53. Acute + Critical Care Flashcards
(143 cards)
1
Q
D5W, NS, and LR are all examples of what type of fluids?
A
Crystalloids
2
Q
What are some examples of colloid fluids?
A
Albumin (Albutein, AlbuRx)
Others: Dextran, hydroxyethyl starch (Hespan, Hextend)
3
Q
Which colloid fluid should only be used if other treatments are unavailable d/t boxed warning for morality, renal injury, and coagulopathy (bleeding)?
A
Hydroxyethyl starch
4
Q
Hyponatremia (Na < ___) is usually not symptomatic until sodium is <____ unless serum level falls rapidly
A
<135
<120
5
Q
What are some s/sx of hyponatremia
A
Typical result from cerebral edema and increased intracranial pressure, can range
Mild-moderate: HA, confusion, lethargy, gait disturbances
Severe: seizures, coma, respiratory arrest
6
Q
Explain hypotonic hypervolemic hyponatremia
A
Caused by fluid overload (e.g. cirrhosis, HF, renal failure)
Diuresis with fluid restriction is preferred treatment
7
Q
Explain hypotonic isovolemic (euvolemic) hyponatremia
A
Can be caused by SIADH
Treatment includes diuresis, restricting fluids, and stopping drugs that can induce SIADH (demeclocycline can be used off-label for SIADH)
8
Q
Explain hypotonic hypovolemic hyponatremia
A
Caused by diuretics, salt-wasting syndromes, adrenal insufficiency, blood loss or vomiting/diarrhea
Correct any underlying causes and stop intake of hypotonic solutions
Pts with acute hyponatremia, severe symptoms, and/or Na<120 are candidates for hypertonic (3%) NaCl IV
9
Q
Correcting sodium more rapidly than _____ can cause osmotic demyelination syndrome (ODS) or central pontine myelinolysis, which can cause ____
A
12 mEq/L/24hrs
paralysis, seizures, and death
10
Q
____ may be used to treat SIADH and hypervolemic hyponatremia but role is still being determined (more expensive than 3% saline and use beyond 30 days with oral product ___ is not recommended)
A
Arginine vasopressin (AVP) receptor antagonists (conivaptan, and tolvaptan)
Tovaptan
11
Q
PO arginine vasopressin (AVP) ___ is not recommended to use longer than __ days d/t ___
A
tolvaptan
30 days
hepatotoxicity
12
Q
Boxed warnings for tolvaptan
A
Should be initiated/re-initiated in the hospital with close monitoring
Overly rapid correction of hyponatremia (12mEq/L/24hrs) can lead to ODS (life-threatening)
13
Q
Warnings for tolvaptan (Samsca)
A
Hepatotoxicity (Avoid > 30 days duration and in liver disease/cirrhosis)
14
Q
Side effects for tolvaptan (Samsca)
A
Thirst, nausea, dry mouth, polyuria
Others: weakness, hyperglycemia, hypernatremia
15
Q
Hypernatremia (Na > ____) is a/w _____
A
145 mEq/L
Water deficit and hypertonicity
16
Q
Hypovolemic hypernatremia is caused by ___
A
dehydration, vomiting, or diarrhea
treated with fluids
17
Q
Hypervolemic hypernatremia is caused by ___
A
intake of hypertonic fluids and treated with diuresis
18
Q
Isovolemic (euvolemic) hypernatremia is frequenty cause by ____
A
Diabetes insipidus (DI) which can decrease antidiuretic hormone (ADH)
Treated with desmopressin
19
Q
Hypokalemia (K<___) is common occurrence in hospitalized patient. In general a drop of 1 mEq/L in K below 3.5mEq/L represents a total body deficit of ___ mEq
A
K<3.5
100-400mEq
20
Q
Hypokallemia management
A
treating underlying cause (e.g metabolic alkalosis, overdiuresis, meds (such as amphotericin, insulin)), and administering oral or IV potassium
21
Q
Safe recommendations for administration of IV potassium (usually potassium chloride) through a ___ line include a max infusion rate ___ and max conc of ____
More rapid infusions and higher conc may be warranted in severe or symptomatic hypokalemia
A
Peripheral line
≤10 mEq/hr
10m Eq/100mL
22
Q
T/F: IV potassium can be fatal if administered undiluted or via IV push
A
True
23
Q
