Chapter 53: Acute & Critical Care Medicine Flashcards
(139 cards)
1
Q
Which fluids are less costly and generally have fewer side adverse reactions - crystalloids or colloids
A
Crystalloids
2
Q
Colloids are ____ molecules (typically protein or starch) dispersed in solutions that primarily remain in the ______ space and ____ oncotic pressure
A
Large molecules
intravascular space
Increase
3
Q
Which fluid is used when water is needed intracellularly, as these products contain “free water”
A
Dextrose
4
Q
Which fluids are the most common drugs used for volume resuscitation in shock states
A
Lactated Ringers and Normal saline
5
Q
Which fluid is the most commonly used colloid
A
Albumin
6
Q
When is albumin useful
A
significant edema (e.g., cirrhosis)
7
Q
Boxed warning for hydroxyethyl starch
A
avoid use in critical illness (including sepsis) due to mortality and renal injury
8
Q
Which common fluids are crystalloids
A
D5W
Normal saline
Lactated Ringers
Multiple electrolyte injection (i.e., Plasma-Lyte A)
9
Q
Which common fluids are colloids
A
Albumin 5%, 25% (Albutein, AlbuRx)
Dextran
Hydroxyethyl starch
10
Q
Hyponatremia is Na below
A
< 135 mEq/L
11
Q
How do you treat hypotonic hypovolemic hyponatremia
A
administer sodium chloride IV solutions
12
Q
How do you treat hypotonic hypervolemic hyponatremia
A
Diuresis with fluid restriction (since it is caused by fluid overload)
13
Q
What drugs/drug class can be used to treat SIADH and hypervolemic hyponatremia
A
Arginine vasopressin (AVP) receptor antagonists Conivaptan and tolvaptan
14
Q
Correcting sodium more rapidly than ___ mEq/L over ___ hrs can cause ______ or _____, which can cause paralysis, seizures, & death
A
12 mEq/L over 24 hrs
osmotic demyelination syndrome (ODS) or central pontine myelinolysis
15
Q
Tolvaptan brand name
A
Samsca
16
Q
Tolvaptan is limited to how many days and why
A
less than 30 days due to hepatotoxicity
17
Q
Where must tolvaptan be initiated and re-initiated
A
In a hospital
18
Q
Side effects of tolvaptan
A
Thirst, nausea, dry mouth, polyuria
19
Q
Tolvaptan monitoring
A
Rate of Na increase
20
Q
Hypernatremia is sodium greater than ____ mEq/L
A
145 mEq/L
21
Q
Hypokalemia is potassium less than ___ mEq/L
A
3.5 mEq/L
22
Q
Medications that can cause hypokalemia
A
amphotericin, insulin
23
Q
A drop of 1 mEq/L in serum K below 3.5 mEq/L represents a total body deficit of ___-___ mEq
A
100-400 mEq
24
Q
Through a peripheral line, IV potassium replacement includes a max infusion rate of < / = ___ mEq/hr & a max concentration of ___ mEq/___ mL
A
10 mEq/hr
10 mEq/100 mL
25
IV potassium can be fatal if administered in which ways
undiluted or IV push
26
When hypokalemia is resistant to treatment, what should be checked
serum magnesium
27
What is necessary for potassium uptake
Magnesium
28
When serum Mg is < __ mEq/L with life-threatening symptoms (seizures & arrhythmias), what is recommended
< 1 mEq/L
| IV magnesium sulfate
29
When serum Mg is > 1 mEq/L without life-threatening symptoms, what can be used
oral magnesium oxide
30
When is hypophosphatemia considered severe
When serum phosphate is < 1 mg/dL
31
When serum PO4 is < 1 mg/dL, what is used for replacement
IV Phosphorous
32
What does IV immune globulin contain
Pooled immunoglobulin (IgG)
33
What are some off-label uses for IVIG
MS, myasthenia gravis, Guillain-Barre
34
IVIG brand names
Carimune NF, Flebogamma DIF, Gamunex-C, Octagam, Privigen
35
When should a slower infusion rate be used with IVIG
In renal and CV disease
36
IVIG boxed warnings
- Acute renal dysfunction - rare, but fatal (more likely with products stabilized with sucrose)
- Thrombosis (even without risk factors)
37
IVIG boxed warnings
HA, nausea, diarrhea, injection site reaction, infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)
38
What is the scoring tool used to determine prognosis and estimate ICU mortality risk
The Acute Physiologic Assessment & Chronic Health Evaluation II (APACHE II)
39
Most vasopressors work by stimulating alpha receptors, which causes _______ & (increases/decreases) systemic vascular resistance (SVR), which increases ____
Vasoconstriction (think vasopressor PRESSES down on the vasculature)
Increases
BP
40
_____ is a natural precursor of NE and is recommended for use in symptomatic bradycardia
Dopamine
41
Low (renal) dopamine dose (DA-1 agonist)?
