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pharmacology Flashcards

1
Q

fluids-
rule of 1/3s
for 70kg patient

A

TBW 42 L

  • intracellular = 2/3 = 28L
  • extracellular = 1/3 = 14L
    • Interstitial fluid 2/3 of ECF 9L
      - Intravascular - 1/3 of ECF 5L
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2
Q

total blood volumes for:
adults
children
neonates

A 
adults = 70mls/kg
children = 80mls/kg
neonates = 90mls/kg
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3
Q

define osmolality

A

osmoles per kg of solvent (usually water)

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4
Q

define osmolarity

A

osmoles per litre

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5
Q

define tonicity

A

the ability of a solution to cause water movement

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6
Q

name two types of fluid

A

crystalloid - better for resus

colloids

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7
Q

what happens if you leave people on just a normal saline drip?

A

hypernatraemia
hyperchloraemia
acidotic

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8
Q

if you provide someone with glucose what happens to their potassium?

A

lowers potassium
as when you process the glucose by glycolysis this is co-transported into cells with potassium
so if you give someone shit loads of sugar expect their potassium to decrease

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9
Q

hartmanns/plasmolyte

what is it?

A

very close ionically to our own plasma so its good

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10
Q

requirements per day of water, sodium, potassium, energy

A

water - 30mls/kg/day
sodium - 1-2mmols
potassium - 1mmols
energy - 30kcal

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11
Q

if you have a patient that is hypovolaemic, but you are loading them with lots of fluids. what can be the explanation for this?

A

this is commonly seen in people with pancreatitis and severe illness of any kind.
there is this ‘third space’, so not intracellular not extracellular the fluid is just leaking out and going somewhere else.

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12
Q

if someone is on IV fluids consistently in hospital, how often should they be having a U+E?

A

at least every 24/hrs if not more!!

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13
Q

normal urine output

A

0.5ml/kg/hr

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14
Q

fluids formulas for adults

A

deficit:
4mls/kg/hr up to 10kg
2mls/kg/hr up to 20kg
1mls/kg/hr for rest

maintanence
25–30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride
+ 50-100g/day glucose to prevent starvation ketosis.

so prescribe 25-30ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 for routine maintenance

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15
Q

simple analgesia examples

A

paracetamol

NSAIDs - ibuprofen

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16
Q

when can you not prescribe paracetamol

A 
hepatic impairment
severe cachexia (less than 50kg = max 500mg QDS)
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17
Q

when can you not prescribe NSAIDs

A

CI - GI bleeds or ulcer history, asthma

  • renal impairment and platelet count
  • concurrent meds - warfarin, digoxin, steroids
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18
Q

weak opioids

and their problems

A

codeine
dihydrocodeine
tramadol

problems - ceiling effect, therefore if not working go to stronger opioid not add another weak opioid.

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19
Q

strong opioids

A 
morphine
fentanyl 
diamorphine - IM/IV
oxycodone - sibling of morphine - normally better s/e 
buprenorphine
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20
Q

specialist palliative care only analgesia

A

hydromorphone
alfentanil
methadone
ketamine

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21
Q

questions to ask patient before starting strong opioid

A
  1. every had before? if so what happened?
  2. renal function - if low egfr then oxycodone NOT morphine
  3. age/frailty - changes dose
  4. co-morbidities
  5. patient concerns
  6. are they driving?
  7. will they take them as prescribed?
  8. have you prescribed medications for any s/e
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22
Q

how potent is codeine/tramadol in comparison to oral morphine

A

1/10th

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23
Q

if someone was on 60mg QDS of codeine phosphate but this was not managing pain, what would you next prescribe and its dose?

A

currently on 240mg/24hrs of codeine.
/10 to get same potency in morphine.
= 24mg of morphine

so prescribe 10mg BDS of morphine modified release

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24
Q

if someone was on 100mg QDS of tramadol but not coping, next steps are?

