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introduction

we dont use antacid like calcium carbonate in icu pt cuz it oral agent and pt
cant take it and cuz its continue minerals and most pt in icu have renal
abnormality ,and cuz not effective as ppi and h2
hold enoxaparin when platelet less than 100,000 dose adj crcl les than 30
electrolyte disturbances , sodium and potasum
hypo ,hyper natremia kalemia underlying cause
Disseminated intravascular coagulation (DIC) criteria

evaluation number 1
: how to do case presentation
B3d history of present illness > Wight and height an crcl >medication (for dm *
for htn at home )
start medication presentation with acute problem medication and for what *
indication and if u agree or not wbhmni a3ref etha el drug dafo jded wla mashi
3aleh mn el home ex gemfibrozil <TG
then we statrt interpret lab test

any pt with GI pleading always mast be in IV PPI in treatment dose (not on h2 *


blocker )
< omeprazole for stress ulcer prophylaxis 40mg once daily
in GI bleeding treatment dose 40mg IV twice

PPI on active gi pleading (ppi can make healing ,h2 not ) cuz : platelet
aggregation need ph 6 H2 VS
and this achieved by PPI
another different ppi given once daily , h2 tolerance after 30 day , s/e h2
thrombocytopenia (so always should monitor platelet when pt on ranitidine ) , h2
need renal dose adj but ppi need hepatic adj especially omeprazole .lanzoprazol
bt9eer max 30 mg which is bel a2sas given 30 mg once
another different h2 can make headache and diarrhea ,and increase risk of
aspiration pneumonia (both h2 and ppi) ppi on long term can cause osteoporosis
cuz decrease vit d absorption
you should know when to use ppi or h2 blocker for stress ulcer prophylaxis

main use for metoprolol for HR and migraines prophylaxis (not common for
htn)
the main complication for gi bleeding is hypotension so for any pt have
active gi bleeding always check BP anf u mast give fluid
any pt on icu should not receive any po medication
RBG in icu should be less than 180
on care plan u should right : pt have blood glucose higher than goal which is
<180 so start sliding scale with coverage
any oral hyperglycemia agent should be avoided in icu why ? to avoid
glucose level fluctuation
to achieve beter blood glucose level , oral agent need dose adj in renal impaired
Glasgow Coma Scale (GCS) to detriment level of conscious or conscious state
Eye response(E)2 Verbal response (V) 3 Motor response (M ) EVM1
gemfibrozil and statin Category x > rhabdomyopathy >aki

basic steppes in management upper gi bleeding : 1-ppi treatment dose 2- any patient have
active bleeding regardless HGB should take packed rbc
indication for packed rbc: active bleeding regardless HGB 2-hgb less than 7 3- hgb less than 10
with pt have solid tumor (cancer)
packed rbc complication : fluid overload 2-viral infection(hiptits) 3. anaphylaxis 4- iron overload
insensible loss ; water loss from skin and lungs in healthy adults ( evaporation) and it calculate by
adding 10ml/kg on output
balance should be zero but we accept +- 1000
gi bleeding underlying cause:cancer , Esophageal varices, ulcer
leukocytes increase in infection ,stressful condition ,corticosteroid
Corrected calcium = serum calcium + 0.2 * (40 - serum albumin) if mg/dl 0,8 =4

Decompensated Heart Failure : we should not be uprtly d/c BB blocker cuz its
may case Broncho spasm and exacerbation edema
maximum dose of lactulose 60 ml more dose in liver cirrhosis
(encephalopathy) becose it not absorbed and it useful in decrease ammonia
to say the diuretic is effective : fluid balance with insensible loss mast be
negative (-500 ml)

?tolerance for furosemide how to solve it


first thing in workup anemia is reticulocyte : precursor rbc
LDL,HDL,TC *38.6
TGC *88.5-
GLS *18-
UREA /59.5
Left Bundle Branch Block (LBBB)
need to mummeries cocroft and gault equation
? in dka (icu ) type of insulin givin is regular >nph not given why
enoxaparin treatment dose 1/kg twice or once if crcl less than 30 ,prophylaxis
dose 40 mg once daily
enoxaparin maximum dose 225
empirical and hospital acquired need duple coverage with different
mechanism
tecoplanin indication : mrsa > catheter>gram positive
manistifation of mrsa is hypotension so if pt On antibiotic and still
hypotensive so we empirically add tecoplanin
Tamiflu> Oseltamivir :75 mg twice daily , prophylaxis dose once daily when
h1n1 negative d/c
KCL given peripheral and central line but it prefer to give peripheral
kcl deferent in maximum infusion rate and maximum concentration in
peripheral and central line
peripheral line maximum concentration for peripheral infusion is 10 mEq/100 mL and maximum rate
of administration is 10 mEq/hour
central line Concentrations of 20 to 40 mEq/100 mL at a maximum rate of 40 mEq/hour via central *
line have been safely administered

