Special Populations

Crystalloids

• Less costly & fewer ADR

• D5W

• Normal Saline

• Lactated Ringer’s (LR)

• Plasma-Lyte A

Colloids

• Large molecules primarily remain in the intravascular space & increase oncotic pressure

• Albumin 5%, 25% (Albutein, AlbuRx)

• Dextran

• Hydroxyethyl starch

Hyponatremia

Hypervolemic Hyponatremia

• By fluid overload

• Diuresis with fluid restriction

Hypovolemic Hyponatremia

• By diuretics

• Correct any underlying causes & stop intake of hypotonic solutions

• Severe symptoms and/or Na <120 → Hypertonic (3%) NaCl IV

***Correct Na > 12 mEq/L/24hours can cause Osmotic Demyelination Syndrome

Arginine Vasopressin Receptor Antagonists for Hyponatremia

Conivaptan

• AVOID hypovolemic hyponatremia, anuria

Tolvaptan (Samsca)

• Boxed - Should be initiated & re-initiated in a hospital; ODS risk if rapid correct (>12mEq/L/day)

• Hepatotoxicity

• For Hypervolemic Hyponatremia

Hypernatremia

• Caused by water deficit & hypertonicity

Hypokalemia

A drop of 1 mEq/L of K below 3.5 mEq/L = A Total Body Deficit of 100 - 400 mEq

• IV potassium must be administered by a peripheral line

• Max infusion rate </= 10mEq/hr & Max concentration 10mEq/100mL

If Hypokalemia is Resistant to Treatment

• Check Magnesium

If Hypokalemia & Hypomagnesemia

• Replace Magnesium FIRST (most commonly with Magnesium Oxide)

Hypophosphatemia

• Treat with IV phosphorus when PO4 is < 1 mg/dL

Int

Intravenous Immunoglobulin (IVIG)

Gammagard, Gamunex-C, Octagam, Privigen

• Only for immunodeficiency conditions

• Can impair vaccination response

• Slower infusion rate in renal & CVD

• Don’t freeze, shake, or heat

• Boxed - Acute renal dysfunction; Thrombosis

Vasopressors

MOA: Stimulate alpha receptors to cause peripheral vasoconstriction & increase SVR

• Boxed for Dopamine & NE - Extravasation (Treat with Phentolamine)

• All are vesicants when IV & should via Central IV line

• Arrhythmias, Tachycardia, Necrosis (gangrene)

• Bradycardia (Phenylephrine), Hyperglycemia (Epinephrine)

Dopamine	1-4 mcg/kg/min -→ Dopamine-1 Agonist 5-10 mcg/kg/min → Beta-1 Agonist 10-20 mcg/kg/min → Alpha-1 Agonist
Epinephrine (Adrenalin)	Alpha-1, Beta-1, Beta-2 Agonist
Norepinephrine (Levophed)	Alpha-1 agonist > Beta-1 agonist
Phenylephrine	Alpha-1 agonist
Vasopressin (AVP & ADH)	Vasopressin receptor agonist

Vasodilators

Nitroglycerin Low dose: venous vasodilator High dose: arterial vasodilator	AVOID SBP < 90 AVOID PDE5-inhibitors or Riociguat Headache, Tachycardia, Tachyphylaxis Requires a non-PVC container
Nitroprusside (Nipride) Mixed (equal) arterial & venous vasodilator	Boxed - metabolism produces Cyanide (blue) Boxed - excessive hypotension Boxed - must be diluted (D5W preferred) Thiocyanate/cyanide toxicity (increased risk in renal & hepatic impairment) Need light protection

Inotropes

MOA: increase contractility of the heart

Dobutamine - Beta-1 agonist

Milrinone - Phosphodiesterase-3 (PDE-3) inhibitor [can cause significant vasodilation]

Hypovolemic Shock

• Fluid resuscitation with Crystalloids [FIRST LINE]

• Vasopressor not effective unless intravascular volume is adquate 

Distributive Shock (e.g., Septic, Anaphylactic)

• Fluid + Vasopressors

Septic Shock

• Target a mean arterial pressure of >/= 65 mmHg

  • MAP = [(2 x DBP) + SBP]/3

• Optimize preload with IV crystalloids (LR preferred)

• Alpha-1 agonist to increase SVR

• Beta-1 agonist to increase myocardial contractility & CO

• Norepinephrine → vasopressor of choice

Acute Decompensated Heart Failure (ADHF)

Edema (pulmonary or lower extremity), JVD, and/or acites → Volume Overload

• Loop diuretics

• Vasodilators can be added

Reduced renal function, altered mental status, and/or cool extremities —> Hypoperfusion

• Inotropes

• If PT becomes hypotensive → add vasopressor (Dopamine, NE, Phenylephrine)

• AVOID vasodilators → can reduce BP & worsen hypoperfusion

Both Volume Overload & Hypoperfusion

• A combination of agents above