NHS Guidelines

The Bedside Clinical Guidelines Partnership
Medical
Guidelines
2010/11
General Adult Medicine
These guidelines are advisory, NOT mandatory
Unless stated, drug doses assume normal renal and hepatic
function
See British National Formulary for further advice
Contents 2009-10
Click on the topic

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relevant page
CONTENTS
Preface
Prevention of contrast induced nephrotoxicity .
Aggressive and violent patients
Management of a pregnant woman with a non-obstetric problem
Practice and ethics of nutritional support in medical patients..
Administration of blood and blood components for adults..
Modified early warning scoring system (MEWS) for patient monitoring
Verification of death..
EMERGENCIES
Acute anaphylaxis
Cardiopulmonary resuscitation life support procedure
Cardiopulmonary resuscitation clinical justification
INFECTION CONTROL
Standard infection control
Hand hygiene
Use of personal protective equipment..
Screening for MRSA and ESBL/MGNB on admission or transfer
Management of patients with MRSA.
Topical MRSA decolonisation treatment..
Management of patients with ESBL..
Management of patients with clostridium difficile
HIV Infection testing
INFECTION
Sepsis, severe sepsis and septic shock
Meningitis
Acute hot joint, septic arthritis and gout.
Infective endocarditis
Neutropenic sepsis after chemotherapy or radiotherapy
Fever in the returning traveller
Cellulitis ..
ACUTE POISONING/DRUG OVERDOSAGE

Acute poisoning/drug overdosage.
Drug overdosage Paracetamol..
Withdrawal of drug(s) of dependence..
Alcohol withdrawal
ENDOCRINE
Triage of patients with hyperglycaemia
Control of hyperglycaemia in the ill patient..
Diabetic ketoacidosis and hyperosmolar hyperglycaemic non-ketotic state..
Contents 2009-10
Acute hypoglycaemia
Acute adrenal insufficiency
FLUIDS AND ELECTROLYTES

Fluid management flowchart New for 2010-11 ..
Maintenance fluid therapy
Fluid resuscitation .
Electrolyte disturbances
Hypomagnesaemia ..
Hypercalcaemia..
GASTROENTEROLOGY
Acute upper gastrointestinal haemorrhage
Acute liver failure with encephalopathy
Acute ulcerative colitis and Crohns disease..
CARDIOVASCULAR DISEASE
Management of suspected cardiac chest pain New for 2010-11
Unstable angina.
Acute myocardial infarction..
Aortic dissection.
Cardiac tamponade...
Acute cardiac failure..
Cardiac arrhythmias
Atrial fibrillation.
Infective endocarditis.
VENOUS THROMBOEMBOLISM
Prophylaxis against venous thromboembolism
Deep venous thrombosis..
Massive pulmonary embolism ....
Small-to-moderate pulmonary embolism...
Heparin induced thrombocytopenia
RESPIRATORY DISEASE
Spontaneous pneumothorax
Acute severe asthma in adults
Exacerbation of chronic obstructive pulmonary disease
Community-acquired pneumonia
Hospital-acquired pneumonia..
Respiratory failure.
Pleural infection and empyema..
Pleural effusion investigation of ..
NEUROLOGY
Status epilepticus..
First seizure New for 2010-11
Cluster seizures and complex partial and non-convulsive status..
Contents 2009-10
Stroke..
Transient ischaemic attack (TIA) and minor cerebral infarction.
Subarachnoid haemorrhage.
Acute spinal cord compression
RENOVASCULAR DISEASE
Acute renal failure.
Accelerated (malignant) hypertension
ELDERLY CARE
Acute confusional state (delirium) in older people
Hypothermia in older people..
Management of constipation in hospitalized elderly patients
Management of falls in A&E and wards New for 2010-11
Syncope New for 2010-11..
HAEMATOLOGY
Chronic anaemia..
Crisis in sickle cell disease
Bleeding disorders in adults
PRESCRIBING REGIMENS AND NOMOGRAMS

Acid-base diagram
Aminophylline
Introduction of an angiotensin-converting enzyme (ACE) inhibitor..
Digoxin
Dobutamine hydrochloride
Dopamine hydrochloride
Doxapram.
Gentamicin
Glasgow coma scale
Glyceryl trinitrate..
IV unfractionated heparin
Labetalol
Oxygen therapy in acutely hypoxaemic medical patients.
Pain control in palliative care..
Phenytoin adjustment of oral dosage
Phenytoin intravenous .
Salbutamol..
Sodium nitroprusside
Therapeutic drug monitoring
Vancomycin
Warfarin..
For further advice on drug therapy please contact Medicines Information
Contents 2009-10
PRACTICAL PROCEDURES
The following is included in each Practical procedure:
Indications, contraindications, Equipment, Procedure, Specimens, Aftercare
Administration of fluid and insulin infusions ..
Flushing intravenous lines New for 2010-11.....
Percutaneous central venous cannulation.
Tapping ascites and paracentesis
Insertion of Sengstaken-Blakemore tube
Arterial puncture
Investigation of pleural effusion
Pleural aspiration of fluid
Pleural aspiration of air
Pleural biopsy
Intercostal tube drainage
Pleurodesis
Insertion of long lines
Urethral catheterisation
Lumbar puncture
Knee aspiration
Collection of blood culture specimens
Compiled by : Dr. Phyu Wai

Approved date : January 2011
Review date : January 2012
Preface 2010-11
PREFACE
Unless stated, drug doses assume normal renal and hepatic function
This book has been compiled as an aide-mmoire for all staff concerned with the management of general
medical adult in-patients, especially those who present as emergencies. It is divided into three sections:
1. GUIDELINES ON THE MANAGEMENT OF COMMON MEDICAL CONDITIONS

These have been drafted with reference to published medical literature and amended after extensive
consultation. For ease of reference, the layout adopts a standard format, covering Recognition and
assessment, Immediate treatment, Subsequent management, Monitoring Treatment, and Discharge and
follow-up.
Wherever possible, recommendations made are evidence based. Where no clear evidence has been
identified from published literature the advice given represents a consensus of the expert authors and their
peers and is based on their practical experience.
No guideline will apply to every patient, even where the diagnosis is clear-cut; there will always be
exceptions. These guidelines are not intended as a substitute for logical thought and must be tempered by
clinical judgement in the individual patient.
The guidelines are advisory, NOT mandatory
2. PRESCRIBING REGIMENS AND NOMOGRAMS

The administration of certain drugs, especially those given intravenously, requires great care if hazardous
errors are to be avoided. This section includes guidance on the Indications, Contraindications, Dosage and
Administration (including Preparation and Diluents) for all drugs in this category referred to in the Guidelines.
For some, there are Tables or Nomograms to assist dose selection or adjustment.
3. PRACTICAL PROCEDURES
This section includes advice on how to perform most forms of clinical intervention feasible at the bedside.
Drafted with reference to published recommendations, they have also been subject to wide consultation with
local experts and put to the test to check their reliability. The layout adopts a standard format, covering
Indications, Contraindications, Equipment, Procedure, Specimens, and Aftercare. The recommendations
should not be applied rigidly to every patient, and must be tempered by clinical judgement.
The illustrations in this section are reproduced with the permission of the BMJ Publishing Group.
DO NOT attempt to carry out any of these Practical procedures unless you have
been trained to do so and have demonstrated your competence
New guidelines and major changes

The following new guidelines have been included in the Elderly care section of this edition:
Management of falls in A&E and wards
Syncope
The following guideline has been included in the Practical procedures section:
Flushing intravenous lines
A Fluid flowchart has been included in the Fluids and Electrolytes section
Investigation of a pleural effusion guideline has been moved from Practical procedures section to
Respiratory section
The following major changes have been included in this edition:
Triage of chest pain guideline has been re-written and re-named Management of suspected cardiac
chest pain
Metabolism has been divided into two sections entitled Fluid and electrolytes and Endocrine
Isolated seizure guideline has been re-written and re-named First seizure
Preface 2010-11
The Oxygen therapy in acutely hypoxaemic patients guideline has undergone major revision to reflect
British Thoracic Society guidance and to ensure the guideline is the same in both this book and the
Surgical guidelines book
The Phenytoin guideline has been split into two guidelines:
- Adjustment of oral phenytoin dosage
- Intravenous phenytoin
The Gastric lavage guideline has been removed
Additions and revisions
The editors acknowledge the infinite time and trouble taken by numerous colleagues in the drafting and
amendment of the text. The accuracy of the detailed advice given has been subject to exhaustive checks.
However, any errors or omissions that become apparent should be brought to the attention of the Clinical
Guidelines Co-ordinator/Developer (Telephone 01782 555391or bedsideclinicalguidelines@uhns.nhs.uk), so
that these can be amended in the next review, or, if necessary, brought to the urgent attention of users.
Constructive comments or suggestions would also be welcome.
Supporting information
Where possible, the guidelines are based on evidence from published literature. It is intended that evidence
relating to statements made in the guidelines and its quality will be made explicit.
Where supporting evidence has been identified, it is graded I to V according to standard criteria of validity
and methodological quality as detailed in the table below. A summary of the evidence supporting each
statement is available, with the original sources referenced, on Trust intranet or by requesting an A4 printed
version from the Guidelines Co-ordinator/Developer (5391 or bedsideclinicalguidelines@uhns.nhs.uk). The
evidence summaries are being developed on a rolling programme, which will be updated as each guideline is
reviewed.
Level of
evidence
I
Strength of evidence
Strong evidence from at least one systematic review of multiple well-designed

randomised controlled trials
II
Strong evidence from at least one properly designed randomised controlled trial of
appropriate size
III
Evidence from well-designed trials without randomization, single group pre-post, cohort,
time series or matched case-control studies
IV
Evidence from well-designed non-experimental studies from more than one centre or
research group
V
Opinions of respected authorities, based on clinical evidence, descriptive studies or
reports of expert committees
JA Muir-Gray from Evidence Based Healthcare, Churchill Livingstone London 1997
Evaluating the evidence base of these guidelines involves continuous review of both new and existing
literature. The editors encourage you to challenge the evidence provided in this document. If you know of
evidence that contradicts, or additional evidence in support of, the advice given in these guidelines, please
forward it to the Clinical Guidelines Co-ordinator/Developer, Room 37, Prince Henry Building (Old Nurses
home), University Hospital of North Staffordshire, North Staffordshire Royal Infirmary, Princes Road
Stoke-on-Trent, ST4 7LN (Telephone 01782 555391 or bedsideclinicalguidelines@uhns.nhs.uk)
Evidence-based developments for which funding is being sought
As new treatments prove themselves more effective than existing ones, the onus falls upon those practising
evidence-based healthcare to adopt best practice. New treatments are usually more expensive than older
ones. Within the finite resources of the Trust and the NHS as a whole, the adoption of these treatments has
to be justified in terms of the improvements they will bring to the quality or cost-effectiveness of care. The
priorities for funding new areas of treatment and patient care will be determined at Trust level.
CIN 2010-11
PREVENTION OF CONTRAST-INDUCED
NEPHROTOXICITY
RECOGNITION AND ASSESSMENT
Contrast medium-induced nephropathy accounts for about 12% of all cases of hospitalacquired renal failure
defined as impairment in renal function occurring within 72 hr of giving contrast medium
characterised by increase in serum creatinine of 44 mol/L or 25% above baseline
Creatinine typically peaks 35 days after contrast administration and returns to baseline
within 2 weeks
Only one in 200 patients require renal replacement therapy
IMMEDIATE TREATMENT
There is no specific treatment management is supportive see Acute renal failure guideline
PREVENTION
Extremely important as contrast-medium induced nephrotoxicity associated with:

prolonged hospital stay
risk of permanent renal impairment (in up to 30% of patients who develop CIN)
a more than five-fold increase in mortality
Risk factors
Fixed (non-modifiable)
Pre-existing renal insufficiency
eGFR <60 mL/min increases risk significantly
Diabetes mellitus
Aged >75 yrs
Congestive cardiac failure [(New York heart association (NYHA)] Class 34 or ejection
fraction <49%)
Acute myocardial infarction
Cardiogenic shock
Renal transplantation
Cirrhosis
Myeloma
Modifiable risk factors
Volume of contrast medium used
Hypotension/volume depletion
Intra-aortic balloon pump
Anaemia and blood loss
Dehydration
ACE inhibitors
Diuretics
Nephrotoxic antibiotics
NSAIDs
PROPHYLAXIS
Requesting imaging
When requesting imaging procedures that may require use of intravenous (particularly
CIN 2010-11
intra-arterial) contrast media, indicate baseline serum creatinine or eGFR on the request if
patient acutely sick, notify imaging department if serum creatinine (eGFR) has changed since
the request was made
If eGFR <60 mL/min

Review need for use of contrast and suitability of alternative media in discussion with
radiologist and consultant in charge of patient
vascular imaging may be possible using CO 2 as alternative contrast medium
use of iso-osmolar contrast media and reduced volumes may reduce risk
Imaging with contrast essential
All patients
Ensure adequate oral intake in all patients
If patient nil by mouth or unable to drink adequately, give IV fluids before angiography
Review medication and, where clinically appropriate, omit potentially nephrotoxic drugs (see
Modifiable risk factors) on day of scan
Non- acute patients with eGFR <60 mL/min
Give sodium chloride 0.9% 1 mL/kg/hr IV for 24 hr, beginning 12 hr before administration of
contrast medium (may start 4 hr before scan if oral intake has been consistently adequate)
Give acetylcysteine 600 mg orally (dissolved in a glass of water) two separate doses
12 hr apart before contrast procedure and two further doses 12 hr apart following procedure
if patient unable to swallow or absorb, or is nil by mouth, give acetylcysteine 600 mg IV over
30 min in 100 mL glucose 5% two separate doses 12 hr apart before contrast procedure
and two further doses 12 hr apart following procedure and keep patient well hydrated i.e. may
require more fluid than just prophylaxis regimen
Acute patients with eGFR <60 mL/min
Where scan required urgently (within hours), give sodium bicarbonate 1.26% 3 mL/kg IV for
1 hr pre-contrast and 1 mL/kg IV for 6 hr post-contrast
Give acetylcysteine as soon as possible pre-contrast and continue for 4 doses total as above
Repeat exposure
If further exposure to contrast agents required, because of need for repeat/additional
procedure, and patient has no major risk factors, delay exposure for >48 hr if major risk
factors present, delay for >72 hr
MONITORING
Daily monitoring of renal function for 4872 hr after procedure
Aggressive patient 2010-11
AGGRESSIVE AND VIOLENT PATIENTS

PREVENTION
Very minor incidents can escalate into a violent situation. Communicate clearly to prevent
escalation
RECOGNITION
Warning signs of impending violence
Spontaneous self-reporting of angry or violent feelings or fluctuating levels of consciousness

with prominent persecutory ideas
Carers warn of imminent violence:
increased restlessness, bodily tension, pacing, arousal
increased volume of speech, erratic movements
facial expression tense and angry, discontented
refusal to communicate, withdrawal
unclear thought processes, poor concentration
delusions or hallucinations with violent content
audible threats, or aggressive gestures
recognition of signs apparent in earlier episodes

Context
Aggression or agitation can occur in:
Psychiatric illness
Physical illness
Substance abuse
Personality disorder
Confusional state irrespective of underlying cause
Patients who have received drugs affecting CNS
PERSONAL (OWN) BEHAVIOUR
Maintain adequate distance

Move towards safe place, avoid corners
Explain intentions to patient and others
Be calm, self-controlled, confident
Ensure own body language is non-threatening
Avoid sudden movements
SAFETY
Do not attempt to deal with a violent patient on your own

Keep other patients clear
Keep other staff clear but within helping distance
If possible, move patient to a quiet area
ASSESSMENT
Assessment must be by a fully registered doctor (SHO/F2 or above). PRHO/F1 doctors are
not qualified to assess mental capacity and must not attempt to do so. Inform senior
member of medical team (SpR or consultant).
If there are signs of impending violence, inform site manager who will identify any staff on
duty who have been trained in restraint techniques
Assess using verbal de-escalation

Engage in conversation, acknowledge concerns and feelings
Ask for reasons for disquiet, encourage reasoning
Ask for any weapon to be put down (not handed over)
If patient too disturbed for such measures, or fails to respond:
consider physical restraint by trained staff and/or police (see below)
History
Try to take a history from the patient and those who know the patient
ask whether this has happened before and how it was handled
ask about any regular psychotropic medication
Mental state examination
Do a mental state examination by noting:
general appearance and behaviour of patient
speech
attention and concentration
mood: subjective and objective
thought: evidence of loosening of association, irrelevant thoughts, delusions, thoughts of self
harm or harm to others
hallucinations
evidence of cognitive impairment
insight
Assess mental capacity
Be aware of Mental Capacity Act (2005)
Capacity assessment is task/decision specific. The legal definition of someone who cannot
make autonomous decisions is one who is unable to undertake at least one of the following:
understand information about proposed treatment, its purpose and why it is being proposed
retain that information long enough to be able to make a decision
use or weigh that information as part of decision-making process
communicate his/her decision by any means possible (e.g. talking, using sign language or
other means)
Where there is any doubt or disagreement whether patient has capacity, an application to
the court will be necessary. You must seek advice, in office hours MondayFriday, from
medico-legal department (1768) .
Physical examination
If safe to do so, gain patients consent and attempt a thorough physical examination,
looking for sources of infection and/or neurological deficits
if unsafe, document reasons and carry out examination once stable, or hand over to
subsequent team if transferring patient to another ward or specialty
Assess risk factors for violence
Young, male, history of violence
Alcohol or other substance misuse, irrespective of other diagnosis
Poor collaboration with suggested treatments
Antisocial, explosive or impulsive personality traits
Active symptoms of schizophrenia or mania, in particular with:
delusions or hallucinations focused on a particular person
delusions of control, particularly with a violent theme
specific preoccupation with violence
agitation, excitement, overt hostility or suspiciousness
IMMEDIATE TREATMENT
Principles
If acute mental illness (e.g. schizophrenia or hypomania) suspected, refer to on-call
psychiatry team
If patient elderly with acute confusion, see Acute confusional state (delirium) in older
people guideline
If patient has symptoms and signs of alcohol withdrawal, see Alcohol withdrawal guideline
If patient intoxicated, but fit to be arrested and taken into custody, request police assistance
(if urgent, dial 9999; if non-urgent, dial 08453 302010)
If none of the above applies, options available depend on patients mental capacity
Capable of making decisions
Hold patient accountable for his/her actions
Manage underlying cause of agitation
Do not administer medication without patients consent
Patient lacks capacity
Always ensure that any intervention used is the least harmful or restrictive of patients
basic rights and freedom, immediately necessary, reasonable, and in their best interest
Conduct multidisciplinary discussion to decide whether rapid sedation is safe and appropriate
Take all necessary means to prevent injury to self, other staff or patients, or damage to
property
consider use of physical restraint and/or medication see below
Manage underlying cause of agitation
PHYSICAL RESTRAINT
Physical restraint is the last resort. Once staff attempt to restrain a patient, a threatening situation
will turn violent. The doctor should not attempt to physically restrain the individual, but should
request assistance from any staff on duty trained in physical restraint techniques and who have
completed the MAPA (Management of actual or potential aggression) course and update
Under the Mental Capacity Act for a person lacking capacity, the person taking action must
reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity
When patients are restrained, it is done under common law to maintain the safety of patient,
staff and other patients
Use restraint only if there are sufficient staff to achieve this effectively and you perceive
imminent danger because patient is:
displaying prolonged and serious verbal abuse, threatening staff, or disrupting ward
threatening or attempting self-injury
at risk of prolonged over-activity with risk of exhaustion
at risk of serious accident to self and others
attempting to abscond if detained under Section and in an open ward
Do not under any circumstance inflict deliberate pain
Avoid restraining a patient in the prone position (face-down). If there is no other way, do not
restrain patient in that position for more than three minutes
If no suitably trained staff available, or patient is making significant physical attacks or serious
efforts to destroy property, leave the scene immediately and request police assistance (dial
9999 and say clearly 'I am in fear for my safety')
The police will always respond to a call for assistance, but are not allowed to
assist in restraining patients for treatment
MEDICATION
If new brain damage suspected, avoid medication until after CT scan. Check prescription
chart for previously prescribed drugs. Use medication sparingly in the elderly
In cases of substance misuse, treat any symptoms suggestive of withdrawal see

Withdrawal of drug(s) of dependence guideline
Try to persuade patient to accept oral medication
if this is not possible, use parenteral route
Recommended medication options are:
lorazepam (prefer as first choice) 1 mg orally/IM repeated 6-hrly if necessary adult
maximum dose 4 mg in 24 hr (elderly 0.51 mg; maximum 2 mg in 24 hr)
If no response 1 hr after lorazepam, and patient is known not to have either epilepsy or
ischaemic heart disease, give haloperidol
haloperidol 5 mg orally/IM repeated once (orally after 4 hr; IM after 6 hr) if necessary (elderly
0.51.5 mg once or twice daily orally/IM)
Observe physical and mental state carefully following sedation
If haloperidol causes acute extrapyramidal effects, treat with procyclidine 5 mg IM
If no response to two forms of medication, seek advice from on-call psychiatry team
SUBSEQUENT MANAGEMENT
Monitor vital signs

Record BP, pulse, respiratory rate, hydration and level of consciousness as agreed by
multidisciplinary team until fully conscious
Record further care plan
Documentation
Record incident clearly and fully afterwards
Complete an Adverse Incident Report form with witness statements
Once stable
Continue close observation as inpatient for at least 24 hr
Reassess mental state and review patients status under Mental Health Act
Continue management of underlying condition
When transferring patient between units, send details of:
incident
medication management
subsequent management plan
any unwanted effects
any advance directives
Pregnant woman 2010-11
MANAGEMENT OF A PREGNANT WOMAN WITH A

NON-OBSTETRIC PROBLEM
INTRODUCTION
Assessment and management of disease unrelated to the pregnancy are altered by the
pregnancy
The need to consider two patients (mother plus fetus) may change treatment decisions
Anatomical and physiological changes in pregnancy result in altered:

clinical features during CVS and RS and abdominal examination
biochemical and haematological values
pharmacological management
response to any systemic pathology
protocols for the management of critical illness
ACTIONS
Nursing
Patients in the second and third trimester must be nursed on a left lateral tilt (never supine) to
prevent aortocaval compression
Contact
If any pregnant woman is seen outside the maternity service you must contact:
senior SpR on call for obstetrics who will then contact the consultant obstetrician on-call
if she is critically ill, or likely to need urgent surgery refer early to the critical care team and/or
anaesthetist
if her gestation is 16 weeks, also contact labour ward co-ordinator
By giving consideration to the pregnancy and the fetus, the maternity service providers can
help with:
assessment of fetal well-being
investigations
treatment
Radiological investigations are not contraindicated during pregnancy
where there is a significant clinical indication. Discuss with obstetric team
Nutrition 2010-11
PRACTICE AND ETHICS OF

NUTRITIONAL SUPPORT IN MEDICAL PATIENTS
(ADULTS)
ASSESSMENT
Nursing staff must assess all patients nutritionally on admission and refer those at risk to a
dietitian. Nutritional status must be regularly reviewed, especially during a prolonged in-patient
stay. Details of assessment are in the nursing admission forms
Consider each patient on their own merits

Provision of food and water by mouth is basic care and is mandatory
Some patients wish to eat but are unable to because of difficulty chewing, poor appetite,
apathy and depression, or weakness. Encourage and assist them to eat by offering them
appetising food of the correct consistency in an appropriate way
People at the end of their lives often eat little. Accept this natural phenomenon
NUTRITIONAL OPTIONS
Oral supplements for patients unable/unwilling to eat sufficiently
Obtain advice from ward dietitian
Review patient regularly as individual requirements will vary with the changing clinical
situation
Tube feeding nasogastric (NG) tube for short-term or percutaneous endoscopic
gastrostomy (PEG) for long-term
If patient not eating sufficiently, consider tube feeding
In end-stage dementia (e.g. when patient fully dependent for all activities of daily living),
there is no evidence that artificial tube feeding is of benefit. If patient fails a swallowing
assessment, consider a two-week trial of NG tube feeding
If no benefit likely from tube/PEG feeding, consider a trial of comfort feeding offering
appropriate food of the correct consistency (discuss with speech and language therapist and
dietitian) even though the patient has failed a swallowing assessment
Tube feeding is a medical intervention and requires consent
PEG feeding does not prevent aspiration pneumonia
For an incompetent adult use a two-doctor consent form 4 signed by two senior
doctors, one of whom must be a gastroenterologist, the other normally being the
consultant or GP looking after patient.
Best practice suggests that any family or next-of-kin should countersign section D to
confirm they have been involved/informed of decision
Refer to ward dietitian and/or nutrition team

Send all PEG referrals to the nutrition team (nutrition nurse specialist)
Post-PEG care is detailed in guidelines held on every ward and on Trust intranet
Patients must not be discharged unless they or their carers are competent in tube care
Indications for PEG insertion
Dysphagia
neurological (e.g. stroke)
mechanical (e.g. oesophageal cancer)
To supplement inadequate intake where alternative measures have failed:
cystic fibrosis
reluctance to eat this is only rarely an indication for artificial nutritional support. If in doubt,
contact nutrition team
Nutrition 2010-11
Contraindications to PEG insertion
Absolute
imminent demise
ascites
oesophageal or gastric varices
advanced dementia
Relative
gastric carcinoma
gastric ulceration
previous gastric surgery each patient will be assessed individually
physical deformity (e.g. severe kyphoscoliosis)
clotting disorder/anticoagulation therapy (ensure INR <1.5)
severe behavioural problems each patient will be assessed individually
Intravenous feeding
Patients are likely to benefit from total parenteral nutrition (TPN) only if this is needed for at least
7-10 days, as the risks of shorter term feeding outweigh the benefits
Send all referrals to nutrition team who will assess and, where appropriate, take over
nutritional care of patient for the duration of feeding
Indications
Non-functioning gastrointestinal tract (ileus, obstruction)
High gut fistulae
Chylous leaks
Monitoring
Further details on requirements, monitoring and complications are in guidelines held on all
wards and Trust intranet
WITHDRAWING NUTRITION
A professional carer has a duty to prolong life, but not inappropriately to prolong dying
In ethical and legal terms, there is no difference between withdrawing and withholding
artificial nutritional support
Withhold tube feeding if it is futile (e.g. advanced cancer, end-stage dementia) but consider
each patient on their own merits
Withdraw tube feeding if, after a trial of feeding (e.g. nasogastric tube after CVA), there is no
recovery and little or no likelihood of recovery or meaningful quality of life. This is an
acceptable practice if the decision is taken in the patients best interests
Where a decision to withhold/withdraw nutritional support has been made, stop artificial
hydration a death from malnutrition takes a lot longer than one from dehydration
If the patients capacity (competence) to consent and their best interests are clear and
beyond doubt, current UK law does not require court approval for withholding or withdrawing
nutritional support except in all cases of the persistent vegetative state
ETHICS AND CONSENT

Make sure you document the decision-making process at the time it happens, in detail
Consent must be obtained for any nutritional intervention or withdrawal. Read the Consent
guideline carefully and follow the steps contained therein
Admin of blood 2010-11
ADMINISTRATION OF BLOOD AND BLOOD

COMPONENTS FOR ADULTS
For further information refer to Trust Policy . For advice contact blood transfusion nurse
Most incompatible blood transfusions result from administrative and clerical errors
ASSESSMENT
Decision to transfuse is taken by a doctor or, after relevant training, a nurse prescriber, who should:
clinically assess patient and write in their notes a clear rationale for transfusion
explain to patient the reason for transfusion and obtain agreement to transfuse
record this in patients notes
give patient a copy of Receiving a blood transfusion patient information leaflet (available from blood
transfusion laboratory or blood transfusion nurse)
Jehovah's witnesses: Transfusion without consent is a gross physical violation. Discuss

consequences of not transfusing. Record discussion in medical notes signed by patient and doctor.
For further advice, contact Jehovahs witness liaison officer or patient visitation co-ordinator
No blood logo wristbands are available from specimen reception or blood bank
PRESCRIPTION
Check patient identification details these must include:

surname
first name
date of birth
NHS number and local hospital number
When no patient name is available, use patients A&E or EPR number and gender as a unique identifier
Prescribe in IV infusion section of prescription chart:
type of blood product to be administered, including any special requirements (e.g. irradiated)
quantity
date of administration
duration of transfusion usually 23 hr for red cells and 30 min for a unit of platelets or FFP
Record any required pre-medication, such as:
hydrocortisone and chlorphenamine in patients with a history of previous reaction
furosemide in patients with CCF
REQUESTING BLOOD PRODUCTS

Blood transfusion request form
Doctor/registered practitioner must complete request form legibly and sign if they have obtained blood
sample
if different person takes sample they must ensure doctor/registered practitioner has completed and
signed request form before putting sample with request form. They must then sign in relevant section
themselves
doctor/registered practitioner must sign request form to say that they have requested crossmatch/group
and save
When no patient name is available, use patients A&E or EPR number and gender as a unique identifier

Telephone
Doctor/registered practitioner must telephone blood transfusion laboratory when:
ordering red cells by converting a group and save into a crossmatch (serum is saved for seven days)
ordering blood components blood bank will automatically defrost frozen blood products before they
are dispatched to ward/department areas
dispatching urgent specimens for crossmatching
BLOOD SAMPLING
Each patients identification wristband must display their:

surname
first name
NHS number
local hospital number
date of birth
gender
Positively identify patients by:
checking that patient identification details on wristband match those on request form
asking them to state surname, first name and date of birth, if capable
Take blood:
9 mL into purple (EDTA) tube (pink clotted tube no longer necessary)
Take blood from only one patient at a time
Do not pre-label sample tubes
Do not use addressograph stickers for sample labelling

