SLMC

Internal Medicine
Handy notes

Luanne Rose E. Dideles-Sandifer, MD

NUTRITION and FEEDING
TOTAL CALORIE REQUIREMENT
TCR=IBW x % act = kcal/day
% act: 45 heavy, 40 mod, 35 light, sedentary 30, 27.5 bed rest
if obese: subtract 500-1000 kcal/day to lose 1-2 lbs/week
if underweight: add 500-1000 kcal/day to gain 1-2 lbs/week
CHO (g/day): TCR x 0.6/4
CHON (g/day): 1g/kg
Fats: the rest
Subtract CHO +CHON from TCR
TCR DISTRIBUTION
60% CHO, 15% CHON, 25% fats
kcal to g: Divided by: 4-4-9
RENAL DIET
1800 kcal/day, 50 g high quality CHON with NPCR (normalized
protein catabolic rate), 50% CHO, 50% fats, 3.5 g Na, 3 g K, < 300
mg cholesterol, div into 3 meals and 2 snacks
DIABETIC DIET
Full, 2000 kcal/ day 50% CHO, 25% CHON, 25% fats. <7%
saturated fat, rest from MUFA and PUFA, 3 g Na, 20 g fiber to be
divided in 3 meals, 2 snacks
IM platinum: 1800 kg/day for a 60 kg px
CHO 270g/day, CHON 60g/day;the rest FATS. Divided into 3
meals and 2 snacks. No source of simple sugars, low salt, low fat.
Na<2g, TC<200mg, Saturated fats <7% MUFA>PUFA
OSTEORIZED FEEDING
Start OF 1600 kcal/day, 60% CHO, 20% CHON, 20% fats; 60 g
CHON of HBV, divided into 6 equal feedings with 30 cc flushing q
4 OR 1 cal/cc divided into 6 equal feedings to run as drip for 1
hour per feeding
Common Formulas

BMI: kg/m2 Underweight <18.

Normal 18.5-22.9
Overweight: 23-24.9
Obese I: 25-29.9
Obese II: ≥30
Ideal Body weight:
Female: 100lbs +(5 lbs per inch over 5 ft)
Male: 106lbs +(6lbs per inch over 5 ft)
Divide by 2.2 to convert to kg

cardiac output Heart Rate x stroke volume

MAP SBP+ 2DBP/3 NV:70-100mmHG
Urine Anion Gap (na +K) –CL
Serum Anion Gap Na- (HCO3 + Cl)
Urine osmolality (SG -1) x 40,000
Plasma OSmolality [2 (Na +K) + RBS (mmol/L) + BUN (mmol/L) or
2 (NA in mmol/L) + (Gluose in mg/dL/18) +
(BUN/2.8)
NV: 180-300mOSM/L
Harrisons: 275-290mOSM/kg
RBS: 1 mmol/L =18mg/dL
Effective plasma Osm 2 NA + RBS in mmol/L or
2 Na +(RBS in mg/dL/18)
Conversion factors
To mg/dL RBS multiply by 18
BUN multiply by 2.8
Crea divide by 88.4
Ca divide by 0.25
Bilrubin divide by 17.10

Equivalents 1cc oral KCL 1.3mEq K

15cc Oral KCL 20mEq
1 k durule 750 10mEq
NahCO3 50ml 45 meq Na
NaHCo3 gr x tab 7mEq
daily req for Na is 21 thats why we give TID
CARDIAC DIAGNOSIS

1. Etiology: aging, degenerative, alcoholism, anemia, atherosclerosis, congenital,

infectious, hypertensive, ischemic, hyperthyroidism, Infection, neoplasm, pregnancy,
pulmonary, rheumatic, SLE, Toxic agent, transplantation, trauma, uremia unknown
2. Anatomic
a. Specific coronary artery disease
b: specific left venricular defect
c: specific valve defect
chambers o valve
3. Physiologic: NSR, AF, Multifocal PVC, reversible Mischemia, LV systolic and
diastoclic dysfunction
4. Functional Capacity
NYHA I: dyspnea on greater physical activity; can climb 2 flights of stairs (
>7mets)
II: dyspnea on ordinary physical activity. 2 flights with difficulty
5-6METS
III: dyspnea on less than ordinary physical activity. 2-4METS
IV: dyspnea at rest 0-1METS
AHA ACC CHF stage
A: high risk for HF but no structural defect
B: Structural HD no symptoms of HF
C: Structural HD and symptoms of HF
D: refractory HF requiring intervention
Cardiovascular History
General Date Risk Factors: elderly and male
HPI: symptoms of CV disease, functional capacity, hx of febrile illness, pregnancy
Past Medical History:
HPN, DM, Dyslipidemia, CVA, Peripheral Vascular disease, thyroid
Disease, Asthma, Medications and allergies
Family History: up to first degree:
HPN, IHD, DM Dyslipidemia
Personal and Social Hx: smoking, alcohol, illicit drugs, Obesity,
Heart sounds
S1: closure of MT valves
Increased: MS, TS, high output,
S2:closure of Aortic and pulmonic valves
S3: altered ventricular filling;pathologic in adults
Systolic failure from CAD
S4: atrial contraction on a non compliant ventricle
Diastolic Heart Failure;IHD;HPN;Cardiomyopathy;Severe AS;elderly
Grade of murmurs:
1- faint
2-soft readily audible
3-loud without thrill
4-loud with palpable thrill
5-heard with a portion of diaphragm off the chest
6- audible with steth off chest
ECG:
Hypokalemia
3-3.5 Prominent U waves at V2 V3
2.7-3 U waves taller than the T
<2.6 St depression with Tall u;fusion of T and U waves
Hyperkalemia
5.5-6 Chest leads: T waves >10mm
Limb leads: T>5mm
Tall peaked waves
6.7-8 QRS widening
Slurring of both initial and terminal portions of the QRS
ST elevation
Low wide P
Arrhythmias; 1s t 2nd AV block, atrial arrest, brady
>8 Marked widening of QRS
Distinct ST-T
High risk for vfib or asystole
Hypocalcemia: prolonged QT
Hypercalcemia: shortened QT
Digitalis effect: prolonged PR
Scooping of the ST
Short QT
Digitalis toxicity: all types of arrhythmias, PVCs , PACs
QRS electrical alternans: QTS height varies
Cardiac tamponade
Large pericardial effusion
Low cardiac output
COPD
Tension Pneumothorax
Poor r wave progression: R in V3<3mm
Old anteroseptal wall MI
LVH
Normal Variant
LBBB
Low voltage QRS: <5mm in all limb leads
Normal in elderly
Obese or edematous
Cardiac tamponade
Large Pericardial effusion
Pneumothorax
Hypothyroidism
Dilated cardiomyopathy
WRONG LEAD Placement:
Upright p in AVR
Normal R wave in precordial leads
Major Coronary arteries
1. Left Main Coronary artery a. LAD: LV wall and anterior septum.
b. Left circumflex: lateral left ventricle, left atrium
2. RCA: RV RA posterior aspect of septum
CAD
Approach to treatment:
1. Increase supply
a. Vasodilation of coro arteries: nitrates
b. Bypass or relieve obstruction
1.Percutaneous transluminal coro angioplasty
2.Coronary artery bypass grafting
c. correct anemia
2. decrease demand
a. decrease heart rate: beta blocker, CCB(Diltia, verap),sedate
anxious pxs
b.decrease contractility: beta blockers
c. decrease afterload: vasodilators: CCb
d,decrease preload: nitrates
ACUTE MYOCARDIAL INFARCTION
Types
1 Spontaneous (coronary)
2 Secondary (htn, embolism, arrhythmia)
3 Sudden Cardiac Death
4 MI w/ PCI (a) or Stent (b)
5 MI w/ CABG

Criteria:
Trop or CKMB >99th Percentile (>3x PCI)(>5x CABG)
With Symptoms
ECG: ST Elev V2-V3 0.2 or 0.15mV, Others 0.1, LBBB, Q V2-V3 0.02 secs, Others 0.03
secs
Cardiac Imaging
Killip:
I No Congestion
II Bibasal rales, S3, JVP, Hepatomegaly
III Rales>50%, Pulmonary Edema
IV Shock
Tx: O2, Nitrates, Beta/Ca Blocker, ASA160-325mg QID or Clopid 75mg/d,
Heparin/LMWH, Morphine2-4mg IV, ACEI, Diazepam, Statin, Duphalac
Absolute Contraindications to Fibrinolytics: Active Bleed, Trauma, Surgery<2w, CVA
<3m, CNS Tumor, BP >180/110, Aortic Dissection
TYPES of MI
I: plaque rupture
II: Ischemic and imbalance
III: sudden unexpected death without biomarkers
IV: PCI
V: CABG: iatrogenic
Criteria for MI: European Society of cardiology/ACC
Any of the ff
1.Typical rise and gradual fall of biomarkers with at least one of the ff.
a. Ischemic symptoms
b. Dev of pathologic q waves on ecg
c. Ecg changes indicative of MI
d. Coronary artery intervention
2. Pathologic findings of an acute MI
Anatomical types of MI
1. Transmural or ST elevation: total thrombotic occlusion with whole
thickness of the myocardium infracted
2. Non transmural or NSTEMI: subtotal thrombotic occlusion with
only the subendocardium infracted
PATHOPHYSIO
1. Acute thrombosis
2. Rupture of unstable plaque
3. Vasospasm
4. Embolism
5. Non thrombotic MI
Characteristic chest pain:
Severe at rest for >30 mins
Same character and location as prev angina pain but more severe
Not relieved by nitroglycerin

3 anginal equivalents
Dyspnea
Cardiac arrhythmia
Exhaustion

Painless MI: elderly, Diabetic, CNCS disease(post stroke)

