Lecture 5: Fluids Flashcards

Question

Answer 1

Pros: * 20-25% albumin is good for liver failure and pacracentsis * 6% hydroxyethyl: bypass or hem stock * Used in ICU if hypoalbum in to keep fluid in vascular Cons: * increase risk of anaphalyic rxn because from blood products

Answer 2

* 2-3 mEq (1mmol)/kg of sodium, 1-2 mEq/kg of potassium, 2-3 mEQ/kg chloride, & 50-100g of glucose, 30mL/kg of H2O * For 70kg patient, that is ~2L/day or 84mL/hour * Commonly D5, 1/2NS + KCl for adults (only for about 3-5 days, if longer then tube feeding)

Answer 3

* Hemodynamically unstable: 500mL bolus of isotonic crystalloid over 30 minutes & repeat as needed * Septic shock: 30ml/kg (pediatrics: initially 20ml/kg then up to 60mg/kg) of isotonic crystalloid within the first 3 hours * Burn victims: Parkland formula

Answer 4

* Volume overloaded: Slower rate and/or lower volume to reduce third spacing * EtOH intoxication: “Banana bag” (thiamine) * Diabetic: Avoid dextrose, may cause hyperglycemia (give if hypogly or NPO when given diabetic meds) * Hypernatremia: isotonic crystalloid until hemodynamically stable, then hypotonic crystalloid such as D5W at slow rate preferred (can use free water def formula)

Answer 5

1. hypertonic 2. isotonic: NS or LR 3. Isotonic only until blood products get there 4. Replacement or maintance (isotonic or hypotonic)

Answer 6

* Hypotonic IV fluids avoided! * Hypertonic IV saline only if severe + neurological symptoms

Answer 7

* Hypovolemic (Na and H2O deficit): dehydration, diuretics, GI losses, diaphoresis. **Isotonic IV fluid is appropriate to replace both water and sodium**. * Euvolemic (H2O excess): SIADH, adrenal insufficiency, hypothyroid, polydipsia. Treat underlying cause & free water restriction. Isotonic IV fluids may worsen. * Hypervolemic (Na and H2O excess): CHF, liver failure, renal failure. Diuresis and free water + Na restriction. Isotonic IV fluids will worsen.

Answer 8

Highest risk in ICU patients due to organ failure/immunocompromised state, prolonged hospitalization, indwelling medical devices, and presence of resistant organisms

Answer 9

* Medical devices lead to compromised mucosal/skin barriers and seeding of microbes * Nosocomial infections are related to devices in 25-50% of cases * The longer a catheter in in place, the higher the risk of infection * Once infection is confirmed, the catheter should be removed if possible

Answer 10

* Highest risk with indwelling catheters, ie Foleys * Work-up: Urinalysis with microscopy & Urine culture + susceptibilities * Pathogens: Enterobacteriaceae (ie E. coli including ESBL) & Enterococci * Less common: Pseudomonas, Staph aureus, and Candida

Answer 11

* Treatment: Removal of catheter & 7 days of antibiotics (14 days if signs/symptoms of upper tract infection) * Antibiotics same as for acute simple cystitis (nitrofurantoin, Bactrim, Fosfomycin); fluconazole if candida

Answer 12

* Risk factors: indwelling vascular catheters, skin breakdown (ie decubitus ulcers), UTI/pneumonia, TPN (because bacteria loves sugar) * Signs & symptoms: fever, leukocytosis, shock, vascular catheter insertion site cellulitis * Work up: blood cultures (aerobic and anaerobic +/- fungal), lactic acid level, procalcitonin level

Answer 13

* Pathogens: Coagulase-negative staphylococci (CoNs), Staph aureus (≥50% methicillin-resistant), enterococci, gram-negative bacilli such as E. coli & Klebsiella, and Candida * Treatment: Removal of catheter, 7-14 days of antibiotics, consider antibiotic line lock

Answer 14

* MRSA coverage: IV Vancomycin or Daptomycin * +/- gram neg bacilli coverage: IV 3rd or 4th generation cephalosporin (ie Cefepime), Beta lactam/lactamase combo, carbopenem, or aminoglycoside * Narrow or “de-escalate” when blood culture identifies organism * Longer than 14 days for “complicated” CLABSI: suppurative thrombophlebitis, osteomyelitis, endocarditis, persistent positive cultures after 72 hours, or active malignancy or immunosuppression

Answer 15

* Early infection (first 3-5 days of admission) similar to CAP- Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and respiratory viruses such as influenza * Later infections caused by Staphylococcus aureus and Gram-negative organisms such as Pseudomonas, Klebsiella, Enterobacter, and Acinetobacter

Answer 16

* Develops >48 hours post initiation of mechanical ventilation * Signs & symptoms: fever, hypoxemia, purulent sputum, leukocytosis, new radiographic infiltrate * Diagnosed via positive culture from endotracheal aspirate or bronchoalveolar lavage