A

400mg/24 hrs
/10
= 40mg morphine

so prescribe 20mg BD of modified release morphine

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25
Q

modified release analgesia

A 
for background pain
acts for 12 hours
examples - 
- morphine = MST (tablet), Zomorph (capsule)
- oxycodone = oxycontin
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26
Q

immediate release analgesia

A

for breakthrough pain
acts for 4 hours
- morphine = ormorph (liquid), sevredol (tablet)
- oxycodone = oxynorm (liquid or capsule)

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27
Q

oxycodone/morphine potency ratio

A

2/1

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28
Q

how to work out PRN doses

A

1/6th of 24hr dose.
for example if they are having 60mg/24hrs of morphine.
PRN dose = 10mg

(!!! DONT forget the potency difference between oxycodone/morphine with this though)

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29
Q

s/e of opioid management

A

antiemetic PRN

laxative - stimulant

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30
Q

opioid s/e
common
less freq
rare

A

common -

  • constipation
  • nausea
  • sedation
  • dry mouth

less frequent

  • psychomimetic effects
  • confusion
  • myoclonus

rare

  • allergy
  • resp depression
  • pruritis
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31
Q

analgesia patches examples, indication and housekeeping

A

fentanyl
buprenorphine

indication - for stable opioid responsive pain, intolerable s/e, oral route difficulties: compliance/dysphagia, renal impairment

DO NOT USE IN ACUTE PAIN - takes 1-3 days to reach analgesic concentrations

housekeeping -

  • hairless, dry, non-inflamed skin
  • always check fully adhered on admission/inbetween changes
  • avoid heat pads as decrease absorption
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32
Q

potency comparison:

5microgram/hour buprenorphine patch changed every 7 days is equivalent to how much morphine over 24hrs

A

12mg

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33
Q

what might you prescribe for neuropathic pain?

A

amitriptylline
duloxetine
pregablin
gabapentin

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34
Q

what might you prescribe for muscle spasms

A

baclofen

tizinidine

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35
Q

what might you prescribe for compression symptoms?

A

dexamethasone

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36
Q

what might you prescribe for spasms, ?neuropathic pain

A

clonazepam

diazepam

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37
Q

what might you prescribe for focal areas of pain

A

topical lidocaine plasters

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38
Q

what might you prescribe for bone pain?

A

bisphosphonates

- zolendronic acid

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39
Q

potency comparison -

injectable opioids: oral opioids

A

2:1

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40
Q

patient is on 50mg BD morphine MR and oramorph 15mg PRN - needing to be converted to syringe driver as of recent swallowing problems. what would you prescribe?

A

50mg x 2 = 100mg
/2 - as of potency when IV = 50mg SC morphine/24hrs
PRN - 7.5mg SC

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41
Q

if on fentanyl patch and stable and wanting to swap to syringe driver to control pain - what do you do with the patch?

A

leave it there

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42
Q

what unit must you always prescribe opioids?

A

mg

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43
Q

nociception nerve fibres -

types

A

A-delta - myelinated and fast conduction

C - non-myelinated and slow conduction

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44
Q

two tracts involved with pain

A

dorsal root ganglion - afferent, first order neurons

spinothalamic tract - second order neuros

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45
Q

formula to work out dose in IV infusions

A

mls/hr x mg/ml

= mg/hr

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46
Q

what is the most common shape for gram positive bacteria?

A

cocci

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47
Q

what is the most common shape for gram negative bacteria?

A

bacilli

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48
Q

name an anaerobic gram negative bacilli

A

bacteroides eg B. fragilis

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49
Q

name the aerobic gram negative bacilli and their growth requirements

A

lactose fermenters - MacConkey Pink or XLD:
- Escherichia Coli
- Klebsiella pneumoniae
(***on XLD = e.coli yellow colonies, salmonella = black)

non-lactose fermenters - MacConkey pale
- salmonella typhi/paratyphi/enterica
- shigella sonnei/dysenteriae
- proteus mirabilis
(***OXIDASE TEST - positive = pseudomonas aerginosa -negative = salmonella, shigella, proteus)

