1. Therapeutics 4 tutoring 3/21/17
Melanie Jaeger

2. Evaluation of the gi tract

3. 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

4. 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

5. 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

6. Upper gi bleed

7. 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

8. 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

9. 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

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

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

12. Stress related mucosal damage

13. 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

14. 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

15. Liver disease

16. 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

17. 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

18. 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

19. 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

20. 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

21. Heart transplant

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Questions? Good luck and happy spring break!