Therapy Exam 3

Front 1

What are the 7 acute complications of sickle cell disease?

Back 1

1) Fever/infection
2) Neurologic complications (stroke)
3) Acute chest syndrome
4) Priapism
5) Vasooclusive pain crisis
6) Aplastic crisis (anemia)
7) Splenic sequestration crisis

Front 2

What are the 5 parts of health maintenance for sickle cell disease?

Back 2

1) Immunizations
2) Penicillin prophylaxis
3) Folic acid
4) Fetal hemoglobin inducers
5) Chronic transfusions

Front 3

What are the common pathogens associated with sickle cell disease infections?

Back 3

1) S. pneumoniae (most common)
2) H. influenzae
3) Salmonella
4) M. pneumoniae (older children)

Front 4

What organ dysfunction puts sickle cell patients at risk for infection?

Back 4

Functional asplenia

Front 5

What is the antibiotic of choice for infections in the sickle cell patient?

What if the patient is allergic?

Back 5

Ceftriaxone 50-75 mg/kg/dose IV Q24h

Clindamycin 10 mg/kg/dose Q8h

Front 6

Acutely ill patients with sickle cell disease are candidates for what additional antibiotic?

Back 6

Vancomycin

Front 7

If a patient with sickle cell disease might be infected with M. pneumoniae, what additional antibiotic should they receive?

Back 7

Macrolide

Front 8

What is the acute therapy for sickle cell patients with stroke?

Back 8

1) Exchange/simple transfusion
2) Anticonvulsants for seizures

Front 9

Sickle cell patients with neurologic complications (stroke) are candidates for what lifelong treatment?

Back 9

Chronic transfusion with 10-15 mL/kg pRBCs Q3-4weeks with goal HbS < 30% total Hb

Front 10

If a sickle cell patient is receiving chronic transfusion therapy, what additional agent might they need and why?

Back 10

Desafirox (Exjade) to prevent iron accumulation

Front 11

What is the management for a sickle cell patient with acute chest syndrome? (4)

Back 11

1) Fluid therapy
2) Broad-spectrum antibiotics (ceftriaxone, azithromycin)
3) Respiratory support
4) Transfusions if necessary

Front 12

What are some non-pharmacologic therapies for priapism in sickle cell patients?

Back 12

Hydration
Hot compress
Frequent urination
Exercise

Front 13

What are the 2 pharmacologic therapies for priapism in sickle cell patients?

Back 13

1) Vasoconstrictors (epinephrine)
2) Vasodilators (tertbutaline, hydralazine)

Front 14

What are the 2 main management strategies for sickle cell patients with vasooclusive pain crises?

Back 14

1) Hydration
2) Pain management
* Antibiotics for infection

Front 15

What is the main management strategy for sickle cell patients with aplastic crisis (anemia)?

Back 15

1) Supportive care
* Antibiotics for infection

Front 16

What are the 2 main management strategies for sickle cell patients with splenic sequestration crises?

Back 16

1) Immediate transfusion
2) Splenectomy most likely
* Antibiotics for infection

Front 17

What is the progression of therapy for pain management in sickle cell patients?

Back 17

1) Non-opioid
2) Weak opioid
3) Opioid

Front 18

Which immunizations are recommended for sickle cell patients?

Back 18

1) Influenza
2) Pneumovax
3) Meningococcal (for splenectomy)

Front 19

Sickle cell patients should be given what antibiotic maintenance prophylaxis?
Which agents can be used and what age range?
What if there is an allergy?

Back 19

Penicillin prophylaxis
1) Penicillin VK
2) Benzathine penicillin
Allergy - macrolide
For ages 2 months - 5 years

Front 20

What is the dosing for folic acid in patients with sickle cell disease?

Why is folic acid necessary?

Back 20

Infants - 0.1 mg/day
Children &lt; 4 - 0.3 mg/day
Children 4+ - 1 mg/day

Increased demand because of accelerated erythropoeisis

Front 21

What fetal hemoglobin inducer is most commonly used in patients with sickle cell disease?

What are the 3 specific indications?

Back 21

Hydroxyurea
1) Painful episodes > 2 times per year
2) Severe symptomatic anemia
3) History of acute chest syndrome

Front 22

What ages are approved for use of hydroxyurea in sickle cell disease?

