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IPT: CC > Block 1 > Flashcards

Block 1 Flashcards

1
Q

What is inpatient hyperglycemia?

A

≥140mg/dl

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2
Q

What are the major classes of drugs that cause hyperglycemia?

A

Corticosteroids

Atypical antipsychotics (Risperidone, Olanzapine, Quetiapine)

Immunosuppressants

Catecholamines

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3
Q

Insulin is given to those with a range of ______ to keep them off of >180mg/dl

A

140-180

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4
Q

What are the rapid acting insulins?

A

Aspart, Lispro, Glulisine

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5
Q

How do you determine the dose of insulin experienced and insulin naive patients?

A

Experienced = take 1/2 to 1/3 of their normal dose

Naive = 0.1u/kg/day (outpatient)

If well controlled or at higher risk of hypoglycemia = 0.2u/kg/day

If poorly controlled = 0.5-0.8u/kg

BUT naive pt use sliding scales but should remain the sole treatment

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6
Q

Which insulin is typically used in ICU patients?

A

Insulin regular IV bags

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7
Q

When a patient is stable, how do you transition from IV to SQ insulin?

A

Calculate TDD by taking average rate/hr in the past 6-8hrs

Multiply number by 24 (total IV insulin) then multiplying it by 0.8 (total SC insulin)

SC is given as 50/50 basal and bolus

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8
Q

When should you monitor pt on basal only insulin?

A

Once daily with morning labs

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9
Q

When should you monitor pt on basal + bolus regimen?

A

Before each meal and at bedtime

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10
Q

What is hypoglycemia?

A

Warnings begin at <70 but officially ≤54mg/ml

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11
Q

How do you manage hypoglycemia?

A

BG checked q15min

D50W 25ml if <70
D50W 50ml if <54

Glucagon if <70 + no IV access

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12
Q

Differentiating pieces of DKA and HHS?

A

DKA - metabolic acidosis + ketonemia; tachypnea, kussmaul breathing, acetone breath

HHS - high serum osmolality + dehydration; hypotension

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13
Q

How often should you monitor a DKA pt?

A

Every 2-4 hours

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14
Q

When treating DKA or HHS, what kind of insulin plan do we utilize?

A

Bolus 0.1u/kg

0.1u/kg/hr continuously IV infusion

DKA BG <200 or HHS BG<300; decrease dose to 0.02-0.05u/kg/hr and switch fluids to D51/2NS

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15
Q

What is the corrected sodium equation?

A

Measured Na + ((0.016*(glucose-100))

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16
Q

When do we correct potassium during insulin therapy?

A

<3.3 = hold insulin, give 20-30mEq/hr until potassium is above 3.3

3.3-5.2 = give 20-30mEq/hr in 1L fluid

> 5.2 = dont give potassium and check q2hrs

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17
Q

How do you measure anion gap?

A

Na - (Cl+HCO3)

Normal <12

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18
Q

How do you manage fluids in DKA/HHS?

A

Regardless of condition, 1L bolus of NS

If <135 Na, Give NS 250-500ml/hr

If >135 Na, Give 1/2NS 250-500ml/hr

If glucose range is below their targets, just add D5W

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19
Q

DKA is resolved in what criteria?

A

Glucose <200 and two of the following:

Bicarb≥15
Venous pH>7.3
Anion gap≤12

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20
Q

HHS is resolved in what criteria?

A

Normal osmolality and normal mental status

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21
Q

Post resolution care, when should you start SQ admin of insulin?

A

1-2 hrs before stopping IV

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22
Q

What are some complications of DVT and PE?

A

DVT = swelling and pain, unilaterally

PE = Arrhythmias and death, SOB, chest pain

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23
Q

RF for VTE?

A

Stasis

ICU

Cancer

Rx (estrogen, vasopressor, ESAs)

Patient-related

Surgery

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24
Q

What is a good thing about using the PADUA prediction score for VTE?

A

If you score low, it has a 99% value stating that you have a low risk for VTE, it is not specific nor sensitive

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25
Q

Which diagnostic tests are used in DVT vs PE?

A

DVT = compression ultrasound

PE = CT and ventilation/perfusion scans

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26
Q

Prophylactic dosing of:

Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)

A

Enoxaparin 40mg daily

Dalteparin 5000u daily

Heparin 5000u q8-12hrs

Fondaparinux 2.5mg daily

DOACs not recommended

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27
Q

MOA of:

Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)

A

Enoxaparin + Dalteparin + Fondaparinux = Indirect Xa inhibitors

Heparin = indirect IIa and Xa inhibitor

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28
Q

Dose of heparin and lovenox in BMI>40?

A

Heparin 7500 TID

Lovenox 40mg BID or 0.5mg/kg/day

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29
Q

Dose of heparin and lovenox in low body weight <50kg

A

Heparin 5000 BID or TID

Lovenox 30mg QD

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30
Q

Dose of heparin and lovenox in renal dysfunction?

A

Heparin = no change

Lovenox; if CrCl<30 its 30mg QD or switch to heparin

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31
Q

Dose of heparin and lovenox in surgery?