w e dont give KCL as polus cuz it cause Extravasation( irritant) and cause
tachycardia arrhythmia
piperacillin/tazopcatm :s/e hypokalemia and hypernatremia
,thrombocytopenia , seizure so give lower dose
we should know if antibiotic bacteriostatic and bactericidal
final Q Acinetobacter and choice between tigecycline , colistin : cuz its
bactericidal or we use combination
main s/e for fluoroquinolones is hallucination ,nephrotoxic ,qt prolongation
acid base disturbances*
first thing we should know the normal range of ABG
PH :7,35-7,45
HCO3:22-26
PCO2: 35-45
ABG sample O2% should be more than 90 to say the result of ABG reliable
primary acid base disturbances include primary acidosis(ph <7.35) and
primary alkalosis (ph>7.45)
metabolic acidosis or alkalosis related to hco3
primary metabolic acidosis(hco3 less 22), respiratory acidosis( pco2 more 45)
primary metabolic alkalosis(hco3 more 26) , respiratory alkalosis(pco2 less 35)

metabolic acidosis: two type ionic gap metabolic acidosis and NON-Anion Gap
Metabolic Acidosis
ionic gap normal range 8-16 : if more 16 ionic gap metabolic acidosis
some pt have both ionic gap plus NON-Anion gap : like dka pt and have
vomiting
we have 3 method to r/o ionic gap plus NON-Anion gap
method #1
ionic gap = Na - (Cl + HCO3)
ionic gap = pt ionic gap -12
ionic gap+ HCO3
if the result less 22 : have both ionic gap plus NON-Anion gap
if between 22-30 : ionic gap metabolic acidosis
if more 30 : ionic gap metabolic acidosis plus metabolic alkalosis

method #2
comparison between ionic gap and HCO3
HCO3=24 - pt HCO3
if the HCO3 less ionic gap: have both ionic gap plus anionic gap
if = : ionic gap metabolic acidosis
if more ionic gap: ionic gap metabolic acidosis plus metabolic alkalosis

method #3
ionic gap - HCO3
if the result less -6 : have both ionic gap plus anionic gap
if between -6-6: ionic gap metabolic acidosis
if more 6 : ionic gap metabolic acidosis plus metabolic alkalosis

compensation for metabolic acidosis


after we check acid base disturbances we should check Compensatory
Responses
The body responds to metabolic acidosis by trying to restore the PCO2 /
[HCO3-] ratio. This is done by reducing the PCO2. by hyperventilation
example if pt have metabolic acidosis ,he will develop respiratory alkalosis by
hyperventilation
if PCO2 in normal range : 35-45 we can say non compensation
Compensatory Responses type: well compensation, under compensation ,over
compensation
we can determine Compensatory Responses by calculate expected pco2
expected pco2= 35 - (1.2xHCO3)
HCO3=24 - pt HCO3
make expected plus mines 2
if pt pco2 less than 35 but still above the expected range we say under
Compensatory
if within the range we say well Compensatory
if less the range over Compensatory

underlying cause of anionic gap metabolic acidosis( acat mudpiles) back to


handbook page 773
A:analgesia C:carbon monoxide T:toluene m:metformin u: uremia D:dkaP:
paraldehyde I: iron lactic
underlying cause of non-anionic gap metabolic acidosis:1-loss of hco3 like
renal impairment , acetazolamide, diuretic,2- gaining of acid like hcl and nh4cl 3-
any thing can cause hypokalemia like Adison diseases 4- any thing can cause
hyperkalemia

management of metabolic acidosis :treating underlying case

:criteria to give sodium bicarbonate


in non-dka case : ph less 7,2 or phco3 less 8
in case of DKA ph less( 7 or 6,9) or phco3 less 8

: how to give sodium bicarbonate in non-DKA cases (nahco3)


Nahco3 dose = wt x0.5 x(24-hco3)
half the dose over 30-60 min and the other half over 12-24 h

in case of DKA the dose of Nahco3 depend on ph value


if PH <6.9 100meq in 400cc N.S over 2 hours
if PH 6.9-7 50meq in 200cc N.S over 2 houre

final q :pt(weight not known) with non ionic gap metabolic acidosis secondary to
hyperkalemia and criteria to give sodium bicarbonate not applicable fkan el
jawab bs treatment hyperkalemia

metabolic alkalosis ph more 7.45 hco3 more 26


underlying cause of metabolic alkalosis
1hypokalima a-insulin b-albetarol c- diuretic d- Cushing syndrome-e vomting
nasogastric tube suctioning -2

compensation metabolic alkalosis

The body responds metabolic alkalosis by trying to restore the PCO2 / [HCO3-]
ratio. This is done by increase the PCO2. by hypoventilation (respiratory acidosis)

management for metabolic alkalosis (handbook algortham)

we determine if Sodium chloride responsive or not by calculate chloride in


urine

treatment of choice for metabolic alkalosis is normal saline but if pt


contraindication to normal saline like pt have hyponatremia ,fluid overload we
/give Acetazolamide PO 250375 mg QD or BID plus potassium if K <3.5 mEq
if pt have sever metabolic alkalosis ph >7.6 we give hcl or nh4cl( Ammonium
chloride)
hcl complication :1 irritant and cause hemolysis <> nh4cl cause
encephalopathy

if pt Sodium chloride resistant type: the best management is treat underlying


cause las choice is amiloride
we can determine Compensatory Responses to for metabolic alkalosis by
calculate expected pco2

expected pco2= 45 + (1.6xHCO3)


if pt pco2 less than more 45 but still less the expected range we say under
Compensatory
if within the range we say well Compensatory
if more the range: over Compensatory

primary respiratory acidosis(ph <7.35 and pco2 more 45)


compensation for primary respiratory acidosis done by metabolic alkalosis *
if hco3 within the normal range(:22-26) no compensatory response