Back 22

Ages > 5

Front 23

What is the dosage for hydroxyurea in sickle cell patients?
(Starting dose, titration schedule, max dose)

Back 23

* Initiation at 15 mg/kg/dose PO Qday
* Increase by 5 mg/kg Q12weeks
* Max 35 mg/kg/day

Front 24

Discontinue hydroxyurea when the following parameters meet what level?
1) ANC
2) Platelets
3) Hb
4) Reticulocytes
5) SCr
6) LFTs

Back 24

1) ANC < 2,000
2) Platelets < 80
3) Hb < 5
4) Reticulocyte count < 80
5) SCr increase by 50%
6) LFTs increase by 100%

Front 25

What does the acronym SICKLE stand for?

Back 25

S - strokes, swelling, spleen probs
I - infections, infarctions
C - crises, cholelithiasis, chest syndrome, chronic hemolysis, cardiac probs
K - kidney disease
L - liver disease, lung probs
E - erection, eye problems

Front 26

What are normal albumin levels?

What are normal pre-albumin levels?

Back 26

Albumin 3.5 to 5

Pre-albumin 15 to 30

Front 27

What are the general caloric requirements for a person per day?

Back 27

25-35 kcal/kg/day

Front 28

What are the 3 different protein requirements per day?
(mild stress, moderate stress, severe stress)

Back 28

Mild stress - 0.8-1 g/kg/day
Moderate stress - 1-1.2 g/kg/day
Severe stress - 1.5-2 g/kg/day

Front 29

How do you convert grams Nitrogen to grams of protein that a patient needs?

Back 29

Grams N * 6.25 = Grams protein

Front 30

In what percentages are amino acids generally supplied for parenteral nutrition?

Back 30

10% and 15%

Front 31

Each gram of amino acids has ___ kcal

Back 31

4

Front 32

In what percentages is dextrose generally supplied for parenteral nutrition?

Back 32

70%

Front 33

Each gram of dextrose has ___ kcal

Back 33

3.4

Front 34

In what percentages are lipids generally supplied for parenteral nutrition?

Back 34

10%, 20%, 30%

Front 35

Each gram of lipids has ___ kcal

Back 35

9

Front 36

What are the typical fluid requirements for patients on a parenteral formula?

Back 36

30-35 mL/kg/day

Front 37

What are 3 common additives to nearly all infusions?

Back 37

1) Stress ulcer prophylaxis
2) Heparin
3) Insulin if needed

Front 38

What are some important labs to be monitored weekly?

Back 38

1) Pre-albumin
2) CMP
3) TGs
4) PO4
5) Mg
6) Ca
7) CBC
8) PT/INR

Front 39

What percentage of total Kcal should lipids comprise?

Back 39

30-60%

Front 40

What are 4 common complications when using a TPN?

Back 40

1) Hyperglycemia
2) Hypertriglyceridemia
3) Liver enzyme elevation
4) Loss of intestinal integrity

Front 41

If a patient on a TPN has renal failure (CrCl < 25), what should we limit daily amino acids to?

Back 41

0.6-0.8 g/kg/day

Front 42

What BUN levels are we worried about when giving TPNs?

Back 42

BUN > 100

Front 43

When a patient's sodium level is 149 on a TPN, how much NaCl do you add?

Back 43

None if Na > 145

Front 44

When a patient's sodium level is 138 on a TPN, how much NaCl do you add?

Back 44

For Na 135-145, add 70 mEq/L NaCl

Front 45

When a patient's sodium level is 122 on a TPN, how much NaCl do you add?

Back 45

For Na < 135, add 140 mEq/L NaCl

Front 46

What is normal input/output (volume)?

Back 46

2,600mL

Front 47

How do you calculate daily water requirements for patients on a TPN?

Back 47

When > 20kg = 60 mL/hr + 1 mL/hr for every kg > 20
(or 30-35 mL/kg/day)

Front 48

What is the normal range for potassium?

Back 48

3.5 to 5.3 mmol/L

Front 49

What is the treatment for a patient with hyperkalemia with changes in the EKG?

Back 49

Calcium chloride (or gluconate) 1g over 5 minutes, repeat Q30minutes until it normalizes

Front 50

If a patient on a TPN has a pH of < 7.3 (acidotic), what therapy should be administered?

Back 50

NaHCO3

Front 51

What is the normal range for magnesium?

Back 51

1.6 to 2.5 mg/dL

Front 52

What normally happens to patients on TPNs in regards to potassium and magnesium levels?