PE: anxious, cold clammy extremities
VS: large infarct: hypotensive, tachycardic and tachypneic
James reflex: hypertension and tachycardia ff anterior wall MI
Bezold-Jarisch reflex: hypotension and bradycardia ff inferior wall MI
Cardiac exam: apex beat difficult to palpate
Signs of CHF: Neck vein engorgement, bibasal rales, S3 gallop, soft s1, murmur of
MR
DDX: AA dissection, Acute pericarditis, costochondritis, PE, esophageal spasm, acute
gastritis, ruptured viscus
ECG criteria:
ST elevation: > = to 2mm in 2 or more contiguoug chest leads
> = 1 mm in 2 or more contiguous limb leads
Q waves: > = 0.04 sec (1 small square)
V1-V2: septal wall MI
V1-V3: antero-septal wall MI
V1-V6: antero-ateral wall MI
Mirror image of V1-V2: posterior LV wall MI
I,avL, V5-V6: Lateral wall MI
II, III,avF: inferioir wall MI
II,III,AvF,V5 V6: lateral wall MI
II, III AVF V3R V4R inferioir wall with RV MI
Almost all leads: Massive MI, Global or diffuse
tests Time to Peak Duration Sampling shed
detection
Trop T 3-12H 24 H 5-14d Once at least
Sen: 94% 12 hours after
Spec 60% chest pain
 Trop I 3-12h 24h 5-10d Once at least
Sen 95% 12 hours after
Spec 90% chest pain
Cpkmb 3-12hours 24h 2-3 d Every 12 hours
x 3: start at 6
hours after
chest pain
4 main objectives:
1. Restore coronary flow as early as possible ex thrombolytics
2. Preserve ischemic or jeopardiazed myocardium
Betablockers, nitrates, aspirin, heparin, free radiacal savenger
3. Treat cardiac complications
Ace, diuretic for HF, anti arrhythmics for arrhtmia
4. Treat coexisting diseases prevent death
Antibiotics for pneumonia
Indications for thrombolytic therapy
1. Chest pain consisitent with MI
2. ECg changes ST, new left bundle branch block
3. Time from chest pain to thrombolytic therapy
<6 hours most beneficial
6-12 hours: kisser but still important benefits
12-24 hours: diminishing benefit but may still be useful in some(those with ongoing
chest pain)
Absolute contraindications to thrombolyse
1. Active internal bleeding excluding menstruation
2. Recent(2 weeks) invasive or surgical procedure
3. Previous hx of hemorrhagic CVA or subarachnoid hemorrhage
4. Recent head trauma or known surgical intervention
5. Persistent BP >200/120
Relative contraindications
1. Known bleeding diathesis(severe thrombocytopenia,
coagulipathies) or current use of anticoagulants
2. Previous streptokinase tx given for the past 6-9mos( instead give
TPA)
3. BP>= 180/100on at least 2 readings
4. Active peptic ulcer diasease
5. History of thrombotic CVA
6. Prolonged CPR of >= 10 minutes of traumatic CPR
7. DM hemorrhagic retinopathy or other hemorrhagic ophthalmic
condition
8. Pregnancy
Streptokinase: 1.5 million units over 1 hour
rTPA: 100mg over 90 minutes
PTCA
Aspirin 160 mg chewed on admission, 160 mg PO reduces 30 day mortality
Clopidogrel 75 OD
Heparin- to maintain patency of infarct related arteries recanalized by rTPA
especially during the first 24-48 hrs
Beta blockers reduce myocardial oxygen demand, oppose the action of elevated
catecholamines and posses anti-arrhythmic properties. Limit infarction size and
reduce mortality
ACE inhibitors are potent vasodilators reduces afterload, limit ventricular
remodelling
Nitrates: oppose coronary arterial spasm and reduce myocardial oxygen demand by
reducing both preload and afterload
Calcium channel blockers” reduce myocardial oxygen demand, dilate coronary
arteries and reduce infarct size
Framingham criteria for Heart failure
2 major
1 major or 2 minor
Major
PND
Weight loss of 4.5 in 5 days in response to treatment
Neck vein distention
Acute pulmonary edema
Rales
Hepatojugular reflex
S3 gallop
Radiographic cardiomegaly
CVP greater than 16cm H2O
Minor
Nocturnal cough
Dysnea on ordinary exertion
Decrease in vital capacity by 1/3 the maximal value recorded
Pleural effusion
Tachycardia greater than 120
Bilateral ankle edema

TX: Sodium and fluid restriction

Appropritae physical activity
Vasodilator, inotrope, anticoagulant, beta blocker, digoxin

HYPERTENSION
Stages:
Pre >120/80
I >140/90
II>160/100
a) HTN URGENCY : Dias >120-130, No target organ damage, Dec BP in 2-3days
Tx Oral: Nifedipine 5, 10mg/cap chew, SL or PO Q30, Captopril 25mg ½-1 tab SL or
PO Q30, Clonidine 75mcg 1 tab SL or PO Q1
b) HTNEMERGENCY: Sys >210, Dias >130 w/ HA, BOV, Stroke, Angina, MI, HF,
CKD, Retinopathy, Dec BP in 24 h
Tx IV AntiHpn: Nicardipine 5mg/hr, Inc by 1-2.5 mg/hr Q15 upto15 mg/hr,
Hydralazine, Enalaprilat, ISDN
Labs: CBC, U/A, FBS, Na, K, BUN, Crea, SGPT, Lipids, CXR, ECG
Tx: Stage I Thiazide, ACEI, ARB, BB, CCB
II 2 or more Drugs e.g ACEI + Thiazide
w/ CHF Diur, ACEI, ARB, AA w/ CKD ACEI, ARB
 w/ MI BB, ACEI, Aldo Ant w/ ESRD Diuretic, CCB
w/ CAD Diur,, BB, ACEI, CCB w/ Stroke Diuretic, ACEI
w/ DM Diuretic, ACEI, ARB, w/ Dyslipid CCB, ACEI
Cheap Meds: Captopril 25, 50 BID, Imidapril (Norten/Vascor) 5, 10mg OD, Losartan
(Lifezaar) 50mg 1-2tabs OD, Metop (Neobloc) 50, 100 BID, Nifedipine (Calcibloc)
30mg OD, Spirono + Butizide (Aldazide) 25/2.5 mg ½ - 1 tab OD
JNC 8 Recommendations
1. In the general population aged ≥60 years, initiate pharmacologic treatment to
lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic
blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP
<90 mm Hg.
2. In the general population aged ≥60 years, if pharmacologic treatment for high BP
results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and
without adverse effects on health or quality of life, treatment does not need to be
adjusted.
3. In the general population <60 years, initiate pharmacologic treatment to lower BP
at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg.
4. In the general population <60 years, initiate pharmacologic treatment to lower BP
at SBP ≥140 mm Hg and treat to a goal SBP <140 mm H
5. In the population aged ≥18 years with chronic kidney disease (CKD), initiate
pharmacologic treatment to lower BP at SBP ≥140 mm Hg or
DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg.
6. In the population aged ≥18 years with diabetes, initiate pharmacologic treatment
to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm
Hg and goal DBP <90 mm Hg.
7. In the general nonblack population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic, calcium channel
blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin
receptor blocker (ARB)
8. In the general black population, including those with diabetes, initial
antihypertensive treatment should include a thiazide-type diuretic or CCB.
9. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive
treatment should include an ACEI or ARB to improve kidney outcomes. This applies
to all CKD patients with hypertension regardless of race or diabetes status
10. The main objective of hypertension treatment is to attain and maintain goal BP.
If goal BP is not reached within a month of treatment, increase the dose of the initial
drug or add a second drug from one of the classes in recommendation 6 (thiazide-
type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and
adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached
with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI
and an ARB together in the same patient. If goal BP cannot be reached using only the
drugs in recommendation 6 because of a contraindication or the need to use more
than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be
used. Referral to a hypertension specialist may be indicated for patients in whom
goal BP cannot be attained using the above strategy or for the management of
complicated patients for whom additional clinical consultation is needed.
CP CLEARANCE
Clinical Predictors
Major
 Unstable coronary syndromes (acute MI)
 Unstable or severe angina (Canadian class III or IV)
 Decompensated heart failure
 Significant arrhythmias, high-grade AV block, symptomatic ventricular
arrhthymias with uncontrolled ventricular rate
 Severe valvular disease
Intermediate
 Mild angina pectoris (Canadian Class I or II)
 Previous MI by history or pathologic Q waves
 Compensated or prior heart failure
 DM (particularly insulin-dependent)
 Renal insufficiency
Minor
 Advanced age
 Abnormal ECG (LVH, LBBB, ST-T abnormalities)
 Rhythms other than sinus (a-fib)
 Low functional capacity
 History of stroke, uncontrolled systemic hypertension
Surgical Predictors
High (>5%)
 Emergent major operation, particularly in the elderly
 Aortic and other major vascular operations
 Peripheral vascular surgery
 Anticipated prolonged surgical procedures w/ large fluid/blood loss
Intermediate (<5%)
 Carotid endarterectomy
 Head and neck surgery
 Intraperitoneal and intrathoracic surgery
 Orthopedic surgery
 Prostate surgery
Low (<1%)
 Endoscopic procedures
 Superficial procedure
 Cataract surgery
 Breast surgery
Functional Predictors (Metabolic Equivalents/METs)
 Poor (<4 METs): vacuuming, ADLs, walking 2mph, writing
 Moderate (4-7 METs): Cycling, flight of stairs, golf, walking 4mph, yard
work
 Excellent (>7 METs): jogging, scrubbing floors, tennis
ORDER
Stratified as ______ risk in developing perioperative complications
Still for final risk stratification (if still awaiting labs, or awaiting consultant’s
approval)
 LEE
Risk Factors Points
High risk surgery (intra-peritoneal, intra-thoracic, suprainguinal 1
vascular procedures)
Ischemic heart disease 1
History of congestive heart failure 1
History of cerebrovascular disease 1
Insulin treatment for DM 1
Pre-op scr> 176.8 mol/L 1
Class Risk factors CV
Complic(%)
I 0 0
II 1 8.89
III 2 21.05
IV 3
Revised Goldman Cardiac Risk Index (RCRI)
Six independent predictors of major cardiac complications*
 High-risk type of surgery (includes any intraperitoneal, intrathoracic, or
suprainguinal vascular procedures)
 History of ischemic heart disease (history of MI or a positive exercise test,
current complaint of chest pain considered to be secondary to myocardial
ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not
count prior coronary revascularization procedure unless one of the other
criteria for ischemic heart disease is present)
 History of HF
 History of cerebrovascular disease
 Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >2.0 mg/dL (177 mol/L)

AHA/ACC 2007
Rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest according to
the number of predictors
No risk factors - 0.4 % (95% CI 0.1-0.8 %)
1 risk factor - 1.0 % (95% CI 0.5-1.4 %)
2 risk factors - 2.4 % (95% CI 1.3-3.5 %)
≥ 3 risk factors - 5.4 % (95% CI 2.8-7.9 %)
Rate of cardiac death and nonfatal MI, cardiac arrest or ventricular
fibrillation, pulmonary edema, and complete heart block according to the
number of predictors and the nonuse or use of beta blockers
No risk factors - 0.4 to 1.0 % vs <1 % with beta blockers
1-2 risk factors - 2.2 to 6.6 % vs 0.8 to 1.6 % with beta blockers
≥ 3 risk factors - >9 % vs >3 % with beta blockers
High risk (reported risk of cardiac death or nonfatal MI often)
Aortic and other major vascular surgery
Peripheral arterial surgery
Intermediate risk (reported risk of cardiac death or nonfatal MI 1-5%)
 Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery
Low risk* (reported risk of cardiac death or nonfatal MI < 1%)
Ambulatory surgery
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
* Do not generally require further preoperative cardiac testing

