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Speciality Medicine > Lecture 5: Fluids > Flashcards

Lecture 5: Fluids Flashcards

1
Q

What are the indications for IV fluids?(5)

A
  • Resuscitation for hypovolemia-> Correction of hypotension (ie hypovolemic or septic shock)
  • Replacement of ongoing fluid losses
  • Routine maintenance fluid
  • Correction of electrolyte imbalances
  • Solvent for IV drugs or TP
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2
Q

What is ohm’s law?

A
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3
Q

What are the different components you need to know for ordering IV fluids?(4)

A
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4
Q

How much do you give in volume?

A
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5
Q

What are the ways that we can lose water?

A
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6
Q
  • Calculating free water deficit is useful in who?
  • What is the equation?
A
  • Calculating free water deficit is useful in patients with severe dehydration and/or hypernatremia
  • Total H2O deficit (L) = k x weight (kg) x (current [Na+]/140)-1
    * k= 0.6 in adult male/children, 0.5 adult female/elderly males, 0.45 elderly females
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7
Q

What is net volume equation?

A

Net volume = (Total Input) – (Total Output)

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8
Q

What happens with hypovolemic patients?

A

hypotension, tachycardia, orthostasis, dry mucous membranes, skin tenting, decrease in weight >2kg, net negative I/Os, azotemia (increase in bun+creatine+NO but not as accurate becasue increase in muscle loss), hypernatremia, low CVP, reports thirst, low urine output (<0.5ml/kg/hour)

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9
Q

What happens with euvolemic patients?

A

normotenstive, normocardic, moist mucous membranes, taut skin, stable weight, net even I/Os, stable renal function

Periop pt= Need IV fluids even if they look good

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10
Q

What happens with Hypervolemic patients?

A

hypertensive, normo- or bradycardic, dependent peripheral edema/anasarca, crackles on lung auscultation, hypoxia, orthopnea, increase in weight >2kg, net positive I/Os, JVD, S3 gallop, pleural or pericardial effusions, ascites, chemosis, ileus (due to gut edema)

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11
Q

What type of IV fluid you give depends on what?(4)

A
  • Goal of administration
  • Volume status
  • Chemistry panel: electrolytes, glucose, renal function
  • Co-morbidities
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12
Q

What is osmosis?

A

a process by which molecules of a solvent tend to pass through a semipermeable membrane from a less concentrated solution into a more concentrated one, thus equalizing the concentrations on each side of the membrane

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13
Q

What is osmolarity? What is the equation?

A

Osmolarity: total number of solute particles per volume of solution

Calculating serum osmolarity: 2 [Na+] + [glucose]/18 + [BUN]/2.8 = 285

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14
Q

What is tonicity?

A

Tonicity: a measure of the effective osmotic gradient between two fluids separated by a semi-permeable membrane

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15
Q

How does our fluids get broken down?

A
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16
Q

What happens to cells in a hypotonic, isotonic and hypertonic solution?

A
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17
Q

What happens in hypotonic solution? What do you use it for? 3rd spacing?

A
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18
Q

What happens in isotonic solution? What is it used for? 3rd spacing?

A
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19
Q

What is hypertonic solution? What is it used for?

A
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20
Q

Isotonic:
* What can it be used for?
* What are 2 examples?
* What can be added?

A
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21
Q

hypotonic:
* What is it used for?
* No role in what?
* What are 3 examples?
* What can be added?

A
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22
Q

Hypertonic:
* What is it used for?
* What is an example?
* What is a risk?

A
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23
Q
A
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24
Q

What does studies show about isotonic fluids?

A
  • NS: Can make metabolic acidosis
  • LR: the lactate is converted to bicard via kerb cycle therefore can make metabolic acidosis better. Do NOT give if has increase K
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25
Q
A
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26
Q

What are the pros and cons of colloid fluids?

