythropoietin (takes time)
IV & Oral Iron
Tranexamic acid

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20
Q

What is tranexamic acid used for?

A

To reduce interoperate bleeding and therefore reduce transfusion requirements

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21
Q

What are the rates of transfusion for the following?

Red blood cells
Platelets
FFP
Cryoprecipitate

A

RBCs - 1-2 hours - no slower than 4 hours
Platelets - 30-60mins
FFP - 10-20ml/kg/hour
Cryoprecipitate - quickly - 15-30 mins at a time

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22
Q

What is the difference between FFP and Cryoprecipitate

A

Both are made from plasma however cryo has more concentrated clotting factors in it such as Von Willebrand Factor, Factor 8 and fibrinogen

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23
Q

Which are the clinical S&S of a transfusion reaction?

A

Fever, chills or rigors
Hyper or hypotension
Collapse
Flushing
Urticaria
Pain (bone, muscle, chest, abdomen)
Nausea
Respiratory distress
General malaise

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24
Q

What are the 3 grades of transfusion reaction?

A

Mild, moderate or severe

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25
Q

What is the easiest way to differentiate the transfusion reaction severity?

A

Pulse - minimal or no change = mild
Inc of 10 bpm+ = moderate
Inc of 20 bpm+ = severe

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26
Q

What should you do if you suspect a transfusion reaction?

A

Stop the transfusion. Measure obs.

Check identity of patient, their bracelet and the label of the bag and the tag attached to the bag.

Mild reaction - stop transfusion but leave connected - continue at reduced rate for 30 mins and observe. If ok then resume at prescribed rate.

Moderate reaction - stop and leave connected. Urgent clinical review, check identity of patient and bag. If symptoms improve in 15 mins - restart with antihistamines or antipyretics.

Severe reaction - stop and disconnect - recheck details - inform transfusion lab & complete appropriate documentation.

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27
Q

What is the mechanisms of action of Aspirin?

A

Irreversible COX1 inhibitor

This stops thromboxane A2 being produced - and therefore reduces the attraction of other platelets and reduces them sticking together.

Less adhesion, activation and aggregation.

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28
Q

Which chemical is produced by normal endothelium that has an inhibitory effect on platelet activation by having an opposite effect to thromboxane?

A

Prostacyclin (PGI2)

29
Q

Why do we not use aspirin at high dose for anticoagulation?

A

At high doses aspirin will inhibit production of both thromboxane and prostacyclin. At lower doses it will selectively inhibit platelets (but not endothelial cells which produce prostacyclin) - so will have the desired effect.

30
Q

What dose of aspirin is considered a low dose?

A

75-325 mg/day

31
Q

ADP is released by platelets when they are activated. How is it considered an agonist of platelets?

A

ADP binds to P2Y12 receptor on other platelets - increasing the aggregation, activation and adhesion of them.

32
Q

What is the mechanism of action of clopidogrel?

A

Clopidogrel is a P2Y12 receptor inhibitor

33
Q

Which drug is first line for peripheral arterial disease?

A

Clopidogrel

34
Q

Apart from clopidogrel - which other drugs target the P2Y12 receptor?

A

Ticagrelor
Prasugrel

More reliable and potent - however greater bleeding risk than clopidogrel

35
Q

Which MOA anti-thrombotic drugs are the most powerful and carry the highest bleeding risk?

A

Glycoprotein 2b3a receptor antagonists - stops the platelets being bound together with fibrinogen.

E.g. Tirofiban
Abciximab

36
Q

Which factors does warfarin inhibit?

A

1972 was the diSCo era

10, 9, 7, 2 and Protein C & S

37
Q

What is the lag period for warfarin?

A

3-4 days

38
Q

Warfarin has a narrow therapeutic window which is monitored by INR (the extrinsic clotting pathway). What INR should Ps aim for?

A

2-3

39
Q

What does Warfarin interact with?

A

Alcohol
Green vegetables
Main drugs - esp Abx

40
Q

What does INR measure?

