Intravenous Drugs, Fluids, And Antidotes

Front 1

What are PCV and DEHP? What are their significance?

Back 1

PVC = Polyvinylchloride = 3rd most widely used plastic - can be made softer by "plasticizers"

Virtually all PVC materials utilize the plasticizer Di (2-ethylhexyl) phthalate or DEHP

There are two concerns with PVC bags: Leaching and sorption

Front 2

What is leaching?

Back 2

One substance is pulled from another - the concern here is the leaching of DEHP from PVC bags

DEHP has been shown to adversely affect the male reproductive system - little available study data in humans

Drugs known to be leaching agents should be put in non-PVC bags and use non-DEHP tubing

Front 3

Which drugs are known to leach?

Back 3

Tacrolimus
Temsirolimus
Teniposide
Cabazitaxel
Docetaxel
Paclitaxel

Front 4

What is sorption?

Back 4

One substance pulls in another

The PVC pulls in some of the drug reducing the concentration of drug in solution

Pharmacists should use a polyolefin container which reduces sorption and leaching

Front 5

Which drugs have the potential for sorption by PVC bags?

Back 5

Amiodarone
Carmustine
Lorazepam
Sufentanil
Thiopental
Regular insulin
Nitroglycerin

Front 6

What are the two types of fluids?

What are these composed of?

Back 6

Crystalloids - Sodium with added electrolytes to approximate the content of human plasma

Colloids - albumin 5% and 25%, hetastarch 6%, pentastarch 10%, dextran and others

Front 7

Which solutions are crystalloid?

Back 7

Normal Saline solutions with or without KCl
Lactated Ringers

***Na is a small molecule and does not create a large oncotic pressure gradient - only about 25% of the solution will remain intravascular within 30 minutes***

Front 8

Crystalloids and colloids can be used for fluid resuscitation. What are the benefits an drawbacks of each?

Back 8

Crystalloids - more volume needed in comparison to colloids

Colloids - Associated with hypersensitivity reactions and bleeding disorders

Front 9

What are the different types of shock?

Back 9

Hypovolemic (hemorrhagic)
Cardiogenic
Distributive (septic)
Obstructive (massive pulmonary embolism)

Front 10

What is first line therapy for hypovolemic shock?

Back 10

Fluid resuscitation with crystalloids or colloids

Can also administer blood products

Front 11

What is given if the patient does not respond to fluid resuscitation?

Back 11

Vasopressors (won't work without adequate fluid resuscitation - at least 30 ml/kg)

Front 12

What is used in cardiogenic shock?

Back 12

Vasopressors and positive inotropes

Front 13

Sepsis =
Septic Shock =

Back 13

Presence of an infection with Systemic Inflammatory Response Syndrome (SIRS)

Development of hypotension in an patient with sepsis

Cystalloids or colloids, vasopressors, positive inotropes, antibiotics, corticosteroids

Front 14

Mechanism of Dobutamine and Milrinone:

Back 14

Dobutamine: Primarily Beta - 1 stimulation - increased CO and HR (used in cardiogenic shock)

Milrinone: Selective phosphodiesterase inhibitor in cardiac and vascular tissue leading to vasodilation and inotropic effects with little chronotropic effects

Front 15

Adverse effects of dobutamine and milrinone:

Back 15

Hypo/hypertension
Increased HR (more dobutamine)
Tachyarrhythmia
Ventricular arrhythmia
Thrombocytopenia (milrinone)
Amrinone (Inocor) no longer used due to thrombocytopenia

Front 16

What are the main vasopressors?

Back 16

Dopamine
Epinephrine (Adrenalin)
Norepinephrine (Levophed)

Vasopressin (V1, V2 agonist causing vasoconstriction and increased systemic vascular resistance)

Front 17

Mechanism of action of dopamine:

Back 17

Dopamine: Endogenous precursor of norepinephrine
Low dose (1-3 mcg/kg/min): Dopamine receptor stimulation
Medium dose (5-10 mcg/kg/min): Beta - 1 stimulation
High dose (10-20 mcg/kg/min): Alpha - 1 stimulation

Front 18

Mechanism of action of norepinephrine:

Back 18

Epinephrine: Beta agonist at low doses - More alpha agonist at higher doses

Norepinephrine: Beta - 1 agonist and alpha receptors causing increased contractility and heart rate as well as vasoconstriction - alpha > beta

Front 19

What agent do you use to limit necrosis if norepinephrine extravasates into the surrounding tissue?

Back 19

Phentolamine (Regitine) - alpha antagonist - given SC to infiltrated area

Front 20

Which agent is preferred to induce analgesia in the ICU?

Back 20

Fentanyl

Front 21

Which drugs are recommended for sedation?