Back 52

Hyperkalemia
Hypomagnesemia

Front 53

What are the 5 steps to making a TPN?

Back 53

1) Calculate protein requirements
2) Calculate TPN's total kcal (25-35)
3) Calculate amount of dextrose and lipids needed per day
4) Calculate remaining volume of TPN (from total fluids - dextrose/lipids/proteins)
5) Add supplemental IV fluids

Front 54

What therapy should be given twice weekly to prevent essential fatty acid deficiency in patients on a TPN?

Back 54

250mL of 20% intralipids

Front 55

What is the body's normal pH?

Back 55

7.35-7.45

Front 56

What is the body's normal arterial oxygen (PaO2)?

Back 56

80-100

Front 57

What is the body's normal CO2 (PaCO2)?

Back 57

34-45

Front 58

What is the body's normal arterial bicarbonate (HCO3)?

Back 58

22-26

Front 59

What is the body's normal serum anion gap?

Back 59

3-11 mmol/L

Front 60

PaCO2 (arterial CO2) is an acid or a base?

Back 60

Acid

Front 61

Venous CO2 is an acid or a base?

Back 61

Base

Front 62

What are the 6 steps to determine acid-base status?

Back 62

1) Evaluate pH for acidity/basicity
2) Evaluate PaCO2 for respiratory status
3) Evaluate HCO3 for metabolic status
4) Compare PaCO2 and HCO3 with pH (same direction analysis)
5) Compare PaCO2 and HCO3 with pH (opposite direction analysis)
6) Evaluate PaO2 and O2 saturation for hypoxemia

Front 63

PaCO2 is measured on which side - arterial or venous?

Back 63

Arterial

Front 64

PaCO2 (arterial CO2) is a measure of respiratory or metabolic status?

Back 64

Respiratory

Front 65

When the pH is < what value would you give NaHCO3?

Back 65

When pH < 7.2 (acidotic), give NaHCO3

Front 66

What is the treatment for respiratory alkalosis?

Back 66

Self-limited in most cases - slow breathing or breathe into a bag

Front 67

A decrease in bicarbonate leads to what acid-base disorder?

Back 67

Metabolic acidosis

Front 68

What are some common causes of elevated SAG metabolic acidosis?

Back 68

1) Lactic acidosis
2) CKD with ESRD
3) Ketoacidosis
4) Toxin ingestion

Front 69

What are some causes of normal SAG metabolic acidosis?

Back 69

1) Diarrhea
2) Pancreatic fistula
3) Urethral acidosis
4) Renal tubular acidosis
5) Toxin ingestion

Front 70

What is the formula for SAG?

Back 70

SAG = Serum Na - (venous CO2 + venous Cl)

Front 71

What is the dosing for IV sodium bicarbonate?

Back 71

LD = 0.5(weight) * (HCO3desired - HCO3current)

Front 72

When do you consider use of tromethamine?

Back 72

Metabolic acidosis when pH < 7.2
3.6-10.8g IV over one hour

Front 73

What are contraindications to tromethamine? (3)

Back 73

1) Heart failure
2) ESRD
3) Asthma (soft contraindication)

Front 74

When is the only time we give oral sodium bicarbonate?

Back 74

Chronic renal disease (metabolic acidosis)

Front 75

What are some causes of normal urine chloride metabolic alkalosis?

Back 75

1) Excessive alkali administration
2) Contraction alkalosis (diuretics)
3) Decreased chloride intake
4) Non-urinary loss of chloride
5) Post-hypercapnia

Front 76

What are some causes of elevated urine chloride metabolic alkalosis?

Back 76

1) Medications (glucocorticoids, diuretics)
2) Hypokalemia (diuretics)
3) Mineralocorticoid excess

Front 77

What is the treatment for metabolic alkalosis?

Back 77

Chloride supplementation

Front 78

What pH is criteria for chloride supplementation?

Back 78

Chloride is for metabolic alkalosis when pH is 7.45-7.5 (mild)

NS bolus, then maintenance dosing

Front 79

In what acid-base disturbance would you use HCl or L-arginine?

Back 79

Metabolic alkalosis

Front 80

What pH is criteria for HCl supplementation?

Back 80

HCl is for metabolic alkalosis when pH is > 7.5

Front 81

What pH is criteria for L-arginine supplementation?

Back 81

L-arginine is for metabolic alkalosis when pH > 7.5

Front 82

What therapy is used for slowing progression of CKD in diabetics?

