Abd pain, N/V, dizziness, and confusion
Digitalis toxicity
Digoxin + furosemide
- Loops can cause hypokalemia
HypoK increases the risk of Dig toxicity
Digoxin + metoprolol
- both drugs cause bradycardia
- Increase risk AV block
Furosemide + metropolol + lisinopril
All lower BP, increase risk hypotension
- Lower BP can reduce renal blood flow and contribute to prerenal azotemia –> increase Dig blood level
Most common cause of prerenal azotemia?
Hypoperfusion of the kidney (due to hypotension)
20 - 30% of Dig
bound to serum albumin
80% of Dig
unchanged by kidneys
Dig metabolized
by liver
Serum levels of Dig risk to peak at ____ then slowly decline until plateau reached in _____
- 30 - 90 min
- 6 - 8 hrs
Therapeutic range for Digitalis
0.5 - 2.0 ng/ml
How do you decide if you have administered enough Dig?
“Treat the pt, not the Dig level”
Drugs that potentiate the effects of Dig
- Diuretics (except spironolactone)
- Propranolol
- Amiodarone
- Erythromycine, tetracycline
- IV Calcium
- Nifedipine, Verapamil (CCB)
- Quinidine
- Thyroid hormone
Digitalis toxicity
- Aggressive tx depends on clinical features and blood level
- D/C drug
- Ensure adequate blood K level
- Cardiac monitor
- Avoid cardioversion, except as last resort
- Dig specific Fab antibody for life-threatening Dig tox
Elevated BUN to Cr level indicates
- Prerenal
What can lead to renal failure
- NSAIDs
- Volume depletion
What will UA show in dehydrated pt
High specific gravity
What meds would you stop in the dehydrated pt in ARF?
Ibuprofen (NSAIDs) and ACE-I
ARF findings in UA, Renal US
UA - WBC/RBC casts, LE, SG
Renal U/S - urinary obstruction (post renal issues such as stones, obstruction, hydronephrosis)
What 2 drugs can you administer in case of hyperK
- Insulin (drive K into cell)
- Kayexalate ( K binding resin)
Normal DM value for A1C
6.5 - 7
BUN > 20:1
Prerenal
BUN
intrinsic or post renal
DM can lead to what type of renal failure
intrinsic (DM nephropathy)
Why do you need to d/c ACE-I in the case of renal dz?
Causing hyperK, reduced K excretion due to drug and poor renal fxn
What should be addressed for a pt with kidney dz who needs abx?
- Dose dep adjustment
- oral vs IV
- Can pt be sent home or is hospitalization indicated?
Options for Community Acquired PNA
- Ceftriaxone PLUS Azithromycin
- Levaquin
- Doxycycline
Ceftriaxone/Azithromycin dose
1 gm IV q 24 hrs Ceftriaxon
500mg IV q 24 hrs Azithromycin
Ceftriaxone/Azithromycin Renal dosing
No initial adjustment, monitor serum levels
- If on dialyzed, give dose after dialysis
Levaquin dose
750 mg initially, then renal dose
Levaquin renal dose
- Cr 20 - 49: 750 mg q 48 hrs
- Cr 10 - 19: 500 mg q 48 hrs
- Cr
Doxycycline dose
100 mg PO BID
Doxycycline renal dose
No adjustment needed
What is the best way to determine how to adjust med dosing in pt with renal failure?
Consult renal dosing chart
What do you do with metformin if pt has renal failure?
D/C metformin –> Risk of Lactic Acidosis (esp if Cr
What do you do with ACE-I if pt has renal failure?
D/C the pril –> Risk of HyperK
–100% excreted in urine, unchanged
What do you do in the case of refractory hyperK that is unresponsive to meds (lasix)?
Dialysis
Most acute renal failure is reversible or irreversible?
reversible
Most causes of ARF
prerenal
What studies should you avoid in a pt with ARF?
iodine contrast studies (IVP, CT)
