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Masterclasses Flashcards

1
Q

Fast-acting insulin

A

Soluble human (peak 2-4hrs) - humulin s, actrapid
Short-acting analogue (peak 1hr) - novorapid (aspart), humalog (lispro)

Take before meals/ snacks

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2
Q

Intermediate acting and pre-mixed insulin

A

isophane (NPH, peak 6-10hrs) - insulatard, humulin I

Control overnight/ between meals

Pre-mixed (cloudy, biphasic) - humulin M3, novomix 30

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3
Q

Long acting insulin

A

Lantus (glargine), levemir (detemir)

Peak 5 hours, last <24hours

Control overnight/ between meals

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4
Q

Multiple daily dose injection/ basal-bolus

A

Pre-meal short-acting x3 (1u per 10g carbs)
Isophane/ long-acting x1-2

0.5-0.75u/kg body weight (50% long, 50% short)

DAFNE programme

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5
Q

Biphasic/ twice daily regimen

A

Combination of short-acting and intermediate e.g., novomix 30
More in type 2

0.5-0.75u/kg body weight (66% morning, 33% evening)

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6
Q

Once daily long acting insulin

A

Type 2
Bedtime dose of long-acting combined with other oral hypoglycaemic agents
Titrated against fasting blood glucose (6)

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7
Q

Oral hypoglycaemic agents

A

Biguanides - metformin
Sulphonylureas - glimepiride
DPP-4 inhibitors - sitagliptin
Alpha-glucosidase inhibitors - acarbose
Thiazolidinediones - pioglitazone
GLP-1 analogue - exenatide

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8
Q

Continuous SC insulin infusion

A

1/1000 type 1 (>12yrs, poor control)
Continuous delivery

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9
Q

Diabetic Ketoacidosis definition

A

an extreme metabolic state caused by insulin deficiency. breakdown of fatty acids (lipolysis) produces ketones (ketogenesis) which are acidic. exceeds the body’s buffering capacity.

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10
Q

DKA treatment

A

Fluid replacement
1L 0.9% NaCl in 1st hour if systolic >90
1L 0.9% NaCl + 40mmol KCL (if <5.5) over next 2 hours, 2 hours, 4 hours etc.

Fixed rate IV insulin infusion
0.1u/kg/hr of human soluble insulin (actrapid or humulin s) made up to 50ml with 0.9% NaCl
Continue long acting as normal

Add 10% glucose 125ml/hr if blood glucose falls <14 mmol/L

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11
Q

Diabetic advice

A

Diabetic nurse support
Follow-up with endocrine/ diabetes
Insulin training

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12
Q

Drugs to avoid in children

A

Tetracyclines: discolouration and pitting of tooth enaeml
Aspirin: reye’s syndrome
SSRI: suicidal ideation
Codeine: respiratory depression in CYP2D6 ultrarapid metabolisers (to morphine)

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13
Q

Dosing in children

A

Dose based on age, weight, body surface area

Round sensibly (never over the maximum)

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14
Q

Resus fluids in kids

A

10ml/kg of glucose free sodium containing fluid (131-154mmol/L) over <10mins
E.g., 0.9% NaCl or Hartmann’s

10-20ml/kg if renal impairment, HF, neonates

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15
Q

Fluid maintanence in kids

A

4ml/kg/hr for first 10kg (or 100ml/kg/day)
2ml/kg/hr for next 10kg (or 50ml/kg/day)
1 ml/kg/hr for every kg over 20kg (or 20ml/kg/day)

E.g., 0.9% NaCl or Hartmann’s

Don’t give glucose without sodium (risk of hyponatraemia)

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16
Q

Body surface area

A

cBNF conversion table to aid drug calculations

Also, table for mean weight based on age

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17
Q

Drug principles in pregnancy

A

Avoid any in first trimester
Lowest clinically effective dose
Avoid polypharmacy
Drugs with proven safety record

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18
Q

‘Safe’ drugs in pregnancy

A

paracetamol
b-lactam Abx
steroids
bronchodilators

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19
Q

Teratogenic drugs A-N

A

ACE inhibitors - renal abnormalities, IUGR, PDA
Atenolol - low BW
Carbimazole - neonatal hypothyroidism (in 1st trimester)
Lithium - Ebstein’s
Methotrexate - termination
NSAIDs - premature PDA closure, oligohydramnios, persistent pulm HTN

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20
Q

Teratogenic drugs P-W

A

Phenytoin - craniofacial, growth, mental
Quinolones
Retinoids - CNS, renal, ear, eye, parathyroid
Sodium valproate - NTD
Statins
Tetracycline - tooth discolouration
Warfarin - fetal warfarin syndrome, neonatal/ placental haemorrhage

