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BPH and more
| Question | Answer |
|---|---|
| testosterone replacement | can cause or exacerbate BPH |
| a-agonists (pseudoephedrine) | can cause or exacerbate BPH |
| beta agonists (terbutafine) | can cause or exacerbate BPH |
| medications with anticholinergic properties | can cause or exacerbate BPH |
| antihistamines | can cause or exacerbate BPH |
| tricyclic antidepressants | can cause or exacerbate BPH |
| antispasmodics with anticholinergic properties | can cause or exacerbate BPH |
| parkinson's disease medications with anticholinergic properties | can cause or exacerbate BPH |
| diuretics | can cause or exacerbate BPH |
| PSA >1.4 | BPH |
| AUA <7 | mild |
| AUA 8-19 | moderate |
| AUA >20 | severe |
| if AUA <8 or >8 but no symptoms | watchful waiting - reevaluate annually - decrease fluid intake at night, caffeine/alcohol, avoid medications that can exacerbate symptoms |
| if AUA >8 with bothersome, moderate to severe symptoms (normal prostate) | alpha blockers |
| alpha blockers | -osin |
| uroxatral | alfuzosin |
| cardura | doxazosin |
| rapaflo | silodosin |
| flomax | tamsulosin |
| hytrin | terazosin |
| intraoperative floppy iris syndrome (IFIS) | occurs more often in patients on alpha blocker who get cataract surgery |
| drugs associated with intraoperative floppy iris syndrome (IFIS) | doxazosin, silodosin, tamsulosin |
| drugs not indicated for BPH | prazosin, phenoxybenzamine |
| if AUA >8 with bothersome, moderate to severe symptoms (large prostate) | a blocker or 5-ARI or both |
| if AUA >8 with bothersome, moderate to severe symptoms (with ED) | a blocker or PDE-5 inh or both |
| if AUA >8 with bothersome, moderate to severe symptoms (predominantly irritative symptoms) | a blocker + anti-ach or a blocker + b3 agonist |
| men with LUTS secondary to BPH who have prostate enlargement | 5-alpha reductase inhibitor |
| avodart | dutasteride |
| proscar | finasteride |
| 5-alpha reductase inhibitor | -steride |
| qualifications (just have to have one) | >30g prostate measured ultrasound PSA >1.5 "large" finding in DRE assessment |
| if men have LUTS secondary to BPH without elevate PRV and when LUTS is a PREDOMINANTLY IRRITATIVE (caution in patients with PRV >250-300mL) | anticholinergic agents |
| anticholinergic notes | tolterodine best studied but can use all antimuscarinics used in overactive bladder monitor 4-6 weeks after starting mirabegron (B3 agonist) as an alternative |
| no guidelines ED and BPH exist | PDE-5 inhibitors |
| DDI with alpha blockers | PDE-5 inhibitors |
| tadalafil | the ONLY fda-approved PDE-5 inhibitor for BPH |
| Tadalafil dosing | 5 mg PO daily |
| cialis | tadalafil |
| PDE-5 inhibitors | -afil |
| herbals such as saw palmetto, stinging nettle, star grass, pumpkin seed, african plum | Guidelines: No complimentary and alternative medicine is recommended for the management of LUTS secondary to BPH |
| surgical options | Consider an option for moderate to severe BPH May be necessary if patient experiencing BPH related complications Most fail medication before proceeding with surgery |
| a blockers onset | fast (1-6 weeks) |
| 5-ARIs onset | very slow (6-12 months) |
| a blockers 2nd gen | doxazosin (cardura), terazosin (hytrin), alfuzosin (uroxatral) |
| a blockers 3rd gen (a-1a) | tamsulosin (flomax), silodosin (rapaflo) |
| a blocker clinical efficacy | AUA-SI Change: improve AUA-SI 30-40% (often 3-6 points) Urine Flow: ↑ flow rate 2-3 mL/s in most patients Prostate Size: no effect Other: reduces post-void residual (PVR) urine volume |
| 5-ARIs | dutasteride (avodart), finasteride (proscar) |
