Chapter 53: Acute & Critical Care Flashcards
Crystalloid
- what is it + examples/ when to use it ?
- contains various conc of sodium and / or dextrose
- passes freely b/w semipermeable membranes. Volume does not remain in intravascular space (inside blood vessels) - however it moves into extravascular or interstitial space
- cost less and with fewer AEs compared to Colloids
- Exs:
—- 5% Dextrose (contains free H2O and is used when H2O is needed intracellularly)
—– Lactated Ringer’s and NS are most commonly used for volume resuscitation in shock state.
Colloids
- what is it/ examples + when to use it?
- Large molecules (protiens or starch)
- primarily remains in intravascular space (in blood vessels) and increases oncotic pressure.
- MORE $$$ and no clear benefit over crystalloids
- EXs:
—— Albumin %5, 25% (Albutein, AlbuRX) -most common colloids, useful when there is significant edema (ie, cirrhosis). Albumin shouldnt be used for nutritional supp if albumin is low!
—– Hydroxyethyl starch - only used if no other TX is available due to boxed warning for mortalitiy, renal injury, and coagulopathy (bleed)
Electrolyte Disorder: Sodium (Hyponatremia): general/ the different types
- Define as **Na < 135 mEq/L **
- However, patient is usually not symptomatic until Na < 120!
- Symp mostly result from cerebral edema and increases intracranial pressure and can range from mild/mod (HA, confusion, gait distrubances) to severe (SZ, coma, death!)
- Include difference classifications: hypotonic hypervolemic hyponatremia, hypotonic isovolemic hyponatremia, hypotonic hypovolemic hyponatremia
Electrolyte Disorder: Sodium (Hyponatremia)
Why should hyponatremia not be corrected too quickly?
Correction goal is only 4-8 mEq/L/24hrs! Correcting Na more rapidly than 12mEq/L/24hrs can cause osmotic demyelination syndrome (ODS) or central pontine myelinolysis (which can cause paralysis, SZ, death)
Electrolyte Disorder: Sodium (Hyponatremia)
Hypotonic hypervolemic hyponatremia: causes and treatment?
- Causes: fluid overload (ie. HF, renal failure, cirrhosis )
- TX: Diuresis with fluid restriction
Electrolyte Disorder: Sodium (Hyponatremia)
Hypotonic Isovolemic Hyponatremia: causes and treatment?
- Causes: syndrome of inappropriate antidiuretic hormone (SIADH)
- TX: Diuresis, fluid restriction, and stopping drugs that can cause SIADH)… Demeclocycline can be used off-label for SIADH!
Electrolyte Disorder: Sodium (Hyponatremia)
Hypotonic Hypovolemic Hyponatremia: causes and treatments?
- Causes: diuretics, salt-wasting syndromes, adrenal insuff., blood loss, or V/D
- Treatment: correct the underlying causes. patient with acute hyponatmia, severe sympts, or Na below 120? can use **Hypertonic 3% NaCL IV **
Electrolyte Disorder: Sodium (Hyponatremia)
The use of arginine vasopressin (AVP) receptor antagonists?
- Ex of drugs: conivaptan and **tolvaptan **
- may be used to treat SIADH and hypervolemic hyponatremia
- MOA: increase excretion of H2O while maintaining sodium
- role TBD… more expensive than just using 3% NaCL and you cannot use the oral product (tolvaptan) for more than 30 days!
Electrolyte Disorder: Sodium (Hyponatremia)
Arginine Vasopressin Receptor Antagonist: Conivaptan
- brand
- doses
- contraindications
- warning
- SE
- monitoring
- brand: Vaprisol
- doses: LD 20mg IV over 30 mins and MD 20mg IV over 24 hrs (avoid use in CrCL less than 30
- contraindications: hypovolemic hyponatremia, strong CYP4A4 inhibitors
- warning: over rapid correct of Na = ODS!
- SE: orthostatic hypotension, fever, hypokalemia, infusion rxn site
- monitoring: rate of Na increase, BP, volume, urine output
Electrolyte Disorder: Sodium (Hyponatremia)
Arginine Vasopressin Receptor Antagonist: Tolvaptan
- brand
- doses
- boxed warning
- contraindications
- warning
- SE
- monitoring
- brand: Samsca
- doses: 15mg po QD (max 60mg po qd) limit use to less than 30 days due to hepatox! avoid if CrCl is less than 10
- boxed warning: initiated/ reinitated only at hospital, rapid correct of Na can = ODS!
- contraindications: hypovolemic hyponatremia, strong CYP4A4 inhibitors, ppl unable to sense or respond to thirst
- warning: hepatox
- SE: thirst, N, dry mouth, polyuria, hyperglycemia, hypernaturemia
- monitoring: rate of Na increase, BP, volume, urine output, signs of hepatox
Electrolyte Disorder: Sodium (Hypernatremia): general, causes, types
- **Na > 145 mEq/L **! associated with water deficit and hypertonicity
- Hypovolemic hypernatremia: dehydration, V/D - treated with fluids
- Hypervolemic Hypernatremia: intake of hypertonic fluids - treated with diuresis
- Isovolemic Hypernatremia: diabetes insipidus, which can decrease antidiuretic hormones (ADH), treated with desmopressin
Electrolyte Disorder: Potassium K+ (hypokalemia)
Electrolyte Disorder: Potassium K+ (hypokalemia)
- general
- management
- 10 mEq will raise serum K+ by how much?
- hyperkalemia is often due to CKD!
