LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.Which of the following medication’s dose are adjusted for poor renal function?
Answer(s): B
Famotidine and Metoclopramide would need to be adjusted for poor renal function. Since his CrCl is less than 50, famotidine would need to be adjusted by decreasing the dose by 50% or increasing the interval to every 36 to 48 hours. Metoclopramide would also need to be adjusted by 50% of the normal dose since his CrCl is less than 40. ACEInhibitors and ARBs should be held if serum K is greater than 5.6 or there is a rise in serum creatinine greater than 30% after initiation.
LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L. The bioavailability of levothyroxine is roughly 50%.The physician requests you for a dose recommendation to convert her home dose of 75mcg po daily to intravenous.What would be the appropriate intravenous dose?
Answer(s): A
Since the bioavailability of levothyroxine is roughly 50% (given in the Question:). To convert the home dose to intravenous, it would be 50% of the oral dose. So 50% of oral 75 mcg would be 37.5 mcg intravenously.
LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20 mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125 mls/hour and Hydromorphone PCA at 0.2 mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L. Day 3 post-operation LN’s pain was much better and only used 3 mg of hydromorphone in the 24hrs.Physician wants to change to oral morphine. What would be your best recommendation?
Answer(s): E
Since LN used 3 mg of hydromorphone, this would be equivalent to a total of morphine 60 mg po daily. Since you would start with 70-80% of that dose, Morphine 15mg ER po q12hr and morphine 5mg po q6h prn breakthrough pain would be appropriate regimen.
LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.What is LN’s creatinine clearance using Cockcroft and Gault equation based on IBW?
Answer(s): D
ABW = 85 kg IBW = 50 kg + 2.3 kg (4) = 59.2 kg 85/59.2 = 1.44 AdjBW = 59.2 kg + 0.4(85 kg-59.2 kg) = 69.52kg CrCl (IBW) = [(140-84) 59.2]/(72 × 1.4) = 32.8 CrCl (AdjBW) = [(140-84) 69.52]/(72 × 1.4) = 38.6
If LN receives Dextrose 5% half Normal Saline with 20 meq of Potassium as IVF at 125mls/hour. How much dextrose is he getting in 24hrs?
0.05 (1000 mL) = 50 g 1000 mL × (1 hour/125 mL) = 8 hours 50 × 3 = 150 g
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