Label tubes by hand at patients bedside once blood has been drawn, with a minimum of surname, first
name, NHS number, date of birth and gender (obtained from patients ID wristband), and signature of
person completing label
When labelling sample tubes, REFER ONLY to patients ID wristband
DO NOT USE patients medical record or any other reference source for this information
Send samples to blood transfusion laboratory

allow 90 min for full crossmatch
in event of extreme emergency O Rh D negative flying squad units are available at A&E, Maternity
and CGH blood bank. Group-specific blood may also be requested
Unconscious patients
When identifying unconscious patients, be especially careful to use both notes and wristband
After major trauma, or where an unconscious A&E patient requires transfusion, minimal acceptable
labelling as a unique identifier will comprise:
local hospital number
EPR number or major incident number
gender
Send new request labels with patients full identification details to blood transfusion laboratory as soon
as possible once these details are known
STORAGE
Store red cells in designated blood refrigerators do not leave out for >30 min
Do NOT refrigerate platelets
Blood components are dispatched directly to ward/theatre for immediate use
Transport all blood products in validated transfer boxes available from blood bank
Never store blood/blood products in a non-designated refrigerator
RECEIPT
The units are received by a doctor/registered practitioner who:

checks correct blood has been delivered
records date/time received and signs against delivered units on compatibility report form (pink slip)
ADMINISTRATION
Only doctors/registered practitioners may administer units of blood. Student nurses and trainee ODP
may assist in checking and administration of blood and blood components provided their practice is
supervised and all signatures are countersigned
perfusionists may connect units of blood as instructed by anaesthetist who will take overall
responsibility for checking and administration of blood
Bedside checks
Two members of staff (each of whom must be a doctor/registered practitioner) must check patients
identification and unit of blood at patients bedside according to Trust Policy
do not involve healthcare support worker (HCSW) in checking process
Check that identification details on patients wristband, medical notes, prescription chart, and
compatibility label attached to unit of blood all match. In accordance with NPSA Safer Practice notice,
do not use compatibility report form (pink slip) as a means of checking identification
ask conscious patients to state their surname, first name and date of birth
When no name is available, use patients A&E/EPR number and gender as a unique identifier
Remember that consecutive patients admitted through A&E or SAU will have EPR numbers that
differ by only one digit
check that product pack number and blood group match those on compatibility label attached to unit of
blood
if any discrepancies found, do not transfuse
check expiry date on unit
check unit for evidence of leaks, unusual discolouration or presence of clots
Transfuse units as soon as possible
Transfusion of red cells must start within 30 min of removal from refrigerator and be completed
within a maximum of 4 hr
Procedure
To be carried out only by doctor/registered practitioner
Patient
Explain procedure and advise patient to report:
fever
itching/rashes
shortness of breath
general malaise
As a minimum, record temperature, pulse and BP within final 60 min before connecting unit
Start infusion
Check cannula size is appropriate for size of vein and rate of infusion
Check giving set
administer red cells and blood components through dedicated, sterile giving set
Give any prescribed pre-medication
Flush dedicated cannula with sodium chloride 0.9%
Set up giving set and start transfusion
Record
Record date/time of commencement of each unit of blood/blood component on prescription
Check details on return slip issued with each unit of blood/blood component
complete date and time of transfusion

print name, sign and send return slip to blood bank via internal post system
Record stop date/time of each unit of blood/blood component on prescription and compatibility report
form (pink slip)
Change of unit
At each change of unit, repeat bedside checks
Change giving set after 12 hr or 3 units of blood, whichever occurs first
ensure transfusion of each unit is completed within 4 hr of removal from blood fridge
Transfusion reaction
See Table 1
MONITORING
During transfusion:
Record temperature, pulse and BP before and 15 min after starting each NEW unit, and when each unit
has finished
If patient alert, orientated and capable of informing staff of transfusion reactions, observe throughout
infusion of remainder of unit with a final recording of temperature, pulse and BP at end of unit
If patient unconscious or unable to communicate, becomes unwell or develops reaction (see Adverse
reactions), in addition to three sets of minimum observations, record hrly observations throughout
transfusion
Maintain a fluid balance chart
Monitor access site
Watch for any change in patients condition
DOCUMENTATION
Ensure permanent record of transfusion is kept in medical notes

Documentation must include:
completed compatibility report form (pink slip) with signature of receiving practitioner and date and time
received
complete prescription sheet with start and stop date/time of transfusion of each unit and signature of
doctor/registered practitioner who administered/checked unit
nursing observations
indications for transfusion and outcome
Record final fate of product by completing traceability return slip (pale blue shaded form attached to
compatibility label) with name of doctor/registered practitioner who administered/checked unit, whether
unit was transfused or wasted, and date/time of administration
Detach return slip along perforation and return to transfusion laboratory who will update laboratory
computer system
later in 2010, ward/theatre areas will confirm final fate of unit electronically and paper based return slip
system will be used as backup in the event of computer downtime
ADVERSE REACTIONS
Acute and delayed complications can occur (see Tables 1 and 2)

If temperature <1.5C above normal, prescribe and administer paracetamol 1 g orally and reduce
transfusion rate to a unit of blood over 4 hr
recheck temperature after 1 hr
if temperature has fallen, continue transfusion at original rate; if not, inform doctor
Signs of severe reaction include:
pyrexia >1.5C above normal
hypotension
tachycardia
headache of sudden onset
rash
swelling and pain at access site
bleeding
pain in abdomen, loin or chest

feeling of agitation or undue apprehension
shivering
sweating
dyspnoea
Immediate management of severe reaction

If severe reaction or septic shock suspected, follow instructions in Table 1
Table 1: Acute complications of transfusion
Complication
Presentation
Management
Severe reactions
Acute intravascular haemolysis of
transfused red cells caused by
ABO incompatibility often
caused by clinical or
administrative errors
Warmth along the vein

Flushing
Pain in lumbar area
and chest
Fever
Hypotension
Acute shock
Disseminated
intravascular
coagulation and renal
failure can develop
Septic shock
Severe shock
Subnormal
temperature, later
pyrexia
Stop infusion immediately and replace giving

set
Inform doctor and blood transfusion
laboratory
Check patient identity and blood unit for
compatibility
Check temperature, pulse, BP and
respiratory rate
Maintain systolic BP >100 mmHg and urine
flow >100 mL/hr without overloading:
sodium chloride 0.9% 1 L IV over 4-6 hr
(review rate of infusion every 30-60 min)
furosemide 20-80 mg IV
continue fluids and diuretics
Transfuse compatible red cells
Contact on-call consultant haematologist
Alert renal and ITU outreach teams
Return all used blood products together with
details of the reaction, and a post-transfusion
group and save request taken from vein in
arm opposite to that of access site
Complete an Adverse Incident Report
set
laboratory
respiratory rate
Refer to Sepsis, severe sepsis and septic
shock guideline
Contact on-call consultant microbiologist
Send blood cultures (see Collection of
blood culture specimens guideline)
Anaphylaxis
Mild pyrexia with rash

Peri-orbital and/or
laryngeal oedema with
dyspnoea
Hypotension
Bronchospasm
Vomiting
Pain in abdomen or
chest
Transfusion-related acute lung

injury (TRALI)
Rapid onset of
breathlessness
Raised pulmonary
wedge pressure (if
Swan-Ganz catheter in
situ)

set
Start sodium chloride 0.9% 46 hrly, rate of
infusion to depend on urine output and
systolic blood pressure aim to maintain
urine output >100 mL and systolic blood
pressure >100 mmHg
laboratory
respiratory rate
Give:
adrenaline/epinephrine 500 microgram IM
(0.5 mL of 1:1000 solution)
chlorphenamine 1020 mg slowly IV (over
1 min)
hydrocortisone 100 mg IV
if bronchospasm apparent, salbutamol 5 mg
via a nebulizer
set
laboratory
respiratory rate
Administer high concentration O 2 see
Oxygen therapy in acutely hypoxaemic
medical patients guideline
Treat as for acute respiratory distress
syndrome
Alert ITU outreach team
Mechanical ventilatory support may be
urgently needed
Mild reactions
Urticaria
Intense itching
Urticarial hives
Febrile non-haemolytic reactions
Chill
Fever
Hypotension
Inform doctor
Slow down transfusion rate
Give:
chlorphenamine 20 mg slowly IV (over
1 min)/IM
(if febrile), paracetamol 1 g orally
Inform doctor
respiratory rate
Slow down transfusion rate to a unit over 4 hr
Give paracetamol 1 g 6 hrly orally/rectally
(maximum 4 g in 24 hr)
Table 2: Delayed complications of transfusion

Complication
Presentation
Delayed haemolysis of transfused Fever
red cells
Haemoglobinaemia or
symptoms that resemble
serum sickness
Post-transfusion purpura
Severe
thrombocytopenia, often
causing bleeding
Post-transfusion viral infection
Systemic infection
including: fever, malaise,
flushing, headache
Iron overload (patients on long Iron deposits in liver,
term transfusion only)
heart and endocrine
organs causing failure of
the organs
Transfusion-associated graft vs
Fever, rash, nausea,
host disease
vomiting, diarrhoea, liver
changes
Management
No specific treatment antibodies will be a
problem for further transfusions, contact
consultant haematologist
Contact consultant haematologist urgently
Contact consultant microbiologist
Contact consultant haematologist
Contact consultant haematologist
MEWS 2010-11
MODIFIED EARLY WARNING SCORING (MEWS)

SYSTEM FOR PATIENT MONITORING
INTRODUCTION
Modified early warning scoring (MEWS) is a nursing track and trigger protocol that
monitors vital observations to detect subtle changes in patient physiology see Nursing
guidelines
Score will trigger responses in accordance with escalation strategy
Nurse will complete a full set of patient observations and record on MEWS chart
MEWS SCORING
Respiration counted over 1 full minute

Temperature
Pulse
Blood pressure
Oxygen saturation
AVPU score (Alert, Verbal, Pain, Unresponsive)
Urine output
if urine output unknown, score 0. If not catheterised, ask patient if they have passed urine
recently
if urine output not documented or unknown, commence a strict intake and output chart
ALERTING MEDICAL STAFF
Any progress/sudden change will prompt nurse to escalate a patient with increased
MEWS score at risk of sudden deterioration and cardiac arrest
Verification 2010-11
VERIFICATION OF DEATH
PROCEDURE
Assess patients condition against following criteria:

no heart beat heard over a full minute
no brachial or carotid pulse felt over a full minute
no breath sounds heard and no chest movement seen over a full minute
pupils fixed and dilated
corneal reflex absent
Information to be recorded in patients medical notes

Date and time of examination of body
Entry stating that:
no heart beat heard over a full minute
no brachial or carotid pulse felt over a full minute
no breath sounds heard and no chest movement seen over a full minute
pupils fixed and dilated
corneal reflex absent
Patient verified as dead
Signature, name and designation of verifier
LEGAL ISSUES
A doctor who has attended a deceased person during their last illness is required to issue a
medical certificate stating cause of death to the best of his/her knowledge and belief
To issue a certificate, doctor is not obliged to view the body but good practice requires that, if
they have any doubt about fact of death, they should satisfy themselves in this way
As the doctor is not obliged in law to see the body in order to issue a certificate, appropriately
trained nurses may expand their role into verification of expected death
It is the hospital doctors responsibility to:
inform coroner where necessary
issue death certificate
inform deceaseds GP
The Coroner
When registering the death at the genral office (1105, 1107), ask if coroner must be informed.
The registrar is regularly updated with coroners requirements
Circumstances of death about which coroner must be informed include:
sudden death (within 24 hr of admission to hospital)
all deaths in those aged <17 yr
patients in whom diagnosis uncertain
cause of death that cannot readily be certified as natural causes
unusual or disturbing features
deceased either not attended by a doctor during last illness or not seen within last 14 days
death caused by accident (fall, road traffic collision, incident at work or home)
self-neglect or neglect by others
self harm
suicide
death unnatural/suspicious/resulting from violence
patients in custody (even if due to natural causes)
patients detained under Mental Health Act
patients with industrial diseases, even if these did not cause death
Verification 2010-11
pneumoconiosis/chronic bronchitis and emphysema/pulmonary fibrosis (including farmers

lung)/mesothelioma/asbestosis. Give smoking history
death caused or exacerbated by medicines [e.g. GI bleeds (associated with warfarin, aspirin,
NSAIDs etc)] or pseudomembranous colitis (following antibiotics)
death attributable to chemotherapy, immunosuppressive drugs, corticosteroids, etc
major and minor surgery in last 12 months
death during procedure or operation/before recovery from anaesthetic
fractured limbs in last 12 months
cerebral haemorrhage, unless certifying doctor satisfied that haemorrhage did not follow
trauma (e.g. CVA, CVD). If bleed caused or exacerbated by drugs (e.g. warfarin, heparin)
report death
bladder cancer if born before 1935 (especially if suggested link with Michelin factory) or
where dye works implicated
carcinomatosis unknown primary
terms such as 'failure' (e.g. cardiac failure, respiratory failure, renal failure), 'obstruction',
'sepsis' and 'peritonitis', where not adequately qualified with underlying aetiology to indicate
cause of death
The coroner must be contacted to discuss any case where there is any doubt regarding
any of the above circumstances
All staff are advised to read Guidance for doctors certifying cause of death from the
Office for National Statistics Death Certification Advisory Group, April 2005
www.gro.gov.uk/medcert
A copy of Reportable deaths a guide can be obtained from the Coroner (01925442483)
Anaphylaxis 2010-11
ACUTE ANAPHYLAXIS
Anaphylaxis is a severe systemic allergic reaction. Consider whenever there has been a
rapid onset of respiratory difficulty and/or hypotension, especially if skin changes and
angioedema present
Symptoms and signs
General:
feeling of impending doom
hypotension and/or collapse
feeling faint, light-headedness, loss of consciousness
confusion
reduced capillary refill (>2 sec)
flushing
palpitations
nausea, vomiting, abdominal pain and/or diarrhoea
Upper airways obstruction:

swelling of lips, face, neck and/or tongue
difficulty breathing, speaking and/or swallowing, sneezing
hoarseness and/or stridor
Lower airways obstruction:

retrosternal tightness
dyspnoea
wheeze
signs of respiratory failure
Skin and mucosa:

erythema and/or urticaria
itching
angioedema
rhinitis and/or conjunctivitis
Investigations
Mast cell tryptase sample serum (7 mL red top bottle) at following times and send to
immunology:
immediately after reaction
at 13 hr when concentration peaks
between 624 hrs following exposure (provides a baseline concentration)
Patient may present late. Take as many serum samples as time since presentation allows
Although mast cell tryptase test is not listed on immunology card, it can be added
indicate time and date clearly to allow interpretation of results
Differential diagnosis
Syncope (rapid recovery) with bradycardia in vagal reaction
Acute cardiac event
Panic attack with hyperventilation (unlikely to be hypotensive)
Acute severe asthma
Other causes of central airways obstruction
Acute abdominal or cardiac emergency
IMMEDIATE TREATMENT
Lay patient flat and elevate feet to restore/maintain BP Do not stand patient up
if respiratory difficulty dominant, sit patient up
Anaphylaxis 2010-11
O 2 at high flow rate (1015 L/min) if no contraindication see Oxygen therapy in

acutely hypoxaemic medical patients guideline
CPR if required (see CPR life support procedure guideline)
Establish IV access
If concerned about patients respiratory effort/airway obstruction, contact anaesthetist
consider tracheotomy
For hypotension or respiratory distress with stridor or wheezing, give adrenaline
(epinephrine) 500 microgram (0.5 mL of 1:1000 solution) IM into midpoint of anterolateral
aspect of thigh
If hypotension and respiratory distress do not respond within 5 min:
give further dose of adrenaline (epinephrine) 500 microgram IM (0.5 mL of 1:1000
solution). Can be repeated at 5 min intervals according to BP, heart rate and respiratory
function
Chlorphenamine 10 mg by IM or slow IV injection
if there is bronchospasm, give salbutamol 5 mg via O 2 driven nebuliser
for further treatment of bronchospasm, see Acute severe asthma in adults guideline
If patient has been taking a non-cardioselective beta-blocker [e.g. propranolol, oxprenolol,
sotalol, timolol (including eye drops)], severity of anaphylaxis may be increased and
response to adrenaline (epinephrine) antagonised. Consider giving salbutamol
by slow IV injection see Salbutamol guideline
If severe hypotension persists:
give sodium chloride 0.9% or compound sodium lactate (Hartmanns) solution 12 L by
rapid IV infusion
Hydrocortisone 200 mg by slow IV or IM injection
Severely ill patient

When patient severely ill and there is real doubt about adequacy of circulation and
absorption after IM injection, call critical care staff to attend urgently
transfer ASAP to critical care
Further treatment under critical care supervision
Consider giving adrenaline (epinephrine) 50 microgram (0.5 mL of the dilute 1 in 10,000
adrenaline injection) by slow IV injection, no faster than 1 mL/min while monitoring
cardiac rhythm. Repeat according to response
if multiple doses required, give adrenaline (epinephrine) as slow IV infusion, stopping
when response obtained
If patient has been taking a tricyclic antidepressant or an MAO inhibitor, dose of
adrenaline (epinephrine) should not exceed 200 microgram (2 mL of 1:10,000 solution) by
slow IV injection, no faster than 1 mL/min while monitoring cardiac rhythm
IV adrenaline (epinephrine) is hazardous, use only with extreme care for those in
profound shock that is immediately life-threatening
MONITORING
Monitor continuously all patients experiencing severe anaphylaxis until condition stabilised
and then every 15 min for 1 hr. Until completely stable, continue to record hrly:
Heart rate
Blood pressure
Respiratory rate
If possible, peak expiratory flow (PEF)
SpO 2
Take detailed clinical history to identify possible allergens e.g. drugs, foods (within
previous hr), insect stings, latex
Prednisolone 30 mg orally daily until all allergic symptoms have subsided completely
Anaphylaxis 2010-11
Chlorphenamine 4 mg orally 6 hrly (for at least 2472 hr to prevent relapse) until all
allergic symptoms have subsided completely
Warn patient of possible early recurrence and keep under observation for 824 hr.
Likelihood of early recurrence increased in patients:
with slow-onset severe reaction resulting from idiopathic anaphylaxis
with severe asthma
at risk of continued absorption of allergen
with previous history of biphasic reactions
Consider prolonged observation for patients who:
developed symptoms during night, who may not be able to respond to any deterioration in
clinical condition
live in areas where access to emergency care difficult
DISCHARGE AND FOLLOW-UP
All patients must be reviewed by a senior clinician before discharge and given clear
instructions to return to hospital if symptoms return
Advise avoidance of allergen if appropriate and management plan to include use of antihistamines for any allergic symptoms and epipen and 999 call for life-threatening
symptoms of dyspnoea or faintness
Prescribe two auto-injector devices containing adrenaline (epinephrine) 300 microgram.
Instruct patient on when and how to use
Grasp EpiPen in dominant hand, with thumb closest to grey
safety cap
With other hand, pull off grey safety cap (Fig. 1)
Hold EpiPen approximately 10 cm away from outer thigh
Black tip should point towards outer thigh (Fig. 2)
Jab firmly into outer thigh, through clothing if necessary
Hold in place for 10 seconds (Fig. 3)
Give patient phone number for SOS Talisman (0141 639 7090) or MedicAlert
(0800 581420) to organise a bracelet with information for those in attendance. Further
information can be found at www.medical-bracelets.co.uk or www.medicalert.org.uk
Give patient contact details of Anaphylaxis Campaign, 1 Alexandra Road, Farnborough,
Hampshire GU14 6BU (01252 546100)
CPR 2010-11
CARDIOPULMONARY RESUSCITATION LIFE SUPPORT

PROCEDURE
PROCEDURE FOR IN-HOSPITAL RESUSCITATION
This algorithm is an aide-memoire for hospital personnel trained in Advanced Life Support (ALS). For full review of ALS see
www.resus.org.uk
Algorithm
Note that each successive step is based on the assumption that the one before has been unsuccessful
Collapsed/sick patient
Shout for HELP and assess patient
Signs of life?
YES
Assess ABCDE
Recognise and treat life-threatening
problems
Oxygen, monitoring,
IV access
NO
Call resuscitation team
If appropriate, call for resuscitation

team or senior medical support
CPR 30:2
with oxygen and airway adjuncts
Apply pads/monitor
Handover to resuscitation team or

senior medical support
Assess rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA**/asystole)
Check pulse
if required
ROSC*
1 shock
150-360 J biphasic
or 360 J monophasic
Immediately resume
CPR 30:2
for 2 min
During CPR:
Correct reversible
causes
Check electrode position
and contact
Attempt/verify:
IV access
airway and oxygen
Give uninterrupted
compressions when
airway secure
Give adrenaline
(epinephrine) every
3-5 min
Consider amiodarone,
atropine, magnesium
Go to Postarrest
management
Immediately resume
CPR 30:2
for 2 min
Reversible Causes
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia/
metabolic
Hypothermia
Tension pneumothorax
Toxins
Thrombosis (coronary or
pulmonary
* Return of spontaneous circulation

** Pulseless electrical activity
CPR 2010-11
POST-ARREST MANAGEMENT
Immediate goals of post-resuscitation care are to:

provide cardiorespiratory support to optimise tissue perfusion, especially to brain
transport patient to appropriately equipped critical care unit
attempt to identify precipitating causes of arrest
institute measures to prevent recurrence (e.g. anti-arrhythmic therapy) see Cardiac
arrhythmias in Medical guidelines
Establish cause of cardiac arrest and treat underlying diagnosis if in doubt, seek advice
from on-call medical registrar
Patients with ventricular tachycardia or ventricular flutter/fibrillation, occurring >48 hr after

acute myocardial infarction or with no obvious reversible factors, should be considered for
implantation of an ICD (implantable cardioverter defibrillator). Seek advice of cardiology team
IMMEDIATE POST-ARREST INVESTIGATION
Blood gases
U&E, glucose
Chest X-ray
Cardiac enzymes
Diagnostic ECG
Dependent upon underlying cause
CPR clinical justification 2010-11
CARDIOPULMONARY RESUSCITATION
CLINICAL JUSTIFICATION
Unless an emergency, discuss DNAR status with patient, if mentally competent and/or
family and carers before documenting in the notes.
If an emergency, document but discuss with them as soon as possible.
Document clearly see below for format
Cardiopulmonary resuscitation (CPR) is mandatory when any person suffers a cardiorespiratory
arrest unless there is a valid Do not attempt resuscitation order written in patients notes
DO NOT ATTEMPT RESUSCITATION
Do not attempt resuscitation (DNAR) applies solely to CPR

It does not affect any other aspect of treatment
Clinical justification
A DNAR order is in the best interests of the patient if one or more of the following applies:
patient is irreversibly close to death in the short term
resuscitation presents an unacceptably high probability of death or severe brain damage
even if procedure is successful
length and quality of life after resuscitation are unlikely to be valued by patient
patient, who is mentally competent and suffering from a terminal illness, has expressed
consistent desire not to be resuscitated
ETHICS AND CONSENT

Consent must be given for a DNAR order.
Make sure you document the decision-making process at the time it happens, in detail
Read the Consent guideline carefully and follow the steps therein
DOCUMENTATION
Once decision not to attempt resuscitation has been made, most senior doctor present
must write in the medical notes:
date and time
'In the event of cardiopulmonary arrest, (name of patient) is not for cardiopulmonary
resuscitation because of (clinical justification from list on first page of this guideline). This has
been discussed with (appropriate persons) with their views'
record patients documented consent if applicable
sign entry and write name and post in capitals
complete the red Trust DNAR form and place at front of medical notes
Once decision not to attempt resuscitation has been made, the qualified nurse caring for the
patient must:
write not for cardiopulmonary resuscitation prominently in nursing notes
sign entry and write name and post in capitals
It is the duty of this nurse to ensure the ward team are informed of the DNAR decision
Red Trust DNAR form is not part of the medical record
You must also document the DNAR order in the medical and nursing notes
REVIEW
If patients clinical condition changes, review DNAR order

Procedure for review is same as for original order
CPR clinical justification 2010-11
If DNAR order is cancelled, and when the patient is discharged from hospital, the Do Not
Attempt Resuscitation form should be crossed through with 2 diagonal lines in black ballpoint
ink and CANCELLED written clearly between them. The date, name and signature of the
healthcare professional cancelling the order must also be clearly documented. The form
should then be removed from the front of the patients medical records and filed
chronologically with the appropriate medical notes. If the patient remains in hospital it is vital
that the nursing staff are informed of this decision immediately and details are clearly
recorded in the medical records
DISCHARGE
The DNAR decision is only valid during the patients current in-patient admission and is
automatically revoked on discharge from hospital. Follow the procedure stated above to
cancel the decision on discharge
Hand hygiene 2010-11
HAND HYGIENE
Good hand hygiene is the most effective way to prevent spread of infection
Use this safe method of working at all times to protect staff, patients and others from
infection.
All practitioners are personally accountable for their hand hygiene practices
Infection Control Policy Good Practices
ASSESSMENT OF NEED TO DECONTAMINATE HANDS

Decontaminate hands before initiating a care activity for each patient and between
different care activities for the same patient
Decontaminate hands
On arrival at and before leaving ward or department
After visiting the toilet
Before and after aseptic procedures
Before every episode of care that involves direct contact with patient skin, food, invasive
devices and dressings
After caring for a patient with diarrhoea and/or vomiting
After any activity or contact that potentially results in hands becoming contaminated
On entering and leaving an isolation cubicle
After removal of gloves
Caring for patients with Clostridium difficile
Wash hands with soap and water. Alcohol hand gel is not effective in killing spores
General social contact and most clinical care activities
Apply alcohol-based hand rub or wash hands with liquid soap and water before initiating a
care activity for each patient, or between different care activities on same patient
Alcohol-based hand rubs are not effective in removing dirt and organic material, but offer
a practical and effective alternative to hand washing when hands are not soiled, and are
less likely to cause skin irritation
Wash hands that are visibly soiled or potentially contaminated with dirt or organic material
with liquid soap and water
Wash hands with soap and water after consecutive applications of hand rub
TECHNIQUE FOR HAND HYGIENE
Bare below elbow (i.e. no sleeves below elbow, no wrist watches, etc)
False nails, nail extensions and nail varnish must not be worn
Keep nails short and clean
Before clinical work shift begins, remove stoned rings, wrist watches or other wrist
jewellery before carrying out clinical care that includes hand hygiene
Cover cuts and abrasions on hands and arms with waterproof dressings
Washing with soap and water

Turn on taps using elbows if possible
Wet hands under warm running water before applying soap, lather well and rub vigorously
for a minimum of 1015 sec, paying particular attention to tips of fingers, thumbs and
between fingers
Use a technique that covers all surfaces of hands and wrists
Rinse thoroughly, and dry with paper
Turn off taps using elbows if possible
Using alcohol hand gel
Use a technique that covers all surfaces of hands and wrists
Hand hygiene 2010-11
Apply alcohol gel and rub vigorously, paying particular attention to tips of fingers, thumbs
and between fingers, until solution has evaporated and hands are dry
SKIN PROTECTION
Apply an emollient hand cream regularly to protect skin from damaging effects of regular
hand washing and use of alcohol hand rub
If any lesions or recurrent skin infections or any decontamination product causes skin
irritation, contact occupational health
Prot equip 2010-11
USE OF PERSONAL PROTECTIVE EQUIPMENT

As it is not always possible to identify individuals with an infection, adopt this safe
method of working at all times to protect staff, patients and others from infection
Personal protective equipment selected for a procedure will follow a risk assessment, which
will be carried out by person performing the procedure
Use personal protective equipment if risk of:
Transmission of micro-organisms to patient or healthcare practitioner
Contamination of healthcare practitioners clothing and skin by blood, body fluids,
secretions and excretions
GLOVES
When
Wear non-powdered disposable gloves for:
Invasive procedures
Contact with sterile sites, non-intact skin or mucous membranes
Managing surgical wounds
Anticipated contact or exposure to blood, body fluids, secretions and excretions
Handling sharp or contaminated instruments
Application of topical preparations
Contact with cytotoxic agents
Contact with chemicals
How
If patient or professional latex sensitive, use non-latex gloves
Following removal of gloves, wash or disinfect hands
Change gloves between care activities for different patients or between different care
activities on the same patient
gloves are single-use items
Choice
Latex gloves and an alternative to latex gloves must be available
choice of sterile or non-sterile will depend on whether risk is to patient (sterile) or user
(non-sterile)
FLUID-REPELLENT GOWNS AND PLASTIC APRONS

Fluid-repellent gowns
If there is a risk of extensive splashing of blood and body fluids (e.g. dealing with major
trauma or during major surgical procedures), wear a full-body fluid-repellent gown
Plastic aprons
If there is a risk that clothing or uniform may be exposed to blood, body fluids, secretions
and excretions, wear a disposable plastic apron
Change plastic aprons between patients
aprons are single-use items
Colour coding:
White General duties
Blue
Aseptic techniques
Green Serving food
Yellow Isolation nursing
MASKS, AND EYE AND FACE PROTECTION
Whenever there is risk of blood, body fluids, secretions or excretions splashing into face
and eyes, wear mask and goggles/plain spectacles or a full face visor
Masks are not required clinically during routine ward procedures (e.g. when dressing
wounds or during invasive medical procedures)
Prot equip 2010-11
Pulmonary tuberculosis and other serious specified respiratory infections (e.g.

pandemic and avian flu, SARS)
When direct exposure to respiratory secretions from patients with infectious pulmonary
tuberculosis and other serious specified respiratory infections is unavoidable (e.g. sputum
induction, bronchoscopy and dental surgery, or during prolonged care of a highdependency patient), wear a disposable theatre-type dust mist mask
For multi-drug resistant pulmonary tuberculosis, SARS, or avian and pandemic flu, you
must wear an FFP3 mask
MRSA Screening 2010-11
SCREENING FOR MRSA

For details, see Infection Control - MRSA Elective Pre-Admission Screening
Screening non-elective patients will commence in 2010
MRSA Management 2010-11
MANAGEMENT OF PATIENTS WITH MRSA

Presumptive or confirmed
MRSA reported
Risk assessment
Has patient:
an exfoliating skin condition OR
productive sputum OR
extensive wound areas OR
multiple positive sites?
YES
NO
Nurse patient in single room

Use standard infection control
precautions (Infection Control Policy
- Good Practices on intranet)
Commence 5-day decolonisation regimen unless patient is to be

discharged home and is not expected to be re-admitted within
12 months. See Topical MRSA decolonisation treatment guideline.
Abort decolonisation and isolation if presumptive MRSA cannot be
confirmed by culture
Decolonisation
regimen
Nurse patient in single room if

available or cohort nurse with
other patients with recent positive
MRSA reports.
Use standard infection control
precautions Infection Control
Policy - Good Practices on intranet
Screen weekly in MRSA infection high risk area
Screen patient after any systemic and/or topical antibiotic

treatment has been stopped for 48 hr
Maintain barrier nursing pending three consecutive clear screens
If three clear screens: patient may come out of single

room or cohort and no longer requires barrier nursing
Always consult Infection Prevention and Control Team
before discontinuing isolation nursing.
MRSA infection high risk areas:
All wards.
If eradication has failed, do not

repeat decolonisation until any
indwelling lines or medical
devices have been removed.
Do not attempt to eradicate more
than twice during any one
admission
For detailed information see intranet:

Infection Control - Good Practices Policy
Infection Control MRSA policy
Infection Control - MRSA Elective Pre-Admission Screening
policy
MRSA Screening 2010-11
TOPICAL MRSA DECOLONISATION TREATMENT

Who
Decolonise all patients in Macclesfield Hospital found to be colonised with MRSA unless patient
about to be discharged home, unlikely to be re-admitted within 12 months and at low risk of
Staph aureus infection (skin intact, no diabetes, no malignancy and not on immunosuppressive
treatment)
Patients awaiting implant surgery can start treatment at home and, if time allows, attempt to
eradicate MRSA before admission. Suppression therapy is best given for 5 days before the date
of operation. The patient should be assumed to remain MRSA positive and be managed
accordingly.
When treatment cannot be commenced 5 days pre-operatively, it should be started at earliest
opportunity and continued for a full 5 days
How
Nasal mupirocin 8 hrly for five days. For mupirocin-high level resistant MRSA, use chlorhexidine
0.1% with neomycin 0.5% (Naseptin) nasal cream topically to each nostril 6 hrly for 10 days
Wash body once daily for five days, and hair twice in five days, with chlorhexidine gluconate
solution 4% (Hibiscrub)
if chlorhexidine gluconate solution 4% not tolerated, use Octenisan.
Do not use mupirocin for prolonged periods, or repeatedly (for more than two courses of five
days during an admission) as this can encourage resistance
Special circumstances
If patient has medical device in situ that breaches skin or mucous membranes (central venous
catheter, tracheal cannula, drain, external pacemaker), or a urinary catheter, decolonisation is not
likely to be successful. Discuss with a member of the Infection Prevention and Control Team
(1597).
If a wound or ulcer infected with MRSA (not just colonised), carry out decolonisation once
infection has improved. Discuss with a member of the Infection Prevention and Control Team.
Repeat screening
Take screening swabs 3 days after completion of topical decolonisation and any other antibiotic
treatment.
if swabs positive, repeat course of topical decolonisation may be indicated, but do not give more
than two courses during a single inpatient episode. Discuss with a member of the Infection
Prevention and Control Team (1597).
Eradication is known to fail if 5 days of topical treatment are not completed
Results of MRSA screening will be available after 12 days
ESBL 2010-11
MANAGEMENT OF PATIENTS WITH EXTENDED

