medicina interna 2
Post on 14-May-2017
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SIUnitsTherapeutic level 10-50 g/mL 49-243 mol/LToxic level 100-700 g/mL 485-3395 mol/L
Overdose Symptoms and TreatmentNote: Treatment choice(s) depend(s) on clients history and condition and episode history.Symptoms. The amount of ibuprofen ingested does not correlate well with symptoms. Ibuprofen overdose usually produces minimal symptoms of toxicity and is rarely fatal. Onset of symptoms generally occurs within 4 hours after ingestion, and clients with normal renal function usually recover completely within 24 hours with supportive care. Typical signs and symptoms include mild gastrointestinal symptoms such as nausea, anorexia, vomiting, and abdominal pain. Other signs and symptoms that may occur include gastrointestinal hemorrhage (especially in the elderly), headache, CNS depression (light-headedness, drowsiness, lethargy, coma), seizures, nystagmus, diplopia, tinnitus, hyperventilation, rash, hypotension, bradycardia, hypoprothrombinemia, hypo-thermia, hepatic failure, apnea, respiratory depression, and cardiac arrest. Renal insufficiency and secondary acute renal failure are generally reversible with supportive therapy.
Treatment of Overdose in Adults
Ingestion of 100 mg/kg Empty the stomach by emesis using ipecac syrup or gastric lavage. (Do NOT induce vomiting in clients with a decreased level of consciousness, clients with an absent or depressed gag reflex, or a client with a history of a seizure disorder.) After gastric emptying, a saline cathartic should be given.
Laboratory Monitoring Renal function studies (BUN, creatinine, urinalysis): baseline and repeated in 1-2 weeks, ABG, CBC, liver function studies
Management of Specific Symptoms
Hypotension IV fluids and dopamine if neededSeizures (recurrent) IV diazepam, followed by barbituratesSymptomatic Atropine for bradycardiaSevere metabolic May treat with sodium bicarbonate (acidosis, pH
3. Monitor for hematuria and proteinuria.4. Observe and assess vital signs and neurologic status of symptomatic adults for 24 hours.5. Asymptomatic adults should be observed for 4 hours.6. Safety considerations and psychiatric consultation are indicated in intentional overdose.
Treatment of Overdose in ChildrenAmountIngested Treatment400 mg/kg, or a client with a history of a seizure disorder.)
200-400 mg/kg Gastric decontamination, followed by cathartic. Observe at least 4 hours.
>400 mg/kg Immediate gastric lavage. Observe child carefully for seizure activity.
Usage. Ibuprofen blood levels are not gen-erally indicated; however, they may be useful to identify drug concentrations when over-dose, misuse, toxicity is suspected. Monitor-ing therapeutic levels in long-term ibuprofen use or when high doses are used in children with cystic fibrosis.
Description. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is also used for its antipyretic and analgesic activity. Its anti-inflammatory action is believed to be attributable to the inhibition of the synthesis or release of prostaglandins and to its antipyretic effect because of its action on the hypothalamus, with heat dis-sipation increased as a result of vasodilata-tion and increased peripheral blood flow. Ibuprofen is rapidly absorbed from the gas-trointestinal tract and is 99% protein bound. It is metabolized in the liver and almost completely excreted in the urine 24 hours after ingestion. Half-life is 2-4 hours, with peak blood levels reached in 1-2 hours, though it may take up to 2 weeks to achieve therapeutic response for chronic inflamma-tory problems. Ibuprofen is used for rheumatoid arthritis and osteoarthritis, musculoskeletal disorders, fever, primary dysmenorrhea, gout, and dental pain. It can increase bleeding time by inhibiting platelet aggregation, though this action is reversible within 24 hours after the medication is dis-continued. High-performance liquid chro-matography is used to establish ibuprofen blood levels.
ProfessionalConsiderationsConsent form NOT required.
Preparation1. Tube: Red topped. Plasma may be accept-
able from tubes with heparin (green topped), EDTA (lavender topped), or sodium fluoride/potassium oxalate (gray topped). Use of gel tubes (red/gray topped) is NOT advised.
Procedure1. Draw blood from opposite arm if client is
receiving ibuprofen intravenously. Draw a 3-mL blood sample.
2. Refrigerated samples can be used for up to 2 weeks.
PostprocedureCare1. If toxic levels are found, withhold the
drug and notify the physician.
