Special Populations Flashcards
(51 cards)
Common fluids used in acute care/ICU
Crystalloids: 5% Dextrose, 0.9% NaCl, lactated Ringers, Plasma-Lyte-A
Colloids: Albumin 5%, 25%, Dextran, Hydroxyethyl starch (has BBW) –> overall very $$
Electrolyte disorders: sodium: hypo
Hyponatremia: NA < 135
–> Hypovolemic: low volume caused by diuretics, salt wasting syndromes, blood loss, or vom/diarrhea
-give sodium containing fluids (NS, 1/2NS)
–> Hypervolemic: fluid overload (cirrhosis, HF, renal failure)
-give diuretics, fluid restrict, AVP receptor antagonist
–> Isovolemic: SIADH (inappropriate antidiuretic hormone)
-give diuretics, fluid restrict, demecloyline (SIADH), AVP receptor antagonist
rate of sodium correction
-correct sodium by 4-8 meq/L/24hr
–> doing more than 12 meq/L/24hr can least to osmotic demyelinattion syndrome (ODS) or central pontine myelinolysis
Arginine vasopressin receptor antagonists
-Conivaptan - injection
-Tolvaptan (Samsca)- oral :)
–> used for isovolemic (SAIDH) and hypervolemic hyponatremia
–> Risks: osmotic demyelination syndrome (ODS), hepatotoxicity (can only be used for 30 days)
-must start/restart in the hospital, monitor Na
Electrolyte disorders: sodium hyper
Hypernatremia: Na > 145 mEq/L
-hypovolemic: dehydration, vomiting or diarrhea
–> give fluids
-hypervolemic: intake of hypertonic fluids
–> give diuretics
-Isovolemic: caused by diabetes insipidus, which can dec ADH
–> give desmopressin
Electrolyte imbalances: potassium, magnesium and phosphors
-drop of 1 mEq/L in K (below 3.5) represents a total body deficit of 100-400 mEq
*via peripheral line: give max infusion rate < 10 mEq/hr and max concentration of 10 meq/100 ml
-magnesium is necessary for potassium uptake: Mg < 1 mEq/L with life-threatening (seizures) symtpoms, replace IV with mag sulfate
-phosphorus: when PO4 < 1 mg/dL, replace IV
IV Immunoglobulin
-used for immunodeficiency (off label for MS, myasthenia gravis, gullian-barre syndrome)
–> Gammagard, Gamunex-C, Octagam, Privigen
Warnings: acute renal dysfunction, thrombosis
SEs: HA, nausea, diarrhea, infusion reaction, renal failure, blood dyscarsias (rare)
*impairs pts response to vaccines- needs to be spaced out from them
ICU meds: Vasopressors
used to inc BP, HR, CO
-Dopamine: dose dependent receptor effects, D1 –> beta 1 –> alpha 1
-Epinephrine/Norepinephrine: mixed alpha-1 and beta-1 agonists
-Phenylephrine: pure alpha-1 agonist
-Vasopressin: vasopressin agonist
-Angiotensin II: vasoconstriction, aldosterone release
BBW: extravation: severe tissue damage/necrosis = medical emergency
—> tx with phentolamine (alpha 1 blocker)
SE: arrhythmias, tachycardia
Dopamine Dosing
–> Low (renal) dose: 1-4 mcg/kg/min
-dopamine-1 agonist
–> Medium dose: 5-10 mcg/kg/min
-beta-1 agonist (heart: + ionotropic)
–> High dose: 10-20 mcg/kg/min
-alpha-1 agonist (vasopressor effect)
ICU meds: Vasodilators
use for active MI or uncontrolled HTN
-Nitroglycerin: LD = venous vasodilator, HD = arterial vasodilator
–> can cause tachyphylaxis, use in non PVC container
-Nitroprusside: mixed vasodilator: cyanide (limit use in renal failure), protect from light
-Nesiritide: mixed vasodilator
ICU meds: Inotropes
used to increase contractility of the heart
-Dobutamine: beta 1 agonist
-Milrinone: phosphodiesterase-3 inhibitor (also a vasodilator)
General principles for treating septic shock
-Target a MAP > 65 [ (2* DBP) + SBP]/3
Fill the tank: optimize preload with IV crystalloids (LR)
Squeeze the pipe and kick the pump:
—> alpha-1 agonist activity to inc SVR
–> beta-1 agonist activity to inc myocardial contractility and CO
Acute care: Types of Shock
-hypo perfusion and hypotension = medical emergency!