When hypokalemia is resistant to treatment, ___ should be checked
A
Magnesium - necessary for potassium uptake, should be replaced first
24
Q
Hypomagnesemia (Mg <___) common causes are ____
A
1.3
chronic alcohol use, diuretics, amphotericin B, vomiting, diarrhea
25
When serum Mg is <1 with life-threatening symptoms (e.g. ___,____), ___ is recommended
seizures, arrhythmias
IV magnesium sulfate
26
Hypophosphatemia is considered severe and is usually symptomatic when serum PO4 is <___
1mg/dL
27
S/sx of hypophosphatemia
muscle weakness and respiratory failure
28
When PO4 < 1mg/DL, ___ is used for replacement
IV phosphorus
29
Patients with hypophosphatemia often have ___ and ___ that will require correction
hypokalemia
hypomagnesemia
30
Incentive spirometry is a technique used to facilitate ____ in patients with ____
lung expansion
atelectasis (i.e. completely or partially collapsed lung with reduced lung volume)
31
What is IVIG used for
Immunodeficiency conditions
Off-label indications (e..g MS, MG, Guillain-Barre syndrome)
32
Note: IVIG treatment can impair the response to ___
vaccination
33
Patients with ___ and ___ should have slower infusion rate or IVIG
renal and CV disease
34
Storage/Handling for IVIG
Do NOT freeze, shake, or heat
35
Boxed warnings for IVIG
Acute renal dysfunction, usually within 7 days (more likely with products stabilized with sucrose -- use caution in elderly, renal disease, DM, volume depletion, sepsis, paraproteinemia, or taking nephrotoxic meds
Thrombosis
36
Side effects of IVIG
Infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)
Others: HA, nausea, diarrhea, injection site reaction, renal failure, or blood dyscrasias (rare)
37
Patients should be asked about past IVIG infusions; __ and __ may be needed
slower titration and premedication
38
____ is a scoring tool used to determine prognosis and estimate ICU mortality risk
Acute physiologic assessment and chronic health evaluation II (APACHE II)
39
How do most vasopressors work?
Stimulates alpha receptors > peripheral vasoconstriction ("presses down on vasculature") >> increases systemic vascular resistnace (SVR), which increases BP
40
Dopamine stimulates diff receptors depending on the dose
Low renal dose: 1-4 mcg/kg/min = ____ agonist
Medium dose: 5-10 mcg/kg/min = ____ agonist
High dose: 10-20 mcg/kg/min = ____ agonist
Dopamine-1 agonist
Beta-1 agonist
Alpha-1 agonist
41
MOA epinephrine (Adrenalin)
Alpha-1, Beta-1, Beta-2 agonist
42
MOA norepinephrine (Levophed)
Alpha-1 agonist > beta-1 agonist activity
43
MOA phenylephrine
Alpha-1 agonist
44
MOA vasopressin (Vasostrict) - aka arginine vasopressin (AVP) and antidiuretic hormone (ADH)
Vasopressin receptor agonist
Vasoconstrictor, no inotoropic or chronotropic effects
45
Boxed warning for dopamine and NE
extravasation
46
All vasopressors are ___ when administered IV; treat with ___
vesicants
Treat extravasation with phentolamine
47
Side effects of vasopressors
Arrhythmias, tachycardia (esp dopamine, Epi), necrosis (gargrene), bradycardia (phenylephrine), hyperglycemia (Epi), tachyphylaxis, peripheral and gut ischemia
48
All vasopressors should be administered via ___ line
central IV line
49
Epinephrine IV push is ___mg/mL (____ ratio strength) while IM injection or compounding IV products is ___ mg/mL(___ ratio strength)
0.1mg/mL (1:10,000 ratio strength)
1mg/mL (1:1000 ratio strength)
Note: ratio strength has been removed from labeling per FDA
50
Extravasation is considered a medical emergency. To reduce risk, vasopressors should be administered via ___. If Vasopressor extravasation occurs, treat with ___
central line
Phentolamine (alpha-1 blocker that antagonizes the effects of vasoprsesor)
51
When vasopressor extravasation occurs, why is phentolamine used?