Back 21

Midazolam
Propofol (also preferred for procedural sedation)

Front 22

What caution is necessary with propofol?

Back 22

Propofol-related infusion syndrome - cardiac arrhythmias and death

Front 23

Which agent is a good alternative to propofol?

Back 23

Dexmedetomidine

Associated with fewer days on mechanical ventilation, less incidence of delirium, less sedating/more sleep like state, but significantly more expensive

Front 24

Lorzepam is used for:
Midazolam is used for:

Back 24

Long-term sedation (>48 hours)
Short-term sedation (<48 hours) - shorter acting- highly lipophilic - may accumulate in obese patients

Front 25

Propofol brand name:

Propofol adverse effects:

Back 25

Diprivan

Hypotension, apnea, hypertiglyceridemia, green urine, propofol-related infusion symdrome (PRIS - rare but fatal)
Monitor TG's if longer than 2 days
Formulated in a lipid emulsion - provides 1.1 Kcal/mL

Front 26

Dexmedetomidine brand name:
MOA:
What is the maximum allowed infusion time?

Back 26

Precedex
Alpha-2 agonist
24 hours
Patients are arousable and alert if stimulated - does not cause respiratory depression

Front 27

Key difference between morphine and fentanyl:

Back 27

Fentanyl = Less hypotension due to no histamine release
100 times more potent than morphine
Preferred agent with unstable hemodynamics - morphine metabolite (morphine - 6 - glucuronide) accumulates in renal impairment

Front 28

What is typically given for agitation in the ICU?

Back 28

Haloperiold (Haldol) - IV push repeated every 15-30 minutes until calm

Front 29

Metabolic acidosis causes:
1) non-elevated anion gap
2) elevated anion gap

Back 29

1) renal tubular acidosis, diarrhea, administration of acidic substances
2) cyanide, uremia, toluene, ethanol (alcoholic ketoacidosis), diabetic ketoacidosis, isoniazid, methanol, propylene glycol, lactic acidosis, ethylene glycol, salicylates

Front 30

Metabolic alkalosis causes:

Back 30

Loop and thiazide diuretics
High dose PCNs
Vomiting
Cystic fibrosis

Front 31

Respiratory acidosis causes:

Respiratory alkalosis causes:

Back 31

Opioids, sedatives, anasthetics, stroke, asthma/COPD

Pain, Fever, Brain tumors, salicylates, catecholamines, theophylline

Front 32

What is the cause of stress ulcers in the ICU?




What are the risk factors?

Back 32

Patients with critical illness have reduced blood flow to the gut as blood is diverted to vital organs - this leads to a breakdown of gastric mucosal defense mechanisms including prostaglandin synthesis, bicarbonate production and cell turnover
Risk Factors: Mechanical ventilation, Coagulopathy, Sepsis, Traumatic brain injury, Burn patients, Acute renal failure, High dose corticosteroids

Front 33

Many patients in the ICU are at high risk of developing DVT/PE due to risk factors in this population. Which 3 agents are used as DVT prophylaxis?

Back 33

Lose dose unfractionated heparin - 5,000 units SC BID-TID
Low Molecular Weight Heparin - Enoxaparin 30 mg SC BID or 40 mg SC daily; Dalteparin 2,500 - 5,000 units SC daily
Factor Xa inhibitor - Fodaparinux 2.5 mg SC daily; Rivaroxaban 10 m PO daily

Front 34

What if the patient has CrCl < 30 ml/min?

Back 34

Factor Xa inhibitors are not used if CrCl < 30 ml/min

Enoxaparin 30 mg SC daily

Front 35

3 types of anesthesia:



General MOA:

Back 35

Local (numb an area)
Regional (block pain)
General (surgery)

Decrease permeability of neuronal sodium ions - this decreases initiation and conduction of nerve impulses

Front 36

Common anesthetic side effects:



Inhaled anesthetics can cause this additional effect:
How do you treat it?

Back 36

Hypotension
Bradycardia
NV
Mild drop in body temperature
Overdose = respiratory depression/cardiac arrest

Malignant hyperthemia (rare)
Dantrolene

Front 37

Commonly used anesthetics (local, inhaled, injectable):

Back 37

Local: lidocaine, benzocaine

Inhaled: desflurane, sevoflurane, isoflurane, nitrous oxide, others

Injectable: bupivacaine, lidocaine, ropivacaine, others

Front 38

Scenarios where skeletal muscle paralysis is ideal:

Back 38

Facilitation of mechanical ventilation
Increased intracranial pressure
Treatment of muscle spasms (tetany)
Prevent shivering in therapeutic hypothermia after cardiac arrest
***Must also provide sedation prior to paralysis***
***Must also mechanically ventilate as these paralyze the diaphragm***

Front 39

Two types of neuromuscular blockers:

Back 39

Depolarizing
Non-depolaring

Front 40

Name the only depolarizing agent and when it is typically used:

Back 40

Succinycholine

Typically reserved for intubation - not used for continuous blockade

Rarely associated with malignant hyperthermia (particularly with the use of inhaled anesthetics)

Front 41

Succinylcholine MOA:

Non-depolarizing MOA:

Back 41

Binds acetylcholine receptors and desensitizes them

Binds acetylcholine receptors and block the actions of endogenous acetylcholine

Front 42

Name the common non-depolarizing agents:

Which are short, intermediate, and long acting agents?

