Chapter 53: Acute & Critical Care Medicine Flashcards
(155 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, renal injury, and coagulopathy
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
stop any offending agent (diuretics)
12
Q
How do you treat hypotonic hypervolemic hyponatremia
common causes
A
Diuresis with fluid restriction (since it is caused by fluid overload)
cirrhosis, heart failure, renal failure
13
Q
What drugs/drug class can be used to treat SIADH and hypervolemic hyponatremia
A
tx: diuresis, stop offending agent, fluid restriction Arginine vasopressin (AVP) receptor antagonists Conivaptan and tolvaptan
14
Q
when is NaCl 3% an option
A
when Na < 120 mEq/L
or severe symptoms
15
Q
Rate to correct hyponatremia
Correcting sodium more rapidly than ___ mEq/L over ___ hrs can cause ______ or _____, which can cause ________
A
usually 4-8 mEq/L/day
max: 12 mEq/L over 24 hrs
osmotic demyelination syndrome (ODS) or central pontine myelinolysis –> paralysis, seizures and death
16
Q
Tolvaptan brand name
A
Samsca
17
Q
Tolvaptan is limited to how many days and why
A
≤ 30 days due to hepatotoxicity
18
Q
administration of tolvaptan
conivaptan?
A
tablet (PO)
IV
19
Q
Where must tolvaptan be initiated and re-initiated
why?
A
In a hospital
close monitoring of serum Na
20
Q
Side effects of tolvaptan
A
Thirst, nausea, dry mouth, polyuria
21
Q
Tolvaptan monitoring
A
Rate of Na increase
risk of ODS (increase ≥ 12 mEq/L/day)
22
Q
Hypernatremia is sodium greater than ____ mEq/L
what is it associated with?
A
145 mEq/L
water deficit and hypertonicity
23
Q
Hypokalemia is potassium less than ___ mEq/L
A
3.5 mEq/L
24
Q
Medications that can cause hypokalemia
A
amphotericin, insulin
25
A drop of 1 mEq/L in serum K below 3.5 mEq/L represents a total body deficit of ___-___ mEq
100-400 mEq
26
Through a peripheral line, IV potassium replacement includes a max infusion rate of ≤ ___ mEq/hr & a max concentration of ___ mEq/___ mL
10 mEq/hr
10 mEq/100 mL
| > 10 requires continuous EKG monitoring
27
IV potassium can be fatal if administered in which ways
undiluted or IV push
| never never never IV push
28
When hypokalemia is resistant to treatment, what should be checked
serum magnesium
29
Most likely cause of hyper-kalemia or magnesemia
renal dysfunction
30
When serum Mg is < __ mEq/L with life-threatening symptoms (seizures & arrhythmias), what is recommended
< 1 mEq/L
IV magnesium sulfate
31
Magnesium < 1 mEq/L with no symptoms tx
IV or IM administration
32
When serum Mg is > 1 mEq/L but < 1.5 without life-threatening symptoms, what can be used
oral magnesium oxide
33
When is hypophosphatemia considered severe
When serum phosphate is < 1 mg/dL
34
When serum PO4 is < 1 mg/dL, what is used for replacement
IV Phosphorus
35
What does IV immune globulin contain
Pooled immunoglobulin (IgG)
36
What are some off-label uses for IVIG
MS, myasthenia gravis, Guillain-Barre
37
IVIG brand names
Gammagard, Gamunex-C, Octagam, Privigen
38
IVIG can impact the response to what?
vaccinations
39
When should a slower infusion rate be used with IVIG
In renal and CV disease
40
IVIG boxed warnings
- Acute renal dysfunction - rare, but fatal (more likely with products stabilized with sucrose)
- Thrombosis (even without risk factors)
41
IVIG boxed warnings
infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)
| a slower titration and premedication may be needed if hx
42
What is the scoring tool used to determine prognosis and estimate ICU mortality risk
The Acute Physiologic Assessment & Chronic Health Evaluation II (APACHE II)
43
Most vasopressors work by stimulating ____ receptors, which causes _____ & (increases/decreases) systemic vascular resistance (SVR), which increases ____
Alpha receptors
Vasoconstriction (think vasopressor PRESSES down on the vasculature)
Increases
BP
44
_____ is a natural precursor of NE and is recommended for use in symptomatic bradycardia
Dopamine
45
Low (renal) dopamine dose ?
| acts on what receptors?
1-4 mcg/kg/min
| DA-1 agonist
46
Medium dopamine dose?
| acts on what receptors?
