Special Populations: Acute & Critical Care Medicine Flashcards
Crystallids vs Colloids
Crystallaoids: cheaper, less adverse reactions, most volume doesnt remain in intraveascalr space
Colloids: More $$$, remain primarily in intravascular space, inc oncotic pressure
not shown to have clear benefit
Common Colloids
Albumin
Dextran
Hydrocyethyl starch
Common Crystalloids
D5W
NS
Lactated Ringers
Multiple electrolyte injections
When is Hyponatremia usually symptomatic?
< 120 mEq/L
Osmotic demyelination syndrome can occur when.
sodium is corrected too rapidly, more than 12 mEq/L/24hrs
Who is candidate for hypertonic 3% sodium chloride IV
severe symptoms and NA 120 mEq/L
Drugs that can be used to treat SIADH? and Hypervolemic hyponatremia?
Arginine vasopressin receptor antagonist
AVP receptor antagonists
Conivaptan
Tolvaptan
Tolvaptan dosing limited to how many days
< 30 days due to hepatoxicity
Tolvaptan Boxed warning
only to be started in hospital with close monitoring
rapid correction of hyponatrema associated with ODS (life threatening)
Tolvaptan Warnings
Hepatotoxicity
dry mouth
excessive urination
Tolvaptan monitoring requirements
Rat of Na Increase
BP
Max infusion rate and concentration of IV Potassium
rate = < 10 mEq/hr
conc = 10 Meq/100ml
If both low potassium and magnesium, which should be replaced first?
magnesium, its necessary for potassium uptake
Hypophosphatemia considered severe and symptomatic when
< 1 mg/dL
IVIG Boxed warnings
acute renal dysfunction = rare, usually within 7 days
thrombosis
IVIG side effects
infusion reactions = facial fusing, chest tightness, fever, chills, hypotension = stop/slow infusion
slow infusion rate w/ renal and CV disease patients
Vasopressors
Dopamine = MOA is dose dependent
Epinephrine = MOA is Alpha 1, Beta 1/2 agonist
Norepinephrine = MOA is Alpha 1 agonist > Beta 1 agonist
Phenylephrine = MOA is Alpha 1 agonist
Vasopressin = MOA is Vasopressin receptor agonist
Vasopressor boxed warnings
Dopamine & Norepi = extravasation
All vasopressors are vesicant tho
treat extravasation with phentolamine
Vasopressor warnings
use caution on patients taking an MAOI
Vasopressor Side effects
Arrhythmias + tachycardia (dop + Epi)
necrosis (gangrene)
bradycardia (phenylephrine)
hyperglycemia (Epi)
Vasopressor monitoring
constant BP monitoring
Vasopressor notes
should be admin via Central IV line
dont used if discolored or precipitate
Nitroprusside should not be used in…
active myocardial ischemia
Nitroglycerin MOA
Low doses: venous vasodilator
High doses: arterial vasodilator
Nitroglycerin Contraindications
SBP < 90
using with PDE-5i or riociguat
Nitroglycerin warnings
severe hypotension and inc intracranial pressure
Nitroglycerin Side effects
HA
Tachycardia
Tachyphylaxis
Nitroprusside MOA
mixed equally arterial and venous vasodilator
Nitroprusside Boxed warnings
metabolism produces cyanide
excessive Hypotension
Nitroprusside warnings
Inc ICP
Nitroprusside Side effects
Headache
Tachycardia
Thiocyanate/cyanide toxicity (risk inc w/ renal and hepatic impairment)
Nitroprusside notes
use only clear solutions, if blue means degradation to cyanide
requires light protection
How to reduce risk of thiocyanate toxicity with Nitroprusside
can give Hydroxocobalamin
Inotrope meds for Vasodilation
Dobutamine
Milrinone
Dobutamien MOA
Beta-1 agonist, some beta 2/alpha 1 agonism
inc HR and force of myocardial contraction = inc CO
Milrinone MOA
PDE-3i
produces sig vasodilator
If dobuatmine is slightly pink?
its okay, just oxidation but didnt lose potency
Types of Shock
Hypovolemic = hemorrhagic
Distributive = sepsis, anaphylactic
Cardiogenic = post MI
Obstructive = massive PE
Hypovolemic shock treatment
fluid resuscitation with crystalloids generally 1st line
blood products if due to bleeding
can do vasopressors if doesnt respond to initial crystalloid/blood products
Septic shock is sepsis with…..
persistent hypotension requiring vasopressor to maintain MAP > 65 mmHG and serum lactate lvl > 2 mEq
Vasopressor of choice for septic shock?
Vasopressin
Volume overload patient treatment options
loop diuretic
vasodilators can be added
Dexmedetomidine (Precedex) side effects
Hypotension
HTN
bradycardia
dry mouth
nausea
constipation
Dexmedetomidine (Precedex) notes
doesnt req refrigeration
duration of infusion < 24hrs
used for sedation in intubated and on-intubated patients
Propofol (Diprivan) CI
Hypersensitivity to egg, egg product, soy or soy product
Propofol (Diprivan) Side effects
Hypotension
apnea
hypertriglyceridemia
green urinehair/nail beds
Propofol-related infusion syndrome = rare but can be fatal)
Midazolam CI
dont use with patient CYP 3A4 inhibitors
Midazolam boxed warnings
respiratory depression, start low
Midazolam in renal impairment & obese patients
metabolic can accumulate, caution continuous infusion
Ketamine warnings
Vivid dreams
hallucinations
delirium
Risk factors for developing stress ulcers
Mech ventilation > 48hrs
coagulopathy
sepsis
TBI
major burns
acute renal failure
high dose systemic steroids
Medicatons for Stress ulcers prevention
H2RAs or PPIs
the only depolarizing NMBA
Succinylcholine
Non depolarizing NMBAs side effects
flushing
bradycardia
hypotension
tachyphylaxis
Hemostatic agents
Tranexamic acid
Recombinant Factor VIIa
Aminocaproic acid
