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1
Q

Fast-acting insulin

A

Soluble human (peak 2-4hrs) - humulin s, actrapid
Short-acting analogue (peak 1hr) - novorapid (aspart), humalog (lispro)

Take before meals/ snacks

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2
Q

Intermediate acting and pre-mixed insulin

A

isophane (NPH, peak 6-10hrs) - insulatard, humulin I

Control overnight/ between meals

Pre-mixed (cloudy, biphasic) - humulin M3, novomix 30

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3
Q

Long acting insulin

A

Lantus (glargine), levemir (detemir)

Peak 5 hours, last <24hours

Control overnight/ between meals

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4
Q

Multiple daily dose injection/ basal-bolus

A

Pre-meal short-acting x3 (1u per 10g carbs)
Isophane/ long-acting x1-2

0.5-0.75u/kg body weight (50% long, 50% short)

DAFNE programme

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5
Q

Biphasic/ twice daily regimen

A

Combination of short-acting and intermediate e.g., novomix 30
More in type 2

0.5-0.75u/kg body weight (66% morning, 33% evening)

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6
Q

Once daily long acting insulin

A

Type 2
Bedtime dose of long-acting combined with other oral hypoglycaemic agents
Titrated against fasting blood glucose (6)

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7
Q

Oral hypoglycaemic agents

A

Biguanides - metformin
Sulphonylureas - glimepiride
DPP-4 inhibitors - sitagliptin
Alpha-glucosidase inhibitors - acarbose
Thiazolidinediones - pioglitazone
GLP-1 analogue - exenatide

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8
Q

Continuous SC insulin infusion

A

1/1000 type 1 (>12yrs, poor control)
Continuous delivery

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9
Q

Diabetic Ketoacidosis definition

A

an extreme metabolic state caused by insulin deficiency. breakdown of fatty acids (lipolysis) produces ketones (ketogenesis) which are acidic. exceeds the body’s buffering capacity.

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10
Q

DKA treatment

A

Fluid replacement
1L 0.9% NaCl in 1st hour if systolic >90
1L 0.9% NaCl + 40mmol KCL (if <5.5) over next 2 hours, 2 hours, 4 hours etc.

Fixed rate IV insulin infusion
0.1u/kg/hr of human soluble insulin (actrapid or humulin s) made up to 50ml with 0.9% NaCl
Continue long acting as normal

Add 10% glucose 125ml/hr if blood glucose falls <14 mmol/L

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11
Q

Diabetic advice

A

Diabetic nurse support
Follow-up with endocrine/ diabetes
Insulin training

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12
Q

Drugs to avoid in children

A

Tetracyclines: discolouration and pitting of tooth enaeml
Aspirin: reye’s syndrome
SSRI: suicidal ideation
Codeine: respiratory depression in CYP2D6 ultrarapid metabolisers (to morphine)

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13
Q

Dosing in children

A

Dose based on age, weight, body surface area

Round sensibly (never over the maximum)

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14
Q

Resus fluids in kids

A

10ml/kg of glucose free sodium containing fluid (131-154mmol/L) over <10mins
E.g., 0.9% NaCl or Hartmann’s

10-20ml/kg if renal impairment, HF, neonates

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15
Q

Fluid maintanence in kids

A

4ml/kg/hr for first 10kg (or 100ml/kg/day)
2ml/kg/hr for next 10kg (or 50ml/kg/day)
1 ml/kg/hr for every kg over 20kg (or 20ml/kg/day)

E.g., 0.9% NaCl or Hartmann’s

Don’t give glucose without sodium (risk of hyponatraemia)

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16
Q

Body surface area

A

cBNF conversion table to aid drug calculations

Also, table for mean weight based on age

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17
Q

Drug principles in pregnancy

A

Avoid any in first trimester
Lowest clinically effective dose
Avoid polypharmacy
Drugs with proven safety record

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18
Q

‘Safe’ drugs in pregnancy

A

paracetamol
b-lactam Abx
steroids
bronchodilators

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19
Q

Teratogenic drugs A-N

A

ACE inhibitors - renal abnormalities, IUGR, PDA
Atenolol - low BW
Carbimazole - neonatal hypothyroidism (in 1st trimester)
Lithium - Ebstein’s
Methotrexate - termination
NSAIDs - premature PDA closure, oligohydramnios, persistent pulm HTN

