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🧪 Valè Laboratwa · Leson 4 sou 5 · 7 min

Nivo Medikaman Terapetik ak Tès Koagilasyon yo

Therapeutic Drug Levels and the Clotting Tests

💉 Digoxin 0.5 a 2.0. Lithium 0.6 a 1.2. Phenytoin 10 a 20. Nimewo yo sanble o aza jiskaske ou remake egzamen an ba ou yon nivo ak yon sentòm epi li atann ou di 'toksik' anvan founisè swen an fè l.

💉 Digoxin 0.5 to 2.0. Lithium 0.6 to 1.2. Phenytoin 10 to 20. The numbers look random until you notice the exam gives you a level and a symptom and expects you to say 'toxic' before the provider does.

💡 Ide prensipal

Trough anvan dòz la, peak apre. Digoxin anba 2, lithium anba 1.2, phenytoin anba 20. INR 2 a 3 sou warfarin pou pifò endikasyon, aPTT 1.5 a 2.5 fwa kontwòl sou heparin.

Trough before the dose, peak after. Digoxin under 2, lithium under 1.2, phenytoin under 20. INR 2 to 3 on warfarin for most indications, aPTT 1.5 to 2.5 times control on heparin.

🧠 Poukisa sa enpòtan

DIGOXIN 0.5 a 2.0 ng/mL (toksisite: noze, bradycardia, alo vizyèl). LITHIUM 0.6 a 1.2 mEq/L (toksisite depase 1.5: tranbleman grosye, vomisman, ataxia). PHENYTOIN 10 a 20 mcg/mL (toksisite: nystagmus, ataxia, pawòl ki anpate; hyperplasia gingival ak itilizasyon lontan). CARBAMAZEPINE 4 a 12 mcg/mL. VALPROIC ACID 50 a 100 mcg/mL (fwa ak plakèt). THEOPHYLLINE apeprè 10 a 20 mcg/mL, ak nouvo sib 5 a 15 (toksisite: tachycardia, kriz). Yo kontwole VANCOMYCIN ak nivo trough, yo pran jis anvan pwochen dòz la, oswa dòz gide pa AUC, selon famasi a; GENTAMICIN bezwen nivo peak ak trough tou de: peak la konfime dòz la ase wo pou l efikas, epi trough la konfime medikaman an ap elimine pou li pa domaje ren yo ak zòrèy yo. Yo pran yon TROUGH imedyatman anvan yon dòz; yo pran yon PEAK apre l, apeprè 30 minit apre yon perfusion IV fini. KOAGILASYON: PT apeprè 11 a 13.5 segonn epi INR 0.8 a 1.2 nòmalman, ak yon objektif INR 2 a 3 sou warfarin pou pifò endikasyon (pi wo pou kèk valv mekanik); aPTT apeprè 30 a 40 segonn nòmalman, 1.5 a 2.5 fwa kontwòl sou heparin; FIBRINOGEN desann epi D-DIMER monte nan koagilasyon entravaskilè disemine, ki prezante ak senyen nan tout kote plis kayo. Pran etid koagilasyon yo nan yon liy yo pa t rense ak heparin.

DIGOXIN 0.5 to 2.0 ng/mL (toxicity: nausea, bradycardia, visual halos). LITHIUM 0.6 to 1.2 mEq/L (toxicity above 1.5: coarse tremor, vomiting, ataxia). PHENYTOIN 10 to 20 mcg/mL (toxicity: nystagmus, ataxia, slurred speech; gingival hyperplasia with long use). CARBAMAZEPINE 4 to 12 mcg/mL. VALPROIC ACID 50 to 100 mcg/mL (liver and platelets). THEOPHYLLINE about 10 to 20 mcg/mL, with newer targets of 5 to 15 (toxicity: tachycardia, seizures). VANCOMYCIN is monitored with trough levels, drawn just before the next dose, or AUC-guided dosing, per pharmacy; GENTAMICIN needs both peak and trough levels: the peak confirms the dose is high enough to be effective, and the trough confirms the drug is clearing so it does not damage the kidneys and ears. A TROUGH is drawn immediately before a dose; a PEAK is drawn after it, about 30 minutes after an IV infusion ends. COAGULATION: PT about 11 to 13.5 seconds and INR 0.8 to 1.2 normally, with an INR goal of 2 to 3 on warfarin for most indications (higher for some mechanical valves); aPTT about 30 to 40 seconds normally, 1.5 to 2.5 times control on heparin; FIBRINOGEN falls and D-DIMER rises in disseminated intravascular coagulation, which presents with bleeding from every site plus clotting. Draw coagulation studies from a line that has not been flushed with heparin.