5-10 mcg/kg/min
| beta-1 agonist
47
High dopamine dose?
| acts on what receptors?
10-20 mcg/kg/min
| alpha-1 agonist
48
Epinephrine MOA
Alpha-1, beta-1, beta-2 agonist
49
epinephrine brand name
Adrenalin, EpiPen
50
Norepinephrine brand name
Levophed
51
Norepinephrine MOA
Alpha-1 agonist > beta-1 agonist
52
Phenylephrine MOA
Alpha-1 agonist
53
What are the other names for vasopressin
ADH and arginine vasopressin (AVP)
54
All vasopressors are ____ when administered IV
Vesicants
55
How should vasoconstrictor extravasation be treated
phentolamine
56
Vasopressor side effects
Arrhythmias, tachycardia (esp DA, Epi, and vasopressin), necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)
57
What should be monitored with all vasopressors
continuous BP
58
don't use vasopressor solutions if...
discolored or precipitate
59
How should all vasopressors be administered
central IV line
60
Dose of epinephrine used for IV push
0.1 mg/mL (1:10,000 ratio strength)
61
Dose of epinephrine used for IM injection
1 mg/mL (1:1,000 ratio strength)
62
T/F: extravasation is a medical emergency with vasopressors
True, all vasopressors are vesicants and should be treated with phentolamine (alpha blocker)
63
Phentolamine MOA
alpha-1 blocker
64
When is nitroglycerin often used
When there is severe myocardial ischemia or uncontrolled HTN
65
Effectiveness of nitroglycerin may be limited after __-__ hrs due to ____
24-48 hrs due to tachyphylaxis (tolerance)
66
Nitroglycerin MOA
low doses: venous vasodilator
high doses: arterial vasodilator
67
Nitroprusside MOA
mixed (equal) arterial and venous vasodilator at all doses
68
When should nitroprusside NOT be used
active myocardial ischemia (can cause blood to be diverted away from the diseased coronary arteries - "coronary steal")
69
Metabolism of nitroprusside results in:
formation of thiocyanate and cyanide (both can cause toxicity)
| esp in renal or hepatic insufficiency
70
What can be administered to reduce the risk of thiocyanate toxicity with use of nitroprusside
Hydroxycobalamin
71
What can be administered to reduce the risk of cyanide toxicity with use of nitroprusside
Sodium thiosulfate
72
nitroprusside brand name
Nipride
73
NTG contraindications
SBP < 90 mmHg
| Use with a PDE-5 inhibitor or riociguat
74
Side effects of NTG
HA, tachycardia, tachyphylaxis
75
What kind of container does NTG require
non-PVC container (e.g., glass, polyolefin)
76
Nitroprusside is not for direct injection & must be diluted with
D5W preferred
77
Nitroprusside can cause increased:
Intracranial pressure
78
If nitroprusside turns this color, it indicates degradation to cyanide
Blue
79
Inotropes increase:
contractility of the heart
80
Dobutamine MOA
Beta-1 agonist
81
Milrinone MOA
PDE-3 inhibitor in cardiac and vascular tissues
82
Which drugs are inotropes
Dobutamine & milrinone
83
Dobutamine may turn what color due to oxidation, but it does not indicate potency has been lost
Slightly pink
84
How is shock characterized?
How it is defined?
Hypoperfusion usually in the setting of hypotension
SBP < 90 or MAP < 70
85
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
86
First-line therapy for hypovolemic shock that is not caused by hemorrhage
Fluid resuscitation with Crystalloids
87
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
88
Example of distributive shock
Sepsis
| anaphylactic, neurogeninc
89
Two common causes of ICU infections
- Mechanical ventilation pushes air into the lungs for pts who cannot breathe on their own
- Foley catheters
90
Bundles to reduce mortality from sepsis and septic shock includes
Early administration of broad-spectrum abx & IV fluid resuscitation with IV crystalloids
91
How to define septic shock
persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg
92
If adequate perfusion cannot be maintained with IV crystalloids in septic shock, what is the vasopressor of choice that can be used
Norepinephrine
93
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
| without hypotension and hypoperfusion it's called
Cardiogenic shock
| actue decompensated heart failure
94
Beta-blockers should only be stopped in an acute decompensated HF episode if:
hypotension or hypoperfusion is present
95
What is the name of the catheter that some patients with acute decompensated HF require
Swan-Ganz catheter
| = pulmonary artery catheter
96
What does the Swan-Ganz catheter measure in acute decompensated HF?