ENDOCRINOLOGY
Diabetes Mellitus
TERMS
Hyperglycemia > 140 mg/dl; A1C > 6.5%
Hypoglycemia < 70 mg/dl
Severe hypoglycemia < 40 mg/dl
< 50 mg/dl – cognitive impairment
Hba1C x 28.7 – 46.7 = estimated Average Glucose
Risk Factors for DM
Family hix of DM with type 2
Obesity BMI≥25
Physical inactivity
Race (African Amercain, Latino, Native American, Asian American, Apcific
Islannder
Previously identified with IFG, IGT or an AIC≥5.6-6.7
History of GDM of or delivery of a baby >4kg or 9lbs
Hypertension BP ≥140/90
HDL ≤35 AND/OR A Trig ≥250mg/dL
PCOS ir acantosis nigricans
History of cardiovascular disease
GLUCOSE TARGETS
Critically ill 140-180 mg/dl
Non-critically ill <140 mg/dl (pre-meals)
<180 mg/dl (CBG)
Higher targets: terminally ill, severe comorbidities, frequent glucose
monitoring, close nursing supervision
DIABETES MELLITUS
Diagnostics:
FBS >126mg/dL (>7mmol/L)
OGTT / RBS >200 plus Polyphagia, Polydipsia, Polyuria
Goals:HgbA1c <6.5%
FBS 90-110 mg/dL
Peak Post-prandial <140 mg/dL
Tx:
Non-pharma: Diet, Exercise
OHA
Sulfonylureas: Glipizide B/TID, Glibenclamide(Older pt) 2.5-5mg OD/ BID,
Gliclazide 80mg BID/TID
Biguanides: Metformin 500 mg TID
Alpha glucosidaseInh:Acarbose 50-100 mg TID w/ meals
Thiazolidine: Rosiglitazone 4-8 mg OD
Insulin rapid: Lispro, Novolog, Aspart, Novorapid
shoRt: Humulin-R, Actrapid HM, Humalog
iNtermed: Humulin-N, Monotard HM, Protophane HM, Lente
Long: HumulinUltralente, Ultratard HM, Lantus, Glargine
Insulin 1 U SQ (E.g. Actrapid) = Decrease 10mg/dL Blood glucose
DEFER INSULIN IF
1. short acting insulin for CBG < 100 mg/dl
2. on NPO
3. on HD
Basal insulin keeps sugar below 140
Prandial insulin keeps sugar below 140
Supplemental insulin if > 140
Start insulin drip if in ICU setting; SC insulin if non-ICU
RABBIT-2 TRIAL- INSULIN PROTOCOL
Basal Bolus with Insulin Glargine (Lantus) &Glulisine (Apidra)
- discontinue all OHAs
- total daily insuliln dose as follows if CBG on admission is:
140- 200 mg/dl: 0.4 u/kg/day
201-400 mg/dl: 0.5 u/ kg/day
If with comorbids, elderly, decreased appetite, possible nephropathy, poor oral
intake: 0.3 mg/dl
- give ½ total daily dose as insulin glargine (basal) and ½ as
insulin glulisine (prandial)
- give insulin glargine once daily at the same time of the day
- give insulin glulisine in 3 equally divided doses before each
meal
hold scheduled insulin glulisine if patient is not able to eat
ex#1: 60 kg male, CBG 180 mg.dl
60 x 0.4 = 24
ORDER: Give Lantus (basal) 12 units SQ OD at _____.
Give Apidra (prandial) 4 units SQ TID before meals as follows: (then make the
scale)
ex#2: 80 kg, male, CBG 301
80 x 0.5 = 40
ORDER: Give Lantus 20 units SQ OD at _____.
Give Apidra 6 units SQ TID before meals as follows
110-140 mg/dl 6 u
141-180 10 u
181- 220 12 u
221- 260 14 u
261- 300 16 u
>300 18 u
Supplemental Insulin Scale
Sensitive Usual Resistant
110-140 P R A N D I A L D O S E
140-180 2u 4u 6u
181-220 4u 6u 8u
221-260 6u 8u 10u
261-300 8u 10u 12u
301-350 10u 12u 14u
351-400 12u 14u 16u
>400 14u 16u 18u
Insulin Adjustment
- If fasting mean blood glucose is > 140 in the absence of hypoglycemia,
increase insulin glargine by 20% everyday
- if patient develops hypoglycemia, decrease glargine by 20%.
CBG monitoring
- CBG TID premeals and HS (q 6 if NPO)
DIABETIC KETOACIDOSIS / HYPEROSMOLAR HYPERGLYCEMIC SYNDROME
1 Inc RBS
2 Plasma Osm> 320 mOsm/L
3 Metab. Acidosis
4 Ketonemia (+) in DKA
Labs: RBS, ABG, U&S Ketone, CBC, HgbA1c, U/A, Na, K, Cl, PO4, BUN, Crea, Amylase, CXR,
ECG
Tx:
1. Confirm the diagnosis (inc plasma glucose, serum ketones, met acid)
2. admit to hospital: ICU may be necessary for frequent monitoring or if pH <7 or ig
unconscious
3. Assess: Serum Elec: K, NA, Mg, Cl, bicarb, phosphate
Acid base status
Renal function (crea, utine output)
4. Replace fluids: 2-3L of 0.9% saline over first 1-3h (15-20ml/kg/hour) subsequently
0.45% saline at 150-250ml/h when plasma glucose reaches 200mg/dL
5. Administer short acting insulin: IV (0.1units/kg), then 0.1units/kg per hour by
continuous IV infusion;increase two-threefold if no response by 2-4hours IF THE INITIAL
seru, K is <3.3, DO NOT administer insulin until serum Kis corrected. If initial serum K is >
5.2 do not supplement K until potassium is corrected
6. Assess Px;what precipitated the episode(non compliance, infection trauma, infarction,
cocaine? Initiate appropriate work up (cultures, ECg, CXR)
7. Measure capillary glucose every 1-2h; measure electrolytes (esp K, HCO3, phosphate)
and anion gap every 4 hours for the first 24h
8. Monitor BP, pulse, respirations, mentalstatus, fluid intake,and otput every 1-4hours
8. replace K: 10mEqs/h when plasma K <5-5.2 (or 20-30mEq/L of infusion fluid), ECg
normal, urine flow and normal creatinine documented.
Administer 40-80meq/hour when plasma <3.5meq/L or if bicarbonate is given
9. Continue above until patient is stable, glucose goal is 150-250mg/dL, and acidosis is
resolved, insulin infusion may be decreased to 0.05-0.1 units/kg/h,
10. Administer long acting insulin as soon as patient is eating. Allow for overlap in insulin
injection
DIABETIC FOOT ULCERS
WAGNER
Gr 0 – pre or post ulcerative lesions
1 – partial/ full thickness
2 – probing to tendon or capsule
3 – deep with osteitis
4 – partial foot gangrene
5 – whole foot gangrene
METABOLIC SYNDROME
Syndrome X, Insulin resistance syndrome
Consists of a constellation of Metabolic Abnormalities that confer an increased risk of
cardiovascular Disease and Diabetes Mellitus
NCP-ATPIII 2001 Criteria: 3 or more of the ff
1. Central Obesity: waist circumference >102 cm(M) >88cm (F)
2. Hypertriglyceridemia ≥150mg/dl or specific medication
3. low HDL Colesterol <40mg/dL and 50mg/dL respectively or on specific meds
4. Hypertension:≥130/85 or on specific meds
5. Fasting Glucose ≥100mg/dL or on meds or previously diagnosed DM
Thyroid Diseases
Hypothyroidism
Symptoms Signs
Tiredness, weakness Dry, coarse skin, cool peripheral
Dry skin extremities
Feeling cold Puffy hands and feet
Hair loss Diffuse alopecia
Difficulty concentrating and poor memory Bradycardia
Constipation Peripheral edema
Weight gain with poor appetite Delayed tendon reflex relaxation
Dyspnea Carpal tunnel syndrome
Hoarse voice Seous cavity effusion
Menorrhagia
Paresthesia
Impaired hearing
Treatment:
Daily replacement dose of levothyroxine is 1.6 ug/kg(100-150)
Adult >60 withour evidence of heart disease may be strated on 50-100 levothyroxine
daily.
Goal is normal TSH. Should be measured 2 months after startin TX
Adjustment made in 12.5 or 25 increments
Pxs with a suppressed TSH and T4overtreatment have an increased risk of AF and reduced
bone density
Once goal TSh is achieved ff up TSH requested at annual intervals
THYROTOXICOSIS
Symptoms Signs
Hyperactivity, irritability, dysphoria Tachycardia, AF in the elderly
Heat intolerance and sweating Tremor
Palpitations Goiter
Fatigue and weakness Warm, moist skin
Weight loss with increased appetite Muscle weakness, proximal myopathy
Diarrhea Lid retraction or lag
Polyuria Gynecomastia
Oligomenorrhea, loss of libido
Treatment:
Antithyroid drugs (Thionamides- PPU, Carbimazole, Methimazole)
1.Propylthiouracils inhibits deiodination T4T3
100-200 q6-8
2. Methimazole: 10-20 mg q8 or q12
Review TFT after 3-4 weeks
 NEPHRO NOTES

CHRONIC KIDNEY DISEASE

1: >90 4: 15-29
2: 60-89 5: <15
3: 30-59
CKD w/o Atrophy: DM, PKD, MM, Amyloidosis, Sarcoidosis

Dx: Dec GFR or IncCrea for 3 mos; Renal atrophy; Anemia; Uremic Sx: Fluid &Elec;
Endo/Metabolic: osteodystrophy, amenorrhea; Neuro: fatigue, HA, sleep disorder,
seizures, altered ment; CV, Pulmo: HTN, CHF, Pericarditis, Cardiomyopathy; GI:
anorexia, vomiting, fetor, bleed; Derma: pigment, pruritus; Hema: normo anemia,
lymphocytopenia, splenomeg; Elec: Hyper Na, K, P, Hypo Ca
ACUTE RENAL FAILURE
Sudden Increase in Creatinine, Decreased UO
*Fractional Excretion of Sodium (FENa)
*Renal Failure Index (RFI)
FENa: U Na x P Cr x 100 FENa or RFI < 1 = Pre Renal
U Cr x P Na FENa or RFI >1 = Renal
RFI: U Na + (U Cr / P Cr) BUN/Crea: >20 = Pre, <15 = Renal
Tx: Fluid, Elec, HD B/C Ratio: BUN x 2.8 / Crea x 0.011
BUN-CREA RATIO
lnc urea reabsorption—prerenal azotemia, hypovolemia
lnc urea production—hyperalimentation,hyprproteinemia,glucotx, GI bleed
plasma osmalality-275-290mosml/kg
pOsm-2Na+Glu+BUN
lnc=15-20 mosml/kg
=serum na is low
=serum osmolyte in plasma-Na,Glu
pre-renal>20:1
intrinsic<10-15:1
post renal>20
DIALYSIS
Indications:
Acidosis
Electrolyte Imbalance (Intractable HyperK)
Intoxication
Overload (Fluid)
Uremia [BUN > 100-150; Crea > 8-10 mg/dL]