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20
Q

Teratogenic drugs P-W

A

Phenytoin - craniofacial, growth, mental
Quinolones
Retinoids - CNS, renal, ear, eye, parathyroid
Sodium valproate - NTD
Statins
Tetracycline - tooth discolouration
Warfarin - fetal warfarin syndrome, neonatal/ placental haemorrhage

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21
Q

Epilepsy in pregnancy

A

Preference for lamotrigine
Avoid SV if childbearing age

5mg folic acid if on antiepileptics

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22
Q

Vitamin D in pregnancy

A

All pregnant/ BF should receive 10micrograms (400units) daily
Cholecalciferol or ergocalciferol

1000units if high risk (obese, dark skin, little sun)

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23
Q

Avoid in BF A-C

A

Amiodarone - neonatal hypothyroidism
Aspirin - theoretical risk of Reye’s
Barbiturates - drowsiness
Benzos - Lethargy
Carbimazole - hypothyroidsim
Codeine - opiate OD

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24
Q

Avoid in BF

Study These Flashcards
A

COCP - diminish milk supply
Cytotoxic drugs - IS, neutropenia
Dopamine agonists - suppress lactation, present in milk
Ephedrine - irritable
Tetracyclines - tooth discolouration

25
Adrenaline
1 in 1000 = 1g adrenaline in 1000ml so 1mg in 1ml
26
Aminophylline
If previously treated with theophylline then already distributed so don’t need the loading dose Straight to IV infusion
27
Overweight/ underweight child
If overweight then prescribe using ideal weight If underweight then prescribe using actual weight
28
Toxidromes
'clinical fingerprint', characterised by a classic constellation of symptoms and signs due to toxic effects of a drug
29
Common toxidromes
Anticholinergic - antihistamine, TCAs, anti-psychotics, atropine Cholinergic - organophosphates, mushrooms, insecticides Sympathomimetic - amphetamines, cocaine, salbbutamol Sedative-hypnotic - opioids, benzos, ethanol, anticonvulsants Opioid - morphine, heroin, oxycodone, codeine
30
Antidotes
Opiate - naloxone Benzo - flumazenil (only if resp dep requiring mechanical) SE: seizure threshold Salicylates - sodium bicarb (alk urine) TCA - sodium bicarb Paracetamol - acetylcysteine Digoxin - digibind Insulin/ betablockers - glucagon Iron salts - desferrioxamine mesilate Methanol, ethylene glycol - fomepizole Warfarin - vit K1 SSRI/ ethanol - none
31
Alcohol dependence
Local guidelines for withdrawal prescribing in inpatients Regular chlordiazepoxide (diff prescription for diff doses) ? pabrinex 1 + 2 (pair, two vials), after this has ended start thiamine + multivitamin
32
Paracetamol OD guidelines
<8hrs after ingestion - consider charcoal if <1 hr ago - measure plasma level after 4hours Revised treatment nomogram (treat above line), use 110kg max if obese 8-24hrs - urgent plasma level - treat now if expect >150mg/kg or liver injury - stop when asymp + normal LFTs/ creatinine and INR >24hrs - treat if jaundice/ hep tenderness - treat if ^ALT, INR>1.3, para conc detectable - repeat bloods 8-16hrs, other causes?
33
Paracetamol OD staggered
treat ALL patients bloods 4 hours after last dose
34
Paracetamol monitoring
4 hours to deplete glutathione levels - why you can't test before
35
Acetylcysteine anaphylactoid
Not a contraindication to treatment Management - temp stop and restart at lower rate, anti-histamines, neb salbutamol
36
Aspirin OD management
regular plasma levels correct hypokalaemia from met acidosis resp support If plasma conc >500mg/l (350 in kids) Sodium bicarbonate IV ^serum and urinary PH so v transfer into CNS and ^renal excretion IV fluids (crystalloid + glucose) >700 consider haemodialysis
37
Aspirin OD monitoring
Sodium and potassium 1-2hourly Hourly urine pH
38
Critical Medications
Systemic corticosteroids Anti-epileptics Anti-parkinsons Insulin Anticoagulants All emergency drugs
39
Anti-epileptics (can't swallow)
