Special Populations Flashcards
Common fluids used in acute care/ICU
Crystalloids: 5% Dextrose, 0.9% NaCl, lactated Ringers, Plasma-Lyte-A
Colloids: Albumin 5%, 25%, Dextran, Hydroxyethyl starch (has BBW) –> overall very $$
Electrolyte disorders: sodium: hypo
Hyponatremia: NA < 135
–> Hypovolemic: low volume caused by diuretics, salt wasting syndromes, blood loss, or vom/diarrhea
-give sodium containing fluids (NS, 1/2NS)
–> Hypervolemic: fluid overload (cirrhosis, HF, renal failure)
-give diuretics, fluid restrict, AVP receptor antagonist
–> Isovolemic: SIADH (inappropriate antidiuretic hormone)
-give diuretics, fluid restrict, demecloyline (SIADH), AVP receptor antagonist
rate of sodium correction
-correct sodium by 4-8 meq/L/24hr
–> doing more than 12 meq/L/24hr can least to osmotic demyelinattion syndrome (ODS) or central pontine myelinolysis
Arginine vasopressin receptor antagonists
-Conivaptan - injection
-Tolvaptan (Samsca)- oral :)
–> used for isovolemic (SAIDH) and hypervolemic hyponatremia
–> Risks: osmotic demyelination syndrome (ODS), hepatotoxicity (can only be used for 30 days)
-must start/restart in the hospital, monitor Na
Electrolyte disorders: sodium hyper
Hypernatremia: Na > 145 mEq/L
-hypovolemic: dehydration, vomiting or diarrhea
–> give fluids
-hypervolemic: intake of hypertonic fluids
–> give diuretics
-Isovolemic: caused by diabetes insipidus, which can dec ADH
–> give desmopressin
Electrolyte imbalances: potassium, magnesium and phosphors
-drop of 1 mEq/L in K (below 3.5) represents a total body deficit of 100-400 mEq
*via peripheral line: give max infusion rate < 10 mEq/hr and max concentration of 10 meq/100 ml
-magnesium is necessary for potassium uptake: Mg < 1 mEq/L with life-threatening (seizures) symtpoms, replace IV with mag sulfate
-phosphorus: when PO4 < 1 mg/dL, replace IV
IV Immunoglobulin
-used for immunodeficiency (off label for MS, myasthenia gravis, gullian-barre syndrome)
–> Gammagard, Gamunex-C, Octagam, Privigen
Warnings: acute renal dysfunction, thrombosis
SEs: HA, nausea, diarrhea, infusion reaction, renal failure, blood dyscarsias (rare)
*impairs pts response to vaccines- needs to be spaced out from them
ICU meds: Vasopressors
used to inc BP, HR, CO
-Dopamine: dose dependent receptor effects, D1 –> beta 1 –> alpha 1
-Epinephrine/Norepinephrine: mixed alpha-1 and beta-1 agonists
-Phenylephrine: pure alpha-1 agonist
-Vasopressin: vasopressin agonist
-Angiotensin II: vasoconstriction, aldosterone release
BBW: extravation: severe tissue damage/necrosis = medical emergency
—> tx with phentolamine (alpha 1 blocker)
SE: arrhythmias, tachycardia
Dopamine Dosing
–> Low (renal) dose: 1-4 mcg/kg/min
-dopamine-1 agonist
–> Medium dose: 5-10 mcg/kg/min
-beta-1 agonist (heart: + ionotropic)
–> High dose: 10-20 mcg/kg/min
-alpha-1 agonist (vasopressor effect)
ICU meds: Vasodilators
use for active MI or uncontrolled HTN
-Nitroglycerin: LD = venous vasodilator, HD = arterial vasodilator
–> can cause tachyphylaxis, use in non PVC container
-Nitroprusside: mixed vasodilator: cyanide (limit use in renal failure), protect from light
-Nesiritide: mixed vasodilator
ICU meds: Inotropes
used to increase contractility of the heart
-Dobutamine: beta 1 agonist
-Milrinone: phosphodiesterase-3 inhibitor (also a vasodilator)
General principles for treating septic shock
-Target a MAP > 65 [ (2* DBP) + SBP]/3
Fill the tank: optimize preload with IV crystalloids (LR)
Squeeze the pipe and kick the pump:
—> alpha-1 agonist activity to inc SVR
–> beta-1 agonist activity to inc myocardial contractility and CO
Acute care: Types of Shock
-hypo perfusion and hypotension = medical emergency!