Answer 17

* Mimickers: tracheobronchitis, sinusitis, pulmonary edema, atelectasis, pulmonary embolism, aspiration pneumonitis, vasculitis, pulmonary hemorrhage, pneumothorax, organizing pneumonia, and ARDS * Complications: septic shock, empyema, pulmonary abscess, diffuse alveolar hemorrhage (DAH), ARDS * Treatment: 7 days of IV antibiotics

Answer 18

* Cephalosporin: ceftazidime, cefepime * Carbapenem: meropenem, imipenem * Piperacillin-tazobactam * Aztreonam * Fluoroquinolone: ciprofloxacin, levofloxacin * Aminoglycoside: amikacin, tobramycin, gentamicin (resereved for the sickest dt toxicity? ## Footnote Double antibiotics: For structural lung disease

Answer 19

* Vanco or linezolid

Answer 20

* Risks: Inadequate sterile technique, patient factors such as diabetes * Pathogens: **MRSA**, enteric and anaerobic pathogens (enterococcus, E coli, pseudomonas) * Signs & symptoms: localized erythema, induration, warmth, purulent discharge, and pain at the incision site

Answer 21

* Prevention: Antibiotics, wound care * Treatment: Wound opened, explored, drained, irrigated, debrided, and dressed open. Packing for deep wounds. * Antibiotics with MRSA coverage

Answer 22

* Transmitted via fecal oral route * Risks: recent exposure to antibiotics, gastric acid suppression (PPIs), older age * Signs & symptoms: asymptomatic carrier, watery diarrhea, abdominal pain, fever, leukocytosis, dehydration, toxic megacolon, shock

Answer 23

Oral fidaxomicin, vancomycin, or metronidazole. Bezlotoxumab. Avoid anti-motility agents.

Answer 24

Standard precautions: * Hand hygiene * Wearing PPE when in contact with body fluids * Avoiding practices that increase risk

Answer 25

* Screening for colonization (MRSA, VRE) * Compliance with infection prevention policies * Chlorhexidine bathing in ICU * Transmission- based precautions (isolation) * Judicious use of antibiotics

Answer 26

* Standard precautions → hand hygiene when entering and exiting the room, covering mouth when coughing/sneezing * Contact precautions→ gown and gloves required * Droplet precautions→ gown, gloves, and surgical mask required * Airborne precautions→ gown, gloves, and N95 mask required

Answer 27

* VTE = pulmonary embolism (PE) & deep vein thrombosis (DVT) * Diagnosed via CT-angiogram of chest or venous doppler ultrasound of extremity * May lead to significant morbidity and mortality

Answer 28

* Screening required for all hospitalized patients * Assessing risk: Padua, IMPROVE, Geneva, Caprini (surgical), Gestalt (surgical-ortho) * Highest risk: Surgical, critically ill, ischemic stroke, CHF or COPD exacerbation, acute respiratory failure, cancer, pregnant, history of prior VTE, sepsis, acute neurologic disease, severe inflammatory disease

Answer 29

Pharmacologic prophylaxis * for patients with **moderate to high risk of VTE**, unless there is an absolute contraindication Mechanical prophylaxis * for patients with **low risk of VTE** or contraindications to pharmacological prophylaxis

Answer 30

* Sequential compression devices (SCDs) * Graduated compression stockings (TED hose) * Venous foot pump * Walking: prevents clots, pneumia, decrease muscle lost

Answer 31

* Medical patients: at time of admission or when/if VTE risk increases (ie ICU transfer) * Surgical patients: 2-12 hours post-op

Answer 32

* All medical & most surgical patients, discontinued at time of hospital discharge * Select high risk surgical patients, course extended post discharge: **10-14 days or longer** * May be discontinued sooner if complications occur & risks outweigh benefits (ie development of acute bleed or plan for invasive procedure)

Answer 33

* Case Managers assist with assessing and coordinating the most appropriate discharge destination. Help clinicians and patients understand what services will be covered by the patient’s insurance. Help arrange home health care, equipment, & supplies. * Social workers also assist with identifying and coordinating the most appropriate discharge destination. Skilled at assessing patients’ support systems and identifying psychosocial barriers to a successful discharge.

Answer 34

* Give the staff the “okay” for patient to leave; sometimes conditional * May contain patient instructions

Answer 35

* For referral to skilled nursing facilities: need for a “qualifying event” of a preceding 3-night inpatient hospitalization * For home health services: documentation of a face-to- face physician (or nonphysician provider) encounter must be provided along with evidence that the patient is homebound and has skilled needs that can be met on an intermittent basis

Answer 36

* For home oxygen: must document O2 sat of ≤88% on room air with or without ambulation within 48 hours of discharge * Durable Medical Equipment (ie hospital bed, wheelchair, transfer chair): documentation of medical need in daily progress note as well as separate order

Lecture 5: Fluids Flashcards

(90 cards)