Therapeutics 4 tutoring 3/21/17 Melanie Jaeger

Evaluation of the gi tract

1. a physician asks you to do a profile review for a patient who has gerd in order to identify any medications that may be causing it. Which of these is the most likely culprit? Phenytoin Hydrochlorothiazide Warfarin Nifedipine D nifedipine

Important gi-related lab tests AST/ALT: released from hepatocytes Nonspecific Half-lives: AST 17 hrs, ALT 47 hrs PT/aPTT, INR Nonspecific; anormalities associated with liver issues Amylase/lipase Pancreatitis Ammonia Liver disease, encephalopathy

2. Which of the following is true about polyethylene glycol (PEG)? It’s a hyperosmotic GI lavage solution. It has to be diluted in a larger volume than other solutions. It can cause large fluid and electrolyte shifts. It’s in the same class of agents as bisacodyl and senna. B

Upper gi bleed

PUD vs. SRMD PUD: direct damage to the GI tract (H. pylori, NSAIDs) SRMD: due to ischemic damage This is why we do stress ulcer prophylaxis in the ICU Only treatment for these is PPIs H2RAs are NOT ok to use; do not prevent rebleeding These are NON-VARICEAL

3. DK presents to the ed with likely ugb 3. DK presents to the ed with likely ugb. Which of these drug regimens would be standard of carE? Protonix 60 mg bolus, then 6 mg/hr infusion. Lansoprazole 80 mg bolus, then 8 mg/hr infusion. Protonix 80 mg bolus, then 8 mg/hr infusion. Esomeprazole 60 mg bolus, then 6 mg/hr infusion. C

4. Which of these would be the preferred first line agent for a variceal ugb? Pantoprazole 80 mg bolus, then 8 mg/hr infusion Octreotide 25 mcg bolus, then continuous infusion of 50 mcg/hr Vasopressin 0.4 unit bolus, then 0.4 units/min Octreotide 10 mcg bolus, then continuous infusion of 100 mcg/hr B

Variceal ugb Often related to cirrhosis Antibiotics, vasopressin and octreotide important here

5. Which of the following drugs is the doc for primary prophylaxis of variceal ugb? Losartan Clonidine Propranolol metoprolol C

Stress related mucosal damage

6.Which of the following clinical findings would not be typical in srmd? Hemoglobin decreased by 2 Increased BP Increased HR Coffee ground aspirate B

Tips for srmd Know your risk factors Mechanical ventilation Coagulopathy Trauma, etc Prophylaxis options are broader than treatment of GI bleed Sucralfate, H2RAs, PPIs No difference in risk of SRMD when stress ulcer prophylaxis given with enteral feeding When do you d/c stress ulcer prophylaxis? Off vent, d/c from ICU, tolerating oral intake

Liver disease

7. Which of the following would be first line treatment for someone suffering from ascites with SAAG > 1.1? Sodium restriction to less than 5g per day. Dual diuretic therapy: loop+thiazide Alcohol abstinence paracentesis C

8. Which of the following is true about ascites and paracentesis? The appropriate ratio for dual diuretic therapy is furosemide 80 mg to spironolactone 160 mg. If 5 L of ascitic fluid are drained, 40 g of albumin need to be replaced. Albumin needs to be replaced if more than 3 L of fluid are drained. If 7 L of fluid are drained, 16 g of albumin need to be replaced. D

9. Your patient is diagnosed with spontaneous bacterial peritonitis 9. Your patient is diagnosed with spontaneous bacterial peritonitis. Which of the following would be an appropriate initial therapy? cefotaxime 2g IV every 8 hours Ceftriaxone 2g IV every 12 hours Albumin 1g/kg Cefotaxime 2g IV every 24 hours A

10. Which of the following is appropriate therapy for hepatic encephalopathy? A. Lactulose 100g every hour, then 30g TID-QID. B. Lactulose 20g every hour, then TID-QID. Add on rifaximin 550 mg BID. C. Rifaximin 550 mg BID. D. Metronidazole 250 mg BID. B

11. Which of the following is false about hrs? Type 1 HRS is characterized by a rapid doubling of SCr. Type 2 HRS survival is typically about 6 months. Type 2 HRS is typically treated with albumin, octreotide, and midodrine. Type 1 HRS can be treated with albumin and NE in the ICU. C

Heart transplant

12. Which of the following is not an absolute contraindication for transplant? Active infection ESRD COPD Cervical cancer 7 years ago D

13. Which of the following patients would be a vad destination therapy candidate? Patient w/ high surgical risk Patient w/ pulmonary HTN Patient w/ active bleed Patient w/high PRA unable to easily find a match B

14. Which of the following statements is not true about VADs? VAD can increase risk of both thromboembolism and bleeding. Patients with supraventricular arrhythmias are not candidates for VADs. PRA increases over time after VAD placement. Warfarin INR goal with Heartmate II is 2-3. C

15. Ph is a heart transplant candidate getting milrinone 0 15. Ph is a heart transplant candidate getting milrinone 0.5 mcg/kg/min. he does not have a swan-ganz. What status is he on the list? 1A 1B 2 7 B

16. Lt is on the heart transplant list 16. Lt is on the heart transplant list. He is mechanically ventilated and is currently being treated for pneumonia. What is his status on the list? 1A 1B 2 7 D

More tips for heart transplant Know CIs for transplant, VAD Know how to determine transplant list status Know problems post-transplant and how to help resolve Most patients have some post-op right sided HFpreload optimization CMV prophylaxis: induce with 900 mg BID valgan/ganciclovir, MD 900 daily ACR treatment Know grades and treatments 1R oral steroid pulse, 2R or 3R high dose IV steroids

Questions? Good luck and happy spring break!