Back 82

1) Insulin therapy with goal 70-120
2) Hypertension goal < 130/80
*ACEI/ARB
*Non-DHP CCBs may be used

Front 83

What therapy is used for slowing progression of CKD in non-diabetics?

Back 83

1) Hypertension goal < 130/80
*ACEI/ARB
*Non-DHP CCBs

Front 84

What are the 3 components of symptom management in patients with CKD?

Back 84

1) Fluids and electrolytes
2) Calcium/phosphorus maintenance
3) Hematologic abnormalities (anemia)

Front 85

What happens to sodium, water, and potassium levels in patients with CKD?

Back 85

Increased sodium and water
Increased potassium
(Also increased acidosis)

Front 86

How do you manage sodium and water homeostasis in patients with CKD?

Back 86

Patients often have increased sodium and water

1) Fluid and salt restriction
2) Loop diuretics +/- metazolone

Front 87

How do you manage potassium homeostasis in patients with CKD?

Back 87

Patients often have increased potassium

1) Restriction of dietary potassium
2) Avoidance of potassium supplements
3) Avoidance of potassium-retaining meds
4) Potassium-shifting agents when EKG changes
5) Potassium-binding agents if needed

Front 88

What are the 3 potassium-shifting agents used for hyperkalemia in CKD?

Back 88

1) Insulin (+dextrose)
2) NaHCO3
3) High-dose albuterol

Front 89

K-exalate is what type of medication?

Back 89

Potassium-binding resin

Front 90

Metabolic acidosis in CKD is managed with what?

Back 90

Oral NaHCO3 (bicitra) when pH < 7.35

Front 91

What effect does CKD have on phosphate levels?

Back 91

Increased phosphate levels

Front 92

What effect does phosphate levels have on calcium and PTH?

Back 92

Increased levels of PO4 bind calcium and reduce serum calcium

Reduced serum calcium stimulates PTH release

Front 93

What effects does PTH have on calcium and phosphate? (3)

Back 93

1) Decreases phosphate reabsorption from kidneys
2) Increases calcium reabsorption from kidneys
3) Calcium mobilization from bones

Front 94

Why is there reduced vitamin D levels in patients with CKD?

Back 94

Failing kidneys can't convert vitamin D to the active form

Front 95

What are the 5 phosphate-binding agents?

Back 95

1) Calcium carbonate
2) Calcium acetate
3) Calcium citrate
4) Sevelamer
5) Lanthanum

Front 96

Which phosphate-binding agent is best in patients with acidic pH?

Back 96

Calcium carbonate

Front 97

Which phosphate-binding agent is best in patients with alkaline pH and can bind 2x as much calcium as its counterpart?

Back 97

Calcium acetate

Front 98

Which phosphate-binding agents will NOT cause an increase in calcium?

Back 98

1) Sevelamer
2) Lanthanum

Front 99

When would you consider using vitamin D in patients with CKD? (2)

Back 99

1) Low calcium levels
2) Elevated PTH despite use of phosphate-binders

Front 100

What are the 3 active forms of vitamin D?

Back 100

1) Calcitriol
2) Paracalcitol
3) Doxercalciferol

Front 101

Which vitamin D analog is the most active?

Back 101

Calcitriol

Front 102

In what situation are calcimimetics approved?

Back 102

Secondary hyperparthyroidism in ESRD

Front 103

Normocytic, normochromic anemia results from decreased levels of what?

Back 103

EPO

Front 104

Hypochromic or macrocytic anemia results form decreased levels of what?

Back 104

Folate and B12

Front 105

Microcytic anemia results from decreased levels of what?

Back 105

Iron

Front 106

For anemia in CKD patients, what therapy do we administer? (3)

Back 106

1) EPO agents - epoetin, darbepoeitin
2) Iron supplementation
3) B12 and folate supplementation

Front 107

What is the goal for the following CKD anemia parameters:

Hgb
Hct
TSAT
Ferritin

Back 107

Hgb 11-12
Hct 33-36%
TSAT > 20% (20-50)
Ferritin 100-800

Front 108

How often do you monitor Hgb/Hct for patients receiving treatment for anemia with CKD?

Back 108

Monitor once weekly until stable, then twice monthly

Adjust doses at 4 week intervals

Front 109

What two drugs are likely to slow progression of CKD?

Back 109

1) ACE inhibitors
2) ARBs

Front 110

What is the definition for acute renal failure?