:each 10 in pco2 (above 45)--------- 1 hco3 in acute

)in chronic : each 10 in pco2 (above 45)--------- 4 hco3


example if pt have pco2 75 so we expect that hco3 in acute will be 29(26+3)
and in chronic 38 (26+12)

Causes of respiratory acidosis : opioid ,BDZ ,COPD(ASTHMA cause of


respiratory alkalosis )

ASA make metabolic acidosis , BUT ASA overdose make respiratory alkalosis

management :treat underlying cause

we should know when to start O2 thereby : Po2 less 55 (hypoxia)

respiratory alkalosis
primary respiratory alkalosis(ph>7,45 and pco2 less 35)

compensation for primary respiratory alkalosis done by metabolic acidosis


if hco3 within the normal range(:22-26) no compensatory response

:each v 10 in pco2 (uder 35) 2 v hco3(3n the upper limit 35) in acute

in chronic : each 10 v in pco2 (above 35)--------- v 5 hco3(3n the upper limit 35)
example pco2 15 >>>>22-4=18
more than 18 over compamsatory
if less undr

hypokalemia(k <3,5)
mild hypokalemia 3__3,5
moderate hypokalemia 2,5__3
severe hypokalemia less 2,5

k daily need 1- meq/kg


potassium deficit = wt x 0.4(4-k level for the pt )
total= deficit +daily
peripheral line maximum concentration for peripheral infusion is 10 mEq/100 mL and maximum rate
of administration is 10 mEq/hour
*we can give maximam 200 meq over 24 h
central line Concentrations of 20- 40 mEq/100 mL at a maximum rate of 40 mEq/hour via central *
line have been safely administered
we can give maximam 400 meq over 24h

w e give KCL as continues infusion cuz it cause Extravasation( irritant) and cause
tachycardia arrhythmia and cerebral edema
Evaluation
criteria for machine ventilator : O2,ABG

Gestational diabetes develops during pregnancy (gestation) between the 24th


and 28th weeks of pregnancy and we should test HBA1C After 6 month of
delivery to rollout dm2 secondary to gestational dm
? criteria for increase risk of dvt
Tamiflu (oseltamivir):prodrug when active is a neuraminidase inhibitor treatment
dose( when h1n1 positive not flu a) 75 bid for 10 days prophylaxis dose :75 mg
once for 5 day
we should know equivalent between cortisone since hydrocortisone 250mg
minor criteria for stress ulcer prophylaxis
the main reason for stress ulcer prophylaxis in ICU ,that pt on NPO and this
lead to increase acid excretion without food in stomach and this increase risk for
stress ulcer

nifedipine formulation available at icu ??>extended release 20 mg >> what


max dose?? 90-120mg
max dose of atenolol 25-50 mg but they find 50mg of atenolol in icu pt not
increase risk of S/E s
hydralazine must be given continues infusion in HTN crises
all vasodilator including hydralazine not used in strok cuz its increase
intrarenal pressure
so labetalol iv is DOC in case of strok but Unfortunately its not available in KAUH
so we use hydralazine
maximum infusion rate of hydralazine is 10 mg/h
the major s/e of hydralazine lupus like syndrome(type of allergy)
if pt Afebrile and blood culture show gram positive cocci we dont start vanco
or tecoplanin
immediately cuz the blood sample contaminated blood sample is common ,since
gram postive cocci in skin so we need clinical sign of infection

Tecoplanin need dose adjustment in loading dose (not in maintenance dose ) if


crcl less 20
one complication of intracranial hemorrhage is seizure so we should give
phenytoin as prophylaxis's
Nimodipine is a dihydropyridine calcium channel blocker originally developed
for the treatment of high blood pressure. It is not frequently used for this
indication, but has shown good results in preventing a major complication of
subarachnoid hemorrhage ,termed vasospasm; this is now the main use of
.nimodipine
one complication of subarachnoid hemorrhage rebleeding =
Pneumatic compression devices (PCD) for dvt prophylaxis in stork pt

how to write formal case


write problem by problem (daily not within the problem) 30:30 icu 3

phenytoin s/e : hypotension ,gingival hyperplasia hepatotoxicity. Arrhythmia,


qt prolongation
all anti epileptically agent can effect vitmin d and calcium
amlodipine and nifedipine also cause gingival hyperplasia
metoprolol not need dose adj in renal impairment >>which one of bb need
? dose adj
colistin moa? interact with the bacterial outer membrane>> a detergent
what is the underlying cause of dvt and type of dvt
when to give antibiotic in COPD pt ? 1-incrasing volume of sputum 2- color and dyspnea 3
fever
morphen never used as analgesic in intubation pt cuz s/e : respiratory distress, dependence ,
increase histamine release so cause hypotension ,increase intrcranial pressure

fentanyl not require renal or hepatic dos adj


spironolactone moa and side effect
theophylline s/e seizure and arrhythmia level 5-20 not exeed 15
side effect of opioid
valporic acid moa ? sodium channel booker % gaba inhancer
ticagrelor vs clopidogrel
hyponatremia and evaluation
# Fluid calculation
balance in fluid =input-output
input example :iv fluid ,oral or nasogastric intake ,iv medication
don't forget to consider amount of fluid used to reconstitute medication in calc *
balance
output example : urine , sweeting ,berthing , lachrymation *
normal balance should be zero but we accept 1000cc
example of positive and negative balance
? how to calculate maintenance fluid(total daily requirement over 24h)
: method #1
maintenance fluid=35cc/KG/Day (over 24h)
: method #2
we can use it in adult and pediatric
the first 20 kg give 1500 cc then any KG multiple it by 20cc