others -

  • pseudamonas aeurginosa
  • vibrio cholerae

fastidious growth requirements - chocolate agar

  • parvobacteria - haemophilus influenzae, bordatella pertussus, legionella pneumophilia, brucella, campylobacter jejuni (grown on CCDA - charcoal plate)
  • helicobacter pylori
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50
Q

name the gram neg cocci

A

neisseria meningitidis
neisseria gonorrhoeae
moraxella catarrhalis

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51
Q

gram positive cocci - pairs/chains

A

CATALASE NEGATIVE
streptococcus - blood agar used to detect haemolysis, CBA plate

alpha haemolytic - DARK GREEN

  • strep pneumoniae - optochin sensitive
  • strep oralis
  • strep sangius
  • strep viridans
  • enterococci

beta haemolytic - PALE YELLOW AND TRANSPARENT

  • step pyogenes -A
  • strep agalactiae - B

non-haemolytic - NO CHANGE

  • strep mutans
  • strep milleri - lung abscess
  • enterococcus faecalis
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52
Q

gram positive cocci - clusters

A

CATALASE POSITIVE
staphylococcus

coagulase negative - staph epidermis, staph saprophiticus

coagulase positive - staph aureus - lung abscess

53
Q

mycobacterium TB - staining and growth and cell type

A

weakly gram positive bacilli
doesnt gram stain well
ACID FAST BACILLI - high lipid content in cell wall
ziehl-neelson stain - stain is coloured red
can also use lowenstein jensen medium - takes 3-8 weeks

54
Q

b-haemolytic strep groups

A

group A - pyogenes
B - perinatal
C- bowel/UTI

55
Q

gram positive bacilli-

A

anaerobic-

  • clostridium perfringens
  • c. tetani
  • c. botulinium
  • c. dificile

aerobic

  • cornybacterium diptheriae
  • listeria monocytogenes
  • bacillus anthracis
  • bacillus cereus
56
Q

the penicillin group - coverage and what are they effective against

A

penicillin V -
- narrow spec, strep throat, can be added to fluclox in skin infections

amoxicillin - broader than pen v and much better absorption

57
Q

neuropathic pain ladder

A

1st line - amitriptyline or pregablin
2nd - amitriptyline + pregab
3rd - refer to pain specialist - give tramadol in the interim (avoid morphine)

58
Q

what do you prescribe a diabetic if they have neuropathic pain

A

duloxetine

59
Q

anaesthetic analgesic ladder

A

management of acute pain
severe pain to moderate so normally the opposite to WHO ladder
1st - strong analgesic + local anaesthetic block and peripherally acting drug
2ns - restore use of oral route. should be fine with weak opioids + para/ibup
3rd - just para/ibup

60
Q

WHO analgesic ladder

A

para/ibup
weak opioid eg codeine
strong opioid eg morphine

61
Q

if large volumes of 0.9% saline is given what is your patient at risk of and why?

A

hyperchloraemic metabolic acidosis

saline causes a overload of chloride ions into the blood which forces bicarb to move intracellularly to maintain ionic equilibrium, thus reducing the available bicarbonate for the pH buffering system leading to net acidosis.

62
Q

when should Hartmann’s NOT be used

A

in patients with hyperkalaemia as it contains potassium!!!

63
Q

when is hartmans preferred to be used

A

after surgery

64
Q

what is not recommended for post surgery patients for fluid replacement

A

5% dextrose and dextrose/saline combs

65
Q

if you have a patient who is oedematous but also hypovolaemic what do you do

A

hypovolaemia should be treated first
followed by a negative fluid balance (higher UO than input fluids) monitored using Na excretion levels.
however solutions such as dextran 70 should be used in caution in patients with sepsis as there is a risk of AKI

66
Q

what is a crystalloid fluid?

what is colloid fluid?