1-4 mcg/kg/min
42
Medium dopamine dose (beta-1 agonist)?
5-10 mcg/kg/min
43
High dopamine dose (alpha-1 agonist)?
10-20 mcg/kg/min
44
Epinephrine MOA
Alpha-1, beta-1, beta-2 agonist
45
Norepinephrine brand name
Levophed
46
Norepinephrine MOA
Alpha-1 agonist > beta-1 agonist
47
Phenylephrine MOA
Alpha-1 agonist
48
What are the other names for vasopressin
ADH and arginine vasopressin (AVP)
49
All vasopressors are ____ when administered IV
Vesicants
50
How should vasoconstrictor extravasation be treated
phentolamine
51
Vasopressor side effects
Arrhythmias, tachycardia (esp DA, Epi, and vasopressin), necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)
52
What should be monitored with all vasopressors
BP
53
How should all vasopressors be administered
central IV line
54
Dose of epinephrine used for IV push
0.1 mg/mL (1:10,000 ratio strength)
55
Dose of epinephrine used for IM injection
1 mg/mL (1:1,000 ratio strength)
56
Phentolamine MOA
alpha-1 blocker
57
When is nitroglycerin often used
When there is severe myocardial ischemia or uncontrolled HTN
58
Effectiveness of nitroglycerin may be limited after __-__ hrs due to ____
24-48 hrs due to tachyphylaxis (tolerance)
59
Nitroprusside MOA
mixed (equal) arterial and venous vasodilator at all doses
60
When should nitroprusside NOT be used
active myocardial ischemia (can cause blood to be diverted away from the diseased coronary arteries - "coronary steal")
61
Metabolism of nitroprusside results in:
formation of thiocyanate and cyanide (both can cause toxicity)
62
What can be administered to reduce the risk of thiocyanate toxicity with use of nitroprusside
Hydroxycobalamin
63
What can be administered to reduce the risk of cyanide toxicity with use of nitroprusside
Sodium thiosulfate
64
Nesiritide MOA
recombinant B-type natriuretic peptide that binds to vascular smooth muscle and increases cGMP, resulting in vasodilation
65
MOA of NTG at low doses
venous vasodilator
66
MOA of NTG at high doses
arterial vasodilator
67
NTG contraindications
SBP < 90 mmHg
| Use with a PDE-5 inhibitor or riociguat
68
Side effects of NTG
HA, tachycardia, tachyphylaxis
69
What kind of container does NTG require
non-PVC container (e.g., glass, polyolefin)
70
Nitroprusside brand names
Nitropress, Nipride
71
Nitroprusside is not for direct injection & must be diluted with
D5W
72
Nitrprusside can cause increased:
Intracranial pressure
73
If nitroprusside turns this color, it indicates degradation to cyanide
Blue
74
Inotropes increase:
contractility of the heart
75
Dobutamine MOA
Beta-1 agonist
76
Milrinone MOA
PDE-3 inhibitor
77
Which drugs are inotropes
Dobutamine & milrinone
78
Dobutamine may turn what color due to oxidation, but it does not indicate potency has been lost
Slightly pink
79
How is shock characterized
Hypoperfusion usually in the setting of hypotension
80
General principles of treating shock
- Optimize preload with IV crystalloid bolus (PRN)
- Peripheral vasoconstrictor (alpha-1 agonist) to increase systemic vascular resistance (SVR)
- Beta-1 agonist to increase myocardial contractility & CO
81
First-line therapy for hypovolemic shock that is not caused by hemorrhage
Fluid resuscitation with Crystalloids
82
If the patient does not respond to initial crystalloid therapy in hypovolemic shock, vasopressors may be indicated, but they will not be effective unless:
Intravascular volume is adequate
83
Example of distributive shock
Sepsis
84
Two common causes of ICU infections
- Mechanical ventilation pushes air into the lungs for pts who cannot breathe on their own
- Foley catheters
85
Bundles to reduce mortality from sepsis and septic shock includes
Early administration of broad-spectrum abx & IV fluid resuscitation with IV crystalloids
86
If adequate perfusion cannot be maintained with IV crystalloids in septic shock, what is the vasopressor of choice that can be used
Norepinephrine
87
Sudden weight gain, inability to lie flat without becoming SOB, decreasing functionality, increasing SOB and fatigue is called acute decompensated HF & when hypotension and hypoperfusion are also present it is called
Cardiogenic shock
88
Beta-blockers should only be stopped in an acute decompensated HF episode if:
hypotension or hypoperfusion is present
89