Back 110

SCr increase of 0.5 or 50% increase

Front 111

What is normal urine output per day?

Back 111

0.5-1 mL/kg/hr
(500-1,000 mL/day)

Front 112

What are the indications for dialysis (acronym)?

Back 112

A = acidosis
E = electrolyte imbalance
I = intoxication
O = overload of fluid
U = uremia

Front 113

When a patient is on CRRT, what CrCl should you dose them on?

Back 113

CrCl of 30-50 mL/min

Front 114

What are the 3 protective therapies for patients with renal dysfunction receiving contrast dyes?

Back 114

1) Hydration (normal saline)
2) NaHCO3 infusion
3) N-acetylcysteine

Front 115

What combination of drug classes are used for induction immunosuppression in renal transplant? (2)

Back 115

1) Antibody agents
2) Corticosteroids

Front 116

Which 4 agents are used for both induction AND rejection?

Back 116

1) OKT3
2) Thymoglobulin
3) ATGAM
4) Alemtuzumab

Front 117

Which 4 agents for renal transplant require pre-medication?

Back 117

1) OKT3
2) Thymoglobulin
3) ATGAM
4) Alemtuzumab

Front 118

When pre-medicating certain drugs for renal transplant, what agents should you use?

Back 118

1) Antipyretic
2) Antihistamine
3) Corticosteroid

Front 119

What is the dosage for OKT3 for renal transplant?

Back 119

Induction AND Rejection
5mg daily for 7-14 days

Front 120

What are the dose-limiting toxicities of thymoglobulin?

Back 120

1) Thrombocytopenia
2) Leukopenia

Front 121

What is the dosage for thymoglobulin for renal transplant?

Back 121

Induction AND Rejection
1) 1.5 mg/kg/day for 7-14 days
2) 50 mg/day for 3 days, then dose until CD3 > 10

Front 122

What are the dose-limiting toxicities of ATGAM?

Back 122

1) Thrombocytopenia
2) Leukopenia

Front 123

Which anti-proliferative antibody requires a test dose of 0.1mL of 1:1,000 intradermally?

Back 123

ATGAM

Front 124

What is the dosage for ATGAM for renal transplant?

Back 124

Induction AND Rejection
10-30 mg/kg/day for 5-14 days

Front 125

What is the specific mechanism of basiliximab and daclizumab for renal transplant?

Back 125

IL-2 receptor blocker - inhibits activated T-cells from proliferation

Front 126

What is the dosage for basiliximab for renal transplant?

Back 126

Induction ONLY
20mg IV at transplant, then again on day 4

Front 127

What is the dosage for daclizumab for renal transplant?

Back 127

Induction ONLY
1 mg/kg/dose IV at transplant, then again every 14 days (2 weeks) for 5 doses (10 weeks total)

Front 128

What is one adverse effect of daclizumab?

Back 128

Hyperglycemia

Front 129

What is the dosage for alemtuzumab for renal transplant?

Back 129

Induction AND Rejection
30mg single dose, may give second dose 5 days later

Front 130

What 4 drug classes comprise the therapy for maintenance immunosuppression in renal transplant?
Which 2 are always required?

Back 130

1) Calcineurin inhibitors (required)
2) Corticosteroids (required)
3) +/- Anti-proliferatives
4) +/- Sirolimus

Front 131

What are the calcineurin inhibitors?

Back 131

1) Cyclosporine
2) Tacrolimus

Front 132

What are the anti-proliferative agents?

Back 132

1) Mycophenolate
2) Azathioprine
3) Sirolimus

Front 133

Which drugs' absorption is affected by food?

Back 133

1) Cyclosporine
2) Tacrolimus
3) Mycophenolate

Front 134

What is the therapeutic range for cyclosporine?

Back 134

100-400 ng/mL (trough)

Front 135

What are some adverse effects seen with cyclosporine (calcineurin inhibitor)?

Back 135

1) Nephrotoxicity
2) Hirsutism
3) Gingival hyperplasia
4) Hyperlipidemia
5) Electrolyte disturbances (inc K, dec Mg)
6) CNS effects (HA, tremor, seizures)

Front 136

Which drug can be given with diltiazem in order to allow for lower doses of concomitant steroids?

Back 136

Cyclosporine (maintenance)

Front 137

Cyclosporine can be given with what drug in order to allow for lower doses of concomitant steroids in maintenance therapy?

