TDM
Chemotx-induced Nausea and Vomiting
Ondansetron
Dexamethasone
Prochlorperazine
Metoclopramide
ACS- UA/NSTEMI
DAT
NTG
BB/CCB
Heparin (UFH, LMWH, fondaparinux)
ACS- STEMI
DAT
ACE-I
Nitrates
BB
Heparin
Edema
Na+/fluid restriction
Elevate legs
Compression stockings
Spironolactone - if liver failure
Furosemide- if Renal failure (ClCr <50ml)
HCT - if no failures.
If hypokalaemia, use spironolactone. If hyperkalaemia, prefer HCT
Identify overdiuresis by monitoring for:
weakness
hypotension
azotemia, hypokalaemia or metabolic acidosis
Dehydration in children
Deficit = 100mL/kg for 10% dehydration. eg for a 15kg baby = 15 x 100 = 1500mL.
Replace 50% in first 8h ie 750mL over 8hrs = 94mL/h
Maintainance = 100mL/Kg/day for first 10kg, then 50mL/kg/day for each subsequent kg.
eg 15kg would be 1000mL/day + 2500mL/day = 1250mL/day = 50mL/hr
Therefore, Total replacement = 94 + 50 = 144m/h for first 8 hrs.
Na+ loss would be approx 10mmol/kg/day
K+ loss would be approx 10mmol/kg/day: Max replacement is 4mmol/kg/day
Solution of choice: NaCl 0.45% + D5W
Ca
Correct for albumin
Repeat the following day to exclude lab errors
Do PTH & Phosp
Asx hyperca = HPTH
Na
SODIUM DISORDER (ie abn Na level)
Do Sosm, Uosm, UNa
HYPERNA
99% are Unwatered vegetables (dried out elderly): elderly nursing home patients who are bed bound, neglected
Serum osm high, urine osm high,
Rx
Correct volume FIRST with 2L Bolus NS (Dont worry about central pontine myelinolysis- its for hyponatraemia)
Then correct free water with either PEG/PO Tap or D5W at calculated rate
Endocrine eg PP, Central DI, Nephro DI. Very rare
HYPONA
Measure Sosm.
If high -> fats + prot. Dont worry about it
Normal: Osmotically active compound eg blood glucose, BUN, etoh, toluene etc
Low Sosm: Hypoptonic hyponatraemia
Hypervolaemic from hx (CCF, Cirhosis, peripheral edema, crackles, BNP elevation)? diuresis
Hypovolaemic (fever, tachpnea, diuretics etc)? give vol
Euvolaemic if not above: RATS
RTA (renal tubular acidosis) = CKD/AKI
Addisson's dx = Cortisol
Thyroid low = TSH
SIADH- diagnosis of exclusion of above. Uosm low
Rx
If acute & severe: ie obtunded, initially Na was normal, seizing, coma, : 3% saline- central pontine myelinolysis
Severe & Chronic: Normal saline. Calculate to change Na by 0.25mEq/hr. (do BMP every 4 hrs to ensure sodium changes by 1mEq). If it increases by > 1 every 4 hrs reduce rate and maybe give free water. Tip: best use computer to calculate rate, but can know normal saline contains Na at 152mEq/L?
Mild-to mod: as chronic & severe
Potassium
HypoK
K change of 0.1
3.0 - 4.0 10mEq
2.5 - 3.0 15mEq
2.0-2.5 20mEq
IV rate. <10mEq/hr (burns) eg so give 40mEq KCl q4H x 3 per day (=120) AND
PO: 40mEq PO qAC x 3 (=120)- Elixir /pill
Do BMP at 2:00 hrs
Mg 1g IV
HyperK