| 5-ARIs clinical efficacy | AUA-SI Change: improve AUA-SI ~2-4 points Urine Flow: ↑ flow rate 1.6-2 mL/s Prostate Size: decrease size by 25% Other: decrease risk of AUR and need for surgery (↓ progression) |
| PDE-5 inhibitors | tadalafil (cilais) |
| PDE-5 inhibitors clinical efficacy | AUA-SI Change: improve AUA-SI ~2-4 points Urine Flow: minimal increase Prostate Size: no effect Other: tadalafil is only PDE-5 inhibitor approved for BPH (2011) |
| PDE-5 inhibitors onset | moderate (4 weeks) |
| anticholinergic agents | tolterodine (detrol LA) |
| anticholinergic agents onset | fast (1-2 weeks) |
| anticholinergic agents clinical efficacy | Efficacious at decreasing irritative urinary symptoms (urinary frequency, urgency, and nocturia) Avoid with ↑ post-void residual (>250mL) may ↑ urinary retention |
| Likely all OAB anticholinergic agents effective | Tolterodine, oxybutynin, darifenacin, solifenacin, fesoterodine, trospium |
| β3-agonists | mirabegron (myrbetriq) |
| β3-agonists onset | moderate (2-8 weeks) |
| β3-agonists clinical efficacy | Efficacious at decreasing irritative urinary symptoms Similar efficacy to anticholinergics (better tolerated) Relaxes detrusor muscle (contracts bladder) Does not inhibit voiding, ↓ urine flow rate, or ↑ PVR |
| a blockers 2nd gen side effects | First-dose syncope Orthostasis Dizziness IFIS (rare) |
| a blockers 2nd gen other | Start low, go slow ↑ dose, ↑ efficacy, ↑ BP effects Take at bedtime Monitor BP (esp. if on anti-HTN meds) |
| 3rd gen a blockers (plus alfuzosin) side effects | Ejaculatory dysfunction IFIS (rare) |
| 3rd gen a blockers (plus alfuzosin) other | Alfuzosin – uroselective at usual doses ↓ BP effects vs. 2nd generation Take anytime during day Jalyn (dutasteride 0.5mg + tamsulosin 0.4mg combination capsule) |
| PDE-5 inhibitors side effects | Headache Flushing Dyspepsia |
| PDE-5 inhibitors other | Can be used with or without ED Caution with PDE-5 inhibitors and alpha blockers that can drop BP Only use tadalafil 5mg po daily |
| 5-ARIs side effects | ↓ libido Erectile dysfunction Ejaculatory dysfunction Gynecomastia (rare) ED may be secondary to nitric oxide synthase inhibition |
| 5-ARIs other | Sexual side effects may be significant and effect use in sexually-active men Pregnancy category X (RPh of childbearing age gloves) |
| anticholinergic side effects | Anticholinergic side effects (anti-SLUD) |
| anticholinergic other | Consider total anticholinergic burden Urinary retention tolterodine = placebo in trials |
| B3-agonists side effects | Hypertension |
| B3-agonists other | Use for irritative symptoms when anticholinergics not tolerated expensive! |
| functional incontinence | cant get to the restroom on time (elderly) Spinal problems |
| Medications that can affect bladder function | Allergy medications Analgesics/sedatives Anticholinergic Diuretics SNRI Muscle relaxants |
| urgency incontinence | Sudden or compelling urge to pass urine that is difficult to defer Overactive bladder: syndrome characterized by urinary urgency, frequency, and nocturia, with or without incontinence Associated with detrusor muscle overactivity |
| the ONLY UI we have meds for | urgency incontinence |
| antimuscarinics | Often used as initial pharmacotherapy Start low and go slow! ER preferred over IR Have anticholinergic effects that may limit tolerability and dose escalation Not one is better than another in the class in regards to efficacy |
| antimuscarinics CI | narrow angle glaucoma |
| antimuscarinics caution | Caution with dementia, decreased GI motility, urinary retention, tachyarrhythmias (atrial fibrillation) |
| oxybutynin | most anticholinergic |
| trospium | least anticholinergic |
| expensive but has least side effects | trospium |