🏥 Nan lavi reyèl

👁️ Yon pasyan sou phenytoin pou kriz rapòte vètij epi enfimyè a remake je l yo ap sekwe ale vini lè li gade sou kote. Nivo a retounen 28. Yo kenbe dòz la epi yo rele founisè swen an. Nystagmus se siy toksisite phenytoin egzamen an pi renmen, epi li vizib depi nan papòt la.

👁️ A client on phenytoin for seizures reports dizziness and the nurse notices the eyes jerking back and forth when he looks to the side. The level comes back at 28. The dose is held and the provider is called. Nystagmus is the exam's favorite phenytoin toxicity sign, and it is visible from the doorway.

📌 Sa pou retni

  • Digoxin: 0.5–2.0, lithium: 0.6–1.2, phenytoin: 10–20, theophylline: 10–20Digoxin 0.5–2.0, lithium 0.6–1.2, phenytoin 10–20, theophylline 10–20
  • Trough jis anvan pwochen dòz la, peak apre l; aminoglycosides bezwen tou deTrough just before the next dose, peak after it; aminoglycosides need both
  • INR 2–3 sou warfarin pou pifò endikasyon; aPTT 1.5–2.5 fwa kontwòl sou heparin; DIC montre fibrinogen ki ba ak D-dimer ki woINR 2–3 on warfarin for most indications; aPTT 1.5–2.5 times control on heparin; DIC shows low fibrinogen and high D-dimer

📖 Tèm nan leson sa a

Nivo pi ba (trough) (Trough level): Nivo medikaman ki pi ba nan san an, yo pran l jis anvan pwochen dòz la, yo itilize l pou siveye aminoglycosides, ak vancomycin sof si famasi a itilize dòz gide pa AUC.

Nivo digoxin (Digoxin level): Entèval terapetik apeprè 0.5 jiska 2.0 ng/mL; toksisite pote noze, bradikadi ak alo vizyèl jòn-vèt.

Nivo lithium (Lithium level): Entèval terapetik 0.6 jiska 1.2 mEq/L; pi wo pase apeprè 1.5 pote tranbleman gwo, vomisman ak ataksi.

Tan pwotronbin (PT) (Prothrombin time (PT)): Apeprè 11 jiska 13.5 segonn, ak yon INR 0.8 jiska 1.2 san antikoagulan; li alonje ak warfarin, maladi fwa ak defisyans vitamin K, epi sou warfarin se INR a, pa segonn yo, ou rapòte.

Fibrinogen: Nòmal apeprè 200 jiska 400 mg/dL; li bese anba 100 nan kayo entravaskilè gaye paske kayo a konsome l, kidonk yon fibrinogen ba ak yon D-dimer k ap monte nan yon pasyan k ap senyen montre DIC.

Nivo phenytoin (Phenytoin level): Terapetik 10 a 20 mcg/mL; pi wo pase 20 pote nistagmis, ataksi ak pawòl anboulaye, epi medikaman an lakòz tou ipèplazi jansiv ak itilizasyon lontan, kidonk anseye bon swen bouch epi pa janm sispann li bridsoukou.

Nivo theophylline (Theophylline level): Terapetik ozanviwon 10 a 20 mcg/mL (sib ki pi resan yo 5 a 15); pi wo pase 20 pote kè plen, takikadi ak kriz, epi kafeyin, chanjman nan fimen ak anpil antibyotik chanje nivo a.

Nivo carbamazepine (Carbamazepine level): Terapetik 4 a 12 mcg/mL; pi wo pase ozanviwon 12 a 15 pote vètij, diplopi ak ataksi, epi medikaman an ka siprime mwèl zo a, kidonk rapòte lafyèv, malgòj oswa ematom epi atann CBC peryodik.

Nivo valproic acid (Valproic acid level): Terapetik 50 a 100 mcg/mL; pi wo pase ozanviwon 100 a 150 pote sedasyon, tranbleman ak konfizyon, epi medikaman an ka blese fwa a epi bese plakèt, kidonk yo tcheke anzim fwa ak yon CBC.

Nivo vancomycin (Vancomycin level): Objektif trough la te 10 a 20 mcg/mL (15 a 20 pou enfeksyon MRSA grav); anpil famasi kounye a bay dòz dapre yon AUC 400 a 600 pito, epi nivo ki pi wo pase entèval sa a menase ren yo ak tande a.

