IVDrugsFluidsAntidotesFC Flashcards
(241 cards)
1
Q
What are the two main types of catheters?
A
Peripheral and central
2
Q
How long is the peripheral catheter?
A
A few centimeters
3
Q
Where is the peripheral catheter inserted?
A
through the skin into the peripheral vein, usually in the hand or arm.
4
Q
Where is the central catheter inserted?
A
It is placed in a large vein (eg. subclavian, internal jugular, inferior vena cava) located in the chest, neck, or groin. The tip of the catheter sits in the vena cava.
5
Q
What are the advantages of using a central IV line over a peripheral line?
A
- It can deliver fluids/medications that are overly irritating to peripheral veins
- Multiple parallel compartments (or lumens) within the catheter so multiple medications can be given at once. Larger volumes and rates of drugs
- Some central lines can measure central venous pressure and other hemodynamics (cardiac output, etc)
6
Q
What are disadvantages to central lines?
A
- higher risks of bleeding
- infection
- thromboembolism
- more difficult to insert correctly
7
Q
What is a commonly used central line?
A
Peripherally inserted central catheter (PICC line)
8
Q
When are PICC lines best used?
A
They are used when access to the vein is required for a prolonged period of time or when the infused substance would damage a peripheral vein (eg patients that require long-term TPN or long courses of IV antibiotics)
9
Q
What does PVC stand for?
A
Polyvinyl chloride
10
Q
What are the two concerns with the use of PVC infusion bags?
A
Leaching and sorption
11
Q
What does leaching mean?
A
Leaching means one substance is pulled from another, in this case, the primary concern is the leaching of diethylhexyl phthalate (DEHP) from PVC bags.
12
Q
What does DEHP stand for?
A
diethylhexyl phthalate.
13
Q
What is DEHP?
A
DEHP is a plasticizer used to make PVC bags softer and more flexible.
14
Q
What effect does DEHP have shown in animal studies?
A
In animal studies, DEHP has been shown to adversely affect the male reproductive system. There is very little known data on humans.
15
Q
What should be done with drugs known to cause leaching?
A
Put in non-PVC bags and use polyethylene-lined, non-DEHP administration tubing.
16
Q
Drugs known to have leaching issues: (6)
A
- tacrolimus
- temsirolimus
- teniposide
- cabazitaxel
- docetaxel
- paclitaxel
tic tac toe, craving delicious pho - amiodarone
17
Q
What does sorption mean?
A
Sorption means one substance pulls in another, in this case, the PVC bag pulls in some of the drug, which reduces the concentration of the drug in solution.
18
Q
What should be done with drugs known to cause sorption?
A
pharmacists should use the newer polyolefine containers, which have reduced sorption and leaching potential. Occasionally, with some of these drugs, glass containers are used.
19
Q
Drugs that cause sorption: (7)
A
- amiodarone (infusion >2 hours)
- carmustine
- lorazepam
- sufentanil
- thiopental
- regular human insulin
- nitroglycerin
ACLS TIN
20
Q
What are intravenous fluids used to treat?
A
- hypoperfusion
- shock
21
Q
What are 2 types of fluids?
A
- Crystalloids
- Colloids
22
Q
What does crystalloids consist of?
A
- Salt solution (NS, 1/2 or 1/4 NS with or without KCl, and hypertonic saline solutions (3%, 7.5%, 23.4%))
- Lactate Ringer’s
23
Q
True or False: After crystalloids administration, only about 25% of the volume in the solution will remain intravascular 30 minutes after administration.
A
true
24
Q
True or false Crystalloids can be isotonic (0.9% NaCl), hypertonic (3% NaCl), or hypotonic (0.45% NaCl)
A
TRUE
25
What can a hypertonic solution be used to treat?
Hyponatremia or intracranial hypertension (elevated intracerebral pressures from trauma or non-traumatic causes).
26
How should hypertonic solution be administered? (peripheral or central)
Central
27
Do colloids freely diffuse across a semi-permeable membrane?
No, in doing so it keeps the fluid within the intravascular space.
28
(Colloids or crystalloids) are used to increase the osmotic pressure in patients and are substantially more expensive than (colloids or crystalloids).
Colloids are used to increase the osmotic pressure in patients and are substantially more expensive than crystalloids.