| cheap but most side effcts | oxybutynin |
| OTC patch option | oxybutynin |
| QTC prolongation | solifenacin (vesicare) |
| QTC prolongation | tolterodine (detrol, detrol LA) |
| interaction with 3A4 inhibitors | darifenancin (enablex) |
| interaction with 3A4 inhibitors | fesoterodine (toviaz) |
| interaction with 3A4 inhibitors | solifenacin (vesicare) |
| interaction with 3A4 inhibitors | tolterodine (detrol, detrol LA) |
| B3-agonist for UI | Can be used in initial therapy or in patients that do not tolerate antimuscarinics Combination of antimuscarinic + beta3 agonist may be used |
| more B3-agonists | mirabegron, vibegron (gemtesa) |
| stress incontinence | Involuntary leakage of urine with increases in intra-abdominal pressure Sneezing, coughing, laughing, exercising |
| stress incontinence treatments | 1) lifestyle modifications + pelvic floor exercises (Kegals) 2) support devices 3) surgery |
| stress incontinence treatments NON-FDA approved | Topical vaginal estrogen - menopause Duloxetine (Cymbalta) |
| stress incontinence treatments lifestyle modifications | Recommended for most types of incontinences Weight loss Dietary changes Smoking cessation Bladder training (most effective for urgency incontinence) Exercises: pelvic floor (Kegel) most effective for stress incontinence |
| overflow incontinence | Continuous urinary leakage or dribbling in the setting of incomplete bladder emptying Caused by detrusor underactivity or bladder outlet obstruction |
| overflow incontinence treatments | Treatment depends on cause: Detrusor muscle underactivity not a lot of treatment options Bladder outlet obstruction urologist |
| Urinary Incontinence in men | treat BPH Lifestyle modifications preferred like women BPH + UI Alpha blockers first line If irritative symptoms persist add antimuscarinic or beta3 agonist |
| vibegron DI | Vibegron is a better substrate for the PGP – outcompetes digoxin – digoxin goes into blood increases cmax and auc |
| tolterodine metabolism | 2D6 (3A4 in 2D6 poor metabolizers) |
| tadalafil MOA | MOA not completely understood Inhibits phosphodiesterase type 5, increasing cGMP levels in prostate, urethra, bladder, and pelvic blood vessels This relaxes smooth muscles of intrinsic urethral sphincter and in prostate |
| a-adrenergic antagonists | Relax intrinsic urethral sphincter and prostatic smooth muscle Do not reduce prostate size Do not affect prostate specific antigen (PSA) |
| Drugs Relaxing Prostatic Smooth Muscle | α1-Adrenergic antagonists Phosphodiesterase 5 inhibitors |
| postsynaptic | 2nd gen |
| prostatic | 3rd gen |
| dutasteride | nonselective - type I and II |
| finasteride | selective - type II |
| Drugs Reducing Prostate Enlargement | 5a-reducatase inhibitors |
| static factor | enlargement |
| dynamic factor | smooth muscle contraction |
| as men age | Intracellular levels of DHT in prostate remain constant with aging (due to 5a reductase) estrogen converts |
| Which a1-adrenergic antagonists have cardiovascular side effects? | Terazosin, doxazosin |
| Which a1-adrenergic antagonist is uroselective? | Alfuzosin |
| Which has a potential for a drug allergy? | Tamsulosin (sulfonamide) |
| Which quinazoline derivative has a rotatable propylenediamine group? | Alfuzosin |
| Which ones are the a1A subtype? | Tamsulosin and silodosin |
| 5a reductase inhibitor process? | Irreversible modification of 5 a reductase |
| Which 5a reductase inhibitor is non selective? | Dutasteride (type I and II) |
| Which 5a reductase inhibitor has a higher logP? | Dutasteride |
| Which 5a reductase is more potent | dutasteride |
| Which of the following drugs has CYP3A4 metabolism? (like a select all) | Doxazosin, alfuzosin, tamsulosin, silodosin, finasteride, dutasteride |