A

crystalloid - solutions of small molecules in water (eg nacl, hartmann’s, dextrose)

colloid - larger organic molecules (eg albumin, gelofusine). they carry a risk of anaphylaxis and research has shown that crystalloids are superior in initial fluid resus

67
Q 
describe the tonicity of each of these fluids:
NaCl
hartmanns
NaCl 0.18%/ glucose 4%
5% dextrose
A

NaCl - isotonic (used for resus)
hartmanns - isotonic (used for resus)
NaCl 0.18%/ glucose 4% - hypotonic
5% dextrose - hypotonic

68
Q

what does hypotonic fluid mean

A

less fluid, salt, sug than blood

69
Q

what does isotonic fluid mean

A

similar fluid, salt, sug than blood

70
Q

assessing a patient for fluid prescription

A

look at fluid chart - input/output
ask nurses about - vom/diarrhoea
check for any drains
co-morbs? heart/renal failure

71
Q

aims of initial evaluation of trauma

A

aims:

  1. stabilise
  2. identify life-threatening conditions in order of risk and initiate supportive treatment
  3. organise definitive treatments or transfer for it
72
Q

trauma a-e

A

prep!!

  • airway equip - laryngoscopes
  • IV fluids + warming equip
  • monitoring equip
  • methods of summoning extra medical help
  • prompt labs and radiology backup
  • transfer arrangements with trauma centre

CABCDE

73
Q

trauma a-e

prep

A

prep!!

  • airway equip - laryngoscopes
  • IV fluids + warming equip
  • monitoring equip
  • methods of summoning extra medical help
  • prompt labs and radiology backup
  • transfer arrangements with trauma centre

TTBTO - turn the blood tap off - if an obvious massive haemorrhage sort that first (ie squirting) - direct manual pressure

C - cpsine immobilise - then follow ABCDE as normal, except:

A - will probs need to intubate

B- more important to get full vision of chest to chest for trauma
think about potential:
- tension pneumo
- flail chest
- haemothorax

C - see rest on A+E notes

74
Q

when to expect electrolyte changes in fluid losses and therefore need to alter fluid replacement regime

A 
vomiting
NG tube
diarrhoea/excess colostomy loss
jujenal loss
high vol ileal loss via new stoma
lower vol ileal loss via established stoma or fistula
pancreatic drain or fistula loss
bilary drainage loss
inapprop urinary loss (monitor elec closely as can be highly variable)
75
Q

if you suspect any electrolyte losses then which is the best solution to give in hypovolaemia in a bolus

A

hartmanns - as will replace them

76
Q

when do you stop giving boluses to someone in an emergency

A

when you reach 2000mls

if reach this and not better - SENIOR HELP

77
Q

which compartment are fluids put into?

A

intravascular

however certain amount will be redistributed across all compartments depending on their osmotic gradient

78
Q

hierarchy of how long IV fluids stay intravascularly before being redistributed into other compartments (longest -> shortest)

A 
colloids
saline
hartmanns
dex-saline
dex
79
Q

when would you give 5% dextrose? and why is it bad?

A

if just need to give pure water and they cannot swallow - as glucose is just used up
bad - resus, too much too quick = hyponatraemia

80
Q

good/bad things about normal saline

A

can add 20-40mmol KCl per 1L bag
good as maintainence - alternate with 5% dex in those with normal electrolytes (1 salty + 2 sweet)

bad
hypernatraemia
using it alone without alternating with dex can be renotoxic - massive sodium load on kidneys causing renal vasoconstriction
give hyperchloraemic acidosis

81
Q

good/ bad about hartmanns

A

good - anaesthetics choice, excellent to replace plasma during GI losses/surg

bad - shouldnt be used as maintanence alone as will give 3x too much sodium and not enough pot
- cannot add extra pot or mag to bag

82
Q

what causes electrolyte loss

A 
D+V
NG aspirate
stoma
burn
pancreatitis
83
Q

dehydration loss and its replacement

A

caused by pyrexia + poor intake

replace with dex-saline

84
Q

what does raised creat + urea indicate when there has been fluid losses

A

dehydration

urea will rise first

85
Q

the classic fluids prescribed for a 70kg man maintenance

A

CHECK U+E FIRST!!!