Discuss with pharmacy Consider early placement of NG as liquid/ dispersible preps not available for levetiracetam, topiramate and lamotrigine Older ones can be IV/ rectal
40
Parkinsons (can't swallow)
Dispersible or NG or swap to rotigotine patch (convert from l-dopa, benefit >risk) Talk to pharmacy/ senior
41
Anticholinergic burden
3. Tolterodine, oxybutynin, promethazine, amitriptyline, solifenacin 2 - cetirizine, sertraline, prochlorperazine
42
Intracellular space and extracellular space
Intracellular space (2/3 total body fluid) Extracellular space (1/3) - intravascular (20%), interstitial (80%), third
43
What is third space? Examples?
Areas of the body that don't normally contain fluid Peritoneal, pleural, pericardial, joints (also interstitial oedema)
44
Fluid intake and output
Intake - PO, nasogastric/ PEG, IV, TPN Output - urine, bowel, stoma, vomit, NG, stomach aspiration, bile drain, bleeding, sweating, fistula, hyperventilation Insensible is difficult to measure (breath, burns, sweat)
45
Hypovolemia presentation
Reduced extracellular volume BP <100, HR >90, cap refill, cold peripheries, ^RR, dry membranes, v turgor, v urine output, sunken eyes, weight loss, polydipsia In third spacing may also have signs of overload
46
Crystalloid
Small particles in solution that readily diffuse E.g., 0.9% NaCl, 5% dextrose, 0.18% NaCl in 4% glucose, Hartmann's + resus, vomiting - hyperchloraemic met acidosis (saline)
47
0.9% NaCl, 5% dextrose, Hartmann's
0.9% NaCl - 1L water with 154mmol of each (SE: ^Na, ^Cl met acidosis) 5% dextrose - 1L water with 50g glucose, no electrolytes (SE: v Na, oedema) Hartmann's - 1L water with sodium, chloride, potassium, calcium and lactate buffer (v risk of acidosis)
48
Colloids
Larger molecules, stay in intravascular space as can't cross membrane E.g., human albumin solution (^ oncotic pressure of plasma)
49
Tonicity (Hypotonic, Isotonic, Hypertonic)
Osmotic pressure gradient between two fluids across a membrane, determines whether water moves by osmosis Hypotonic = 5% dextrose in 0.18% NaCl (not for resus, SE: dilutional v Na) Isotonic = 0.9% NaCl, Hartmann's, plasma-lyte Hypertonic = 3% saline (conc. solutes > than in plasma)
50
Resuscitation Fluids
Stat 500ml isotonic fluid bolus <15mins (stat), Repeat 250-500ml boluses if required Expert help if not responding after 2L Bolus should have 130-154mmol/L sodium **Do not give over 10mmol/hour of potassium
51
Fluid Maintenance
Indication - NBM, bowel obstruction Stop IV as soon as oral good enough 25–30 ml/kg/day water 1 mmol/kg/day sodium, potassium and chloride 50–100 g/day of glucose (prevent ketosis, not nutritional) Ideal body weight not BMI E.g., 25-30 ml/kg/day 0.18% sodium chloride in 4% glucose with 27 mmol/l added potassium (SE: v Na)
52
Alternative formula for maintenance
Adult = 1.5ml/kg/hr
53
Fluid maintenance – monitoring
Daily (at least) = Fluid status, fluid balance chart and U&Es Max 24hrs of fluids prescribed at one time SE: dilution of Na (with hypotonic solutions), K, Ca, Mg, haemoglobin and haematocrit (anaemia), clotting factors, platelets and fibrinogen causing coagulopathy
54
Consider less fluid if
Elderly, renal impairment, HF, malnourished/ risk of refeeding Consider 20-25ml/kg/day (250ml for resus) Slower bags for maintenance
55
Replacement and redistribution
Issues with electrolyte and fluid replacement/ distribution Maintenance +/- losses and gains Include input from IV Abx etc
56
Potassium replacement
Estimation of deficit (K normal - K measured) x kg x 0.4 Give this in addition to daily requirement
57
Maintenance Fluids: Caution
Avoid dextrose if head injury/ stroke - worsens cerebral oedema (hypotonic) Avoid normal saline in liver disease - worsens ascites (use Hartmann's)
58
Hypercalcaemia: Management
Rehydration with normal saline e.g., 4+ litres/day Following rehydration bisphosphonates may be used. They typically take 2-3 days to work with maximal effect being seen at 7 days

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