Back 137

Diltiazem (P450 inhibitor)

Front 138

What are the IV and PO dosages of Tacrolimus?

Back 138

IV: 0.05-0.1 mg/kg/day continuous
PO: 0.2-0.3 mg/kg/day divided Q12h

Front 139

What is the therapeutic range for Tacrolimus?

Back 139

5-20 ng/mL (trough)

Front 140

Which drugs' absorption is affected by food and must always be given the same way (with or without food)?

Back 140

Tacrolimus
Cyclosporine

Front 141

What adverse effect is seen in Tacrolimus but not in Cyclosporine?

Back 141

Insulin-dependent diabetes

Front 142

What adverse effects are seen with Tacrolimus?

Back 142

1) Nephrotoxicity (worse than Cyclo)
2) CNS effects (HA, tremor, seizures)
3) Insulin-dependent diabetes
4) Electrolytes (inc K, dec Mg)
5) Hypertension

Front 143

What is the F (bioavailability) of the oral and IV forms of Cyclosporine and Tacrolimus

Back 143

IV = 1.0 (obviously)
PO = 0.3

Front 144

What is the formula to convert between IV and PO dosages of Cyclosporine and Tacrolimus?

Back 144

Desired dose = current dose * (Cdes/Ccurr) * (Fcurr/Fnew)

Front 145

What are 3 adverse effects of Mycophenolate to worry about?

Back 145

1) Bone marrow suppression
(neutropenia, thrombocytopenia)
2) Increased risk of viral infections
3) CNS effects

Front 146

What effect dose food have on Mycophenolate absorption?

Back 146

Delays absorption - take on empty stomach

Front 147

What 2 drugs decrease absorption of Mycophenolate?

Back 147

1) Antacids
2) Cholestyramine

Front 148

What are 3 adverse effects of Azathioprine to worry about?

Back 148

1) Bone marrow suppression
2) Alopecia
3) Pancreatitis

Front 149

What is the dosage for Sirolimus?

Back 149

Maintenance
2 mg/day PO once daily

Front 150

What is the therapeutic range for Sirolimus?

Back 150

10-15 mcg/mL

Front 151

What are 3 adverse effects of Sirolimus to worry about?

Back 151

1) Bone marrow suppression
2) Hyperlipidemia
3) Interstitial lung disease

Front 152

What is the first treatment strategy to try for acute rejection of renal transplant?

Back 152

High-dose steroids (pulse therapy)
1mg methylprednisolone x 3 days
200mg PO prednisone, taper to 20mg

Front 153

What are H2RAs and PPIs used for post-transplant?

Back 153

GI prophylaxis

Front 154

What drugs can be used for thrush prophylaxis post-transplant?

Back 154

1) Nystatin
2) Mycelex

Front 155

What drug is used for herpes prophylaxis post-transplant?

Back 155

Acyclovir (one month)

Front 156

What therapy is used for osteoporosis treatment/prevention post-transplant?

Back 156

Calcium supplements

Front 157

What drug is used for CMV prophylaxis post-transplant?

Back 157

Gancyclovir

Front 158

What drug is used for polyomavirus-associated nephropathy from BK virus post-transplant?

Back 158

Reduce immunosuppression, then
Cidofovir

Front 159

Which drugs are best to use for HTN associated with transplant therapy?

Back 159

CCBs
ACE inhibitors
ARBs

Front 160

What drug is used for hyperlipidemia associated with transplant therapy?

Back 160

Statins

Front 161

What drugs are used for PCP prophylaxis post-transplant?

Back 161

1) Bactrim
2) Dapsone
3) Pentamidine

Front 162

What are the 4 complications of liver failure?

Back 162

1) Portal hypertension/varices
2) Ascites
3) Spontaneous bacterial peritonitis
4) Encephalopathy

Front 163

What CP score is Class A?
Class B?
Class C?

Back 163

Class A = score of 5-6
Class B = score of 7-9
Class C = score > 10

Front 164

What are the 3 components of managing portal hypertension/varices?

Back 164

1) Endoscopic treatment (banding)
2) Pharmacotherapy (vasoconstrictors/dilators)
3) TIPS (salvage)

Front 165

What pharmacotherapy agents are used for management of portal hypertension/varices?

Back 165

Splanchnic vasoconstrictors - octroetide, vasopressin

Vasodilators - propranolol, nadolol, *nitrates

Front 166

When should a patient receive prophylaxis when diagnosed with a varix?