SPECTRUM BETA-LACTAMASE-PRODUCING
BACILLUS (ESBL) OR OTHER MULTIRESISTANT GRAM-NEGATIVE BACILLUS
(MGNB)
ESBL/MGNB isolated
If surgical antibiotic prophylaxis required, in

patient colonised with ESBL/MGNB,
Discuss choice of antibiotic with
microbiologist (1810)
Discuss with infection control (IC) team (1597)
Standard IC precautions
Nurse patient in single room or as cohort in single bay if several patients infected/colonised
If urinary catheter in situ, remove if possible. If catheter needed,

use silver-coated catheter
YES
Does patient have clinical signs of infection?
NO
Contact microbiologist (1810) for advice on

antibiotic treatment
Nurse in single room or as cohort in single
bay if several patients infected/colonised
Send further rectal swabs, swab from site

originally positive, and CSU (if catheter still in
situ) weekly
Patients may be moved from side room or

cohort after 1 set of negative screens
Keep in side room or cohort and do not send

further samples for ESBL screening if 3 weekly
screens have been reported positive
CDiff 2010-11
CLOSTRIDIUM DIFFICILE-ASSOCIATED
DIARRHOEA
If patient with Clostridium difficile identified on your ward, contact infection control
nurses (1597)
PREVENTION
Use antimicrobials appropriately. Follow hospital Antibiotic Policy available on

intranet under Antibiotic Policy on front page
When prescribing antimicrobials, document clinical indication and choice in
patient notes, and route and duration on prescription chart
Use narrow spectrum agents whenever possible and in conjunction with
microbiology results
Always record reason for prescribing and the duration of course or a review
date.
Review all antimicrobials daily
Switch IV antimicrobials to oral route after 48 hr where possible, and stop
antimicrobials after a total of 5 days treatment (including IV treatment) unless
a specific infection justifies an extended duration of treatment
Note: in patients who have had a recurrent episode of C. difficileassociated
disease, the risk of further recurrence is 4060%. Clinicians should bear this
in mind if considering prescribing an antibiotic or proton pump inhibitor in
these patients
If patient fails to respond, seek advice from microbiologist before extending course of
antimicrobial treatment for a prolonged period
Avoid giving successive uninterrupted courses of different antimicrobials
CDiff 2010-11
TREATMENT
Stool positive for Clostridium difficile toxin
Diarrhoea continues 2 or more loose stools (entirely

liquid no solid pieces) in 24 hr
Patient asymptomatic (diarrhoea has resolved)
Standard infection control precautions plus additional cleaning using a chlorine-based disinfectant.
Use yellow apron and gloves when caring for patient
Promptly (within 2 hr) transfer to single room (any ward)
Wash hands using soap and water
Review any current antibiotic treatment and if possible stop. If patients condition warrants
continuation, seek advice of microbiologist (1810)
Stop any medicines that decrease stomach acid (e.g. proton pump inhibitors and H2 antagonists)
unless there is a compelling indication
Do NOT prescribe anti-diarrhoeal agents
Diarrhoea continues
No diarrhoea for at least 24 hr
Standard infection control

precautions
No treatment required
Patient requires treatment assess severity
Mild
No raised
WBC
<3 type 57
stools* in
24 hr
Moderate
WBC raised,
but <15 x 109/L
35 type 57
stools* in 24 hr
Metronidazole 400 mg orally

8 hrly for 1014 days (stop at
10 days if asymptomatic);
if worsening or if not responding
within 1 week: treat as severe
Severe (1 of the following

present):
WBC 15 x 109/L
Acute rising serum
creatinine (>50% increase
above baseline)
Temperature >38.5C
Evidence of severe colitis
(abdominal or radiological
signs)
Vancomycin 125 mg orally

6 hrly for 1014 days (stop at
10 days if asymptomatic). If not
responding, increase vancomycin
dose up to 500 mg orally 6 hrly
and add metronidazole 500 mg IV
by infusion 8 hrly.
Consider colectomy
Nurse patient in side roomuntil symptom-free for 72 hr
* Using Bristol Stool Chart
Life threatening
Hypotension
Partial or
complete ileus or
toxic megacolon
CT evidence of
severe disease
Consider colectomy.
Vancomycin dose up
to 500 mg orally
6 hrly plus
metronidazole
500 mg IV by infusion
8 hrly for 1014 days
(stop at 10 days if
asymptomatic)
Do not send further specimens

unless symptoms recur, as stool
can remain positive for several
weeks
RECURRENCE
If not severe, treat first recurrence with the same antimicrobial to which initial
episode responded
If first episode was treated with metronidazole and recurrence is severe, use
vancomycin
CDiff 2010-11
In subsequent recurrences, use vancomycin orally 125 mg 6 hrly and discuss

with a microbiologist (1810)
HIV 2010-11
HIV INFECTION TESTING

INTRODUCTION
HIV is a treatable medical condition and the majority of those living with the virus in the
UK are well
Many are unaware of their HIV infection but their own health remains at risk and they may
pass the virus unwittingly to others
Late diagnosis is the most important factor associated with HIV-related morbidity
HIV testing should occur in a wider variety of settings and all doctors should be able to
obtain informed consent for an HIV test in the same way they do for any other medical
investigation
HIV testing remains voluntary and confidential
WHO SHOULD BE OFFERED A TEST?
Patients presenting with clinical features compatible with HIV, including primary HIV
infection, as a differential diagnosis (see table)
Exposed to HIV risk e.g. needlestick injury, both the person exposed and potential source
Primary HIV infection (PHI)

PHI occurs in approximately 80% of individuals, typically 24 weeks after exposure
Typical symptoms include a combination of any of:
fever
rash (maculopapular)
myalgia
pharyngitis
headache/aseptic meningitis
Resolve spontaneously within 23 weeks
If PHI suspected, urgent referral to GUM clinic 01625 264 116/9
Table 1: Clinical indicator diseases for adult HIV infection
Respiratory
Neurology
AIDS-defining conditions
Pneumocystis pneumonia
Tuberculosis
Cerebral toxoplasmosis
Primary cerebral lymphoma
Cryptococcal meningitis
Progressive multifocal
leucoencephalopathy
Dermatology
Kaposis sarcoma
Gastroenterology
Persistent cryptosporidiosis
Oncology
Non-Hodgkins lymphoma
Gynaecology
Cervical cancer
Others where testing should be offered

Bacterial pneumonia
Aspergillosis
Aseptic meningitis
Space occupying lesion of unknown cause
Guillain Barr syndrome
Transverse myelitis
Peripheral neuropathy
Dementia
Leucoencephalopathy
Severe/recalcitrant
seborrhoeic dermatitis/psoriasis
Multidermatomal or recurrent herpes zoster
Oral candidiasis
Oral hairy leukoplakia
Chronic diarrhoea/weight loss of unknown
cause
Salmonella, shigella or campylobacter
Hepatitis B/C infection
Anal cancer/intraepithelial dysplasia
Lung/head and neck cancer
Seminoma
Hodgkins lymphoma
Castlemans disease
Vaginal intraepithelial neoplasia
HIV 2010-11
Haematology
Ophthalmology
ENT
Cytomegalovirus retinitis
Other
Cervical intraepithelial neoplasia Grade 2 or

above
Any unexplained blood dyscrasia
Infective retinal diseases
Lymphadenopathy of unknown cause
Chronic parotitis
Lymphoepithelial parotid cysts
Mononucleosis-like syndrome
Pyrexia of unknown origin
Anyone with a mother who is HIV +ve no
matter what age
Anyone who has a partner who is HIV +ve
Men who have sex with other men
Female sexual contacts of men who have
sex with men
Patients reporting use of injecting drugs
Anyone from a country of HIV prevalence
>1%
Anyone who has had sex in a country of
HIV prevalence >1%
Anyone who has had sex with someone
from a country of HIV prevalence >1%
All pregnant women
HOW
Who can test?
Doctor, nurse, midwife or trained healthcare worker
Pre-test discussion
Primary purpose of pre-test discussion is to establish informed consent for HIV testing
Lengthy pre-test HIV counselling is not a requirement unless patient requests or needs
this
Address patient issues and concerns. It is important that information given about the test
and the virus is adequate to enable patient to make an informed decision
If patient refuses test, explore reasons for refusal to ascertain this is not because of
incorrect beliefs about the virus or the consequences of testing
If patient raises concerns about insurance cover or criminal prosecution for transmission
of the virus as reason for not testing, explore further and correct any factual inaccuracies
(see www.bhiva.org/cms1222621.asp)
Some patients may need additional help to make a decision (e.g. English not their first
language). It is essential to:
ensure they have understood what is proposed and why
establish they understand what a positive/negative HIV result means (some patients
could interpret positive as good news)
Children and young people, and those with learning difficulties or mental health problems,
may need additional support and time to understand what is proposed and to make a
decision. (see below)
Discuss and agree arrangements for communicating result with patient at time of testing
(particularly if test performed in out-patient or emergency care setting)
Testing where patient lacks capacity to consent (including unconscious patient)
See Consent guideline valid consent for an adult patient who is found to lack
capacity
Discuss with consultant in infectious diseases/genitourinary medicine
Assessment of capacity relates to the specific issue in question ) i.e. consent to HIV
testing)
Start from presumption that patient has capacity to make this decision
HIV 2010-11
Consider whether they understand what decision they are being asked to make and can
weigh up the information relevant to the decision
If patient lacks capacity to consent to an HIV test, consider whether this is temporary or
permanent. If temporary, defer testing until they regain capacity, unless testing is
immediately necessary to save patients life or prevent serious deterioration of their
condition
If lack of capacity likely to be permanent, seek a decision from any person with relevant
powers of attorney or follow the requirements of any valid advance statements. If patient
has not appointed an attorney or there is no advance directive, HIV testing may be
undertaken where this is in patients best interests
The source patient in a needlestick injury or other HIV risk exposure

Consent must be obtained from source patient before testing
The person obtaining consent must be a healthcare worker, other than person who
sustained the injury (see Sharps Injury and Body Fluid Exposure Policy on Trust
intranet)
Documentation
Document offer of an HIV test in patients notes together with any relevant discussion:
if patient refuses test, document reasons
Written consent is usually not necessary and may discourage HIV testing by
exceptionalising it, but record on laboratory request form that consent has been
obtained
Confidentiality
Testing clinician (or team) must give result of HIV test (if positive) directly to patient and
not via any third party (including relatives or other clinical teams) unless patient has
specifically agreed to this
POST-TEST DISCUSSION
Clear procedures as to how patient will receive result must be in place, especially where
result is positive
Face-to-face provision of HIV test results is strongly encouraged for:
ward-based patients
patients more likely to have an HIV-positive result
those with mental health issues or risk of suicide
those for whom English is a second language
young people under 16 years
those who may be highly anxious or vulnerable
HIV negative result post-test discussion

Inform all patient of genitourinary clinical services and provide telephone number for selfreferral
If still within window period after a specific exposure, discuss need to repeat test at three
months to definitively exclude HIV infection
Seek specialist advice from/referral to GUM/HIV services in the following situations:
those at higher risk of repeat exposure to HIV infection who may require advice about risk
reduction or behaviour change, including post-exposure prophylaxis
if reported as reactive or equivocal, refer to infectious diseases 0161 624 0420 or
genitourinary medicine 01625 264 116/9 (may be seroconversion)
HIV positive result post-test discussion
Non-genitourinary/HIV specialist must discuss follow-up programme with
infectious diseases/genitourinary specialist before informing patient of positive
result
HIV 2010-11
For all new HIV positive diagnoses, carry out appropriate confirmatory assays and test a
second sample
Testing clinician must give result personally to patient in a confidential environment and in
a clear and direct manner
If patients first language not English, consider using an appropriate confidential
translation service
Refer to infectious diseases or genitourinary medicine who will arrange appointment
within 72 hr
GUM/HIV specialist team will perform more detailed post-test discussion (including
assessment of disease stage, proposed treatment and partner notification)
Further information
http://www.britishinfectionsociety.org/documents/GlinesHIVTest08.pdf
Sepsis 2010-11
SEPSIS, SEVERE SEPSIS & SEPTIC SHOCK

For management of neutropenic haematology patients/oncology patients refer to
Neutropenic sepsis after chemotherapy or radiotherapy in Medical guidelines

Sepsis is any suspected or known infection associated with a systemic inflammatory response. It
can occur in any patient. Immunocompromised patients and patients infected with bacteria known
to cause sepsis, such as pneumococcus, meningococcus, are at particular risk. Others at risk
include those with GI tract perforation (iatrogenic or spontaneous) who have indwelling lines,
catheters and other devices, or who have recently undergone surgical or invasive procedure (e.g.
urethral catheterisation)
Symptoms, signs and laboratory results
Rigors, sweating, fever
Headache, muscle pain
Features of primary infection. Consider urinary tract infection, lower respiratory tract infection,
meningitis, skin infection, endocarditis, intra-abdominal infection, pelvic inflammatory disease,
osteomyelitis, sexually-transmitted diseases
Sepsis is presence of one of above symptoms plus two of following:
heart rate >100 beats/min
respiratory rate >24 breaths/min
temperature >38 C or <36 C

9
WBC >11 or <4 10 /L
Life-threatening features
Severe sepsis: sepsis with impaired organ function [e.g. diminishing renal function, impaired
cardiac function, hypoxia, acidosis, acute respiratory distress syndrome (ARDS), clotting
disturbance, plasma lactate >4.0 mmol/L]
Septic shock: severe sepsis with systolic BP <90 mmHg or MAP (mean arterial pressure)
<65 mmHg
Investigations
FBC and differential WBC
Chest X-ray
Biochemical screen (save serum for cortisol)
Glucose
If severe sepsis suspected, measure venous plasma lactate. Ring biochemistry lab to warn of
urgent transfer on ice
Arterial blood gases (ABG), acid-base and lactate
INR, APTT
Culture
blood 2 (take 3 only if infective endocarditis suspected: see Infective endocarditis in
Medical guidelines)
urine
faeces (if patient has travelled abroad recently or enteric infections suspected)
CSF (if any hint of meningitis; omit if patient confused or intracranial pressure raised)
If source of infection not apparent, consider CT, ultrasound and nuclear medicine imaging
Check whether patient has been found positive methicillin-resistant Staphylococcus
aureus (MRSA) or Multi-resistant Gram-negative bacilli (MGNB).
Sepsis 2010-11
Systemic infections: staphylococcal toxic shock syndrome, malaria, viral haemorrhagic
fevers, rickettsial infections
Systemic disease: occult haemorrhage, myocardial infarction, adrenal insufficiency,
pulmonary embolism
IMMEDIATE TREATMENT
Early, aggressive and adequate fluid and oxygen therapy are essential. Please refer to
flowchart
Type of patient
Alternative (penicillin
allergy)
Assume penicillin allergy only if convincing history of either rash within 72 hr of dose or
anaphylactic reaction. If any doubt about whether patient truly allergic to penicillin, seek
advice from a microbiologist (1810) or via switchboard
Unknown source
Piperacillin/tazobactam 4.5 g
Vancomycin 1 g IV 12 hourly
IV 8 hrly
(500 mg if >65 yrs)
and gentamicin IV 7mg/Kg to
and Ciprofloxacin 400 mg IV
max 500 mg (See antibiotic
BD
Policy)
and Metronidazole 500 mg IV
(Add Vancomycin if MRSA is
TDS
possible)
If sepsis appears to be due to
Neisseria meningitidis,
pneumonia, UTI, intraabdominal infection,
complicated soft tissue
infection:
See Antibiotic Policy on
Trust intranet and its
appendix: Guidelines for the
Management of Severe
Sepsis in the Critically ill Adult
Patient
First line
Sepsis 2010-11
Flowchart 1: Immediate treatment of sepsis, severe sepsis and septic shock

Sepsis ( two of following markers but
no organ dysfunction)
heart rate >100 beats/min
respiratory rate >24 breaths/min
temperature >38C or <36C
WBC >11 or <4 109/L
Severe sepsis/septic
shock
Ensure adequate fluid replacement

20 mL/kg colloid or 40 mL/kg crystalloid [compound
sodium lactate (Hartmanns) or sodium chloride
0.9%] over <30 min then reassess see Fluid
resuscitation guideline
AND
adequate O2 therapy see Oxygen therapy in
acutely hypoxaemic medical patients guideline
AND
Discuss with specialist
registrar and consultant
ITU
Source identified.
If appropriate, remove
source (e.g. infected
lines, abscess,
perforated bowel)
Treat as per
appropriate guideline,
(in Antibiotic Policy )
Source unclear
Source identified?
No
Yes
Continue further
investigation
If appropriate, remove
source (e.g. infected lines,
abscess, perforated bowel)
If source cannot be
removed (e.g. pneumonia,
urinary tract infection,
cellulitis),
treat as per appropriate
guideline or BNF
Oral antibiotics often
effective
Seek review by senior

colleague
Deterioration
Stable/improving
Diagnosis made
Start antibiotics see

Antibiotic Policy
Further investigations
No diagnosis made
Refer to infectious
diseases for
investigation of
unexplained fever
Sepsis 2010-11
MONITORING TREATMENT
MEWS observations see Modified early warning system for patient monitoring
guideline
FBC
Biochemical screen
If severe sepsis suspected, measure venous plasma lactate. Ring biochemistry lab to warn of
urgent transfer on ice
Further cultures as clinically indicated
Improvement will be shown by heart rate <100/min, BP recovering, urine output
>12 mL/kg/hr, plasma lactate improving or <2.0 mmol/L
if improvement not shown by clinical measures, reconsider referral to ITU
If improving:
adjust antibiotics to cover organism(s) and sensitivities reported. Change to oral route after
resolution of symptoms and signs of sepsis and continue for a further five days
if S. aureus bacteraemia, identify focus; treat with at least two weeks IV antibiotic
If not improving:
reassess, reconsider diagnosis, discuss with ITU if appropriate
Where severe sepsis resolves, recovery is usually complete. Out-patient follow-up depends
on severity and source of infection
In event of death, inform HM Coroner
Meningitis 2010-11
MENINGITIS
Symptoms and signs
Headache, neck stiffness, photophobia
Fever
Impaired consciousness, coma and fits
Clinical features of septicaemia or severe sepsis
In the elderly, confusion can occur as the only symptom of meningitis in the absence of
meningism or even of fever
Altered consciousness
Focal neurological deficit
Raised intracranial pressure
Convulsions
Concurrent evidence of sepsis
Investigations
CSF see flowchart 1
FBC, differential WBC and coagulation screen
U&E, glucose and CRP
Throat swab
Blood culture
Chest X-ray
Meningococcal/pneumococcal PCR (EDTA tube to microbiology)
Subarachnoid haemorrhage
Other intracranial sepsis
Systemic sepsis
Other causes of confusion or of raised intracranial pressure
Encephalitis
Malaria in travellers
IMMEDIATE TREATMENT
See flowchart 1
Interval between patient's arrival and commencement of antibiotic treatment (door-toneedle time') should not exceed 1 hr.
Meningitis 2010-11
Flowchart 1 Initial Management
Does patient have classical

meningococcal rash, or
features of severe sepsis? See
Sepsis guideline
Yes
Ensure adequate fluid replacement/O2 therapy
see Fluid resuscitation guideline and Oxygen
therapy in acutely hypoxaemic medical
patients guideline
and
Give Cefotaxime 3 g by IV infusion 6 hrly
After 24 hours, reduce cefotaxime to 2g 6 hourly
and
Discuss with consultant and ITU
No
Does patient have one or more of
the following:
GCS <15?
seizures?
focal neurological signs?
No
Yes
Perform lumbar puncture see Lumbar

puncture guideline
Send samples for microbiology/virology
(PCR)/biochemistry and cytology
Pending CSF results, give single dose of:
dexamethasone phosphate 8 mg IV
(immediately before first dose of cefotaxime,
where possible)
Cefotaxime 3 g by IV infusion. After 24
hours, reduce cefotaxime to 2g 6 hourly
CSF acellular
Stop antibiotics
and corticosteroids
and seek
alternative
diagnosis
CSF shows
neutrophil
predominance
Continue cefotaxime
3 g by IV infusion
6 hrly AND
dexamethasone 4 mg
orally 6 hrly
After 24 hours,
reduce cefotaxime to
2g 6 hourly
If aged >50 yr, ADD
amoxicillin 2 g by IV
infusion 4 hrly
Alter antibiotics if
necessary according to
culture results
CSF shows lymphocyte

predominance
Consider stopping
cefotaxime and
dexamethasone and
consider other
diagnoses (e.g. viral
meningitis, tuberculous
meningitis)
Discuss with consultant
+ infectious disease
team
Give:
dexamethasone phosphate 8 mg IV
6 hrly (first dose immediately before
first dose of ceftriaxone, where
possible)
AND
Cefotaxime 3 g by IV infusion 6 hrly
After 24 hours, reduce cefotaxime
to 2g 6 hourly
AND
if aged >50 yr, amoxicillin 2 g by IV
infusion 4 hrly (to cover listeria)
if HSV encephalitis possible,
consider aciclovir 10 mg/kg by IV
infusion 8 hrly
consider CT head scan
If GCS <15 or seizures occur, defer
lumbar puncture even if CT normal
If no CSF, send EDTA blood for
meningococcal/pneumococcal PCR
Consider ITU referral (after discussing
with consultant) if GCS <10, or <12 and
falling
Meningitis 2010-11
Neurological observations, including GCS, every 15 min in severe cases initially, then at
decreasing intervals as recovers
If bacterial meningitis proven or probable, continue antibiotic treatment for 7 days, then
review
if meningococci isolated, treat for 7 days, then review
if pneumococci isolated, treat for 1014 days, then review
If alert and orientated after 48 hr, withdraw dexamethasone gradually
Cases of meningitis must be notified to consultant in communicable disease control (0151
290 8360)
Follow-up in clinic to check for hearing loss

Refer patients with persisting neurological deficit to appropriate specialist for rehabilitation
Hot joint 2010-11
ACUTE HOT JOINT, SEPTIC ARTHRITIS AND

GOUT
Symptoms and signs
Acutely painful, swollen joint
Warm, tender, swollen joint ( effusion)
Pyrexia may not be a feature of septic arthritis in the elderly or immunocompromised, or in
patients with diabetes, renal failure or rheumatoid arthritis
In patients with prosthetic joint and PUO consider prosthesis infection
Investigations
Immediate
If knee joint swollen, aspirate for urgent synovial fluid analysis (polarised microscopy), Gram
stain and culture see Practical procedures Knee aspiration guideline. For cytology/
polarising microscopy send fluid in synovial fluid cytology tube (small orange topped with
lithium heparin inside no beads) to Dept of Osteoarticular Pathology Manchester (via
ECNHST pathology service)
Out of hours contact on-call orthopaedic team for urgent joint aspiration +/- arthroscopic
washout and further management. For medical in-patients contact Rheumatology team (SpR
bleep 5117, office extension 1586); at weekends if Rheumatology Consultant advice needed
contact Consultant Rheumatologist on call for Macclesfield/South
Manchester/Stockport/Central Manchester: rota and contact details are held on ward A10 at
SHH: tel. no. 0161 419 5103)
FBC
U&E, CRP
Microbiology:
Gram stain and culture of synovial fluid
blood cultures see Collection of blood culture specimens guideline
swab from any infected skin lesion
if gonococci suspected, swab rectum, urethra and throat, and contact genitourinary medicine
01625 264 116/9
Within 24 hr
ESR
CRP, Liver function tests
Serum uric acid (NB may not be elevated in acute gout)
X-ray of affected joint
Septic arthritis
Crystal arthritis, including gout
Acute inflammatory arthritis (e.g. reactive arthritis or rheumatoid arthritis)
Haemarthrosis
If patient has acute arthritis affecting more than one joint, discuss case with
Rheumatology team SPR bleep 5117; Rheumatology office ext 1586 Fax 1212. At
weekends if Consultant Rheumatologist advice required contact consultant on call see
Hot joint 2010-11
above. If the patient is already under the care of the Rheumatology team contact patients
Consultant Rheumatologist for advice via switchboard at MDGH in first instance.
IMMEDIATE TREATMENT
Supportive
Adequate analgesia for joint pain: Diclofenac 50 mg orally 8 hrly (if not contraindicated
avoid in renal impairment, patients who are anti-coagulated and those with history of NSAID
related GI toxicity) plus gastroprotection plus:
step 1: paracetamol 1 g orally 6 hrly.
step 2: if paracetamol alone not adequate, add codeine phosphate 30-60 mg orally 6 hrly
step 3: if codeine phosphate not adequate, substitute morphine sulphate solution 10 mg orally
4 hrly
Refer to physiotherapists for ice pack and splint on joint
Rehydrate see Maintenance fluid therapy guideline
If patient already taking low-dose corticosteroids, consider increasing to prednisolone 10 mg
orally daily
Antibiotic therapy
Start as soon as joint aspirated. Review choice after Gram stain result
Most common microbe causing septic arthritis is Staph. aureus
Type of patient
First line
allergy)
See Antibiotic Policy (Page 54) on Intranet
If patient immunocompromised or has prosthesis, contact Dr Wills, Consultant

Microbiologist for advice. For patients with a possible infected joint prosthesis ensure
Orthopaedic team on call are asked to see patient.
If gonococci isolated and strain sensitive:

ciprofloxacin 500 mg orally 12 hrly for 14 days
if strain resistant to ciprofloxacin, contact consultant microbiologist (1810)
If severe sepsis present, refer to Sepsis, severe sepsis and septic shock guideline and
treat with appropriate IV antibacterials
Pulse, BP, temperature 4 hrly until patient stable

While effusion persists, repeat culture of joint effusion daily (see below)
WBC, ESR, CRP, U&E every 48 hr
If using sodium fusidate, liver function tests weekly
Septic arthritis
Supportive treatment, as above
Refer to physiotherapists for passive exercise and rehabilitation
Perform regular aspiration of the joint to dryness +/- arthroscopic lavage while a significant
effusion persists
Antibiotic therapy
Adjust antibiotics once results of therapy and bacterial sensitivities available
if no bacteria isolated, consider stopping antibiotics discuss with rheumatology team (call
Rheumatology SpR or contact Rheumatology team as above. NB office ext no 1586)
Hot joint 2010-11
If infection likely or proven, continue IV antibiotics until apyrexial and no systemic symptoms;
then change to equivalent oral antibiotics
Continue oral antibiotics for a further four weeks, or longer if joint not settled
Failure to respond to therapy

Reconsider diagnosis
Repeat cultures
If no response within 48 hr, contact rheumatology team (Rheumatology SpR bleep 5117 or
contact Rheumatology team as above. NB office ext no 1586)
Confirmed gout
Gout is confirmed by microscopic identification of urate (negatively birefringent) crystals in
synovial fluid. Note that septic arthritis and gout can co-exist.
Rehydrate see Maintenance fluid therapy guideline. Consider stopping diuretics
Assess whether it is safe to give NSAIDS if so administer Naproxen 750 mg single dose
then 250 mg orally 8 hrly OR diclofenac 50 mg orally 8 hrly (with gastro-protection). If NSAID
contraindicated assess whether it is safe to give Colchicine if so administer colchicine 500
microgram orally tds. NB Higher doses can be used but beware abdominal pain, vomiting or
diarrhoea (maximum 6 mg per course; see BNF for further guidance). In general it is best to
avoid high dose Colchicine because of the high incidence of side effects if necessary
discuss with Rheumatology team.
Do not start allopurinol in acute gout
In difficult or resistant cases, contact rheumatology team (Rheumatology SpR bleep 5117 or
contact Rheumatology team as above. NB office ext no 1586)
If patient already under follow-up because of arthritis, review existing follow-up arrangements:
ensure relevant Consultant Rheumatologist is made aware of the admission and discuss
follow up arrangements.
Refer new cases to a consultant rheumatologist
Infective endocarditis 2010-11
INFECTIVE ENDOCARDITIS
Presentation of infective endocarditis (IE) is highly variable; symptoms can be non-specific and of
insidious onset. A high index of suspicion is often required
Symptoms and signs
Systemic symptoms: fever, anaorexia, weight loss, lethargy (especially in the elderly),
nausea, dyspnea, myalgia
Peripheral lesions: mucocutaneous petechiae; Janeway lesions (macular plaques on palms
and soles);Roth spots (small, retinal haemorrhages with pale centres); splinter haemorrhages
Splenomegaly may be present in 15-50% of cases
New onset regurgitant murmur, not an accentuation of pre-existing murmur
Sytemic emboli: Limbs, digits, spenic, renal, splenic, coronary, mesenteric, cranial arteries.
Clinical picture will be defined by the location of the emboli. One of the most common cause
of death is embolic process related in SBE.
Neurologic symptoms: related to mycotic emboli, mycotic aneurysms; cerebritis, very rarely
cerebral abcess
Renal insufficiency: Immune complex glomerulonephritis; embolic renal infarcts; impaired
hemodynamics; drug toxicity
Risk factors
Previous infective endocarditis (IE)

Pre-existing abnormal intra-cardiac flow due to valvular heart disease, or congenital heart
disease such as VSD, PDA, or further complex congenital HD
In situ Prosthetic heart valve
Recent intra-cardiac device implantation such as PPM and ICD
(PCI and coronary stent implantation are not risk factors)
IV drug users
Immunosuppressed patients, especially those with an indwelling IV catheter (Hickmann line)
Investigations
BLOOD CULTURES are the key investigation.
Three set of blood cultures, obtained via three separate venepuncture site and not from an
indwelling catheter, should be obtained immediately via aseptic technique.
Inform microbiologist of suspected IE; cultures then will be incubated for three weeks
Consider fungal cultures for special groups such as those with prosthetic valve; IV drug
users and immunsupressed cases
In an acutely ill patient

Three sets of blood cultures within first 24 hr before starting antibiotic therapy (one aerobic
and one anaerobic bottle per set), without waiting between the three separate venepunctures
START ANTIBIOTIC therapy following 3 sets of blood cultures, without any delay
If IE suspect is not high and patient is not acutely ill