Short Term Complications: Septicemia, Arrhythmia, Dysequilibrium, Hypo, HBV/HCV,

Air Emboli, Anaphulaxis, Heparin complications,Cramps
Long Term Complications: MI, CVA 2 to Uremia, Dialysis dementia, Osteomalacia
RENAL TUBULAR ACIDOSIS
Type I Distal Tubule—H
Type II Proximal Tubule—HCO3
Type III (combined I & II)
Type IV Hypo Aldo ↑K
PLASMA OSM (mOsm/L):
2 Na + BUN (mmol/L) + RBS (mmol/L)
*BUN mg/dL / 2.8; RBS mg/dL /18 = mmol/L
*NV: 280-300
HCO3 DEFICIT:
0.4 x Wt x (Desired HCO3 (16) – Actual HCO3) OR [(BE x Wt x 0.3)/2]
Note: Give only 1/2 of computed deficit as bolus
½ can be thru drip in 24 h in D5W(1 amp = 44 mEq)
Central Venous Pressure (CVP): Normal 8-12, on mech vent 12-15
Poisoning: Activated Charcoal 100mg in 300cc water via NGT
MAINTENANCE FLUID
Total fluid/day: 35 cc/kg/day
BM: 1 bm= 100 cc
Fever: for each 1 degree rise above 37+ 100-150 cc/day
Diarrhea: 1 cc/kg hydration
Febrile: 2 cc/kg
INTRAVENOUS FLUID
Glucose Na Cl K Lactate Others
D5W 50g/L MI, HTN
D10W 100g/L
PNSS (0.9) 154 154 CVA
D5 0.3NaCl 50 51 51 CKD
PLR 130 109 4 28 Ca 3
NM 40 40 13 Mg 3 Acetate 26
D5NMK 50 40 40 30 Mg 3 Acetate 26
NR 140 98 5 Mg 3 Acetate 27
D5 IMB 50 25 22 20 23 Mg 3 PO4 3
WATER DEFICIT
[(Serum Na -140)/140 x TBW ] *TBW=wt x 0.6 or 0.5
Correction: ½ Given in 12-24h, ½ next 24 h OR 10mEq/L/h
use IVF D5W
[Plasma Na concentration – 140/140] x 0.6 x BW in kg OR
[(Actual NA-Desired Na)/Desired na] x 0.6 x BW ni kg
TBW: 0.6 males
0.5 females
Desired Na is 140
HYPERNATREMIA

[(Na-140)/140]x k x wt in kg Male 0.6 elderly Male 0.5

24 Female 0.5 elderly F 0.45

HYPONATREMIA
NV: 135-145 mEq/L
Na Deficit = 0.6 x Wt x 10 or (Desired – Actual) x wt x k
24
Na deficit x 1000 cc
Na infusate

Na Deficit/2/154 (per bottle of PNSS)

Correction: 1/2 Given in 8-12h, ½ next 16-24 h
0.5-1 mEq/L/hr or 15-20 mEq/L/day
OR NaCl tabs 1-2 tabs TID-QID
NaCl tab = 17 meqs
If using hypertonic solution (3%): repeat serum Na after 6 hours
If using pNSS: repeat serum Na after 24 hours
CM: brain swelling or cerebral edema
Stupor, seizure, coma (Na 120mmol/L)
Goal: 1 raise plasma NA concentration by either restricting water intake or
promoting water loss.
CPM: Flaccid Paralysis, Dysarthria, Dysphagia 2 weeks post rapid correction
HYPERKALEMIA
Check if with ECG changes: dec P wave amplitude, widened QRS, tenting of T wave
a) If < 5.5: restrict K in diet
b) 5.5-6.5: Kalimate 1 sachet TID x 3 doses
c) >6.5: with or without ECG changes, as follows:
D5050 + 10 units HR/ SIVP for 3 doses, 4 hrs apart
Ca gluc 500 mgSIVP x 3 doses, 4 hours apart
MgSO4 500 mg SIVP x 2 doses, 4 hours apart
NaHCO3 1amp SIVP in 10min
Salbutamol neb 20mg
Furosemide 40-80mg stat
Repeat serum K, after 6-8 hours
HYPOKALEMIA
Causes:
Decreased intake Starvation, clay ingestion
 Redistribution into cells A.Acid Base: Metabolic alkalosis
B. Hormonal: Insulin
increased B2 adrenergic
sympathetic activity;post MI, head injury
B2 adrenergic agoinist:
bronchodilators and tocolytics
Alpha adrenergic antagonists
Thyrotoxic periodic paralysis
Downstream stimulation of Na K
AtpaseTheophylline and caffeine)
C. Anabolic state: Vit B12 or folic administration
Granulocyte CSF
TPN
D. Other: psuedohyperkalemia, hypothermia,
Familial HPP, Barium Toxicity (Inhibition of leak
K channels
Increased loss NON Renal: diarrhea, sweat
Renal:
1. Increased distal flow and distal Na + delivery:
diuretics, osmotic diuresis, salt-wasting
nephropathies
2. increased secretion of K
a. Mineralocorticoid excess: primary
hyperaldosteronism [aldosterone-producing
adenomas (APAs)], primary or unilateral adrenal
hyperplasia (PAH), idiopathic
hyperaldosteronism (IHA) due to bilateral
adrenal hyperplasia, and adrenal carcinoma],
familial hyperaldosteronism (FH-I, FH-II,
congenital adrenal hyperplasias), secondary
hyperaldosteronism (malignanthypertension,
renin-secreting tumors, renal arterystenosis,
hypovolemia), Cushing's syndrome, Bartter's
syndrome, Gitelman's syndrome
b. Apparent mineralocorticoid excess:
c. distal delivery of nonreabsorbed anions:
vomiting, nasogastric suction, proximal renal
tubular acidosis, DKA, glue sniffing, penicillin
derivatives
3. Magsiuim deficinecy
NV: 3.5-5.3 mEq/L
0.3 x Wt x (Desired – Actual K) or (4 – actual deficit) x 150
K durule= 10 meqs= Inc 0.1 mEq/L Serum K
KCL syrup 1 ml= 1meq
KCL drip: 40 meqs + pNSS to make 250cc to run at 5 meqs/ hr for 2 cycles
Maximum drip peripeheral: 10Meqs per hour
Central: 20 Meqs/hour
At SLMC max is 10meqs per hour via central line without cardiac monitor
HYPERMAGNESEMIA
Hydrate
HYPOMAGNESEMIA
MgSO4 500 mg/IV in 200 cc; 1 g/IV in 250 cc; 2 g/IV in 200 cc
To run for 8h/12h/24h for ____ cycles (usually 2 cycles)
MILD
1. 1g MgSO4 has 8meqs (4mmol) of elemental Mg
2. Assume a total Mg deficit of 1-2 meq/kg
3. Bec. 50% of infused Mg can be lost in the urine, assume that the total Mg
required is 2x the Mg deficit
4. Replace 1 meq/kg for the first 24 hrs and 0.5 meq/kg daily for 3-5 days
MODERATE
1. Add 6g of MgSO4 (48 meq) to 250 or 500 ml PNSS and infuse over the next
6 hrs
2. Follow 5g MgSO4 (40 meq) + 250 or 500 cc PNSS x 6 hrs
3. Continue 5g of MgSO4 every 12 hrsby continous infusion for the next 5
days
SEVERE
1. Infuse 2g MgSO4 (16 meq) iv over 2 mins
2. Follow with 5g (40 meq) in 250 ml or 500 ml PNSS, infuse over the next 6
hrs
3. Continue 5mg MgSO4 every 12 hrsby continous infusion for the next 5 days
CALCIUM
Corrected Calcium (mg/dL)
[ (40 – Albumin in g/L) x 0.02] + Measured Ca in mmol/L OR
(4 –Albumin in g/dL x 0.08) + Measured Ca in mg/dL
A fall in serum albumin of 1 g/dL is associated with a fall in 0.8mg/dL in total Calcium
LOW: Renal failure, hypoparathyroidism, Severe hypomagnesemia,
hypermagnasemia, Acute Pancreatitis, Tumor Lysis Syndrome, Vitamin D def,
Pseudohypoparathyroidism, rarely due to multiple Ctrated BT, critically ill, Anti
neoplastic agents, antimicrobilas
Use with hypocalcemia only if iCA cannot be measured.
About 50% of Total Calcium is ionized, the rest is bound to albumin.
HYPERCALCEMIA
Hydrate: 0.9% NSS at 150-600cc/hour (up to 1-4L in 24h)
Furosemide 20-40 mg/IV q8-12h
Bisphosphonate: Pamidronate 30-90 mg/day, single dose x 3 days
Calcitonin: 4-8 IU/kg/min SQ q 6
HYPOCALCEMIA
Corrected Ca: (4 – alb) x 0.8 + serum Ca
Ca gluc 1 g in 100 cc pNSS to run for 2 hours x 1 dose followed by MgSO4 drip 4 g in
250 cc pNSS to run over 12h x 1 dose
Ca gluc 500 mg/SIVP q 4-6 h under CM
Ca gluc 1 g + 250 cc pNSS x 4 hours under CM (usually for 2-3 cycles)
Ca gluc = 45 mg Ca (?)
Ca carbonate = 27 mg Ca
Calcium Gluconate 10% solution of 10ml/amp (1g) SIVP with caridac monitor
Chronic treatment:
Calcium Carbonate 500mg/tab 1 tab BID to TID
Vitamin D3 supplementation (Calcitriol 0.25mcg/cap OD-BID)
Treat hypomagnasemia
HYPOALBUMINEMIA ALBUMIN-FUROSEMIDE (LASIX) INFUSION
Albumin 25% (50 ml) + 20 mg Furosemide to run for 1 hr. q 12 for 4 doses or
Albumin 25% to run for 1 hr followed by Furosemide 20 mg IV q 12 for 3 doses
SODIUM BICARBONATE
Weight x 0.4 x (desired – actual)
If HCO3 < 12 or pH < 7.2 – correct deficit
Give ½ deficit in bolus, then ½ in drip:
D5W 1li x 1 amp or 250 cc D5W + 100 meqs NaHCO3 to run for 24h
Desired HCO3 of 15-18 if with CKD
For severe acidosis pH<6.2 in PURE HAGMA goal is to increase HCO3 to 10mEq/L and
pH 7.15
RCIN (Radiocontrast-Induced Nephropathy) PROPHYLAXIS
1. Fluimucil 600 mg q 6 dissolved in 50 cc water, 12 hours and 6 hours before
procedure, then 6 hours and 12 hours after procedure
2. Start NaHCO3: 150 megs NaHCO3 in 1 li D5W to run at 60 cc/hr—
start 3 hours prior until 6 hours post procedure
3. Maintain TFR: 80 cc/hr; pNSS 1 li x 80 cc/ hr
4. Ascorbic Acid 500 mg I tab tid
5. d/c pNSS once NaHCO3 strated
6. Monitor I/O
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)
 Priming: PNSS 1L + heparin 5000u/L, then PNSS 1L
 Modality: SCUF/ CVVH/ CVVHD/ CVVHDF
 Blood flow: start at 80 to 100cc/min .....and increase to ___ cc/min (4-
5cc/kg/min) as tolerated....(max 180ml/min)
 Dialysate: ___ cc/hr (35 cc/kg/hr or 2000cc/hr/1.73m2)...1000ml/min
PNSS 1L at 0cc/hr/ Dianeal 1.5% 5L/HEMOSOL 5L at 1000ml/hr
Additive:
None/ KCl (___meq/L)/ Ca-gluconate (___amps/5L bag)/Other: ___
 Replacement fluid: ___ cc/hr (35 cc/kg/hr or 2000cc/hr/1.73m2)
PNSS 1L at 0cc/hr/ HEMOSOL 5L
Additive:
None/ KCl (___meq/L)/ Ca-gluconate (___amps/5L bag)/ Other:
___
 Target net UF: ___ cc/hr (1-2 cc/kg/hr)
 Anticoagulation:
o No heparin: flush with 200-300cc NS every q hr, and prn TMP >
150, blood streaking in filter
o Heparin with target ACT = _____ (170-210)
Prepare heparin 5000 units in 500cc PNSS (10u/hr) for drip
Check baseline ACT:
 If ACT < 150, give heparin IV bolus (20u/kg), then start
heparin drip at ___ u/hr (10u/kg/hr). Repeat ACT in 4
hours.
 If ACT 150-200, no bolus, start heparin drip at ___ u/hr
(10u/kg/hr). Repeat ACT in 4 hours.
 If ACT> 200 -- no heparin and repeat ACT in 2 hours.
 When CRRT ongoing, draw post-filter ACT from blue port
on R side of system.
  If ACT < 170 -- give heparin IV bolus (10u/kg) then
increase heparin drip at ___ u/hr (10%) MORE than
previous rate, Repeat ACT in 4 hours.
 If ACT 170-210 -- keep drip rate same, repeat ACT in 6
hours.
 If ACT > 210 -- hold heparin x 1 hour, the restart drip at
___ u/hr (10%) LESS than previous rate. Repeat ACT in 4
hours.
 Flush with 200-300 cc NSS every 2-3 hours prn TMP > 150,
blood streaking in filter.
 Labs:
o When CRRT on-going, may draw chemistries and CBC from red port
at bottom of system, or from central line, unless otherwise
ordered
 Other orders
o Refer all alarms to NFOD
o May use remaining dialysate/ replacement fluid with next system
o Prime back-up machine when filter clotting is imminent