–> hypovolemic: low volume, low BP, caused by trauma/GI bleed
-tx with fluids (LR, dextrose)
–> Distributive: vessels are leaking, caused by anaphylaxis/sepsis
-tx with fluids, vasopressors (sepsis)
–> cardiogenic: caused by acute decompensated HF
-tx with Inotropes, diuretics, vasopressors
Treating acute decompensated heart failure*
A. pts with edema (pulmonary or lower extremity), JVD and/or ascites are VOLUME OVERLOADED:
–> tx with loop diuretics, vasodilators can be added (NTG, nitroprusside, nesiritide)
B. pts with dec renal function, AMS and/or cool extremities have HYPO PERFUSION:
–> tx with Inotropes (dobutamine, milrinone), if pt becomes hypotensive, consider adding a vasopressor (dopamine, norepinephrine, phenylephrine)
C. some pts are both VOLUME OVERLOAD & HYPO PERFUSION:
–> tx options are a combo of agents above
ICU: drugs for agitation & sedation
NON BENZOS:
–> Dexmedetomidine (Precedex): alpha 2 agonist, can be used in both intubated and non-intubated pts
–> Propofol (Diprivan): oil in water emulsion = cause hypertriglyceridemia - pt should be intubated
BENZOS:
–> Lorazepam (Ativan): propylene glycol toxicity
–> Midazolam (Versed): short acting, active metabolite accumulates in renal dysfunction
ICU: stress ulcer prophylaxis (SUP)
-results from dec blood flow to gut, dec gastric defense mechanisms
-risk factors: mechanical ventilation > 48 hrs, coagulopathy, sepsis, traumatic brain injury, major burns, acute renal failure, high dose systemic steroids
–> H2RAs and PPIs are rec:
-Famotidine etc: risk of thrombocytopenia and CNS side effects (dec to qd dosing)
-Pantopropazole etc: risk of C.diff, osteoporotic fractures, nosocomial pneumonia
–> use for short period of time
ICU: anesthetics
-Local: Lidocaine (Xylocaine), benzocaine
-Inhaled: Desfluraine (Suprane), Sevoflurane (Ultane) –> can cause malignant hyperthermia
-Injectable: bupivacaine (epidural!), lidocaine, ropivacaine
ICU: neuromuscular blocking agents
**paralyzing agents = causes respiratory arrest!!
**does NOT provide sedation or analgesia: pt MUST be on a ventilator
–> Succinylcholine: activates the acetylcholine receptors and desensitizes them
–> Cisatracurium (Nimbex): blocks acetylcholine from binding to the receptor (also rocoronium, vecurinium)
Acute Care meds: hemostatic agents
-work by inhibiting fibrinolysis or enhancing coagulation = STOP bleeding
-topical agents: Recothrom, Thrombin-JMI: used during surgery
–> Aminocaproic acid (Amicar)
–> Tranexamic acid
-Cyklokapron IV
-Lysteda oral: used for heavy menstural bleeding
–> Recombinant factor VIa (NovoSeven RT): used for hemophilia & factor 7 deficiency
When to seek urgent care for a child
-age < 3 mon w/ a temp of 100.4F (R)
-age 3-6 mon w/ temp of 101F (R)
-age > 6 mon w/ a temp of 103F (R)
Newborn baby health
-APGAR score, healthy - 7-10
-congenital screening (heel prick)
-meds: vitamin K IM, opthalmic abx.