29
What are in colloids?
Colloids includes albumin 5% and 25%, hetastarch 6%, pentastarch 10%, dextran and others.
30
True or false: Crystalloids and colloids cannot be used for fluid resuscitation.
False. Crystalloids and colloids can be used for fluid resuscitation.
31
(Smaller or larger) volume of crystalloids are needed to adequately resuscitate patients with shock as compared to colloids.
Larger volume.
32
What risk factors are associated with the use of colloids?
Hypersensitivity reactions and bleedings disorders.
33
What are crystalloids used for?
Crystalloids are used for maintaining fluid status and keeping the IV lines open.
34
What causes shock syndrome?
Shock results from a lack of oxygen due to hypoperfusion.
35
What are signs of shock?
hypotension, or low blood pressure (SBP <90 mmHg)
36
What are the 4 main types of shock?
1. Hypovolemic (hemorrhagic)
2. Cardiogenic
3. Distributive (septic)
4. Obstructive (massive pulmonary embolism)
37
How are pts with hypovolemic shock treated?
1. First line is colloids or crystalloids (fluid resuscitation)
2. Vasopressors may be used if the pt does not respond to fluid challenge. (Vasopressors will not be effective without adequate fluid administration - at least 30 mL/kg)
38
How are pts with cardiogenic shock treated?
Vasopressors or ionotropes
39
How are pts with sepsis shock treated?
1. Colloids or crystalloids
2. Vasopressors
and/or
3. Inotropes
4. Antibiotics
5. Corticosteroids
40
How do inotropes work?
By increasing contractility either through beta-adrenergic stimulation or through inhibition of phosphodiesterase. These mechanisms lead to an increase in cardiac output (CO).
41
How do vasopressors work?
Vasoconstriction and thereby increasing systemic vascular resistance (SVR)
42
List inotropes used in shock syndromes.
1. Dobutamine
2. Milrinone
3. Dopamine
4. Epinephrine (Adrenalin)
5. Norepinephrine (Levophed)
6. Phenylephrine (Neo-synephrine)
43
List vasopressors used in shock syndrome.
Vasopressin (Pitressin)
44
What medical emergency may occur with the use of vasopressors/inotropes?
Extravasation (leakage of IV into surrounding tissue) may lead to tissue damage or necrosis.
45
What drug has antagonist effects on norepinephrine?
phentolamine (Regitine) for Extravasation
46
How is phentolamine taken?
Dilute 5-10 mg of phentolamine in 10 mL in NS and give SC to infiltrated area.
Blanching should reverse immediately.
47
Sedation/analgesia is commonly used for patients in the ICU, particularly if the patient is receiving _________ __________.
Mechanical ventilation
48
Why is sedation/analgesia used in mechanically ventilated pts?
1. Limit anxiety and agitation.
2. Maintain synchronized breathing (prevent "bucking" the ventilator).
3. Keep pt free of pain and suffering.
49
What agents are used for ICU sedation and analgesia?
Combination of:
1. Opioids (morphine, hydromorephone, and fentanyl)
2. Benzodiazepines (midazolam, lorazepam)
3. Antipsychotics (haloperidol, quetiapine, risperidone)
4. Hypnotics (propofol, dexmedetomidine)
50
True or False: It's generally NOT recommended to administer and optimize analgesia first.
False.
51
What opioid is preferred drug for achieving rapid analgesia?
Fentanyl
52
Which drugs are recommended for sedation?
Benzodiazepines and propofol
53
Which drug is preferred for rapid achievement of sedation?
Midazolam
54
Which drug is preferred for procedural sedation and rapid awakening?
Propofol
55
How is benzodiazepine administered?
intermittent bolus doses or by continuous infusion.
56
How is propofol administered?
Continuous infusion
57
Care should be taken to limit the dose and duration of propofol due to the risk of propofol-related infusion syndrome, which can result in________ ____________ and _________.
cardiac arrhythmias and death.
58
Dexmedetomidine has been studied as an alternative to the traditional sedative agent. It shown to produce (more/less) sedation, and (more/less) sleep-like state.
Dexmedetomidine shown to produce less sedation, and more sleep-like state.