ClientandFamilyTeaching1. If overdose is suspected, prepare the client
and family for supportive treatment out-lined previously.
2. If overdose or toxicity occurred in child, instruct the childs parents or caregiver in safe, accurate administration of ibupro-fen and review safety issues regarding prevention of accidental poisoning.
3. Refer clients with intentional overdose for crisis intervention.
FactorsThatAffectResults1. None found.
OtherData1. STAT ibuprofen blood levels are not
widely available and are not frequently used in overdose or suspected toxicity cases. Because blood levels are not readily available during the relevant initial 4-hour period and there is little correla-tion between ibuprofen blood levels and symptoms, the management of ibu-profen overdose focuses on symptom management.
2. Ibuprofen blood levels are not generally monitored during routine ibuprofen therapy. Therapeutic response is moni-tored by evaluation of the degree of symptom relief.
3. Ibuprofen may decrease renal function because of the inhibition of renal prosta-glandin synthesis. This is especially important in clients with decreased renal function or congestive heart failure, because renal prostaglandins may have a role in supporting renal perfusion in these clients. Serum BUN and creatinine levels should also be monitored in clients with impaired renal function, heart failure, or hepatic dysfunction, those receiving nephrotoxic drug concomi-tantly, dehydrated clients, and geriatric clients.
4. Liver-function studies should be moni-tored in long-term ibuprofen therapy.
IFNGammaAssaySeeRD1-Interferon Tests for TuberculosisBlood.
iFOBTSeeImmunochemical Fecal Occult Blood TestingStool
125I-LabeledFibrinogen(FibrinogenUptake)LegScanDiagnostic4. Assess for swelling in the calf, tenderness,
and cyanosis of the skin.5. Assess for Homans sign. Once it is deter-
mined to be positive, do NOT repeat Homans sign assessment.
6. Elevate the legs during the imaging pro-cedure, which takes about 10 minutes.
7. Just before beginning the procedure, take a time out to verify the correct client, procedure, and site.
Procedure1. The clients legs are elevated during scan-
ning to prevent pooling of blood in the veins of the legs.
2. 125I-labeled fibrinogen is injected intrave-nously, and serial scans are performed on each leg 1, 4, 24, and 48 hours afterward. Surface radioactivity may be measured daily for as long as 2 days.
3. The extremity is marked in segments along the course of the vein tract.
4. Areas of fibrinogen incorporation into a thrombus are detected with the counter as areas exhibiting increased radioactivity, indicating increased concentration of radioactive tracer.
PostprocedureCare1. Maintain bed rest if thrombi are detected.2. Do not wash off markings on the
extremity.3. Assess the venipuncture site for
infiltration.4. Assess for swelling in the calf, tenderness,
and cyanosis of the skin.5. Observe the client carefully for up to 60
minutes after the study for a possible (ana-phylactic) reaction to the radionuclide.
6. For 24 hours after the procedure, wear rubber gloves when discarding urine. Wash the gloved hands with soap and water before removing the gloves. Wash the ungloved hands after the gloves have been removed.
ClientandFamilyTeaching1. This test involves several leg scans after
the client receives an intravenous tracer that shows up on the scan. Scanning may continue for up to 2 days after the injection.
2. The test poses no risk of radioactive damage to the client.
Norm. No evidence of thrombi. No areas of abnormal concentration in the deep veins of the lower legs.
Usage. Used to monitor the development and progression of deep vein thromboses. Longitudinal screening for clients at risk for thrombotic processes.
Positive. Deep vein thrombosis, thrombo-phlebitis, and thrombosis.
Negative. Normal finding. Also negative after the active clotting process has stopped.
Description. Fibrinogen (factor I) is a complex polypeptide that converts to the insoluble polymer of fibrin after thrombin enzymatic action and combines with plate-lets to clot the blood. The 125I-labeled fibrin-ogen leg scan is an invasive, nuclear medicine test involving the intravenous injection of radionuclide-labeled fibrinogen (fibrinogen labeled with radioactive iodine) and scan-ning with a well counter for subsequent incorporation of the radioactive material into a thrombus. The scan measures increased surface radioactivity (>20%), which indicates uptake by thrombi in the leg(s). The test is most useful in detecting actively forming thromboses of the calf; 85% of positive results are seen within the first 24 hours after the calf is injected with iodine-125.
ProfessionalConsiderationsConsent form IS required.