Take three sets of blood cultures within first 48 hr
Consider discontinuing antibiotic therapy and repeating twice daily blood cultures for 3 days
Other investigations
FBC and differential WCC: anaemia, usually normochromic normocytic may be present
ESR and CRP are usually significantly elevated
Complement C3, C4, CH50
ECG, sinus tachycardia, check for progressive AV block seen in aortic valve endocaditis
Urinalysis may reveal proteinuria and microscopic haematuria
Echocardiogram (discuss with cardiology team)
Diagnostic criteria
Modified Duke criteria is currently used for the diagnosis of definite and probable IE. Table 1,
summarises mjor and minor factors for the diagnosis. Further guidance of European Society of
Cardiology (2009) is also accessable via web link on http://www.escardio.org/guidelinessurveys/esc-guidelines/Pages/infective-endocarditis.aspx
Table 1: Modified Duke criteria for the diagnosis of infective endocarditis (adapted from Li et al.)
IMMEDIATE TREATMENT
Do not give antibiotics until at least 3 separate sets of blood cultures have been taken
In endocarditis the valve may be damaged at an early stage. In an ill patient, do not wait for
blood culture report or echocardiographic confirmation
Initial Rx is: Benzylpenicillin 1.2 g IV 4 hrly + Flucloxacillin 2 g IV 6 hrly (4 hrly if >85 kg) +
Gentamicin 1 mg/kg IV 8 hrly.
Allergic to penicillin: Vancomycin (per Vancomycin guideline) + Gentamicin 1 mg/kg IV 8 hrly.
Intra-cardiac prosthetic material in situ, or MRSA is suspected: Vancomycin + Gentamicin as
above + Rifampicin 600 mg orally 12 hrly (IV infusion if unable to swallow or absorb orally)
If diagnosis is confirmed IE, or probable IE, inform the cardiology team and
arrange transfer to cardiology ward
Serum concentrations of vancomycin and gentamicin must be monitored to avoid toxicity
Culture positive
The choice of antibiotics is determined by the results of blood cultures/sensitivity. Following
regimens are recommendable, but frequently updated by the microbiologists whose advice
should be sought as early as possible.
The duration of the antibiotic therapy would be depending on the causative agent; host conditions
such as immune-supression, IV drug use, significant co-morbidities; presence of intra-cardiac
devices/prosthesis; the response rate measured by clinical recovery rate, presence of
complications such as heart failure, peripheral embolisation; response rate measured by
laboratory parameters of CRP/ESR; echocardiographic course: vegetation size (>5 mm), damage
on the valve/ abcess/ dehiscence.
Strep. viridans and Strep. bovis

If strain fully sensitive to penicillin (MIC <0.1 mg/L), treatment is Benzylpenicillin 1.2 g IV 4
hrly + Gentamicin 1 mg/kg IV 8 hrly for two weeks may be sufficient.
However, most cases require 4 weeks Rx with Benzyl-penicillin, depending above mentioned
factors,or penicillin (0.5>MIC >0.1 mg/L), with Gentamicin confined to the first two weeks
If patient penicillin-allergic continue treatment is IV Vancomycin (as per guideline) for at least
four weeks + Gentamicin for two weeks
Staphylococci
If penicillin-sensitive strain, Benzylpenicillin for at least four weeks at above dose +
Gentamicin 1 mg/kg IV 8 hrly for one week
If penicillin-resistant and methicillin-sensitive strain, Flucloxacillin 2 g IV 6 hrly (4 hrly if >85 kg)
for at least + weeks + Gentamicin 1 mg/kg IV 8 hrly for one week
If methicillin-resistant strain, or patient allergic to penicillin, Vancomycin for four weeks plus a
second antibiotic according to sensitivity of infecting organism, as advised by microbiologist
Enterococci
if sensitive to amoxicillin and not highly resistant to gentamicin, give Amoxicillin 2 g IV by
infusion 4 hrly + Gentamicin 1 mg/kg IV 8 hrly for a minimum of four weeks
Culture negative
Failure to culture may be explained by pre-treatment with antibiotics; inadequate
number/poor quality of samples; infection with atypical pathogen (e.g. Chlamydia spp.,
Legionella spp.); infection with a fastidious organism (e.g. members of the HACEK group)
Continue initial antibiotics while seeking further advice from microbiologists: serological
studies for C. Burnetii or Bartonella may be helpful; consider the possibility of fungal agent
Temperature usually settles within days. A subsequent rise may indicate development of a
complication such as abscess formation; may indicate antibiotic resistance
Clinical examination should include assessment of signs of heart failure which may develop
rapidly, as well as checking for signs of peripheral emboli
Inflammatory markers, WBC, CRP, ESR to be repeated at least weekly
Renal function should be monitored closely
In cases of aortic valve endocarditis, repeat ECG regularly; development of AV block,from PR
prolongation to higher degree, may suggest aortic root abscess development behind NCC
Echocardiographic monitoring, with TOE (transoesophageal echocardiography) early during
the treatment and at the end of antibiotic course in all suitable cases; with additional imaging
if a mechanical complications is considered
Gentamicin and Vancomycin require careful monitoring

Pre-dose gentamicin concentration should be <1 mg/L. Peak concentration, taken 1 hr postdose, should be 35 mg/L. Measure serum gentamicin after 24 hr
Pre-dose vancomycin concentration should be 1015 mg/L.
Complications
Heart failure is one of the most common cause of death in such cases, can develop rapidly
as acute valvular regurgitation occurs
Mycotic embolisation to cerebrum may lead a series of presentation from a limited
neurological focal defect to major change in consciousness levels.
Peripheral embolisation may lead to sudden onset flank or abdominal pain with splenic
infarction (listen for friction rub), or mesenteric emboli. Renal infarction may lead to gross
haematuria and flank pain. Multiple lung abscess, especially if it is bilateral should raise the
question of right-sided IE, especially in IV drug users. Coronary arterial emboli may occur,
right coronary artery ostium is more susceptible, hence inferior MI is more likely to develop
Immune complex disease vasculitic rash, arthritis, glomerulonephritis
Early surgical intervention indicated
Decision to undertake valve surgery/ device extraction (such as PPM/ICD) as part of
treatment of infective endocarditis can be extremely challenging and complicated. The
process requires discussion between cardiologists and cardio-thorasic surgeons regarding
timing, nature and feasibility of the operation.
Discharge arrangements would be made by the Cardiology team for clinical review. Repeat
echocardiographic examination and laboratory tests may be required.
References:
Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version
2009):The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of
the European Society of Cardiology (ESC): European Heart Journal doi:10.1093/eurheartj/ehp285
Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr, Ryan T, Bashore T, Corey GR.
Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
Clin Infect Dis 2000;30:633638.
Neutropenic sepsis 2010-11
NEUTROPENIC SEPSIS
Infections are a significant cause of morbidity and mortality among neutropenic patients.
Infections may be bacterial (Gram-positive or Gram-negative) or viral. Immunosuppressed
patients can also harbour fungal infections. The likelihood of infection depends on both the
severity and the duration of the neutropenia
Risk of infection is proportional to duration of neutropenia (especially if neutropenia lasts
>10 days) and how far and how fast neutrophil count falls
Consider infection in any unwell neutropenic patient even if no fever
Symptoms and signs
Fever
oral or tympanic membrane temperature >38C for 1 hr, or >38.5C on one occasion with
neutrophil count <1 109/L
Significant deterioration in clinical state (e.g. development of rigors, shock (systolic BP <90
mmHg) or falls of normal blood pressure by >50 mmHg)
Signs consistent with infection of respiratory tract, urinary tract, or central venous
catheter/Hickman line/PICC line
Severely ill patient with no obvious other explanation for clinical state
Even if other causes possible, always treat fever in neutropenic sepsis as if caused by
infection
Treat with the utmost urgency any patient with features of severe sepsis
History and examination
Take full history and carry out full examination immediately and complete within one hour of
hour of presentation)
Possible sites of infection
Enquire about, and look for, inflammation/infection at following sites and sample as
appropriate:
teeth, gums, pharynx
ears, nose, sinuses
eyes, including fundi
lungs cough, shortness of breath, sputum
upper gastrointestinal tract
lower gastrointestinal tract if diarrhoea present, consider isolation and discuss with infection
control team
perineum, especially anal area (avoid PR examination)
skin consider fungal, pseudomonas, generalised herpes and varicella zoster infections
genito-urinary tract
vascular access sites, especially central venous line insertion sites, bone marrow aspiration
sites, nail margins, skin tunnels and surgical incision sites
Enquire whether central venous line used or flushed within preceding 24 hr
Timing of chemotherapy
Establish type of chemotherapy administered and date of last dose (refer to patient alert card)
Estimate expected onset and anticipated duration of neutropenia by establishing time
elapsed since first day of current cycle of chemotherapy
Assume that any patient who has received chemotherapy within the last month, or whose last
recorded blood counts show neutropenia may be neutropenic
If a subsequent blood count result shows no neutropenia, choice of antibiotic can be revised
at that time if necessary in discussion with the appropriate specialist team
If any of this information not available, do not delay start of antibiotic therapy. The safest
option is to commence antibiotic treatment and revise later, if necessary
Investigations
FBC
Differential WBC
CRP
Liver function tests
Blood cultures peripheral and through IV catheter lumens (take blood through each lumen
of Hickman line). Do not access Hickman line unless trained to do so
Coagulation screen
Clotted blood sample (710 mL plain tube) for viral serology
If varicella zoster suspected, consider swabs for viral culture and PCR
MSU/CSU
U&E
Appropriate swabs [e.g. throat, mouth, wound, skin/peri-anal area (do not perform PR),
Hickman line/central venous catheter/PICC line exit site, if appropriate]
If chest signs and/or SpO 2 <92% on air, chest X-ray
if no respiratory symptoms or signs, X-ray may be deferred until normal working hours
If GI symptoms (e.g. diarrhoea and abdominal pain), send stool sample for culture/sensitivity
and Clostridium difficile toxins
If urinary symptoms or patient catheterised, urinalysis and culture
Respiratory secretions for rapid testing for viral antigens by immunofluorescence, viral
cultures or PCR (e.g. nasal wash, NPA, BAL). Direct viral detection is preferred method for
diagnosing respiratory viral infections
discuss choice of investigation with consultant haematologist or consultant oncologist
IMMEDIATE TREATMENT
Discuss all neutropenic haematology patients admitted out of hours with evidence of
infection with on-call haematologist or oncologist
Commence antibiotics below as recommended in Antibiotic Policy on Trust intranet

Review any recent microbiology culture results. If these reveal a multi-resistant organism,
ensure this will be covered by empiric antibiotic treatment selected
In cases of varicella zoster, adopt infection control precautions to protect staff and other
patients discuss with infection control team
Severity
allergy)
Refer to Antibiotic Policy (Page 46) in the intranet
advice from a microbiologist (1810) or via switchboard
High risk patients under care
Piperacillin/tazobactam
of Christie Hospital
4.5 g IV 8 hrly
(500 mg if >65 yrs)
Plus Ciprofloxacin 400 mg IV
plus
gentamicin IV 7mgKg to max BD
500mg. see Antibiotic Policy
Patients under care of Dr
Hudson and with anticipated
transient neutropaenia of < 10
days
Known MRSA positive
or
patient has central venous
catheter/Hickman line/PICC
line and clinical evidence
suggests line might be source
of infection [e.g. erythema
around exit site or symptoms
(e.g. fever, rigors) appeared
shortly after line flushed]
First line
Ciprofloxacin 400mg IV BD
And Co-amoxiclav 1.2 g IV
(500 mg if >65 yrs)
TDS for 48 hours
Plus Ciprofloxacin 400 mg IV
Change to oral equivalents
BD
after 48 hrs if afebrile
Add vancomycin 1 g IV 12 hourly (500 mg if >65 yrs)
Colony-stimulating factors
Discuss use of colony-stimulating factors (Lenograstim 263 microgram daily), with consultant
oncologist or haematologist
If patient who has had an allogeneic stem cell transplant is admitted febrile or unwell,
admitting doctor must contact the on-call haematology consultant immediately after initial
assessment
Subsequent management 2472 hr after initiating antibiotic treatment depends on blood culture
results and clinical condition. Always discuss subsequent management plan with consultant
haematologist or consultant oncologist
FBC daily until recovery

U&E daily until recovery
LFT 23 times weekly until recovery (unless significant abnormalities discovered on
admission sample)
Coagulation screen on admission
if normal, no further routine repeats necessary
if abnormal, seek advice from consultant haematologist or consultant oncologist
Serial CRP three times weekly until resolution of infection
If fever persists, repeat blood cultures based on clinical assessment
If clinically indicated, repeat chest X-ray
If fever not resolved after 7296 hr, urgent high-resolution chest CT discuss personally with
consultant radiologist
Infections in neutropenic patients typically take 27 days to respond to antimicrobial therapy
Obtain convalescent sample for viral serology 1014 days after initial sample

Discharge patients only after consultation with appropriate haematology or oncology team
Febrile traveller 2010-11
FEVER IN THE RETURNING TRAVELLER

Initial assessment is aimed primarily at early detection and treatment of falciparum
malaria, which can be rapidly fatal.
10% of patients with falciparum malaria are afebrile at presentation
Symptoms and signs
Temperature >37.5C in patient presenting after recent overseas travel (e.g. malaria
occurring 6 months after travel)
Rigors or night sweats imply fever; myalgia or arthralgia do not
Diarrhoea is non-specific and consistent with malaria, pneumonia or enteric pathogen
Travel history
Where? country and specific locations (e.g. city vs. rural)
Why? business, holiday, visiting relatives
Accommodation? (e.g. 5-star hotel vs. camping)
When? dates of departure and return, and their relation to onset of symptoms
viral haemorrhagic fevers (VHF) can be excluded if onset of symptoms >21 days after leaving
endemic area see http://www.hpa.org.uk/HPA/Topics/TopicsAZ/ and select viral
haemorrhagic fevers
symptoms of falciparum malaria take at least 8 days to manifest after arrival in endemic area.
Symptoms usually occur within 2 months of exposure, but may not present for up to 6 months
Differential diagnosis can be narrowed by considering incubation periods see Table 1
Table 1: Incubation periods
Incubation period
Short (<10 days)
Medium (1021 days)
Infection
Acute gastroenteritis (bacterial, viral)
Respiratory tract infection (bacterial, viral
including avian influenza)
Meningitis (bacterial, viral)
Arboviral infections (e.g. dengue,
Chikungunya)
Rickettsial infection (e.g. tick typhus, scrub
typhus)
Relapsing fever (borrelia)
Protozoal
Malaria (Plasmodium falciparum)
Trypanosomiasis (Trypanosoma
rhodesiensae)
Acute Chagas disease
Viral
HIV, CMV, EBV, VHF
Bacterial
Enteric fever (typhoid and paratyphoid fever)
Brucellosis
Q Fever
Leptospirosis
Long (>21 days)
Protozoal
Malaria (including Plasmodium falciparum)

Amoebic liver abscess
Visceral leishmaniasis
Viral
Viral hepatitis
HIV
What? risk activities

sexual history HIV
swimming in fresh water schistosomiasis (Africa) or rickettsial disease (eastern Europe,
Asia and South America)
tick bites rickettsial disease (North and South America, sub-Saharan Africa, coastal
Mediterranean)
animal/bird contact avian influenza
sickness occurring in fellow travellers or contacts: what? when? especially important in
outbreak situations
for information on outbreaks, visit www.who.int/csr/don/en
Pre-travel history
Pre-travel immunisations, antimalarials and adherence to them
Any previous medical history, specifically conditions/treatments that can induce
immunosuppression
EXAMINATION
Confirm presence of fever

Look for rashes, bites, jaundice, lymphadenopathy, hepatosplenomegaly see
http://www.britishinfectionsociety.org/drupal/sites/default/files/FeverReturnDraftBISNov08.pdf
INVESTIGATIONS
Recommended initial investigations in returning travellers presenting with
(undifferentiated) fever*
Investigation
Interpretation
Malaria film +/- dipstick antigen
Perform in all patients who have visited a tropical country within 1 year
test (RDT)
of presentation
Sensitivity of a thick film read by an expert is equivalent to that of an
RDT. However, blood films are necessary for specification and
parasite count
Three thick films/RDTs over 72 hr (as out-patient if appropriate) to
exclude malaria with confidence
Blood films (thick and thin) to reference laboratory for confirmation
FBC
Lymphopenia: common in viral infection (dengue, HIV) and typhoid
Eosinophilia (>0.5 109/L): incidental or indicative of infectious (e.g.
parasitic, fungal) or non-infectious cause
Thrombocytopenia: malaria, dengue, acute HIV, typhoid, also seen in
severe sepsis
Blood culture
Two sets before administering antibiotics
Sensitivity of up to 80% in typhoid
U&E
LFT
Serum save
Offer HIV to all patients with pneumonia, lymphocytic meningitis,
diarrhoea, unexplained fever
If indicated, other serology (e.g. arboviral, brucella)
EDTA for PCR

Urinalysis
Consider if other features suggestive of arboviral infection, VHF

Proteinuria and haematuria in leptospirosis
Haemoglobinuria in malaria (rare)
CXR
CRP
* In patients at high risk of VHF, avoid taking unessential blood tests before consulting infectious
diseases or microbiology
Thrombocytopenia present in >75% of patients with falciparum malaria, but also seen
in dengue and other infections
Neutrophilia suggests bacterial infection and eosinophilia may suggest parasitic
infection
MANAGEMENT
Contact infectious diseases team early at North Manchester General on 0161
624 0420 or Liverpool Hospital for Tropical Diseases on 0151 705 3100
Unless minor upper respiratory tract infection apparent, admit for assessment and exclude
falciparum malaria in those who have travelled to endemic areas. Three negative films taken
1224 hr apart are required to exclude malaria
If pandemic influenza or haemorrhagic fever suspected at time of GP referral or on admission
out of hours, contact microbiologist on call via switchboard
If malaria confirmed, follow British Infection Society guidelines
http://www.britishinfectionsociety.org/drupal/sites/default/files/MalariaAlgorithm07.pdf
If malaria identified but doubt about type, treat as falciparum especially if patient has returned
from a falciparum endemic area
If Gram-negative bacilli grown in blood of patient returning from a typhoid endemic
area (e.g. Indian sub-continent), give Tazocin and Gentamicin IV; do not use
ciprofloxacin as many strains of Salmonella typhi are resistant
Resistance patterns among pathogens vary according to locality (e.g. pneumococcal

penicillin resistance in Spain)
If patient displays features of sepsis/severe sepsis, seek immediate advice from senior
colleague and ITU see Sepsis, severe sepsis and septic shock guideline
Cellulitis 2010-11
CELLULITIS
Acute spreading bacterial infection below skin surface
Symptoms and signs

Erythema
Warmth
Swelling may be fluctuant
Tender/painful
Demarcated
Crepitus
Pyrexia
Non-severe
Systemically well with temperature 3638C
Cellulitis not involving face or hand
Severe
If any of following present:
lesion spreading rapidly
systemic features (e.g. temperature >38C or <36C, hypotension, tachycardia)
cellulitis involving face or hand
progression despite adequate doses of appropriate oral antibiotics
significant co-morbidities (e.g. asplenia, neutropenia, cirrhosis, immunocompromised,
cardiac or renal failure, or pre-existing oedema)
Likely organisms
Staphylococcus aureus
haemolytic streptococci
Anaerobes, particularly in patients with diabetes and/or ischaemic limbs
Those at risk
Diabetic
Intravenous drug user
Immunocompromised
Peripheral vascular disease
Investigations
FBC
U&E
CRP
ESR
If systemically unwell or pyrexial:
blood culture specimen see Collection of blood culture specimens guideline
Swab from:
portal of entry or aspirate of pus
cannula site and tip for culture (if source)
if skin broken swab for microbiology
If osteomyelitis suspected plain X-ray
If gas gangrene suspected, seek urgent surgical advice
Outline periphery of erythema with pen (indelible ink if possible)
If upper or lower limb involved, consider DVT in the presence of any of the following:
entire leg swollen
previously documented DVT
active cancer (treatment within six months, ongoing or palliative)
paralysis, paresis or recent immobilisation
Cellulitis 2010-11
local tenderness along distribution of deep venous system

calf circumference >3 cm than asymptomatic leg (measured 10 cm below tibial tuberosity)
Lymphangitis
Abscess
Venous eczema/ulcers
Necrotising fasciitis
Gas gangrene
Osteomyelitis
IMMEDIATE TREATMENT
Baseline observations:
temperature
pulse
blood pressure
blood glucose
Treat underlying cause (e.g. toe cleft tinea pedis infection)
Remove source of infection (e.g. cannula)
Severity
First line
Alternative (penicillin allergy)
Refer to Antibiotic Policy (page 56) on Intranet
MONITORING
Outline and monitor size of affected area daily
If patient does not require admission or is fit for discharge but needs IV antibiotics, refer to
Home IV Therapy Service (HITS) Ext. 1023.
Acute poisoning 2010-11
ACUTE POISONING/DRUG OVERDOSAGE

Features of drug overdose
Any comatose patient aged 1555 yr is likely to have taken a drug overdose
Depressed respiration suggests centrally-acting drug
Skin blisters (between knees/toes) common after barbiturates and tricyclics
Hypothermia after exposure or barbiturates
Venepuncture marks and pinpoint pupils suggest opioid overdose
Coma
Cyanosis
Hypotension
Paralytic ileus
Identify likely poison(s)/drug(s)
Ask patient, relatives, GP, ambulance crew. Retain any containers found
Investigations
U&E
Blood gases and acid-base
Save blood and urine for toxicological analysis. Urgent measurement of plasma/serum
concentrations essential in the diagnosis and management of confirmed poisoning with
ethylene glycol, iron, lithium, methanol, paracetamol, theophylline, and salicylate. There is no
need to measure the concentrations of these substances, with the exception of paracetamol,
unless there is a clear history of ingestion
Asymptomatic patients with a reliable history of ingesting <120 mg/kg of aspirin do NOT
require plasma salicylate measurement
Request plasma paracetamol concentration in all unconscious patients
in whom drug overdosage is considered
Seek advice
Use Toxbase on the internet: site address http://www.toxbase.org access and password
available on ECC and A&E
If further information required, contact National Poisons Information Service (0844 892 0111)
IMMEDIATE TREATMENT
A separate guideline gives more detailed advice on the management of overdosage with
paracetamol.
For management of overdosage with other drugs, see guidelines on Toxbase website
www.toxbase.org
Secure and maintain airway

Maintain circulation. If BP <100/60 mmHg with poor peripheral circulation despite being
placed in the head down position, give sodium chloride 0.9% and consider inserting CVP line.
Do not use vasoconstrictor drugs
Give antidote if appropriate
Give activated charcoal 50 g by mouth or nasogastric (NG) tube to patients who have
ingested a life-threatening amount of a toxic agent and who present within 1 hr of ingestion.
Activated charcoal does not affect absorption of acids, alkalis, alcohols, cyanide, ethylene
glycol, iron or lithium
Avoid ipecacuanha it does not empty the stomach reliably and can be dangerous
Acute poisoning 2010-11
Stop any regular medication that might enhance the effect of the substance taken in overdose
If life-threatening features are present:

Contact anaesthetist on call and request transfer to ITU (1032 ,1033) accompanied by a
doctor prepared to intubate if there is:
hypoxia or hypercapnia
feeble respiration
respiratory arrest
Supportive care alone is required for most acutely poisoned patients

After poisoning with certain chemicals/drugs further active measures may be necessary:
increase elimination in patients who have ingested life-threatening doses of
carbamazepine, dapsone, phenobarbital, quinine, or theophylline, give multiple dose
activated charcoal 50 g orally 4 hrly (if vomiting occurs, give 12.5 g hrly via NG tube), to total
of 200 g
if patient has ingested a potentially toxic amount of a modified-release or enteric-coated
formulation, consider whole bowel irrigation with polyethylene glycol (Kleen prep)
2030 mL/min via NG tube (maximum volume 4 L)
for overdose of aspirin, see guideline on Toxbase website www.toxbase.org
If patient has three of the following:
severe clinical intoxication Grade 4 coma, hypotension, hypothermia, hypoventilation
progressive clinical deterioration despite good supportive management
no evidence of improvement despite full resuscitative measures
prolonged coma with complications (e.g. pneumonia); or
high plasma concentrations of barbiturates, salicylate, theophylline or other drugs with a low
volume of distribution, whose elimination cannot be reliably hastened by multiple dose
activated charcoal (e.g. disopyramide, ethchlorvynol, glutethimide, meprobamate,
methaqualone and trichloroethanol derivatives)
Contact National Poisons Information Service (0844 892 0111) with a view to transfer
for haemoperfusion
Monitor conscious level, temperature, respiration, pulse and BP until they return to normal
There is no need to monitor drug concentrations other than to guide the use of measures to
enhance drug elimination
Psychiatric review
For all patients admitted after acute self-poisoning or deliberate drug overdose, follow the
steps on the self harm proforma (available in A&E, ECC and short stay ward). This will enable
you to decide whether to refer to the crisis team, the psychiatry liaison team or to discharge
patient
DISCHARGE POLICY
When discharged from hospital patients should have:

been conscious and alert with normal vital signs for at least 6 hr
no evidence of significant organ dysfunction as a result of poisoning/drug toxicity
Paracetamol 2010-11
DRUG OVERDOSAGE PARACETAMOL

ALSO SEE HOSPITAL MEDICAL PROFORMA

Symptoms and signs
Usually none
Nausea and vomiting occur within a few hours of ingestion of a hepatotoxic dose
Right subcostal pain and tenderness with recurrent nausea, vomiting and jaundice after two
to three days may indicate hepatic necrosis
Confusion may indicate encephalopathy
Investigations
Plasma paracetamol 4-16 hr after overdose (but not before or after this interval) is a reliable
guide to the need for treatment
Compare plasma paracetamol with treatment graph (Figure 1), bearing in mind that some
patients may be at higher risk of toxicity (categories listed below Figure 1)
in patients presenting 24-36 hr after overdose, where timing is certain, detection of
paracetamol in the plasma indicates a very substantial (or a staggered) overdose
If patient presents >8 hr after overdose, request baseline:
FBC, INR
U&E, liver function, phosphate
acid-base (venous sample)
IMMEDIATE TREATMENT
Activated charcoal
If patient is thought to have taken >12 g or 150 mg/kg (whichever is smaller) or >75 mg/kg
(equivalent to approximately 5 g (10 tablets) in a 70 kg patient considered to be high risk and
presents within previous hour of ingesting paracetamol, give activated charcoal 50 g orally or
via nasogastric tube
When using body weight to estimate risk of liver damage based on dose ingested, allow
maximum body weight 110 kg even in very obese patients weighing >110 kg
Acetylcysteine (standard regimen)
Protects liver if given with 24 hr of ingesting paracetamol and is most effective if given within
8 hr
For indications in Table 1, give IV acetylcysteine in 5% glucose: 150 mg/kg (maximum 16.5 g)
in 250 mL over
15 min; then 50 mg/kg (maximum 5.5 g) in 500 mL over 4 hr; then 100 mg/kg (maximum
11 g) in 1 L over 16 hr
if patient has experienced allergic reaction to acetylcysteine on a previous occasion, give
chlorphenamine 10 mg IV (over 1 min) before infusing antidote
For maximum protection treatment must start within 8 hr
Prepare and check infusion bags carefully. Administration errors are common
Acetylcysteine can cause a pseudo-allergic reaction (nausea, vomiting, urticarial rash,
angioedema, flushing, wheezing, tachycardia, hypotension) in up to 15% of patients,
usually within first 30 min of administration when large amounts are given rapidly. If this
occurs, stop infusion and consider giving chlorphenamine 10 mg IV (over 1 min),
nebulised salbutamol (if bronchospasm significant) and (if reaction severe)
hydrocortisone 100 mg IV. Once reaction has subsided, recommence infusion at rate of
Paracetamol 2010-11
100 mg/kg in 1 L over 16 hr. Further reactions are almost unknown
monitor patients with severe or brittle asthma carefully during first few hours
acetylcysteine has been associated with mild elevation of INR (up to but not exceeding 1.3)
Table 1
Time from
overdose
(hr)
4-14
Dose paracetamol/effect
Guidance on use of acetylcysteine
12 g or 150 mg/kg (75 mg/kg

in those at high risk)
Await paracetamol concentration result treat

if above, on, or even slightly below appropriate
treatment line'
Await paracetamol concentration result if this
will be available within 8 hr treat if above, on,
or even slightly below appropriate treatment
line'
Give at once while awaiting paracetamol
concentration result cease if concentration
well below appropriate treatment line
Give at once cease at 24 hr after ingestion if
patient asymptomatic, plasma paracetamol
<10 mg/L and INR 1.3
Plasma paracetamol will confirm ingestion but
cannot be related to the nomogram. Discuss
with hepatologist Dr Koss, Dr. Saravanan
4-7
>12 g or 150 mg/kg (>75 mg/kg

8-14
>12 g or 150 mg/kg (>75 mg/kg

15-24
>12 g or 150 mg/kg (>75 mg/kg

Multiple
doses
(staggered
overdose)
>24
>12 g or 150 mg/kg (>75 mg/kg

in those at high risk) in divided
doses over 24 hr
>24
>12 g or 150 mg/kg (75 mg/kg

OR symptomatic
INR >1.3, ALT >150 IU/L,

abnormal acid/base or
bicarbonate
Give if paracetamol still detectable in the blood

or INR >1.3 or ALT >150 IU/L
If patient has, or is at risk of developing,
fulminant hepatic failure (see life-threatening
features below), continue to give 50 mg/kg in
500 mL every 8 hr
Discuss with hepatologist Dr.Koss or
Birmingham Liver Unit
Other
Monitor urine output, If this cannot be done accurately, insert urinary catheter. Rehydrate to
maintain urine output >100 mL/hr
If concerns about cardiac impairment, insert CVP line to monitor response to IV fluids
In patients with liver necrosis, monitor blood glucose 4 hrly
With any evidence of encephalopathy, maintain Na >135 mmol/L
A poor prognosis is indicated by:
INR >3.0
plasma creatinine >200 mol/L
blood pH <7.3
signs of encephalopathy
If any of these features is present after overdose, seek advice from a hepatologist Dr Koss or
Dr Saravanan
Hypophosphataemia usually occurs after paracetamol poisoning and correlates well with the
degree of hepatic damage
Treat haemorrhage with fresh frozen plasma. Do not correct coagulation unless bleeding
Paracetamol 2010-11
Time of
presentation after
overdose (hr)
<8
8-15
16
Monitoring/continued treatment
Discharge policy
INR, AST/ALT, creatinine,

bicarbonate 24 hr after overdose or
when antidote treatment complete
if INR >1.3 or creatinine raised, or
patient acidotic, continue
treatment (IV acetylcysteine
150 mg/kg over 24 hr)
recheck INR and U&E 12 hrly
until clearly falling
bicarbonate and phosphate 24 hr
after overdose or when antidote
treatment complete
if INR >1.3 or creatinine raised, or
patient acidotic, continue
treatment (IV acetylcysteine
150 mg/kg over 24 hr)
Discharge if INR 1.3,

