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F.E.N Flashcards

1
Q

Fluids for revascularization

A

NS
LR

Fluid mostly stays in intravascular space, hence ideal for revascularization

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2
Q

Fluids for maintenance

A

Ideal: D5W 1/2NS +/- 20 or 40 mEq K

D5W = free water, will distribute into all areas so not ideal for revascularization

20-40 mL/kg/day

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3
Q

Signs/Symptoms of intravascular volume depletion

A

Tachycardia
Hypotension
Orthostatic changes
BUN/SCr > 20:1
Dry mucous membranes
Decreased skin turgor
Reduced UOP
Dizziness
Improved BP/HR after 500-1000mL bolus

**If pt has these factors, first replete with fluids then address other causes for symptoms

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4
Q

IV fluid dose in sepsis

A

30mL/kg

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5
Q

Colloids

A

5%,25% albumin, hetastarch, packed red blood cells, dextran

Too large to cross capillary membrane, so practically all remains in intravascular space

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6
Q

Why avoid hetastarch and dextran?

A

Coagulopathy and kidney impairment

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7
Q

Albumin 25%

A

hyperoncotic - would cause dehydration if given during revascularization

Beneficial in redistribution of fluid (ascities, pleural effusion)

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8
Q

Possible uses for colloids

A

-failure of crystalloids (after ~4-6L)

-large volume parecentesis in cirrhotic patient

-low albumin concentration who have required large volume resuscitation fluids

-25% albumin + diuretics if significant edema and low albumin (if regular diuretic ineffective)

-

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9
Q

Plasma osmolality range

A

275-290 mOsm/kg

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10
Q

Osmolality

A

measure of osmoles of solute per kg of solvent

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11
Q

Osmolarity

A

measure of osmoles of solute per L of solution

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12
Q

Plasma osmolality estimation

A

(2 * Na) + (glucose/18) + (BUN/2.8)

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13
Q

Change in plasma osmolality

A

Increase: osmotic shift of fluid into plasma (cell dehydration, shrinkage)
Ex: NaCl 3% (hypertonic)

Decrease: osmotic shift of fluid into cell (cell overhydration, swelling)
Ex: NaCl 0.225% (hypotonic)

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14
Q

Uses of hypertonic saline

A

TBI to reduce ICP

Symptomatic hyponatremia

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15
Q

Chronic asymptomatic hyponatremia Tx

A

Ex: SIADH

Fluid restriction (<1000mL/day)

Do NOT use hypertonic saline

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16
Q

Pseudohyponatremia Tx

A

Ex: DKA

Insulin - to correct blood sugar. This will then normalize sodium

NOT hypertonic saline

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17
Q

Corrected sodium equation

A

Serum Na + [(1.6 * (glucose - 100))/100]

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18
Q

Hyponatremia with hypervolemia tx

A

Ex: heart failure

Fluid restriction OR diuresis

NOT hypertonic saline

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19
Q

Hypertonic saline dose for TBI

A

3%: 250mL over 1-15 minutes thru central line (or 2-4 mL/kg)

23.4%: 30mL over 20-30 min thru central line

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20
Q

Na increase goal in symptomatic hyponatremia

A

0.5-1 mEq/L/hr (to max of Na 120 mEq/L)

NO MORE THAN 10-12 MEQ IN 24 HRS!!!!

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21
Q

Hypertonic saline rate in symptomatic hyponatremia

A

IBW * desired rise of sodium/hr (ex:1)

Generally, 1-2 mL/kg/hr

Can do 250mL over 30 min
OR
50 mL bolus every 30 min for 2 doses

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22
Q

Osmotic demyelination syndrome

A

Permanent neurologic damage that can occur due to rapid correction of sodium

More likely in cases of chronic hyponatremia than acute

Prevent by increasing Na no more than 10-12 mEq/L in 24 hrs or 18 mEq/L in 48 hrs.

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23
Q

Hypotonic solutions

A

Avoid using IV fluid with <150 mOsm/L (can cause hemolysis, patient death)

NEVER USE STERILE WATER ALONE IV

If 0.225% sodium chloride ordered, try to recommend D5W instead, in combo with D5W or at least thru central line

