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Difference between crystalloids and colloid fluids
crystalloids: most of volume does not remain in the intravascular space (inside blood vessels) but moves into extravascular/interstitial space
colloids: primarily remain in intravascular space and increase oncotic pressure
Examples of crystalloids:
5% dextrose (D5W)
0.9% NaCL (NS)
Lactated Ringers (LR)
Plasma-Lyte A
Examples of colloids
albumin 5%, albumin 25%
Hespan (hydroxyethyl starch, dextran
Colloids provide (smaller/larger) intravascular volume than crystaloids
larger
T/F: Colloids are more expensive and have not shown a clear clinical benefit over crystalloids
true
Fluids most commonly used for volume resuscitation in shock states
NS and LR
lactated ringers contains:
NaCl, KCl, CaCl2, Na-lactate (which is converted to bicarbonate)
The most commonly used colloid ______ is specifically useful when there is _____ such as in conditions like _____
albumin
useful specifically when there is significant edema like in conditions like cirrhosis
T/F: Albumin can be used as a nutritional supplementation when serum albumin is low
FALSE this is now how to raise albumin
Hespan starch has a boxed warning for ____ and should only be used if other treatments are unavailable
boxed warning for mortality
Hyponatremia is usually not sympotmatic until:___ where symptoms can be
<120
symptoms can be headache, confusion, gait disturbances to seizures, coma
3 types of hyponatremia based on osmolality and their preferred treatment
hypotonic hypervolemic hyponatremia: (fluid overload): treat w/ diuresis and fluid restriction
isovolemic: diuresis, stopping offending agents, demeclocycline for SIADH off-label
hypovolemic:(caused by diuretics) stop intake of hypotonic solutions, give hypertonic (3%) sodium chloride IV
Typical treatment goal of sodium correction is ______
4-8 mEq/L/24H
Correcting sodium more rapidly than ______ can cause ________
more rapidly than 12 mEq/L/24H
can cause osmotic demyelination syndrome or central pontine myelinolysis (leading to paralysis, seizures, death)
Treatment for SIADH, hypervolemic hyponatremia
conivaptan and tolvaptan (AVP receptor antagonists)
tolvaptan drug class
arginine vasopressin receptor antagonists (AVP antagonists)
Do not use Samsca beyond ________
30 days
(tolvaptan)
T/F: tolvaptan must be initiated and re-initated in the hospital
true (boxed warning)
boxed warning on Samsca
(tolvaptan)
initiated and re-initiated in a hospital
overly rapid correction of hyponatremia (>12 mEq/L/24H is assoc. w/ ODS (life-threatening)
warnings and side effects with tolvaptan
hepatotoxicity
SE: thirst, nausea, dry mouth, polyuria
Tolvaptan is administered ___ for no more than ____ (due to ____)
PO (tablet)
no more than 30 days due to hepatotoxicity
hypovolemic hypernatremia is typically caused by:
dehydration, vomiting, diarrhea (treat w/ fluids)
hypervolemic hypernatremia is caused by
intake of hypertonic fluids (treat w/ diuresis)
isovolemic euvolemic hypernatremia is usually caused by:
Diabetes insipidus which can decrease ADH
(it is treated w/ desmopressin)
a drop of ____ below 3.5 mEq/L represents a total body deficit of ______ in potassium
a drop of 1 mEq/L in serum K below 3.5 represents a deficit of 100-400 mEq
T/F: The oral route is preferred for potassium when feasible
true
Max infusion rate of potassium and max concentration
10 mEq/hr, max concentration of 10 mEq/100mL
T/F: IV potassium should be adminstered undiluted or via IV push
False: These administration routes are LETHAL
NEVER administered undiluted or via IV push
______ is necessary for potassium uptake
magnesium
When someone is hypokalemic and has low magnesium, _____ should be corrected first
magnesium should be replaced first (M comes before P in the alphabet)
Magnesium replacement via _____ is recommended
IV magnesium sulfate
symptoms of hypomagnesium
seizures, arrx
T/F: Hypophosphatemia is considered severe and is usually symptomatic
True
Hypophosphatemia is replaced via ____
IV phosphorus
Uses for IVIG
MS, myasthenia gravis, Guillain-Barre syndrome, immunodeficiency conditions
IVIG can impair response to
vaccination
Boxed warning with IVIG products
acute renal dysfunction: is more likely w/ products stabilized w/ sucrose
thrombosis can occur even without RFs
Octagam and Privigen are brans of
IVIG products
When dosing IVIG, remember:
use a slower infusion rate in renal and CV disease patients
do not freeze, shake or heat
side effects of immunoglobulin
infusion reaction (facial flushing) chest tightness, fever, chills, hypotension - slow/stop infusion
(may use premedication or slower titration)
Score used to estimate ICU mortality risk
APACHE II
most vasopressors work by stimulating _____ which causes _____
stimulating alpha receptors causing peripheral vasocontriction (think pressing down on the vasculature)
this increases SVR) which increases BP
vasopressors that stimulate beta receptors can increase ______
HR and CO
Phenylephrine is a ______ that increases _______ without _____
pure alpha-agonist that increases SVR without increasing HR
Mixed alpha- and beta-agonists include
epinephrine and norepinephrine
mixed alpha- and beta-agonists increase :
SVR, CO, and HR
dopamine is a natural precursor of
norepinephrine
At a low dose (____-____) dopamine is a _____
Low (renal) dose: 1-4mcg/kg/min
dopamine is a dopamine-1 agonist
at a medium dose (__-____) dopamine is a ____
medium dose: 5-10 mcg/kg/min
dopamine is a beta-1 agonist
at a high dose: (__-____) dopamine is a _____
high dose: 10-20 mcg/kg/min
dopamine is an alpha-1 agonist
Dopamine from low to medium to high dose becomes a
dopamine-1 agonist, beta-1 agonist, alpha-1 agonist
(DBAA)
Vasostrict drug class
(vasopressin)
vasopressin receptor agonist
known as arginine vasopressin (AVP) and antidiuretic hormone ADH
levophed drug class
(norepinephrine)
alpha-1 agonist > beta-1 agonist activity
all vasopressors are _____, when administered IV. This can be treated w/ ______
all vasopressors are vesicants
extravasation can be treated w/ phentolamine
Extravasation from vasopressors can be treated with
phentolamine
Epinephrine IM injection (epipen) strength or compounding IV products is:
1mg/mL (1:1,000)
Epinephrine used for IV push is
0.1mg/mL, 1:10,000 ratio strength
Side effects of Vasopressors
arrx, tachy, necrosis (gangrene), bradycardia, phenylephrine, hyperglycemia (epi)
T/F: Patients on vasopressors should be monitored continuously for BP and MAP
true
Phentolamine drug class
alpha-1 blocker (antagonizes effects of the vasopressor
what to do if extravasation occurs?
