Chapter 53: Acute & Critical Care Medicine Flashcards
(149 cards)
1
Q
Which fluids are less costly and generally have fewer adverse reactions?
A
Crystalloids
2
Q
What are colloids?
A
Colloids are large molecules (typically protein or starch) dispersed in solutions.
3
Q
Where do colloids primarily remain?
A
Colloids primarily remain in the intravascular space.
4
Q
What effect do colloids have on oncotic pressure?
A
Colloids increase oncotic pressure.
5
Q
Which fluid is used when water is needed intracellularly, as these products contain ‘free water’?
A
Dextrose
6
Q
Which fluids are the most common drugs used for volume resuscitation in shock states?
A
Lactated Ringers and Normal saline
7
Q
Which fluid is the most commonly used colloid?
A
Albumin
8
Q
When is albumin useful?
A
In cases of significant edema (e.g., cirrhosis).
9
Q
What is the boxed warning for hydroxyethyl starch?
A
Avoid use in critical illness (including sepsis) due to mortality and renal injury.
10
Q
Which common fluids are crystalloids
A
- D5W
- Normal saline
- Lactated Ringers
- Multiple electrolyte injection (i.e., Plasma-Lyte A)
11
Q
Which common fluids are colloids:
A
- Albumin 5%, 25% (Albutein, AlbuRx)
- Dextran
- Hydroxyethyl starch
12
Q
What is hyponatremia?
A
Hyponatremia is Na below 135 mEq/L.
13
Q
How do you treat hypotonic hypovolemic hyponatremia?
A
Administer Hypertonic 3% sodium chloride IV solutions.
14
Q
How do you treat hypotonic hypervolemic hyponatremia?
A
Diuresis with fluid restriction (since it is caused by fluid overload).
15
Q
What drugs/drug class can be used to treat SIADH and hypervolemic hyponatremia?
A
Arginine vasopressin (AVP) receptor antagonists
(Conivaptan and tolvaptan)
16
Q
What is the maximum rate of sodium correction?
A
12 mEq/L over 24 hrs
17
Q
What can occur if sodium is corrected too rapidly?
A
Osmotic demyelination syndrome (ODS) or central pontine myelinolysis
18
Q
What are the potential consequences of rapid sodium correction?
A
Paralysis, seizures, & death
19
Q
What is the brand name of tolvaptan?
A
Samsca
20
Q
How long is tolvaptan limited to be used and why?
A
Less than 30 days due to hepatotoxicity
21
Q
Where must tolvaptan be initiated and re-initiated?
A
In a hospital
22
Q
What are the side effects of tolvaptan?
A
Thirst, nausea, dry mouth, polyuria
23
Q
What is monitored when using tolvaptan?
A
Rate of Na increase
24
Q
Hypernatremia is sodium greater than ____ mEq/L
A
145 mEq/L
25
Hypokalemia is potassium less than ___ mEq/L
3.5 mEq/L
26
Medications that can cause hypokalemia
amphotericin, insulin
27
A drop of 1 mEq/L in serum K below 3.5 mEq/L represents a total body deficit of ___-___ mEq
100-400 mEq
28
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
29
IV potassium can be fatal if administered in which ways
undiluted or IV push
30
When hypokalemia is resistant to treatment, what should be checked?
serum magnesium
31
What is necessary for potassium uptake?
Magnesium
32
What is recommended when serum Mg is < 1 mEq/L with life-threatening symptoms?
IV magnesium sulfate
33
What can be used when serum Mg is > 1 mEq/L without life-threatening symptoms?
Oral magnesium oxide
34
When is hypophosphatemia considered severe?
When serum phosphate is < 1 mg/dL
35
When serum PO4 is < 1 mg/dL, what is used for replacement?
IV Phosphorous
36
What does IV immune globulin contain?
Pooled immunoglobulin (IgG)
37
What are some off-label uses for IVIG?
MS, myasthenia gravis, Guillain-Barre
38
What are the brand names of IVIG?
Carimune NF, Flebogamma DIF, Gamunex-C, Octagam, Privigen
39
When should a slower infusion rate be used with IVIG?
In renal and CV disease
40
What are the boxed warnings for IVIG?
1. Acute renal dysfunction - rare, but fatal (more likely with products stabilized with sucrose)
2. Thrombosis (even without risk factors)
41
What are common side effects of IVIG?
HA, nausea, diarrhea, injection site reaction, infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)
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
alpha
44
Stimulation of alpha receptors causes _______
Vasoconstriction
45
Stimulation of alpha receptors (increases/decreases) systemic vascular resistance (SVR)
increases
46
Increased systemic vascular resistance (SVR) leads to an increase in _______
BP
47
What is a natural precursor of NE recommended for use in symptomatic bradycardia?