A

The ratio of the patient’s PT to a normal PT.

Prothrombin time (PT) is a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot.

41
Q

When is warfarin used?

A

Mechanical heart valves
Mitral stenosis with AF

42
Q

What are the side effects of warfarin?

A

Bleeding
Teratogenic
Skin necrosis

43
Q
A
44
Q

What do you need to do when you start a patient on warfarin?

A

Also start them on transient heparin at the same time as Ps are in a hypercoagulable state in warfarin induction.

45
Q

How does heparin work?

A

Enhances the affect of anti-thrombin which inhibits factors 2, 7, 9, 10, 11 & 12. Heparin binds to AT and activates it.

46
Q

What is unfractionated heparin used for?

A

CKD
Dialysis

47
Q

What is heparin monitored with?

A

APTTr

Activated partial thromboplastin time (APTT) of the patient

48
Q

How is unfractionated heparin given?

A

IV or subcut

Measured in units (not mg)

49
Q

Name 2 LMWHs

A

Enoxaparin
Tinzaparin

50
Q

What are LMWHs used for?

How are they cleared?

A

MI, AF, PE, iliofemoral DVT, VTE prophylaxis.

Cleared renally

51
Q

What is the dangerous side effect of heparin?

A

HIT
Heparin-induced thrombocytopenia

52
Q

What is the mode of action of Rivaroxaban and Apixaban?

A

Direct Factor Xa inhibition - therefore stops prothrombin being converted to thrombin which stops fibrinogen being converted to fibrin.

53
Q

What is the mode of action of Dabigatran?

A

Direct Factor IIa (Thrombin) inhibitor - stops conversion of fibrinogen to fibrin

54
Q

What are DOACs used for?

A

DVT
PE
AF
Post knee / hip replacement

55
Q

How do DOACs compare to Warfarin?

A
56
Q

Which drug can reduce thrombus breakdown and how?

A

Tranexamic acid

Is a anti-fibrinolytic - so stops plasmin breaking down fibrin.

57
Q

What can vitamin K be used to treat?

A

Vitamin K deficiency
Reverse warfarin effects in OD.

58
Q

Which thrombolytic agents can be used to break down thrombi by converting plasminogen to plasmin?

A

TPA (Tissue Plasminogen Activator)
Alteplase

Used for acute MI, recent thrombotic stroke, major PE or massive iliofemoral thrombosis

59
Q

What is the difference between antiplatelet drugs and anticoagulants?

A

Antiplatelets - stop platelets clumping together to form a clot

Anticoagulants - slow down the body’s process of making clots.

60
Q

What are the two types of antithrombotic drugs?

A

Antiplatelet drugs
Anticoagulants

61
Q

How do we treat bleeding in a patient who is on anti-thrombotic?

A

Stop the drug
Check renal & hepatic function
Baseline coagulation and platelets
Correct any problems - fluids / RBC transfusion
Apply mechanical pressure if needed

Can think about radiological intervention of bleeding source if needed.

62
Q

How can you reverse vitamin K antagonists - e.g. warfarin?

A

Give Vitamin K
Oral or IV 1-10mg
Takes 4-6 hours to work

If urgent need to reverse - can give a prothrombin complex concentrate - e.g. Beriplex, Octaplex - is concentrated Vit K dependent factors. Has effect in 10-30mins but short half life.

63
Q

How can you reverse heparins?

A

Stop heparin

UFH - half life is 45-90 mins
LMWH - half life is 4 hours

Can give protamine sulphate - rapidly reverses UFH and partially reverses LMWH (60%)

64
Q

What is the reversal agent for Apixaban or Rivaroxaban?

A

Andexanet α - is a recombinant form of FXa

65
Q

What is the reversal agent for Dabigatran?

A

Idarucizumab

66
Q

What other things can you give to a patient who is bleeding with a DOAC?

A

PCC or FFP

Tranexamic acid

67
Q

How can you reverse anti-platelet drugs?

A
68
Q
A

MLA - Pharmacology Revision (16 decks)

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