1. Date
2. Identification of prescriber and patient
3. Inscription, subscription, signa
4. Indication
5. Refill information
6. Generic substitution
7. Warnings
8. Container information
9. Prescriber’s signature

Name what I'm describing:

generally preprinted and includes name and title of the prescriber as well as important demographic information.  Generally when the prescriber is a PA the supervising physician’s name is also included. 

Name what I'm describing:

includes name, address, age or date of birth and sometimes weight (particularly for pediatric patients) 

What is this called on a prescription?

heading where the symbol Rx (abbreviation for recipe is found) 

What is the word when writing a prescription that means:

The name and strength of the medication

Generic substitution results in the same active ingredient being given

Therapeutic substitution involves the substitution of a different chemical entity from the same therapeutic class

Both result when “formulary” and “covered product” influence prescribing and dispensing

What are the primary differences between controlled and non-controlled medications?

I. High potential for abuse. No accepted medical use. (ie. marijuana, LSD, peyote)

II. High potential for abuse. Use may lead to severe physical or psychological dependence (morphine, oxycodone, amphetamines)

III: some potential for abuse. Use may lead to limited dependence (diazepam, lorazepam)

IV: low potential for abuse. Use may lead to limited dependence.

V: Subject to state and local regulations. Abuse potential low

50-60% total body weight

most in muscles, skin and organs

lean body-more water

collection resevoir- filter-take sequestered blood nad retransfused to pt.

Dontate your own blood beforehand

intracellular

extracellular: plasma and interstitial fluid

Intracellular fluid

how much total body water?

How much total body weight?

What percent of total body water is extracellular fluids?

what's breakdown btw plasma and interstitial fluid?

1/3 Total body water: extracellular fluid

plasma 1/4 (5% total body weight)

Interstitial fluid: 3/4 (15% total body weight)

K+= 150 mEq

Na+= 10mEq

HCO3= 10 mEq

What moves freely across cell membrane.

It equalizes its concentration on both sides of membrane.

2000 ml water/day

1500 ml oral fluid

500 ml extracted from food

urine: 800-ml urine

stool: 250 ml

insensible losses: 600 ml

75% skin

25% respiration

What provides you with good indicator of hydration and kidney function?

gross test

volume

concentraiton

composition

most common disorder in surgical patients

usually secondary to GI losses (N/G, emesis, diarrhea, enterocutaneous fistula)

Or intra-abdominal (ie. peritonitits)

iatrogenic

renal dysfunction

CHF

osmoreceptors: detect even the slightest changes in osmolality; drive changes in thirst and diuresis through kidneys

Baroreceptors: aortic arches, carotid sinuses

A patient with impaired thirst or restricted access to fluids- would be susceptible to:

hypo or hypernatremia?

a post-op pt is prone to increased ADH, making them susceptible to:

hypo or hypernatremia?

decreased intake: diet, enteral feeding

GI losses: emesis, N/G drainage, diarrhea

Excess solute relative to free water: hyperglycemia, creating osmotic force (draws water out of cell and displaces sodium)

Calculation for correcting Na+ in presence of hyperglycemia:

For every ___ mg/dL increment in plasma glucose above normal, plasma Na+ should decrease by __ mEq/L

Iatrogenic- IV's with Na+

Mineralocorticoids- ie. Cushing's

what type of hypernatremia would this cause?

Renal- Diabetes insipidus, diuretics

Non-renal water loss (GI, skin)

what type of hypernatremia could this cause?

Isotonic GI losses- diarrhea

hypotonic skin fluid- secondary to fever

tracheostomies

What type of hypernatremia would this cause?

hypovolemic hypernatremia

*if no nasal pathway, O2 added to ventilator and has a drying ability)

What percent of the body K+ is extracellular?

This is critical to cardiac and neuromuscular systems.

surgical stress

trauma (cell destruction)

acidosis

tissue catabolism

excess intake

increased release from cells (ie. acidosis)

impaired renal excretion

**even a slight shift of K+ from intracellular to the extracellular space is significant

GI: n/v, intestinal colic, diarrhea

Neuromuscular: weakness, ascending paralysis, renal failure

Cardio-vascular: ECG changes: peaked T waves, widened QRS, v fib

inadequate intake

excessive renal excretion

GI patho: diarrhea, vomiting, N/G, fistulas

Intracellular shift in alkalosis

Mg++ depletion (drags K with it) 

MG depletion brings K with it

If you keep giving K = wont do anything unless you give Mg first!

Potassium decreased by __ mEq/L for every 0.1 increase in pH above normal.

Eg. alkalosis

Sodium chloride

Mildly hypertonic (154 mEq each of Na and Cl)

Normal Saline, NSS, .9% NaCl

This solution is useful for replacing ongoing GI losses.