pulmonary capillary wedge pressure (for congestion)
97
What treatments are used for volume overload in acute decompensated HF
Loop diuretics
| possibly IV Vasodilators can be added (NTG, nitroprusside, nesiritide)
98
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
99
First-line for analgesia in the ICU
Opioids given IV like morphine, hydromorphone and fentanyl
100
____ are preferred for sedation and are associated with improved ICU outcomes
Non-BZDs like propofol and dexmedetomidine
101
dexmedetomidine brand name
Precedex
102
What is the only sedative approved for use in intubated and non-intubated pts
dexmedetomidine
103
how often should sedation vacations be tried?
daily
104
Which atypical antipsychotic may be beneficial in delerium
Quetiapine
105
Fentanyl brand name for ICU
Sublimaze
106
hydromorphone brand name
Dilaudid
107
Morphine brand name
Duramorph, Infumorph
108
dexmedetomidine MOA
Alpha-2 adrenergic agonist
109
dexmedetomidine side effects
Hypo/hypertension, bradycardia
110
Duration of infusion for dexmedetomidine should not exceed ____ hrs per FDA labeling
24 hrs
111
Propofol brand name
Diprivan
112
Propofol contraindications
Hypersensitivity to egg & soy
113
Propofol side effects
Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare but can be fatal), pancreatitis, QT prolongation
114
Propofol vial & tubing should be discarded within how many hours of use due to bacterial growth
12 hrs
115
Propofol oil-in-water emulsion provides ___ kcal/mL
1.1
116
Lorazepam injection can cause
propylene glycol toxicity (acute renal failure and metabolic acidosis)
117
lorazepam brand name
Ativan
118
Midazolam brand name
Versed
119
Midazolam contraindications
Use with potent 3A4 inhibitors
120
Midazolam can accumulate in
renal impairment (active metabolite)
121
Etomidate monitoring
Adrenal insufficiency
122
Ketamine warnings
Emergence reactions (vivid dreams, hallucinations, delirium)
123
ketamine MOA
NMDA receptor antagonist
124
haloperidol brand name
Haldol
125
quetiapine brand name
Seroquel
126
What are the recommended agents for prevention of stress ulcers
H2RAs and PPIs
127
PPIs have been associated with an increased risk of
GI infections (C.diff), fractures and nosocomial pneumonia
128
Which risk factors in the ICU is associated with the development of stress ulcers
Mechanical ventilation > 48 hrs
coagulopathy
| sepsis, major burns, acute renal failure, high dose steroids, TBI
129
Inhaled anesthetics can rarely cause
malignancy hyperthermia
130
Which anesthetic commonly used in epidurals can be fatal if administered IV
Bupivacaine
131
Local anesthetic
Lidocaine (Xylocaine)
132
Inhaled anesthetics
desflurane (Suprane), sevoflurane
133
Injectable anesthetics
Bupivacaine, ropivacaine, lidocaine
134
lidocaine brand name as local anesthetic
Xylocaine
135
Desflurane brand name
Suprane
136
Neuromuscular blocking agents can cause
paralysis of the skeletal muscle
137
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)
138
Patients should receive adequate what before starting and NMBA
Sedation and analgesia
139
Patients must be _____ while on NMBAs since they can paralyze the diaphragm
mechanically ventilated
140
All NMBAs must be labeled with a colored auxiliary label stating:
"WARNING, PARALYZING AGENT"
141
What is the only available depolarizing NMBA
Succinylcholine
142
Succinocholine is typically reserved for
intubation
143
Special care when using NMBAs includes
protecting the skin, lubricating the eyes and suction the airway frequently to clear secretions
144
Which anticholinergic drug can be used to reduce secretions when using NMBAs
Glycopyrrolate
145
medications that can enhance the effect of NMBAs
aminoglycosides
polymyxins
| others: CCBs, vanco, cyclosporine
146
Which drug is a non-depolarizing NMBA
Cisatracurium
| also atracurium, pancuronium, rocuronium, vecuronium
147
Cisatracurium brand name
Nimbex
148
Side effects for all non-depolarizing NMBAs
Flushing, bradycardia, hypotension, tachyphylaxis
149
How is Cisatracurium metabolized
Hofmann elimination (independent of renal and hepatic function)
150
Which non-depolarizing NMBA is long-acting
Pancuronium
151
How do systemic hemostatic drugs work
They inhibit fibrinolysis or enhance coagulation
152
Tranexamic acid injection brand name
Cyklokapron
153
Tranexamic acid tablet brand name
Lysteda
154
Recombinant Factor VIIa brand name
NovoSeven RT
155
Lysteda (tranexamic acid tablet) is approved for
Heavy menstrual bleeding