- hypokalemia < 3.5 mEq/L (common in hospitalized patients)
- a drop of 1 mEq/L below 3.5 mEq/L represents a total body deficit of 100-400 mE!
- Management: treat underlying causes (ie. metabolic alkalosis, overdiuresis, meds like insulin and amphotericin, and admin of IV or oral K+
- 10 mEq of k+ increases the K+ serum level by 0.1 mEq
Electrolyte Disorder: Potassium K+ (hypokalemia)
IV Potassium Replacement
- what is the most common solution used?
- conc and rate?
- K+ relationship with Mg+?
- Potassium Chloride (KCl) IV solution is generally used.
- Safe recc: peripheral line with max infusion rate of < 10 mEq per hour and max conc. of 10 mEq/100mL (although higher infusion rate/ conc may be needed for severe or symptomatic hypokalemia = these also require central line! and cardiac monitoring!)
- Can be fatal if admin. undiluated or via IV push
- Magnesium is needed for optimal Potassium uptake! so you may need to check Mg+ serum if hypokalemia is resistent to tx! Mg+ should be replaced first if both hypoK+ and hypoMg+ is presented
Electrolyte Disorder: Magnesium Mg+ (hypomagnesemia)
Electrolyte Disorder: Magnesium Mg+ (hypomagnesemia)
-general
-when to use IV vs oral? replacement?
- More common than hyperMg+! (hyper is more due to renal insuff.)
- HypoMg+ = < 1.3 mEq/L
- Causes : chronic alcohol use, diuretics, ampB, V/D
- when Mg+ serum is < 1 WITH life threatening symp like SZ, arrhythmias … IV Magnesium Sulfate is recc.
- Mg+ serum 1-1.5? orally replacement reccomended (Mg oxide for ~5 days)
Electrolyte Disorder: Phosphorus (hypophosphatemia)
Electrolyte Disorder: Phosphorus (hypophosphatemia)
- general
- causes
- tx?
- HyperPhos is usually due to CKD
- HypoPho is considered severe and usually symptomatic (< 1 mE/dL)
- symptoms: muscle weakness, respiratory failure
- Causes: phosphate binding drugs (ie. calcium salts, sevelamer), chronic alcohol use, hyperthyroidism
- TX: when <1 ? IV! 0.08-0.16 mmol/kg in 500mL usually reccomended
- patients with hypophos typically have hypoK+ and hypoMg+ as wellso those will need to be corrected as well!
Other TX in hospitalized patients
Incentive Spirometry: what is it/ uses
- a technique used to facilitate lung expansion in patient with atelectasis (complete or partially collapsed lung w/ reduced lung volume)
- Atelectasis is a common complication especially in post op patient. It can lead to retained airway secretion, dyspnea, hypoxemia, and other pulm. complications.
- Incentive Spirometer is a device that facilitate deep breathing
Other TX in hospitalized patients
IV Immunoglobulin: what is it/ uses
- contains IgG (extracted from plasma of many blood donors)
- Given as plasma protein replacement tx for immune def patients who have decreased antibodies production capabilities.
- only used for immuno def conditions! and other off lable uses including: multiple sclerosis, myasthenia gravis, Guillain-Barre syndrome
- can impair responses to vaccines!
Other TX in hospitalized patients: IV IgG
IV Immunoglobulin
- brand
- boxed warning
- contraindication
- warnings
- Ses
- Monitoring
- Notes
- brand: Gammagard, Gamunex-C, Octagam, Privigen
- boxed warning: acute renal dysfunction can occur altho rare!; it usually occurs within 7 days (more likely with products stabilized with sucrose)
- contraindication: IgA deficiency
- warnings: use w/ caution in CV disease
- SEs: HA, n/d, inj site rxn, infusion rxn (flushing, fever, chest tightening, hypotension - stop or slow infusion!), renal failure
- Monitoring: renal func, urine output, volume status, HbG
- Notes: slower tritration/ premed. may be needed if patient had rxn in past !
What is the scoring tool used to determine ICU mortality risk?
The Acute Physiologic Assesment and Chronic Health Evaluation II (APACHE II)
ICU medications that target the sympathetic nervous system
Vasopressors : effects on alpha and beta?
- Work by stimulating Alpha receptors; causing peripheral vasoconstruction and increases systemic vascular resistence (SVR), which increases blood pressure (BP)
- Vasopressors that stimulate Beta receptors can increase heart rate and cardiac output
Vasopressor Drugs: ICU medications that target the symp nervous sys
1.) Dopamine
- MOA
Dose dependent!
- low (renal) dose: 1-4mcg/kg/min: dopamine 1 agonist
- medium dose: 5-10mcg/kg/min: Beta 1 agonist
- High dose: 10-20mcg/kg/min: Alpha 1 agonist
Vasopressor Drugs: ICU medications that target the symp nervous sys
2.) Epinephrine
- MOA
- brands
- notes
- Brands: Adrenalin, Epipen
- Alpha 1agonist , Beta 1 and 2 agonist
- used for push IV is 0.1mg/mL (1:10,000 ratio strenght); for IM inj or compounding is 1mg/mL (1:1,000)
Vasopressor Drugs: ICU medications that target the symp nervous sys
3.) Norepinephrine
- brand
- MOA
- Brands: Levophed
- Alpha 1 agonist > Beta 1 agonist activity
Vasopressor Drugs: ICU medications that target the symp nervous sys
4.) Phenylephrine
- MOA
- Alpha 1 agonist
RICHMOND AGITATION AND
SEDATION SCALE (RASS)
Pain medication used in crit care
List the common pain medications used in crit care/ ICU and their properties