saline 0.9% + 20mmol KCl over 8 hours

dextrose 5% +20mmol KCl over 8 hours
(repeat this for last 8 hours)

86
Q

why does potassium increase post surg

A

cell lysis

as potassium is intracellular

87
Q

whats first line choice fluids post-op if no electrolyte imbalances

A

sodium retaining mechanisms are activated in surg so dex-saline is best choice
if patient can drink just let them dont prescribe

88
Q

first line fluid replacement choice in sepsis

A

hartmanns

as capillary vasodilation and leakiness causes intravascular depletion

89
Q

heart failure fluid requirements

A

NO MORE THAN 2L/24 hrs - aka no more than 2 bags per day

overloaded? furose + max 1.5l per day (try oral) + low sodium diet + daily weights (1kg less = 1L lost)

90
Q

you have a patient that had low systolic BP + low UO but is at risk of LVF -
what two clinical pictures can cause this?

A

dehydration
LVF + overload: LVF causes low SBP, hence low UO - rx = furose which improves LVF and hence paradoxically increase SBP and UO

91
Q

fluid losses in liver failure patient - choice of fluid and why?

A

5% dex

as excess sodium causes ascites

92
Q

fluid choice in AKI

A

no potassium supplementation

93
Q

fluid choice in hx of alc excess/ poor nutrition

A

give pabrinex before giving 5% dex, even if hypoglycaemic or the glucose load may precipitate korsakoffs syndrome

94
Q

fluid replacement in brain haemorrhage

A

avoid dex - can worsen oedema due to osmotic shifts

saline would be a good first choice

95
Q

fluid replacement in risk of refeeding syndrome

A

avoid dex and can precipitate
may have hypomag/kal/phos so these will need replacing

(on placement we gave phosphate polyfuser and the rest sorted itself out??)

96
Q

what are the average insensible fluid losses from a person on a normal day

A

500-800mls

97
Q

What largely determines the movement of water between intra and extracellular compartments

A

sodium

98
Q

what is high/low electrolyte wise in intra/extracellular compartments

what maintains this gradient?

A

intracellular - potassium high, sodium low
(these solute concentrations remain more or less constant)

extracellular - sodium high, potassium low

gradient maintained by sodium-potassium ATPase pump

99
Q

what is the main process called that drives water across membranes and explain it

name another force that can act on this water movement gradient and when this can come into affect

A

osmosis

this pressure is provided mainly by large molecular weight particles eg proteins.

in a normal healthy individual there are more proteins in intravascular space rather than interstitial fluid

another force-
hydrostatic pressure gradient

this can be affected by circ probs and pressure in tissues such as oedema, mech restriction such as with infection, plaster casts and bandaging

100
Q

why add in glucose to fluids?

A

to limit starvation ketosis

101
Q

what may cause an increase in insensible losses of fluid

A

sweating
tachypnoeic
febrile
open cavity surg

102
Q

which electrolytes are lost when you sweat

A

sodium

103
Q

which electrolytes are lost when you have diarrhoes/increased stoma output

A

sodium/potassium/bicarb

104
Q

which electrolytes are lost when you vomit and what may it lead to if excessive

A

k
cl
hydrogen ions

this may lead to hypochloraemic metabolic alkalosis, sometimes also mild hypokalaemia

105
Q

what are insensible losses normally made up of (fluid/electrolyte)

A

pure water

106
Q

how many grams of glucose are in IL bag of 5% dextrose

A

50g

107
Q

what is the checklist of things you need to check before prescribing fluids

A 
type of fluid loss
renal function
cardiac function
concomittant electrolyte abnormalities
BP
CRT
fluid balance charts
skin turgor 
weight 
med review - diuretics?
108
Q

what is a hypertonic solution + examples

A

they increase plasma tonicity and draw fluid out of cells

sodium chloride 3%
mannitol

109
Q

if you give NaCl 0.9% what % of that will go into the interstitial fluid and how much intracellular from intravascular

A

BAZINGA nothing into intravasc as its isotonic with plasma

75% will go interstitial

110
Q

where does 5% dex distribute to

A

follows normal water

so for example if you put 1000mls into intravascular space only 80ml will stay there

111
Q

examples of colloids

A 
blood 
dextrans
gelatin - gelofusine
human albumin solution
hydroxyethyl starch

draw fluid across capillary border from interstital space to intravascular compartment

112
Q

what other abx has a cross over with penicillin?

