pharm exam 1

Drugs + Coagulation

• Clotting factors are made in the liver

• Coagulation is a specific sequence

• Most clotting factors are inactive in the plasma

  • Vitamin K is necessary for synthesis

  • Calcium is required for activation

• Clots need to be dissolved because

  • Loss of blood flow → loss of perfusion → tissue hypoxia → cell death

• Thrombosis: inappropriate clotting

  • Marked by hypoxia, anoxia, localized necrosis

• Bleeding: inability to clot

  • Marked by excess bleeding. Hemophilia and thrombocytopenia

• Antiplatelets: decrease the formation of platelet plug

  • Block receptor sites on the platelet membrane → prevent platelet - platelet interactions and interaction with clotting chemicals

  • Examples:

    • Aspirin

    • Clopidogrel

    • Plavix

  • Uses:

    • Post MI

    • PAD

    • Venous and arterial grafts

  • Pharmacokinetics:

    • Some IV, some PO

    • Well absorbed

    • Highly protein bound

    • Metabolized in the liver

    • Excreted in urine, and enter human milk

  • Contraindications

    • Allergy

    • Known bleeding disorder

    • Recent surgery (body needs to heal by forming clots)

    • Closed head injury (increase the risk of brain bleed, hematoma)

  • Adverse Effects

    • Bleeding

    • Bruising

    • Headache

    • Dizzy

    • Weak

    • N/V

    • Skin rash

    • ASA: tinnitus and Ulcer

• Anticoagulants: interfere with the normal coagulation process and clotting cascade/thrombin formation

  • Example:

    • Heparin

    • Warfarin

    • Antithrombin III/Thrombate III

    • Argatroban

    • Enoxaparin/Lovenox

    • Dabigatran/Pradaxa

    • Rivaroxaban/Xarelto

    • Apixaban/Eliquis

  • Uses:

    • DVT

    • PE

    • Surgery

    • Prevention of stroke

  • Pharmacokinetics

    • IV, SQ, PO

    • Heparin has immediate onset

    • Warfarin onset is 3 days and lasts 4-5 days

    • Others have rapid onset and short acting

  • Contraindications

    • Allergy

    • Known bleeding disorder

    • Trauma

    • Spinal puncture

    • GI ulcers

    • IUD

  • Adverse Effects

    • Bleeding

    • Bruising

    • Warfarin: require frequent blood tests

• Heparin OD (↑PTT) → Protamine Sulfate

• Warfarin OD

  • ↑ INR + no bleeding → Vitamin K

  • ↑ INR + bleeding → K centra

• Thrombolytics: break down already formed clots.

  • Examples:

    • Alteplase/Activase (TPA)

    • Reteplase/Retavase

    • Tenecteplase/TNKase

    • Urokinase/Abbokinase (IV declot)

  • Uses:

    • Acute MI

    • Acute ischemic stroke

    • Acute PE

  • Pharmacokinetics

    • IV

    • Metabolized in liver

    • Cross placenta

  • Contraindications

    • Allergy

    • Known active bleeding

    • Recent surgery

    • CVA within last 3 months

    • Aneurysm

    • Child birth

    • Organ biopsy

    • GI bleeding

  • Adverse Effects

    • Bleeding (huge bleeding risk: brain bleed, GI bleed, surgical site bleed, anywhere-bleed)

    • Reduction of H&H

    • Cardiac arrhythmias

    • Hypotension

    • Mental status changes

    • GI bleeding

    • Bronchospasm

    • Anaphylactic reaction

  • Drugs that increase the effect of Warfarin

• Drugs that decrease the effect of warfarin =  clot risk

• Grapefruit/grapefruit juice decreases the body's ability to metabolize warfarin

Fluids and Bloods

• 60% body weight = total body water

  • Intracellular fluid (40% body weight, inside cells) and extracellular fluid (20% body weight, outside cells, interstitium, blood)

• Normal loss of fluids:

  • Bloodstream

  • Small & large intestine

  • Poop 200 mL/day

  • Pee (800-2000 mL/day)

  • Sweat (500-700 mL/day)

  • Insensible (breathing out, evaporation, 600-900 mL/day)

• People >70 cannot tolerate the fluid shift of colonoscopy

• Dehydration symptoms

  • Thirst

  • Dry mouth and/or lips

  • Nausea

  • Fatigue

  • Lightheadedness

  • Darked and decreased urine

  • Loss of 2% bodyweight

    • Irritability, difficulty concentrating, headaches

• Dehydration causes

  • Vigorous exercise

  • Not drinking enough water

  • Vomiting

  • Diarrhea

  • Excessive sweating

  • Inability to swallow

  • Diuretics

  • Substances (alcohol, medication)