: type of fluid
crystalloid fluid like normal saline , Lactated Ringer's ,dextrose-1
source of enrage ,contain minerals like ca :(Lactated Ringers, dextrose ) *
normal saline : zero enrage
type of normal saline(different osmolarity) : 1- hypotonic 0.45% nacl 2- isotonic
0.9% nacl 3- hypertonic saline 3%
* glucose : glucose 5% , glucose 4.3

calloid : albumin , Hetastarch ,dextran , gelatin-2

crystalloid :cheaper ,more easier to administration ,more Compatible with


medication ,lower s/e like allergic reaction(serum sickens) ,bleeding ,infection
,kidney injury
disadvantage: increase risk to developed Hyperchloremic acidosis(non anion gap
metabolic acidosis) when we give more than 3L of crystalloid

colloid:more viscous so we need less volume,, so its favorite for HF pt .(have


higher retention site

normal osmolarity in blood : range of 285 to 310 mosmoles/liter


always we should calc osmolarity in blood in pt have DKA (hyperglycemia
increase osmolarty ) ,pt with change in sodium ,pt with change blood urea
nitrogen
osmolarity in blood= 2 X Na + Glucose + Urea ( all in mmol/L)
OR= 2* Na + [Glucose]/18 + [ BUN ]/2.4 where [Glucose] and [BUN] are measured in mg/dl

fluid osmolarty = % X 106 X (equivalent /M.W)


example :normal sline 0.45%
x106x(2/58.44)=154 mosmoles/liter (hypo)(0.45/100)

if pt osmolarity in blood hypo give hypo fluid if hyper give hyper if normal range *
give iso fluid

example #2 :glucose saline 0.18 (in this case we calc osmolarity for glu and
saline separately b3den mnjm3ahom lab3d)

hypernatremia hyponatremia calculator

Na normal level is 135-145 so hyponatremia less than 135


:we should know the type of hyponatremia *
:hypotonic hyponatremia-1
a- euvolemic : (SIADH) syndrome of inappropriate secretion of antidiuretic
hormone
b- hypovolemic :diuretic use
c- hypervolemia (dilutional hyponatremia): volume over load like HF, nephrotic
syndrome liver crosi
isotonic hyponatremia : hyperlipidemia or hyperproteinemia> increase -2
extracellular volume
hypertonic hyponatremia: like in case elevated glucose: glucose increase -3
osmalirty and work as osmotic diuretic

management of hyponatremia
in general we give normal saline
sodium daily 1-2meq /kg (1)
sodum deficit =total body water(TBW) x (sodium Desired-serium sodium=12)
total body water(TBW)= pt Weight x 0,6 for male and 0,5 for female

in acute sodium deficit the correction should not be exceed 8-12meq daily
(increase or decrase) cuz risk of Osmotic demyelination syndrome

total Na requirement = sodium daily(1/kg) + sodum deficit(TBWx12meq)


we give it as 0,45 nacl in dka pt cuz they are dehydration > 0.9nacl or 3% in
.case HF and
each letter of 0,45% contain 77na
each letter of 0,9% contain 154na
each letter of 3% contain 513na


/ 24

hypernatremia and evaluation


Hypernatremia Na >145 mmol/l
most common cusses for Hypernatremia : water deficiency(fluid loss),diuretic
(can cause both hypo and Hypernatremia bt3tmed sho 6ala3 akther water wla na
)

:for Hypernatremia pt we calculate water deficit

Na desired =na measured -12


Water deficit(L) x1000 given q8h or q6h or q4h example 2L x1000=2000cc so
give 500cc every 4h
keep in mind the volume of fluid of other type that used for medication ***
administration
example : if we use 500ml of .9% to reconstructed levofloxacin so should be
2000cc-500cc
Type of fluid that given in Hypernatremia : tap water ,dextrose(if pt have
hypoglycemia)
if the pt was on 0,9% normal saline and developed Hypernatremia so we convert
him to 0.45%
or ,dextrose(if pt have hypoglycemia)

: evaluation

octreotide : somatostatin analog used in GI bleeding: octreotide inhibit secretion


gastrin so this reduce aced secretion also can xbeforused
maleas0.6
antidiarrheal
given as iv bolus 50-100mic then 25-50mic 0,5x
perforhour
female
as continues
infusion for 5 day

if pt have history of ESBL so impirc thereby should be carpanem


critiria for dka diagnosis
dka fluid bnefti to wash keton and uti
dka fluid 500-1000 n.s 0.9% over 30 min bolus then maintenance 150-250 ml
per h
or 4-14ml/kg/h
type of fluid detetermination affected by two fctor glucose level ,and corrected
Na

