OSCEs Flashcards
You may be asked about a scenario when potassium chloride concentrate is being used to prepare an infusion. What is the risk here, and what can be done to minimise this risk?
Potassium overdose can be fatal due to cardiac toxicity
Ideally ready mixed infusion solutions should be used, but if potassium chloride concentrate must be used then the infusion must be MIXED THOROUGHLY
Make sure you check the patients potassium level before therapy and throughout
Check renal function- avoid if severe
Concentrated vials should not be mixed with less then 50X its volume of SODIUM CHLORIDE 0.9%
MIX WELL
so one 10ml vial (containing 20mmol K+) should be mixed with 500mL NaCl 0.9%, 2 vials would be mixed with 1000ml etc.
The concentration should not normally exceed 40mml/L when given PERIPHERALLY (ask what line)
The infusion should be given SLOWLY over 2-3 hours
ECG monitoring should be carried out
Advise on importance of selecting the correct strength.
Spironolactone OR co-amilofruse (amiloride and furosemide) OR Furosemide
Which one has the most evidence for use in Heart Failure?
Spironolactone has better evidence for HF- RALES trial
Fine to manage with IV Furosemide as an inpatient
However recommend switching to PO spironolactone on discharge- check renal function as avoided in AKI/ severe impairment
When completing a drug history you note that a patient on warfarin buys St Johns Wort OTC. What is the problem here?
You also note this patient takes OTC ibuprofen for gout. What do you recommend?
St Johns Wort decreases the anticoagulant affect of warfarin- advise against concomitant use
Ibuprofen should not be taken: warfarin is predicted to increase the risk of bleeding events when given with Ibuprofen. Manufacturer advises use with caution or avoid- avoid all NSAIDs for gout management
Instead, use oral colchicine to manage acute attacks of gout, and can use allopurinol for prophylaxis
A patient is admitted to hospital for acute asthma exacerbation. He has had two previous admission for asthma that year.
He is prescribed prednisolone 40mg OD for 5 days then to stop
Discuss
Find out if the patient received steroids during his last admissions/ at any other point that year
If so, the steroid should be weaned down not stopped abruptly as tapering the drug gives the adrenal glands time to return to their normal patterns of secretion. If this is not done, prednisone withdrawal symptoms may present: Severe fatigue. Weakness.
Can reduce to 30mg after 1 week, then 20mg, then 10mg after another week then 5mg then stop. Ensure patient is counselled and a steroid card is given.
Think about the bigger picture-
Why have they been admitted frequently?
Assess inhaler technique and understanding of different uses of different inhalers
Determine what step they are in the BTS guidelines: recently changed- now everyone at STEP 1 needs both reliever and preventer therapy
What questions need to be asked when taking a drug history?
ALLERGIES? Regular meds? Herbal meds? OTC meds? creams/ ointments? Ear/eye/nose drops? Inhalers? Alcohol status? Smoking status?
Ensure you ask ALL of these, 1 mark for each, plus 1 mark for DOCUMENTING each as a pharmaceutical issue
What medications do we normally see used in HEART FAILURE?
ACE inhibitors
Beta blockers offered to all patients with HF due to left ventricular systolic dysfunction
Can add in an ARB or an aldosterone antagonist such as SPIRONOLACTONE (best evidence- RALES trial) if ACEi + beta blocker ineffective. If Spironolactone used with ACE/ARB- monitor potassium as both can cause hyperkaleamia
Can consider Hydralazine in combination with a nitrate (e.g. isosorbide mononitrate) especially if patient is Afro Carribean
Adjunct therapy to consider:
Ischeamic Heart Disease management risk-
> Aspirin
> Statin
?Digoxin for severe HF with LVSD
How should an ACE inhibitor be initiated?
Baseline Blood Pressure and U&E’s before initiation
Check BP and U&E’s within 2 weeks after initiation or change of dose, then annually
If renal function deteriorates, stop ACEi- don’t stop if only a small rise though (e.g. Cr 99 goes to 110). Look at eGFR- max. initial dose 1.25 mg once daily if eGFR <30.
Cough is not an indication for drug withdrawal
Why are NSAIDs avoided in patients with Heart Failure?
NSAIDs can cause sodium retention and vasoconstriction
They can cause Kidney injury
They can reduce effectiveness and increase toxicity of ACE inhibitors and diuretics (through kidney injury?)
Recent findings suggest higher risk of CV events in patients on NSAIDs
You receive a medicines information query regarding the compatibility of amphotericin B and potassium infusion runnning together. What two resources could you use to answer this enquiry?
Handbook of Injectable drugs (trissell)
UCLH Injectable Medicines Administration Guide
You receive a medicines information query regarding the compatibility of amphotericin B and potassium infusion runnning together.
Potassium is already running down a peripheral line but patient needs a dose of Amphotericin now.
What MI questions would you ask? Try and think of 8 points you need to note.
Enquirer details:
Name, role
Contact details
When is the answer needed
Patient details:
Name, hospital number, DOB, weight, height, allergy status, PMH, PC
What other drugs is the patient on?
What lines does the patient have in place?
Why is amphotericin to be used? Indication? Micro approval?
Dose of amphotericin is usually based on WEIGHT so ensure you ask weight
Blood results- creatinine, LFT’s, POTASSIUM level
Amphotericin can potentiate hypokaleamia
Why may two drugs not be compatible?
Solubility
Interactions
pH
Stability? Crystalisation?