59
What are the advantage and disadvantage of Dexmedetomidine to benzodiazepines and propofol.
Advantages of dexmedetomidine:
- fewer days of mechanical ventilation
- less incidence of delirium
Disadvantages of dexmedetomidine:
- more expensive than benzodiazepines and propofol.
60
How frequent are pts monitored?
generally every 2-3 hours
61
Why are daily interruptions of continuous infusions of sedative drugs recommended?
to limit the duration of mechanical ventilation, doses of drugs administered, and length of ICU stay
62
How is delirium assessed?
Using the Confusion Assessment Method (or CAM-ICU)
63
How is delirium treated in the ICU?
antipsychotics (haloperidol)
64
Lorazepam brand name drugs used in ICU
Ativan, Lorazepam Intensol
65
Lorazepam side effects
Respiratory depression, oversedation, hypotension
66
Lorazepam monitoring
BP, HR, sedation scale
67
Lorazepam price
Inexpensive
68
when to use lorazepam over midazolam
Used for long-term sedation (>48 hours)
No active metabolite
Longer t1/2 than midazolam
69
midazolam side effects
Respiratory depression, oversedation, hypotesion
70
midazolam contraindications
Use small, initial doses in elderly (e.g. 1 mg, not to exceed 2.5 mg).
71
why avoid rapid administration with midazolam
Contains benzyl alcohol, avoid rapid injection or prolonged infusion
72
midazolam monitoring
BP, HR, sedation scale
73
midazolam DDI / renal interaction
many drug interaction (major 3A4 substrate)
increase levels with 3A4 inhibitors
active metabolite accumulates in renal failure
74
when to use midazolam over lorazepam
use for short-term sedation (<48 hours), shorter acting than lorazepam if pt has preserved organ function (no hepatic or renal impairment or CHF)
drug is highly lipophilic and may accumulate in obese pts
active metabolite accumulates in renal dysfunction
75
Propofol brand name drug
Diprivan
76
Propofol dosing ICU
MD: 5-80 mcg/kg/min
77
Propofol side effects
hypotension, apnea
hypertriglyceridemia
green urine
-propofol-related infusion syndrome (PRIS-rare but can be fatal)
78
Propofol monitoring
BP
respiration
-triglycerides (if on longer than 2 days)
signs and symptoms of pancreatitis
sedation scale
79
Propofol how to handle? When to throw out vial? What type of filter to use? What if the emulsion separates, what do you do?
Shake well before use
use strict aseptic technique due to potential for bacterial growth
-Discard vial and tubing within 12 hours of use.
Do not use if there is separation of phases in the emulsion.
-Do not use filter of <5 micron for administration
80
propofol formulation consistency
Formulated in 10% lipid emulsion (provides 1.1 kcal/mL)
81
Fospropofol brand name drug
Lusedra
82
Fospropfol controlled substance class
C IV
83
Fospropofol side effects
Paresthesias, pruritus, hypotension
84
Fospropofol monitoring
BP, respiration, patient responsiveness
85
Fospropofol MOA
Prodrug of propofol; delayed onset due to need for conversion to active metabolite.
86
dexmedetomidine brand name drug
Precedex
87
dexmedetomidine drug class MOA
alpha2-adrenergic agonist
88
dexmedetomidine Fluid compatibility
Mix with NS only
89
dexmedetomidine side effects
transient hypertension during loading dose (may need to decrease infusion rate)
hypotension
bradycardia
dry mouth
90
dexmedetomidine monitoring
BP, HR, sedation scale
91
dexmedetomidine, what is the sedation like and for which patients it used for?
Used for sedation in intubated and non-intubated patients
Pts are arousable and alert when simulated
92
max infusion time for precedex
-*Duration of infusion should not exceed 24 hours
93
advantage of precedex
Does not cause respiratory depression
94
Morphine dosing
LD: 2-4 mg IV push
MD: 2-30 mg/hr
95
Morphine side effects
respiratory depression
hypotension
oversedation
bradycardia
pruritus
xerostomia
constipation
others
96
Morphine monitoring
BP, HR, respiratory status, sedation/pain scale
97
Why is renal funciton to mx with morhpine?