What is the name of the catheter that some patients with acute decompensated HF require
Swan-Ganz catheter
90
What does the Swan-Ganz catheter measure in acute decompensated HF
pulmonary capillary wedge pressure (for congestion)
91
What treatments are used for volume overload in acute decompensated HF
Loop diuretics
| Vasodilators can be added (NTG, nitroprusside, nesiritide)
92
What treatments are used for hypoperfusion in acute decompensated HF
Inotropes (dobutamine, milrinone)
If the pt becomes hypotensive, consider adding a vasopressor
*avoid vasodilators since they can ↓ BP and worsen hypoperfusion
93
First-line for analgesia in the ICU
Opioids given IV like morphine, hydromorphone and fentanyl
94
____ are preferred for sedation and are associated with improved ICU outcomes
Non-BZDs like propofol and dexmedetomidine
95
dexmedetomidine brand name
Precedex
96
What is the only sedative approved for use in intubated and non-intubated pts
dexmedetomidine
97
Which atypical antipsychotic may be beneficial in delerium
Quetiapine
98
Fentanyl brand name for ICU
Sublimaze
99
dexmedetomidine MOA
Alpha-2 adrenergic agonist
100
dexmedetomidine side effects
Hypo/hypertension, bradycardia
101
Duration of infusion for dexmedetomidine should not exceed ____ hrs per FDA labeling
24 hrs
102
Propofol brand name
Diprivan
103
Propofol contraindications
Hypersensitivity to egg & soy
104
Propofol side effects
Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare but can be fatal)
105
Propofol vial & tubing should be discarded within how many hours of use due to bacterial growth
12 hrs
106
Propofol oil-in-water emulsion provides ___ kcal/mL
1.1
107
Lorazepam injection can cause
propylene glycol toxicity (acute renal failure and metabolic acidosis)
108
Midazolam brand name
Versed
109
Midazolam contraindications
Use with potent 3A4 inhibitors
110
Midazolam can accumulate in
renal impairment (active metabolite)
111
Etomadite monitoring
Adrenal insufficiency
112
Ketamine warnings
Emergence reactions (vivid dreams, hallucinations, delirium)
113
What are the recommended agents for prevention of stress ulcers
H2RAs and PPIs
114
PPIs have been associated with an increased risk of
GI infections (C.diff), fractures and nosocomial pneumonia
115
Which risk factors in the ICU is associated with the development of stress ulcers
Mechanical ventilation > 48 hrs
| Coagulopathy
116
Inhaled anesthetics can rarely cause
malignancy hyperthermia
117
Which anesthetic commonly used in epidurals can be fatal if administered IV
Bupivacaine
118
Local anesthetic
Lidocaine (Xylocaine)
119
Inhaled anesthetics
desflurane (Suprane), sevoflurane
120
Injectable anesthetics
Bupivacaine, ropivacaine
121
Neuromuscular blocking agents can cause
paralysis of the skeletal muscle
122
Patients can require the use of a NMBA agent in surgery for what reasons:
to facilitate mechanical ventilation
to manage increased intracranial pressure
to treat muscle spasms (tetany)
123
Patients should receive adequate what before starting and NMBA
Sedation and analgesia
124
Patients must be ______ while on NMBAs since they can paralyze the diaphragm
mechanically ventilated
125
All NMBAs must be labeled with a colored auxiliary label stating:
"WARNING, PARALYZING AGENT"
126
What is the only available depolarizing NMBA
Succinylcholine
127
Succinocholine is typically reserved for
intubation
128
Special care when using NMBAs includes
protecting the skin, lubricating the eyes and suction the airway frequently to clear secretions
129
Which anticholinergic drug can be used to reduce secretions when using NMBAs
Glycopyrrolate
130
Which drug is a non-depolarizing NMBA
Cisatracurium
131
Cisatracurium brand name
Nimbex
132
Side effects for all non-depolarizing NMBAs
Flushing, bradycardia, hypotension, tachyphylaxis
133
How is Cisatracurium metabolized
Hofmann elimination (independent of renal and hepatic function)
134
Which non-depolarizing NMBA is long-acting
Pancuronium
135
How do systemic hemostatic drugs work
They inhibit fibrinolysis or enhance coagulation
136
Tranexamic acid injection brand name
Cyklokapron
137
Tranexamic acid tablet brand name
Lysteda
138
Recombinant Factor VIIa brand name
NovoSeven RT
139
Lysteda (tranexamic acid tablet) is approved for
Heavy menstrual bleeding