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21
Q

Epilepsy in pregnancy

A

Preference for lamotrigine
Avoid SV if childbearing age

5mg folic acid if on antiepileptics

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22
Q

Vitamin D in pregnancy

A

All pregnant/ BF should receive 10micrograms (400units) daily
Cholecalciferol or ergocalciferol

1000units if high risk (obese, dark skin, little sun)

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23
Q

Avoid in BF A-C

A

Amiodarone - neonatal hypothyroidism
Aspirin - theoretical risk of Reye’s
Barbiturates - drowsiness
Benzos - Lethargy
Carbimazole - hypothyroidsim
Codeine - opiate OD

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24
Q

Avoid in BF

A

COCP - diminish milk supply
Cytotoxic drugs - IS, neutropenia
Dopamine agonists - suppress lactation, present in milk
Ephedrine - irritable
Tetracyclines - tooth discolouration

25
Q

Adrenaline

A

1 in 1000 = 1g adrenaline in 1000ml so 1mg in 1ml

26
Q

Aminophylline

A

If previously treated with theophylline then already distributed so don’t need the loading dose
Straight to IV infusion

27
Q

Overweight/ underweight child

A

If overweight then prescribe using ideal weight
If underweight then prescribe using actual weight

28
Q

Toxidromes

A

‘clinical fingerprint’, characterised by a classic constellation of symptoms and signs due to toxic effects of a drug

29
Q

Common toxidromes

A

Anticholinergic - antihistamine, TCAs, anti-psychotics, atropine
Cholinergic - organophosphates, mushrooms, insecticides
Sympathomimetic - amphetamines, cocaine, salbbutamol
Sedative-hypnotic - opioids, benzos, ethanol, anticonvulsants
Opioid - morphine, heroin, oxycodone, codeine

30
Q

Antidotes

A

Opiate - naloxone
Benzo - flumazenil (only if resp dep requiring mechanical) SE: seizure threshold
Salicylates - sodium bicarb (alk urine)
TCA - sodium bicarb
Paracetamol - acetylcysteine
Digoxin - digibind
Insulin/ betablockers - glucagon
Iron salts - desferrioxamine mesilate
Methanol, ethylene glycol - fomepizole
Warfarin - vit K1
SSRI/ ethanol - none

31
Q

Alcohol dependence

A

Local guidelines for withdrawal prescribing in inpatients

Regular chlordiazepoxide (diff prescription for diff doses)

? pabrinex 1 + 2 (pair, two vials), after this has ended start thiamine + multivitamin

32
Q

Paracetamol OD guidelines

A

<8hrs after ingestion
- consider charcoal if <1 hr ago
- measure plasma level after 4hours

Revised treatment nomogram (treat above line), use 110kg max if obese

8-24hrs
- urgent plasma level
- treat now if expect >150mg/kg or liver injury
- stop when asymp + normal LFTs/ creatinine and INR

> 24hrs
- treat if jaundice/ hep tenderness
- treat if ^ALT, INR>1.3, para conc detectable
- repeat bloods 8-16hrs, other causes?

33
Q

Paracetamol OD staggered

A

treat ALL patients
bloods 4 hours after last dose

34
Q

Paracetamol monitoring

A

4 hours to deplete glutathione levels - why you can’t test before

35
Q

Acetylcysteine anaphylactoid

A

Not a contraindication to treatment

Management - temp stop and restart at lower rate, anti-histamines, neb salbutamol

36
Q

Aspirin OD management

A

regular plasma levels
correct hypokalaemia from met acidosis
resp support

If plasma conc >500mg/l (350 in kids)
Sodium bicarbonate IV
^serum and urinary PH so v transfer into CNS and ^renal excretion

IV fluids (crystalloid + glucose)

> 700 consider haemodialysis

37
Q

Aspirin OD monitoring

A

Sodium and potassium 1-2hourly
Hourly urine pH

38
Q

Critical Medications

A

Systemic corticosteroids
Anti-epileptics
Anti-parkinsons
Insulin
Anticoagulants
All emergency drugs

39
Q

Anti-epileptics (can’t swallow)

A

Discuss with pharmacy

Consider early placement of NG as liquid/ dispersible preps not available for levetiracetam, topiramate and lamotrigine

Older ones can be IV/ rectal

40
Q

Parkinsons (can’t swallow)

A

Dispersible or NG or swap to rotigotine patch (convert from l-dopa, benefit >risk)

Talk to pharmacy/ senior

41
Q

Anticholinergic burden

A
  1. Tolterodine, oxybutynin, promethazine, amitriptyline, solifenacin
    2 - cetirizine, sertraline, prochlorperazine
42
Q

Intracellular space and extracellular space

A

Intracellular space (2/3 total body fluid)
Extracellular space (1/3) - intravascular (20%), interstitial (80%), third

43
Q

What is third space? Examples?

