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PHAR 503 Exam 2 PHAR 503 Exam 2 Rho Chi Acid-Base Disorders Which medication would most likely NOT lead to a metabolic alkalosis? A. Loop Diuretic B. Thiazide Diuretic C. Desmopressin D. Citrate Which medication would most likely NOT lead to a metabolic alkalosis? A. Loop Diuretic B. Thiazide Diuretic C. Desmopressin D. Citrate Diuretics increase loss of H+, vomiting, hypokalemia, citrate is metabolized to HCO3- A patient suffering from an acute panic attack might be at risk for developing: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory Acidosis D. Metabolic Acidosis A patient suffering from an acute panic attack might be at risk for developing: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory Acidosis D. Metabolic Acidosis Hyperventilating -> blowing off CO2 (acid) If you have a patient who is experiencing a respiratory acidosis, which of the following sets of labs would most likely match the patient? A. pH: 7.41, HCO3-: 20 B. pH: 7.35, CO2: 52 C. pH: 7.35, HCO3-: 20 D. pH: 7.45, CO2: 32 If you have a patient who is experiencing a respiratory acidosis, which of the following sets of labs would most likely match the patient? A. pH: 7.41, HCO3-: 20 B. pH: 7.35, CO2: 52 C. pH: 7.35, HCO3-: 20 D. pH: 7.45, CO2: 32 Metabolic: HCO3- abnormalities, respiratory: PaCO2 What is the normal range for PaCO2? What is the normal range for HCO3-? What is the normal range for PaCO2? 35-45 (40!) What is the normal range for HCO3-? 22-26 (24!) ROME Respiratory Opposite: PaCo2 and pH go in opposite directions Metabolic Equal: HCO3- and pH go in the same direction Which of the following would NOT cause a metabolic acidosis? A. Ketoacidosis B. Salicylate poisoning C. Severe diarrhea D. CKD E. Decreased tidal volume Which of the following would NOT cause a metabolic acidosis? A. Ketoacidosis B. Salicylate poisoning C. Severe diarrhea D. CKD E. Decreased tidal volume (respiratory acidosis, Can’t breathe) A patient has developed a respiratory acidosis due to PE. If their PaCO2 was 60 mmHg and HCO3- was 24 mmol/L on admission, what would you expect the HCO3- to be 36 hours later? What about 5 days later? What is this process called? A patient has developed a respiratory acidosis due to PE. If their PaCO2 was 60 mmHg and HCO3- was 24 mmol/L on admission, what would you expect the HCO3- to be 36 hours later? 26 mmol/L What about 5 days later? 30 mmol/L What is this process called? Metabolic Compensation In the previous question what if your HCO3- was higher than the predicted value? What if it was lower? What is it was lower but the respiratory acidosis only developed 12 hours ago? In the previous question what if your HCO3- was higher than the predicted value? Concurrent metabolic alkalosis What if it was lower? Concurrent metabolic acidosis What is it was lower but the respiratory acidosis only developed 12 hours ago? Not yet compensated 5-step approach: A patient presents to the ED with a HCO3- of 20, PaCO2 of 40, and a pH of 7.3. Albumin: 3.0 Which values are abnormal? Is there an acidosis or alkalosis? Is this a metabolic issue or respiratory issue? 5-step approach: A patient presents to the ED with a HCO3- of 20, PaCO2 of 40, and a pH of 7.3. Albumin: 3.0 Which values are abnormal? Is there an acidosis or alkalosis? Is this a metabolic issue or respiratory issue? Metabolic acidosis Calculate the anion gap for the patient. Would need Na+, and Cl- values. Remember to correct for albumin! Calculate the delta ratio Let’s Review Metabolic Acidosis: respiratory compensation immediately. Calculate via Winter’s Formula If PaCO2 is high: concurrent respiratory acidosis If PaCO2 is low: concurrent respiratory alkalosis CALCULATE ANION GAP, DELTA RATIO Let’s Review Metabolic Alkalosis: respiratory compensation immediately. Calculate PaCO2 = (0.7 x HCO3-) + 20 +/- 5 If higher than predicted: concurrent respiratory acidosis If lower than predicted: concurrent respiratory alkalosis Let’s Review Respiratory Acidosis: metabolic compensation in acute and chronic ratios Respiratory Alkalosis: metabolic compensation in acute and chronic ratios Hypercalcemia/Hypophosphatemia Calculate the patient’s corrected calcium. Serum Ca = 8.3 mg/dL Albumin = 4g/dL Corrected: 8.3 Which of the following drugs cause hypercalcemia? A. Furosemide B. Cinacalcet C. Lithium D. Vitamin C Bonus: Explain how the drug causes hypercalcemia. Which of the following drugs cause hypercalcemia? A. Furosemide B. Cinacalcet C. Lithium D. Vitamin C Bonus: Explain how the drug causes hypercalcemia. Lithium resets PTH hormone Which of the following statements is false? A. Calcium levels correlate with signs and symptoms B. Acuity of rise in calcium levels determines therapy C. Chronic hypercalcemia results from primary hyperparathyroidism, sarcoidosis, and CKD D. Calcium can deposit in the heart, skin, and kidneys Which of the following treatments is used in symptomatic patients? A. Zoledronic acid B. Calcitonin C. Furosemide D. Pamidronate Which of the following may cause hypophosphatemia? A. Administration