Medications, Consultations & Prevention of Inpatient Complications Flashcards
What are the approaches to fluid management?
4Rs
Routine Maintenance
Replacement
Redistribution
Resuscitation
What do intravascularly dry patients look like?
Decreased urine output
CVP
IVC
Hypotension
Tachycardia
Decreased weight
What is the goal of fluids
maintain hemodynamic stability, euvolemic state
What are the daily fluid requirements
25-30ml/kg/day of water (total fluid)
*rarely more than 3L per day
When should enteral nutrition be considered
if NPO > 3days
how should fluids be dosed for obese patients
weight based dosing should be off ideal body weight, not actual body weight
who are fluid requirements lower for
elderly
CKD
CHF
malnourished patients
What does tonicity define
the cell
What is hypertonic fluid
tonicity higher than that of the blood
for TBI, fluid shifts, hyponatremia
3% NACL, 7% NACL, D10W and higher concentrations
What are Colloids
high molecular weight, will stay in intravascular space longer
albumin (16hrs intravasc vs 30min NS), hetastarch
What is Isotonic
denoting or relating to a solution having the same osmotic pressure as some other solution, especially one in a cell or a body fluid
NS, LR, D5W, plasmalyte
what is Hypotonic fluid
tonicity is lower thant hat of the blood, used for hypernatremia
.45% NACL (1/2NS), D2.5W
What is Crystalloids
isotonic but hypo-oncotic lack the large proteins that keep fluid intravascularly
NS, LR
What are balanced crystalloids
include lactate or acetate, they are buffered, low Cl-
LR, Plasmalyte
What does 0.45% hypotonic saline increase the risk of
cerebral edema
rarely used
used in patients with hypovolemia in setting of hypernatremia
when do we use 3% hypertonic saline
symptomatic hyponatremia
elevated ICP (d/t TBI, bleed, concern for herniation)
What can occur with innapropriate 3% hypertonic saline administration
osmotic demyelination syndrome
What is the pH of LR
6.5
What is within LR
(components)
Ca2+, K+, Cl-, Na+
Will patients who recieve LR get lactic acidosis
NO
may cause increase lactate but not lactic acid
what is contraindicated in newonates with LR
Ceftriaxone
What are the CONS of NS
intracellular potassium depletion
Hypercholremic metabolic acidosis
neutrophil activation
pH 5.5
(high volume can cause hypercholremic metabolic acidosis)
What is Plasmalyte
balanced crystalloid fluid
What is D5W
dextrose 5% in free water
used in hypoglycemia
what makes up 50% of all plasma proteins
albumin
If a trauma patient is hypotensive, what fluids should they NOT recieve
crystalloid fluids
in a trauma if a patient looses 1L of blood how much fluid and what type will they need
3L (ish) of crystalloid to maintain normovolemia
how much of fluids will remain as intravascular volume
30%
What is the preferred method of nutrition management
enteral nutrition
requires working GI tract
what are the risk with enteral nutrition
not meeting nutritional requirements
aspiration (NG)
GI distress
wound infection if surgically placed
what are the indications for parenteral nutrition
if requirements not met via enteral
if Gi tract issues
what are the risks of parenteral nutrition
systemic infection
occlusion of line
thrombosis
what are IV opioid options
Morphine
Hydromorphone (Dilaudid)
Fentanyl
what is the PK of fentanyl
RAPID onset < 1 minute, only lasts about 1 hour
What does MME stand for
Morphile Miligram Equivalents (MME)
what is the MME that are at higher risk of OD
Over 50 MME/Day
What is pyshiologic decline exacerbated by inactivity/immobility
deconditioning
How are pressure ulcers managed
consult wound care early
document
dibridement and clean
dressings
monitor for infection
What is Virchows Triad
stasis
endothelial injury
hypercoagulable state
What are provoking facotrs for VTE
estrogen/BC
smoking
immobility
trauma
What is the treatment of VTE
anticoagulation
(LMWH, DOACs)
What are the Ws of post-op fever
wind
water
walk
wound
wounder about drugs
What are Risk factors with Hospital acquired infections (HAIs)
hospital associated
immunosuppression, older age, increased LOS, medical comorbidites, frequent hospitalization, etc
What are common hospital acquired infections
c. diff
CLABSI
CAUTI (e.coli, pseduomonas)
SSI (s. aureus)
HAP/VAP
What is CLABSI
central-line associated blood stream infections
What is CAUTI
catheter-associated UTIs
What is a VAP
ventilator associated pneumonia
what is HAP
hospital acquired pneumonia
what is a SSI
surgical site infection
What is a CDI
c.diff infection
What is the management of HAI
removal/replacement of offending agent if possible
site +/- Blood cultures
lab workup for sepsis
empiric abx
fluid resuscitation if needed
monitor for deterioration
What is the #1 HAI
what are the pathogen associated with this
CAUTI
cath is the m/c indwelling device
E.coli, Pseudomonas, klebsiella, proteus, enterococcus, staph
what is the presentation of a CAUTI
often fever w/o urinary symptoms
hematuria, suprapubic pain, flank pain, CVA tenderness
bacteremia + positive urine culure and no other source
pyuria
how is a CAUTI diagnosed
dx of exclusion
Urine culture (from foley bag)
blood cultures
What is the treatment of CAUTI
change foley (biofilm)
debatable when abx should be started
abx (pipercillin-tazo, ceftazidime, aztronam)
What are contraindications for IO
osteoporosis
osteogenesis imperfecta
bone fracture
recent placement of IO
cellultitis, infection, burn over insertion site
what are the inerstion sites for IO’s
proximal tibia (m/c)
humerus
what are the risks of IO
infection
skin necrosis (extravasation)
compartment syndrome (if through bone completely)
epiphyseal injury
fat embolism
pain
What are the indications for central lines
cant get peripheral access
need access for procedures
measure central venous pressure
administer certain meds
What meds often need a central line
pressors, calcium chloride, potassium
What are complications of central line
hematoma/pain
extravasation of fluids
phelbitis
cellulitis
neurovascular injury
bacteremia/sepsis
DVT
tissue necrosis
What is the most common procedure for central lines
seldinger technique
needly used to intoduce guidewire, batheter is then placed over the guidewire
What is a paracentesis
removes ascited for fluid analysis and/or assistance with symptoms management associated with large ascites volume
therapeutic and diagnostic
what is a thoracenesis used for
pleural effusion
d/t CHF, pneumonia, cancer, PE< cirrhosis
what are the contraindications for thoracentesis
loculations (need special US guided drainage)
infection to overlying skin
coagulation abnormalities
how is a patient positioned for a thoracentesis
sitting upright and bending forward
What are the compliations of thoracentesis
pneumothorax, bleeding, hemothorax, puncture of spleen or liver
Where is CSF made
ventricles
produced by choroid plexus
What are the inidcation of LP
Meningitis (CNS Infection)
MS
Aneurysms
unexplainedd seizures
instil chemo/contrast
assess or elevated ICP
what are contraindications of LP
overlying infection
space occupying lesion
increased ICP
coagulopathy
lumbar fusion/laminectomy
What is BIPAP
Bilevel Positive Pressure
senses when pt inhails and provides expiratory PEEP