Conditions in Preterm Babies
–> Patent Ductus Arteriosus (PDA): opening between aorta and pulmonary artery
-tx w/ INSAIDs (IV indomethacin)
–> Persistent Pulmonary Hypertension of the Newborn (PPHN): constricted blood vessels in the lungs, blocking airflow (increased risk if mother takes SSRIs)
-tx: supportive care, can use inhaled Nitric Oxide (rare)
–> Respiratory Distress Syndrome (RDS): deficiency of surfactant (production starts at gestational week 24, adequate at week 35)
-tx: surfactant (Curosurf, Infasurf)
OTC products to reduce fever in infants
-Acetaminophen (Tylenol): 10-15 mg/kg/dose q 4-6 hrs
-Ibuprofen (Advil/motrin): 5-10 mg/kg/dose q 6-8 hrs (do not use in < 6 months)
**NO ASA in < 16 y/o: reyes syndrome
Common conditions in young children: Bacterial Meningitis
< 1 month: strep. agalactiae (Group B strep), E. coli, Listeria monocytogenes, Klebsiella
–> ampicillin + cefotaxime
–> ampicillin + Aminoglycoside (gentamicin)
1-23 months: Step. pneumoniae, N meningitidis, S. agalactiae, H. influenza, E. Coli
–> Vancomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
2 + yrs: N. meningitidis, S. pneumoniae
–> Vancomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
**ceftriaxone use in neonates can cause bilirubin induced brain damage (Kernicterus), and w/ ca containing solutions- can precipitate and cause embolus
Common conditions in young children: Respiratory Syncytial Virus (RSV)
-enveloped, non-segmented, neg strand RNA virus
Presentation: apnea, non specific cold symptoms
TX: supportive care, inhaled Rivabirivin (Virazole) if high risk
**Prevention: hand hygiene, infection control
–> Immunophrophylaxis: Palivizumab (Synagis) - given to high risk pts during sept-april, IM 15 mg/kg Q 30 d (max 5 doses)
Who gets it?:
-preterm infants (< 29 weeks)
-preterm infants (< 32 weeks) w/. chronic lung disease
-infants w/ congenital heart disease
-anatomic pulmonary abnormalities or neuromuscular disorders
Common conditions in young children: Croup
-inflammation of the upper airway: leads to erythema + narrowing of the trachea; common in infants & children < 6 y/o
-presentation: inspiratory strider, cough, hoarseness = barking cough
TX: dexamethasone 0.6 mg/kg (MAX 16), nebulized racemic epinephrine (more severe cases) 0.05-0.1 mL/kg (MAX 0.5mL- duration is 2 hours), fever reducer and abx if bacterial suspected
Common conditions in young children: Nocturnal Enuresis (bed wetting)
-not treated before 5 y/o, behavioral approaches (can go to drug after 3 mon trial failure)
–> Desmopressin (DDAVP): PO
-synthetic analogue for ADH, dec noturnal urine production - 0.2mg PO QHS (up to 0.6 mg)
CI: hyponatremia, Crcl < 50
AE: HA, fatigue, hyponatremia
Drugs to avoid in pediatric pts *
Contraindicated:
-Codeine in age < 12 y/o
-Tramadol in age < 12 y/o
-Promethazine in age < 2 y/o
-Ceftriaxone in neonates ( 1-28 days)
Not generally recommended:
-Quinolones: musculoskeletal effects
-Aspirin in children and teens
-Tetracycline in age < 8: teeth staining
-OTC teething medication containing benzocaine in age < 2 y/o
-OTC cough and cold preps in age < 2 (per FDA), < 4 y/o (Per package) < 6 y/o (per AAP)
Order of inhaled medications for Cystic Fibrosis *
1) inhaled bronchodilators (albuterol): open the airways
2) Hypertonic saline (HyperSal): mobilize mucus to improve airway clearance
3) Dornase alfa (Pulmozyme): thins mucus to promote airway clearance
4) Chest physiotherapy: mobilize mucus to improve airway clearance
5) Inhaled antibiotic (TOBI, azithromycin) : control airway infection
Lung complications in CF: Infections
Intermittent infection: give 2 IV abx : aminoglycosides, beta-lactams, quinilones
Chronic infections:
–> inhaled abx (Tobramycin, aztreonam lysine inhalation solution): give 28 days on, 28 days off
–> PO azithromycin: 6 month trial, works by disrupting biofilm formation
Pancreatic Enzyme products for Cystic Fibrosis
Pancrealipase (Crean, Viokace, Zenpep) - help pts digest food, maintain weight and improve nutrient absorption
-PEP formulations are not interchangeable
–> Viokace: enteric coated tablet & must be given with a PPI
–> All others are capsules:
-do not crush or chew the contents of the capsules
-DR caps with coated spheres can be opened and sprinkled on soft, acidic foods (applesauce)
-do not retain capsules in mouth
-take PEPs before or w/ all meals and snacks (high fat meals may require higher doses) –> use 50% of mealtime dose with snacks
-protect from moisture; dispense in original container, do not refrigerate.