Dopamine
48
What is the low (renal) dopamine dose (DA-1 agonist)?
1-4 mcg/kg/min
49
Medium dopamine dose (beta-1 agonist)?
5-10 mcg/kg/min
50
High dopamine dose (alpha-1 agonist)?
10-20 mcg/kg/min
51
Epinephrine MOA
Alpha-1, beta-1, beta-2 agonist
52
Norepinephrine brand name
Levophed
53
Norepinephrine MOA
Alpha-1 agonist > beta-1 agonist
54
Phenylephrine MOA
Alpha-1 agonist
55
What are the other names for vasopressin
ADH and arginine vasopressin (AVP)
56
All vasopressors are ____ when administered IV
Vesicants
57
How should vasoconstrictor extravasation be treated?
phentolamine
58
Vasopressor side effects
Arrhythmias, tachycardia (esp DA, Epi, and vasopressin), necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)
59
What should be monitored with all vasopressors?
BP
60
How should all vasopressors be administered?
central IV line
61
Dose of epinephrine used for IV push?
0.1 mg/mL (1:10,000 ratio strength)
62
Dose of epinephrine used for IM injection
1 mg/mL (1:1,000 ratio strength)
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 how many hours due to what?
24-48 hrs due to tachyphylaxis (tolerance).
66
What is the mechanism of action (MOA) of nitroprusside?
Nitroprusside is a mixed (equal) arterial and venous vasodilator at all doses.
67
When should nitroprusside NOT be used?
Nitroprusside should not be used in active myocardial ischemia.
68
What are the metabolic byproducts of nitroprusside?
Metabolism of nitroprusside results in the formation of thiocyanate and cyanide, both of which can cause toxicity.
69
What can be administered to reduce the risk of thiocyanate toxicity with use of nitroprusside?
Hydroxycobalamin
70
What can be administered to reduce the risk of cyanide toxicity with use of nitroprusside?
Sodium thiosulfate
71
MOA of NTG at low doses
venous vasodilator
72
MOA of NTG at high doses
arterial vasodilator
73
NTG contraindications
SBP < 90 mmHg
## Footnote
Use with a PDE-5 inhibitor or riociguat
74
What are the side effects of NTG?
HA, tachycardia, tachyphylaxis
75
What kind of container does NTG require?
non-PVC container (e.g., glass, polyolefin)
76
What are the brand names of Nitroprusside?
Nitropress, Nipride
77
What must nitroprusside be diluted with before use?
D5W
78
What can nitroprusside cause an increase in?
Intracranial pressure
79
What color indicates degradation of nitroprusside to cyanide?
Blue
80
What do inotropes increase?
Contractility of the heart
81
What is the MOA of Dobutamine?
Beta-1 agonist
82
What is the MOA of Milrinone?
PDE-3 inhibitor
83
Which drugs are considered inotropes?
Dobutamine & milrinone
84
What color may Dobutamine turn due to oxidation?
Slightly pink
85
Does the color change of Dobutamine indicate loss of potency?
No, it does not indicate potency has been lost.
86
How is shock characterized?
Hypoperfusion usually in the setting of hypotension.
87
What is the first-line therapy for hypovolemic shock that is not caused by hemorrhage?
Fluid resuscitation with Crystalloids
88
What may be indicated if the patient does not respond to initial crystalloid therapy in hypovolemic shock?
Vasopressors may be indicated.
89
When will vasopressors not be effective?
They will not be effective unless intravascular volume is adequate.
90
What is sepsis?
Lifethreatening organ dysfunction caused by dysregulated host response to infection
91
What is the first principle of treating shock?
Optimize preload with IV crystalloid bolus (PRN)
92
What is the role of a peripheral vasoconstrictor in treating shock?
To increase systemic vascular resistance (SVR)
## Footnote
Example: Alpha-1 agonist
93
What is the purpose of using a beta-1 agonist in shock treatment?
To increase myocardial contractility & cardiac output (CO)
94
MAP formula
MAP= [(2xDBP)+SBP]/3
95
What are two common causes of ICU infections?
* Mechanical ventilation pushes air into the lungs for patients who cannot breathe on their own.
* Foley catheters.
96
What is septic shock?
Septic shock is sepsis with persistent hypotension requiring a vasopressor to keep MAP > 65.
97
What are the components of bundles to reduce mortality from sepsis and septic shock?
Early administration of broad-spectrum antibiotics and IV fluid resuscitation with IV crystalloids.
98
In septic shock, what is the vasopressor of choice?
Norepinephrine.
99
What is acute decompensated HF characterized by?
Sudden weight gain, inability to lie flat without becoming SOB, decreasing functionality, increasing SOB and fatigue
100
What is the condition called when hypotension and hypoperfusion are present along with acute decompensated HF?