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24
Q

Hypovolemic hyponatremia

A

from fluid loss, renal loss, third spacing, cerebral salt wasting

If Urine Na <20 = nonrenal loss (diarrhea, emesis)
If Urine Na >20 = renal loss

Give fluids or NaCl tabs or fludrocortisone

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25
Euvolemic hyponatremia
Dilutional sodium (SIADH, meds) Urine Na >20, Urine Osmolality >100 fluid restriction, demeclocycline, conivaptan/tolvaptan
26
Hypervolemic hyponatremia
HF, cirrhosis, nephrotic syndrome Urine Na <20 (HF, cirrhosis) Urine Na >20 (acute/chronic renal failure) Na, water restriction, treat underlying cause, conivaptan/tolvaptan, diuretic
27
Meds associated with hyponatremia
Thiazide diuretics Antiepileptics (carbamazepine, oxcarbazepine) SSRI, TCAs
28
Symptoms of hyponatremia with levels of Na
120-125: nausea, malaise 115-120: HA, lethargy, obtundation, unsteadiness, confusion <115: delirium, seizure, coma, respiratory arrest, death
29
Vasopressin antagonists
Conivaptan (IV) tonivaptan (PO) -use in SIADH or HF, cirrhosis -Increases sodium but not shown to improve clinical outcomes -Substrate & inhibitor of CYP3A4. Interactions may increase sodium too rapidly! -Do not use along with fluid restriction - may increase too rapidly!
30
Hypernatremia symptoms
Lethargy, weakness, irritability >158: severe (twitching, seizures, coma, death)
31
Hypernatremia treatment
-reduce by 0.5mEq/L/hr or 12mEq/L/day -Need to replace free water - do orally or by D5W -Can use D5W + 0.225% NaCl
32
Estimated water deficit
(0.4 * IBW) * ((Serum sodium/140) -1)
33
Hypokalemia causes
-Increased intracellular shift of K (alkalosis, insulin/carb load, B-agonism, hypothermia) -increased GI losses -Increased urinary losses -Hypomag
34
Symptoms of hypokalemia
Usually occur when K <3.0 -muscle weakness -ECG changes (flattened T wave, elevated U wave) -Cardiac arrhythmia -Digoxin toxicity -Rhabdomyolysis
35
K 3.0-3.5 Tx
PO 40-80 mEq/day Divide doses > 60 mEq to avoid GI side effect
36
K 2.5-3.0 tx
PO : 120 mEq/day in divided doses Or IV: 60-80 mEq at 10-20 mEq/hr if s/s Check K 2 hr post infusion
37
K 2.0-2.5 tx
IV KCl 10-20mEq/hr until normalized Consider continuous ECG
38
K <2.0 tx
IV KCl 20-40 mEq/hr until normalized MUST have continuous ECG monitoring
39
Hyperkalemia causes
-Increased intake of K -Increased exctracellular shift (acidosis, insulin deficiency, B blockade, Digoxin overdose, rewarming after hypothermia, succinylcholine) -Reduced urinary excretion (K sparing diuretic, ACE/ARB, TMP)
40
Symptoms of hyperkalemia
-Muscle weakness or paralysis (If K >8) -Abnormal ECG (peaked T waves, QRS widening) -Arrhythmia (initial manifestation can be ventricular fibrillation)
41
Urgent/immediate Treatment of hyperkalemia when
K >6.5 Severe muscle weakness ECG changes
42
Hyperkalemia Treatment
1) Normalize ECG --Calcium gluconate 10mL slowly over 2-10 min, may repeat in 5 min --Caution w/ digoxin due to risk of hypercalcemia causing sudden death 2) Shift K intracellulary --Insulin and glucose --Sodium bicarb 50mEq slowly over 5 min --Albuterol 10-20 mg neb over 10 min 3) Increase K excretion --Diuretic --Patiromer or sodium zirconium cyclosilicate > sodium polysterene sufonate --Dialysis as last line
43
Magnesium concentration
1.7-2.3
44
Rate of magnesium IV
1g/hr to avoid hypotension & increased renal excretion due to rapid administration
45
Phosphorus concentration
2.5-4.5
46
Hypomagnesemia causes
-impaired intestinal absorption (UC, diarrhea, pancreatitis, laxative abuse) -inadequate intake -hypokalemia -increased renal excretion -alcoholism, delirium tremens
47
Hypophosphatemia causes
-Increased renal excretion (diuretic, glucocorticoid, sodium bicarb) -refeeding syndrome -respiratory alkalosis -DKA treatment
48
Max rate of phosphate infusion
7.5mmol/hr (usually given over 3-6 hours)
49
Calcium concentration
8.5-10.5
50
Corrected Ca equation =
serum Ca + 0.8 (4-albumin)
51
Administration of calcium IV concerns
Calcium chloride: must be central line due to risk of limb ischemia Calcium gluconate: may be given peripherally Rate: no faster than 60mg/min due to risk of hypotension, bradycardia, asystole Usually give over 1-2 hours
52
Water needs while on EN
30 mL/kg/day of water
53
Macro kcal/g
Dextrose: 3.4 kcal/g Lipid: 10 kcal/g AA: 4 kcal/g
54
PN Caloric requirements
BMI <30: 25-35 kcal/kg/day based on ABW BMI > 30: 11-14 kcal/kg based on ABW or 22-25kcal/kg based on IBW
55
PN fluid requirements
30-35 mL/kg/day OR 2500-3500 mL/day Maintain UOP 0.5-2 mL/kg/hr
56
PN AA requirements
0.8-2 g/kg/day on ABW Maintenance: 0.8-1 g/kg/day Moderate stress: 1.3-1.5 g/kg/day Severe stress: 1.5-2 g/kg/day Higher requirements ok for BMI >30 CKD: may need protein restriction
57
PN lipid reqiurements
After figuring out protein needs, subtract protein kcal from total kcal. 20-30% of that is kcal of lipid needed
58
PN dextrose requirements
kcal will be the remainder after figuring out protein & lipid Usually around 150-200 g/day
59
PN Maintenance electrolyte needs
Na: 1-2 mEq/kg/day K: 1 mEq/kg/day Phos: 10-40 mmol/day Ca: 10-15 mEq/day Mg: 8-20 mEq/day
60
Concentration of Ca, phos to prevent precipitation
Ca: 6mEq/L or less Phos: 30 mmol/L or less
61
Refeeding syndrome
Risk: anorexia, alcohol use disorder, cancer, chronically ill, poor nutritional intake for 1-2 weeks, malabsorption, unintentional weight loss) Hypophosphatemia, hypokalemia, hypomagnesemia Prevent by providing 1/2 strength, monitoring, increasing prn Replace prior to initiating PN
62
Prealbumin
use to monitor nutritional status, preferred over albumin. normal 16-40
63
PN acid-base imbalances
Metabolic alkalosis: change Na / K to chloride Metabolic acidosis: change Na / K to acetate Respiratory: address underlying cause (hypercapnia = overfeeding)
64
When to withhold lipids in PN
Trig > 400

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