| Which anticholinergic agent has a patch formulation that bypasses first pass hepatic and gut metabolism? | Oxybutynin |
| The immediate release formulation of Oxybutynin undergoes extensive first pass metabolism to be activated into this metabolite? | DEO (N-desethyloxybutynin) |
| Which anticholinergic does not pass through the BBB? | Trospium Chloride |
| Why does trospium chloride not pass through the BBB? | The quaternary amine |
| Which anticholinergic agent is excreted through active tubular secretion (and can lead to a DDI)? | Trospium chloride |
| Which anticholinergic agent should the dose be adjusted for severe renal impairment? | Trospium chloride |
| Which anticholinergic agent is metabolized by estereases (no CYP enzymes)? | Trospium chloride |
| In poor 2D6 metabolizers, the metabolism of detrol occurs by? | CYP3A4 |
| In Metabolism of Detrol through the CYP3A4 pathway what type of reaction does the drug undergo? | N dealkylation and then further goes through hydroxylation |
| In Metabolism of Detrol through the CYP2D6 pathway what type of reaction does the drug undergo? | Oxidation reaction |
| Which anticholinergic is classified as a Prodrug? | Fesoterodine fumarate (Toviaz) |
| What is a prodrug? | Inactive drug that is metabolized into an active metabolite |
| What is fesoterodine fumarate metabolized into? | 5-hydroxymethyl tolterodine |
| What is fesoterodine fumarate activated by? | Plasma esterases |
| Something about solifenacin half life? | Its long (55 hr) |
| Which anticholinergic has an Oral bioavailability of 15-25%? | Darifenacin |
| Finasteride and Dutasteride are both known as what kind of chemical structure? | Azasteroid |
| As men age testosterone ----- and estrogen ----- and intracellular DHT in prostate -----. | Decreases, increases, remains constant |
| What is responsible for later growth in men that causes BPH? | DHT |
| Which is true about estrogen? | Stimulates stromal tissues of prostate May induce androgen receptors |
| How much more potent is DHT to testosterone? | 10x |
| What is a marker for prostate cancer? | PSA >4 |
| What is a static factor? | Prostate enlargement |
| What is a dynamic factor? | Contraction of prostate around urethra |
| Which of the following class of medication may exacerbate BPH symptoms? | Testosterone replacement a-Adrenergic agonists Anticholinergics Diuretics |
| Which class of medications reduce serum PSA levels by 50%? | 5-a Reductase inhibitors |
| What are the adverse effects of 5a-reductase inhibitors | ED and nitric oxide synthase inhibition |
| Which drugs relax prostatic smooth muscle? | a1 - adrenergic antagonists PDE5 inhibitors |
| Which drugs reduce prostate enlargement? | 5a reductase inhibitors like finasteride and dutasteride |
| Which drugs are 2nd gen postsynaptic a adrenergic antagonists and can cause cardiovascular side effects? | doxazosin and terazosin |
| Silodosin and tamsulosin are? | 3rd gen prostatic a1A adrenergic antagonists |
| Which type of drugs do not reduce prostate size and do not affect PSA? | A1 adrenergic antagonists |
| What are the adverse effects of Terazosin and doxazosin? | First-dose syncope, orthostatic hypotension, and dizziness |
| ____ and _____ often occur together | BPH, ED |
| Which part of the bladder is voluntary? | External urethral sphincter |
| What is the term for when the detrusor muscle is overactive and contracts inappropriately during filling? | Bladder over activity |
| What is compromised during stress urinary incontinence? | Urethral sphincter |
| What is overflow incontinence? | Urethral overactivity- resistance to urine flow during urination Bladder under activity- detrusor muscle has weakened |