AST/ALT and plasma
creatinine normal at 24 hr after
overdose, or after antidote
treatment complete, with
warning to return if vomiting or
abdominal pain occur
Observe for signs of

encephalopathy (mental confusion,
drowsiness, spatial disorientation,
asterixis)
Urine output
Capillary blood glucose 4 hrly
Blood gases and acid-base daily
bicarbonate and phosphate 24 hr
after overdose or when antidote
treatment complete
if INR >1.3 and rises, or
creatinine raised, or patient
acidotic, continue treatment (IV
acetylcysteine 150 mg/kg over
24 hr) until INR <2.0
If INR 1.3, AST/ALT and

plasma creatinine normal:
discharge asymptomatic
patients 12 hr after antidote
treatment with warning to
return if vomiting or abdominal
pain occur
If INR >1.3 and rises, and/or
plasma creatinine raised after
antidote treatment, monitor and
observe until these indices are
falling and INR <2.0
If INR 1.3, AST/ALT and
plasma creatinine normal:
discharge asymptomatic
patients 72 hr after antidote
treatment with warning to
return if vomiting or abdominal
pain occur
If INR >1.3 and rises, and/or
plasma creatinine raised after
antidote treatment, monitor
and observe until these indices
are falling and INR <2.0
Patients presenting
24-36 hr after overdose can
develop hepatic dysfunction
after this time, even if INR,
ALT and creatinine normal at
time of presentation repeat
these indices 12 hr later
Paracetamol 2010-11
Figure 1: Treatment graph for paracetamol overdose. Agreed by National Poisons Centres-July
1995
Prognostic accuracy after 15 hours uncertain

Use high risk treatment line' for patients taking enzyme-inducing drugs (e.g. barbiturates,
phenytoin, carbamazepine, rifampicin, St Johns wort), who regularly consume alcohol in excess
of recommended amounts, or who may have glutathione depletion (e.g. eating disorders, cystic
fibrosis, HIV infection, starvation, cachexia); they are at higher risk of hepatic necrosis
Acetylcysteine is indicated in patients with values on or above appropriate treatment line
Drug withdrawal 2020-11
WITHDRAWAL OF DRUG(S) OF DEPENDENCE

Withdrawal syndromes are specific to:

type of drug involved
route of administration
frequency of use
quantity used
individual variation in sensitivity
psychological state
Mild symptoms occurring after withdrawal of a drug do not require routine medical intervention.
Explaining to patient likely course of withdrawal has been shown to reduce severity of withdrawal
symptoms
Investigations
Obtain witnessed urine sample for drug screen in a plain white top bottle and send to
laboratory.
Check patients prescribed medications with GP when surgery open
if patient states they are taking opiate substitute, contact prescriber.
Pregnancy test, if indicated

Pregnancy is an indication for very detailed assessment and close management of
withdrawal because of risks to fetus. and contact obstetric team on call see Management
of a pregnant woman with a non-obstetric problem guideline
OPIATE WITHDRAWAL
Symptoms and signs
Nausea, vomiting
Diarrhoea
Restlessness, anxiety
Irritability, insomnia
Muscle and bone pains
Running eyes and nose
Sneezing, yawning
Sweating, flushing
Dilated pupils, pilo-erection
In a hospital setting assess severity using Table 1

score 0 if not present
score 1 if mildly present
score 2 if strongly present
Table 1:
Signs
Pupillary dilation
Rhinorrhea
Lacrimation
Pilo-erection
Nausea/vomiting
Diarrhoea
Yawning
Cramps
Restlessness
Subjective evaluation
Score <5, no medical treatment indicated

Score >5, treatment may be indicated
IMMEDIATE TREATMENT
Where withdrawal symptoms are of sufficient severity to warrant medical treatment, several
options are available
Symptomatic treatment
Nausea, vomiting and insomnia promethazine hydrochloride 25 mg orally 12 hrly
Somatic anxiety propranolol 40 mg orally 8 hrly
Diarrhoea loperamide 4 mg orally single dose
Stomach cramps hyoscine butylbromide 10-20 mg orally 6 hrly
Pain paracetamol 1 g orally 6 hrly or ibuprofen 400 mg orally 8 hrly if required
Opiate substitution
Do not give substitutes unless a urine test confirms presence of opiates. Drug of choice is
methadone mixture (1 mg/1 mL) do not use injectable or tablet forms of methadone. Do
not give alternative forms of opiate unless discussed with
Initial dose
Measure withdrawal symptoms using Table 1 at 6 hrly intervals. If score >5, give methadone
1 mg per point (i.e. score of 5 = no dose, score of 7 = 7 mg)
if patient has used a significant amount of heroin immediately before admission, perform a
second 24 hr assessment and use higher of the two dosage estimates to manage withdrawal
Maintenance dose
Total amount administered using initial regimen over 24 hr is daily dose required to control
withdrawal state
give methadone as single daily dose once the stable dose has been achieved
Maximum dose in 24 hr should not exceed 50 mg without specialist advice
Aim to allow patient to stabilise on the dose of methadone reached by titration with any
reductions arranged by continuing care teams once discharged
On discharge
Complete withdrawal table 6 hrly (Table 1)
Contact agency that has agreed to continue prescribing allow as much warning as possible
in order for necessary arrangements to be made
relevant agency will confirm arrangements for prescription and appointment
Do not write methadone prescription as a TTO
Notify GP
SEDATIVE WITHDRAWAL
Benzodiazepines and other sedative hypnotic drugs

Alcohol see Alcohol withdrawal guideline
Symptoms and signs

Confusion
Nystagmus
Tremor
Agitation, irritability
Insomnia
Pyrexia
Hyperreflexia
Weakness
Convulsions
IMMEDIATE TREATMENT
In initial stages, treatment of sedative withdrawal is similar to that for alcohol see Alcohol
withdrawal guideline. Once symptoms controlled, change to long-acting benzodiazepine
(chlordiazepoxide, diazepam) in an equivalent dose (Table 2) to maintain clinical state and
discuss a longer term strategy with either patients GP.
Table 2: Equivalent dosages
Drug
Dosage
Chlordiazepoxide
15 mg
Diazepam
5 mg
Loprazolam
500 microgram
Lorazepam
500 microgram
Oxazepam
15 mg
Temazepam
10 mg
Nitrazepam
5 mg
STIMULANT WITHDRAWAL
There are no acute symptoms of stimulant withdrawal that need medical treatment as a matter of
urgency. Insomnia and anxiety can be treated symptomatically. Advice and support are valuable.
Depressive symptoms sometimes occur as a later withdrawal effect and can be treated with an
antidepressant
VOLATILE SUBSTANCES
Commonly misused are butane, toluene, glues, petrol
As there are no physical withdrawal syndromes, it is best to discontinue use abruptly. Treatment
of intoxication involves general supportive measures
CANNABIS
Treat anxiety and insomnia symptomatically
Alcohol withdrawal 2010-11
ALCOHOL WITHDRAWAL
Alcohol withdrawal can be a presenting feature or occur as an unexplained development in a
patient who has been admitted for other reasons and deprived of alcohol. Untreated, it carries a
15% mortality rate. Mild withdrawal generally begins 68 hr after last drink, but can be sooner or
considerably delayed. Moderatesevere withdrawal occurs about 48 hr after last drink
Symptoms and signs
Anxiety
Sweating
Tremor
Ataxia
Confusion
Frequent attendance at emergency services (e.g. with upper GI symptoms)
Assess severity using Clinical Institute Withdrawal Assessment of Alcohol Scale (revised CIWAAr) form (example below) available from Trust intranet Clinical section>clinical guidelines. Ask
specific questions shown for each category and use CIWA-Ar form to derive score from answers
or observations
Score 08 absent or minimal withdrawal
Score 919 mild to moderate withdrawal
Score >20 severe withdrawal
For advice on assessment, contact alcohol liaison.
Note that a patient can develop a withdrawal state whilst consuming large quantities of alcohol if
there is a high degree of tolerance towards alcohol
Detailed alcohol history
Quantity
Frequency of use
Highest intake
Previous treatment
Previous abstinence
Triggers for drinking
Psychiatric problems
Motivation
Investigations
FBC
U&E
LFT, phosphate, calcium, magnesium, blood glucose
INR
Arterial blood gases (moderatesevere withdrawal)
Urine drug screen
Breath/blood alcohol
See Acute confusional state (delirium) in older people guideline
Acute alcoholic hepatitis with hepatic encephalopathy
Withdrawal of intoxication with drug(s) of abuse see Withdrawal of drug(s) of
dependence guideline
Alcohol withdrawal assessment (based on CIWA-Ar scale)

Patient name __________________________________________ Hospital no:________________________
1.
2.
3.
4.
Assess vital signs and record on MEWS chart (review alongside CIWA-Ar assessments)
Complete Assessment using CIWA-Ar scale (full form available on Trust intranet Clinical section>clinical Guidelines>Forms)
If initial CIWA-Ar score 8 repeat assessment hrly for 8 hr. If stable, repeat assessment 2 hrly for 8 hr, if stable assess 4 hrly
If initial score <8 assess 4 hrly for up to 72 hr. If score <8 for 48 hr, discontinue assessments. If score increases to 8 at any
point, return to step 3
5. If indicated (see below) administer PRN medication as prescribed and record on MEWS and drug chart
6. Prescribe diazepam unless patient elderly, has significant COPD or severe liver impairment, in which case use lorazepam
Assess and rate each of the following (CIWA-Ar Scale)
Date
Time (24 hr clock, midnight = 00.00)
Nausea/ vomiting (07)
0none. 1 mild nausea only. 4
intermittent nausea. 7 constant nausea,
frequent dry heaves & vomiting
Tremors (07)
0 none. 1 not visible, can be felt. 4
moderate w/ arms extended. 7 severe,
even w/ arms not extended
Anxiety (07)
0 none. 1 mild anxiety. 4 moderately
anxious. 7 equivalent to acute panic state
Agitation (07)
0 none. 1 fairly normal activity
4 moderately fidgety/restless. 7 very
agitated/thrashing about
Paroxysmal sweats (07)
0 none. 1 barely perceptible sweats,
palms moist. 4 sweat beading forehead.
7 drenched with sweat
Orientation (04)
0 orientated. 1 uncertain about date.
2 disorientated to date by no more than
2 days. 3 disorientated to date by
>3 days. 4 complete disorientation
Tactile disturbances (07)
0 none. 1 v. mild itch, P&N, numbness.
2 mild itch, P&N, burning, numbness.
3 mod. itch, P&N, burning, numbness.
4 mod. hallucinations. 5 severe
hallucinations. 6 extremely severe
hallucinations. 7 cont. hallucinations
Auditory disturbances (07)
0 none. 1 v. mild, ability to startle.
2 mild, ability to startle. 3 mod.
harshness, ability to startle. 4 mod.
hallucinations. 5 severe hallucinations.
6 extremely severe hallucinations.
7 cont. hallucinations
Visual disturbances (07)
0 none. 1 v. mild sensitivity. 2 mild
sensitivity. 3 mod. sensitivity. 4 mod.
hallucinations. 5 severe hallucinations.
6 extremely severe hallucinations.
7 cont. Hallucinations
Headache (07)
0 none. 1 v. mild. 2 mild.
3 moderate. 4 mod. severe. 5 severe.
6 v. severe. 7 extremely severe
Total CIWA-Ar score
As required med (circle one)
given (mg)
Diazepam Lorazepam
Route
Dose

Time of as required medication
administered
Assessment of response (CIWA-Ar score)
3060 min after medication
RN signature / initials
Scale for scoring
09 = absent or minimal withdrawal
1019 = mild to moderate withdrawal
>20 = severe withdrawal
Symptom control
If CIWA-Ar score >8, start symptom triggered treatment with benzodiazepines:
If patient elderly, has significant COPD or severe liver impairment, prescribe
lorazepam 1 mg as required
otherwise, prescribe diazepam 5 mg as required
If CIWA-Ar score >15, consider higher dose diazepam 10 mg /lorazepam 2 mg
Indications for senior review and possible transfer to ITU

Seek senior advice on possible transfer to ITU if :
CIWA-Ar score >35
patient has needed assessments hrly for >8 hr
patient has required >4 mg lorazepam over 3 hr or 30 mg diazepam
over 3 hr
patient in respiratory depression
ADMISSION OR DISCHARGE
If alcohol withdrawal sole clinical problem, patient not elderly and there is no other reason to
warrant admission to hospital, discharge patient but consider community detoxification. only
patients as defined below require in-patient treatment/detoxification
Patients with mild or moderate withdrawal features can be managed in the community subject
to liaison with community alcohol team and ensure that detoxification will be appropriately
supervised and patients followed up
Admission criteria (taken from SIGN guidelines)

Patient confused or has hallucinations
Patient has epilepsy or history of fits
Patient undernourished
Severe vomiting or diarrhoea
At risk of suicide
Severe dependence coupled with unwillingness to be seen daily
Uncontrollable withdrawal symptoms
Acute physical or psychiatric illness
Multiple substance misuse
Home environment unsupportive of abstinence
Previous complicated withdrawal
Home-assisted withdrawal failed previously
IMMEDIATE TREATMENT
Fluids and electrolytes
Monitor and replace electrolytes, magnesium and phosphate and give adequate hydration
see Maintenance fluid therapy guideline (defer glucose infusions until after first dose of
thiamine replacement given as it can precipitate Wernickes encephalopathy)
Vitamin therapy
This is most effective when given parenterally as oral absorption is poor; IV route is
preferable but if this is not available, use IM route. Unless continuing diet likely to be poor,
oral thiamine supplementation is unnecessary following IV treatment
Low risk drinkers
If no neuropsychiatric complications, appears healthy and believed to take a reasonable diet,
give thiamine 100 mg orally 8 hrly and vitamin B compound strong 2 tabs orally 8hrly during
detoxification or periods of particularly high alcohol intake
At risk patients
At risk of developing Wernickes (e.g. malnourished, poor diet, significant weight loss, memory
disturbance, past history of Wernickes);
Give parenteral thiamine as Pabrinex IV High potency injection one pair of ampoules (mixed)
by IV infusion in sodium chloride 0.9% 100 mL over 30 min once daily for first three days of
detoxification
If IV route not available, give one pair of ampoules IM into gluteal muscle once daily for
three days. Use Pabrinex preparation specific to IM injections

Symptoms of Wernickes encephalopathy
Confusion, ataxia, nystagmus, ophthalmoplegia or neuropathy
Give parenteral thiamine as Pabrinex IV High potency injection two pairs of ampoules
(mixed) by IV infusion in sodium chloride 0.9% 100 mL over 30 min 8 hrly for first three
days of detoxification. Give parenteral thiamine (IM or IV) two pairs of ampoules pabrinex for
3 days, followed by one pair of ampoules once daily for 35 days or as long as some
symptoms continue and some improvement is observed
If IV route not available, give one pair of ampoules IM into gluteal muscle 12 hrly for three
days. Use Pabrinex preparation specific to IM injections
If physical symptoms persist beyond 3 day, give one pair of ampoules IV or IM once daily
for as long as some symptoms continue and some improvement is observed
Symptom control
The aim is to prevent features of withdrawal without oversedation. Individual dose
requirements vary considerably and can be decided only by assessing response regularly
and omitting or adding doses as necessary
If CIWA-Ar score >8, start symptom triggered treatment with benzodiazepines:

If patient elderly, has significant COPD or severe liver impairment, prescribe lorazepam 1 mg
as required
otherwise, prescribe diazepam 5 mg as required
If CIWA-Ar score >15, consider higher dose diazepam 10 mg/lorazepam 2 mg
Indications for senior review and possible transfer to ITU

Seek senior advice on possible transfer to ITU if :
CIWA-Ar score >35
patient has needed assessments hrly for >8 hr
patient has required >4 mg lorazepam over 3 hr or 30 mg diazepam over 3 hr
patient in respiratory depression
If drowsy, confused or concern about previous readings, blood glucose 2 hrly
Seizures
Manage seizures First seizure and Cluster seizures guidelines. However, withdrawal
seizures alone do not signify epilepsy and maintenance anticonvulsant therapy is
unnecessary
Refer all patients to liaison service ideally whilst in-patient otherwise on discharge
Generate discharge letter for GP
Triage hyperglycaemia 2010-11
TRIAGE OF PATIENTS WITH HYPERGLYCAEMIA

Metabolic acidosis;
pH <7.3 and HCO3
<15 mmol/L
Persistent hyperglycaemia
(blood glucose >12 mmol/L)
How ill is the patient?

Do they have the following
features of
ketoacidosis/hyperosmolar
hyperglycaemic state
Thirst
Polyuria
Flushed appearance
Sighing respiration
(Kussmaul breathing)
Odour of ketones on breath
Dehydration
Drowsiness
Yes
No
Follow diabetic ketoacidosis fluid

and insulin regimen in Diabetic
ketoacidosis and hyperosmolar
hyperglycaemic state guideline
Follow hyperosmolar hyperglycaemic

state fluid and insulin regimen in
Diabetic ketoacidosis and
hyperosmolar hyperglycaemic state
guideline
No
Dehydration and/or vomiting,

and/or unable to drink?
No
Yes
See Control of hyperglycaemia in the ill

patient guideline (unstable patients)
Yes
See Control of hyperglycaemia in the ill

patient guideline (stable patients)
Hyperglycaemia control 2010-11
CONTROL OF HYPERGLYCAEMIA IN THE ILL

PATIENT
Check that this is the correct guideline see Triage of hyperglycaemia in the ill patient
The guideline below must not be used in patients with metabolic acidosis and/or
severe dehydration see Diabetic ketoacidosis and hyperosmolar hyperglycaemic
state guideline
Patients with blood glucose persistently >12 mmol/L during monitoring

in all ill diabetic patients, acute illness increases counter-regulatory (stress) hormones
that oppose the action of insulin and lead to a deterioration of glycaemic control
patients who normally have acceptable glycaemic control will usually show deterioration
in glucose control when they are given therapeutic doses of corticosteroids
Investigations
Blood glucose (capillary)
monitor at least 4 hrly in ill diabetic patients and/or when starting therapeutic doses of
corticosteroids
if persistently high, check venous blood glucose
MANAGEMENT
Never give single doses of insulin (e.g. Actrapid) they lead to large swings in glucose
concentration
Withhold metformin if there is significant renal impairment (creatinine >130 mmol/L and
eGFR <45 mL/min), decompensated cardiac failure, liver failure or lactic acidosis
Decide whether patient stable or unstable (see below); if in any doubt, discuss with
diabetes nurse specialist or SpR/consultant in diabetes
Stable patients
In patients with persistent hyperglycaemia (but no acidosis) who have mild or no dehydration,
and who are able to eat and drink:
If using insulin, increase usual total daily insulin dose by 1020%
If taking oral agents, add low-dose insulin, such as 1012 units of Isophane or lantus:
at bedtime (if morning fasting glucose is >12 mmol/L), OR
at breakfast time (if pre-evening meal glucose is >12 mmol/L), OR
at bedtime and breakfast time (if both morning fasting and pre-evening meal glucose are
>12 mmol/L)
monitor capillary blood glucose 4 hrly
If taking pioglitazone, be alert for appearance of dyspnoea or peripheral oedema as
introduction of insulin can precipitate heart failure
Unstable patients
In patients with persistent hyperglycaemia (but no acidosis) who have definite dehydration
and/or are vomiting or unable to drink:
Stop usual antidiabetic regimen
Infuse BOTH of the following through an antisyphon valve (see Administration of fluid
and insulin infusions guideline):
+
sodium chloride 0.9% IV at rate according to state of hydration and serum K see
Maintenance fluid therapy guideline
soluble insulin infusion 1 unit/mL in sodium chloride 0.9% (50 units/50 mL) via IV pump at
3 units/hr
Monitor
Check capillary blood glucose (CBG) with meter 1 or 2 hrly as indicated in Table 1
At each CBG check, follow Table 1, aiming to keep glucose between 6 and 11 mmol/L
Avoid large step changes in insulin infusion rate that will lead to large swings in
plasma glucose. Patients very rarely require >4 units/hr or <2 units/hr
Table 1: Unstable patients
Capillary blood glucose
(CBG)
<3.0 mmol/L
(check CBG hrly)
3.05.9 mmol/L
(check CBG hrly)
Target range
6.011.0 mmol/L
(check CBG 2-hrly)
>11.0 mmol/L
(check CBG 2-hrly)
Action
Insulin infusion rate (units/hr) and fluid (remember K+ replacement)
NOTIFY DOCTOR IMMEDIATELY
Check pump and patency of IV cannula and that adequate and
appropriate fluids being given
Consider reducing insulin infusion rate to 0.5 unit/hr and/or
changing IV infusion fluid to glucose 20%
Do NOT STOP insulin infusion in patients with type 1 diabetes
In patients with type 2 diabetes, if above actions have not resolved low
CBG, consider stopping insulin infusion for 30 min ONLY and
monitoring blood glucose
For difficult to control patients, contact diabetes team or medical SpR
(out of normal working hours)
If insulin infusion rate is 2 units/hr or more, reduce rate by 1 unit/hr
If, after reducing insulin infusion rate to 1 unit/hr, CBG remains
3.05.9 mmol/L for two consecutive hr, continue at 1 unit/hr and change
infusion fluid:
if infusion fluid is sodium chloride 0.9%, change to glucose 5%
if infusion fluid is glucose 5%, change to glucose 10%
if infusion fluid is glucose 10%, NOTIFY DOCTOR consider changing
to glucose 20% and reducing insulin infusion rate further to 0.5 unit/hr
Maintain same insulin infusion rate
Increase insulin infusion rate by
1 unit/hr
Restarting or commencing SC insulin regimen

Restart SC insulin as soon as patient eating and drinking, and capillary blood glucose
maintained at <11 mmol/L for most of day by IV insulin and fluid infusions
if patient previously using SC insulin, restart and maintain usual insulin at a dosage
1020% higher than previous dosage for first two to three days
if patient not previously using SC insulin, add up total insulin dosage in previous 24 hr and
divide into four equal doses give three of these as soluble insulin SC
(e.g. Novorapid, Humalog), one 10-15 min before each meal, and the fourth as long
acting insulin SC (e.g.Lantus, Levemir ) at 22.00 hr
after first dose of insulin, continue IV insulin pump and fluid infusion for 1 hr if dose was
soluble (e.g. Humulin S) or for 4 hr if it was Isophane or long acting insulin ( Lantus,
Levemir )
Adjusting SC insulin regimen
Once patient using SC insulin regimen, adjust doses to achieve target range of
611 mmol/L
if using soluble insulin before breakfast, lunch and dinner, plus Isophane at 22.00 hr, use
Table 2 as guide to insulin adjustment, raising or lowering appropriate insulin by 24 units
if patient usually using insulin analogue (e.g. lispro/aspart + glargine/detemir), additional
Isophane may be needed discuss with diabetes team
Table 2
Time of capillary blood
glucose
Pre-breakfast (0800 hr)
Pre-lunch (1200 hr)
Pre-dinner (1700 hr)
Pre-bed (2200 hr)
Glucose >11 mmol/L

bedtime Isophane
morning soluble
lunchtime soluble
evening soluble
Glucose <6 mmol/L

bedtime Isophane
morning soluble
lunchtime soluble
evening soluble
RECOVERY
As patient recovers and/or corticosteroid dosage reduced, monitor glycaemic control and
reduce insulin dosage appropriately
if reintroduction of pre-admission anti-diabetic regimen proves difficult, refer to diabetes
nurse specialist
If in any doubt about diabetic control on discharge, discuss with diabetes nurse specialist
/ Diabetes team
DKA 2010-11
DIABETIC KETOACIDOSIS AND HYPEROSMOLAR

HYPERGLYCAEMIC STATE
Check you are using correct guideline see Triage of hyperglycaemia in the ill patient
The guideline below must not be used in patients who have neither metabolic acidosis nor
severe dehydration see Control of hyperglycaemia in the ill patient guideline

Symptoms and signs
Thirst
Polyuria
Flushed appearance
Hyperventilation (Kussmaul breathing)
Odour of ketones on breath
Dehydration
Drowsiness
Coma
Investigations
Initial
Blood glucose (capillary)
Test for ketones in urine
U&E
Blood glucose (venous)
Arterial blood gases
MSU
If febrile, blood culture
ECG
Chest X-ray
Search for precipitating causes of diabetic ketoacidosis (DKA) or hyperosmolar
hyperglycaemic non-ketotic state, such as sepsis (signs of shock) or recent myocardial
infarction
Monitoring treatment
Monitor patient for complications of over-rapid treatment:
hypoglycaemia
cerebral oedema (decreased conscious level +/- focal neurological deficit) in absence
of hypoglycaemia
ARDS (Adult Respiratory Distress Syndrome; hypoxia resistant to high FiO2)
consider transfer to ICU
Investigation
Blood glucose strip (capillary)
Serum electrolytes
Blood glucose laboratory (venous)
pH if initial pH <7.0
If no hypoxia on initial blood gases,
subsequent venous blood gas is less painful
and as reliable for pH, pCO2, HCO3 and base
excess
Time (time 0 hr = admission)

Hrly for 6 hr, then 2 hrly
At change of each IV fluid bag
2, 6 hr
DKA 2010-11
IMMEDIATE TREATMENT
General
If patient febrile and septic and no obvious cause can be found see Sepsis, severe sepsis
and septic shock guideline
If patient hypotensive or comatose, or fails to pass urine within 3 hr of starting IV fluids,
introduce urethral catheter to monitor urine volume see Urethral catheterisation guideline
If hypotension persists beyond 6 hr, look again for evidence of sepsis, myocardial infarction
or pancreatitis discuss further management with medical registrar and consider transfer to
ICU
If patient unconscious, request review by ICU team for endotracheal intubation and insertion
of a nasogastric tube in order to aspirate stomach
If not on ICU, admit patient to an endocrinology ward 7
If hyperglycaemia (blood glucose usually >15 mmol/L) accompanied by metabolic acidosis
and dehydration, manage as Diabetic ketoacidosis
If hyperglycaemia severe (blood glucose usually >30 mmol/L), accompanied by severe
dehydration without metabolic acidosis, manage as Hyperosmolar hyperglycaemic nonketotic state
Otherwise Control of hyperglycaemia in the ill patient guideline
DIABETIC KETOACIDOSIS
Administer insulin and glucose infusions via the same cannula using an antisyphon
valve see Delivery of fluid and insulin infusions guideline in Practical procedures
Insulin
Soluble insulin infusion ( Actrapid ) 1 unit/mL in sodium chloride 0.9% via IV syringe pump
at 6 units/hr
If no fall in glucose after 2 hr (very unusual check pump and patency of IV cannula),
consider doubling dose repeatedly every 2 hr until response occurs
If patient using basal bolus insulin regimen (with short-acting insulin injections before meals
and a basal insulin am/pm) before admission and basal insulin is glargine (lantus) or detemir
(levemir), continue same dose of insulin glargine or detemir subcutaneously, in addition
to insulin infusion
prescribe basal insulin glargine (lantus) or detemir (levemir) separately on the main
prescription chart in such situations do not write in the once only section
When glucose falls to <15 mmol/L and serum bicarbonate has improved, reduce insulin
infusion rate to 3 units/hr follow Subsequent management
IV fluid and potassium
Always use commercially produced pre-mixed bags of sodium chloride 0.9% and
potassium chloride. NEVER add potassium chloride to infusion bags
Measure serum potassium (K+) together with venous glucose on admission and whenever a bag
of fluid is replaced. Use last serum K+ to determine which bag should be used in the following
regimen (Table 1)
Table 1
Time (hr)
First 30 min
before K+ known
K+ >5.5
Sodium chloride 0.9% 1 L
K+ 3.55.5
Sodium chloride
0.9% 1 L
K+ <3.5
Sodium chloride 0.9%
1L
Next 1 hr
Sodium chloride
0.9% 1 L with
potassium chloride

1 L with potassium
chloride 40 mmol
DKA 2010-11
Next 2 hr
Next 4 hr
20 mmol
Sodium chloride
0.9% 1 L with
potassium chloride
40 mmol
Sodium chloride
0.9% 1 L with
potassium chloride
40 mmol

2 500 mL, each with
potassium chloride
40 mmol/500 mL.
First over 1 hr, next over
following 1 hr
2 500 mL, each with
potassium chloride
40 mmol/500 mL.
following 2 hr
While potassium is being infused, attach patient to cardiac monitor
Further fluid and K+ requirement dictated by patients condition and serum K+ usually 1 L of
fluid over next 6 hr (Table 2), repeated until glucose fallen to 15 mmol/L and serum
bicarbonate has improved, move to Subsequent management
Table 2
Time (hr)
Next 6 hr
K+ >5.5
K+ 3.55.5
1 L with potassium
chloride 40 mmol
K+ <3.5
2 500 mL with
potassium chloride
40 mmol/500 mL. First
over 3 hr, next over
following 3 hr
Bicarbonate
Use only with extreme caution after discussion with a consultant physician
If initial pH <7, recheck pH after 2 hr of infusing fluid regimen as in Table 1

consider other causes of severe acidosis (e.g. salicylate poisoning)
if pH >6.9, sodium bicarbonate is unnecessary
if pH 6.86.9, stop IV replacement fluid as in Table 1 and give sodium bicarbonate
1.26%
300 mL IV over 30 min simultaneously with sodium chloride 0.9% 500 mL with 10 mmol
potassium (commercially produced pre-mixed bag)
if pH <6.8, stop IV replacement as in Table 1 and give sodium bicarbonate 1.26% 600
mL IV over 1 hr simultaneously with sodium chloride 0.9% 1 L with 20 mmol potassium
(commercially produced pre-mixed bag)
Resume former IV fluid regimen (Table 1) after giving sodium bicarbonate
HYPEROSMOLAR HYPERGLYCAEMIC STATE

Administer insulin and glucose infusions via same cannula see Administration of fluid
and insulin infusions guideline in Practical procedures
Insulin
Soluble insulin infusion 1 unit/mL in sodium chloride 0.9% via IV syringe pump at 3 units/hr
If no fall in glucose after 2 hr (very unusual check pump and patency of IV cannula),
consider doubling dose repeatedly until response occurs
DKA 2010-11
IV fluid and potassium

Always use commercially produced pre-mixed bags of infusion fluid and potassium
chloride.
NEVER add potassium chloride to infusion bags
Measure serum K+ together with venous glucose on admission and whenever a bag of fluid is
replaced. Use last serum K+ to determine which bag should be used in the following regimen
(Table 3)
Table 3
Time (hr)
First 8 hr
K+ >5.5
K+ 3.55.5
1 L with potassium
chloride 40 mmol
Next 8 hr