• IV fluids (come in crystalloids and colloids)

  • Crystalloids - see through

    • Contain mineral salts and/or water soluble molecules that flow easily through semi permeable membrane

    • Allow for easy transfer from the bloodstream into cells/tissues

  • Colloids - not see through

    • Solution containing larger molecules used to expand plasma

    • Always hypertonic

  • Water follows salt

• Hypertonic solution - high salt, low water. Osmotic flow OUT of the cell. Shrink the cell

• Isotonic solution - equal salt and water. No osmotic flow

• Hypotonic solution - low salt, high water. Osmotic flow INTO the cell. Swell the cell.

• Isotonic Solution

  • Indications:

    • Replacement of extracellular fluid loss!!

    • Expand intravascular volume

    • Promote urine output

  • Cautions:

    • Intravascular increase → intravascular overload

    • Circulatory overload

    • Potential dilution of Hgb and Hct

  • Types:

    • NS (0.9% NaCl)

      • Primary fluid of choice for dehydration and resuscitative efforts

      • The ONLY fluid used when administering blood products (must prime the tubing with NS for blood products)

      • DKA
        Hypercalcemia

      • Hyponatremia

      • Metabolic alkalosis

      • Shock 

    • LR (Lactated Ringers)

      • Used for acidosis!!

      • Good for burn and surgical patients

      • Helps to prevent development of lactic acid that contributes to acidosis

      • Acute blood loss

      • Lower GI tract fluid loss (risk for acidosis)

      • Hypovolemia (caused by 3rd spacing, fluid moving out of IV space to other areas)

      • NOT COMPATIBLE WITH MANY OTHER SOLUTIONS

      • Can be bolused

    • D5W (5% Dextrose in Water)

      • First isotonic… then become hypotonic in the body

        • Isotonic because the ratio of dextrose in the solution makes the tonicity similar to intravascular fluid.

        • Hypotonic because once the dextrose is metabolized it provides free water (which will push water into the cells)

      • Good choice for NPO patients and surgical patients

      • Hypernatremia

      • Cannot be bolused

• Hypotonic Solutions

  • Not typically bolused

  • Fluid shifts out of intravascular space to both intracellular and interstitial spaces (into the cell)

  • Reduces fluid circulating

  • Types

    • 0.45 NaCl (½ NS)

    • D5W

    • 0.33 NaCl (⅓ NS)

  • Indications

    • Intracellular dehydration (DKA, hyperosmotic hyperglycemia-type II equivalent of DKA)

  • Concerns/Cautions

    • Can deplete the circulatory volume, even though cells are being hydrated

  • Contraindications

    • DO NOT GIVE IT TO PATIENTS WITH INTRACRANIAL SWELLING OR PRESSURE

    • Extensive burns

• Hypertonic Solution

  • Pulls water out of the cell and interstitial spaces and into the intravascular compartment →  increase extracellular fluid volume

  • Dangerous, and most common uses are in emergency or ICU

  • Mostly for very, very sick individuals

  • Types:

    • D10W

      • Pediatric patients dependent on TPN that is interrupted (lost access to their TPN)

      • Severe hypoglycemia (check their blood sugar before removing D10W)

    • D5NS

    • D5 ½ NS

    • D5LR

    • 3% NaCl (can be bolused for cerebral edema)

      • RAPIDLY decreases cellular edema - particularly in the brain

      • MAJOR stroke or trauma causing cerebral edema

      • It pulls the pressure away, and they pee it out

      • Severe hyponatremia

    • 7.5% NaCl

  • Nursing considerations

    • Vascular irritant (phlebitis)

    • Monitor lung sounds frequently

    • Assess for tachypnea

    • Assess for tachycardia

    • Frequent neuro-monitoring

  • Concern

    • High potential for intravascular fluid volume overload

    • Pulmonary edema (leaking can lead to)

    • Hypernatremia

• Always think: what will kill the patient first???