| What drugs are used for overactive bladder? | Anticholinergics, Beta 3 adrenergic agonist, TCAs, topical estrogen |
| How do anticholinergics help with overactive bladder? | Antagonize muscarinic cholinergic receptors to prevent detrusor muscle contractions Enhances bladder storage and relieves UI symptoms |
| Which of the following are Nonspecific muscarinic receptor antagonists? | Oxybutynin Trospium |
| Which drugs have greater selectivity for M3 receptors than oxybutynin and trospium? | Solifenacin and Darifenacin |
| What is tolterodine metabolized to? | Active 5-hydroxymethyl metabolite (DD01) |
| What drug has a major DI with Vibegron? | Digoxin |
| What is the TCA mentioned for UI | Imipramine |
| What class is imipramine? | SNRI TCA |
| What do the anticholinergic properties of Imipramine help with? | Over active bladder |
| What does the SNRI portion of imipramine help with? | Stress incontinence |
| What are the SSNRIs for stress UI? | Duloxetine and Venlafaxine |
| What is topical estrogen used for? | Stress UI |
| normal urine output | 0.5-1.0 mL/kg/hr |
| Non-oliguria | >500 mL/day |
| oliguria | <500 ml/day |
| anuria | <50-100 ml/day |
| AKI | ↑ SCr by > 0.3 mg/dL within 48 hours ↑ SCr to > 1.5 x baseline within 7 days Urine volume < 0.5 mL/kg/hr x 6-12 hours |
| R | SCr 1.5 – 1.9 x baseline GFR ↓ by 25% - 49% UO < 0.5 mL/kg/hr x 6-12 hours |
| I | 2.0 – 2.9 x baseline GFR ↓ by 50% - 74% < 0.5 mL/kg/hr x > 12 hours |
| F | > 3.0 x baseline OR GFR ↓ by > 75% OR > 4 mg/dL with acute ↑ > 0.5 mg/dL < 0.3 mL/kg/hr x > 24 hours OR Anuria x > 12 hours |
| L | complete loss of kidney function > 4 weeks |
| E | ESRD (> 3 months) |
| prerenal AKI | Volume Depletion Dehydration Hemorrhage Gastrointestinal losses Arterial Occlusion/Stenosis Renal artery stenosis ↓ Effective Blood Volume Sepsis Heart Failure Valvular abnormalities Liver cirrhosis ACEIs/ARBs, NSAIDS |
| NSAID and ACE/ARB effects | Ace inhibitors/arbs blocks Ang II – no constriction in the efferent arteriole NSAIDS block this PG and there will not be vasodialation – decreased perfusion |
| acute interstitial nephritis | Most often caused by drugs/infections *NSAIDs *Beta-lactam antibiotics (penicillins, cephalosporins) *Sulfonamides (trimethoprim-sulfamethoxazole, loop/thiazide diuretics) *Proton pump inhibitors |
| acute tubular necrosis | Aminoglycosides (gentamicin) Amphotericin B (antifungal) Cisplatin (chemo/cancer) Foscarnet (antiviral) Radiocontrast agents Vancomycin (MRSA) |
| postrenal AKI | obsrtuctions Anticholinergic medications (anti-dumbelss) Crystal deposition (acyclovir (IV), indinavir) |
| fena | <1 - prerenal >2 - ATN |
| use feurea when | patient on diuretics |
| indications for acute hemodialysis | metabolic acidosis, hperkalemia, toxification, overload, symptomatic uremia |
| ethacrynic acid | most ototoxic - use if allergic to other loops |
| F 40 B 1 T 20 | IV to oral furosemide 1:2 |
| maximal ceiling dose for loops (IV blous) | 200 mg fursosemide |
| diuretic combo therapy | loop + metolazone |
| aminoglycoside induced nephrotoxicity prevention | Avoid when possible and use for shortest necessary time when not possible to avoid Dose based on therapeutic drug monitoring (____TDM____): Monitor peaks and troughs Consider extended-interval dosing |
| amphotericin b prevention | Avoid when possible and use _lipid_ formulations when not possible to avoid Correct electrolyte abnormalities Hydration with 0.9% NaCl prior to infusion then daily |
| cisplatin prevention | Consider alternatives (i.e. carboplatin) if possible Consider addition of ___amifostine___ (cytoprotective inorganic phosphate) in high-risk patients Correct electrolyte abnormalities Hydration with 0.9% NaCl 12-24 hours prior to infusion x 2-3 days |