–> hypovolemic: low volume, low BP, caused by trauma/GI bleed
-tx with fluids (LR, dextrose)
–> Distributive: vessels are leaking, caused by anaphylaxis/sepsis
-tx with fluids, vasopressors (sepsis)
–> cardiogenic: caused by acute decompensated HF
-tx with Inotropes, diuretics, vasopressors
Treating acute decompensated heart failure*
A. pts with edema (pulmonary or lower extremity), JVD and/or ascites are VOLUME OVERLOADED:
–> tx with loop diuretics, vasodilators can be added (NTG, nitroprusside, nesiritide)
B. pts with dec renal function, AMS and/or cool extremities have HYPO PERFUSION:
–> tx with Inotropes (dobutamine, milrinone), if pt becomes hypotensive, consider adding a vasopressor (dopamine, norepinephrine, phenylephrine)
C. some pts are both VOLUME OVERLOAD & HYPO PERFUSION:
–> tx options are a combo of agents above
ICU: drugs for agitation & sedation
NON BENZOS:
–> Dexmedetomidine (Precedex): alpha 2 agonist, can be used in both intubated and non-intubated pts
–> Propofol (Diprivan): oil in water emulsion = cause hypertriglyceridemia - pt should be intubated
BENZOS:
–> Lorazepam (Ativan): propylene glycol toxicity
–> Midazolam (Versed): short acting, active metabolite accumulates in renal dysfunction
ICU: stress ulcer prophylaxis (SUP)
-results from dec blood flow to gut, dec gastric defense mechanisms
-risk factors: mechanical ventilation > 48 hrs, coagulopathy, sepsis, traumatic brain injury, major burns, acute renal failure, high dose systemic steroids
–> H2RAs and PPIs are rec:
-Famotidine etc: risk of thrombocytopenia and CNS side effects (dec to qd dosing)
-Pantopropazole etc: risk of C.diff, osteoporotic fractures, nosocomial pneumonia
–> use for short period of time
ICU: anesthetics
-Local: Lidocaine (Xylocaine), benzocaine
-Inhaled: Desfluraine (Suprane), Sevoflurane (Ultane) –> can cause malignant hyperthermia
-Injectable: bupivacaine (epidural!), lidocaine, ropivacaine
ICU: neuromuscular blocking agents
**paralyzing agents = causes respiratory arrest!!
**does NOT provide sedation or analgesia: pt MUST be on a ventilator
–> Succinylcholine: activates the acetylcholine receptors and desensitizes them
–> Cisatracurium (Nimbex): blocks acetylcholine from binding to the receptor (also rocoronium, vecurinium)
Acute Care meds: hemostatic agents
-work by inhibiting fibrinolysis or enhancing coagulation = STOP bleeding
-topical agents: Recothrom, Thrombin-JMI: used during surgery
–> Aminocaproic acid (Amicar)
–> Tranexamic acid
-Cyklokapron IV
-Lysteda oral: used for heavy menstural bleeding
–> Recombinant factor VIa (NovoSeven RT): used for hemophilia & factor 7 deficiency
When to seek urgent care for a child
-age < 3 mon w/ a temp of 100.4F (R)
-age 3-6 mon w/ temp of 101F (R)
-age > 6 mon w/ a temp of 103F (R)
Newborn baby health
-APGAR score, healthy - 7-10
-congenital screening (heel prick)
-meds: vitamin K IM, opthalmic abx.
Conditions in Preterm Babies
–> Patent Ductus Arteriosus (PDA): opening between aorta and pulmonary artery
-tx w/ INSAIDs (IV indomethacin)
–> Persistent Pulmonary Hypertension of the Newborn (PPHN): constricted blood vessels in the lungs, blocking airflow (increased risk if mother takes SSRIs)
-tx: supportive care, can use inhaled Nitric Oxide (rare)
–> Respiratory Distress Syndrome (RDS): deficiency of surfactant (production starts at gestational week 24, adequate at week 35)
-tx: surfactant (Curosurf, Infasurf)
OTC products to reduce fever in infants
-Acetaminophen (Tylenol): 10-15 mg/kg/dose q 4-6 hrs
-Ibuprofen (Advil/motrin): 5-10 mg/kg/dose q 6-8 hrs (do not use in < 6 months)
**NO ASA in < 16 y/o: reyes syndrome
Common conditions in young children: Bacterial Meningitis
< 1 month: strep. agalactiae (Group B strep), E. coli, Listeria monocytogenes, Klebsiella
–> ampicillin + cefotaxime
–> ampicillin + Aminoglycoside (gentamicin)
1-23 months: Step. pneumoniae, N meningitidis, S. agalactiae, H. influenza, E. Coli
–> Vancomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
2 + yrs: N. meningitidis, S. pneumoniae
–> Vancomycin + 3rd gen cephalosporin (ceftriaxone or cefotaxime)
**ceftriaxone use in neonates can cause bilirubin induced brain damage (Kernicterus), and w/ ca containing solutions- can precipitate and cause embolus