A

Pros:
* 20-25% albumin is good for liver failure and pacracentsis
* 6% hydroxyethyl: bypass or hem stock
* Used in ICU if hypoalbum in to keep fluid in vascular

Cons:
* increase risk of anaphalyic rxn because from blood products

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27
Q

Flow rate:
* Depends on what? (4)
* How much fluid do you need in an hour to keep vein open?
* For continous fluid, how much ml/hr?
* For boluses, what is the ml/hr
* What is wide open?

A
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28
Q

Maintenance fluids:
* What are the average adult needs?
* What is commonly used?

A
  • 2-3 mEq (1mmol)/kg of sodium, 1-2 mEq/kg of potassium, 2-3 mEQ/kg chloride, & 50-100g of glucose, 30mL/kg of H2O
  • For 70kg patient, that is ~2L/day or 84mL/hour
  • Commonly D5, 1/2NS + KCl for adults (only for about 3-5 days, if longer then tube feeding)
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29
Q

What do you use for fluids in peds patients?

A
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30
Q

Special considerations:
* What do you give for hemodynamically unstable?
* What do you give for Septic shock?
* What formula for burn victims?

A
  • Hemodynamically unstable: 500mL bolus of isotonic crystalloid over 30 minutes & repeat as needed
  • Septic shock: 30ml/kg (pediatrics: initially 20ml/kg then up to 60mg/kg) of isotonic crystalloid within the first 3 hours
  • Burn victims: Parkland formula
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31
Q

Special considerations:
* Volume overloaded:
* EtOH intoxication:
* Diabetics:
* Hypermatremia:

A
  • Volume overloaded: Slower rate and/or lower volume to reduce third spacing
  • EtOH intoxication: “Banana bag” (thiamine)
  • Diabetic: Avoid dextrose, may cause hyperglycemia (give if hypogly or NPO when given diabetic meds)
  • Hypernatremia: isotonic crystalloid until hemodynamically stable, then hypotonic crystalloid such as D5W at slow rate preferred (can use free water def formula)
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32
Q

IV fluid of choice:
1. 55-year old man presents A&O x2 and with visual hallucinations. He has no focal neurological deficits. CT head unremarkable. His serum sodium is decreased to 119mEq/L. Vitals: BP 124/79, HR 87, RR 16, O2 98%, Temp 97.9F
2. 26-year old woman presents with 2nd and 3rd degree burns covering 36% of her BSA sustained in a kitchen grease-fire. Vitals: BP 92/46, HR 115, RR 16, O2 91%, Temp 97.1F
3. 81-year old man presents after a falling down 3 flights of stairs. He is unconscious and has a rigid abdomen on exam. Vitals: BP 86/42, HR 122, RR 18, O2 96%, Temp 98.3F
4. 63-year old woman is admitted to the hospital for influenza infection. She feels too tired and weak to drink any fluids or eat. Vitals: BP 138/97, HR 72, RR 14, O2 94%, Temp 101.9F

A
  1. hypertonic
  2. isotonic: NS or LR
  3. Isotonic only until blood products get there
  4. Replacement or maintance (isotonic or hypotonic)
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33
Q
A
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34
Q

IV fluids for Patient with Hypotonic/“True” Hyponatremia
* What should be avoided?
* What do you use if severe+ neurologic symptoms

A
  • Hypotonic IV fluids avoided!
  • Hypertonic IV saline only if severe + neurological symptoms
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35
Q

IV fluids for Patient with Hypotonic/“True” Hyponatremia
* How does isotonic IV fluids depending on volume status?

A
  • Hypovolemic (Na and H2O deficit): dehydration, diuretics, GI losses, diaphoresis. Isotonic IV fluid is appropriate to replace both water and sodium.
  • Euvolemic (H2O excess): SIADH, adrenal insufficiency, hypothyroid, polydipsia. Treat underlying cause & free water restriction. Isotonic IV fluids may worsen.
  • Hypervolemic (Na and H2O excess): CHF, liver failure, renal failure. Diuresis and free water + Na restriction. Isotonic IV fluids will worsen.
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36
Q

Nosocomial infections:
* What is it? (3)

A
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37
Q

What patients are at highest risk of infections?