A

Major orthopedic surgery, then Lovenox 30mg BID

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32
Q

What RF are there for hemorrhages?

A

Increasing doses of anticoagulation, concomitant antiplatelet therapy

Low body weight (<50kg)

Malignancy, HF, renal failure

h/o bleed

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33
Q

What is a major bleed?

A

Fatal bleed

Symptomatic bleed in critical organ

Bleeding causing Hgb >=2g/dl

Transfusion w/ 2+ units of blood

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34
Q

What is a life-threatening bleed?

A

Symptomatic intracranial bleed

Bleeding causing Hgb >=5g/dl

Transfusion w/ 4+ units of blood

Bleed associated w/ hypotension

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35
Q

What do they inactive:

Protamine

A

Protamine - UFH + LMWH

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36
Q

1mg Protamine neutralizes ____ units of UFH

A

100

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37
Q

Utilize the last _____ hours of heparin administered when using protamine

A

2-3

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38
Q

Max dose of protamine = ___ mg

A

50

39
Q

Max infusion rate of protamine = ____mg/min

A

5

40
Q

IV vs SQ heparin reversal, how do you administer protamine?

A

IV = just give protamine infusion rate of 5mg/ml

SQ = bolus dose protamine of 25mg, then remaining dose of IV over 8hours

41
Q

When administering protamine for heparin, how much does it reverse LMWH?

A

Only 60%

42
Q

Protamine dosing for LMWH?

A

Time since last dose:

<8hrs = 1mg (100u) / 1mgLMWH

8-12hrs = 0.5 (50u) / 1mg LMWH

> 12hrs = n/a

Max dose of protamine = 50mg

43
Q

How is protamine administered for LMWH?

A

SQ only

44
Q

What intervention is needed with warfarin if INR is supratherapeutic but <4.5 and NO bleed?

A

Hold 1-2 doses OR reduce warfarin dose

45
Q

What intervention is needed with warfarin if INR is 4.5-9.9 and NO bleed?

A

Hold doses

46
Q

What intervention is needed with warfarin if INR is >10 and NO bleed?

A

Hold dose AND give Vit. K PO 1-2.5mg

47
Q

What intervention is needed with warfarin at any INR with major/life-threatening/emergency bleed?

A

Hold dose AND give 4-factor PCC and Vit. K IV 5-10mg

Recheck INR 30-60 min after 4-factor PCC, then every 6 hours

48
Q

What is fresh frozen plasma used to reverse? Dose and considerations?

A

Warfarin reversal

15ml/kg

Time consuming (90min from order to admin), must find ABO blood type match and thawing process, volume overload

49
Q

Kcentra is dosed based on ______

A

Factor IX/kg (actual body weight)

50
Q

What is recombinant factor VIIa used for?

A

Warfarin reversal

BBW of serious thrombotic events

51
Q

What is andexant alfa used for?

A

Rivaroxaban and apixaban reversal

52
Q

Andexant alfa dose?

A

400-800mg IV bolus then 4-8mg/min infusion for 2 hours

53
Q

What is idarucizumab used for?

A

Dabigatran reversal

54
Q

Idarucizumab dose?

A

50mg/kg IV *max dose of 5000u. Typically uses 2 separate 2.5g vials 15 min apart

55
Q

What is the metabolism of critical ill patients?

Carbs
Lipids
Protein

A

Carbs = increased glucose production + insulin resistance = hyperglycemia

Lipids = increased lipolysis

Protein catabolism > protein synthesis

Net effect = decreased lean body mass

56
Q

Which lab values should not be included for nutrition screening?

A

Albumin, transferrin, prealbumin

57
Q

What NRS-2002 score indicates nutritionally at-risk?

A

Anything greater than 2

58
Q

What mNUTRIC score indicates worse clinical outcome AND likely to benefit from aggressive nutrition therapy?

A

Anything greater than 4

59
Q

What are the weights to measure calories needed for patients? Some cons?

A

Indirect Calorimetry**gold standard

Predictive equations **not super accurate, less accurate in pt w/ obesity or are underweight

Simplistic weight-based estimation

60
Q

Indirect calorimetry info?

A

Gold standard

Estimates energy expenditure from measures of CO2 production and O2 consumption

Uses respiratory quotient (normal = 0.8-0.85)

Can provide resting energy expenditure

61
Q

What is the most “important” macronutrient? Who needs more of them?

A

Protein, generally higher amount in ICU patients

Dont reduce protein need in acute kidney or hepatic failure

62
Q

What is used to measure adequacy or protein administration?

A

Weekly urine urea nitrogen

63
Q

High dose protein should be given to which specific patients?

A

Burn or multitrauma

64
Q

Obese + critical patient, what kind of feeding should they get?

A

Early EN within 24-48hrs

High protein + hypocaloric

65
Q

Those w/ HD or CRRT, how is protein intake adjusted?

A

Increases protein to 2.5g/kg/day

66
Q

Nutritionally needs for those w/ respiratory failure?

A

If they have the condition for >72hrs, low/moderate risk get trophic fee for 6 days and high risk gets for 2-3 days

Low/moderate risk get PN on top of EN after a week of EN

High risk gets PN ASAP on top of EN

67
Q

EN complications?