Cardiogenic shock
101
When should beta-blockers be stopped in acute decompensated HF?
Beta-blockers should only be stopped if hypotension or hypoperfusion is present.
102
What does the Swan-Ganz catheter measure in acute decompensated HF?
Pulmonary capillary wedge pressure (for congestion).
103
What treatments are used for volume overload in acute decompensated HF?
Loop diuretics.
IV Vasodilators can be added (NTG, nitroprusside, nesiritide).
104
What treatments are used for hypoperfusion in acute decompensated HF?
Inotropes (dobutamine, milrinone)
105
What should be avoided in the treatment of hypoperfusion?
Vasodilators
106
What is the first-line for analgesia in the ICU?
Opioids given IV like morphine, hydromorphone and fentanyl
107
What type of sedatives are preferred for sedation in ICU?
Non-BZDs like propofol and dexmedetomidine
108
What is the brand name of dexmedetomidine?
Precedex
109
What is the only sedative approved for use in intubated and non-intubated patients?
dexmedetomidine
110
Which atypical antipsychotic may be beneficial in delirium?
Quetiapine
111
What is the brand name for Fentanyl used in ICU?
Sublimaze
112
What is the mechanism of action (MOA) of dexmedetomidine?
Alpha-2 adrenergic agonist
113
What are the side effects of dexmedetomidine?
Hypo/hypertension, bradycardia
114
Duration of infusion for dexmedetomidine should not exceed ____ hrs per FDA labeling
24 hrs
115
Propofol brand name
Diprivan
116
Propofol contraindications
Hypersensitivity to egg & soy
117
What are the side effects of Propofol?
Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare but can be fatal)
118
How many hours should a Propofol vial & tubing be discarded after use?
12 hrs
119
How many kcal/mL does Propofol oil-in-water emulsion provide?
1.1 kcal/mL
120
What can Lorazepam injection cause?
Propylene glycol toxicity (acute renal failure and metabolic acidosis)
121
What are the contraindications for Midazolam?
Use with potent 3A4 inhibitors.
122
What can cause Midazolam to accumulate?
Renal impairment (active metabolite).
123
What should be monitored with Etomidate?
Adrenal insufficiency (hypotension, hyperkalemia).
124
What are the emergence reactions associated with Ketamine?
Vivid dreams, hallucinations, delirium
125
What are the recommended agents for prevention of stress ulcers?
H2RAs and PPIs
126
What risks are associated with PPIs?
Increased risk of GI infections (C.diff), fractures, and nosocomial pneumonia
127
Which risk factors in the ICU are associated with the development of stress ulcers?
Mechanical ventilation > 48 hrs and coagulopathy
128
What rare condition can inhaled anesthetics cause?
Malignant hyperthermia
129
Which anesthetic commonly used in epidurals can be fatal if administered IV?
Bupivacaine
130
What is a common local anesthetic?
Lidocaine (Xylocaine)
131
What is the purpose of adding epinephrine to lidocaine?
Epinephrine is added for vasoconstriction which keeps lidocaine localized.
132
What can neuromuscular blocking agents cause?
Paralysis of the skeletal muscle
133
Why might patients require the use of a NMBA agent in surgery?
To facilitate mechanical ventilation, to manage increased intracranial pressure, to treat muscle spasms (tetany)
134
What should patients receive adequate of before starting an NMBA?
Sedation and analgesia
135
What must patients be while on NMBAs?
Patients must be mechanically ventilated.
136
What must all NMBAs be labeled with?
All NMBAs must be labeled with a colored auxiliary label stating: 'WARNING, PARALYZING AGENT'.
137
What is the only available depolarizing NMBA?
The only available depolarizing NMBA is Succinylcholine.
138
What is succinycholine typically reserved for?
Intubation
139
What special care is needed when using NMBAs?
Protecting the skin, lubricating the eyes, and suctioning the airway frequently to clear secretions.
140
Which anticholinergic drug can be used to reduce secretions when using NMBAs?
Glycopyrrolate
141
Which drug is a non-depolarizing NMBA?
Cisatracurium
142
What is the brand name of Cisatracurium?
Nimbex
143
What are the side effects for all non-depolarizing NMBAs?
Flushing, bradycardia, hypotension, tachyphylaxis.
144
How is Cisatracurium metabolized?
Hofmann elimination (independent of renal and hepatic function).
145
Which non-depolarizing NMBA is long-acting?
Pancuronium
146
How do systemic hemostatic drugs work?
They inhibit fibrinolysis or enhance coagulation.
147
Tranexamic acid injection brand name?
Cyklokapron.
148
Tranexamic acid tablet brand name?
Lysteda.
149
Recombinant Factor VIIa brand name?
NovoSeven RT.