A

cephalosporin by 20%

113
Q

what do you have to think about when prescribing for the elderly

A

decrease in metabolism - renal impairment/liver
polypharmacy
potentially more serious outcomes of adverse events from prescribing

114
Q

things that cause worsening AKI - pharmacological

A

loop diuretics

ACEi

115
Q

what drugs are affected by CYP450 enzyme in liver?

A

bhjbk

116
Q

what drugs cause enzyme induction?

A

aka reduce drug concs PC BRAS

P - phenytoin
C - carbamazepine

B- barbituates
R - rifampicin - interaction with methadone 33-66% reduction after just one dose
A - alcohol (chronic excess)
S - sulphonylureas

117
Q

what drugs cause enzyme inhibition (CYP450)?

A

aka increase drug concs
AO DEVICES

A - allopurinol, azole antifungals
O - omeprazole

D- disulfiram
E - eryhtromycin
V - valporate 
I - isoniazid
C - ciprofloxacin
E - ethanol (acute intox)
S - sulphonylureas

macrolide inhibitor - clarithromycin is a p glycoprotein inhibitor (eg statins with this)

classic situ - person on warfarin started on erythromycin and can cause a massive rise in INR. warfarin needs to be reduced in this case

118
Q

what is a narrow therapeutic index drug?

A

drugs in which the effective therapeutic conc is close to or exceeds the toxic conc
small changes in drug level can result in significant toxic effect
level monitoring eg aminoglycosides, phenytoin, lithium, warfarin

119
Q

what does smoking do to drugs?

A

enzyme inducer

120
Q

what drugs should definitely not be stopped for surgery

A

CCB

BB

121
Q

drugs to be stopped for surg

A

I LACK OP

Insulin - variable stopping (look at local policy)
Lithium - day before
Anticoags/antiplatelets - variable stopping (local pol)
COCP/HRT - stop 4 weeks before
K-sparing diuretics - day of
Oral hypoglycaemics - local pol
Perindopril and other ACEi - day of

122
Q

drugs to change around the time of surgery

A

?long term pred have adrenal atrophy - unable to cope with physiological stress response to surg = profound hypotension if theyre stopped.
as with ‘sick day rules’ where patients double their dose when ill, at induction of anaesthesia pts given IV steroids to prevent this

123
Q

how do acei cause a cough and hyperkalaemia

A

cough - accumulation of bradykinin

hyperkalaemia - reduced aldosterone production

124
Q

how does ibuprofen cause renal failure and gastric probs

A

inhibits prostaglandin synthesis which is needed for gastic mucosal protection + also reduces renal art diamter = renal hypoperfusion + function

125
Q

what drugs are notorious for causing confusion in elderly

A

tramadol
cyclizine
diazepam

126
Q

what should never be paired with a BB

A

CCB

risk of asystole

127
Q

type 1 allergic reaction

A 
itching 
urticaria
hypotension
angioedema
wheeze
128
Q

patient follow up requirements after severe anaphylactic shock

A 
pred 3days
non-sed antihistamine for 3 days
issue medical alert band
document
communicatw with GP
advise of what drugs they need to avoid
provide written info on this to patinet
prescribe 2 x adrenaline auto-injector for self-admin only
refer to specialist centre for possible ix into -> all severe reactions, gen anaesthetic.
129
Q

explain how when a patient following an AKI can then suddenly start to have low pot/sodium on U+Es and high urine output following aggressive fluid management?

A

they sometimes follow a phenomena called polyuric phase - can cause urine output >200mls/hr - leads to dehydration again
general input should match output so with treatment regimes follow that - choice should be guided by patients abnormal electrolytes

finals (17 decks)

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