CFTR Modulators for CF
-Ivacaftor (Kalydeco): increases the time CFTR channels are open
–> must possess a mutation responsive to Kalydeco (not approved for the homo F508del mutation
Warnings: inc LFTs, cataracts in children
*take with high fat foods
-Ivacaftor + Lumacaftor (Orkambi) or Tezacaftor (Symdeko) : helps correct the CFTR folding defect, which increases the amount of CFTR on the surface
*for homo F508del mutation ONLY
Transplant: Prevention of Graft Rejection
-before any transplant:
–> Human leukocyte antigen (HLA)
–> ABO blood group
-followed by a Panel Reactive Antibody (PRA) test: degree to which the recipient is “sensitized” to foreign proteins
Prevention of graft rejection: Induction Immunosuppression (2 agents)
most often consists of a short course of very effective IV agents- helps prevent rejection until calcineurin inhibitor (CNI) levels are therapeutic
–> Basiliximab (Simulect): interleukin-2 receptor antagonist, prevention of rejection only
–> Antithymocyte globulin (ATGAM- equine/horse, Thymoglobilin- rabbit): lymphocyte depleting, used in higher risk pts, pre medicate to lessen infusion reactions
Transplant: Maintenance Immunosuppression
Regimen includes:
-Calcineurin Inhibitor (Tacrolimius, Cyclosporine)
-Anti proliferative agents (Mycophenolate mofetil, mycophenoic acid) +/- steroids (Prednisone - should be d/c if pt is low immunologic risk, short time/lowest dose)
Transplant: Antiproliferative agents
-Mycophenolate mofetil (CellCept)
-Mycophenolic acid (Myfortic) - makes BC less effective
BBW:
-inc risk of infection
-inc risk of lymphoma and skin malignancies
-inc risk of congenital malformations and spontaneous abortions when used during pregnancy
SE:
-GI upset (diarrhea) - Myfortic is enteric coated to dec diarrhea
-Leukopenia
Notes:
-CellCept and Myfortic should not be used interchangeably
-Cellcept IV should be diluted in D5W only
-take on an empty stomach to avoid variability in absorption
[ not commonly used: Azathioprine (Imuran, Azasan), BBW: hematologic toxicities, TPMT genetic testing, bone marrow supp]
Transplant: Calcineurin Inhibitors (CNIs): Tacrolimus
Tacrolimus (Prograf, Astagraf XL, Envarsus XR) DOSED q12 h!!
BBW:
-inc susceptibility to infections
-poss development of lymphoma
-Astagraf XL associated with inc mortality in female liver transplant recipients
SE: HTN, nephrotoxicity, hyperglycemia, neurotoxicity (tremor, HA), electrolyte abnormalities (inc K, dec Mg) & QT prolongation *avoid grapefruit and St. johns wort (CYP3A4)
Monitoring: trough levels (right before next dose), renal function, serum electrolytes, blood pressure, BG
Notes:
-take w/ or w/o food- avoid alcohol, do not interchange XL to IR, PO IR dose is 3-4 times the IV dose; start oral dosing 8-12 hrs after last IV dose. CYP450 3A4 substrate
Transplant: Calcineurin Inhibitors (CNIs): Cyclosporine
Cyclosporine (Neoral - dilute with juice, Gengraf, Sandimmune- dilute w/ milk or orange juice )
BBW: renal impairment (with high doses), inc risk of malignancies & skin cancer, inc risk of infection, HTN, Gengraf/Neoral has inc bioavailability compared to Sandimmune = NOT interchangeable
SE: HTN, nephropathy, electrolyte abn (inc K, dec Mg), hirsutism, gingival hyperplasia, edema, hyperglycemia, neurotoxicity, QT prolongation *avoid grapefruit and St. johns wort (CYP3A4)
Monitoring: trough, renal function, serum electrolytes, BP, BG, lipid profile
Notes: CYP3A4 and P-gp substrate, avoid alcohol, do not switch brands, do not use a plastic or styrofoam cup with oral liquid
Transplant: mTOR inhibitors (2 agents)
-Everolimus (Zortress, Afinitor) and Sirolimus (Rapamune) : inhibit T lymphocyte activation/proliferation
BBW:
E: dec dose w/ cyclosporine, risk of renal thrombosis, do not use w/ heart transplant
S: do not use in liver or lung transplant
SE:
E: peripheral edema, HTN
S: irreversible pneumonitis/bronchitis/cough
-monitor w/ trough levels
-CYP3A4 substrates
Transplant drugs: Whats used when*
INDUCTION:
-Basiliximba (IL-2)
-Antithymocyte globulin (in pts w/ higher risk of rejection)
-High dose IV steroids
MAINTENANCE:
-CNI (Tacrolimus, cyclosporine)
–> Belatacept as an alt