-*Has an active metabolite (morphine-6-glucuronide) which can accumulate in renal impairment
causes a histamine release (hypotension)
preferred agent in Pts who are hemodynamically stable
98
Fentanyl dosing
LD: 25-50 mcg IV push
MD: 0.7-10 mcg/kg/hr
99
Fentanyl side effects
respiratory depression
bradycardia
oversedation
constipation
rigidity with high doses
100
Fentanyl monitoring
BP, HR, respiratory status, sedation/pain scale
101
Fentanyl advantages
-*Less hypotension than morphine due to no histamine release
Fast onset of action and short duration of action
-100x more potent than morphine
preferred agent in Pts with unstable hemodynamics
102
Hydromorphone brand name drug
Dilaudid
103
Hydromorphone dosing
LD: 0.2-0.6 mg IV push
MD: 0.5-3 mg/hr
104
Hydromorphone side effects
respiratory depression, oversedation, high potential for abuse
105
Hydromorphone monitoring
Breathing rate, HR, respiratory status, sedation/pain scale
106
Hydromorphone notes
No active metabolites; not commonly used for ICU sedation
107
Remifentanil brand name drug
Ultiva
108
Remifentanil monitoring
Breathing rate, HR, respiratory status, sedation/pain scale
109
Remifentanil advantage
Metabolized by tissue esterases, no accumulation
110
Haloperidol brand name drug
Haldol
111
Haloperidol dosing
2-10 mg IV push
may repeat Q15-30 minutes until calm,
then administer 25% of last dose Q6h
112
Haloperidol side effects
hypotension
QT prolongation
Tachycardia
Extrapyramidal symptoms (EPS)
Anticholinergic effects
Neuroleptic malignant syndrome
others
113
Haloperidol monitoring
QT interval and ECG
EPS
Abnormal involuntary movement
Vital signs
114
Haloperidol hw not to administer
Not to be given via continuous infusion
115
Normal pH of blood is:
7.4 (range 7.35-7.45)
116
What is the primary buffering system of the body?
Bicarbonate/carbonic acid system
117
What organ help maintain a neutral pH by controlling bicarbonate (HCO3-) resorption and elimination?
kidney
118
What is normal bicarbonate level?
24 mEq/L (range 22-26)
119
Which organ help maintain a neutral pH by controlling carbonic acid?
Lung
120
What is the normal partial pressure of carbon dioxide?
40 mmHg (range 35-45 mmHg)
121
Bicarbonate acts as a buffer and as (a base/an acid), whereas carbon dioxide acts as a buffer and (a base/an acid).
Bicarbonate acts as a buffer and as a base, whereas carbon dioxide acts as a buffer and an acid.
122
True or False: Alterations from the normal values lead to acid-base disorders.
TRUE
123
What lead to a large production of H ion that needs to be excreted to maintain acid-base balance?
Diet and cellular meteabolism
124
What can determine acid-base status of a pt?
arterial blood gas (ABG)
125
pH < 7.35 is called:
acidosis
126
pH >7.45 is called:
alkalosis
127
Acidosis and alkalosis can be classified as:
metabolic or respiratory in origin
128
How does metabolic acidosis present?
low plasma bicarbonate (HCO3-) and may have increased anion gap (>12)
129
How is anion gap calculated?
AG = Na - (Cl- + HCO3-)
130
How does metabolic alkalosis present?
high plasma bicarbonate (HCO3-)
131
How does respiratory acidosis present?
high PaCO2
132
How does respiratory alkalosis present?
low PaCO2
133
What are the etiologies of metabolic acidosis non-elevated anion gap?
renal tubular acidosis, diarrhea
administration of acidic substance
134
What are the etiologies of metabolic acidosis elevated anion gap?
cyanide
uremia
toluene
ethanol (alcholic ketoacidosis)
diabetic ketoacidosis
isoniazid
methanol
propylene glycol
lactic acidosis
ethylene
salicylates
CUTE DIMPLES
135
What are the etiologies of metabolic alkalosis?
loop and thiazide diuretics
high doses of penicillins
vomiting
cystic fibrosis
136
What are the etiologies for respiratory acidosis?
opioids
sedatives
anesthetics
stroke
asthma/COPD
137
What are the etiologies for respiratory alkalosis
pain
fever
brain tumors
salicylates
catecholamines
theophylline
138
What is used to treat metabolic acidosis to raise pH to >/= 7.2
sodium bicarbonate
139
True or False: Treating pts with metabolic acidosis with sodium bicarb has no benefit in morbidity and mortality compared to general supportive care.