Simplified Renal Index (SRI) Scoring

for Estimating Risk of Post-cardiac surgery Renal Replacement
Therapy (RRT)
Variable Points
eGFR 31-60 ml/min 1
eGFR< 30 ml/min 2
DM requiring medication 1
LVEF < 40% 1
Previous cardiac surgery 1
Procedures other than CABG or isolated 1
ASD repair
Non-elective procedure 1
Pre-operative intra-aortic balloon pump 1
Points Risk of
Risk
RRT (%)
Low risk 0-1 0.4
Intermediate risk 2-3 3
High risk ≥4 10

Risk factor Points

Female Gender 1
Congestive Heart Failure 1
LV EF <35% 1
COPD 2
Pre-operative use of IABP 1
Insulin requiring DM 1
Previous cardiac surgery 1
Emergency surgery 2
 Valve surgery (reference to CABG) 1
CABG + valve surgery (reference to CABG) 2
Other cardiac surgeries 2
Pre-operative Scr 1.2 to 2 mg/dl 2
Pre-operative Scr> 2.1 mg/dl 5

Pre-operative ARF-HD
n 95% CI
Risk Score/ Class (%)
1 (0-2) 8,416 0.4 0.28 to 0.56
2 (3-5) 6,097 1.8 1.5 to 2.2
3 (6-8) 1,181 7.8 6.3 to 9.5
4 (9-13) 144 21.5 15.1 to 29.1

GENERAL SURGERY ACUTE KIDNEY INJURY (AKI) RISK INDEX

Age >56 yrs
Male sex
Active congestive heart failure
Ascites
Hypertension
Emergency Surgery
Intra-peritoneal surgery
Renal insufficiency – mild or moderate (Pre-operative Screa>1.2 mg/dl)
Diabetes mellitus – oral or insulin therapy

Total Acute Kidney

Pre-operative Hazard ratio
Patients Injury
Risk Class (95% CI)
n (%) Incidence (%)
Class I
(0-2 risk 31, 500 (55) 0.2
factors)
Class II
4.0
(3 risk 12,576 (22) 0.8
(2.9 to 5.4)
factors)
Class III
8.8
(4 risk 7,933 (14) 1.8
(6.6 to 11.8)
factors)
Class IV
16.1
(5 risk 3,615 (6) 3.3
(11.9 to 21.8)
factors)
Class V 46.3
1,456 (3) 8.9
(6+ factors) (34.2 to 62.6)

RADIO CONTRAST-INDUCEDNEPHROPATHY (RCIN) RISK SCORE

Variable Points
Hypotension 5
IABP 5
CHF 5
>75y/o 4
Anemia 3
DM 3
Contrast Vol 1 /100cc
Crea>1.5 or 4
Crea Cl MDRD
40-60 2
20-40 4
<20 6

Risk score Risk of RCIN Risk of dialysis

0-5 7.5 % 0.04 %
6-10 14 % 0.12 %
11-16 26.1 % 1.09 %
>16 57.3 % 12.6 %
RCIN RISK ASSESSMENT
Dx:
ECC:
Contemplated procedure:
Approxvol of contrast:
Risk Stratification
risk of RCIN:
risk of RCIN requiring HD:

The risk stratification has been explained to the pt. The patient is
aware & fully understands the above risk & consequences of RCIN.
Final disposition for procedure c/o AMD.

In order to reduce the risk of RCIN, the following prophylaxis

measures are recommended:
1. FLUIMUCIL
o Fluimucil 600mg/tab dissolved in 100cc H2O 12
hours and 6 hours before contrast administration,
then 6 hours and 12 hours after procedure or
o Flumucil 150 mg/kg dilute in 500cc PNSS, give 30
mins before procedure then another 50 mg/kg
during and til 4 hours after procedure (preparation:
25mg/vial, 200mg/ml, 1 vial = 5 gram)
o Hydration 1 cc/kg/hr
o Repeat Crea 24-48 hours after procedure
2. NaHCO3 BASED HYDRATION
o Plain LR or D5W 1 L + 150 meq NaHCO3 to run at 3
cc/kg/hr 1 hour before procedure, then decreased
to 1 cc/kg/hr during procedure till 6 hours
thereafter

CKD IN RADIO CONTRAST-INDUCED NEPHROPATHY (RCIN)

CreaCl
DM Non-DM
(mL/min)
 50 0.2 0.04
40 2.1 0.3
30 10 2
20 43 12
10 84 48

RIFLE CRITERIA
RISK: sCr x 1.5; < 0.5 ml/kg/hr x 6 hours
INJURY: sCr x 2; < 0.5 ml/kg/hr 12 hrs
FAILURE:sCr x 3 or sCr≥ 4 mg/dl with an acute rise; > 0.5 mg/dl; < 0.3 ml/kg/hr
x 24 hours, or anuria x 12 hrs
LOSS: persistent ARF = complete loss of kidney function; > 4 weeks
ESRD: ESRD > 3 months

RENAL PANEL
2 – BUN Crea Na K Cl HCO3
3 – Ca P Mg Na K Cl HCO3
4 – BUN Crea Uric acid Mg P Ca Na K Cl HCO3

WORK-UP FOR GN
CBC, BUN, crea, electrolytes
o ASO, ANA, C3, HepB, HepC, VDRL,
o albumin, 24hr urine CHON,
o 24hr crea cl, UTZ of KUB

HYPERTONIC SALINE PROTOCOL

For 2% HS start at 60 ml/hr9ie total fluid rate of 120 ml/hr= 60 ml 2% HS and
60 ml/hr NSS
For 3% HS, always to be infused thru central line
Start at 30 ml/hr and run PNSS to equal desired fluid intake/day

HYPERTONIC SODIUM LACTATE (Totilac)( premixed solution)

Always to be infused thru central line
Start at 15 ml/he and run with PNSS to equal desired TFR
Repeat Na, K q6hrs, BUN crea, serum osm as desired
Goal Na 145-155
NaCl 1 vial: 2.5 meqs/mL, 20 mL= 50 meqs/vial
0.9% NaCl: 154 meqs
2% NaCl: NSS 920 ml + NaCl 80 ml (2.5 meqs/mL=200meqs)
3% NaCl:NSS

Na level 2% NaCl 1L 3% NaCl 1L Totilac 250 ml

Increase by 10
Increase by 20 Increase by 5
Na <135 ml/hr to max 50
ml/hr ml/hr
ml/hr
Increase by 5
Increase by 10 Increase by 2.5
135-144 ml/hr to max 50
ml/hr ml/hr
ml/hr
 Maintain current Maintain current Maintain current
145-150
rate rate rate
Decrease by 10 Decease by 5 Decrease by 2.5
151-153
ml/hr ml/hr ml/hr
Decrease by 20 Decrease by 10 Decrease by 5
154-157 ml/hr then q4hr ml/hr then q4hr ml/hr then q4hr
renals renals renals
Hold 2% for 1 hr Hold 3% for 1 hr Hold Totilac for 1
158-159 then resume ½ then resume ½ of hr then resume
of prev rate prev rate ½ of prev rate
Shift 2% HS to Shift 3% HS to Shift Totilac to
160-162
Plain 0.45% NaCl Plain 0.45% NaCl Plain 0.45% NaCl
>163 Refer Refer Refer

Totilac
2% NaCl 1L 3% NaCl 1L
250 ml
Content 20 g 30g 56.5g
Amount of Na in
7.866g 11.799g 11.5g
solution
Milliequivalents 342 513 504
% Sodium 0.8% 1.18% 1.15%
1020
Osmolality 684 mosm/L 1027 mosm/L
mosm/L
 HEMA NOTES
EPO 50-100 u/kg/BW/wk
Anemia class by who
Vitamin K= 5 mg in 10 ml pNSS/ SIVP
Agrabulocytosis: DOC: Cefepime
Albumin T ½: 21 days
IV IRON (COSMOFER)
Incorporate 50mg into 50ml pnss into a soloset. infuse the above solution for 10
mins..refer for any untoward reactions
 -if no adverse reaction noted after 30-45mins after the test dose. may give the
remaining 50mg cosmofer iv for 10mins.
ANEMIA
Category DDX CBC clues PBS clues
Microcytic IDA Increased RDW Anisocytosis
Poikilocytosis
Elliptocytosis
Thalassemia Normal or Plolychromasia
Elevated RBC Target Cells
Normal or elev
RDW
Anemia of Normal RDW Basophilic stippling
Chronic Disease Unremarkable(Rouleaux
formation)