Adjuvant agents w/ a CNI:
-Antiproliferative (mycophenolate (cellcept/myfortic) or azathioprime
-mTOR (Everolimus or sirolimus)
-steroids at lower or tapering doses
Infection Risk Reduction:
-self monitoring for symptoms of infection
-Prophylactic drug use if likely
-Treatment of opportunistic infections in that is used in HIV
Transplant: drug monitoring/risks
-Drugs with levels that can be measured: tacrolimus, cyclosporine, everolimus, sirolimus
-Highest risk of nephrotoxicity: tacrolimus, cyclopsorine
-Highest risk of inc BG: steroids, tacrolimus, cyclosporine
-Highest risk of increased BP: steroids, tacrolimus, cyclosporine
-Highest risk of worsening chol panel: mTOR (everolimus, sirolimus), steriods, cyclosporine
Transplant: Acute Rejection
-initial tx is high-dose steroids; biopsy is needed to determine the type of rejection
–> T-cell (cellular) = higher levels of maintenance immunosuppressants
–> B-cell (humoral or antibody) = Plasmapheresis, Intravenous immunoglobulin (IVIG), Rituximab
Transplant: reducing infection risk & vaccinations
-Pneumocystis pneumonia: Bactrim +/- prednisone x 21d
-Candida: fluconazole
-CMV: valacyclovir
**hand washing
Vaccines:
-influenza (inactivated) yearly
-Pneumococcal in adults > 19 y/o:
–> PCV20 (prevnar 21) x 1 OR
–> PCV15 (vaxneuvance) x1 followed by PPSV23 (Pneumovax 23) x 1 > 8 weeks later
Key drugs that cause weight gain *
-antipsychotics (clozapine, olanzapine, risperidone, quetiapine)
-DM meds (insulin, sulfonylureas, meglitinides, tzds)
-Divalproex/valproic acid
-Gabapentin, pregabalin
-Lithium
-Mirtazapine
-Steroids
-TCAs (amitriptyline, nortriptyline)
Conditions: hypothyroidism
Key drugs that can cause weight loss*
-ADHD (amphetamine, methylphenidate)
-Bupropion
-GLP-1 (semaglutide)
-Pramlintide
-SGLT-2 (-gliflozin’s)
-Roflumilast - used for severe COPD
-Topiramate
-Tirzepatide
Conditions: hyperthyroidism, celiac disease, inflammatory bowel disease
What are 2 cases that would warrant rx drugs for weight loss?
1) BMI > 27 + comorbid condition (HTN, DM 2, dyslipidemia)
2) BMI 30-39.9 (obesity)
-BMI > 40: bariatric surgery
Weight loss: Phentermine/topiramate (Qsymia)
C-IV
P: sympathomimetic amine, with effects similar to amphetamines
T: effects due to decreased appetite and satiety
CI: hyperthyroidism, glaucoma. MAOi use within past 14 days, pregnancy
–> REMS drug: teratogenic risk
Caution w/ use in HTN and seizures
SE: cognitive impairment, insomnia, tachycardia, CNS effects, dec serum bicarbonate, constipation, dry mouth, URTI, pharyngitis
Weight loss meds: Naltrexone/Bupropion (Contrave)
N: opioid antagonist, dec food craving
B: antidepressant, inc NE and dopa; decs appetiti
CI: use w/ another form of bupropion, chronic opioid use, uncontrolled HTN, use of MAOis, seizure disorder or seizure hx
SE: nausea, constipation, insomnia, HA, vomiting, dizziness
–> do not that with high-fat meals
–> caution w/ psychiatric disorders
Weight loss: Liraglutide (Saxenda) & Semaglutide (Wegovy)
-GLP-1 agonists: delays gastric emptying + increases satiety
BBW: risk of thyroid C-cell carcinomas
Warnings: pancreatitis, hypoglycemia
SE: GI effects, pancreatitis + hypoglycemia (must titrate dose)
Weight loss: Orlistat (Xenical, Alli)
Inhibits lipase to prevent absorption of dietary fat
RX: X- 120 mg TID
OTX: A- 60 mg TID
–> both must be taken with means and used with a low fat diet
CI: pregnancy, chronic malasoprtion, cholestasis
AE: GI (flatus w/ discharge, fecal urgency, fatty stool), kidney stones, liver damage (rare)
–> take vits A,D,E,K and beta carotene at bedtime or sep by 2+ hrs
–> do not use with cyclosporine or separate by 3+ hrs, separate levothyroxine by 5 hrs
–> must stick to dietary plan
Weight loss: Stimulants (2)
Phentermine (Adipex-P) and Diethylpropion (Tenuate) = C-IV, take in the am
–> used for 3-4 weeks to “jump start” a diet (up to 12 weeks)
CI: MAOi use within past 14 days, avoid use with cardiovascular disease (HTN, arrhythmias, HF), hyperthyroidism, glaucoma, pregnancy, drug abuse hx
SE: agitation, tachycardia, BP elevations, insomnia, dependence, cardiovascular complications, psychotic symptoms, dizziness, tremor