: dopamine
low dose (renal dose) :work on dopamine receptor and increase kidney perfusion
(5mic/kg/min)
we dont exceed 20 mic cause increase risk of arrthimia without addition
advantage
Dose dependent effect
Low doses( 0.5- 3 microgram/kg/min)
Intermediate doses (3-10 mcg/kg/min)
Higher doses (10-20 mcg/kg/min)

dopamine calculation
convert ml/h to mic/kg/min
rate(ml/h)= dose(mic/min) xwt
1ampule of dopamine contain 250mg reconstituted by 500ml

the most common is the adpdominal pain


Metoclopramide bind to dopamine D2 receptors Antagonist
S/E of antagonist dopamine : extrapyramidal effects , restlessness (akathisia), and focal
dystonia
antidote: anticholinergic :benztropine

when we give potassium we should monitor urine output befor start and ECG Whin we givet
k is contraindication in anuria
final q :potassium is low so first correct k by giving 40 meq in 400ml n,s over 4h befor start
insulin then after cortication start insulin
we reduice level of gls by 60-70 /h to avoid cerebral edema

complication of sodium bicarbonate :hypernatremia 2-fluid overload 3-metabolic alkalosis 5-


inercullr acidosis 6-hypocalcemia 7- hypoxia

calcium gluconate in hyperkalemia as cardiac muscle stabilization just! Zero effect on k level
also we give insulin and albuterol
in chronic hyperkaliemia we use sodium resonium and calcium resonium

why we choose levofloxacin in rs infection cuz its cover pseudomonas an d


atypical
in case of AKI we wait 48 h before we make dose adj
digoxin reduce HR and not effect BP

:Evaluation and quiz topics number 1


Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting
factors, which include Factors II, VII, IX, and X, and the anticoagulant proteins C
and S 1972
the longest half life for this factor 7 day ,, so this way we see the effect of
.warfarin after 7 d
when we use enoxaparin as bridge therapy with warfarin we can stop it two
constitutive INR within the goal
levofloxacin it functions by inhibiting DNA gyrase and topoisomerase IV
levofloxacin s/e : hallucination , photosensitivity, nephrotoxicity, QT
prolongation
,glargine insulin :given on fixed time , peakless
psychiatric pt with obstructive sleep apnea ,oxygen thereby due to sever
obesity ,infection , DIC
d/5 wter and have metabolic acidosis >give normak sline, positive budding yeast
in urine, acino bacter >colstin dose actul wt

Criteria for brain death: fixed pupil , irreversible loss of brain function (functional brain death )
loss of the brain nerve reflexes including the light reflex

Tamiflu (oseltamivir):prodrug when active is a neuraminidase inhibitor


treatment dose( when h1n1 positive not flu a) 75 bid for 10 days
prophylaxis dose :75 mg once for 5 days

ticoplanin Glycopeptide antibiotics: inhibits peptidoglycan synthesis


Initial: IV: 400-800 mg every 12 hours for 3-5 doses maintenenance 6-12 mg/kg once daily
Tecoplanin need dose adjustment in loading dose (not in maintenance dose ) if
crcl less 20
adj CrCl 30-80 mL/minute: maintenance dose once every 48 hours, or administer one-half of
previous maintenance dose once daily
CrCl <30 mL/minute (including hemodialysis patients): Administer previous maintenance dose once
every 72 hours, or administer one-third of previous maintenance dose once daily
tecoplanin indication : mrsa > catheter>gram positive

not all pt have fever with budding yeast positive in urine should start
fluconazole
we should r/o bacterial infection first by covers all thing then if still febrile and
hymodynmic unstable we can start
fluconazole 200mg iv once daily require dis adj renal 50% dose
fluconazole maxim dose 800

normally we can find pt with sepsis with normal wbc since the criteria for
sepsis is wbc>12 or less 4

nifedipine>CCB> dihydropyridine>S/E >edema ,constipation when given with


vepramil diltiazem
reflex tachycardia , in long term gingival hyperplasia
moxonidine> antihypertensive> selective agonist at the imidazoline receptor
subtype 1
intial dose 0,2 maximum daily dose of 0.6 mg>>GFR 30-60 mL/minute: Maximum single
dose: 0.2 Maximum daily dose: 0.4 mg ; GFR <30 mL/minute: Use is
contraindicated

< Haloperidol> typical antipsychotic medication> prn


s/e wt gain , Extrapyramidal s/e including: Distonia ,Muscle rigidity Akathisia,
Parkinsonism
Extrapyramidal antidote> diphenhydramine>BZD>BB>cholinergic
final Q : Haloperidol s/e Neuroleptic malignant syndrome (NMS)( consists of
muscle rigidity, fever, autonomic instability) what is the antidote ? . Dantrolene

the major s/e of hydralazine lupus like syndrome(type of allergy)


allopurinol > allopurinol for tumor lysis syndrome (TLS) prophylaxis
TLS >increase uric aced ,phosphors ,ca
inhibitor allopurinol is a purine analog; of the enzyme xanthine oxidase
daily dose 300-600 mg in divided dose the maximum daily dose 800mg/daily
CrCl 10 to 20 mL/minute: 200 mg/day
.CrCl 3 to 10 mL/minute: Do not exceed 100 mg/day
CrCl <3 mL/minute: The dosing interval may need to be extended; do not exceed
100 mg/day
major s/e allopurinol skin allergy ,kft monitoring