stop infusion, don't dc needle/cannula, don't flush the line, aspirate the drug
phentolamine can be given
NG ointment is sometimes used if phentolamine is unavailable
Effectiveness of nitroglycerin for myocardial ischemia or uncontrolled HTN may be limited to ____ due to ______
24-48H due to tachyphylaxis (nitrate)
Nitroprusside drug class
mixed (equal) arterial and venous vasodilator at al doses
T/F: Nitroprusside has a greater effect on BP than Nitroglycerin
true
T/F: Nitroglyceride can be used in active myocardial ischemia
False: should NOT be used here because it can cause blood to be diverted away from diseased coronary arteries (coronary steal)
metabolism of nitroprusside results in
thiocyanate and cyanide formation
_______ can be administered to reduce the risk of _____ toxicity from nitroprusside
hydroxocobalamin can reduce the risk of thiocyanate toxicity or treat cyanide toxicity
Sodium thiosulfate is used for
cyanide toxicity
Drug used for cyanide toxicity
sodium thiosulfate (nithiodote (+sodium nitrite)
Nitroglycerin is a ____ at low doses_ and a _______ at high doses
low doses: venous dilator
high doses: arterial vasodilator
T/F: Nitroprusside must be further diluted
true
Dilute nitroprusside with ____
D5W
Pharmacists should be warned that nitroprusside can increase
increase ICP
Contraindications to NG
SBP <90, use with PDE-5 inhibs
NG requires a ____ container
non-PVC container (exe. glass, polyolefin)
There is increased risk of cyanide/thiocyanate toxicity in_____- with nitroprusside
renal and hepatic impairment
Nipride requires ____ during administrations
light protection
Only use ___ solutions with Nipride, as a blue color indicates _____
clear solutions
blue color indicates degradation to cyanide
Inotropes work by
increasing contractility of the heart
Dobutamine is a ______ that works by increasing ____
dobutamine is a beta-1 agonist
works by increasing HR and force of contraction (therefore increasing CO)
(also has weak beta-2 and alpha-1 agonism but is less important)
Milrinone is a _____ that produces ____ effects
it is a phosphodiesterase-3(PDE-3)inhibitors in cardiac and vascular tissue
produces inotropic effects (vasodilation)
Vasodilators include:
nitroglycerin, nitroprusside
inotropes include:
Dobutamine
Milrinone
notes regarding dobutamine
may turn slightly pink due to oxidation, but potency is not lost
Shock usually is characterized by:
hypoperfusion (usually from hypotension): <90SBP or MAP<70
4 types of shock
hypovolemic (exe. hemorrhagic)
distributive (ex. septic, anaphylactic)
cardiogenic (ex. post-myocardial infarction)
obstructive (ex. massive pulm. embolism)
First line treatment for hypovolemic shock
fluid resuscitation with crystalloids when it is not caused by hemorrhage
blood products when there is hypovol shock due to bleeding
vasopressors may be indicated if they do not respond, but will not be effective unless intravascular volume is adequate
T/F: If the volume cannot be correct in a patient with hypovolemic shock, vasopressors can be given
False: Vasopressors will NOT be effective unless intravascular volume is adequate. Vasopressors can be given if patients don't respond to initial crystalloid/blood product therapy (fluid challenge)
Sepsis and anaphylaxis are examples of _____ shock
distributive
sepsis is defined as _______ caused by ______
life threatening organ dysfunction
caused by dysregulated host response to infection
T/F: NEWS and SIRS criteria are recommended over the qSOFA assessment for Sepsis
true
In sepsis, target a MAP of _____
65 or higher
MAP equation
MAP = [(2 x DBP) + SBP]/3
General principles in treating sepsis
target MAP of 65+mmHg
optimize preload w/ IV crystalloids (LR preferred)
alpha-1 agonist to increase SVR (peripheral vasoconstriction)
beta-1 agonist to increase contractility and CO
(squeeze the pipe (alpha 1) and kick the pump (beta 1)
Septic shock is:
sepsis in presence of persistent hypotension, requiring vasopressor to maintain MAP 65+
(and serum lactate 2+ despite adequate fluid resus)
Bundles in surviving sepsis campaign include interventions like:
early administration of broad-spectrum Antibiotics
fluid resuscitation w/ IV crystalloids
Vasopressor of choice in septic shock
norepinephrine (levophed)
Commonly used in addition to norepinephrine in septic shock
vasopressin
Cardiogenic shock is:
acute decompensated heart failure (ADHF: worsening HF sx)
+ hypotension and hypoperfusion also present
Drugs that can worsen HF/cause ADHF
negative inotropes (non-DHP CCBs
drugs that cause NSAIDS
cardiotoxic drugs