1 L with potassium
chloride 40 mmol
Next 8 hr

1 L with potassium
chloride 40 mmol
K+ <3.5
2 500 mL, each with
potassium chloride
40 mmol/500 mL.
following 4 hr
2 500 mL, each with
potassium chloride
40 mmol/500 mL.
following 4 hr
2 500 mL, each with
potassium chloride
40 mmol/500 mL.
following 4 hr
While potassium is being infused, attach patient to cardiac monitor
Repeat Table 3 until glucose fallen to 15 mmol/L, then move to Subsequent management
Once blood glucose has fallen below 15 mmol/L, use glucose 5% in fluid and K+ regimen
(Table 4) to avoid cerebral oedema caused by over-rapid fall in blood glucose
Table 4
Time (hr)
First and
subsequent 8 hr
K+ >5.5
Glucose 5% 1 L
K+ 3.55.5
Glucose 5% 2
500 mL, each with
potassium chloride
20 mmol/500 mL.
Each over 4 hr
K+ <3.5
Glucose 5%
2 500 mL, each with
potassium chloride
40 mmol/500 mL. First
over 4 hr, next over
following 4 hr
reduce insulin infusion rate to 3 units/hr, giving enough insulin to suppress

ketogenesis
Blood glucose may rise as a result. Do not revert to sodium chloride 0.9% unless
plasma pH falls
If glucose falls below 6 mmol/L, change fluid regimen to glucose 10% (Table 5)
DKA 2010-11
check capillary glucose in 1 hr

if glucose continues to fall, reduce insulin infusion rate to 2 units/hr do not stop
insulin
Table 5
Time (hr)
First and
subsequent 8 hr
K+ >5.5
Glucose 10% 1 L
K+ 5.5
Glucose 10% 2 500 mL, each with potassium
chloride 20 mmol/500 mL. First over 4 hr, next
over following 4 hr
if patient with DKA still acidotic or very dehydrated, simultaneously give sodium
chloride 0.9% 1 L over next 8 hr
as a rule, SC insulin can be substituted completely for IV insulin within 48 hr of
admission, by which time patient should be normoglycaemic and eating normally. If
patient previously using SC insulin, restart usual insulin, increasing previous dose by
1020% for first two to three days. Otherwise, add up total insulin dose in previous 24
hr and divide into four equal doses. Give three of these as soluble insulin SC (e.g.
Humulin S, Novorapid, Humalog ) one 1015 min before each meal, and the fourth as
long acting insulin SC (e.g. Insulatard/Humulin I)Lantus at 2200 hr
continue IV insulin pump and fluid infusion after first dose of insulin; for 1 hr if dose
was soluble (e.g. Humulin S, Novorapid, Humalog ) or for 4 hr if it was Isophane (e.g.
Insulatard/Humulin I) Long acting insulin (e.g. Lantus insulin )
Refer all patients to diabetes team within 24 hours of admission: use in-patient ward
consultation referral to diabetes team and also to fill in referral form to community diabetes
specialist nurses team
Check that diabetes team have made appropriate follow-up arrangements
Hypoglycaemia 2010-11
ACUTE HYPOGLYCAEMIA
Symptoms and signs
Skin cold, clammy
Tachycardia
Restlessness
Confusion
Coma
Focal neurological deficit (e.g. hemiparesis)
Consider hypoglycaemia in any patient with acute agitation, abnormal behaviour or
impaired consciousness. These signs do not usually occur unless blood glucose falls
below 2.5 mmol/L, but can occur at higher concentrations in patients with insulindependent diabetes whose day-to-day blood glucose is above normal
Investigations
Finger-prick blood glucose strip (if not available, treat after taking venous sample)
Venous sample for blood glucose (if venous access not possible, give glucose immediately)
If hypoglycaemia recurrent, consider:
LFTs
U&E
short tetracosactide (Synacthen) test
TSH/free T4
anti-tissue transglutaminase
IMMEDIATE TREATMENT
If semi-conscious:
Glucose gel (GlucoGel) one or two tubes (each 25 g contains 10 g glucose) orally repeat as
necessary after 1015 min
If unconscious:
Glucose 20% 50 mL IV into large vein through green Venflon (largest gauge you can insert)
over 15 min and flush with sodium chloride 0.9% 10 mL if still unconscious after 15 min,
repeat
Once conscious, give oral glucose or further carbohydrate intake
If hypoglycaemia induced by excess oral agents or overdose of insulin, consider maintenance
IV infusion of glucose 5% or 10%
Admit all patients with severe hypoglycaemia for observation and monitoring, especially if
caused by oral agents
Do not use glucagon, especially in sulphonylurea-induced hypoglycaemia as any
response will be short-lived and followed by further hypoglycaemia
If patient has diabetes, review maintenance treatment

Seek cause of hypoglycaemia (e.g. poor control, too much insulin, alcohol excess)
If hypoglycaemia prolonged, continue IV glucose infusion (hypoglycaemia can persist for
several days in patients taking chlorpropamide/glibenclamide)
Do not start IV insulin unless recommended by diabetes team
If admission necessary due to severity of hypoglycaemia, discuss with diabetes nurse
specialist /diabetes team
Hypoglycaemia 2010-11
Blood glucose (finger-prick) four times daily before meals
Ensure diabetes control stable

Follow-up severe cases in diabetic clinic within four weeks; in case of difficulty, contact
diabetes nurse specialist
Acute adrenal insufficiency 2010-11
ACUTE ADRENAL INSUFFICIENCY

Most common cause is secondary adrenal failure, where mineralocorticoid production is generally
preserved
Symptoms and signs
Lethargy
Nausea
Weight loss
Hypoglycaemia
Primary adrenal failure
Hypotension (postural/sustained)
Pigmentation (palmar/buccal/scars/pressure areas)
Vitiligo
Secondary adrenal failure
Pallor
Loss of pubic/axillary hair (because of co-existing secondary hypogonadism)
Risk factors
Primary adrenal failure
Auto-immune disease (diabetes/hypothyroidism/pernicious anaemia)
TB
Metastases, especially from carcinoma of lung
Secondary adrenal failure
Withdrawal of oral (or potent topical or inhaled) corticosteroids
Pituitary surgery/radiotherapy
INVESTIGATIONS
FBC
U&E
Blood glucose
Random serum cortisol
Plasma ACTH ( EDTA purple top bottle on ice : contact Dr. Oleesky at laboratory prior to
taking sample and send immediately to request separation of plasma on arrival)
Unless severely ill, perform short tetracosactide (Synacthen) test (SST) (serum cortisol
before, then 30 min after tetracosactide 250 microgram IM)
primary adrenal failure confirmed by serum cortisol <150 nmol/L (when ACTH >80 pg/mL);
excluded by basal or peak serum cortisol >550 nmol/L during SST
Indicators of severity
Hyponatraemia
Hypoglycaemia
In primary adrenal failure only
Hyperkalaemia
Raised urea
Acute adrenal insufficiency 2010-11
IMMEDIATE TREATMENT
Inform biochemistry laboratory in advance and obtain blood sample for serum cortisol
( yellow top bottle no need for ice) and plasma ACTH (purple top bottle on ice) before
hydrocortisone is given but treatment must not await result
If severely ill:
hydrocortisone 100 mg as slow IV bolus, followed by 100 mg by slow IV bolus 6 hrly
sodium chloride 0.9% 1 L by IV infusion over 3060 min, followed by 34 L IV over next 24 hr
If hypoglycaemic, give simultaneous infusion of:
glucose 20% 100 mL by IV infusion over 30 min, followed by glucose 10% 1 L by IV infusion
over 12 hr. Monitor blood glucose and change to glucose 20% if 10% inadequate
glucagon is unhelpful in this situation
Admit to an endocrinology ward 7

When improving and tolerating oral fluid:
hydrocortisone 20 mg orally 8 hrly
refer to endocrinology team for advice on maintenance dosage
if diagnosis in doubt, seek advice from endocrinology team about substituting
dexamethasone 1 mg orally 8 hrly for hydrocortisone and perform SST within three days
In primary adrenal failure:
add fludrocortisone 50100 microgram orally daily
request adrenal autoantibodies
arrange chest and abdominal X-rays
if TB suspected, request CT scan of adrenals
If secondary adrenal failure suspected, refer to endocrinology team
MONITORING
U&E daily
Lying and standing BP twice daily, looking for orthostatic hypotension
Patients must carry Steroid card and wear Medic Alert bracelet
Patients must understand need for:
lifelong hydrocortisone
doubling the daily dose for the duration of any intercurrent illness
parenteral hydrocortisone if vomiting (supply with ampoule of hydrocortisone 100 mg to keep
in fridge for use by paramedics in emergency)
Arrange follow-up with endocrinology team
Parental fluid principles 2010-11
FLUID MANAGEMENT FLOWCHART

Yes
Does patient have fluid

deficit?
Assess deficit volume and nature (biochemically and

haematologically see Fluid resuscitation, Electrolyte
disturbances, Post-operative haemorrhage, Acute upper GI
haemorrhage and Chronic anaemia guidelines)
No
Patient able and
permitted* to ingest and
absorb normal fluid load?
Patient able and permitted*

to ingest and absorb extra
fluid required?
Yes
No
No
Yes
Prescribe and administer parenteral resuscitation

volume see Fluid resuscitation guideline
Reassess and manage persisting deficit as per Fluid
Able
Commence and continue maintenance fluid (see Maintenance fluid therapy

guideline) as soon as possible
If deficit occurs or persists despite maintenance fluid, ensure adequate
maintenance fluid prescribed and administration continued concurrently with
appropriate resuscitation fluid see Fluid resuscitation guideline
Do not simply increase maintenance fluid rate, unless inadequate

maintenance has been prescribed. Some fluids used for maintenance can
be dangerous when given in large volumes required for resuscitation
Reassess
Unable
Reassess ability to ingest
and absorb fluid
requirement twice daily
Switch to oral/gastric fluids
as soon as possible
Remove IV access, as
soon as no longer required
Reassess
No
Patient has continued excess

loss (e.g. fistula output,
diarrhoea, vomiting)
Yes
Prescribe replacement of excess loss matching

hourly volumes lost and appropriate
electrolyte/blood product content see
Continuing excess losses section of
Maintenance fluid therapy guideline
Prescribe and administer this replacement in
addition to the maintenance prescription
Discontinue when excess losses cease, or extra
requirements can be given orally
Encourage
patient to drink
and/or give
patient fluids via
gastric tube
*Allowed = not nil by mouth in preparation for intervention such as anaesthesia or due to
aspiration risk if swallow/gag/conscious level impaired
Parental fluid principles 2010-11
NOTES
Blood products
Haemodynamically stable patient
If required, blood products replace some or all the calculated maintenance volume
requirement
Haemodynamically unstable patient
Blood products replace some or all the calculated resuscitation volume
Content
It is important to administer fluid with an appropriate concentration of electrolytes see
Electrolyte disturbances guidelines
Use blood products only where they are specifically indicated
Note glucose (dextrose) 5% behaves as a hypotonic solution, as glucose is
metabolised to water and carbon dioxide. Excessive use can cause dangerous dilution of
electrolytes (e.g. hyponatraemia)
Fluid Therapy 2010-11
MAINTENANCE FLUID THERAPY

HOW TO USE THIS GUIDELINE
In all patients at risk of hypovolaemia, make a clinical assessment of degree and type
of fluid deficit. See Fluid resuscitation guideline
Specific conditions
Follow appropriate condition-specific guideline in Medical or Surgical guidelines if patient
has any of the following conditions:
Diabetic ketoacidosis
Hyperosmolar hyperglycaemic non-ketotic state
Acute GI haemorrhage
Hypo/hypernatraemia
Acute cardiac failure
Acute liver failure
Established acute renal failure
Diabetes mellitus requiring fluids to cover surgery
Post-operative haemorrhage
Hypercalcaemia
Clinical application of guidance
Each patients fluid balance needs careful initial assessment and regular reassessment to
monitor their clinical response to treatment. In particular, guidance may need to be
modified if patient suffers from:
chronic cardiac failure
chronic liver failure seek advice of liver specialist
hyperkalaemia (K+ >6.0 mmol/L) see Hyperkalaemia guideline
Indication for use of parenteral fluid therapy
If possible, use enteral replacement. Re-evaluate need for parenteral fluids at least
twice daily
Patient unable to ingest or absorb fluid and electrolyte requirements via enteral route
MAINTENANCE
If patient requires additional resuscitation fluid after commencing maintenance
regimen, follow guidance in Fluid resuscitation guideline
If patient has continuing excess losses, measure and replace using an appropriate volume
and type of fluid. Give this replacement fluid in addition to maintenance see Continuing
excess loss section at end of this guideline
Total volume of fluid required (oral and parenteral) in 24 hr
Table 1: Volume of fluid over 24 hr and in mL/hr
Body weight
No fever No fever
Fever
Fever
(kg)
L/24 hr
mL/hr
present
present
L/24 hr
mL/hr
<60
2L
83
2.5 L
104
6080
2.5 L
104
3L
125
>80
3L
125
3.5 L
146
Give as much fluid volume as possible orally or (if inserted) via nasogastric or PEG tube.
Give remainder IV or, in selected medical patients, SC
If signs of fluid overload in any patient, review need for IV fluids. If essential, give
sodium chloride 0.9% 500 mL/day
Choice of fluid
Choice of fluid is important: stressed patients cannot handle excessive sodium,
chloride or free water (from glucose solutions). Inappropriate administration of any of
these causes significant morbidity and mortality
Table 2 - Choice of maintenance fluid when no hypovolaemia
Serum sodium
(mmol/L)
Patient
Hyponatraemia
(Na+ <125)
Mild hyponatraemia
(Na+ 125135)
135Na+125
All
Isonatraemia
(Na+ 136140)
140Na+136
Stressed patients (e.g.

post-operative, septic)
requiring IV fluid because of
impaired oral intake
Unstressed patients
requiring IV fluid because of
impaired oral intake
Isonatraemia
(Na+ 141150)
150Na+141
Hypernatraemia
(Na+ >150)
All
All
All
Type of fluid
If K+ <3.5 mmol/L, use fluid in table
with premixed potassium chloride
see Management of potassium below
Follow Hyponatraemia guideline
Sodium chloride 0.9%.
Check U&E 12 hrly initially.
If Na+ rises by >5 mmol/L in 12 hr or
hyperchloraemia develops, reduce rate
of infusion by 30% or change infusion
fluid to compound sodium lactate
(Hartmanns)
Compound sodium lactate (Hartmanns)
Monitor serum sodium 12 hrly as
hyponatraemia can develop irrespective
of choice of fluid
One half of volume as sodium chloride
0.9% and remainder as glucose 5%
One half of volume as compound
sodium lactate (Hartmanns) and
remainder as glucose 5%.
Monitor U&E 12 hrly
Follow Hypernatraemia guideline
MANAGEMENT OF POTASSIUM
Compound sodium lactate contains potassium 5 mmol/L. This is sufficient to maintain
serum potassium in most patients where there is no further K+ loss but insufficient to
replete patients who are already depleted
Hypokalaemia present (K+ <3.5 mmol/L):
Use sodium chloride 0.9% (or glucose 5%) with potassium chloride 40 mmol 1 L bags in
above regimens
Monitor U&E daily
Once serum K in normal range, change to fluid recommended in Table 2
Rapid infusion of bags containing potassium 40 mmol/L will cause dangerous
arrhythmias.
Suggestion place a handwritten warning label on bag containing K+ advising staff
NOT TO INCREASE INFUSION RATE
Always use commercially produced pre-mixed bags of sodium chloride 0.9% or
glucose 5% and potassium chloride. NEVER add potassium chloride to infusion bags
CONTINUING EXCESS LOSSES

If patient has continuing excess losses from any source (e.g. fistulae, vomiting, diarrhoea and
drains), measure volume of losses and replace volume using an appropriate fluid (see below)
in addition to maintenance regimen
Choice of fluid
Depends on type of fluid lost (biochemical analysis of fluid may be helpful), and impact
upon haematocrit, biochemistry and serum protein
replace gastric losses using sodium chloride 0.18% and glucose 4% +/- potassium
chloride, unless hypochloraemia present in which case use sodium chloride 0.9% +/potassium chloride
replace diarrhoea/small bowel/bowel prep losses with compound sodium lactate
MONITORING
Chart
Hrly
Urine output
6hrly
BP
Daily
Fluid balance chart
Serum U&E
Body weight
Examine daily
JVP
Check for peripheral oedema
Auscultate lung fields
FLUID OVERLOAD
If signs of fluid overload appear and parenteral fluid remains necessary, reduce rate of
infusion to 50% of calculated rate
As soon as possible, re-establish oral fluids and remove indwelling intravenous lines
Fluid resus 2010-11
FLUID RESUSCITATION
In all patients at risk of hypovolaemia, make a clinical assessment of degree and type of fluid
deficit
Oliguria in early post-operative period in absence of other signs of volume depletion
does not indicate need for intravenous fluid therapy. It is a normal physiological
response to surgery
Table 1: Assessment of fluid deficit (patients will not exhibit all of the clinical signs)
Signs
Mental status
Dry mouth
Reduced skin
turgor
Sunken eyes
Capillary refill
time
Heart rate
Respiratory rate
Blood pressure
JVP when
supine
Urine output
FLUID DEFICIT
Severe
Anxious/confused
(GCS 1214)
Normal
Normal
(GCS 15)
see Glasgow
coma scale
guideline
No
No
Moderate
Mildly
anxious
(GCS 15)
Yes
Yes
Yes
Yes
Yes
Yes
No
<2 sec
No
<2 sec
Yes
25 sec
Yes
>4 sec
<100
1420
Normal
Visible
>100
2030
Normal
May not be
visible
2030
mL/hr
>120
3035
Decreased
Not visible
>140
>35
Decreased
Not visible
520 mL/hr
<5 mL/hr
>30 mL/hr
Critical
Confused/lethargic/
comatose
(GCS <12)
Clinical notes
Heart rate increases will be masked in the elderly and by beta blocking drugs
Interpret BP in light of any history of hypertension and patients age. If patient in pain,
reductions will be masked
Review all diuretics. Oliguria may be masked by diuretics
Investigations
Early
Urine output (renal failure likely if <0.5 mL/min)
U&E
Glucose
Late
If renal failure suspected, urinary urea and electrolytes. Prerenal failure is suggested by:
urine sodium <20 mmol/L
urine osmolality >500 mmol/kg
urine:serum creatinine ratio >40
If >4 L of fluid required in 24 hr or drop in Hb suggests possible blood loss, FBC
When peripheral perfusion is poor, arterial blood gases to look for metabolic
acidosis/lactate
Serum proteins
Coagulation studies
Fluid resus 2010-11
INITIAL MANAGEMENT
Specific conditions
Follow appropriate condition-specific guideline in Medical or Surgical guidelines if patient
has any of following conditions:
Diabetic ketoacidosis
Non-ketotic hyperosmolar coma
Acute GI haemorrhage
Hypo/hypernatraemia
Acute cardiac failure
Acute liver failure
Established acute renal failure
Diabetes mellitus requiring fluids to cover surgery
Post-operative haemorrhage
Hypercalcaemia
Treatment
All treatment is given as boluses of fluid in addition to, or before starting, maintenance
therapy
Table 2: Initial treatment of fluid deficit
Fluid deficit
Normal/mild
Moderate
Fluid bolus and other management

Give oral maintenance if possible.
Otherwise move to Maintenance
fluid therapy guideline
500 mL over 15 min, then reassess
Severe
Critical
Other management
Give oxygen see Clinical notes

below
Measure U&E and FBC
below
Measure U&E and FBC
Ensure airway patency
below
Measure U&E and FBC
Clinical notes
Give high flow oxygen via reservoir mask to all patients with shock, major trauma, sepsis,
or other critical illness. Aim for SpO 2 9498%. Adjust dosage in patients with chronic
respiratory failure at risk of hypoventilation once ABG results known see Oxygen
therapy in acutely hypoxaemic surgical patients (or those with suspected poor
regional perfusion) guideline
In patients at risk of pulmonary oedema because of heart failure, reduce fluid volume by
half
Regular reassessment is required to assess magnitude and duration of response to
initial treatment, and to exclude iatrogenic fluid overload
Choice of initial fluid
Resuscitate using fluid recommended in Table 3. If maintenance fluids have been
prescribed, leave them running at maintenance rate. Do not consider them in your
assessment of required resuscitation volume or increase their rate to use them for
resuscitation; if hypotonic or potassium-containing, they may be inappropriate for use
as resuscitation fluid
Fluid resus 2010-11
Table 3: Choice of fluid for resuscitation

Fluid deficit
Severe diarrhoea/vomiting
Gastrointestinal fistula
Poor intake (many medical patients)
Loss of fluid of plasma constituency or
severe patient stress (majority of surgical
patients) resulting from:
blood loss
surgery
injury
systemic inflammatory response
burns
increased insensible losses due to fever or
environmental factors
increased losses from respiratory tract in
acute respiratory failure (includes acute
severe asthma)
epidural anaesthesia
Initial fluid
Compound sodium lactate

(Hartmanns)
MANAGEMENT OF POTASSIUM
Never infuse fluids containing more than 5 mmol/L potassium (compound sodium
lactate contains 5 mmol/L) rapidly. If a patient requiring rapid fluid boluses for
resuscitation is also hypokalaemic, prescribe potassium separately in their
maintenance fluid regimen or, if hypokalaemia severe (serum potassium <3 mmol/L),
follow Hypokalaemia guideline
OUTCOME
Continuing resuscitation
If hypovolaemia has resulted from haemorrhage, follow Acute upper gastrointestinal
haemorrhage or Post-operative haemorrhage guideline
Reassess as indicated in Table 1 and give further fluid boluses as required
Signs of hypovolaemia do not resolve
If patient shows only transient recovery despite 2000 mL fluid as boluses within 1 hr,
perform arterial blood gas analysis to detect metabolic acidosis secondary to inadequate
tissue perfusion
request senior review to consider insertion of CVP line, advice on specific treatment and
referral to critical care
Signs of hypovolaemia resolve
Commence or continue maintenance fluid regimen. See Maintenance fluid therapy
guideline
Reassess for clinical signs of hypovolaemia at 30 min intervals until signs of
hypovolaemia have resolved for at least 2 hr and there is no evidence of continuing
losses. A significant proportion of patients will have only a transient response to fluid
bolus
Hyponatraemia 2010-11
ELECTROLYTE DISTURBANCES
Further information available from Clinical biochemistry
or from endocrine teams
HYPONATRAEMIA (serum Na+ <125 mmol/L)

Symptoms
and signs
Investigations
Clinical
assessment
Nausea, cramps, confusion, fits, varied CNS manifestations

+
Unless serum sodium (Na ) falling rapidly, concentrations in range 125135 mmol/L are usually
asymptomatic
U&E, glucose, osmolality (urine plus serum), urine Na
Assess state of hydration: BP, pulse, skin turgor
Dehydration
No dehydration
or oedema
Commonly
Mechanism
Expected
results
Cause
Relative depletion
of salt to water
1. Blood sample taken

from drip arm
2. Excess of water to
salt
Uosm >280 and

Surea >7 mmol/L
UNa >20 and

Surea <7 mmol/L
UNa >20
UNa <20
Consider:
Addison's,
diuretics,
renal
tubular
disease,
osmotic
diuresis
Fluid loss
(e.g. GI
loss,
sweat,
poor
intake)
Oedema
Rarely
High concentration
of lipid or protein in
blood may give
+
false Na result
Retention of
water greater
than salt
Uosm <
Sosm
Acute
onset:
excess
intake IV
post-op,
polydipsia
Uosm >
Sosm
Chronic onset:
SIADH? cause
(e.g. lung, CNS
disorders,
tumours, drugs
commonly
diuretics,
carbamazepine)
Sosm
>275 mmol/L
Pseudohyponatraemia.
The lab will usually
comment that the
sample is lipaemic
or viscous and
difficult to analyse
Cardiac,
hepatic
failure,
nephrotic
syndrome,
renal failure
Hyponatraemia 2010-11
Treatment
Treat
underlying
cause. RAPID
CHANGES IN
SODIUM ARE
MORE
DANGEROUS
THAN LOW Na+
ITSELF, even
when the
change is
towards the
normal range
Restore normovolaemia
and continue fluid
replacement with sodium
chloride 0.9% 1-2 L in
12 hr see
Maintenance fluid
therapy guideline for
more detailed guidance
on fluid volume
requirement.
Check U&E 12 hrly
initially
If sodium rises by
>5 mmol/L in 12 hr,
reduce rate of infusion
by 30%
ACUTE
(<48 hr)
hyponatraemia
is usually the
result of
inappropriate
IV fluid
administration
and usually
self-corrects
when infusion
is discontinued
or prescribed
appropriately
see
Maintenance
fluid therapy
guideline
1. Restrict fluid
intake 1.5
L/day initially
and further to
1 L/day
depending on
response
2. If poor
response,
give Slow
Sodium 1 tab
(10 mmol)
8 hrly plus
furosemide
20 mg daily
(double
dosage if
response still
poor)
3. If
symptomatic,
consider
demeclocycli
ne 300 mg
orally 8 hrly
No treatment
for
hyponatraemia
Check serum
triglycerides
and protein
electrophoresis
Restrict Na intake
<100 mmol/day
and fluid
<1.5 L/day. For
renal and cardiac
failure: furosemide
80 mg oral or 40
mg IV. For hepatic
failure, stop all
diuretics. See
respective
guidelines. If
hypokalaemic or
HCO3 >32 mmol/L

+
correct K deficit
see
Hypokalaemia
guideline
Serum Na
should not rise
by >10 mmol/L
Hypertonic saline is almost never justified, carries a significant risk
and should be given only with consultant approval
Failure to correct, or recurrence of, hyponatraemia merits referral to the team appropriate to the
underlying cause (e.g. renal, endocrine, psychiatric). Review drug treatment before discharge
Hypernatraemia 2010-11
HYPERNATRAEMIA (serum Na+ >150 mmol/L)

Symptoms
and signs
Various CNS symptoms from lethargy to coma and fits

Dehydration hypovolaemia
Mechanism
Loss of water in excess of salt
Investigations
Serum: U&E, glucose
Urine: U&E, osmolality
Clinical
assessment
Assess volaemic status
Hypovolaemic
Expected
results
Cause
Immediate
treatment
Uosm >300 mmol/L
1. Osmotic diuresis, (e.g.

hyperglycaemia)
2. Excess water loss (e.g.
sweat)
3. Inability to drink, failure of
thirst
Normovolaemic
Uosm <300 mmol/L
Diabetes insipidus:
a. pituitary
b. nephrogenic
Uosm >300 mmol/L

+
UNa >5 mmol/L
Excess salt administration
Encourage oral fluids in conscious patient the safest route
Discontinue Na excess
Asymptomatic
Oral fluids
Monitor serum Na daily
Hypovolaemic +
symptomatic
sufficient to achieve
haemodynamic stability
see Fluid resuscitation
guideline.
Then correct
hypernatraemia with
glucose 5%
Symptomatic and normovolaemic
Estimate the water deficit from:

+
0.4 lean bodyweight* (serum Na
140)/140/L. Aim to replace 50% of this
in 24 hr as glucose 5% IV
+
Monitor serum Na 12 hrly

+
Serum Na must not decrease by
>10 mmol/L in 24 hr
Further
investigations
If cause not apparent at this stage, consider diabetes insipidus

and refer patient to endocrine team
* see Prescribing regimens and nomograms: Gentamicin
Hypokalaemia 2010-11
HYPOKALAEMIA (serum K+ <3.5 mmol/L)

Often none, or neuromuscular symptoms (e.g. muscle weakness, absent reflexes, ileus).
ECG changes depressed ST, flat T, U waves, arrhythmias. (Arrhythmias may cause
cardiorespiratory symptoms) Metabolic alkalosis increased HCO3
Symptoms
and signs
Investigations
Immediate
1.
2.
3.
1.
Helpful
2.
3.
ECG see Symptoms and signs

+
+
Repeat K (U&E) on plasma sample (lithium heparin) as release of K
from cells during clotting may give a falsely higher concentration in serum
FBC, glucose
HCO3 a raised concentration indicates chronic depletion; if <22 mmol/L

in absence of GI loss, suspect renal tubular acidosis refer to renal team
+
Urine K if cause not obvious
2+
+
Serum magnesium (Mg ) for persistent urine K loss especially
patients with diarrhoea or on diuretics
1. Blood taken from drip arm

+
2+
2. Renal loss: urine K >20 mmol/L diuretics, mineralocorticoid excess, Mg deficiency see Hypomagnesaemia guideline,
renal tubular disease, also occurs secondary to GI fluid loss and volume depletion
3. Any GI fluid loss
4. Intracellular shift: insulin or bicarbonate treatment, theophylline, beta2 agonists, periodic paralysis, rapid blood cell
proliferation
5. Intravenous fluid therapy, with inadequate electrolyte replacement
Common
causes
Treatment
Plasma K
3.03.5 mmol/L
Always use
commercially
produced
pre-mixed bags of
infusion fluid.
NEVER add
potassium
chloride to
infusion bags
Monitor plasma
K+ concentration
+
at least daily if K
given IV
No immediate
treatment. If taking
digoxin and/or
symptoms present,
give potassium
chloride
effervescent
72 mmol/day
Sando-K 2 tabs
(12 mmol/tab)
8 hrly
Plasma K
<3.0 mmol/L with
symptoms but no
pre-existing cardiac
disease
Monitor plasma K
daily for change
identify and correct
underlying cause;
if cause nonremediable, give
potassium chloride
effervescent
72 mmol/day
Sando-K 2 tabs
(12 mmol/tab)
8 hrly if poor
response, increase
dose to max 192
mmol/day
Plasma K
<3.0 mmol/L with
pre-existing cardiac
disease, but no new
symptoms
Give sodium
chloride 0.9%
500 mL with
potassium chloride
20 mmol IV, as
commercially
prepared premixed bag, over
2 hr, with
continuous ECG
monitoring
Plasma K
<2.5 mmol/L with persistent losses
or poor absorption
+
OR Plasma K
<3.0 mmol/L plus new
tachyarrhythmia or muscle
weakness
Use central intravenous

route, in a high
dependency area with
continuous ECG
monitoring. Give
40 mmol potassium
chloride diluted to
100 mL over 2 hr. In
intractable cardiac
arrhythmia, contact
cardiology team
urgently
If cause not obvious, refer to renal or endocrine team for further evaluation
Hyperkalaemia 2010-11
HYPERKALAEMIA (serum K+ >6 mmol/L)

Symptoms
and signs
Frequently none, or non-specific neuromuscular symptoms

+
Muscular weakness may occur if K >7.0 mmol/L
Cardiac arrest without warning
ECG changes (see Treatment)
1. Artefact: release from blood cells (e.g. during clotting, blood dyscrasias, haemolysis, delayed
centrifugation of sample for >2 hr)
2. Low-molecular-weight heparin
+
3. Failure of excretion: renal failure, mineralocorticoid deficiency, drugs (e.g. K -sparing diuretics, ACE
inhibitors, NSAIDs, ciclosporin)
4. Release from cell: severe tissue damage, acidosis
Common
causes
Investigations
Treatment
1. Repeat K (U&E) on plasma sample (lithium heparin) as K released from cells during clotting in serum
+
can give an artificially high concentration. Management should depend on plasma K
2. FBC
3. HCO3 in venous blood (or from blood gases, if indicated for other reasons)
4. Monitor urine output
5. ECG
6. If cause not obvious, take blood for cortisol
Plasma K
6.16.4 mmol/L
Plasma K
6.56.9 mmol/L
and
or
ECG No K -related
changes
ECG Peaked T,
small P
Plasma K
>7.0 mmol/L
and
ECG Peaked T,
small P or no
+
K -related changes
ECG Absent P, wide

QRS, blurring of ST into T.
ECG changes override
+
plasma K
Monitor plasma K .
Identify and
correct cause
Calcium gluconate
10% 10 mL IV over
5 min. This corrects
only the ECG.
Continue ECG
monitoring and
repeat as necessary
while awaiting
+
correction of K
(see below)
Low K diet
Change diuretics to
thiazide or loop
diuretics
1.
Give Actrapid 10 units IV and glucose 50% 50 mL IV

over 10 min into a large vein see Administration of
fluid and insulin infusions in Medical guidelines or, if
access poor, arrange insertion of, and give through, a
central line
2. Then give glucose 5% 1 L IV in 12 hr, but no insulin
unless glucose >10 mmol/L
3. Start calcium resonium resin 15 g orally in water (not
fruit juice) 6 hrly
Monitoring
treatment
1. Give glucose and insulin (as described to left)