A

Areas of the body that don’t normally contain fluid
Peritoneal, pleural, pericardial, joints (also interstitial oedema)

44
Q

Fluid intake and output

A

Intake - PO, nasogastric/ PEG, IV, TPN
Output - urine, bowel, stoma, vomit, NG, stomach aspiration, bile drain, bleeding, sweating, fistula, hyperventilation

Insensible is difficult to measure (breath, burns, sweat)

45
Q

Hypovolemia presentation

A

Reduced extracellular volume

BP <100, HR >90, cap refill, cold peripheries, ^RR, dry membranes, v turgor, v urine output, sunken eyes, weight loss, polydipsia

In third spacing may also have signs of overload

46
Q

Crystalloid

A

Small particles in solution that readily diffuse
E.g., 0.9% NaCl, 5% dextrose, 0.18% NaCl in 4% glucose, Hartmann’s

+ resus, vomiting
- hyperchloraemic met acidosis (saline)

47
Q

0.9% NaCl, 5% dextrose, Hartmann’s

A

0.9% NaCl - 1L water with 154mmol of each (SE: ^Na, ^Cl met acidosis)
5% dextrose - 1L water with 50g glucose, no electrolytes (SE: v Na, oedema)
Hartmann’s - 1L water with sodium, chloride, potassium, calcium and lactate buffer (v risk of acidosis)

48
Q

Colloids

A

Larger molecules, stay in intravascular space as can’t cross membrane
E.g., human albumin solution (^ oncotic pressure of plasma)

49
Q

Tonicity (Hypotonic, Isotonic, Hypertonic)

A

Osmotic pressure gradient between two fluids across a membrane, determines whether water moves by osmosis
Hypotonic = 5% dextrose in 0.18% NaCl (not for resus, SE: dilutional v Na)
Isotonic = 0.9% NaCl, Hartmann’s, plasma-lyte
Hypertonic = 3% saline (conc. solutes > than in plasma)

50
Q

Resuscitation Fluids

A

Stat 500ml isotonic fluid bolus <15mins (stat), Repeat 250-500ml boluses if required
Expert help if not responding after 2L

Bolus should have 130-154mmol/L sodium

**Do not give over 10mmol/hour of potassium

51
Q

Fluid Maintenance

A

Indication - NBM, bowel obstruction
Stop IV as soon as oral good enough

25–30 ml/kg/day water
1 mmol/kg/day sodium, potassium and chloride
50–100 g/day of glucose (prevent ketosis, not nutritional)
Ideal body weight not BMI

E.g., 25-30 ml/kg/day 0.18% sodium chloride in 4% glucose with 27 mmol/l added potassium (SE: v Na)

52
Q

Alternative formula for maintenance

A

Adult = 1.5ml/kg/hr

53
Q

Fluid maintenance – monitoring

A

Daily (at least)
= Fluid status, fluid balance chart and U&Es
Max 24hrs of fluids prescribed at one time

SE: dilution of Na (with hypotonic solutions), K, Ca, Mg, haemoglobin and haematocrit (anaemia), clotting factors, platelets and fibrinogen causing coagulopathy

54
Q

Consider less fluid if

A

Elderly, renal impairment, HF, malnourished/ risk of refeeding
Consider 20-25ml/kg/day
(250ml for resus)

Slower bags for maintenance

55
Q

Replacement and redistribution

A

Issues with electrolyte and fluid replacement/ distribution

Maintenance +/- losses and gains
Include input from IV Abx etc

56
Q

Potassium replacement

A

Estimation of deficit
(K normal - K measured) x kg x 0.4

Give this in addition to daily requirement

57
Q

Maintenance Fluids: Caution

A

Avoid dextrose if head injury/ stroke - worsens cerebral oedema (hypotonic)

Avoid normal saline in liver disease - worsens ascites (use Hartmann’s)

58
Q

Hypercalcaemia: Management

A

Rehydration with normal saline e.g., 4+ litres/day

Following rehydration bisphosphonates may be used. They typically take 2-3 days to work with maximal effect being seen at 7 days

PPT (3 decks)

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