digoxin :nhibition of the sodium/potassium ATPase pump, Direct suppression of the AV node
digoxin toxicity sign :gi s/e ,cardiovascular>brady or tache arthmia ,vf ,cnc s/e ,,ophthalmic s/e>green
, yellow spoting
antidote :fab antibodi

dexamethasone
Extubation or airway edema: Oral, IM, IV: 0.5 to 2 mg/kg/day in divided doses
every 6 hours beginning 24 hours prior to extubation and continuing for 4 to 6
doses afterwards
Cerebral edema: IV: 10 mg stat, 4 mg IM/IV (should be given as sodium
phosphate) every 6 hours until response is maximized, then switch to oral
regimen, then taper off if appropriate; dosage may be reduced after 2 to 4 days
and gradually discontinued over 5 to 7 days

enxoparin max dose 225


hydrocortisone:14 days then oral
hydrocortisone tapering : every 3days decrease the dose 2.5-5 mg until to
reach the lowest dose which is 5mg then u d/c it
dic management
in dic fibrinogen level is low and high FDB (degradation product of fibrinogen)
but in some condition like sepsis fibrinogen level will be normal or high
DIC is suspected, platelet count, PT, PTT, plasma fibrinogen level, and plasma
d-dimer level
rbc indication
fresh frozen plasma contain clotting factor so given in case bleeding
indication for fresh frozen plasma (FFP):1-elevation in INR(1,5) 2- PT(apove 45)
3-active bleed all3
in case we give FFP and the patient still bleeding and the fibrinogen less than 1
,so we give cryoprecipitated (antihaemophilic factor(factor a))
indication for platelet ? 1- platelet cunt less 10.000 regardless if there is
bleeding or no
platelet cunt less 30,000 and their is risk of bleeding 3-pletelet less 50.000 -2
and have active bleeding
condition cause of dic :sepsis ,cancer ,hepatitis, snake bite

Topic in quiz : 1-shock and sepsis and septic shock


DVT and stress ulcer prophylaxis
DVT :contraindication for enoxaparin 2-dose enoxaparin in DVT treatment and
prophylaxis dose adj
unfractionated heparin prophylaxis dose
stress ulcer : major/minor criteria (one major or two minor)5726

topic 2
head trauma and sub-arachnoid hemorrhage
head trauma >falling down or rod traffic accident(rta) and this may led to )
(fracture
we have types of fracture:1- simple skull fracture 2- depressed skull fracture 3-
compound depressed skull fracture 4- Basal fracture (the most dangerous one
cuz of risk of leakage of CF fluid and risk of meningitis
Basal fracture have two sign : Raccoon eyes(ecchymosis around eyes) and
battle sign(ecchymosis temporal eria)
: management
mainly we do management for complication
sizure : we give seizure prophylaxis -1
phenytoin : for 7 days >>>>if he developed seizure 6-12month
note :if pt exceed 7 days and still on phenytoin but he on Mechanical ventilation
and not stable so we keep him on phenytoin
we should know phenytoin vs levetiracetam dose and every thing *

elevation intracranial pressure So we expected ischemic or hemorrhage -2


cerebral perfusion pressure = MAP - ICP
if ICP >MAP so cerebral perfusion well decrease and we expected ischemic
? how we decrease intracranial pressure *
non pharma :surgery+ cefazolin surgery prophylaxis
: pharmalogical
first line :hypertonic saline 3%
second line :mannitol (dose, contraindications, duration of treatment not exeed 3
day why ?)
in mannitol we should calc serum osmalirety if the result more 325: mannitol
contraindication

some study recommend to give combination mannitol and furosemide low dose
10-20mg since its give synergistic diuretic effect to decreases cerebral edema

? meningitis: we should know when to start meningitis prophylaxis and what -3


we usually give ceftriaxone and vancomycin but if frontal area involve we add
metronidazole to cover anaerobic

criteria for meningitis prophylaxis*


sub-arachnoid hemorrhage: the main complication vasospasm so we give -4
nimodipine (dose: 60mg po q ? duration 21 days) after the pt be com stable
other complication include :1-rebleeding2-sizure 3- hemorrhage 4-
( hyponatremia ??)

Two mechanisms have been proposed as causes: syndrome of inappropriate anti-diuretic hormone
and cerebral salt wasting

topic 3
glycemic control
we give regular insulin as continues infusion cuz mixterid contain NPH ,and particles occlusion iv line

topic 4
acid-and base disturbances and electrolyte disturbances
antibiotic case

:sepsis
we treat :hypotension ,infection and supportive (stress ulcer and DVT prophylaxis)
* hypotension: 500-1000 bolus normal saline then maintenance
:if pt still hypotension despite adequate fluid resuscitation so we give vasopressors
norepinephrine first line why ? cuz it work both in alpha and beta resptor but more in
alpha so less risk of tachycardia and more vasoconstriction
epinephrine a=b
dopamine=low dose dopamine receptor mod dose :b high :alpha
the most risk for elevate hr with dopamine so not use in arrhythmia

bp=co x pvr
to give dobutamine 1-SBP>90 2-hct>30%(cuz its increase risk of hypoxia) 3-cardic
index low(EF Less 45)

dose and when to use each one


norepinephrine maximum dose In septic shock 3mic/kg/min
other type of shock :30mic/min
dose range
dopamine :max dose practically 20mic/kg/min theoretically 50
dobutamine : max dose practically 20mic/kg/min theoretically40