A

Highest risk in ICU patients due to organ failure/immunocompromised state, prolonged hospitalization, indwelling medical devices, and presence of resistant organisms

38
Q

What are the multi-drug resistant organism (MDROs)?

A
39
Q

Catheter related infection:
* Medical devices lead to what?
* Nosocomial infections are related to what?
* The longer what in place, increase infection?
* Once infection is confirmed, what is possibe?

A
  • Medical devices lead to compromised mucosal/skin barriers and seeding of microbes
  • Nosocomial infections are related to devices in 25-50% of cases
  • The longer a catheter in in place, the higher the risk of infection
  • Once infection is confirmed, the catheter should be removed if possible
40
Q

Catheter associated UTI
* Highest risk with what?
* What is the work up?
* What are the pathogens? What are the less common pathogens?

A
  • Highest risk with indwelling catheters, ie Foleys
  • Work-up: Urinalysis with microscopy & Urine culture + susceptibilities
  • Pathogens: Enterobacteriaceae (ie E. coli including ESBL) & Enterococci
  • Less common: Pseudomonas, Staph aureus, and Candida
41
Q

What is the txt of catheter associated UTI?

A
  • Treatment: Removal of catheter & 7 days of antibiotics (14 days if signs/symptoms of upper tract infection)
  • Antibiotics same as for acute simple cystitis (nitrofurantoin, Bactrim, Fosfomycin); fluconazole if candida
42
Q

What are non-invasive alternatives to a foley?

A
43
Q

What is the different Catheter-Associated Asymptomatic Bacteriuria (CA-ASB) and Catheter-Associated Urinary Tract Infection (CA-UTI)?

A
44
Q

Blood stream infections:
* What are the risk factors?
* What are the sxs?
* What is the Work up?

A
  • Risk factors: indwelling vascular catheters, skin breakdown (ie decubitus ulcers), UTI/pneumonia, TPN (because bacteria loves sugar)
  • Signs & symptoms: fever, leukocytosis, shock, vascular catheter insertion site cellulitis
  • Work up: blood cultures (aerobic and anaerobic +/- fungal), lactic acid level, procalcitonin level
45
Q

Blood stream infections:
* What are the most caustive pathogens?
* What is the txt?

A
  • Pathogens: Coagulase-negative staphylococci (CoNs), Staph aureus(≥50% methicillin-resistant), enterococci, gram-negative bacilli such as E. coli & Klebsiella, andCandida
  • Treatment: Removal of catheter, 7-14 days of antibiotics, consider antibiotic line lock
46
Q

CLABSI Empiric Therapy
* What do you need to cover?
* When do you de-escalate anx?
* When do you need longer antibiotics?

A
  • MRSA coverage: IV Vancomycin or Daptomycin
  • +/- gram neg bacilli coverage: IV 3rd or 4th generation cephalosporin (ie Cefepime), Beta lactam/lactamase combo, carbopenem, or aminoglycoside
  • Narrow or “de-escalate” when blood culture identifies organism
  • Longer than 14 days for “complicated” CLABSI: suppurative thrombophlebitis, osteomyelitis, endocarditis, persistent positive cultures after 72 hours, or active malignancy or immunosuppression
47
Q

Hospital Acquired Pneumonia (HAP)
* What it CAP and what are the pathogens?
* What is HAP and what are the pathogens?

A
  • Early infection (first 3-5 days of admission) similar to CAP- Streptococcus pneumoniae,Haemophilus influenzae,Moraxella catarrhalis, and respiratory viruses such as influenza
  • Later infections caused byStaphylococcus aureusand Gram-negative organisms such asPseudomonas,Klebsiella, Enterobacter, andAcinetobacter
48
Q

Ventilator Associated Pneumonia (VAP)
* Develops when?
* What are the sxs?
* How do you dx?

A
  • Develops >48 hours post initiation of mechanical ventilation
  • Signs & symptoms: fever, hypoxemia, purulent sputum, leukocytosis, new radiographic infiltrate
  • Diagnosed via positive culture from endotracheal aspirate or bronchoalveolar lavage
49
Q

VAP:
* What are the mimickers?
* What are the complications?
* What is the txt?