alpha-1 blocker that antagonizes the effects of vasoprsesor
52
Vasodilators that are administered by continuous IV infusion include ___
nitroglycerin and nitroprusside
53
Monitoring for vasodilators
BP (hypotension)
54
Nitroglycerin is often used when _____ but effectiveness may be limited to 24-48hrs d/t ___
MI or uncontrolled HTN
tachyphylaxis (tolerance)
55
T/F: Both nitroglyceride and nitroprusside are mixed (equal) arterial and venous vasodilator at all doses
False - nitroglyceride is dose dependent, nitroprusside is equal at all doses
56
Which vasodilator has a greater effect on BP: nitrogylcerin vs ntiroprusside
Nitroprusside
57
Which vasodilator should NOT be used in active MI because it can cause blood to be diverted away from diseased coronary arteries ("coronary steal")
Nitroprusside
58
Metabolism of nitroprusside results in __ and ___ formation, causing toxicity in pts with renal and hepatic insufficiency, respectively
Thiocyanate
Cyanide
59
____ can be administered to reduce the risk of thiocyanate toxicity
Hydroxocobalamin
60
___ is used for cyanide toxicity
Sodium thiosulfate + sodium nitrite (Nithiodote)
61
Nitroglycerin at low doses is a (venous/arterial) vasodilator vs high doses a (venous/arterial) vasodilator
Low doses = venous
High doses = arterial
62
Contraindications for nitroglycerin
SBP <90
Use with PDE-5i or riociguat
63
Side effects of nitroglycerin
HA, tachycardia, tachyphylaxis (within 24-48 hrs of continuous administration), lightheadedness
64
Nitroglycerin packaging notes
Requires non-PVC container (eg.. glass, polyolefin); use administration sets (tubing) intended for nitroglycerine
65
Nitroprusside boxed warning
Metabolism produces cyanide (use the lowest dose for the shortest duration necessary), excessive hypotension (continuous BP monitoring required), not for direct injection (must be further diluted; D5W preferred)
66
Warnings for nitroprusside (Nipride)
icnreased ICP
67
Side effects for nitroprusside (Nipride)
HA, tachycardia, thiocyanate/cyanide toxicity (increased risk with renal/hepatic impairment)
68
Nitroprusside packaging notes
Require light protection during administration
Use only clear solutions - blue color indicated degradation to cyanide (do NOT use)
69
Effect of inotrops
Increases contractility of heart
70
Dobutamine MOA
Beta-1 agonist with some beta-2 and alpha-1 agonism
Increases HR and force of myocardial contraction >> increases CO
71
Milrinone MOA
Selective PDE-3i in cardiac and vascular tissue
Produces inotropic effects with sig vasodilation
72
Dobutamine may turn slightly pink d/t oxidation. Can it still be used?
Yes, potency is not lost
73
Shock is a medical emergency common in ICU patients. It is characterized by ____
hypoperfusion, usually in the setting of hypotension (SBP <90 or MAP <70)
74
What are the 4 types of shock?
Hypovolemic (e.g. hemorrhagic)
Distributive (e.g septic, anaphylactic)
Cardiogenic (e.g. post-MI)
Obstructive (e.g. massive PE)
75
What is recommended as first-line for hypovolemic shock?
Fluid resuscitation with crystalloids if not caused by hemorrhage
Blood products should be administered if caused by hemorrhage
76
____ will not be effective in hypovolemic shock unless intravascular volume is adequate
Vasopressors
77
What may be indicated if hypovolemic shock pt does not respond to first line therapy
Vasopressors
78
Distributive shock is characterized by ___
low SVR and initially high CO followed by low or normal CO
Sepsis is an example
79
Sepsis is defined as
life-threatening organ dysfunction caused by dysregulated host response to infection
80
MAP formula
[(2*DBP)+SBP]/3 OR
2/3 DBP + 1/3 SBP
81
General principles for treating septic shock
Target MAP ≥65mmHg
Fill the tank - optimize preload with IV crystalloids (LR preferred)
Squeeze the pipe and kick the pump - Alpha-1 agonist to increase SVR // beta-1 agonist to increase myocardial contractility and CO
82
2 common causes of ICU infections
Mechanical ventilation (increase time on ventilator = increased risk of infection, including lung)
Indwelling urinary catheter (increased time with Foley catheter = increased risk of bladder infection)
83
Septic shock is sepsis with ____
persistent hypotension requiring vasopressor to maintain MAP ≥65 and serum lactate level ≥2 mEq/L despite adequate fluid resuscitation
84
____ is considered the vasopressor of choice in septic shock
Norepinephrine
85
Septic shock interventions include early administration of ___ and ___
Broad spectrum abx and fluid resuscitation with IV crystalloids
86
What is acute decompensated HF (ADHF)?