S/E of dopamine and norepinephrine is renal failure and skin necrosis so we make .==
irrigation and give ( antidote nitroglycerine topical or phentolamine topical ) alpha
antagonist

last option is hydrocortisone 100mg q8h max 300 for 7days

infection
FINAL Q :culture with Pseudomonas and positive cocci's :to antibiotic should be given
?homework four indication for double coverage for pseudomonas

supportive

what is complications for sepsis? End organ damage ,dic Acute Respiratory Distress

The APACHE II Scoring System is designed to measure the severity of disease in


patients admitted to the intensive care unit

, type of shock cardiogenic shock


DKA
aki diagnosis criteria: Increase in serum creatinine to 1.5 times
baseline or Increase in serum creatinine by 0.3mg/dL or more within 48
h
criteria for dka :1- Hyperglycemia: >250 mg/dL 2- Metabolic acidosis:
pH < 7.3
serum bicarbonate < 18 mmol/l 4- positive Urine or serum ketones -3
non-dka ketones in urine : pregnancy , infection ,dehydration ,stress
the major source of energy for the body is glucose , insulin is
required for glucose uptake in tissue ,anyway as consequence of
absolute or relative insulin deficiency body accompanied that by an
increase lipolysis result in increases serum ketones
symptoms of dka Abdominal pain and vomiting
Ketone bodies have generally included acetone, beta-
hydroxybutyrate, and acetoacetate
acetoacetate is the predominant ketone bodies
nitroprusside is used as reagent for the detection of beta-
hydroxybutyrate (not the predominant ketone acetoacetate) so same
patent have DKA but negative ketone because theres no adequate
amount of beta-hydroxybutyrate
dka causes : infection, hyperthyroidism ,stressful condition
medication (isotretinoin, corticosteroids, beta blocker ,oral
contraceptive , antimalarial) hyperthyroidism
beta blockers can cause hypoglycemia or hyperglycemia depend on
beta blocker receptor selectivity (beta 1, beta 2, beta 3 )
hyperglycemia in dka can cause pseudohyponatremia so we should
calculate corrected sodium .Na = Measured Sodium + 0.016 *
(Glucose - 100)

the first step in management in dka is rehydration : 500-1000cc


normal saline iv bolus over 30 min regardless sodium level
then we give maintenance(125-250cc /hour) (N.S or N.S) with or
without D5% depend on corrected sodium and glucose level (if
corrected sodium normal or hypernatremia give N.S ,IF hyponatremia
give N.S) and if glucose level less than 250 add D5% if glucose less
150 hold insulin and give D5%

the second step check potassium level


if potassium level is normal we can immediately start insulin and we
give 20-30 meq potassium
if the patient have hypokalemia so we should first correct potassium
level before start insulin
if K level 3.3 -5.5 give 20-30 meq for each liter of maintenance fluid
if K level 3.3 to 3.5 give 30 meq KCL as bolus +insuln
if K level less than 3.3 give 40 meq as bolus , after k level correction
add insulin
if K level more 5.5 dont give kcl and start insulin

type of insulin is regular dose: 1-10 unit/kg/h as continues infusion


glucose level is measured every hour
electrolyte is measured Q 2h if abnormal and Q 4h if normal

:criteria to give sodium bicarbonate


in non-dka case : ph less 7,2 or phco3 less 8
in case of DKA ph less( 7 or 6,9) or phco3 less 8

: how to give sodium bicarbonate in non-DKA cases (nahco3)


Nahco3 dose = wt x0.5 x(24-hco3)
half the dose over 30-60 min and the other half over 12-24 h

in case of DKA the dose of Nahco3 depend on ph value


if PH <6.9 100meq in 400cc N.S over 2 hours
if PH 6.9-7 50meq in 200cc N.S over 2 houre

S/E OF sodium bicarbonate : metabolic alkalosis ,cerebral edema , hypernatremia


,hypoxia ,intracellular acidosis ,fluid over load ,hypocalcemia

hypokalemia(k <3,5)
mild hypokalemia 3__3,5
moderate hypokalemia 2,5__3
severe hypokalemia less 2,5

k daily need 1- meq/kg


potassium deficit = wt x 0.4(4-k for the pt )
total= deficit +daily
peripheral line maximum concentration for peripheral infusion is 10 mEq/100 mL and maximum rate
of administration is 10 mEq/hour
*we can give maximam 200 meq over 24 h
central line Concentrations of 20- 40 mEq/100 mL at a maximum rate of 40 mEq/hour via central *
line have been safely administered
we can give maximam 400 meq over 24h

w e give KCL as continues infusion cuz it cause Extravasation( irritant) and cause
tachycardia arrhythmia and cerebral edema
DKA means diabetic ketoacidosis and HHS means Hyperosmolar
.Hyperglycemic Syndrome
?what the different between DKA and HHS
ceftriaxone: biliary excretion

:Resolution of DKA
clinical symptom improvement with Plasma glucose <200 mg/dl
Serum bicarbonate concentration >18 meq/L
Venous blood PH >7.3
Anion gap =12 2

-----------------------------------------------------------------------------------------------------------------
---------------------
SEPSIS AND VAP
Old definition

infection>SIRS>Sepsis>Severe Sepsis>Septic Shock

SIRS (Systemic inflammatory response syndrome) criteria


two or more of the following conditions :

temperature >38C or < 36C;


