Medications, Consultations & Prevention of Inpatient Complications

Question 1

What are the approaches to fluid management?

4Rs

Answer 1

Routine Maintenance
Replacement
Redistribution
Resuscitation

Question 2

What do intravascularly dry patients look like?

Answer 2

Decreased urine output
CVP
IVC
Hypotension
Tachycardia
Decreased weight

Question 3

What is the goal of fluids

Answer 3

maintain hemodynamic stability, euvolemic state

Question 4

What are the daily fluid requirements

Answer 4

25-30ml/kg/day of water (total fluid)
*rarely more than 3L per day

Question 5

When should enteral nutrition be considered

Answer 5

if NPO > 3days

Question 6

how should fluids be dosed for obese patients

Answer 6

weight based dosing should be off ideal body weight, not actual body weight

Question 7

who are fluid requirements lower for

Answer 7

elderly
CKD
CHF
malnourished patients

Question 8

What does tonicity define

Answer 8

the cell

Question 9

What is hypertonic fluid

Answer 9

tonicity higher than that of the blood
for TBI, fluid shifts, hyponatremia

3% NACL, 7% NACL, D10W and higher concentrations

Question 10

What are Colloids

Answer 10

high molecular weight, will stay in intravascular space longer

albumin (16hrs intravasc vs 30min NS), hetastarch

Question 11

What is Isotonic

Answer 11

denoting or relating to a solution having the same osmotic pressure as some other solution, especially one in a cell or a body fluid

NS, LR, D5W, plasmalyte

Question 12

what is Hypotonic fluid

Answer 12

tonicity is lower thant hat of the blood, used for hypernatremia

.45% NACL (1/2NS), D2.5W

Question 13

What is Crystalloids

Answer 13

isotonic but hypo-oncotic lack the large proteins that keep fluid intravascularly

NS, LR

Question 14

What are balanced crystalloids

Answer 14

include lactate or acetate, they are buffered, low Cl-

LR, Plasmalyte

Question 15

What does 0.45% hypotonic saline increase the risk of

Answer 15

cerebral edema

rarely used

used in patients with hypovolemia in setting of hypernatremia

Question 16

when do we use 3% hypertonic saline

Answer 16

symptomatic hyponatremia
elevated ICP (d/t TBI, bleed, concern for herniation)

Question 17

What can occur with innapropriate 3% hypertonic saline administration

Answer 17

osmotic demyelination syndrome

Question 18

What is the pH of LR

Answer 18

6.5

Question 19

What is within LR

(components)

Answer 19

Ca2+, K+, Cl-, Na+

Question 20

Will patients who recieve LR get lactic acidosis

Answer 20

NO

may cause increase lactate but not lactic acid

Question 21

what is contraindicated in newonates with LR

Answer 21

Ceftriaxone

Question 22

What are the CONS of NS

Answer 22

intracellular potassium depletion
Hypercholremic metabolic acidosis
neutrophil activation
pH 5.5
(high volume can cause hypercholremic metabolic acidosis)

Question 23

What is Plasmalyte

Answer 23

balanced crystalloid fluid

Question 24

What is D5W

Answer 24

dextrose 5% in free water
used in hypoglycemia

Question 25

what makes up 50% of all plasma proteins

Answer 25

albumin

Question 26

If a trauma patient is hypotensive, what fluids should they NOT recieve

Answer 26

crystalloid fluids

Question 27

in a trauma if a patient looses 1L of blood how much fluid and what type will they need

Answer 27

3L (ish) of crystalloid to maintain normovolemia

Question 28

how much of fluids will remain as intravascular volume

Answer 28

30%

Question 29

What is the preferred method of nutrition management

Answer 29

enteral nutrition requires working GI tract

Question 30

what are the risk with enteral nutrition

Answer 30

not meeting nutritional requirements aspiration (NG) GI distress wound infection if surgically placed

Question 31

what are the indications for parenteral nutrition

Answer 31

if requirements not met via enteral if Gi tract issues

Question 32

what are the risks of parenteral nutrition

Answer 32

systemic infection occlusion of line thrombosis

Question 33

what are IV opioid options

Answer 33

Morphine Hydromorphone (Dilaudid) Fentanyl

Question 34

what is the PK of fentanyl

Answer 34

RAPID onset < 1 minute, only lasts about 1 hour

Question 35

What does MME stand for

Answer 35

Morphile Miligram Equivalents (MME)