A
  • Mimickers: tracheobronchitis, sinusitis, pulmonary edema, atelectasis, pulmonary embolism, aspiration pneumonitis, vasculitis, pulmonary hemorrhage, pneumothorax, organizing pneumonia, and ARDS
  • Complications: septic shock, empyema, pulmonary abscess, diffuse alveolar hemorrhage (DAH), ARDS
  • Treatment: 7 days of IV antibiotics
50
Q

What is the patho of VAP?

A
51
Q

HAP/VAP prevention
* What can help for HAP?

A
52
Q

HAP/VAP prevention
* What can help for VAP?(7)

A
53
Q

HAP/VAP empiric therapy:
* How do you cover pseudomonas coverage?

A
  • Cephalosporin: ceftazidime, cefepime
  • Carbapenem: meropenem, imipenem
  • Piperacillin-tazobactam
  • Aztreonam
  • Fluoroquinolone: ciprofloxacin, levofloxacin
  • Aminoglycoside: amikacin, tobramycin, gentamicin (resereved for the sickest dt toxicity?

Double antibiotics: For structural lung disease

54
Q

What can you use for HAP/VAP empiric therapy to cover MRSA?

A
  • Vanco or linezolid
55
Q

Surgical Site infections:
* Risks?
* What are the pathogens?
* What are the sxs?

A
  • Risks: Inadequate sterile technique, patient factors such as diabetes
  • Pathogens: MRSA, enteric and anaerobic pathogens (enterococcus, E coli, pseudomonas)
  • Signs & symptoms: localized erythema, induration, warmth, purulent discharge, and pain at the incision site
56
Q

Surgical site infections:
* Prevention?
* What is the txt?
* Antibiotics with what?

A
  • Prevention: Antibiotics, wound care
  • Treatment: Wound opened, explored, drained, irrigated, debrided, and dressed open. Packing for deep wounds.
  • Antibiotics with MRSA coverage
57
Q

Clostridium/Clostridioides difficile “C. diff” Colitis
* Transmitted via what?
* What are the risks?
* What are the sxs?

A
  • Transmitted via fecal oral route
  • Risks: recent exposure to antibiotics, gastric acid suppression (PPIs), older age
  • Signs & symptoms: asymptomatic carrier, watery diarrhea, abdominal pain, fever, leukocytosis, dehydration, toxic megacolon, shock
58
Q

Clostridium/Clostridioides difficile “C. diff” Colitis
* What is the txt?

A

Oral fidaxomicin, vancomycin, or metronidazole. Bezlotoxumab. Avoid anti-motility agents.

59
Q

What can you use for prevention of recurrent C.diff infection?

A
60
Q

What are the less common nosocomial infections?

A
61
Q

Prevention of nososcomial infection?
* What about precaution?

A

Standard precautions:
* Hand hygiene
* Wearing PPE when in contact with body fluids
* Avoiding practices that increase risk

62
Q

Prevention of Nosocomial Infections
* Screening?
* Compliance with what?
* What do you clean with?
* What type of precautions?
* Judicious use of what?

A
  • Screening for colonization (MRSA, VRE)
  • Compliance with infection prevention policies
  • Chlorhexidine bathing in ICU
  • Transmission- based precautions (isolation)
  • Judicious use of antibiotics
63
Q

What is standard, contact, droplet, airborne precautions?

A
  • Standard precautions → hand hygiene when entering and exiting the room, covering mouth when coughing/sneezing
  • Contact precautions→ gown and gloves required
  • Droplet precautions→ gown, gloves, and surgical mask required
  • Airborne precautions→ gown, gloves, and N95 mask required
64
Q
A
65
Q
  • What is VTE?
  • Dx via what?
  • May lead to what?
A
  • VTE = pulmonary embolism (PE) & deep vein thrombosis (DVT)
  • Diagnosed via CT-angiogram of chest or venous doppler ultrasound of extremity
  • May lead to significant morbidity and mortality
66
Q

What are the risk factors of VTE?