Normocytic Bleeding Usuallu Polychromasia

unremarkable
Nutritional Increased RDW Anisocytosis
anemia (Iron,
Vitamin, Vit
B12/folate
deficiency)
Anemia of CKD Normal RDW Dimorphic RBCs

Hemolysis Normal or Polychromasia

elevated RDW
Thrombocytosis Spherocytes
Anemia of Normal RDW Unremarkable
chronic dse
Primary bone Inc RDW Dimorphic RBCs
marrow d/o Other cytopenias Pseudo Pelger-Huet
anomaly
Monocytosis Oval Macrocytes
Leukocytosis Myelopathies (MMM)
Thrombocytosis Rouleaux (myeloma)
Abnormal DIFF Blasts (acute LEukemia)
Macrocytic Medical Drug-
induced
Nutritional Increased RDW Oval Macrocytes
Marked or mild Hypersegmented Neutro
macrocytosis
MDS Increased RDW Dimorphic RBCS
Liver dse, Normal RDW, Round Macrocytes
alcohol use Thrombocytopenia Target cells
Hypothyroidism Normal RDW Round macrocytes
Hemolysis Normal or Polychromasia
elevated RDW
 ANEMIA:
Microcytic, hypochromic:
- IDA
- THalassemia
- Chronic Inflammatory Disease
- MDS
Macrocytic
- Megaloblastic
- Hemolysis
- Liver Disease
- Alcoholism
- Hypothyroidism
- Aplastic
Normocytic, Normochromic
- Anemia of chronic Disease
- Endocrine failure: mild normocytic, normochromic
- Anemia of Chronic Renal failure (decreased retic)
Aplastic anemia, Pure Red Cell aplasia, Myelophthisic, MDS
- Hypoproliferative associated with marrow damage
Reticulocyte Count (0.005-0.015
To know if marrow problem or anemia secondary to hemolysis or blood loss
Corrected retic:
Patient’s retic x pt’s Hct/ Normal Hct x 1000
Normal Hct values: 0.4-0.5 males; 0.38-0.48 females
Reticulocyte index: Corrected retic/2
Interpretation:
- Low retic: marrow problem because of decreased production
- High retic: Compensatory or destruction or blood loss
Absolute Reticulocyte Count
Retic count x 1000 [hgb of patient/expected hgb for age and
gender]
Corrected Retic: Absolute retic/Maturation time
Maturation Time
Maturation time HCT of Patient
1 45%
1.5 35%
2 25%
2.5 15%
ANC: WBC x (Neutro + Stabs) x 1000
Revised Local Transfusion Guidelines
1. Hgb <7g/dl or HCt <21% ( if not due to a treatable cause, such as Iron deficiency,
pRBC is warranted
2. Symptomatic anemia, regardless of haemoglobin level ( usually <10g/dL)
Dyspnea
Syncope
Postural hypotension
Tachycardia
Chest pain
 TIA
3. Hgb <7 g/dL or Hct <21% with concomitant hemorrhage, COPD, CAD,
Hemoglobinopathy, Sepsis
4. Patients receiving General Anesthesia, if
Pre op hgb <7 or Hct <21
Major bloody surgery,pre og hgb<10
Signs of hemodynamic instability or inadequate O2 carrying
capacity
1unit pRBC raises Hgb by 1g/dL and hct by 3%

Platelet Transfusion
Indications: therapeutic (bleeding)
Prophylactic (surgery)
At >100,000 bleeding time is not affected
At 10,000 bleeding time is prolonged
At <10,000 bleeding time is >30minutes and not related to platelet count
At <5,000 spontaneous bleeding
Pooled/Random Donor Single donor/apharesis
Platelets
Dose 1 unit/10kg BW 1 pack = to 6 units
Advantage: decrease risk of
infectious disease
response 1 unit increase PC 5-10,00 Corrected count
cells/uL increment(CCi) ≥10,000
within 1 hour and ≥7500
within 24 hours post
transfusion
Volume 50cc 200-600cc
Platelets not useful in
- Drug induced thrombocytopenia
- ITP, HUS ITP
- HIT
If plt <10,000 give prophylaxis
Major surgeries- maintain >50,000
If Minor surgeries maintain >30,000
FRESH FROZEN PLASMA
Indication: Control or Prevention of bleeding in Multiple Coagualtion Disrode
- Liver Disease with coagulopathy
- Hemophilia
- DIC
- Reversal of wararin effect
Dose: 4-7 units for an average adult (15-20mL/kg)
Response: increase coagulation factors by 2%
Shelf life: 1 year when frozen at -30CVon WB disease
Cryoprecipitate Transfusion
Indications
- Hemophilia A with bleeding or anticipated
- Fibrinogen Deficiency in DIC
- Factor XIII Deficiency
Shelf life: 1 year when frozen at -30C
Dose: in pools of 6 units each
Response: increase fibrinogen by 30-60mg/dL
Granulocyte Concentrate transfusion
Indications:
- Gram – Sepsis with ANC <500, not responding to antibiotics
Screening Assyas
PT
- assess factor I (Fibrinogen), II (prothrombin), V, VII, X
- Measures the time for clot formation of the citrated plasma
after recalcification and addition of thromboplastin
Prolonged: factor VII deficiency, early Vit K deficiency, warfarin anticoagulation
aPTT: assess the intrinsic and common coagulation factors
(XI,IX,VIII,X,V,II,I,Prekallikrein)
prolonged: factor deficiency, Heparin

PULMO NOTES
Four basic mechanisms of hypoxia
1. decrease in inspired PO2
2. Hypoventilation
3. Shunt
4. Ventilation/Perfusion mismatch (V/Q)
Shunt: Alveolar collapse (atelectasis)
Intraalveolar filling (Pneumonia, Pulmonary edema)
Intracardiac shunt
Vascular shunt within lungs
V/Q mismatch: airway disease (asthma COPD)
Interstitial lung disease
Alveolar disease
Pulmonary vascular disease
WHEN TO INTUBATE
RR > 35cpmApnea <20s
PaO2 <50mmHgPaCO2 >60
GCS <7Arrythmia
Shock
MECHANICAL VENTILATOR
Hook to MV on AC mode with the following settings:
TV= 6-10 ml/kg
BUR= 12-18
FiO2= see formula
Repeat CXR, ABG 30 minutes post intubation
RESPIRATORY FAILURETYPESHYPOXEMIA (pO2)
I Hypoxemic 60-79 Mild
II Hypercarbic /vent 40-59 Mod
III Post-op atelec<40 Severe
IV Shock
ABGs NORMAL VALUES
pH 7.35-7.45 HCO3 22-26
pCo2 35-45 BE -2 to +2
pO2 80-100 O2 Sat >90%
DESIRED FiO2 P/F RATIO
A = pCO2 / 0.8
B = (713 x FiO2 )– A this is the formula for pAo2
C = pO2 / B
D = (expected PaO2/c) + A
E = D/713 x 100
FLOW RATE CONVERSION
(DFiO2 – 20) / 4
FiO2
Room Air = 0.21
Per nasal cannula (LPM x 4) + 20
Per face mask (LPM – 1) x 10
EXPECTED pO2
< 60 y/o: 104 – (Age x 0.43)
> 60 y/o: 80 – Yrs>60
OXYGENATION
TV = 6-8 ml x wt in kg
≤ 60 yo = 400-500
>60 yo =
ABGs: Acidemic or Alkalemic?
Respiratory or Metabolic?
If respiratory, acute or chronic?
If metabolic, anion gap normal or abnormal?
If metabolic, is respiratory compensating?
ACIDOSIS ALKALOSIS
pH<7.4 pH >7.4
Metabolic: HCO3 <24 Metabolic: HCO3 >24
Respiratory: pCO2 >40 Respiratory: pCO2 <40

ANION GAP: Na – (Cl + HCO3) ; (NV 8-16)

Unmeasured cations: K, Ca, Mg, Globulinn, lithium
Unmeasured anions: lactate, ketones, uremic anion, toxic anion, albumin

RESPIRATORY ACIDOSIS
pH: 7.4 – ( 0.008 (actual pCO2 – 40)
pH: 7.4 – ( 0.003 (actual pCO2 – 40) chronic

RESPIRATORY ALKALOSIS
pH: 7.4 + (0.008 (40- actual pCO2))
pH: 7.4 + (0.003 (40- actual pCO2))
* If actual pH is less than the expected: Respiratory acidosis with concomitant
metabolic acidosis
* If actual pH is more than the expected: Respiratory acidosis with concomitant
metabolic alkalosis
* Acute: for every 10 mmHg dec in pCO2, pH inc by 0.08
* Chronic: for every 10 mmHg dec in pCO2, pH inc by 0.03

METABOLIC ACIDOSIS
Expected pCO2: (1.5 x actual HCO3) + 8 +/- 2

METABOLIC ALKALOSIS
Expected pCO2: (0.75 x actual HCO3) + 20 +/- 5
* If actual pCO2 is greater than expected, there is concomitant Respiratory acidosis
* If actual pCO2 is lesser than expected, there is concomitant respiratory alkalosis
PLEURAL EFFUSION LIGHT’S CRITERIA
Pleural/Serum CHON>0.5
Pleural/Serum LDH>0.6
Pleural LDH >2/3Serum

Thoracentesis Specimen
Bottle 1: Cell ct, diff ct
Bottle 2: TP, LDH, glu
Bottle 3: AFB, GS, CS
Bottle 4: Cytology and Cell block
PTB ATS CLASS
0 No Exposure 3 Disease
1 Exposure 4 Treated
2 Infxn (+PPD) 5 Suspect
PTB WHO CATEGORIES:
I New Smear +/- Extensive D’se 2HRZE 4HR
New Severe ExtrapulmoD’se
II Smear + After Tx Failure 2HRZES 1HRZE 5HRE
Relapse / Interruption
III New Smear – Less Extensive 2HRZ(E) 4HR
Less Severe Extrapulmo
PTB SPUTUM
Pus >25, Epith<10, Bacteria 10-100/lpf
MYRIN
<55kg 3 tabs
55-70kg 4 tabs
>70kg 5 tabs
CAP HIGH RISK
BTS Criteria: CURB 65ATS Criteria ICU:
Confusion Major: Need for Mech. vent
Urea Nitrogen >20mg/dl Septic Shock/ Vasopressors
RR >30 Minor: CURB
BP <90/60PaO2/FiO2 <250
Multi-lobar infiltrates,
Hypothermia<36
Leukopenia<4,
Thrombocytopenia<100
HEALTH CARE ASSOCIATED PNEUMONIA
>48h after admission
Early <5d
Late >5d
ASTHMA (GINA 2006) PEFV: >20% (Post – Pre) / ½ (Post +Pre) x 100
CONTROLLED Daytime Sx<2x/wkShort B2 agonists
 (M Int) No Nocturnal sx
Relievers <2x/wk
PARTLY Daytime sx>2x/wkB2 + Inh Corticosteroid
CONTROLLED w/ Nocturnal sx+ anticholi
(Mild P) Relievers >2x/wk (>1 attack/s per yr)
PEF / FEV1 <80%
UNCONTROLLED >3 features in any week B2 + inh + anti + oral
(Mod-Sev P) (1 attack in any wk) steroid + LTM