| vancomycin prevention | Dose based on ___weight__________ , renal function, and therapeutic drug monitoring (TDM) Monitor vancomycin _____trough________ levels or AUC depending on institution protocol |
| prevention of CIN | Use hydration to prevent CIN in high-risk patients 0.9% NaCl 1.0 – 1.5 mL/kg/hr 3-12 hours before __and___ 6-12 hours after contrast |
| calcium | Normal serum Ca 8.0-10.4 mg/dL (total calcium) Ionized (free) Ca: 4.25-5.25mg/dL |
| calcium albumin | ALWAYS correct total calcium for albumin Corrected calcium = calcium + 0.8 (4 – albumin) |
| hypocalcemia | Bisphosphonates Cinacalcet Loop diuretics |
| hypocalcemia treatment | PO vs IV IV if symptomatic or corrected Ca ≤7.5 mg/dL (ionized ≤3mg/dL) Do not give >60mg of elemental Ca per minute --> risk of cardiac arrhythmias Limit 500-600mg elemental Ca per dose to maximize absorption CONSTIPATION |
| hypercalcemia | Lithium Thiazide diuretics |
| hypercalcemia treatment | NS 3-6 L over 24 hours ± loop diuretics (if volume overload occurring due to aggressive hydration) Calcitonin (IV) Bisphosphonates (zoledronic acid or pamidronate) |
| calcitonin after 48 hrs | tachyphylaxis |
| Denosumab (Xgeva)- Hypercalcemia of malignancy | Option to treat hypercalcemia that is refractory to zolendronic acid or when bisphosphonates are contraindicated due to renal function |
| hypomagnesium | Loop diuretics Amphotericin B Aminoglycosides Calcineurin inhibitors Digoxin Cisplatin |
| best friends | mg, ca, k |
| hypomagnesium treatment | PO magnesium (one study showed doses increased serum Mg levels on median of 0.1mg/dL) Mild-moderate Dose limiting effect- DIARRHEA |
| hypomagnesium treatment IV | 2g IV increases serum Mg 0.2mg/dL |
| mg monitoring | Mild-moderate: within 24 hours Severe- several hours after IV infusion (takes time to distribute to tissues) |
| isoosmolar | 275-290 mOsm/kg |
| isotonic crystalloids | Normal Saline-0.9% NaCl (NS) Lactated Ringer (LR) (balanced crystalloid) Plasmalyte or Normosol (balanced crystalloid) |
| hypotonic crystalloids | Dextrose 5% in water (D5W) (free water) ½ Normal Saline-0.45% NaCl (1/2 NS) |
| hypertonic crystalloids | Hypertonic Saline- generally 3% NaCl (red flag drug!) |
| colloids | Albumin (5% or 25%) Packed Red Blood Cells (pRBC) Dextran Hetastarch |
| normal sline | Commonly used for fluid resuscitation (replenishing fluid in vasculature |
| LR | Most similar to blood plasma concentration Commonly used in trauma or burns |
| 1/2 NS | Hypernatremia with hypovolemia |
| 3% Sodium chloride (HIGH ALERT MEDICATION) | Critical care medication General use: Severe hyponatremia with neurological symptoms; traumatic brain injury (used to shrink the swelling from this injury) |
| NS | 154 Na |
| 4-2-1 | 1st 10 kg 4ml/kg/hr 2md 10 kg 2ml/kg/hr >20 1ml/kg/hr |
| 100-50-20 | 100 ml/kg/day 50 ml/kg/day 20 ml/kg/day |
| Na | 135-145 |
| K | 3.5-5.0 |
| Cl | 97-107 |
| BUN | 5-20 |
| HCO3 | 23-29 |
| SCr | 0.8-1.2 |
| Ca | 8-10.4 |
| Mg | 1.5-2.4 |
| PO4 | 2.5-4.5 |
| WBC | 5-10x10^3 |
| Plt | 150-400x10^3 |
| Hgb | F 12-16 M 14-18 |
| Hct | F 36-46 M 41-53 |
| fluid loss treamtnet | Treatment: Replace fluid (~1kg loss= 1L fluid replaced) |
| signs of excess fliud | peripheral edema, JVD, pulmonary edema |
| hypokalemic goal | Goal: >3.5 mEq/L but PREFER >4 mEq/L in cardiac patients and ICU patients |
| hypokalemic treatment | replace Mg KCl |
| hypokalemic PO | Max oral doses should be 60mEq (ideally 40 mEq max) per dose Can cause nausea/vomiting (especially if doses >40mEq at a time) |
| hypokalemic IV | peripheral - 10 mEq/hr central w ekg - 20-40 mEq/hr |
| (K) For every 10mEq given, | serum K will increase by ~0.1 |