• Colloids

  • Hypertonic, volume expanders

  • Draw fluid from the cells into the plasma

  • Increase plasma osmolality and osmotic pressure

  • Types

    • Blood

      • Whole blood

      • PRBC’s

      • Platelets 

    • Albumin

    • Plasma

      • FFP

  • Uses

    • Hypovolemic shock due to hemorrhage, surgery, burns

    • Severe anemia

  • Increases intravascular space without excessive volume

• Whole blood

  • Contains everything lol (RBC, WBC, plasma, platelets, plasma proteins, immunoglobulins)

  • Increases circulating blood volume in acute blood loss following trauma or surgery. Hypovolemia & shock

  • Not very efficient, rarely needed

  • High allergy risk

  • Must be transfused within 24 hours of collection

• Packed red blood cells

  • Just red blood cells

  • Increases RBCs in controlled volume for symptomatic anemia and blood loss. Increases circulating volume of red blood cells capable of carrying oxygen

  • Reaction: allergy risk, hemolytic and non hemolytic reactions, sepsis, and hyperkalemia

  • Reaction will typically occur within first 50 mL of the transfusion (15-30 minute)

• Fresh frozen plasma

  • Portion of blood with clotting factors

  • 92% water, 8% plasma proteins (albumin, fibrinogen, globulins, & clotting proteins)

  • Increased ability to clot, increased blood volume

  • Used for extensive burns, massive hemorrhage, shock, DIC, TTP, replace coag factors for deficiencies, liver disease, and hemophilia

  • Reaction: anaphylaxis/allergy, volume overload, hemolytic and non hemolytic reaction, sepsis

  • FFP does not need to be and crossed to patient because it does not contain antigens

• Platelets

  • Portion of blood containing platelets (obviously), assisting in clotting processes in vascular injury

  • Given to people with platelet deficiency, bleeding disorder (thrombocytopenia), 

  • Reaction: febrile non hemolytic, allergy, sepsis, chemo patients (to help with platelet plug formation)

• Albumin

  • Increases fluid volume using oncotic pressure

  • Used for hemolytic disease, hypovolemia, burns, dialysis, hypoalbuminemia

  • Drawbacks: fluid over load

  • Most common use!!! DIALYSIS

• Type A blood has A antigen, B blood has B antigen, etc

  • O blood has no antigen, AB blood has both antigen

  • Type O: universal donor

  • Negative blood types can only receive negative, Positive can receive positive or negative

• RH

  • Presence of D antigen = Rh positive

  • Absence of D antigen = Rh negative

  • Women who are Rh- with Rh+ fetus, RhoGAM is given

• When hanging blood, you only have 30 minutes to do so once its delivered or you must return it to the bank

• Only order blood products one at a time unless EMERGENCY with multiple patent PIVs

• Blood administration

  • ID patient with 2 identifier

  • Document VS with temperature

  • Confirm patient name, MRN, patient blood type, blood bank ID number, blood type, expiration date, and volume

  • Administer blood per institutional protocols

  • Assess and reassess patient for transfusion reaction

  • Assess VS 15 minutes post initiation of transfusion then 30 minutes x 2 then Q1 hour during the remainder of the transfusion

• Transfuse blood in 4 hours or less from receipt

• Prime tubing with NS and do NOT administer any other medications with blood besides NS

• HEMOLYTIC REACTION: chest pain, chest pressure, low back pain

• Allergic reaction: hives, rash, wheeze, BP drop, anxiety

• Febrile reaction: headache, tachycardia, tachypnea, fever, chills, anxiety

• If there is reaction

  • Stop the transfusion immediately (obviously)

  • Assess for presence of emergency conditions

  • Keep PIV open for life saving medications

  • Notify doctor, carry out orders

  • Document and complete incident report

  • Notify blood bank, return remaining blood and tubing to blood bank

• Why administer blood/fluid

  • Fluid imbalances

    • Loss of fluid increases blood solute concentration and serum sodium

  • Fluid overload

    • Fluid moves out of blood vessels into interstitial spaces

    • Cause edema in tissues and lungs

    • Weight gain, big ol ankles, bounding pulse, hypertension, pale cool and moist skin, moist lung sounds, JVD, low Hgb and Hct

• NEVER TRY TO “MOVE” A BLOOD CLOT (why would you do that TwT)

Pharm Basics

• Controlled substances (DEA scheduling)

  • C-1: no medical use, high abuse (heroin, LSD)

  • C-2: severe dependence potential (narcotics, amphetamines)

  • C-3: Moderate risk (nonbarbiturate sedatives, some narcotics)

  • C-4: Lower abuse potential (antianxiety meds, nonnarcotic pain meds)