Worsening HF symptoms (sudden weight gain, an inability to life flat w/o becoming SOB, decreasing functionality, increasing SOB and fatigue)
87
When ___ and ___ are also present with acute decompensated HF, it is called cardiogenic shock
Hypotension
Hypoperfusion
88
Some ADHF pts require invasive monitoring with a catheter that is called ___
Swan-Ganz or pulmonary artery catheter
89
Why is a Swan-Ganz (or pulmonary artery catheter) used?
Provides hemodynamic measurements of congestion (pulmonary capillary wedge pressure or PCWP), hypoperfusion (cardiac output) and other measurements (e.g. SVR, CVP) useful to guiding treatment
90
Treatment of ADHF generally consists of _____ used in various combinations depending on patient symptoms
diuretics, inotropes, and vasodilators
91
____ should only be stopped in an ADHF episode if hypotension or hypoperfusion is present
Beta-blockers
92
ADHF pt is volume overloaded(edema, jugular venous distention (JVR), and/or ascites). What are the treatment options?
Loop diuretics
Vasodilators can be added (NTG, nitroprusside)
93
ADHF pt is hypoperfused (decreased renal fxn, altered mental status, and/or cool extremities). What are the treatment options?
Inotropes (dobutamine, milrinone)
If pt becomes hypotensive, consider vasopressor (dopamine, NE, phenylephrine)
94
ADHF pt is both volume overloaded and hypoperfused. What are the treatment options?
A combination of loop diuretics, vasodilators, inotropes
95
Why should vasodilators be avoided when treating ADHF?
Can decrease BP and worsen hypoperfusion
96
The vasodilatory and inotropic properties of ___ and ___ make them uniquely suited to treat ADHF in pts with adequate BP and symptoms of both congestion and hypoperfusion.
If BP is inadequate, inotropes will often be used in combination with ____
dobutamine and milrinone
Vasopressors
97
ICU Pain first line options
IV opioids (e.g. morphine, hydromorphone, fentanyl)
98
Agitation in ICU is managed with ____
benzodiazepines (lorazepam, midazolam) and/or non-BZD hypnotics (propofol, dexmedetomidine)
99
____ are preferred for sedation and a/w improved ICU outcomes, shorter mechanical ventilation duration and decrease length of stay
Non-BZD (propofol, dexmedetomidine)
100
____ is the only sedative approved for use in intubated and non-intubated patients
Dexmedetomidine (Precedex)
101
_____ have an important role in sedation in the presence of seizures or alcohol/BZD withdrawal
BZD
102
Sedatives are used with validated sedation scales that allow for titration to light sedation (preferred) or deep sedation. What are some common sedation scales used?
Richmond Agitation Sedation Scale (RASS)
Ramsay Agitation scale (RAS)
Riker Sedation-Agitation Scale (SAS)
103
How often are "sedation vacations" used to asses readiness to wean off/stop sedative?
Daily
104
Providing sedation with ____ may reduce the incidence of delirium and/or shorten duration in pts who already have it
Non-BZD
105
Atypical antipsychotics, primarily ___, which is mildly sedating and has little risk for movement disorders, can be useful in delirium
Quetiapine
106
MOA dexmedetomidine (Precedex)
Alpha-2 adrenergic agonist
107
Side effects of dexmedetomidine (Precedex)
hypo/hypertension, bradycardia, dry mouth, nausea, constipation
108
T/F: dexmedetomidine (Precedex) needs to be refrigerated
False
109
Duration of infusion of dexmedetomidine should not exceed ___ per FDA labeling
24 hrs
110
Contraindiications for propofol (Diprivan)
Hypersenstivity to egg or soy (or egg/soy products)
111
Side effects of propofol (Diprivan)
Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare, but can be fatal)
Others: myoclonus, pancreatitis, pain on injection (particularly peripheral vein), QT prolongation
112
If pt is on propofol for longer than 2 days, make sure you monitor ____
triglycerides
113
When using propofol, use strict aseptic technique d/t potential of bacterial growth; discard vial and tubing within ____ of use
12 hrs
114
What type of emulsion is propofol?