Acute attack: B2 q20 x 3, O2, Medrol 16mg BID or Pred 60mg OD or Hydrocort
250mgIV taper, Aminophylline IV bolus 5-6 mg/kg, Epinephrine
WHEEZING
Check O2 sat, nebulize with salbutamol/ combivent x 3 doses q 20 min
COPD (GOLD2006) FEV1/FVC <70%
Stage I Mild FEV1 >80% Short B2 Agonist + Anticholi
II Mod 50-80% Long B2 + Anticholi + theo
III Severe 30-50% Long B2 + Anti + Inh Steroid + theo
IV Very Severe <30% Same as severe + O2

Acute attack: Combivent neb, Amino, PO/IV steroid (Prednisolone 30-40mg/d),

Antibiotics, O2 (MV if RR>35, pH<7.25, PCO2 >60mmHg)
CAP
LOW RISK Moderate Risk High Risk
RR < 30 RR 30 Moderate risk PLUS
PR < 125 PR 125 SEVERE SEPSIS:
BP 90/60 T 36 40 Wbc>12
No altered BP 90/60 UO < 0.5ml/kg
mental state Altered mental Crea> 2
No state Bilirubin > 2
suspected Suspected Plt < 100,000
CXR aspiration aspiration SEPTIC SHOCK
No/ stable Decompensat Not responsive to
comorbids ed comorbid 500ml fluid challenge
No effusion/ Multilobar Need for mech vent
abscess infiltrates
Pleural
effusion/
abscess
Mortalit 1-3 % 8-10 % 20-30%
y
OPD WARD ICU
AdMISSION
Blood Cs, GS Sputum GS CS ET
GS CS
Sttrep Same as Low Same with moderate
Pneumoniae risk PLUS
atypical H influenza Plus Staph aureus
Chlamydoph Legionella (lung abscess,
ila Pneu Anaerobes pneumatocoela,
Mycoplasma (aspiration) pylothorax)
recent Moxarella Gram – Psedomonas
Antibiot catarrhalis bacteroides, aeruginosa
ic use Prevotella
Enteric Gram+
Gram Peptostrep
Negative
Clostridium,
actinomyces
Previously IV Non No risk for P
healthy antipseudomo aeruginosa:
Amoxicillin nal Blactam + IV Non
500TID ext macrolide antipseudomonal
Supect or respi Blactam + IVext
atypical fluoroquinolon macrolide or IV respi
Extended e fluoroquinolone
MAcrolides MACROLIDE:
Azithromyci Azithro 500 With RISK for
n dehydrate q24 PO/IV PseudomonasAerugin
500 OD Clarithro 500 osa:
Clarithro q12 PO/IV (prior use of broad
500 BID Erythro 0.5-1g antibx >7days past
Stable q6 PO/IV month, COPD
comorbids bronchiec,
BLIC Respi fluro malnutrition, chronic
Coamox 625 antipneumo steroid >7.5mg/day2)
TID Levoflox 500- IV Antipneumococcal,
1g 750 q24 antipseudomonal B
BID PO/IV lactam
Amox sulba Moxiflox 400 + IV aminoglycoside
1g TID q24 PO/IV + extended macrolide
Sultamicillin Non OR
750 BID antipsedomon + IV Cipro/Levo High
2nd gen al dose
cephalospori .BLIC
n CO-Amox AMINOGLY
Cefaclor 500 1.2g IV q8 Amikacin 15mg/kg
TID Ampi Sul 1.5g q24
IV q8 Gentamicin 3mk q24
750 BID Netilmicin 7mk q24
Cefu axetil 2nd gen Tobramycin 3mk q24
500 BID Cefotiam 1g Anti
3rd gen q8 IV pseudo,antipneumo
Cepha Cefoxitin 1g Cefoperazone-sulbac
Cefdinir 300 q8 IV 1.5-3g q8-12
BID With Pip-Tazo 2.25- 4.5g
Cefixime anaerobic q6-8
200 BID activity Ticarcillin-clavulanic
Cefpodoxim Cefuroxime 3.2g/IV q6
e proxotil Na 1.5g q8 IV Cefepime 2g q8-12
200 BID Imipenem-Cilastatin
3rd gen 0.5-1g q6-8
Cefotaxime 1- Meropenem 1-2g q8
2g q8 IV FLUORO
 Ceftizoxime 1- Cipro 400mg q12
2g q8 IV Levo 750mg q12
Ceftriaxone 1-
2g q24 IV Staph
Oxacillin 1-2g q4-6
Carbapenem Staph + anaerobes
Ertapenem 1g Clindamycin 600mg
q24 q6-8

Bacteroides
(anaerobes)
Metronidazole 500mg
q6-8

MRSA
Linezolid 600mgq12
Vancomycin 1g q12
Indications for streamlining to oral:
1. NO fever >24 hrs
2. Normal RR
3. Improving WBC, no bacteremia
4. Etio is not: Legionella, Staph aureus or gram –
5. NO MI, CHF, Complete heart block, new AF, SVT
6. No sign of organ dysfxn (hypotension, mental changes, BUN:Crea
ratio >10:1, hypoxemia, metabolic acidosis
7. Clinically hydrated, taking oral fluids, able to take oral meds
CoAMox 625 TID/ 1g BID Cefaclor 500 TID or 750 BID
Amox sulbactam 1gm TID Cefuroxime 500 BID
Levoflox 500-750OD Sultamicillin 750 BID
Cefdinir 300 BID Moxiflox 400 OD
Clarithro 500mg BID Cefpodoxime 200 BID

Duration of tX
LOW: 5-7 days
MR: Gram -, Staph, Pseudomonas : 14-21 days
Mycoplasma, Chlamydophila: 10-14 days
Legionella: 14-21
5 day oral or IV low risk
Patients should be afebrile NO SIGNS of instability before discontinuation of tx
DISCHARGE: 24 hours prior px should
Temp: 36.5-37.5
Pulse <100
Rr: 16-24
SBP>90
O2 sat >90
Functioning GI tract
PREVENTION:
1. Pneumococcal vaccine: 0.5ml IM
>60
COPD, bronchiec, CV, Dm, Alcoholic, CKD, CA, Nursing homes, smoker/asthma 19-64
2. Influenza
>50
Chronic illness, immunocompromised
Pregnant 2nd or 3rd tri
Nursing hom
Household contact <5, >50
0.5ml yearly
3. smoking cessation
Ceft
Hospital Acquired Pneumonia
Diagnosis made >48 hours after admission
Ventilator Associated Pneumonia:
Diagnosis made 48-72 hours after endotracheal intubation
Healthcare Associated Pneumonia:
Diagnosis made <48hours after admission with any of the ff
1.hospitalized in acute care hospital for >48 hours within 90 days of the
diagnosis
2. resided in a nursing home or a long care facility
3. received recent IV antibiotic therapy, chemotherapy or wound care within
the 30days preceding the diagnosis
4. attended a hospital or hemodialysis clinic
Treatment :
Early onset: <5days since admission and no risk factors fpr MDR
Ceftriaxone 2 g/IV or IM q24
Levoflox 750mg/IV or PO q24
MOxiflox 400 mg /IV or PO q24
Ciproflox 400mg/IV or PO q8
Ampi-Sul 3g/IV or IM q6
Ertapenem 1 g/IV or IM q24
Duration: 8 days
Late onset: ≥ 5 days since admission, MDR risk factors present or DX
HCAP
Cefepime 2g/IV q8 PLUS Vancomycin 15mg/kg q12
Ceftazidime 2g/IV q8 Linezolid 600mg/IV q12
Imipinem 500 mg/IV q6 or 1g/IV q8 PLUS
Meropenem 1g/IV q8 Cipro 400/IV q8
Pip Taz 4.5g/IV q6 Levox 750 IV q24
Duration: If clinical improvement is noted in 48-72and cultures are negative,
consider stopping antibiotics
If clinical improvement in 48-72 hours, cultures are positive, adjust regimen per
susceptibilities and continue antibiotics for 7-8days
IF no improvement an cultures neg, look for alternative DX
Indications of Mechanical Ventilation
ARF with hypoxemia
Hypercarbic ventilatory failure
Exacerbations of cold
Neuromuscular diseases
Types of Mechanical Ventilation
Noninvasive (BIPAP)
Indications: 1) Exacerbation of COPD
2) Cardiogenic edema
Contraindications: Decreased sensorium
Cardiac or respiratory arrest
Severe encephalopathy
Hemodynamic instability
Unstable angina and MI
Facial surgery or trauma
Upper airway obstruction
Inability to clear secretions
IPAP and EPAP
Minimum I-8 and E-4
Maximum I-20 E-16
Minimum difference between I and E of 4
Increase the difference to decrease PCO2

To decrease pCO2 - inc IPAP

To increase pO2 - inc EPAP, FiO2
FiO2 - start with 100% and adjust when ABG is available
Invasive
Sedation: opiates and benzodiazepines
Avoid morphine with asthma
Avoid ketamine with hypertensive crisis
Propofol, Precedex
Settings:
Mode - manner in which ventilator breathes
are triggered, cycled, and limited
AC Mode - patient breathes on his own, ventilator senses the effort and delivers
the preset tidal volume (TV, BUR, PEEP, PF, FiO2)
Usual Value
Tidal Volume (TV) IBW x 8-10 mL
 IBW x 6-8 mL (for ARDS)
Back-up Rate (BUR) 16-22 cpm, USUAL 14-16
Increase BUR (ex. 22) to blow off
CO2
FiO2 Start with 100% and adjust when
ABG is available
Positive End-Expiratory Pressure Physiologic: 3-5 cmH2O
(PEEP) O cm H20 - hypotension
-avoids collapse/atelectasis Increased in ARDS
(pressure to keep airways open at
end-expiration)
Peak Flow - rate at which air is 40-60 L/min
delivered If Normal RR-40; IF RR is 30 (+30) -
60
I:E ratio 1:2-1:3
To dec To inc To dec po2 To incr
pCO2 PCo2 po2
TV Increase Decrease
BUR Increase Decrease
Fio2 decrease Increase
PEEP increase
PF Increase Decrease
I:E ratio increase decrease
Desired T (TVxPCO2)/Desired PCO2
Increase BUR if with no spontaneous RR
SIMV
PS pressure support Physio: 4-6 no maximum
BUR 70% of actual RR
Fio2 Based from computation