2. If persistent hyperkalaemia or renal failure present
(poor urine output, rising creatinine or acidosis)
consider use of bicarbonate (If pH <7.1 give 250 mL
1.26% sodium bicarbonate IV over 30 min may be
repeated hrly) and early dialysis refer to renal team
+
3. If continuing K retention and dialysis unlikely within a few
hours start calcium resonium resin 15 g orally in water
(not fruit juice) 6 hrly or 30 g rectally in methylcellulose
solution (irrigate rectum after 9 hr)
Monitor plasma U&E and glucose 2 hrly until K stable and <6.0 mmol/L
Attend to underlying cause (e.g. drugs); if patient in renal failure, refer to renal team
Insulin/glucose or calcium encourage K+ to enter cells. They do not cause

excretion of excess total body K+. Use only as temporary measures until
Hypomagnesaemia 2010-11
HYPOMAGNESAEMIA
DEFINITION
Calculation of correct serum magnesium (Mg2+)

Serum magnesium is underestimated if albumin low
If albumin <40 g/L correct serum Mg2+ using following formula:
correct serum Mg2+ = measured serum Mg2+ + 0.005 (40 albumin g/L) mmol/L
Severe deficit
Serum Mg2+ <0.5 mmol/L
Moderate deficit
Serum Mg2+ 0.50.7 mmol/L
Mild deficit
Magnesium is largely intracellular so mild deficiency can occur with a normal serum
concentration, but urine excretion will be reduced:
urine Mg2+ /urine creatinine <0.1 = deficiency; <0.05 = severe deficiency, except if
secondary to renal loss see Investigations
COMMON CAUSES
Gastrointestinal loss
Diarrhoea
Stoma
Fistula
Malabsorption states
Renal loss
Tubular damage
Genetic syndromes (e.g. Gitelmans syndrome)
Chronic acidosis
Phosphate or potassium depletion
Hypoparathyroidism
Drug-induced (e.g. loop and thiazide diuretics, aminoglycosides, ciclosporin, cisplatin)
Other
Alcoholism
Insulin administration
Critical illness
SYMPTOMS AND SIGNS
Non-specific and often attributed to hypocalcaemia or hypokalaemia
Musculoskeletal
Muscle twitching
Tremor
Tetany
Cramps
CNS
Apathy
Depression
Hallucinations
Agitation
Confusion
Fits
Hypomagnesaemia 2010-11
Cardiovascular
Tachycardia
Hypertension
Arrhythmias (e.g. torsade de pointes)
Digoxin toxicity
INVESTIGATIONS
Cause usually apparent from clinical picture investigation necessary only if not obvious:
Calculate fractional excretion of Mg2+ in a random urine sample from :
urine Mg2+ serum creatinine 100
0.7 serum Mg2+ urine creatinine
fractional excretion of Mg >3% indicates renal loss. See above for causes
If hypocalcaemia or hyperphosphataemia present, check plasma parathyroid hormone
IMMEDIATE TREATMENT
For severe deficiency, intractable loss or symptoms of hypocalcaemia or hypokalaemia,

use IV route
Magnesium sulphate 5 g (20 mmol in 10 mL) into 100 mL glucose 5% over 6 hr [may also
be given with sodium chloride 0.9%, or the compound formulation of sodium chloride
(0.18%) and glucose (4%)]
In presence of life-threatening features, a bolus of 24 g over 20 min is appropriate but

requires high dependency facilities/critical care staff
For mild asymptomatic deficiency (serum Mg2+ >0.5 mmol/L), use oral route see
Maintenance or mild deficiency
MONITORING
Leave at least 2 hr after end of infusion before checking serum Mg2+

if still <0.5 mmol/L, repeat dose
otherwise, check again after 24 hr
Toxicity rare if renal function normal
Clinical signs of overdose:
loss of tendon reflexes (>5 mmol/L)
hypotension
bradycardia
respiratory depression (>7.5 mmol/L)
MAINTENANCE OR MILD DEFICIENCY
Oral magnesium glycerophosphate 4 mmol (unlicensed)

2 tablets 8 hrly often required but, if tolerance of oral intake may be limited by diarrhoea,
reduce dose to maximum tolerated
Hypercalcaemia 2010-11
HYPERCALCAEMIA
HYPERCALCAEMIA (serum calcium >2.6 mmol/L)
Symptoms and
signs
Investigations
2+
Unusual unless calcium (Ca ) >3.0 mmol/L

GI:
nausea, vomiting, constipation, abdominal pain
Renal:
polyuria, polydipsia
CVS:
hypertension, on ECG: altered QT interval, long PR, wide QRS, arrhythmias
CNS:
various including depression, cognitive difficulties, headache, altered consciousness, acute
psychosis
2+
Immediate: U&E, Ca , albumin, chest X-ray, ECG

Non-urgent to find cause: PTH (EDTA), FBC, ESR, alkaline phosphatase, myeloma screen
Determine degree of hypercalcaemia after correcting to albumin of 40 g/L

2+
= serum Ca + 0.02 (40 albumin g/L) mmol/L
MILD
2+
Ca 2.62.9 mmol/L
Treatment
MODERATE
2+
Ca 3.03.4 mmol/L
Symptoms absent
Immediate treatment not

usually necessary but
ensure adequate fluid
intake, and stop thiazides
and any vitamin A, D or
2+
Ca supplements
SEVERE
2+
Ca >3.4 mmol/L
Symptoms present
Oral rehydration if
possible: water 23 L/day.
If oral route inappropriate
give sodium chloride 0.9%
2-3 L by IV infusion/day.
2+
Ca should decrease by
0.5 mmol/L within 48 hr
Rehydrate with sodium

chloride 0.9% 34 L/24 hr
depending on severity of
2+
symptoms and Ca .
If fluid overload, give
furosemide 2040 mg
12 hrly. Large doses of
furosemide (160 mg) may
2+
lower Ca more quickly, but
are not recommended as
electrolytes must be
accurately replaced, based
on urinary loss.
If symptoms life-threatening,
consider calcitonin (see
Other treatments)
See Further management
Check U&E,
2+
Ca at 48 hr
Check U&E
2+
Ca at 12 hr
Hypercalcaemia 2010-11
Check Ca2+
response to
initial treatment
2+
Ca <3.0 mmol/L
See Further management
2+
2+
Ca 3.03.4 mmol/L
no symptoms
Ca >3.4 mmol/L, or
Continue rehydration
Disodium pamidronate 60
2+
mg (90 mg if Ca >3.5
mmol/L) in sodium chloride
0.9% 500 mL over 2 hr, then
continue sodium chloride
2+
0.9%. Ca usually returns to
normal within seven days
>3.0 mmol/L with symptoms
2+
Recheck U&E, Ca , phosphate daily.

If no response within 48 hr, see Further management
Other treatments
Further
management
CALCITONIN: Used only during first 24 hr for severe hypercalcaemia when symptoms are life-threatening.
2+
Effective rapidly but response lasts only for a few hrs 4 unit/kg over 6 hrs IV 12 hrly lowers Ca by 0.5
mmol/L
CORTICOSTEROIDS: If cause known to be granulomatous disease or calcitriol excess: hydrocortisone 100
mg by slow intravenous injection 8 hrly (or prednisolone 40 mg orally daily). Calcitriol excess usually
responds poorly to disodium pamidronate
HAEMODIALYSIS: Consider if renal function poor
MITHRAMYCIN, GALLIUM NITRATE, PHOSPHATE: toxic and should not be used
Find and treat cause: Albumin <30 g/L suggests malignancy, but PTH most helpful for diagnosis to
arrange early result if PTH necessary to speed further investigation
PTH detectable >1.5 pmol/L
Primary hyperparathyroidism
Familial hypocalciuric hypercalcaemia
Consider endocrine opinion for further
evaluation with possible referral for
parathyroidectomy
Renal patients may have tertiary
hyperparathyroidism
Further
treatment to
maintain normal
calcium if cause
not treatable
Ensure hydration maintained

Contact endocrinology team for advice
PTH absent 1.5 pmol/L
Consider: malignancy (lung, breast,

haematological rarely); granulomatous
disease; acute renal or adrenal insufficiency;
2+
excess Vitamin D/ Ca intake; drug therapy
(e.g. lithium, oestrogens, progestogens,
tamoxifen).
Essential to treat underlying cause as soon as
possible
PALLIATIVE CARE EMERGENCIES

HYPERCALCAEMIA
Presentation:
Corrected serum calcium >2.7mmol/L
In Primary Care seek specialist advice
Assessment:
May develop insidiously
Frequently missed, consider in unexplained nausea/vomiting or confusion
Severity of symptoms related to speed of rise of serum calcium

Cause:
Common tumour types (breast, myeloma, lung, kidney, cervix, bony metastases)
Ectopic parathyroid hormone (PTH)secretion
Can occur without bony metastases

Table 28 Symptoms and Signs:
General
Gastro Intestinal
Dehydration
Polydipsia
Polyuria
Pruritus
Anorexia
Weight loss
Nausea
Vomiting
Constipation
Ileus
Neurological
Fatigue
Lethargy
Confusion
Myopathy
Hyporeflexia
Seizures
Psychosis
Coma
Cardiological
Arrhythmias
Conduction defects
Management / Treatment:
Check urea, electrolytes, creatinine
Correct dehydration
I/v Fluids 0.9% Sodium Chloride, 2-3 Litres/24hrs
Potassium supplements
Administer either i/v pamidronate or i/v zoledronic acid (please seek senior
medical and pharmacy advice) - see Table 29
Table 29
Initial Corrected Serum
Calcium (mmol/Litre)
Up to 3.0
3.0 3.5
3.5 4.0
> 4.0
Infusion rate
Do not exceed concentration:Duration of effect
Side Effects
Disodium Pamidronate
dose (mg) *
Zoledronic Acid dose

(mg) *
15 30
30 60
60 90
90
< 60mg/hr
60mg/250ml normal saline
4mg
4mg
4mg
4mg
Not less than 15 minutes
Dilute in 100mls sodium
chloride or 5% dextrose
Onset 3-7 days
Onset 2-3 days
Duration 3 weeks
Duration > 3 weeks
Pyrexia, flu-like symptoms and fatigue
Late effects: osteonecrosis of jaw
* seek specialist advice if impaired renal function and see BNF Appendix 3
Monitor for Recurrence:

Recurrence can be a poor prognostic sign, especially if resistant to treatment. Repeat
i/v bisphosphonates or commence oral bisphosphonates (see BNF 6.6.2 for guidance)
December 2008 revised December 2009
Page 38 of 51
AUGI 2010-11
ACUTE UPPER GASTROINTESTINAL

HAEMORRHAGE
Symptoms and signs
Coffee-ground vomit (dark brown, denatured blood in vomit)
Haematemesis (bright red or clotted blood in vomit)
Melaena (black, tarry, smelly stool containing digested blood). Rarely, severe upper GI
haemorrhage can present as dark altered blood per rectum with no other features to suggest
upper GI pathology
Postural dizziness or fainting
Evidence of severe bleeding defined as presence of shock with tachycardia (heart rate
>100 beats/min), hypotension (systolic BP <100 mmHg) and clammy skin, or of postural
hypotension in patient who is not clinically shocked
Evidence of anaemia
Features of precipitating disease, jaundice, stigmata of liver disease
Features of bleeding disorder (petechiae)
Buccal or facial telangiectasia
Bright red rectal bleeding in the absence of hypotension is likely to arise from lower
gastrointestinal tract
Previous history
Enquire about:
peptic ulceration
previous bleeds
liver disease
family history of bleeding
ulcerogenic medication/anticoagulants
alcohol
weight loss
ASSESSMENT OF RISK
It is essential to categorise patients according to their risk of death high (severe) or low
(non-severe)
If more than one of the following are present, patient is at high risk:
Heart rate >100 beats/min and systolic BP <100 mmHg, or postural hypotension (fall 10
mmHg)
Severe liver, cardiovascular, respiratory or renal disease or disseminated malignancy, though
these may render patient unfit for surgery
Rebleeding after admission
Actively bleeding ulcer or visible non-bleeding vessel at endoscopy
Haemoglobin (Hb) <10 g/dL
GI bleeding arising after admission with another condition
AUGI 2010-11
Figure 1 is an aid to clinical judgement
Figure 1:
Chronic
liver disease
Yes
No
Consider adverse prognostic features:
Heart rate >100 beats/min
Systolic BP <100 mmHg
Postural hypotension (>10 mmHg)
Hb <normal range
One feature
present
None present
Consider pre-existing
adverse prognostic
features:
Age >60 yr or
Any pre-existing
liver, cardiovascular,
respiratory or renal
disease
Disseminated
malignancy
Yes
No
Consider
managing as
outpatient after
arranging early
endoscopy date
Investigations
Non-severe bleeding:
FBC
Group and Save (non-urgent)
Consider additional
adverse prognostic
features:
Age >60 yr or
Severe liver,
cardiovascular,
respiratory or
renal disease
Disseminated
malignancy
Hb <10 g/dL
Two or more
features present
Yes
No
Manage in
hospital as nonsevere nonvariceal bleeding
Manage in
hospital as
severe nonvariceal
bleeding
Manage in hospital
as variceal
bleeding (always
severe)
AUGI 2010-11
all other investigations can wait until normal working laboratory hours
Severe bleeding:
FBC
U&E
LFTs
INR
crossmatch (four units) notify blood transfusion laboratory of clinical problem and degree of
urgency
IMMEDIATE TREATMENT
Non-severe non-variceal bleeding
Baseline observations with a view to upper GI endoscopy within 24 hr/next available
endoscopy list
Allow food and drink until 4 hr before endoscopy
No treatment necessary before endoscopy
If admission indicated, send patient to ward 3
If history is of minimal upper GI bleed, and no adverse prognostic features (see fig 1),
consider managing in clinical decision unit (CDU) with a view to discharge with date for early
outpatient endoscopy
Severe non-variceal bleeding
The first priority is to replace fluid loss and restore BP
Insert two large bore (1416 G) venous cannulae

Infuse sodium chloride 0.9% 12 L over 30120 min to achieve systolic BP >100 mmHg
In patients with significant cardiac disease, consider inserting central venous pressure (CVP)
line to guide IV fluid replacement
Stop antihypertensives, diuretics, NSAIDs, anticoagulants
If BP still low, infuse plasma expander (Volplex) one unit over 30 min until systolic BP >100
mmHg
Measure urine output. Adequately resuscitated patients have urine output of >30 mL/hr
Keep patient nil by mouth
If not already an in-patient admit to Ward 3
Transfuse as soon as blood available see Administration of blood and blood
components guideline
prefer packed cells
use O negative blood only if patient in extremis
Once resuscitation has begun, give IV omeprazole 80 mg IV bolus injection slowly over
10 min followed by omeprazole 40 mg in 100 mL sodium chloride 0.9% IV by infusion at
20 mL/hr (8 mg/hr) for 72 hr
Arrange upper GI endoscopy by phoning gastroenterology unit
After preliminary resuscitation, discuss all patients with severe non-variceal bleeding with oncall surgical team. If appropriate, transfer patient to general surgical care, usually in the SAU,
for further management:
if doubt about realistic possibility of surgery, duty surgeon and duty physician to review
patient in consultation
if any difficulties are encountered with this policy, inform on-call consultant physician. Contact
a senior gastroenterologist via call centre only if on-call team unable to resolve the clinical
management problem satisfactorily with duty surgical team
Indications for surgical intervention are:
exsanguinating haemorrhage (too fast to replace or requiring >4 units of blood to restore
blood pressure)
failed medical therapy
special situation (e.g. patients with rare blood group or refusing blood transfusions)
Oesophageal variceal bleeding
AUGI 2010-11
Haemorrhage from oesophageal varices is always life threatening
Identify patients from clinical history, previous hospital notes or by clinical signs (e.g.
jaundice, ascites, spider naevi)
Insert two large bore (1416 G) venous cannulae, In patients with significant cardiovascular
disease, a CVP line is advisable
Initially infuse sodium chloride 0.9% 1 L over 24 hr:
if Hb <10 g/dL, transfuse one unit of blood for every g/dL <10 g/dL see Administration of
blood and blood components guideline
Correct raised INR with fresh frozen plasma
Continue fluid replacement, aiming to restore heart rate <100 beats/min, systolic BP
>80 mmHg and Hb 10 g/dL, but avoid rapid fluid replacement as it increases risk of
rebleeding
Whilst awaiting endoscopy, give terlipressin 2 mg IV bolus then 1 mg 6-hrly, duration directed
by endoscopist
If haemorrhage still not controlled, discuss with gastroenterology team
Give co-amoxiclav 625 mg orally or 1.2 g IV 8 hrly for three days
always obtain blood culture before giving an IV antibiotic see Collection of blood culture
specimens in Medical guidelines
If septic see Sepsis, severe sepsis and septic shock guideline
In patients with grade 4 encephalopathy see Acute liver failure with encephalopathy in
Medical guidelines, discuss endotracheal intubation with gastroenterology team
If not already in-patient, admit to ward 73. If no bed available, admit to ward 3
Contact gastroenterology team for advice on further management
Do not refer to surgical team
Non-variceal bleeding
Continue observations until outcome of upper GI endoscopy known
Follow advice appearing on endoscopy report
Preferred eradication regimen for Helicobacter pylori is:
omeprazole 20 mg orally 12 hrly
amoxicillin 500 mg orally 8 hrly
metronidazole 400 mg orally 8 hrly
for one week, then continue omeprazole 20 mg orally daily for 6 weeks
In patients allergic to penicillin):
omeprazole 20 mg orally 12 hrly
clarithromycin 250 mg orally 12 hrly
for one week, then continue omeprazole 20 mg orally daily for 6 weeks
Absolute compliance with this regimen is essential in order to achieve an eradication rate
of 90%
Co-prescription of PPIs with clopidogrel may reduce its antiplatelet activity. Refer to BNF
appendix 1 for drugs that interact with clopidogrel
After successful eradication of Helicobacter pylori and course of PPI for ulcer healing, if
NSAID therapy must be reintroduced, continue omeprazole 20 mg orally daily for as long as
NSAID required
If neoplasm identified, refer to surgical team.
Patients who rebleed:

if an otherwise stable patient who is potentially referable for surgery rebleeds, request urgent
endoscopy and discuss with on-call surgical team
AUGI 2010-11
Indications for surgical intervention:

exsanguinating haemorrhage (too fast to replace)
failed endoscopic therapy
major rebleed after successful endoscopic therapy
special situation (e.g. patients with rare blood group or patients refusing blood transfusion)
a major bleed may warrant early surgery
Once agreed with surgical team, transfer high-risk patients to SAU
Variceal bleeding
Contact gastroenterology team for advice on management:
if not admitted directly, transfer patient to a GI ward 3
All patients
4 hrly heart rate and BP
Observe vomit for blood content and test stools for occult blood
Daily Hb until it is stable (not falling)
In patients with severe bleeding, urine output aim for >30 mL/hr
Discharge when stable
Non-variceal bleeding
If H.pylori positive duodenal ulcer, ask GP to arrange faecal antigen testing for H pylori
>4 weeks after completion of eradication therapy
If H.pylori positive gastric ulcer, ask GP to arrange faecal antigen testing for H pylori
>4 weeks after completion of eradication therapy and repeat upper GI endoscopy to check
healing 6 to 8 weeks following discharge
If Hb still <10 g/dL, start ferrous sulphate 200 mg orally 8 hrly
Non-severe bleeding with transient pathology (e.g. MalloryWeiss tear, acute erosion):
discharge promptly after endoscopy with no follow-up
Non-severe bleeding and ulcer-related disease:
discharge young stable patients (aged <45-yrs) promptly after endoscopy
discharge older patients (aged >45-yrs) when their condition is stable
Severe bleeding and ulcer-related disease:
discharge when condition and Hb stable
Variceal bleeding
Start propranolol 40 mg orally 12 hrly, unless contraindicated, as prophylaxis for further
variceal bleeding
Refer to gastroenterologist
Neoplasia
Discuss further investigation and treatment with upper GI cancer team contact cancer nurse
specialist
ALF 2010-11
ACUTE LIVER FAILURE WITH

ENCEPHALOPATHY
Consider liver failure in all patients with abnormal liver function tests or coagulopathy
whose conscious level deteriorates
Symptoms and signs
Altered conscious level (hepatic encephalopathy, see Table 1)
Jaundice
Evidence of coagulopathy (e.g. bruising, petechiae)
Flap
Ascites and oedema
Malaise, nausea, vomiting
Table 1: Grading of encephalopathy
Grade
Symptoms and signs
1
Confused
Altered mood or behaviour
2
Drowsy with inappropriate behaviour
3
Stupor with inarticulate speech
Rousable and can obey simple
commands
Severe agitation, wailing and
decerebrate posturing
4
Coma
Unrousable
Investigations
FBC, INR
U&E, phosphate, calcium and magnesium
Blood glucose
LFT
Liver antibodies:
SMA
ANA
AMA
LKM (liver-kidney-microsome)
ANCA
Hepatitis A and B serology (EBV and CMV if virology negative) and autoantibodies
Even if there is no evidence of paracetamol overdose, take sample to save for toxicology
screen including plasma paracetamol
Arterial blood gases (on air)
Blood and urine cultures
Ascitic fluid culture and white cell count
Chest X-ray
Look for evidence of multiple organ failure
Patient looks severely ill/exhausted/obtunded
ALF 2010-11
Hypotension (mean arterial pressure <80 mmHg) despite initial fluid administration inotrope
dependency
Oliguria/anuria
Spontaneous bruising and/or mucosal bleeding
Cerebral oedema. Evidence: (bradycardia, hypertension, dilated pupils or decerebrate
posturing)
Impaired gas transfer hypoxaemia (PaO 2 <10 kPa) despite 40% oxygen
Metabolic acidosis
Hypoglycaemia
Radiological pulmonary shadowing/oedema
IMMEDIATE TREATMENT AND SUBSEQUENT MANAGEMENT
Admit to GI ward or ITU see Indications for transfer to ITU

Inform a senior member of on-call team (SpR or above)
After patient review, senior member of on-call hepatology team via call centre for urgent
assistance. If unavailable, discuss with regional liver unit
Indications for transfer to ITU

Multiple organ failure in patients with acute liver failure exhibiting Grade 3 or 4
encephalopathy contact duty anaesthetist
Cerebral oedema
Uncomplicated liver failure
Establish IV access
Fluid management
If hypoglycaemia or hyperglycaemia, regulate blood glucose using regimen recommended in
Hyperglycaemia in the ill patient guideline but aiming for tighter control (target range
46.5 mmol/L rather than 611)
Correct hypotension with colloid infusions albumin 4.5%
+
Give maintenance crystalloid 3 L/day to maintain serum Na >130 mmol/L. Give pre-mixed
bags of sodium chloride 0.9% with 20 or 40 mmol/L potassium chloride to maintain serum K+
>3.5 mmol/L
Correct hypophosphataemia with phosphate polyfusor (Fresenius Kabi) IV. A 500mL bag
gives 81 mmol sodium, 9.5 mmol potassium and 50 mmol phosphate
moderate hypophosphataemia (0.50.7 mmol/L),treat with 0.10.2 mmol phosphate/kg
(equivalent to 12 mL/kg) over12 hr
severe hypophosphataemia (<0.5 mmol/L), treat with 0.20.5 mmol phosphate/kg (equivalent
to 25 mL/kg) over 12 hr
total maximum dose of 50 mmol per infusion
repeat doses may be required on subsequent days
reduce dosage in elderly patients and those with reduced renal function
Respiratory failure
Correct hypoxia see Oxygen therapy in acutely hypoxaemic medical patients guideline
Coagulopathy
Give phytomenadione (Konakion MM) 10 mg IV daily by slow IV infusion in 55 mL glucose
5%. Do not give fresh frozen plasma unless clinical evidence of bleeding
Infection
Treat all infections as serious as these patients exhibit few clinical signs of infection
ALF 2010-11
Give antibiotics and antifungals:

for first 48 hr, co-amoxiclav 1.2 g IV 8 hrly; if penicillin allergic, aztreonam 1 g IV 8 hrly plus
vancomycin IV (see Prescribing regimens and nomograms Vancomycin guideline);
plus metronidazole 500 mg IV by infusion 8 hrly
if responding after 48 hr, substitute co-amoxiclav 625 mg orally 8 hrly; if penicillin allergic,
discuss with consultant microbiologist or consultant in infectious diseases. Check culture
results and sensitivities to ensure these antibiotics are appropriate if in doubt, contact
microbiology
if culture negative and ascitic fluid polymorphonuclear leukocytes (PMN) before antibiotic <50
106/L, discontinue after five days, or sooner if significantly improved and >48 hr apyrexial
if not responding after 48 hr with temperature >38C or further deterioration in liver and/or
renal function, repeat blood culture and change to meropenem 1 g IV 8 hrly. If penicillin
allergy is anaphylaxis, discuss with consultant microbiologist or consultant in infectious
diseases
in all patients, add fluconazole 100 mg IV by infusion daily for 2 days, then fluconazole
100 mg orally daily for 5 days. If still not responding after another 48 hr, discuss with
consultant microbiologist
Encephalopathy
Consider giving Pabrinex IV see Alcohol withdrawal guideline
Except in fulminant liver failure, give lactulose 3050 mL orally or via nasogastric (NG) tube
8 hrly, or phosphate enema rectally daily. Adjust dosage to produce two to three soft stools
daily. It is not necessary to produce diarrhoea
Discuss diet with dietitian
Avoid sedatives (benzodiazepines, phenothiazines, opioids)
Complications
Varices
If evidence of upper Gl haemorrhage, refer to gastroenterology team for initiation of
terlipressin infusion and possible endoscopy and variceal sclerotherapy see Acute upper
gastrointestinal haemorrhage guideline
Ascites
Do not treat urgently unless it is causing symptoms. If encephalopathic, avoid or stop
diuretics even if symptomatic
If ascites symptomatic, give spironolactone 100 mg orally daily, increasing by 100 mg every
two to three days if necessary (max 400 mg daily) to achieve weight reduction of
0.51 kg/day. Furosemide 40 mg orally daily (max 40 mg 12 hrly) may be added if
spironolactone not effective
If drainage thought necessary, stop diuretics for 48 hr around period of paracentesis and
replace fluid volume drained with IV infusions of albumin (albumin 20% 100 mL IV at outset,
repeated for every 3 L of fluid drained)
Spontaneous bacterial peritonitis (SBP)
If condition deteriorates or there is evidence of sepsis, SBP must be excluded, as it carries a

high mortality. Arrange urgent ascitic tap for MC&S and ascitic fluid WCC
if ascitic PMN 50250 106/L, repeat in 24-48 hr do not prescribe antibiotics
if SBP confirmed (ascitic PMN >250 106/L), start antibiotics and antifungals (see Infection
above). Give albumin 1.5 g/kg IV over 24 hr and 1 g/kg day 3
with clinical improvement, switch to oral antibiotics (total duration 510 days)
at end of course, start prophylactic ciprofloxacin 250 mg orally 12 hrly on discharge and
continue until ascites resolved
ALF 2010-11
Electrolyte disturbance and renal failure

If patient develops hyponatraemia or doubling of serum creatinine, stop diuretics and restrict
fluid and salt intake
If >50% rise in creatinine in 24 hr and oliguria (<300 mL in 24 hr), discontinue diuretics and
renal toxins (e.g. NSAIDs, ACE inhibitors, gentamicin). Confirm fluid replacement adequate
with CVP monitoring
If CVP >10 cm H 2 O, inform gastroenterology or renal team
Cerebral oedema
Request transfer to ITU seek advice from consultant gastroenterologist
Disturb as little as possible and nurse at 45 degrees head up
Aim to maintain serum Na+ >140 mmol/L with sodium chloride 1.8% by IV infusion
if fluid status required a more concentrated solution, discuss with gastroenterology consultant
For acute episodes, give mannitol 20% 1 L by IV infusion over 30 min and repeat, if
necessary, after 4 hr if urine output and/or serum osmolality fail to rise or vital signs
deteriorate
Treat seizures see Status epilepticus guideline
Avoid terlipressin
In-day
pulse oximetry (continuous)
urine output (hrly)
blood glucose (2 hrly)
BP (4 hrly)
pulse (4 hrly)
temperature (4 hrly)
conscious level (4 hrly)
Daily (if following paracetamol overdose, twice daily)
FBC, INR
U&E
weight and fluid balance
Alternate days
LFT
DISCHARGE AND FOLLOW UP
Arrange outpatient follow-up with gastroenterology team
Ulcerative colitis 2010-11
ACUTE ULCERATIVE COLITIS AND CROHN'S

DISEASE
Symptoms and signs
Severe diarrhoea, tenesmus
Abdominal pain
Anorexia, weight loss
Malaise
Variable amount of blood in stool
Dehydration
Tachycardia
Fever
Anaemia
Severe sepsis/septic shock
Toxic dilatation of colon
Free perforation of colon
Profound electrolyte disturbance
Massive haemorrhage
Obvious weight loss
Secondary multi-organ failure
Investigations
FBC
Biochemical screen, blood glucose
Abdominal X-ray
Erect chest X-ray look for gas under diaphragm
Stool culture (salmonella, shigella, campylobacter), Clostridium difficile toxin
Crossmatch: group and save
Arterial blood gases
Bacterial and amoebic colitis history of travel
Pseudomembranous colitis history of antibiotic use
Diverticular disease
Ischaemic colitis
Bowel cancer
Abdominal lymphoma
Radiation colitis
Ileocaecal TB
IMMEDIATE TREATMENT
In patients with life-threatening features inform duty surgical team

Barrier nurse inflammatory bowel disease can at first be indistinguishable from infective
diarrhoea
Admit to a GI ward
Establish IV access and correct dehydration/electrolyte disturbance
If Hb <8 g/dL, give blood transfusion (4 units plus an extra unit for each g/dL below 8)
Hydrocortisone 200 mg 8 hrly by slow IV injection over 1 min
Metronidazole 500 mg IV 8 hrly, given over 20 min
Ulcerative colitis 2010-11
DO NOT GIVE
anti-diarrhoeal drugs in acute phase they increase the risk of toxic dilatation
DO NOT PERFORM
barium enema or colonoscopy in acute phase there is a high risk of perforation of the
colon
Once infective element has been excluded, relax barrier nursing restrictions
Ensure patient discussed with consultant gastroenterologist
If improving
Substitute prednisolone (not enteric coated) 40 mg orally daily in place of hydrocortisone. If
antibacterial therapy still needed, use metronidazole 400 mg orally 8 hrly
Start restricted oral feeding. Seek dietetic opinion
Give mesalazine (Asacol MR) 800 mg orally 8 hrly
For distal disease, consider prednisolone enema once daily
If extent and severity of inflammation not apparent from supine plain abdominal X-ray, plan
colonoscopy or barium enema in convalescent phase in consultation with consultant
gastroenterologist
If not improving
Consider surgery if no improvement has been achieved by day 5
2 hrly:
temperature
pulse
BP
respiration
Twice daily:
abdominal examination look for local peritonism and check bowel sounds
measure abdominal girth
Daily:
FBC, U&E, stool culture
abdominal X-ray look for free abdominal gas or colonic dilatation >6 cm
count stools and inspect for blood
Alternate days:
erect chest X-ray: look for gas under diaphragm
Plan home treatment regimen:

prednisolone reduce daily dosage by 5 mg each week to zero or previous maintenance
dosage
prednisolone enema once daily
mesalazine (Asacol MR)
nutritional support, as advised by dietitian
If out-patient colonoscopy or barium enema not already performed, arrange in consultation
with consultant gastroenterologist
Arrange follow-up in gastrointestinal out-patient clinic after 4 weeks
Give patient information literature (available from gastroenterology department) and
encourage membership of NACC (National Association for Colitis and Crohn's Disease)
Chest pain 2010-11
MANAGEMENT OF SUSPECTED CARDIAC CHEST