TRUE
140
What is used in severe metabolic alkalosis?
hydrochloric acid, however it's very rare.
141
What is normal sodium concentration in blood?
135-145 mEq/L
142
What serum osmolality is sodium maintained?
275-290 mOsm/kg H20. Changes in serum sodium are usually from changes in water concentration.
143
How is hyponatremia defined?
Na <135 mEq/L
144
What etiologies causes hypertonic hyponatremia?
hyperglycemia
or
use of hypertonic solutions that Do not contain sodium.
145
What etiologies causes hypotonic hyponatremia?
hyperlipidemia
146
What are the etiologies for hypovolemia hypotonic hyponatremia?
diuretic usesalt-wasting syndromes
adrenal insufficiency
blood loss
vomiting/diarrhea
147
How is hypovolemia hypotonic hyponatremia treated?
Correct the underlying cause and to administer saline solutions.
3% NaCl is preferred if Na <120 mEq/L or if severe symptoms are present.
148
What are the etiologies for hypervolemic hypotonic hyponatremia?
fluid overload (usually with cirrhosis, heart failure, or renal failure)
149
How is hypervolemic hypotonic hyponatremia treated?
diuresis with fluid restriction is usually preferred to treat this type of hyponatremia
150
What are the etiologies for isovolemic (euvolemic) hypotonic hyponatremia?
Syndrome of inappropriate antidiuretic hormone (SIADH)
THis results in the normal excretion of sodium with impaired free-water excretion by the kidney.
151
What does SIADH stand for?
Syndrome of inappropriate antidiuretic hormone
152
How is SIADH treated?
directed to water restriction, and in some cases diuresis.
Conivaptan (Vaprisol) and tolvaptan (Samsca) may be used.
153
What is the mechanism of action of conivaptan and tolvaptan?
They antagonize arginine vasopressin receptors (vasopressin V2=receptor antagonists), resulting in excretion of free water and maitenance of sodium.
154
What group of people should conivaptan and tolvaptan be used in caution and avoided?
pts with heart failure and should be avoided in pts with hypotension or hypovolemia.
155
Conivaptan brand name drug
Vaprisol
156
Conivaptan dose
LD: 20 mg IV over 30 minutes; followed by 20 mg IV continuous infusion over 24 hours (0.83 mg/hr).
Do not exceed 4 days
157
Conivaptan contraindications?
allergy to corn/corn products
use in hypovolemic hyponatremia
-concurrent use with strong 3A4 inhibitors
anuria
158
Conivaptan side effects
orthostatic hypotension
fever
hypokalemia
hyponatremia
159
Conivaptan monitoring
rate of serum Na increase
BP
volume status
urine output
160
Tolvaptan brand name
Samsca
161
Tolvaptan dosing
15 mg PO daily
Max 60 mg PO daily
162
Tolvaptan Black Box Warning
Should be initiated and re-initated in a hospital under close monitoring of serum Na+
163
what is the limit of sodium correction for hyponatremia and what could happen?
Too rapid correction of hyponatremia (>12 mEq/L/24 hours) can be life-threatening
164
Tolvaptan contraindications
Do not use in pts who are
unable to sense or respond appropriatedly to thirst
hypovolemic hyponatremia
-concurrent use with strong 3A4 inhibitors
anuria
165
Tolvaptan side effects
thirst
dry mouth
asthenia
constipation
pollakiuria
poyluria
hyperglycemia
166
Tolvaptan monitoring
rate of serum Na increase
BP
volume status
urine output
167
Define hypernatremia.
Na>145 mEq/L associated with a water deficity and hypertonicity.
168
What cause hypovolemic hypernatremia?
Dehydration
vomiting
diarrhea
169
How is hypovolemic hypernatremia usually treated?
-Hypotonic solution (0.45% NaCl)
Dextrose (to replace free water deficit)
170
What cause hypervolemic hypernatremia?
administration of hypertonic solution
171
How is hypervolemic hypernatremia treated?