of insulin B. Constipation C. Normal vitamin D levels D. Respiratory acidosis A patient presents to the clinic complaining of irritability and muscle dysfunction. His Phos is 1.9mg/dL and his K+ is 5.5mg/dL. What medication would you use to treat his symptoms? A. Neutra-Phos tablets B. KPhos Neutral & Phospha 250 Neutral tablets C. Phos-Na-K powder D. Phosphate supplement Which of the following foods is rich in phosphate? A. Chicken B. Potatoes C. Ice cream D. Broccoli Potassium/Magnesium Disorders All of the following lead to a decrease in plasma K+ concentrations except a. Anabolism b. Metabolic Alkalosis c. Insulin excess d. B2 adrenergic antagonist, (B2 agonist would decrease K) Which of the following leads to decrease of plasma K+ concentrations? a. Catabolism b. Exercise c. Alpha 1 antagonist, stimulates Na/K ATPase pump, decrease K d. Injury/Trauma Measure the corrected K+ pH = 7.6 Measured K+ = 4.4 a. 2.0 b. 5.6 c. 4.2 d. 4.0 Calculation explanation 0.1 pH → 0.6mEq/L 7.6 is two 0.1 pH units above 7.4 2 x 0.6 → 1.2 4.4mEq + 1.2mEq = 5.6mEq All of the following can be present on an EKG in someone with hypokalemia except a. QT prolongation b. T wave inversion c. ST segment elevation: associated with hyperkalemia d. Prominent U wave Which food item below has the highest K+ content a. Bananas b. Dried figs c. Dates d. Broccoli Which ways can parenteral K+ be administered? Pick all that apply a. IVP b. Continuous infusion c. IVPB d. IM e. SC What is the maximum rate for peripheral administration of K+? a. 10mEq/hr or no cardiac monitoring, 20 meq/hr for central line with cardiac monitoring b. 40mEq/hr c. 20mEq/hr d. 100mEq/hr In hyperkalemia what is the first line treatment to normalize the EKG? a. Insulin b. B2 agonist c. Kayexalate d. Calcium, IVP to stabilize the membrane, then intra cellular shift medications (insulin or albuterol) can be given and eliminiation medications (kayexalate) can be given Hypomagnesemia can lead to all except: a. Torsades b. Muscle fasciculations c. Cutaneous vasodilation, muscle paralysis and hyporeflexia are all manifestation of hypermagnesemia What is the maximum infusion rate of parenteral magnesium? a. 2g/hr b. 1g/hr, if given too fast, kidney will eliminate the dose and it can cause hypotension and vasodilation c. 3g/hr d. 5g/hr Fluid Disorders Percentage of water of the body weight Based on GENDER: Women … 50% Men … 60% Based on AGE: Peds … 60-70% Elderly men … 50% Elderly women … 45% Bonus: how would you calculate the percentage of water if you have a 50 YO patient weighing 180 lb? His IBW is 135lb. Decrease percentage by 5% becaues the patient is >130% of IBW. TBW = ECF + ICF; ECF = ISF + IVF Difference between tonicity, osmolality, and osmolarity Tonicity: (AKA effective Osmolality: Osmolarity: solute/osmole or osmotic potential), physiological Total solute Osmolarity serum = 2x property, cant be concentration given a [Na+] + glucose/18 + measured weight of water in a given BUN/2.8 compartment Fluid tension b/w ECF Calculated: (mOsm/L and ICF depending on Measured: 280-295 H2O) relative solute mOsm/Kg H2O permeability (averaging 287.5 ~ 288 ↑ pOsm —> lack of H2O mOsm/Kg H2O) ↓ pOsm —> excess of H2O Hypertonic? Hypotonic? Isotonic? Calculate osmolarity Patient presents to the ICU with the following lab values: Na: 144 mmol/L, K:3.4 mmol/L, CO2: 30 mmol/L; BUN: 14 mg/dL, SCr: 0.97 mg/dL glucose 105 mg/dL Calculate serum osmolarity 2 x Na + glucose/18 + BUN/2.8 = 298.8 Choose the correct answer: ❏ Na+ is primarily an extracellular/intracellular cation ❏ K+ is primarily an extracellular/intracellular cation All of these stimulate the release of AVP except: A. High plasma osmolality B. High BP, low BP would stimulate AVP C. Carbamazepine D. SSRIs E. TCA Bonus: what other medications can influence the release of AVP? Haloperidol, opirates, cyclophosphamide For each presentation, choose whether it is likely to be hypovolemia or hypervolemia Syncope, lethargy, confusion (hypovolemia/hypervolemia): HYPO Hypertension (hypovolemia/hypervolemia): HYPER Jugular vein distention (hypovolemia/hypervolemia): HYPER Dry mouth, thirst, N/V (hypovolemia/hypervolemia): HYPO Pitting edema (hypovolemia/hypervolemia): HYPER Decreased skin turgor (hypovolemia/hypervolemia): HYPO Dyspnea (hypovolemia/hypervolemia): HYPER Which of the following lead to hypovolemia s/t dehydration? (more than one answer is correct) A. Increase of age B. Medications like anticholinergic C. Sweating or hyperventilating D. Vomiting and experiencing diarrhea E. Increased AVP secretion: this results in holding onto more water (hypervolemia) Goals of different volume therapies Resuscitation - Maintain organ perfusion Replacement - Replace volume lost Maintenance -Prevent dehydration Bonus: what do you monitor when you plan resuscitating a patient? BP, HR, mental status, urine output Match the characteristic with the appropriate fluid type Distributes similarly to water in the body _____ C Used as a resuscitation fluid _____ A, E Considered a colloid _____ D A.
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