What could happen if two drugs are incompatible and run down the same line?
decreased drug effectiveness/ treatment failure
increase the risk for adverse effects such as injection site reactions
What drugs pose a risk for patients with GI bleeding and should be used with caution/ discontinued?
Aspirin / NSAIDs- stop in patients with peptic ulcer bleeding
SSRI’s- use with caution
Use with caution:
Oral anticoagulants
Steroids
Treatment of G2 reflux oesophagititis involves an 8 week course of omeprazole 20mg OD.
What lifestyle advice would you offer to someone with oesophagitis?
Eat smaller more frequent meals- leave at least 3 hours after eating before going to bed
Raise one end of the bed so that chest and head are above waist level
Have a healthy balanced diet- aim to lose weight
Avoid food or drink that triggers it
Don’t smoke
Decrease alcohol intake
What does treatment for H.pylori involve?
Hint: Triple therapy involving 1 PPI + 2 AB’s
Omeprazole 20 mg BD + clarithromycin 500 mg BD + amoxicillin 1,000 mg BD for one week
OR if penicillin allergy:
Omeprazole 20 mg BD + clarithromycin 250 mg (alternatively 500 mg) BD + metronidazole 400 mg BD for one week
Lifestyle advice!!!:
Recommend avoiding foods, beverages, and drugs that increase the production of stomach acid, since acid can hinder the treatment process.
Cigarettes, aspirin, naproxen, ibuprofen, alcohol, and caffeine can worsen symptoms, as can spicy foods.
Stop smoking and cut down alcohol!!!!
Need to avoid alcohol especially if taking metronidazole- interaction!
What five pointers would a post- surgical treatment plan involve?
VTE prophylaxis- reduced mobility post surgery- check notes from surgeons, consider choice according to patients renal function. Check platelets before initiation- and monitor due to risk of HIT developing.
Antiemetics for post op N&V
Pain control- opioids to start then stepping down the pain ladder
Antibiotics
Laxatives- especially if on opioids
Counsel a patient newly started on Rivaroxaban.
The patient has AF and has been started on Rivaroxaban for prevention of stroke.
Please see counselling sheet in revision notes and ensure all points are covered.
You are asked to write up a treatment plan for a patient withdrawing from alcohol in their medical notes. The guideline is given to you. What basic info should you start with when making a medical entry and what three drugs are you likely to mention?
Medical note entry: Patient name Hospital number DOB 'Pharmacist Entry' Signature, name, bleep
Chlordiazepoxide: PRN (25-50mg 2 hourly for first 24 hours, no more than 300mg per day, 2 hourly monitoring as per CIWA
Then reducing regimen over 2-5 days
Use Lorazepam if evidence of liver impairment!!
Pabrinex- treatment dose or prophylaxis- monitor for anaphylaxis reaction, give as IV infusion over 30 mins, then step down to oral thiamine and vitamin B co strong.
Lactulose 30-50ml TDS- ensure bowels open to prevent hepatic encephalitis
Also consider anticoagulation- dependent on clotting factors and liver function
A patient with a history of previous DVT is due to undergo surgery next week and you are asked by the doctor how to go about bridging with Enoxaparin. What questions do you ask and monitoring requirements, and what does the usual bridging scenario involve PRE-surgery (no need to talk about post just yet) ?
When was the patients DVT? Determine whether they are very high risk- if so they would need to be admitted for a UFH infusion 3 days before surgery.
high risk- stop warfarin 5 days before and start TREATMENT dose enoxaparin (1.5mg/Kg), stop 24 hours before surgery
Medium risk- stop warfarin 5 days before and start PROPHYLACTIC dose
Low risk: stop warfarin 5 days before surgery, give vitamin K by mouth the day before surgery if INR is over 1.5 (blood too thin)
Monitoring: CrCl Platelets K+ Weight
How should we go about managing a patient usually on warfarin bridged with Enoxaparin prior to surgery in the POST operative phase?
Bleed risk needs to be assessed.
Those that are high bleed risk: restart warfarin 48 hours after surgery.
Low risk: restart warfarin imminently.
Reload dependent on INR and as per Trust guidelines:
e.g. GSTT: restart with a loading dose of 1.5 x patient’s usual dose for 3 days, then continue on usual dose. Continue treatment dose enoxaparin until INR is in therapeutic range for 2 consecutive days. Monitor INR daily. Monitor LFT’s for warfarin. Monitor for signs of bleeding
Which antiemetic(s) should be avoided in patients with Parkinsons and why? Which is a safe alternative?
Metoclopramide
Prochlorperazine
These are dopamine antagonists. They therefore worsen parkinsons symptoms- Extrapyridamidal symptoms such as Tardive Dyskinesia, Dystonia, Tremor)
Domperidone is the drug of choice. It is a dopamine antagonist but it doesn’t cross the Blood Brain Barrier. 10-20mg TDS. It prolongs QT interval so be wary with other QT prolonging drugs (monitor)
You are taking in an enquiry regarding how to administer pramiprexole down an NG tube. Take in this enquiry, ask all relevant questions so that someone else would be able to pick this up with the information you obtain. What resources could you use?
Enquirer details: Name, job role, contact number, how long until you need an answer?
Patient details: Name, DOB, ward, hospital number, allergy status, weight, height
Past medical history? Presenting complaint?
Indication for pramiprexole, dose, current route, next dose due?
Reason for NG tube?
Other medication?
Type of tube?
How long are the expected to require this?
Are any feeds being given down the tube?
What other drugs are going down the tube?
Start with BNF, SPC, Martindale
More specific: Handbook of Drug administration via Enteral Tubes
NEWT guidelines