| renal impairment K | generally decrease dose by 50% |
| hyperkalemia | RAAS-active drugs (ACE, ARB) K+ sparing diuretics (spironolactone) NSAIDs Cyclosporine Trimethoprim-sulfamethoxazole (Bactrim) Heparins |
| Calcium gluconate | Does NOT affect K levels in the body Purpose: normalize EKG Do NOT recommend if no EKG changes present Dose: 1 g IV x1 May repeat if necessary Monitor EKG |
| Calcium chloride is an option | NOT preferred due to increase tissue damage in peripheral line |
| shifts K intracellulary | Regular insulin albuterol sodium bicarbonate (only acidosis) |
| eliminates k | loop diuretics, sod poly sul, patiromer, sod zirc cyclo |
| regular insulin | 10 units |
| albuterol | 20 mg in 4 ml NS |
| symptomatic hypernatremia | GOAL: Na by 0.5 mEq/L/hr or MAX of 12 mEq/L/day if CHRONIC hypernatremia GOAL: Na by 1-2 mEq/L/hr or MAX of 12 mEq/L/day for ACUTE hypernatremia MAXIMUM correction in 24 hours: 8-12 mEq/L |
| TBW (female) | = 0.5 L/kg x weight in kg |
| TBW (men) | = 0.6 L/kg x weight in kg |
| free water deficit in liter | TBW x (serum Na/140 - 1) |
| calculate how much to give in 24 hrs | = water deficit x goal change in Na / (serum Na-140) |
| Hyperglycemia-induced hyponatremia (isotonic or hypertonic) | corrected serum Na = measured Na + 1.6 (glucose -100 / 100) |
| SIADH | Antidepressants Anticonvulsants Antipsychotics Chemotherapy Vasopressin analogs |
| calculate sodium deficit | = TBW x (desired serum Na - measured serum Na) |
| estimate change in serum sodium from fluid | = Naiv - Nas / TBW+1 |
| Rapid increase in serum sodium acute decrease in brain cell volume | ODS |
| vaptans | hepatotoxic, CI in hypovolemic hyponatremia |
| hypophosphatemia | Insulin Antacids |
| fleet phospho soda (sodium phosphate solution) | BBW kidneys |
| phosphate treatment | 15mmol phosphate in 250mL D5W or NS over 3 hours May increase phosphate level by 0.5-0.8 mg/dL |
| pH | 7.4 (7.35-7.45) |
| pCO2 | 35-45 mmHg |
| pO2 | 80-100 mmHg |
| HCO3 in blood gas | 22-28 mEq/L |
| anion gap metabolic acidosis (agma) | anion gap >12 |
| anion gap metabolic acidosis (agma) | mudpiles metformin, methanol, uremia, DKA, prop glycol, infection, lactic acidosis, ethylene glycol, salislyates |
| non anion gap metabolic acidosis (nagma) | anion gap <12 |
| non anion gap metabolic acidosis (nagma) | usedcrap uterosigmoid, small bowel fistula, extra chloride, diarheea, carbonic anhydrase inhibitors, RTA, adrenal insuff, pancreatic fistula |
| respiratory acidosis | cans CNS depressants (narcotics), airway obstruct, neuromuscular, sevevre pnemonua |
| metabolic alkalosis | cleverpd contraction, licorice, endocrine, vomiting, axcess alkali, refeeding, posthypercapnia, diuretics |
| resp alkalosis | champs CNS disease, hypoxia, anxity, mech vent, progesterone, salicylates |
| symptoms alkosis | hypoven, hypokalemic |
| calculate anion gap (normal <12) | AG= Na+-Cl--HCO3- Corrected AG= every 1 g/dL decrease in albumin (normal=4), add 2.5 to AG |
| ph <7.4 | acidemia |
| ph>7.4 | alkemia |
| resp alk | low paco2 |
| meta alk | high hco3 |
| Check for compensation | Winter’s formula for metabolic acidosis Expected pCO2 = 1.5 (HCO3-) + 8 (± 2) Expected ↑ in pCO2 with metabolic alkalosis Expected ↑ in pCO2 = 0.75 (patient HCO3- normal HCO3-) + 40 |
| if agma check corrects hco3 | Corrected HCO3- = patient’s HCO3- + (patient’s AG normal AG) |
| For rise in AG by 1 | corresponding decrease of HCO3 by 1 mEq/L |
| If calculated HCO3 is not in the reference range (22-28 mEq/L) coexisting metabolic disturbance | If > 28mEq/L, indicates corresponding metabolic alkalosis If < 22mEq/L, indicates a non-anion gap metabolic acidosis |
Created by:
Urmeme