GI flora changes from antibiotics - ANSWER 1. Decreased GI flora that
produce vitamin K - warfarin patients are prone to bleeding.
2. Reduced synthesis of estrogen metabolites by gut flora makes estrogen-based
contraception less effective.
3. MACROLIDES limit the amount of gut bacteria that metabolize Digoxin, so
the active concentration increases.
Chelation of oral medicines - ANSWER 1: Cipro and antacids
2. Prevalite (cholestyramine) with nearly any other PO medication.
3. Sucralfate and any other antacid require AT LEAST 30 MIN between
administrations.
Major binding proteins: ANSWER Alpha1-acid glycoprotein
Albumin
*Both decreased in critical illnesses.
,Protein-bound medicines, such as warfarin, have an extremely low free fraction.
Changes in diet or health, as well as other medications competing for protein
binding sites, modify the free fraction of a drug, increasing the likelihood of
adverse answers and drug interactions.
Drugs having stronger protein affinity will bind, while other drugs will have an
increased free fraction, such as aspirin replacing warfarin.
Gentamicin's free fraction is relatively independent of protein.
Volume of Distribution - ANSWER The degree to which a medication travels
from the intravascular space into bodily tissues
(A lot of movement out means a big volume of distribution)
Dependent on lipid vs water solubility and protein binding.
HIGH VD - ANSWER Poorly protein bound and lipid soluble
Sepsis - ANSWER qSOFA score > 2.
--> Higher is worst.
qSOFA (quick sequential organ failure assessment): ANSWER respiratory rate
>22
, SBP </=100
GCS <15
Despite receiving appropriate fluid boluses (30ml/kg NS), patients with septic
shock have a MAP <65 and a lactate level >2.
3 hour surviving sepsis bundle - ANSWER: test lactate, get BCs, and hang
ABX within 1 hour of arrival.
-If lactate >4 or MAP <65, administer 30mL/kg fluid bolus.
6-hour surviving sepsis bundle - ANSWER -Pressors to maintain MAP >65 if
insensitive to fluid bolus.
-Reassess volume status if MAP <65 and lactate >4.
-If lactate was initially elevated, continue to remeasure it according to protocol.
Hyperglycemia in sepsis - ANSWER - Begin insulin drip when two consecutive
blood sugar levels exceed 180.
- Aim for a BS of less than 180 instead of lower values.
-Patho: The stress answer leads to enhanced glycogenolysis and hepatic
gluconeogenesis. Cytokine release leads to insulin resistance.
produce vitamin K - warfarin patients are prone to bleeding.
2. Reduced synthesis of estrogen metabolites by gut flora makes estrogen-based
contraception less effective.
3. MACROLIDES limit the amount of gut bacteria that metabolize Digoxin, so
the active concentration increases.
Chelation of oral medicines - ANSWER 1: Cipro and antacids
2. Prevalite (cholestyramine) with nearly any other PO medication.
3. Sucralfate and any other antacid require AT LEAST 30 MIN between
administrations.
Major binding proteins: ANSWER Alpha1-acid glycoprotein
Albumin
*Both decreased in critical illnesses.
,Protein-bound medicines, such as warfarin, have an extremely low free fraction.
Changes in diet or health, as well as other medications competing for protein
binding sites, modify the free fraction of a drug, increasing the likelihood of
adverse answers and drug interactions.
Drugs having stronger protein affinity will bind, while other drugs will have an
increased free fraction, such as aspirin replacing warfarin.
Gentamicin's free fraction is relatively independent of protein.
Volume of Distribution - ANSWER The degree to which a medication travels
from the intravascular space into bodily tissues
(A lot of movement out means a big volume of distribution)
Dependent on lipid vs water solubility and protein binding.
HIGH VD - ANSWER Poorly protein bound and lipid soluble
Sepsis - ANSWER qSOFA score > 2.
--> Higher is worst.
qSOFA (quick sequential organ failure assessment): ANSWER respiratory rate
>22
, SBP </=100
GCS <15
Despite receiving appropriate fluid boluses (30ml/kg NS), patients with septic
shock have a MAP <65 and a lactate level >2.
3 hour surviving sepsis bundle - ANSWER: test lactate, get BCs, and hang
ABX within 1 hour of arrival.
-If lactate >4 or MAP <65, administer 30mL/kg fluid bolus.
6-hour surviving sepsis bundle - ANSWER -Pressors to maintain MAP >65 if
insensitive to fluid bolus.
-Reassess volume status if MAP <65 and lactate >4.
-If lactate was initially elevated, continue to remeasure it according to protocol.
Hyperglycemia in sepsis - ANSWER - Begin insulin drip when two consecutive
blood sugar levels exceed 180.
- Aim for a BS of less than 180 instead of lower values.
-Patho: The stress answer leads to enhanced glycogenolysis and hepatic
gluconeogenesis. Cytokine release leads to insulin resistance.