HR > 90 beats/min;
RR >20 breaths/min
PaCO2 <32 torr; WBC >12,000 cells/mm3,<4,000cells/mm3

New definitions
Sepsis: A life-threatening organ dysfunction caused by a dysregulated host
response to infection.
Septic shock: Sepsis in which underlying circulatory and cellular/metabolic
abnormalities are profound enough to substantially increase mortality.
Terms like severe sepsis/ septicemia removed
Criteria for new definitions SOFA score 2 points consequent to the
infection

norepinephrine ampule available at icu 4mg/4ml so the total dose in 1 ampule


is 16 mg

management of sepsis :
first step : Fluid therapy
septic patients who initially present with hypotension, fluids alone will reverse
hypotension and restore hemodynamic stability
Resuscitation with IV bolus normal saline 500-1000 mL over 15-30 min then
start maintenance fluid
challenge test :maintenance fluid + IV boluses normal saline 500 mL every 15
minutes until the target central venous pressure (CVP)is reached.

if challenge test started and 3 boluses was given and patient still hypotension
or patent become edematous so in these case we keep patient on maintenance
fluid and Vasopressor should be started
type of fluid depend on glucose and Na level

norepinephrine maximum dose In septic shock 3mic/kg/min


other type of shock :30mic/min
dose range
dopamine :max dose practically 20mic/kg/min theoretically 50
dobutamine : max dose practically 20mic/kg/min theoretically40

we treat :hypotension ,infection and supportive (stress ulcer and DVT prophylaxis)
hypotension: 500-1000 bolus normal saline then maintenance *
if pt still hypotension despite adequate fluid resuscitation so we give vasopressors:
norepinephrine first line why ? cuz it work both in alpha and beta receptor but more in
alpha so less risk of tachycardia and more vasoconstriction
epinephrine a=b
dopamine=low dose work on dopamine receptor ,,,mod dose :work on B>>> high
dose :alpha
the most risk for elevate hr with dopamine so not use in arrhythmia

in case AF the first choice is phenylephrine cuz its have zero effect on BETA receptor
so no risk of increase HR
BP=CO x PVR
to give dobutamine 1-SBP>90 2-hct>30%(cuz its increase risk of hypoxia) 3-cardic
index low(EF Less 45)

dose and when to use each one


norepinephrine maximum dose In septic shock 3mic/kg/min
other type of shock :30mic/min

dopamine :max dose practically 20mic/kg/min theoretically 50


dobutamine : max dose practically 20mic/kg/min theoretically40

S/E of dopamine and norepinephrine is renal failure and skin necrosis so we make
irrigation and give ( antidote nitroglycerine topical or phentolamine topical ) alpha
antagonist

last option is hydrocortisone 100mg q8h max 300 for 7days


Ventilator-associated pneumonia (VAP) is pneumonia that develops 48
hours or longer after mechanical ventilation
to determine empiric thereby we should know if patient have risk factor for
MDR or not
Initiate empiric antibiotic within firs hour in sepsis

Risk Factors for MDR Pathogens :


recent or Current hospitalization of 5 days
2 immunocompromised patients : Immunosuppressive disease or therapy
3- High Institution antibiotic resistance rate
4 Antimicrobial therapy in preceding 90 days

if the patient have Risk Factors for MDR so double anti-pseudomonal coverage
and if the pt have risk for MRSA so we add vancomycin (2 anti-pseudomonal
+vanco or tecoplanin)
if nor risk factor for MDR :empiric >ceftriaxone or one anti-pseudomonal
if source of infection is skin: add vanco as empiric
if source of infection is skin with Abscess and foul smelling : carbapenem to
cover anaerobic

Risk Factors for VAP :


1-Age
2- immunocompromised patients
3- respiratory disease
4- nasogastric tube suctioning
5- prolonged m.ventilation

how to decrease Risk Factors for VAP


1- decrease duration m.ventilation > tracheostomy if needed
2- hygiene and good Aseptic technique
3- semi sitting position

if source of infection is skin add vanco as empiric

The goals during the first 6 hours


1)CVP of 8 to 12 mm Hg.
2) MAP 65 mm Hg.
3) urine output 0.5 mL/kg/h.
4) central venous or mixed venous oxygen saturation 70%.
5) lactate less than 4 mmol/L

Early Sepsis (at the first 6 hours) vs Late Sepsis

Early Sepsis: Hyperglycemia, Tachycardia Tachypnea, Hyperbilirubinemia, Fever


or hypothermia

Late Sepsis: Hypoglycemia, Hypotension, Leukopenia, Pulmonary edema,


Oliguria,DIC, Lactic acidosis

Sepsis caused by Candida albicans DOC is Fluconazole


Sepsis caused by Candida non-albicans(C. glabrata, C. krusei, and Candida
lusitaniae) DOC is Caspofungin (Echinocandin)
sulfamethoxazole/trimethoprim : Pneumocystis jirovecii (previously
Pneumocystis carinii)
Voriconazole : Aspergillus species

risk factor for fungal infection :


1)Those receiving total parenteral nutrition. 2) With bowel perforation. 3)With
persistent or new signs and symptoms of infections despite receiving broad-
spectrum antibacterial therapy 4- immunocompromised patients