Diuresis
-5% dextrose
172
What cause isovolemic (euvolemic) hypernatremia?
Diabetes insipidus (DI)
173
What are the two types of diabetes insipidus?
Central (impaired release of antidiuretic hormone)
Nephrogenic (impaired response to antidiuretic hormone)
174
How is central diabetes insipidus treated?
Desmopressin (IV or SC)
175
How is nephrogenic diabetes insipidus treated?
Remove any causative medications
HTCZ or indomethacin
176
True or False: Caution should be taken in treating patients with sodium disorders to prevent correcting too slowly.
False.
177
what happens if your correct the sodium too quickly ?
Caution should be taken in treating patients with sodium disorders to prevent correcting too QUICKLY.
Corrections of sodium >12 mEq/L over 24 have been associated with central pontine myelinosis, which may lead to quadriparesis, seizures, and death.
178
What is normal potassium level?
K = 3.5 - 5 mEq/L
179
Define hyperkalemia.
Depending on the source it may be defined as a K level above 5.3 or above 5.5 mEq/L, although most clinicians are concerned with any level above 5 mEq/L
180
Where is most potassium found? Intracellular or extracellular?
Intracellular.
181
What drugs causes potassium excretion to increase?
Aldosterone
diuretics (strongly by loops, weakly by thiazides)
182
What does insult do to potassium?
Shift potassium into cells.
183
What is the most common cause of hyperkalemia?
Decreased renal excretion due to renal failure.
184
What drugs cause potassium to increase in serum?
Potassium-sparing diuretics
ACEis
ARBs
NSAIDS
Oral Contraceptives containing drospirenones (Yaz)
Cyclosporine
Tacrolimus
Heparin
Pentamidine
Trimethoprim/sulfamethoxazole
Potassium supplements
185
Symptoms of hyperkalemia
Elevated potassium may be asymptomatic or symptomatic depending on the level.
Muscle weakness
bradycardia
fatal arrhythmia
186
True or False: ECG may be needed to check for cardiotoxicity (monitor heart rhythm).
TRUE
187
_______ _______ is administered to stablize the cardiac tissue if there is ECG abnormalities.
IV Calcium
188
How is potassium lowered?
1. Glucose and/or insulin
2. Beta-agonists (such as nebulized albuterol)
3. Loop diuretic, such as furosemide
4. fluidrocortisone (Florinef)
5. Cation exchange resin, sodium polystyrene sulfonate (SPS) (Kayexelate)
6. Emergency dialysis
7. Sodium bicarbonate, if metabolic acidosis is present.
189
How does does glucose decrease potassium?
Increase insulin. Insulin pushes potassium into cells.
190
What is beta-agonists monitor parameters?
Tachycardia
Chest pain
191
What is loop diuretic monitor parameter?
Volume status
192
What kind of pts fludrocortison (Florinef) is best used for to decrease potassium?
pts with hypoaldosteronism
193
How long does it take for Kayexelate take to work?
within 2 hours
194
How much can a single enema of Kayexelate decrease potassium?
by 2 mEq/L
195
SPS (Kayexelate) route of administration.
Rectal or oral
196
What route of administration is preferred for high treatment (emergency)?
rectal
197
What should SPS (Kayexelate) not be mixed with?
Sorbitol due to risk of GI necrosis
198
SPS (Kayexelate) side effects
decrease appetite
Nausea
vomiting
or
constipation (less commonly diarrhea)
199
What does SPS stand for?
Sodium PolystyreneSulfonate
200
Define hypokalemia
K < 3.5 mEq/L
201
Hypokalemia management
Treat underlying cause (e.g. metabolic alkalosis, overdiuresis)
Administer oral or IV potassium
202
When administering potassium for hypokalemia, which route (oral, IV) is preferred?
Oral
203
IV potassium should be administered no more than ___ - ___ mEq/hr with intermittent doses.
10-20 mEq/hr
204
Concentrations > ____ mEq/L should be administered through a central line.
80 mEq/L
205
Pts with critical illness have reduced blood flow to the gut as blood flow is diverted to the major organs of the body. This results in: (3)
breakdown of gastric mucosal defense mechanisms including:
1. Prostaglandin synthesis
2. bicarbonate production
3. cell turnover
206
Which drugs are recommended for stress ulcer prophylaxis?