A

Aspiration pneumonia

Diarrhea

68
Q

How many kcal/gram does dextrose contain and what should the rate be?

A

3.4kcal/gram

Limit to <4mg/kg/min to prevent hyperglycemia

69
Q

What is SMOF?

A

Lipid emulsion (non-soybean oil) even though it has some soybean :/

30% soybean oil
30% median chain TG
25% Olive oil
15% fish oil

70
Q

What factors affect the activity of the Na-K ATPase pump, the rate-limiting step in for potassium entry into cells?

A

Several factors affect the activity of this pump,
including insulin, glucagon, catecholamines, aldosterone, acid-base status, plasma osmolality, and intracellular potassium levels.

71
Q

What are some examples of symptoms of hypokalemia

A

Signs and symptoms of hypokalemia include nausea, vomiting, weakness, constipation, paralysis, respiratory compromise, and rhabdomyolysis

Severe - ECG changes

72
Q

What ECG changes might you see due to hypokalemia?

A

ST-segment depression

T-wave flattening

T-wave inversion

U waves

73
Q

What drugs cause an intracellular shift of potassium?

A

Beta agonists

Insulin

Theophylline

Caffeine

74
Q

What drugs/conditions cause potassium loss?

A

Loop and thiazide diuretics

SPS

Corticosteroids (especially mineralocorticoids
such as fludrocortisone)

Aminoglycosides

Amphotericin B

Magnesium depletion

HD, CRRT, etc

GI losses (e.g., diarrhea, nasogastric suctioning)

75
Q

Which IV fluid will worsen hypokalemia?

A

Dextrose, it will stimulate insulin release

76
Q

What will happen if you inject potassium peripherally?

A

Potassium infusion via a peripheral vein may cause burning pain
and phlebitis at the infusion site.

77
Q

What can you do to minimize pain associated with injecting potassium peripherally? Any issues?

A

Adding 1 mL of 1% lidocaine to a potassium solution of 10–20 meq/100 mL may minimize the pain at the infusion site. However, this could mask a sign of underlying venous
damage.

78
Q

How do you treat hyperkalemia? AE of drugs?

A

Calcium gluconate (antagonizes cardiac complications)

Bicarb (be careful in HF or liver issue, it has sodium in it)

Insulin

Dextrose

Furosemide

SPS (be careful in HF or liver issue, it has sodium in it, GI tract necrosis)

Albuterol

Hemodialysis (removes potassium from plasma)

79
Q

Issues with hypophosphatemia?

A

Respiratory, cardiac, neurologic issues

80
Q

What conditions predispose pt to hypophosphatemia?

A

Malnutrition

Inadequate body phosphorus stores or inadequate phosphate administration

Alkalosis [respiratory and metabolic]

DKA

Alcoholism

Vomiting

81
Q

Which medications can cause hypophosphatemia?

A

CRRT

Insulin

Diuretics

Antacids

Sucralfate,

Administration of carbohydrate loads

82
Q

What can cause hyperphosphatemia? Treatment?

A

Hypocalcemia

Correct calcium levels (calcium x phosphorus must be <60)

Drugs:

Calcium acetate
Calcium carbonate
Aluminum hydroxide
Magnesium hydroxide
Sevelamer
83
Q

Why do we calculate a corrected calcium level? Formula?

A

Calcium is bound to albumin, therefore patients with hypoalbuminemia will have a “low” level

Calcium + ((0.8(4-albumin))

84
Q

What causes hypocalcemia?

A

Hypoalbuminemia.

Hypomagnesemia

Hyperphosphatemia,

Sepsis, pancreatitis, renal insufficiency, hypoparathyroidism, and administration of blood preserved with citrate

The hallmark sign of severe acute hypocalcemia is tetany

85
Q

S/Sx of hypocalcemia?

A

Brittle and grooved nails, hair loss, dermatitis,

and eczema

86
Q

Differences between calcium gluconate and calcium chloride?

A

Calcium chloride provides three times more
elemental calcium than an equivalent
amount of calcium gluconate

87
Q

When is calcium gluconate preferred over calcium chloride?

A

Calcium gluconate should be used as the preferred
salt for routine calcium maintenance and supplementation

Calcium chloride for emergency use

88
Q

What causes hypercalcemia?

A

The primary causes of hypercalcemia are malignancy and

primary hyperparathyroidism

89
Q

How do you treat hypercalcemia?

A

NS

Lasix

HD if severe or renally impaired

Bisphosphonates

Etidronate disodium

90
Q

Hypomagnesemia can impact which other electrolytes?

A

Hypokalemia and hypocalcemia

91
Q

What drugs can cause hypomagnesemia?

A

Loop and thiazide diuretics

Aminoglycosides

Amphotericin B

Cisplatin

Cyclosporine

Digoxin

92
Q

Why must IV admin of magnesium go slowly?

A

It distributes into tissues slowly, but is renally excreted quickly

93
Q

How do you treat hypermagnesemia?

A

IV calcium

IPT: CC (7 decks)

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