A
67
Q

VTE prophylaxis:
* Screening required for all?
* What are assessing risk scores?
* Who is the highest risk?

A
  • Screening required for all hospitalized patients
  • Assessing risk: Padua, IMPROVE, Geneva, Caprini (surgical), Gestalt (surgical-ortho)
  • Highest risk: Surgical, critically ill, ischemic stroke, CHF or COPD exacerbation, acute respiratory failure, cancer, pregnant, history of prior VTE, sepsis, acute neurologic disease, severe inflammatory disease
68
Q

Who gets pharmacologic and mechanical prophylaxis?

A

Pharmacologic prophylaxis
* for patients with moderate to high risk of VTE, unless there is an absolute contraindication

Mechanical prophylaxis
* for patients with low risk of VTE or contraindications to pharmacological prophylaxis

69
Q

What are the mechanical options for prophylaxis?

A
  • Sequential compression devices (SCDs)
  • Graduated compression stockings (TED hose)
  • Venous foot pump
  • Walking: prevents clots, pneumia, decrease muscle lost
70
Q

Pharmacologic options:
* What are the first, second and 3rd line?

A
71
Q

Pharmacologic options:
* What is used for specific orthropedic surgical patients only?
* What are special considerations?

A
72
Q

Prophylactic anticoagulation course:
* When do you start for medical and surgical patients?

A
  • Medical patients: at time of admission or when/if VTE risk increases (ie ICU transfer)
  • Surgical patients: 2-12 hours post-op
73
Q

Prophylactic Anticoagulation Course
* When do all medical and most surgical patients stop?
* Select high risk surgical patients, extend what?
* May be discontinued sooner if what?

A
  • All medical & most surgical patients, discontinued at time of hospital discharge
  • Select high risk surgical patients, course extended post discharge: 10-14 days or longer
  • May be discontinued sooner if complications occur & risks outweigh benefits (ie development of acute bleed or plan for invasive procedure)
74
Q

What are absolute contraindications to anticoagulation?

A
75
Q

What are the relative contraindications?

A
76
Q

Discharge:
* What is it?
* Begins when?
* What happens when unnecessary prolonged hospital stays?
* What type of process?

A
77
Q
  • What are medical providers?
  • What are physical and occupational therapist?
A
78
Q
  • What are case managers?
  • What are social workers?
A
  • Case Managers assist with assessing and coordinating the most appropriate discharge destination. Help clinicians and patients understand what services will be covered by the patient’s insurance. Help arrange home health care, equipment, & supplies.
  • Social workers also assist with identifying and coordinating the most appropriate discharge destination. Skilled at assessing patients’ support systems and identifying psychosocial barriers to a successful discharge.
79
Q

What happens from inpatient to home?

A
80
Q

What are factors that contribute to unsuccessful discharge transitions?

A
81
Q

What are the disposition options?

A
82
Q
A
83
Q

Fill in the bottom three

A
84
Q

What are the discharge steps?

A
85
Q

What is the IDEAL patient education?

A
86
Q

What are discharge orders?

A
  • Give the staff the “okay” for patient to leave; sometimes conditional
  • May contain patient instructions
87
Q

Medicare patients
* For referral to skilled nursing facilities: needs what?
* What is needed for Home health services?

A
  • For referral to skilled nursing facilities: need for a “qualifying event” of a preceding 3-night inpatient hospitalization
  • For home health services: documentation of a face-to- face physician (or nonphysician provider) encounter must be provided along with evidence that the patient is homebound and has skilled needs that can be met on an intermittent basis
88
Q

Medicare patients:
* What is needed for home o2
* What is needed for durable medical equipment?

A
  • For home oxygen: must document O2 sat of ≤88% on room air with or without ambulation within 48 hours of discharge
  • Durable Medical Equipment (ie hospital bed, wheelchair, transfer chair): documentation of medical need in daily progress note as well as separate order
89
Q

Med Rec:
* What is it?
* Communicates what?
* Address what?
* Involve who if possible?

A
90
Q

What are summary discharge componets?

A

Speciality Medicine (12 decks)

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