Weaning
Criteria:
Intact upper airway function
RSBI (rapid shallow breathing index) < 105
Alveolar ventilation is adequate
- Elimination of CO2 is sufficient
- SO2 of >90% can be achieved with FiO2 <50% and PEEP 5
Conditions to be met:
Resolution or improvement of the cause of respiratory failure
Stable CV status
Adequate gas exchange and respiratory pump capacity
Absence of sepsis and marked fever
Correction of electrolyte imbalance and metabolic disorder (Hgb, K, Alb)
Cessation of sedatives and neuromuscular blocking drugs
No plan for general anesthesia

DRIPS& IV PUSH

Flow= desired dose (mcg/kg/min) x wt (kg) x 60 min/hr

Concentration (mcg/ml)
CARDIO
Concn ratio Dopamine(mcg/ml) Dobutamine Levophed-
Concn
1:1 800 1000 1
16
2:1 1600 2000 2
32
4:1 3200 4000 4
64
8:1 (central line) 8 128
ATROPINE
Atropine 1mg IVP or 2-3mg ETT q3-5 until 0.04mg/kg or 3mg
ADENOSINE
Adenosine 6mg rapid IV ff by 20cc NSS, then 12mg q1-2min up to 2 doses
AMIODARONE
For SVTs, VTs
150 mg/SIVP over 10-30 mins then start drip using 150-300 mg in 250 ml pNSS to run
for 24 h
Prep: 150 mg/3 ml vial
IV loading: 5- 10 mg/kg BW/ 24h
500-1000 mg in 24h

150-300mg IV in 10mins then 1mg/min infusion (300mg)x6hrs then 0.5mg/min

x18hrs
DOPAMINE
Renal dose 3-5 mcg D1 receptor
Ino/Chronotropic 5-10 B1 receptor
Max/Pressor 10-20 Deactivates A1 receptor (vasoconstriction,
increase systemic vascular resistance)
4:1 in 250 ml pNSS to run at 5 mcg/kg/min
Ex: 50 kg patient, desired dose at 5 mcg/kg/min = 4.5

D5W 250cc + Dopa 200mg/amp, 2.5-10mcg/kg/min

ugtts/min = (drip mcg x Wt) /13.3 @ 7-60ugtts/min Double dose: 2 amps
DOBUTAMINE
4:1 in 250 ml pNSS to run at 5 mcg/kg/min
Ex: 60 kg patient, desired dose at 5 mcg/kg/min = 4.5

D5W 250cc + Dobu 250mg/amp, 2.5-20ug/kg/min

ugtts/min = (drip ug x Wt) /16.6 @10-60ugtts/min Double dose: 2 amps
NOREPINEPHRINE (LEVOPHED)
4:1 in 250 ml pNSS to run at 0.2 mcg/kg/min
Ex: 70 kg patient, desired dose at 0.2 mcg/kg/min = 13

D5W 72cc + Levophed 2mg/2ml 4 amps, @1mg/kg/hr

1ug/min = 7.5ugtts/min @ 15-60 ugtts/min
EPINEPHRINE
1mg IVP or 2-2.5mg ETT Q3-5 mins

D5W 250cc + 1 amp (1mg) epi

1ug/min = 15 ugtts/min @ 15-150 ugtts/min
NICARDIPINE
10 mg in 90 ml pNSS/D5W x or 20 mg in 80 ml pNSSto run at 6mg/hr, titrate drip by
increments of 2 mg/hr to sustain SBP<160 mmHg
or1 mg/IV push
Prep: 2 mg/ 2ml, 10 mg/10 ml
Conc: 0.1 mg/ml
D5W 90cc+Nicardepine 10mg in Soluset @ 10-50ugtts/min
Site changed q12h if peripheral
METOPROLOL
5mg SIV Q5 x 3 doses
PROPRANOLOL
0.1mg/kg divided into 3 equal doses IV Q2-3min
ESMOLOL
LD: 500mcg/kg/min SIV MD: 50-200mcg/kg/min over 4mins
HYDRALAZINE
D5W 250cc+hydra 2 amps (20mg/amp) @ 5-60ugtts/min
VERAPAMIL
2.5-5mg IV over 2 mins, may rpt w/ 5-10mg IV in 15-30mins
LIDOCAINE
1-1.5mg/kg then 0.5-0.75 mg/kg Q5-10mins (max 3mg) then
infusion of 1-4mg/min (30-50mcg/kg/min

D5W 250cc + Lido 1g @15-60ugtts/min LD: 1mg/kg IV

ISDN (ISOKET)
10 mg in 90 cc pNSS or D5W in a soluset drip to run at 10-50 ugtts/min (equivalent
to 1-5 mg/hr)
20 mg in 80 cc pNSS or D5W in a soluset drip to run at 10-50 ugtts/min (equivalent
to 1-5 mg/hr)
D5W 90cc + ISDN 10mg in Soluset @ 10-50ugtts/min
HEPARIN
5000 units as IV bolus followed by 18 units/kg/h IV infusion via heparin drip as D5W
19 cc + 1 cc (1:5000 units) at 23-24 cc/hr; (decrease by 3 units if PTT > 2x-3x)
Heparin drip
1.5 – 2.5 = 0.2- 0.4 U/mL
PTT 50 s = rebolus 5000 units and increase by 100 u/hr
50-60 s = increase by 100 u
60-85 s = no change
85- 100 s = decrease by 100 u
100- 120 s = stop for 30 mins, decrease by 100 units
> 120 u = stop for 1 hr, decrease by 100 u

D5W 200cc + 10,000u Heparin @ 10-20ugtts/min

LD 3,000-5,000u SIV
STREPTOKINASE
1.5M u + D5W 90cc @ 100cc/hr
PULMO
AMINOPHYLLINE
D5W 250 cc + Aminophylline 250 mg/amp at 15-40 ugtts/min; Maintenance drip of
0.4-0.8 mg/kg/hr is equivalent to 20-40 ugtts/min for a 50 kg person, shd be reduced
to 0.2-0.3 mg/kg/hr for elderly pregnant, CHF, liver dse, or corpulmonale. LD: 5
mg/kg/BW in 30 cc D5W in a soluset

D5W 250cc + Amino 250mg/amp, MD: 0.4-0.8mg/kg/hr

ugtt/min = dose x Wt @ 15-40 ugtts/min LD: 5mg/kg in 30cc
TERBUTALINE (BRICANYL)
D5NSS 500cc + 10amp @ 15ugtts/min
SODIUM BICARBONATE
Prep: 84 mg/ml x 50 ml = 50 meqs
Compute for HCO3 deficit
0.4 x BW in kg x (desired – actual HCO3)
Give ½ as bolus, then ½ as drip

ORDER: Start Sodium Bicarbonate drip as follows: 1 amp in 250 ml D5W to run for 12
-24 hours
* if will use 3 amps, use 1 Li D5W
Rpt ABGs in 4-6 hours
If intractable metabolic acidosis – Hemodialysis
Ex. Wt= 60 kg
ABG: pH 7.12/ pCO2 35/ pO2 88/ HCO3 9/ O2 sat 92%
NaHCO3 deficit= 216

ORDER: Give 100 meqs NaHCO3 IV bolus now, then start drip using 100 meqs
NaHCO3 in 250 ml D5W x 24 hours
*Check serum K (hypokalemia)

D5W 250cc + NaHCO3 1 amp 12-24h @ 20-40ugtts/min

ENDO
INSULIN
100 ccpNSS + 100 u HR to run at 1-10 units/hr
Titrate according to desired blood glucose
Usually, start at 8u/hr or 8 cc/hr
CBG q hr while on HR drip
Prep: 100 u/ml x 10 ml
Conc: 100 units/ 100 ml

PNSS 99cc+ 1cc HumulinR, 1u/hr =5ugtts/min @5-50ugtts/min

NEPHRO
MAGNESIUM SULFATE
NV=1.8-2.4
2-2.5 g in 250 ml pNSS to run for 12 hours (20 ml/hr)
2.5 g/10mL amp

D5W 250cc+ 2g MgSO4 @ 20cc/hr

FUROSEMIDE
D5W250cc+ Furo 250mg/amp, 5-30mg/hr@ 5- 30ugtts/min
GASTRO
OCTREOTIDE
For variceal bleeding/ pancreatitis
Usually given for 5 days or until bleeding stops
50 mcg IV bolus then start drip using 1200-1250 mcg Octreotide in 250 ml D5W to
run at 25-50 mcg/hr
ESOMPEPRAZOLE (NEXIUM/LOSEC)
40mg in 90ml pNSS to run for 5 hours (20 cc/hr)
40mg/10 ml
PANTOPRAZOLE (PANTOLOC)
5 amps in 250 ml D5W to run for 24 hours
40 mg/amp
CARNITINE + PYRIDOXINE + CYANOCOBALAMIN (GODEX)
D5W 250cc + 2 amps x 12 hrs
NEURO
NIMODIPINE (NIMOTOP)
10 mg in 50 ml pNSS x 1-2 mg/hr
Max 2 mg/hr
OTHERS
PULSE STEROID
D5W 100cc + 1gm SOLUMEDROL infusion x 2hrs OD x 3 days
MIDAZOLAM (DORMICUM)
20 mg in 100 cc pNSS to run at 1 mg/hr
Max 5 mg/hr
FENTANYL
100 ug in 250 cc D5W to run at 1ug/kg/hr = 13 cc/hr; 1 cc = 4ug
DIAZEPAM
D5W 100cc + Diaz 10mg Q6 (Max 60mg/d)
DICLOFENAC
D5W500cc+ 2amps @ 25ugtts/min
KETOPROFEN (ORUDIS)
D5W 250cc + 1 vial @ 20 ugtts/min
MORPHINE SULFATE
PNSS50cc+1amp Morph (16mg/amp) @ 6 ugtts/min
Renal Panel
1 2 3 4 6 8 12 15
lipid Na Na Na FBS FBS FBS FBS
profil K K K Cre Cre Crea Crea
e HCO Cl Cl a a BUA BUA
crea 3 HCO HCo BUA BUA Chol Chol
BUN BUN 3 3 Chol Chol BUN BUN
BUA Crea Ca CA BU BU Trig Trig
P P N N HDL HDL
Mg Mg Trig Trig LDL LDL
Crea HDL SGP SGPT
BUN LDL T AP
BUA AP TPA
TP G
Ck
total
AST
LDH