Oil in water emulsion (opaque, white solution)
Provides 1.1 kcal/mL
115
Lorazepam TDD as low as ____ can cause propylene glycol toxicity (acute renal failure and metabolic acidosis)
1 mg/kg/day
116
Contraindications for midazolam (Versed, Nayzilam)
Do NOT use with potent CYP3A4 inhibitors
Intrathecal or epidural administration (benzyl alcohol in formulation) , acute narrow-angle glaucoma
117
What is the concern of using midazolam in obese patients and renal impairment
Accumulation
Obese pts - highly lipophilic
Renal impairment - active metabolite
118
Monitoring for etomidate
S/sx adrenal insufficiency (hypotension, hyperkalemia)
119
Warnings for ketamine (Ketalar)
Emergence reactions (vivid dreams, hallucinations, delirium) CSF pressure elevation, respiratory depression/apnea, dependence/tolerance
120
Risk factors for development of stress ulcers
Mechanical ventilation > 48h
Coagulopathy
Others: sepsis, traumatic brain injury, major burns, acute renal failure, high dose systemic steroids
121
What meds are recommended to prevent stress-related mucosal damage in pts with risk factors for stress ulcers?
PPIs and H2RAs
122
What med used for stress ulcers can cause thrombocytopenia and mental status changes in elderly or renal impairment?
H2RAs
123
Which med used for stress ulcers is a/w increased risk of GI infections (C.diff), fractures, and nosocomial pneumonia?
PPIs
124
What formulation of anesthetics can cause malignant hyperthermia?
Inhaled anesthetics
125
____, commonly used anesthetic for epidurals, can be fatal if administered ____
Bupivacaine
Intravenously
126
Why is lidocaine/epinephrine combination products used for some local procedures?
Epinephrine is added for vasoconstriction which keeps lidocaine localized to the area where numbing is needed
Note: deaths have occurred d/t mix ups with Epi products and lidocaine/epinephrine products
127
Which anesthetic should NOT be given by dual routes of administration (e.g. IV and topical)
Lidocaine
128
What are some commonly used local anesthetics for?
Lidocaine (Xylocaine)
Others: benzocaine, liposomal bupivacaine (Exparel)
129
What are some commonly used inhaled anesthetics?
Desflurane (Suprane), sevoflurane (Ultane)
Others: isoflurane (Forane), nitrous oxide
130
What are some commonly used injectable anesthetics?
Bupivacaine (Marcaine, Sensorcaine)
Lidocaine (Xylocaine)
Ropivacaine (Naropin)
131
Why are neuromuscular blocking agents (NMBA) sometimes used in surgery?
Facilitate mechanical ventilation or treat muscle spasms (tetany)
132
Why do patients on neuromuscular blocking agents (NMBA) have to be mechanically ventilated?
NMBAs cause paralysis of skeletal muscle, even those needed for respiration (e.g. diaphragm)
133
There are 2 types of NMBAs: depolarizing and non-depolarizing. ____ is the only available depolarizing agent
Succhinylcholine
134
How is succhinylcholine similar to ACh?
Resembles ACh, binds to and activates the ACh receptors and desensitizes them
135
Succinylcholine is typically reserved for ___ and not used for continuous neuromuscular blockade
Intubation
136
Which neuromuscular blocking agent is a/w malignant hyperthermia particularly when used with inhaled anesthetics?
Succinylcholine
137
How do non-depolarizing NMBAs work?
Bind to ACh receptor, blocking actions of endogenous ACh.
138
What extra care must be taken for pts who are receiving NMBAs?
Protect the skin, lubricate eyes, and suction airway frequently (these pts are unable to breathe, move, blink, cough)
139
____ is an anticholinergic drug that can be used to reduce secretions in pts using NMBAs
Glycopyrrolate
140
What are some examples of meds that can enhance neuromuscular blocking activities of NMBAs (leading to toxicity)
Aminoglycosides, polymyxins
Others: CCBs, cyclosporine, inhaled anesthetics, lithium, quinidine, vancomycin
141
Side effects of all non-depolarizing NMBAs
flushing, bradycardia, hypotension, tachyphylaxis, acute quadriplegic myopathy syndrome (long-term use)
142
Which non-depolarizing NMBA is metabolized by Hofmann elimination (independent of renal and hepatic function)?
Cisatracurium (Nimbex)
143
Which non-depolarizing NMBA is long-acting and has the risk of accumulation in renal/hepatic dysfunction?
Pancuronium