Back 166

1) Non-bleeding small varix with CP score of B or C
2) Non-bleeding medium/large varix
3) Secondary prophylaxis after acute bleed

Front 167

What are the two reasons (mechanisms) for using non-selective beta blockers in portal HTN/varices?

Back 167

B1 effects - decreases CO
B2 effects - splanchnic vasoconstriction

Front 168

What is the goal HR on non-selective BB for portal HTN/varices?

Back 168

1) 25% reduction in HR
2) HR no less than 55 bpm

Front 169

True or False - Combination therapy with BB and nitrates has been shown beneficial over either alone in portal HTN/varices

Back 169

False - Combination therapy can be considered in patients unable to do EVL, and nitrate monotherapy is NEVER recommended

Front 170

What are the four stagings for varices?

Back 170

1) Cirrhosis, no varix
2) Non-bleeding small varix
3) Non-bleeding medium/large varix
4) Acute bleeding/hemorrhage

Front 171

What are the 4 components in treating acute variceal bleeding/hemorrhage?

Back 171

1) Stabilization/resuscitation (fluids/airways)
2) Control of bleeding (octreotide/banding)
3) Secondary prophylaxis (BB, EVL)
4) SBP prophylaxis

Front 172

What is involved in stabilizing a patient with an acute variceal hemorrhage?

Back 172

1) Volume support (crystalloid/colloid)
2) Airway protection

Front 173

How do you control the bleeding in a patient with acute variceal bleeding?

Back 173

1) Octreotide (splanchnic)
*50-100 mcg bolus
*25-50 mcg/hr infusion for 5 days

2) EGD (banding)
*Use octreotide and banding together

3) TIPS for recurrent hemorrhage

Front 174

What secondary prophylaxis should be administered for a patient with acute variceal bleeding?

Back 174

Combination of non-selective BB and EVL (banding)

Front 175

What 3 bacteria can cause spontaneous bacterial peritonitis?

Back 175

1) E. coli
2) K. pneumoniae
3) S. pneumoniae

Front 176

What patients are considered for SBP prophylaxis? (3)

Back 176

1) History of SBP
2) Variceal hemorrhage
3) Low-protein (<1g) ascites

Front 177

What is first-line for SBP?

Back 177

Broad-spectrum cephalosporin
Cefotaxime 2g IV Q8h for 5 days
Ceftriaxone Q24h for 5 days

Front 178

What is second-line for SBP?

Back 178

Fluoroquinolone (cephalosporin failure)
Ciprofloxacin
Ofloxacin

Front 179

What is prophylaxis treatment for SBP?

Back 179

1) Bactrim DS PO Qday
2) Norfloxacin/ciprofloxacin PO Qday

Front 180

When should you begin empiric antibiotics for patients with ascites?

Back 180

When PMNs from ascitic fluid > 250

Front 181

How do you determine whether ascites is due to portal hypertension?

Back 181

SAAG (serum albumin - ascites albumin)

Front 182

What is the formula for SAAG?

Back 182

Serum albumin - ascites albumin

Front 183

What SAAG values are indicative of portal hypertension?

Back 183

SAAG > 1.1 g/dL

Front 184

What are the 3 components of ascites therapy?

Back 184

1) Alcohol abstinence
2) Sodium restriction < 2 g/day
3) Diuretics

Front 185

What pharmacotherapy agents (and at what doses) are used for ascites?

Back 185

1) Spironolactone 100mg --> 400mg
2) Furosemide 40mg --> 160mg

Front 186

What 3 things do we monitor when using diuretics for ascites?

Back 186

1) Daily weight loss of 0.5kg
2) Sodium, potassium levels
3) Renal function

Front 187

If a patient has more than 5L of ascitic fluid drawn off, what therapy should he receive?

Back 187

5% albumin

Front 188

What is the cause for CNS disturbances in hepatic encephalopathy?

Back 188

Accumulation of unprocessed nitrogenous wastes

Front 189

What are the 2 treatment components for hepatic encephalopathy?

Back 189

1) Lactulose
2) Protein-restricted diet

Front 190

What is the dosing and goals for lactulose?

Back 190

For hepatic encephalopathy:
PO 30-60mL Q1-2h until catharsis
PR 300-700mL enema Q6-8h

Decrease the dose and titrate to produce 2-4 soft stools per day