Theophylline: Yon bronkodilatatè ki pi ansyen ak yon entèval terapetik etwat (ozanviwon 10 a 20 mcg/mL); toksisite montre kòm kè plen, takikadi, ajitasyon ak kriz, kidonk tcheke nivo yo, limite kafeyin, epi konnen fimen bese nivo a pandan ciprofloxacin ak ensifizans kadyak ogmante li.

Phenytoin: Yon medikaman kriz ak yon entèval etwat (10 a 20 mcg/mL) ki gen toksisite ki montre kòm nistagmis, ataksi ak pawòl anboulaye; pouse dòz IV dousman nan saline sèlman ak siveyans kadyak, atann depase jansiv ak itilizasyon lontan, epi kenbe alimantasyon pa tib otou dòz oral yo.

Carbamazepine: Yon medikaman kriz, nevralji trigeminal ak bipolè (entèval 4 a 12 mcg/mL) ak avètisman nan bwat pou anemi aplastik ak sendwòm Stevens-Johnson (pi mal kay moun ki gen orijin Azyatik ak jèn HLA-B*1502 la); rapòte lafyèv, malgòj, ematom oswa gratèl, veye sodyòm, epi evite chadèk.

Valproate (asid valproic, divalproex) (Valproate (valproic acid, divalproex)): Yon medikaman kriz ak bipolè (entèval 50 a 100 mcg/mL) ak avètisman nan bwat pou ensifizans fwa, pankreatit ak domaj nesans; tcheke anzim fwa, plakèt ak amonyak, rapòte doulè vant, jònis oswa ematom fasil, epi atann pran pwa ak tranbleman.

✅ Teste tèt ou

Yo òdone yon nivo trough vancomycin. Ki lè enfimyè a dwe pran san an?A vancomycin trough level is ordered. When should the nurse draw the blood?
  1. Imedyatman anvan pwochen dòz ki pwograme aImmediately before the next scheduled dose
  2. Nan mitan perfusion anHalfway through the infusion
  3. Nenpòt lè nan jounen anAny time of day
  4. 30 minit apre perfusion an fini30 minutes after the infusion ends

Repons: A · Imedyatman anvan pwochen dòz ki pwograme a

Yon trough reflete nivo ki pi ba a epi yo pran l jis anvan pwochen dòz la dwe fèt. Pran l 30 minit apre perfusion an fini kaptire peak la, nivo ki pi wo a, ki se opoze sa yon trough mezire.

A trough reflects the lowest level and is drawn just before the next dose is due. Drawing 30 minutes after the infusion ends captures the peak, the highest level, which is the opposite of what a trough measures.

Yon pasyan k ap pran phenytoin gen yon nivo 26 mcg/mL epi li rapòte vizyon doub. Ki rezilta evalyasyon ki konsistan ak toksisite?A client taking phenytoin has a level of 26 mcg/mL and reports double vision. Which assessment finding is consistent with toxicity?
  1. Polyuria
  2. Nystagmus
  3. Bradycardia
  4. Hyperreflexia

Repons: B · Nystagmus

Toksisite phenytoin pwodwi nystagmus, ataxia ak pawòl ki anpate; nivo ki depase 20 konfime l. Bradycardia se yon risk lè yo perfize phenytoin IV twò vit, pa yon siy klasik yon nivo ki wo; toksisite parèt kòm chanjman newolojik tankou vizyon doub pasyan sa a.

Phenytoin toxicity produces nystagmus, ataxia and slurred speech; the level above 20 confirms it. Bradycardia is a risk of infusing IV phenytoin too fast, not a classic sign of a high level; toxicity shows up as neurologic changes like this client's double vision.

Yon pasyan sou warfarin pou fibrilasyon orikilè gen yon INR 1.3. Kijan enfimyè a dwe entèprete sa?A client on warfarin for atrial fibrillation has an INR of 1.3. How should the nurse interpret this?
  1. INR a nan objektif laThe INR is at goal
  2. Pasyan an gen ensifizans fwaThe client has liver failure
  3. INR a subterapetikThe INR is subtherapeutic
  4. Pasyan an gen risk senyenThe client is at risk for bleeding

Repons: C · INR a subterapetik

Objektif warfarin pou fibrilasyon orikilè se yon INR 2 a 3; 1.3 toupre nòmal, kidonk pasyan an pa antikoagile ase epi li gen risk kayo.

The warfarin goal for atrial fibrillation is an INR of 2 to 3; 1.3 is close to normal, so the client is not adequately anticoagulated and is at risk for clots.

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