-Histamine 2-receptor antagonist (H2RAs)
Proton pump inhibitors (PPIs)
207
What are the risk factors for H2RAs
Thrombocytopenia
-Mental status change (esp in pts >65 yrs c liver and kidney impairment)
Tachyphylaxis
208
What are the risk factors for PPIs
Nosocomial pneumonia
GI infections (c. dif)
209
non-pharmacologic therapy for VTE prophylaxis
Intermittent pneumatic compression (IPC)
Graduated compression stockings (GCS)
Venous foot pump (VFP)
210
Low dose unfractionated heparin dose
5,000 units SC BID or TID
211
LMWH dose
-30 mg SC BID
-40 mg SC daily
Crcl < 30 mL/min
-30 mg SC daily
212
(LMWH) Dalteparin dose
2,500 - 5,000 units SC daily
213
Factor Xa inhitors
Fondaparinux
Rivaroxaban
214
Fondaparinux dose
2.5 mg SC daily
Avoid in pts CrCl < 30 or pts weights < 50 kg
215
Rivaroxaban dose
10 mg PO daily
Avoid in pts with CrCl < 30 mL/min
216
Route of administration for anesthetics
Topical
Inhaled
IV
Epidural
Spinal
217
Main side effects of anesthetics
hypotension
bradycardia
Nausea
vomiting
Mild drop in body temperature that cause shivering
218
Inhaled anesthetics can cause __________ __________ (rare)
Malignant hyperthermia
219
How is malignant hyperthermia treated
Dantrolene
220
If anesthetics are given too much or too high of a dose, it may cause _________ _________ and ________ _________.
respiratory depression and cardiac arrest
221
Commonly used anesthetics: (Topical: 2; Inhaled: 4; Injectable: 3)
Topical: Lidocaine, Benzacaine
Inhaled: Isofurane, sevofurane, desofurane, nitrous oxide, others
Injectable: bupivacine, lidocaine, ropivacaine, others
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Bupivacine brand name drug
Marcaine
Sensorcaine
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Lidocaine brand name drug
Xylocaine
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Ropivacine brand name drug
Naropin
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True or false: Epidurals containing bupivacaine can quickly be fatal if given via IV route.
TRUE
226
When is neuromuscular blocking agents used?
1. Facilitate mechanical intubation
2. Manage increased intracranial pressure
3. Treat muscle spasm (tetany)
4. Prevent shivering in pts undergoing therapeutic hypothermia after cardiac arrest
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True or false: NMBAs are first line in critically ill pts
False.
NMBAs is typically recommended when other methods have been proven ineffective and are not to be routinely used in critically ill pts.
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True or false: NMBAs provide sedation or analgesia.
FALSE
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True or false: Pts should receive NMBAs prior to additional sedation and analgesia.
False. Pts should receive adequate sedation and analgesia PRIOR to starting a NMBA.
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Pts must be _________ _________ as these agents ________ the _________.
Pts must be mechanically ventilated as these agents paralyze the diaphragm.
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True or False: NMBAs are considered high risk medications by ISMP.
TRUE
232
NMBAs should be labeled with bright red auxiliary labels stating: WARNING, _____________ _________.
Paralyzing agent
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What are the two types of NMBAs
depolarizing and non-depolarizing
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The only depolarizing agent is:
Succinylcholine, which is typically reserved for intubation and not used for continuous neuromuscular blockade.
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Succinylcholine has been rarely associated with causing __________ ___________.
Malignant hyperthermia (particularly with inhaled anesthetics
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Depolarizing NMBA mechanism of action
Succinylcholine resembles acetylcholine. It binds to and activates the acetylcholine receptors and desensitizes them.
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Non-depolarizing NMBAs mechanism of action
Bind to acetylcholine receptor and block the action of endogenous acetylcholine
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Non-depolarizing NMBA side effects
Flushing
bradycardia
hypotension
Tachyphylaxis
Long term use
Acute quadriplegic myopathy syndrome (ACMS)
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Examples of nondepolarizing NMBAs
Atracurium
Cisatracurium
Pancuronium
Rocuronium
Vecuronium
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Cisatracurium brand name
Nimbrex
241
Rocuronium brand name
Zemuron