It's used for Post-op maintenance fluid therapy

-sufficient free water forinsensible losses

-Enough Na to aid kidneys in adjusting sodium

.45% sodium chloride, 1/2 NSS

.45% Sodium Chloride, 1/2 NSS

should not be used in pots with ___, ____ and ___.

this solution is good at keeping intracellular fluid from coming out of cells.

maintains osmolality

prevents lysis of RBCs

D5, 5% Dextrose

supplies 200 kcal/L

What is a colloid?

provide 3 examples.

volume expander

controls amt of water in intravascular space

Examples:

1. Albumin- 5% & 25%

2. Dextrans

3. Starches

What do you need to be aware of in the following:

Albumin

Starches

Albumin: caution allergic reaction

Starches: causes renal impairment, coagulopathy, hyperchloremic acidosis

What is protocol for preoperative fluid therapy?

what would be a good choice for solution?

What factors influence the rate of infusion?

healthy pts shoudl require maintence fluids ONLY

will be NPO for 6 hrs to 2-3 days unless surgery is emergent

D51/2 NS is a good choice

Factors influencing rate of infusion: size, age, comorbidities, drains, fever, U/O

What are pre-op IV infusion strategies?

First 0-10 Kg

Next 20-20 Kg

For >20 Kg

First 0-10 Kg: give 100 ml/kg/day

Next 20-20 Kg: give additional 50 ml/kg/day

For >20 Kg: give additional 20 ml/kg/day

U/O, stool, insensible skin losses

* don't forget to check serum Na, Cl, K, temp, etc.

anesthesia precipitated hypotension

Insensible fluid losses

Respiratory losses via ventilator

Blood loss

"Third Space" losses (controversial)

empiric 500-1000 ml/hr of NSS or LR for homeostasis

What is the initial use of isotonic solution?

When?

post-operative

after 24-48 hrs- D51/2NSS

10 mEq/hr monitor electrolytes/BUN/Cr, glucose, HGb/Hct, Platelets, Temp, B/P, Pulse, Resp, U/O, breath sounds, bowel sounds

K: 20 to 40 mEq/L, ≤10mEq/Hr

What are available blood products?

(7)

whole blood 

packed RBC's

platelets

fresh frozen plasma

cryoprecipitate

crystalloids

colloids

If you have Blood Type A:

what antibodies do you have?

what type of blood can you receive?

RBC's contain B antibodies

can receive blood types A and O

If you have blood type B:

what antibodies do you have?

what type of blood types can you receive?

contain A antibodies

can receive blood types B and O

If you have AB blood type:

what antibodies do you have?

what blood types can you receive?

universal recipient of?

contain either A or B antibodies

can receive blood types A, B, AB or O

universal recipient: AB positive

If you have blood type O

what type of antibodies do you have?

universal donor:

antibodies A and B 

can receive only blood type O

Universal donor: O negative

What is the relative frequency of blood types (among caucasians)

Type O

Type A

Type B

Type AB

Type O: 40-45%

Type A: 40%

Type B: 10-15%

Type AB: 5%

How do you prepare for a transfusion?

(2)

Type and Screen:

patients blood tested for type and major antibodies

Commerically prepared controls

Enables blood bank to be relatively prepared

Type and Cross (Cross match)

Patient's serum mixed with donor cells

Required prior to transfusion except emergency

What is the volume of 1 unit of packed RBCs?

What is effect of 1 unit of packed RBCs on Hgb and Hct?

300-400 ml

increase of Hgb by 1 Gm.unit

Increase of Hct by 3 Gm/unit

**monitor H/H approx 1 hr post transfusion

treatment of anemia:

chronic or acute

RBC's leukocyte-reduced/washed

Treatment of thrombocytopenia, DIC

-quantitative platelet deficits

-qualitative platelet disorders (uremia, drugs, von Willebrand's)

What is the platelet count threshold for transfusion?

if surgery is anticipated:

If no surgery and no bleeding:

if surgery: ≤80,000

If no surgery and no bleeding ≤30,000

What is the volume of 1 unit of platelets?

How much do you transfuse?

50 ml per unit

transfuse about 1 unit for each 10kg body weight

Treatment of clotting factor deficiencies

essentially contains all clotting factors without platelets

DIC, Coumadin reversal, liver failure

can't wait 6-12  hrs for Vit K effect

DIC

Massive tranfussion

What is the volume of one unit of fresh frozen plasma?

What do you need to monitor?

It should NOT be used as:

225 ml/unit

Transfuse ~15 ml FFP/kg body wt

Monitor PT/INR & PTT

immunologic

physiologic

infectious

acute hemoylstic transfusion reaction

delyaed hemolytic transfusion reaction

transfusion related acute lung injury

febrile non-hemolytic transfusion reaction

allergic reactions

graft vs host diease

After transfusion, pt shows signs of dyspnea, fever, anxiety, facial flushing, pain, weak pulse, hypotension, shock

what could it be?

what do you do?

What do you check?

What should be maintained?

