Pharmacology and Therapeutics - Fletcher

Question 1

What are the 5 key functions of the kidney?

Answer 1

Hydroxylation of Vitamin D

Excretion of waste products

Excretion of salt and water

Red blood cell production

Control of blood pressure

Question 2

What is an AKI?

And what chemcial changes occur due to it?

Answer 2

Acute Kidney Injury

A sudden reduction in kidney function over hours or days, unsually with no symptoms

Usually causes a rise in serum creatinine and reduction in urine output

Question 3

What are the 3 categories of causes of AKIs?

Answer 3

Pre-Renal –> Reduced blood supply, sepsis (causes drop in BP) or shock

This is the most common

Intrinsic –> Problem with the kidney itself (eg, drugs and inflammation)

Post-Renal –> An outflow obstruction (such as the bladder/ureter or prostate)

Question 4

What are the 2 key risks in the community for AKIs?

Answer 4

Dehydration (potentially N+V)

Nephrotoxic drugs (like NSAIDs)

Question 5

Why are NSAIDs, ARBs and ACEi problematic in AKI?

Answer 5

NSAIDs –> Act on prostaglandins, preventing vasodilation at the afferent arteriole

ARBs/ACEi –> Both act on angiotensin II, which therefore prevents vasoconstriction at the efferent arteriole

Question 6

When is Contrast Media contraindicated?

Answer 6

In AKI grade 2 and 3

Question 7

What are sick day cards?

Answer 7

Advice on what to do if you are acutly unwell (eg, diarrhoea and vomiting) to ensure that an AKI doesnt occur

Things include stopping certain medications, and keeping hydrating

Question 8

What are the conditions needed for VTE prophylaxis in medical and surgical patients?

Answer 8

Medical –> Have had or are expected to have reduced mobility for 3 or more days

Surgical –> Most patients will need anticoagulation

Total anasthetic and surgery time is over 90 mins, or 60 mins for lower limb surgery

Question 9

What is the duration of VTE Prophylaxis for certain surgical procedures?

Answer 9

NOF –> 4-5 weeks

Abdominal/Pelvic Cancer –> 4 weeks

Lower limb in plaster –> Until out of the plaster

Hip/Knee Replacement –> DOAC used for prologed period of time

Question 10

What’s an epidural?

Answer 10

When an anasthetic and an opioid is injected into the epidural space, which paralyses the area

There’s a risk of epidural haematoma when inserting or removing the epidural catheter in an anticoagulanted patient

Question 11

What are the 4 parts of the APFEL score?

Answer 11

Female = 1

History of PONV = 1

Non Smoker = 1

Opiate Use = 1

Question 12

Can you or can you not use metaclopramide in PONV?

Answer 12

It is not very effective!!

Question 13

What are the 3 types of Surgical Site Infections (SSIs)?

Answer 13

Superficial

Deep Incisional

Organ/Space

Question 14

What are the 4 degrees of contamination during surgery?

Answer 14

Clean –> The respiratory and genitouretary tracts arent enetered and no inflammation is encountered. No break in aspetic technique

Clean-Contaminated –> The respiratory or genitouretary tracts are entered, but with minimal spillage

Contaminated –> Operations where inflammation (without pus) is encountered, or there is visible contamination of the wound

Dirty –> Operations in the presence of pus or compound injuries more than 4 hours old

Question 15

On a surgical ward, when would a pharmacist do a medicines reconcilliation/screen the drug chart?

Answer 15

On the day of the surgery BEFORE sedative meds are given to ensure that the patient can be a more useful source

Question 16

What are the 3 different methods of prophylaxis of VTE?

Answer 16

Actions –> Avoid dehydration, and stop medication which could cause problems. Also useful to get people mobilised quickly after surgery

Mechanical –> Stockings, IPCs and Foot impulse devices

Pharmacological –> LMWH, heparin, DOACs, fondupariux

Question 17

What types of medication do we need to be careful with pre-surgery?

Answer 17

Anticoagulants/Anti-platelets

Cardiac drugs

Steroids

Hyperglycaemics

Oral contraceptives

Tamoxifen

MAOIs

Lithium

Question 18

What is the prophylactic dose and treatment dose of dalteparin?

Answer 18

Prophylaxis –> 5000units OD

Treatment –> 15,000units OD

Question 19

When would we not restart wafarin ASAP after surgery?

Answer 19

If the bleeding risk is high

If an epidural is in situ

Question 20

What are the reveral agents for wafarin and for DOACs?

Answer 20

Wafarin –> Vitamin K (slow reveral) and Beriplex (1 hour reversal)

DOACs –> Idarucizumab (for dabigatran only/very expensive) for life threatening emergencies

Question 21

What type of cardiac medication is always continued in surgery?

Answer 21

Beta-Blockers

This is because of the risk of rebound tachycardia and arrhythmias

Question 22

What is the dose of hydrocortisone IV for minor and major surgeries?

Answer 22

Minor –> 25-50mg on induction

Major –> Usual steroid dose in the morning plus 25-50mg on induction

Also 25-50mg TDS for 48-72hrs post op (24 for moderate surgery)

Question 23

When would a Various Rate Intravenous Insulin Infusion (VRIII) be indicated?

Answer 23

When more than one meal has been missed (in major surgery)

When there is uncontrollable hyperglycemaia in a patient that has missed only one meal

Question 24

What type of oral contraceptive can increase the VTE risk of a patient?

Answer 24

Oestrogen containing pills

Progesterone only pills cause no increases risk

Question 25

In terms of **anticonvulsant and parkinsons medication, what medication should be carried on**?

Answer 25

**All of them!** Treatment is essential, and should not be stopped

Question 26

If **lithium** is carried on during surgery, **what class of drug must be avoided**?

Answer 26

NSAIDs

Question 27

What are the **4 levels of critical care**?

Answer 27

**Level 0** --\> Needs can be met on usual wards in an acute hospital **Level 1** --\> Needs can be met on acute wards, just with extra help. Patients are at risk of their condition deteriorating **Level 2** --\> Patients require more detailed monitoring, including support for a single failing organ system. Also the level for those stepping down for level 3 **Level 3** --\> Patients require respiratory support and high levels of sedation. Also includes patients with multi-organ faliure

Question 28

What's the difference between **invasive and non-invasive respiratory support**?

Answer 28

**Non-Invasive** --\> Masks are used (normally) **Invasive** --\> Use of tracheal intubation or a tracheostamy tube Sedation often needed here to promote compliance Always best if the patient can help breath with it, as this keeps the important muscles strong....otherwise they are unused and they will deteriorate

Question 29

What is an **ECMO**?

Answer 29

A type of dialysis, but **used to oxygenate the blood when the patient cannot breathe**

Question 30

What is a **sedation hold**?

Answer 30

When sedation is removed to check that the patient is okay, and then the sedation is reapplied To do this we need short acting sedatives that can be cleared from the body quickly when needed

Question 31

How does a patient go into **shock during sepsis**?

Answer 31

Sepsis causes natural vasodilation, so the BP drops very low This means that tissues get inadequte levels of oxygen This causes cellular hypoxia and so metabolic acidosis

Question 32

What is **Noradrenaline used for in sepsis/shock**?

Answer 32

To increase the strength of the heart (contractability) and so increase BP This is VITAL!