  • C-5: lowest abuse potential (small amounts of codeine in cough syrups)

• Tablets

  • Compression level affects how fast it will dissolve (more packed, slower dissolve)

  • May be scored so you can split the dose

  • Do not crush enteric coated or extended release tablets

• Capsule

  • Medication inside gelatin shell

  • Often sustained-release or extended release

  • Some can be opened or sprinkle (confirm with pharmacy)

• Liquid, Elixir, Syrup

  • Already dissolved = faster absorption

  • Elixirs = alcohol based liquids

  • Syrups = sugar based liquids

• Injection

• Other route

  • Transdermal: skin patches and topical medication

  • Eyedrops and ear drops: local action

  • Rectal suppositories (PR): good for NPO patient, vomiting and seizure

  • Inhaler: direct to lungs (asthma, COPD). Spacers recommended for kids.

• Key absorption fact

  • PO meds go through first pass effect (liver princesses it before the blood stream)

  • IV= 100% bioavailability (straight into the bloodstream, no detour)

• Metabolism

  • First pass effect

  • CYP450 enzyme system: major liver enzymes

    • Some drugs induce metabolism (↑ drug effect)

    • Some drugs inhibit metabolism (↓ risk toxicity)

• Excretion

  • Kidney impairment → drug buildup → watch for toxicity

• Blood brain barrier

  • Only lipid soluble drugs pass easily

• Placenta and breast milk

  • Drugs pass through! Must check for safety during pregnancy

• Protein binding

  • Highly bound drugs (like warfarin) have less free drug, but interactions can displace drugs and cause toxicity

SNS

• α₁

  • *During anaphylaxis, epinephrine acts on α₁

  • Dilate pupil

    • ↑ salivary glands, ↓ mucosal edema

  • Vasoconstriction (↑SVR = ↑BP)

    • Agonists:

      • Epi - stop bleeding

      • Norepi - stop bleeding

      • DA- ↑ dose, shock

      • *Phenylephrine - shock 

    • Antagonists:

      • Prazosin - HTN

    • Constricts bladder

    • Ejaculation & prostate

      • Alpha 1 receptor also control internal urinary sphincter. 

      •  α₁ activation → contraction of sphincter →  directs semen outward → “successful launch”

        • Block α₁ → door doesn’t shut → semen backflow into bladder →  retrograde ejaculation (dry orgasm)

      •  α₁ activation → prostate squeezes → urethra gets narrower → harder to pee

  • Constrict smooth muscle

• β₁

  • ↑HR ↑BP ↑Cardiac contractility = ↑CO & ↑arrhythmias

  • Agonists

    • Epi- ♡ arrest, ↓CO, heart block

    • Norepi- ↓Cardiac output, heart block, shock

    • Isoproterenol- cardiac arrest, heart block

    • DA- shock, heart failure

    • Dobutamine- heart failure

  • Antagonist

    • NONSELECTIVE Propranolol- HTN, heart attack

    • CARDIAC SELECTIVE Metoprolol- HTN, MI, heart failure

  • ↑ release of renin = ↑ BP

    • Agonists

      • DA- low dose for renal failure → ↑ urine perfusion

    • Antagonist

      • Propranolol→  HTN → ↓ renin →  ↓BP

        • ↓ HR→ ↓  heart contract

• β₂

  • Epi loves beta-2! It saturate beta-2, then move to alpha 1.

• Dilates vessels, ↓ SVR

  • Agonist

    • Epi- saturate beta-2 first (cause quick BP drop) then move to alpha 1

• Relax uterus, ↓ contractions

  • Agonist

    • Terbutaline- tocolytic

    • Ritodrine- tocolytic

    • Epi

  • Antagonist

    • Propranolol

• Dilates bronchi (↑ O2)

  • Agonist

    • Epi - anaphylaxis

    • Albuterol - acute asthma (maintenance)

    • Terbutaline - very important for asthma

  • Antagonist

    • Propranolol - any pulmonary issue (asthma, COPD, etc)

      • Increase PVR = increase airway resistance

• Dilate arterioles in skeletal muscle

  • Antagonist

    • Propranolol - constrict

• Bowel motility

• D

  • Increase renal blood flow = increase urine output

  • Agonist

    • DA - AKI, renal failure, shock

• α₂

  • Decrease BP, SVR

  • Increase Sedation

  • Dry mouth

  • Agonist

    • Clonidine- ADHD, opioid withdrawal

• SNS = adrenergic