Question 36

what is the MME that are at higher risk of OD

Answer 36

Over 50 MME/Day

Question 37

What is pyshiologic decline exacerbated by inactivity/immobility

Answer 37

deconditioning

Question 38

How are pressure ulcers managed

Answer 38

consult wound care early document dibridement and clean dressings monitor for infection

Question 39

What is Virchows Triad

Answer 39

stasis endothelial injury hypercoagulable state

Question 40

What are provoking facotrs for VTE

Answer 40

estrogen/BC smoking immobility trauma

Question 41

What is the treatment of VTE

Answer 41

anticoagulation (LMWH, DOACs)

Question 42

What are the Ws of post-op fever

Answer 42

wind water walk wound wounder about drugs

Question 43

What are Risk factors with Hospital acquired infections (HAIs)

Answer 43

hospital associated immunosuppression, older age, increased LOS, medical comorbidites, frequent hospitalization, etc

Question 44

What are common hospital acquired infections

Answer 44

c. diff CLABSI CAUTI (e.coli, pseduomonas) SSI (s. aureus) HAP/VAP

Question 45

What is CLABSI

Answer 45

central-line associated blood stream infections

Question 46

What is CAUTI

Answer 46

catheter-associated UTIs

Question 46

What is a VAP

Answer 46

ventilator associated pneumonia

Question 47

what is HAP

Answer 47

hospital acquired pneumonia

Question 48

what is a SSI

Answer 48

surgical site infection

Question 49

What is a CDI

Answer 49

c.diff infection

Question 50

What is the management of HAI

Answer 50

removal/replacement of offending agent if possible site +/- Blood cultures lab workup for sepsis empiric abx fluid resuscitation if needed monitor for deterioration

Question 51

What is the #1 HAI ## Footnote what are the pathogen associated with this

Answer 51

CAUTI | cath is the m/c indwelling device ## Footnote **E.coli, Pseudomonas**, klebsiella, proteus, enterococcus, staph

Question 52

what is the presentation of a CAUTI

Answer 52

often fever w/o urinary symptoms hematuria, suprapubic pain, flank pain, CVA tenderness bacteremia + positive urine culure and no other source pyuria

Question 53

how is a CAUTI diagnosed

Answer 53

dx of exclusion Urine culture (from foley bag) blood cultures

Question 54

What is the treatment of CAUTI

Answer 54

change foley (biofilm) debatable when abx should be started abx (pipercillin-tazo, ceftazidime, aztronam)

Question 55

What are contraindications for IO

Answer 55

osteoporosis osteogenesis imperfecta bone fracture recent placement of IO cellultitis, infection, burn over insertion site

Question 56

what are the inerstion sites for IO's

Answer 56

proximal tibia (m/c) humerus

Question 57

what are the risks of IO

Answer 57

infection skin necrosis (extravasation) compartment syndrome (if through bone completely) epiphyseal injury fat embolism pain

Question 58

What are the indications for central lines

Answer 58

cant get peripheral access need access for procedures measure central venous pressure administer certain meds

Question 59

What meds often need a central line

Answer 59

pressors, calcium chloride, potassium

Question 60

What are complications of central line

Answer 60

hematoma/pain extravasation of fluids phelbitis cellulitis neurovascular injury bacteremia/sepsis DVT tissue necrosis

Question 61

What is the most common procedure for central lines

Answer 61

seldinger technique ## Footnote needly used to intoduce guidewire, batheter is then placed over the guidewire

Question 62

What is a paracentesis

Answer 62

removes ascited for fluid analysis and/or assistance with symptoms management associated with large ascites volume ## Footnote therapeutic and diagnostic

Question 62

what is a thoracenesis used for

Answer 62

pleural effusion ## Footnote d/t CHF, pneumonia, cancer, PE< cirrhosis

Question 63

what are the contraindications for thoracentesis

Answer 63

loculations (need special US guided drainage) infection to overlying skin coagulation abnormalities

Question 64

how is a patient positioned for a thoracentesis

Answer 64

sitting upright and bending forward

Question 65

What are the compliations of thoracentesis

Answer 65

pneumothorax, bleeding, hemothorax, puncture of spleen or liver

Question 66

Where is CSF made

Answer 66

ventricles produced by choroid plexus

Question 67

What are the inidcation of LP

Answer 67

Meningitis (CNS Infection) MS Aneurysms unexplainedd seizures instil chemo/contrast assess or elevated ICP

Question 68

what are contraindications of LP

Answer 68

overlying infection space occupying lesion increased ICP coagulopathy lumbar fusion/laminectomy

Question 69

What is BIPAP

Answer 69

Bilevel Positive Pressure senses when pt inhails and provides expiratory PEEP