Acute Hemolytic Transfusion Reaction

stop transfusion immediately: confirm diagnosis with Coombs' test

Check urinary Hgb, serum LDH, bilirubin and haptoglobin

Maintain B/P and U/O > 100 ml/hr for 24 hrs.: persistent oliguria and shock are poor prognosis

Pt give transfusion and withing several hours to 4 weeks after infusion develops milder symptoms of acute hemoyltic transfusion reaction-

What might you notice on labs?

What is it?

declining Hgb/Hct, rising LDH and bilirubin

treat same as AHTR

What causes transfusion related acute lung injury?

what would you see on CXR?

How do you manage?

second most fatal complication compared to AHTR

cause by anti-HLA and/or anti-granulocute antibodies in donor plasma

Acute respiratory sxs

CXR: characteristic pattern of noncardiogenic pulmonary edema

General supportive care: avoid diuretics

What are most likely cause sof febrile non-hemolytic transfusion reaction?

What are sumptoms?

What is treatment?

Causes:

antibodies to WBC HLA

cytokines released from WBC's during storage

Most comon in multiparous, multi-transfused

Sxs:

Fever≥1 deg C

Chills, headache, backache

Tx: acetaminophen, Benadryl

pretreat with same in the future

allergic reaction

if bronchospasm: hydrocortisone

if anaphylaxis: epinephrine

prophylactic tylenol

diphenhydramine

What is a graft vs host transfusion reaction?

What type of symptoms may patient have?

cause by transfusion of products containing immunocompetent lymphocytes to immunocompromised pt

symptoms: fever, rash, bullae, vomiting, watery/bloody diarrhea, lymphadenopathy, pancytopenia secondary to bone marrow aplasia, jaundice, elevated liver enzymes

How do you prevent graft vs host transfusion?

how do you diagnose?

What is treatment?

Prevent: irradiate blood products

diagnosis: by bone marrow biopsy

tx: no specific treatment

>90% mortality

fluid overload

blood products possess hig osmotic load

trasnfuse slowly and monitor for volume overload

lasix, furosemide, -routinely given with transusion prophylactically

Altered Oxygen Affinity

Stored RBC's have increased affinity for O2

-due to decreased 2,3 diphosphoglycerate (DPG)

Slower relase of O2 to tissues

2,3 DPG regenerates in 12-24hrs.

hepatitis B and C

CMV transmitted by WBC

Malaria, Chagas disease, brucellosis, syphilis

HIV I and HIV II

Complicated because of body’s ability to compensate

Amount and rate of blood loss; Healthy vs compromised

Class I hemorrhage

Loss of < 15% blood vol or 750 ml

May have minimal to no signs or symptoms

Class II hemorrhage

Loss of 15-30% blood vol or 750-1500 ml

Tachycardia but B/P may be WNL

Class III hemorrhage

Loss of 30-40% blood vol or 1500-2000 ml

Tachycardia, tachypnea, hypotension, oliguria, mentation

Class IV hemorrhage

Loss of > 40% blood vol – considered life-threatening

When assessing your patient for blood loss:

what do you read?

what labs, VS, I/O?

Labs

—H/H, PLT CT, BUN/Cr

VS

—T, P, R, B/P, PCWP, CVP,

I/O’s

—PO, IV, enteral

—U/O, N/G, foley, drains

When checking for blood loss,

what do you see and hear?

¢Skin

—Warm, dry, cool, clammy

¢Respirations

—Shallow, full, audible

¢Affect

—Pleasant, dull, apprehensive

¢Fluid output

—Urine – pale, yellow, dark

—N/G – bile, gastric, blood

—Drains – bile, serous, sanguinous

cardiovascular drugs/HTN

analgesics

sedatives

GI preps

What influences the rate of drug distribution? (3)

What are concerns related specif to elderly in terms of distribution?

cardiac output

blood flow to various tissues

tissue volume

increased fat-lean body mass ratio

decreased total body water

decreased serum albumin

What's important to know about the following drugs in the elderly:

diazepam

digoxin

warfarin

diazepam: distributes in fat so large volume of distribution

digoxin: hydrophilic medication will ahve a decreased volume of distribution

warfarin: albumin levels depend on illness-free to bound drug can increase with illness and pts can develop toxicity

thyroid hormone, digoxin, warfarin, phenytoin

In terms of metabolism in elderly- what do you need to be aware of?

What is an example of a drug that depicts this?

hepatic enzyme activity, maass and blood flow can decrease with age but are highly variable.

Imp to think about drugs with high first pass metabolism: ie. propranolol; small reductions in metabolizing activity can have a great impact

which phase of metabolization in the liver is affected by aging:

phase I: catalyzed by cytochrome P450 through the process of oxidation and reduction

phase II: conjugates drugs through acetylation, glucoronidation, sulfation, and glycine conjugation.

Older adults are more sensitive to medications that depress the CNS (ie. benzos) bc it can cause adverse effects which are 

(3)

delirium 

confusion

agitation

confusion

poor (blurred) vision

dry mouth/eyes

constipation