Back 42

Atracurium - Intermediate
Cisatracurium (Nimbex) - Intermediate
Pancuronium - Long
Rocuronium (Zemuron) - Intermediate
Vecuronium - Intermediate

Front 43

Which of the non-depolarizing agents have short half lives?

Which agents can accumulate in renal or liver impairment?

Back 43

Atracurium, Cisatracurium


Pancuronium, Vecuronium

Front 44

Hemostatic agents used to prevent blood loss:

Back 44

Aminocaproic acid (Amicar)
Tranexamic acid (Cyklokapron)
Recombinant Factor VIIa (NovoSevene RT)

Front 45

In intravenous immunoglobulin formulations, the IgG is extracted from the plasma of a thousand or more blood donors for patients with immune deficiency. It is used for several primary immunodeficiency conditions as well as a variety of other indications with varying results.
The majority of IVIG use today is for this:

Back 45

As an anti-inflammatory agent

Has been tried in SLE and rheumatoid arthritis

***IVIG is a blood product and is subject to supply shortages and infectious disease risks***

Front 46

There are 8 different products currently on the market. They vary based on these variables:

Products = Carimune NF, Flebogamma DIF, Gammagard, Gammagard S/D, Gammaplex, Gammunex - C, Octagam, and Privigen

Back 46

Volume
Osmolarity
IgA content
Sodium content
Sugar content
Stabilizing agents
pH values

Front 47

What type of product should patients with IgA deficiency receive?

Back 47

IVIG typically contains about 95% IgG with trace amounts of IgA and IgM
IgA deficiency increases the patients risk of anaphylaxis - the lowest IgA content should be chosen

Front 48

Black box warning for IVIG products:

Back 48

Renal damage due to osmotic nephritis
Avoid concurrent nephrotoxic drugs, keep hydrated, use isotonic and slow infusions

Front 49

IVIG doses are based on:


Dose adjust in:

Do not:

Back 49

IBW and rounded to the nearest whole vial size (except neonates)

Renal impairment

Shake product (antibody inactivation) or infuse into other IV lines (some require a filter and some do not)

Front 50

Levothyroxine IV:PO conversion

Back 50

1:2 (IV dose 50% of PO dose)

Front 51

Instability =

Back 51

Product/solution is modified because of storage conditions (time, temperature, light, absorption)
Considered unstable when it loses more than 10% of its labeled potency

Front 52

Incompatibility =

Back 52

Product/solution combination makes the product unsuitable for patient use (degradation, precipitation, pH change)

Front 53

Four types of compatibility listed in Trissels:

Back 53

Solution compatibility
Additive compatibility
Syringe compatibility
Y-site injection compatibility

Front 54

ANTIDOTES

Back 54

ANTIDOTES

Front 55

Acetaminophen =
Warfarin =
Anti-cholinesterase insectisides/organophosphate (nerve agents) =
Anticholinergic compounds =
Arsenic, Lead =

Back 55

N-acetylcysteine
Phytonadione

Atropine/Pralidoxime
Physostigmine
Succimer

Front 56

Benzodiazepines =
Beta blockers =
Botulism =
Calcium channel blockers =
Carbon monoxide =

Back 56

Flumazenil (Romazicon)
Glucagon
Botulism anti-toxin
Calcium chloride 10%, glucagon
Oxygen

Front 57

Cyanide =
Digoxin =
Ethylene glycol, methanol =
Heavy metals =
Heparin =

Back 57

Sodium nitrate, sodium thiosulfate, hydroxycobalamin
Digoxin immune Fab (Digibind, DigiFab)
Ethanol or fomepizole
Dimercaprol or penicillamine or calcium disodium acetate
Protamine

Front 58

Iron =
Isoniazid =
Methemoglobinemia =
Opioids =
Salicylate =

Back 58

Deferoxamine (Desferal)
Pyridoxine (Vitamin B6)
Methylene Blue
Naloxone (Narcan)
Sodium bicarbonate

Front 59

Snake bites =
TCA's =

Back 59

Crotalidae polyvalent (Antivenin, Crofab)
Sodium bicarbonate