PAIN
ON PRESENTATION
ECG doctor/trained practitioner to check immediately

Clinical assessment. Include:
full history: pain more likely to be cardiac if >15 min duration, exertional or associated with
nausea/vomiting, breathlessness, sweating and cardiovascular instability
high risk features
cardiac risk factors
examination
Admission and 12-hour Troponin I
TRIAGE OF PATIENTS WITH CHEST PAIN
STEMI follow STEMI guidelines

Cardiac chest pain and high risk features (ST depression or T wave inversion, particularly if
marked or dynamic, adbnormal admission Troponin, recent unstable plaque event, recent
stenting) admit to CCU and follow NSTEACS guidelines
Possible cardiac chest pain and no high risk features manage as Rule-out ACS (ROACS). If
pain-free, initiate rapid ROACS pathway. If on-going symptoms, admit to MAU for close ECG
observation
if ECG changes or Troponin rise, transfer to CCU and follow NSTEACS guidelines
Non-cardiac chest pain investigate and manage appropriately
MANAGEMENT OF POSSIBLE CARDIAC CHEST PAIN
Repeat ECG at 90 minutes, 6 hours and following day

If further chest pain, repeat ECG
If dynamic changes documented, manage as acute coronary syndrome and transfer to CCU
Measure troponin I on admission and 12 hr later
If value >0..06 , manage as NSTEMI and transfer to CCU
Discharged patients
Out-patient exercise testing recommended for most cases of chest pain of uncertain cause.
A&E reception will arrange this for those patients on the rapid ROACS pathway. Otherwise fill
out purple request card for CRD.
Chest pain 2010-11
Patient with ischaemic-type chest pain

Give Aspirin 300 mg
Request Troponin I on admission bloods
Beware atypical presentations:

-elderly
-diabetic
-females
Assess initial 12-lead ECG
ECG strongly suspicious for
ischaemia (ST depression, T
wave inversion)
ST elevation LBBB not

known to be old
Normal or non
diagnostic ECG
Assess for
contraindications to
thrombolysis (see page
3)
Admit to CCU
(elsewhere only
by decision of
clinician)
Treat for
NSTEACS
(see page 5)
Initiate thrombolysis
Still in pain OR
High-risk features
(recent ACS or PCI)
Yes
No
Transfer to CCU as
soon as possible
Close observation for 90

minutes, then repeat ECG
(sooner if worse pain). ST
elevation resolved by at
least 50%?
Consider admission to
MAU for 12-hour ruleout or assessment and
treatment of non-cardiac
causes of chest pain
No
Discuss with on call

Cardiology StR at
University Hospital South
Manchester (Wythenshawe)
for possible rescue PCI
Tel: 0161 998 7070
Rapid ROACS
pathway. If normal,
discharge and arrange
next day Troponin and
ETT
Chest pain 2010-11
Unstable angina 2010-11
UNSTABLE ANGINA
Acute Coronary Syndromes (ACS) refer to various clinical representations as the consequence of
one common pathophysiological feature; myocardial underperfusion related to atherosclerotic
plaque erosion or rupture, with differing degrees of superadded thrombosis and distal
embolisation.
Depending ECG findings and bio-marker levels, three categories of ACS are defined: STE-MI (ST
segment elevation myocardial infarction), NSTE-MI (non-ST elevation MI) and Unstable Angina.
The former two are discussed in relevant sections of the Guidance.
The clinical presentation and electrocardiographic findings of for NSTE-MI and Unstable angina
are very similar. The difference in between the two diagnostic categorie is simply based on the
presence or absence of bio-marker of myocardial injury, which is currently Troponin-I
th
measurement at Macclesfield DGH. The cut-off point, or 99 percentile of the upper reference
limit (with 10% confidence interval) for Troponin I in normal population is 0.07 ng/mL.
Unstable angina pectoris has three components:
Typical chest pain, or equivalent such as dyspnea as described below;
Transient ST segment changes (depression, rarely elevation), or T wave inversion,
Without a rise (and subsequent drop) in bio-marker Troponin I, beyond pre-defined
normal range.
Electrocardiographic findings may not always be present and are not an essential
requisite if clinical suspicion of UA is very high.
Typical angina pain is described as constricting discomfort in the front of the chest, neck,
shoulders, mandible or arms.Occasionally is described as an indigestion, epigastric discomfort.
It may be associated with cold sweat, clamminess and nausea. Stable angina pectoris is
precipitated by exertion or maybe post-prandial. The unstable features would be the onset of
angina for the first time with frequent attacks, or sudden worsening of previously stable angina
without change in medical treatment, or recurrent angina at rest, or on minimal exertion. Dyspnea
may accompany the chest discomfort, or occasionally may be the only presenting symptom, with
similar pattern to angina, without the pain!
An attack of angina that lasts > 20 min or keeps recurring despite repeated use of glyceryl
trinitrate (GTN) is an indication for immediate admission to hospital
Investigations
ECG on admission, during further episodes of chest pain or equivalent (dyspnea, epigastric
discomfort), and 24 hr after admission
ST segment depression occurring only during pain suggests myocardial ischaemia
Consider pericarditis in there is concordant concave ST elevation in more than one coronary
artery territory; variations such as both anterior and inferior leads, all chest leads ,
Transient ST segment elevation during pain is rare and suggests coronary artery spasm
(Prinzmetal angina). In the absence of rapid resolution of ST segment elevation, in response
to GTN administration, initate Rx per Acute myocardial infarction guideline (aiming
thrombolysis within 20 minutes), as true Prinzmetal is an extremely rare condition
Subsequent occurrence of deep symmetrical T-wave inversion, suggests NSTEMI evolution
Markers of myocardial injury: Troponin-I levels should be checked at the presentation
(random) and at 12 hours. If both results are within normal range, Unstable Angina diagnosis
can be entertained with the typical clinical and/or electrocardiographic features

Pulmonary embolism
Oesophageal pain
Musculoskeletal pain
Biliary colic
Peptic ulcer
Aortic valve disease (stenosis)
Hypertrophic cardiomyopathy
IMMEDIATE TREATMENT
Transfer patient to Coronary Care Unit ( CCU). If a CCU bed is not available, discuss with
the senior CCU nurse for ongoing surveillance and organise rhythm monitoring via
Telemetry.
Initiate medical therapy:
Aspirin 300 mg orally (chew, maserate and swallow) unless there is true Aspirin
intolerance/allergy
Clopidogrel 300mg orally stat dose, to be followed by Clopidogrel 75 mg od for a year
Diamorphine 5 mg by slow IV injection (1 mg/min); 2.5 mg injection (1 mg/min) in elderly/frail
Metoclopramide 10 mg IV over 1-2 min
Bisoprolol 1.25-2.5 mg od orally (or Verapamil 80 mg orally if beta blocker contraindicated)
Fondaparinux 2.5mg by SC injection. If eGFR <30, substitute Enoxaparin 1mg/kg ONCE
daily SC. Continue for 5 days. Longer duration of treatment may be required in the
CCU/Cardiology wards.
Consider Isoket infusion (2-20 ml/hrs), if pain fails to respond SL/buccal GTN. This therapy
should be ideally initiated at CCU for monitoring the response.
Consider for glycoprotein IIb/IIIa inhibitor , Tirofiban if any cardiac high risk features exist
(dynamic ST segment changes; recurrent or ongoing ischaemic chest pain, haemodynamic
instability). Tirofiban should be administered in the CCU and on-call Cardiology team at
SMUHT (MRI if Whythenshawe is not available) should be contacted regarding early
angiography and subsequent invasive treatment .
Patients who are due to go for angiography/PCI will require an additional stat dose of
Clopidogrel at 600 mg, and additional aspirin dose prior to their transfer to Whthenshaw/MRI.
Prasugrel may replace Clopidogrel in high-cardio vascular risk younger patients. Treatment
will start at PCI centers, with a loading dose of 60 mg, and require Prasugrel 10 mg od oral
maintenance dose for a year (TRITON-TIMI trial)
Co-prescription of PPIs with clopidogrel may reduce its antiplatelet activity, although there is
no consensus currently. Refer to BNF appendix 1 for drugs that interact with clopidogrel
Prescribe high-dose statin, Atorvastain 80 mg nocte if there is no contra-indication. In very
elderly, those who have renal impairment and those who have potential drug inter-action,
consider Simvastatin 40mg nocte.
Refer patient for in-patient invasive treatment, angiography followed by the relevant treatment
modality PCI or CABG, if age<80 and there is no significant co-morbidity, active bleeding and
contra-indication for anti-platelet use. Routine referral requires access to web-based Greater
Manchester Network- ACS site, Cardiac Acute Transfer abbreviated as CAT. This referral is
triggered by the cardiology registrar/ SHO and senior CCU staff, following discussion/assessment
by the senior medical cardiology team members. The activity is closely audited and regulated by
the Network, as well as local audit activity.
If ECG changes or markers of myocardial injury suggest acute infarction see Acute
myocardial infarction guideline
Refer to Cardiac Rehabilitation team for their input for information in their condition,
implications, non-pharmacological and pharmacological measures: smiking cessation,
exercise, diet; behavioural change/advice; monitoring of therapy and follow up at discharge
Hourly pulse and BP during GTN infusion until stable, then 4 hourly
Daily 12 lead ECG, in addition to repeat recording if chest pain recurs
Monitor FBC, U/E daily or every other day if stable
Consider alternative diagnosis if clinical picture is not typical
Patients with confirmed diagnosis of unstable angina pectoris should be followed up in

Cardiology clinics ; as well as Cardiac Rehabilitation appointments
Acute MI 2010-11
ACUTE MYOCARDIAL INFARCTION

Symptoms and signs
Severe, persistent chest pain
Dyspnoea
Fear
Pallor
Sweating
Anxiety
Peripheral vasoconstriction
Shock
Investigations
ECG (see below)
Markers of myocardial injury
Admission and 12-hour Troponin I
Venous blood glucose
Chest Xray (but do not delay definitive therapy for this unless there is clinical suspicion of
aortic dissection)
IMMEDIATE TREATMENT
Aspirin 300 mg (chew, macerate and swallow)

Morphine 5 mg IV boluses until pain relieved, up to maximum 20 mg (10 mg in elderly or frail
patients)
Metoclopramide 10 mg IV over 12 min (5 mg in young adults 1519 yr <60 kg) with 8 hrs
before repeating
O 2 if SaO2 < 94%
Bisoprolol 1.25-2.5 mg orally, repeat daily, unless contraindicated see BNF section 2.4
Atorvastatin 80 mg for all acute coronary syndromes
Clopidogrel 300 mg oral for all acute coronary syndromes, 600 mg if transferring for primary
PCI
Admit all patients with acute myocardial infarction (MI), or NSTEACS with ST depression
or deep T wave inversion and/or raised troponin I (>0.05 ng/mL) to CCU
If ECG shows ST elevation MI (STEMI), follow MANAGEMENT OF STEMI
If patient has a Non-ST Elevation MI (NSTEMI), follow MANAGEMENT OF NSTEMI
MANAGEMENT OF STEMI
Consider Primary PCI if

o Cardiogenic shock
o Contraindication to thrombolysis
Thrombolytic therapy (STEMI)

Indications
Presentation within 12 hr of onset of symptoms
Typical cardiac chest pain persisting for >30 min
>1 mm ST segment elevation in two or more adjacent limb leads OR >2 mm ST segment
elevation in two or more adjacent pre cordial leads OR > 3 mm ST depression in leads V1-V3
with prominent R waves and no RBBB (suggesting acute posterior infarction) OR LBBB not
known to be old (do not delay thrombolysis by looking for old notes)
Acute MI 2010-11
Contraindications
Absolute: (consider Primary PCI)
active bleeding or bleeding diathesis (excluding menses)
pregnancy
previous intracranial haemorrhage
intracranial neoplasm
suspected aortic dissection
Relative:
major trauma/major surgery within previous four weeks
stroke/TIA within previous three months
traumatic cardiac massage or intracardiac injection
known bleeding disorder
active dyspepsia or history of GI haemorrhage
sustained systolic BP >180 mmHg
proliferative retinopathy
recent head injury
pericarditis
INR >2.0, taking anticoagulants in therapeutic doses or liver disease with high probability of
deranged clotting
Cardiogenic shock and ventricular arrhythmias are not contraindications.
There is no upper age limit for this treatment
Choice of agent
Standard agent is TNK ( tenecteplase), which is delivered as both a pre-hospital agent and
within hospital
administer by giving weight-adjusted bolus according to product information
Follow this with iv Heparin 4000 units if < 67 kg, 5000 units if > 67 kg
Follow this with Fondaparinux 2.5 mg s/c and continue this once daily. If eGFR < 30,
substitute Enoxaparin 1 mg/kg ONCE daily s/c
Referral for urgent coronary intervention

Refer to on call Wythenshawe cardiology registrar urgently if patient has a STEMI and:
thrombolytic therapy contraindicated
thrombolytic therapy fails to settle pain and/or ST segment changes (< 50% resolution of ST
elevation at 90 minutes)
patient has recurrent malignant ventricular arrhythmias
Complications
Hypotension if occurs de novo, review for cardiogenic shock, mitral regurgitation or tamponade.
Bradycardia usually responds to atropine 300 microgram IV
Ventricular tachycardia or idioventricular rhythm usually self-limiting and requires no therapy. If
sustained see Cardiac arrhythmias guideline
Avoid arterial puncture, central venous cannulation and IM injections in patients undergoing
thrombolytic therapy, unless essential to patient care
MANAGEMENT OF NSTEMI
Treatment of choice for NSTEMI is in-patient cardiac catheterisation with early
revascularisation, either by percutaneous intervention (PCI) or CABG.
initiate Fondaparinux 2.5 mg by SC injection . If eGFR < 30, substitute Enoxaparin 1 mg/kg
ONCE daily s/c. Continue for 5 days.
Acute MI 2010-11
NON-DIABETIC PATIENTS WITH BLOOD GLUCOSE >11 mmol/L

AND ALL PATIENTS WITH DIABETES MELLITUS
Check plasma potassium, but do not await result
Give simultaneous IV infusions of glucose 5% and Actrapid insulin via 3-way tap for 2472 hr
glucose 5% 500 mL 12 hrly see Administration of fluid and insulin infusions guideline
Actrapid insulin 50 units in 50 mL sodium chloride 0.9% (1 unit/mL), at initial rate of 4 units/hr
After 1 hr check capillary glucose (Medisense), chart result, and use Table 2 to adjust infusion
rate, aiming for capillary glucose 710 mmol/L
Repeat capillary glucose hrly after each change of infusion rate, otherwise 2 hrly. Chart all results
Table 2: Capillary glucose vs Actrapid infusion rate
Capillary glucose
Actrapid (units/hr = mL/hr)
(mmol/L)
>15
6
1114.9
5
710.9
3
46.9
1
<4
Stop insulin infusion
Give glucose 20% 50 mL IV into large vein
Test capillary glucose every 15 min
Recommence insulin when capillary
glucose >7 mmol/L
Repeat plasma potassium at 6, 12 and 24 hr after starting infusions and immediately in event of
a clinically significant cardiac arrhythmia
In patients with normal renal function but with plasma potassium <4.5 mmol/L, replace the 500
mL bag of glucose 5% by a 500 mL pre-mixed bag of glucose 5% with potassium chloride 20
mmol 12 hrly
Always use commercially produced pre-mixed bags of infusion fluid.
NEVER add potassium chloride to infusion bags
When capillary glucose stable between 410.9 mmol/L for at least 24 hr, substitute SC insulin, as
follows:
add up total insulin requirement during 24 hr of normoglycaemia
divide into four equal doses
give three of the doses as soluble insulin SC (e.g. Actrapid,/Humulin S), giving one dose
before breakfast, lunch and evening meal and fourth dose as Isophane insulin SC (e.g.
Insulatard/Humulin I) at 2130 hr
Subcutaneous insulin should be continued for three months
Aspirin 75 mg orally daily (to be continued indefinitely)
Clopidogrel 75 mg orally daily for one year unless STEMI without PCI, where duration is 28 days
Bisoprolol 2.5 mg orally daily (to be titrated to maximum tolerated dosage and continued
indefinitely)
If no clinical suspicion of significant mitral/aortic stenosis or hypertrophic cardiomyopathy, plasma
creatinine <200 mol/L and there is no other contraindication to using ACE inhibitor, start ramipril
see Prescribing regimens and nomograms. Check electrolytes on day 35
Check statin (atorvastatin 80 mg) has been prescribed
give patient information sheet
If pain persistent, consider post-MI pericarditis, if not give glyceryl trinitrate (GTN) infusion see
Prescribing regimens and nomograms
If pain persists, contact on call Wythenshawe cardiology registrar for consideration of urgent
coronary intervention
Unless complications ensue, recommend early return to physical activity:
Acute MI 2010-11
24 hours sit out
48 hours mobilise round bed
Day 3 walk to toilet
Day 4-5 extend walking distance and try stairs
Refer all patients to rehabilitation co-ordinator
Patients not wishing to join rehabilitation programme should receive appropriate dietary advice
Refer all patients treated with glucose and insulin infusions to diabetes nurse specialist
All patients with acute coronary syndromes should be assessed for in-patient angiography
and revascularisation
Continuous ECG monitoring for 72 hr (longer if continuing instability or arrhythmia)
Measure BP 4 hrly for 24 hr, then twice daily
12-lead ECGs on admission, at 90 minutes, 6 hours, then daily thereafter. Additional ECGs in
response to pain.
Observe for specific complications (more likely to occur if patients not thrombolysed or otherwise
reperfused)
Arrhythmias
See Cardiac arrhythmias guideline (seek further cardiological input)
Cardiac failure
See algorithm (seek further cardiological input)
In patients with left ventricular failure (LVF) or severely impaired LV function and diabetes,
introduce Eplerenone see Acute cardiac failure guideline
Arrange echocardiogram as out-patient
Pericarditis
More likely after large infarcts (seek further cardiological input)
Pain with persistent/intermittent pericardial rub two to five days after infarction
Adequate analgesia (may need diamorphine). Give Ibuprofen 400 mg orally 8 hrly if no
contraindication (beware fluid retention and antagonism of loop diuretic)
Recurrent ischaemic pain (seek further cardiological input)
Isosorbide mononitrate SR orally (GTN infusion if necessary see Prescribing regimens and
nomograms)
If persistent chest pain occurs, refer to cardiology team for consideration of in-patient stress
testing, coronary angiography and possible angioplasty
If re-infarction occurs during admission, contact cardiology team immediately
Acute MI 2010-11
Management of cardiac failure after acute MI

No
Significant arrhythmia?
Yes
See Cardiac arrhythmias guideline
No
New systolic murmur?
Yes
Echocardiography/SwanGanz for ventricular septal

defect and mitral
regurgitation
No
Warm and well perfused?
Yes
Basal crackles >10 cm
Furosemide
Eplerenone
No
Basal crackles?
Yes
No
Inferior MI?
Yes
Consider right ventricular infarct:

Swan-Ganz catheter and fluid
repletion may be required
No
Poor prognosis: Consider SwanGanz catheter and IV dobutamine/

dopamine
Consider balloon pump
BP
>90 mmHg systolic?
Yes
Give furosemide and IV GTN
Acute MI 2010-11

If no complications, discharge home on day 5
Check risk factors for recurrent MI (e.g. smoking, hypertension, obesity) and advise or treat
accordingly (mortality in first two years is doubled in those who continue to smoke)
Explain graded return to full activity (see advice booklet)
Where appropriate, ensure patient has climbed stairs to assess for chest pain/shortness of breath
Ensure advice booklet and chest pain alert card have been issued
Warn about post-infarct angina
Ensure GTN 500 microgram tablets for sublingual use have been prescribed TTO and patient
has been counselled on use, unless patient fully revascularised
Advise not to drive for four weeks and check with insurer (Group 2 drivers must notify DVLA,
taxi drivers must notify local council)
Ensure referral has been made to cardiac rehabilitation team
Request out-patient echocardiogram for all ACS patients with a raised Troponin
Check that follow-up has been arranged in diabetic clinic for all patients treated with glucose and
insulin infusions
Follow-up clinic visit
Ask about smoking, exercise and weight reduction
Ask about angina if occurring, consider referral for angiography
Look for signs of heart failure and measure BP
If patient has not been to catheter lab, consider treadmill exercise
Encourage return to work one to three months after infarction
Resume driving one month after infarction (except Group 2 drivers)
Unless there are contraindications, all patients should be taking the following treatment:
STEMI:
ACE inhibitor
statin therapy
beta blocker
aspirin
clopidogrel ( 28 days, unless stent then 1 year)
NSTEMI:
ACE inhibitor
statin therapy
beta blocker
aspirin
clopidogrel (1 year)
Aortic dissection 2010-11
AORTIC DISSECTION
Symptoms and signs
Chest pain: usually severe, sudden onset, tearing, may radiate retrosternally or to neck, arms,
interscapular area or abdomen
Paralysis owing to involvement of cerebral or spinal arteries
Loss of consciousness
Dyspnoea
Initial BP may be elevated, normal or low
BP discrepancy between limbs may be present, but pressure may be equal
Pulse deficit
Aortic regurgitant murmur
Wide pulse pressure
Neurological signs
Evidence of limb or abdominal ischaemia owing to involvement of major aortic branches:
abdominal pain, bloody diarrhoea, absent bowel sounds
renal failure
paraplegia
limb ischaemia
Cardiac tamponade or evidence of myocardial infarction (MI) if dissection has extended
retrogradely into aortic root
Suspect diagnosis particularly if patient has hypertension, known bicuspid aortic valve
disease or connective tissue disorder such as Marfans.
Investigations
If aortic dissection suspected, request CT Thorax urgently , transfer to CCU and refer to
cardiology team . Do not delay; mortality is 1% per hr and can be reduced by prompt
treatment
Chest X-ray: PA film may show mediastinal widening but is not always present absence
does not exclude the diagnosis
ECG: may be normal or can show inferior MI
U&E
FBC
Group and save
Contact cardiology team urgently, while arranging CT
CT or MR angiography, or transoesophageal echocardiography can be used to confirm
diagnosis and establish extent of dissection. CT is the choice of investigation, as small
mortality is present with TOE.
Transfer to CCU urgently. Adequate BP control with systolic BP <120 mm Hg is crucial to limit
the extention of dissection, subsequenty reduce the mortality.
IMMEDIATE TREATMENT
Pain and BP
Control pain initially with diamorphine 5 mg IV by bolus injection at 1 mg/min
halve dose of diamorphine in the elderly
if pain or distress persists, give further boluses of diamorphine 2.5 mg IV at 10-min-intervals
until control achieved
Aortic dissection 2010-11
If systolic BP >120 mmHg, give labetalol by IV bolus injection over at least 1 min see
Prescribing regimens and nomograms and repeat if necessary until systolic BP <100
mmHg
Once systolic BP <100 mmHg, maintain with IV infusion of labetalol see Prescribing
regimens and nomograms. The beneficial effect of beta-blocker is beyond its actual
benefit on BP control.If labetalol infusion fails to control BP, ADD IV infusion of glyceryl
trinitrate (GTN) [50 mg in 50 mL sodium chloride 0.9% at 0.6 mL/hr (10 microgram/min),
increasing to a maximum of 12 mL/hr (200 microgram/min)] see Prescribing regimens
and nomograms
Sodium nitroprusside infusion is an alternative to add on to beta-blocker Rx, if BP control is not
achieved with aforementioned measures. The initial infusion rate is 20 g /min, to be uptitrated
up to 800 g/min according to BP response.
If there is contra-indication for beta-blockers (severe asthma), verapamil and diltiazem can be
used.
Dissection
If dissection involves ascending aorta, urgent cardiac should be considered
If dissection originates in descending aorta, control pain and BP with medical therapy unless
evidence of involvement of abdominal branches of aorta (see above) when vascular surgery
may be indicated
Involve specialist teams early; cardiothoracic surgeons for ascending aorta/arch dissection
and vascular surgeons for infra-diaphragmatic dissection. New technologies such as stenting
dissection are emerging within specialist units
Ensure systolic BP maintained 100 to 120 mmHg and pain control optimal
Surgical referral if indicated
Temperature, pulse, BP every 30 min

Urine output hrly
Monitor U/E and FBC 12 to 24 hr intervals
Rehabilitation from neurological or vascular complications may be necessary prior to

discharge
Discharge medically treated patients when BP controlled and stable. Arrangement of followup by cardiology team to ensure BP remains well controlled
Discharge surgically treated patients when fully recovered and BP controlled and stable with
F/U in cardiology and relevant surgical clinics.
Tamponade 2010-11
CARDIAC TAMPONADE
Patients at risk
Recent cardiac surgery
Diagnosis of malignancy
Following myocardial infarction
Chest trauma
Symptoms and signs
Dyspnoea
Decreased conscious level
Right heart failure (if tamponade chronic)
Hypotension (systolic BP <100 mmHg)
Systolic BP falls by >10 mmHg during inspiration
Raised jugular venous pressure (JVP)
Rise in JVP with inspiration
Soft heart sounds
Heart rate >80 beats/min
Oliguria or anuria
Investigations
U&E
Chest X-ray
ECG
Echocardiogram
Severe symptoms
Signs of shock (tachycardia >100 beats/min, BP <100 mmHg) with marked hypotension
during inspiration
Large effusion on chest X-ray and/or echocardiogram, with evidence of right ventricular (RV)
diastolic collapse on echocardiogram
IMMEDIATE TREATMENT
If life-threatening features are present, contact cardiology team to arrange immediate

echocardiography to confirm diagnosis:
if effusion confirmed, cardiology team will arrange immediate aspiration
a pericardial drain can be left in situ for several days to facilitate drainage of a large effusion
If features of effusion present without life-threatening features, contact cardiology team to
arrange echocardiography within 24 hr to confirm diagnosis:
if echocardiogram suggests effusion is large, pericardial aspiration for diagnostic purposes
can be carried out safely
Ensure pericardial fluid sent for biochemical, microbiological and cytological investigation to
aid diagnosis
Consider possible causes of pericardial effusion and refer to cardiology and other appropriate
specialities (e.g. renal/haematology)
Arrange appropriate further investigations (seek specialist advice if necessary) for:
malignant disease
acute pericarditis
chronic renal failure
Tamponade 2010-11
connective tissue disease

cardiac rupture complicating myocardial infarction, trauma or cardiac catheterisation
recent cardiac surgery
extension of aortic dissection
Temperature, pulse, BP and urine output hrly if shocked, decreasing to 4 hrly and then twice
daily in stable patients
When haemodynamically stable and effusion tapped, remove aspirating needle or drain
Follow-up and further treatment depends on underlying diagnosis
Cardiac failure 2010-11
ACUTE CARDIAC FAILURE

Heart failure is characterised by the presence of symptoms and signs compatible with cardiac
dysfunction together with objective evidence of ventricular dysfunction. Both criteria must be
present for the diagnosis to be robust
Symptoms
Fatigue
Dyspnoea of effort and, when severe, at rest
Orthopnoea
Paroxysmal nocturnal dyspnoea
Swelling of feet and ankles
Cough, wheeze
Signs
Tachycardia
Hypotension
Raised jugular venous pressure (JVP)
Enlarged heart
Third/fourth heart sound
Mitral regurgitation
Enlarged, tender liver, jaundice
Peripheral oedema
Ascites
Chronic obstructive pulmonary disease (COPD)
Acute severe asthma
Pneumonia
Pulmonary embolism
Interstitial lung disease
Anaemia
Dependent oedema resulting from immobility
Renal failure/nephrotic syndrome
Cirrhosis
Hypoalbuminaemia
Drug induced ankle swelling (eg dihydropyridine Calcium Channel Blocker)
Depression and/or anxiety disorders
Bilateral Renal Artery Stenosis
IMMEDIATE TREATMENT
Acute pulmonary oedema
Nurse patient in sitting position in bed/chair
Oxygen high flow 40 60% (24% in patients with co-existent COPD)
Furosemide 40 mg by slow IV injection
if no response within 20 min, repeat similar dose by slow IV injection
If peripheral oedema gross (above knees), give furosemide 80 mg daily by slow IV injection,
titrating dose upward to achieve daily weight loss of up to 0.5 kg/day (single IV doses greater
than 80 mg should be given by IV infusion, no faster than 4 mg/min). Continue until JVP
normal before changing to maintenance oral dose, to maintain stable dry weight. Divide daily
dosage only if nocturnal dyspnoea troublesome (doses at 0700 hr and 1400 hr)
If systolic BP >100 mmHg, start isoket infusion.
aim to reduce BP until symptoms are relieved, but do not allow BP to fall below 90/60 mmHg
Morphine 5 - 10mg by slow IV injection (2 mg/minute) Reduce dose in elderly or frail patients
Treat hypertension (see Accelerated hypertension) and cardiac arrhythmias (see Cardiac
arrhythmias)
Consider prophylactic low-molecular-weight heparin (see Prophylaxis against venous
thromboembolism guideline)
If not responding
Refer to cardiology team for advice on other measures, that may include:
urgent echocardiogram
aggressive initiation of inotrope/vasodilator
ventilation (invasive or non-invasive)
If systolic BP <100 mmHg and evidence of poor organ perfusion, pulmonary oedema or urine
output <0.5 mL/kg/hr, consider dobutamine (see Prescribing regimens and nomograms)
INVESTIGATIONS
Chest X-ray
ECG
FBC
U&E, LFT, cardiac enzymes, TSH, glucose and fasting serum lipids
If patient has dyspnoea at rest or severe pulmonary oedema, arterial blood gases (ABG)
Echocardiogram
In suspected heart failure, perform echocardiogram as an in-patient if possible
If echocardiogram already performed, repeat only if there is a discrepancy between previous
result and current clinical presentation, or if a new or worsening murmur is apparent
If responding
Reduce salt intake (no added salt, avoid salty food)
Avoid excessive fluid intake
Unless clinical suspicion of critical aortic stenosis, renal function severely impaired (plasma
creatinine >300 mol/L), bilateral renal artery stenosis (RAS) or prior allergic reaction,
introduce ACE inhibitor in all cases as soon as renal function stable and blood pressure
sufficient for systemic perfusion (see Prescribing regimens and nomograms)
raise dosage empirically every 2 days to maximal tolerated by time of discharge. In patients
with systolic BP <90 mmHg, serum creatinine >200 mol/L or serum potassium >5 mmol/L,
the very elderly and if renal artery stenosis suspected (e.g. symptoms/signs of peripheral
vascular disease), proceed more slowly and by smaller dose increments
Review diuretic dosage daily with aim to minimise once ACEI introduced
Regular oral frusemide. Dose depends on previous diuretic requirements
Remember that the cause of persistent peripheral oedema, especially in the elderly, can be
multi-factorial and does not always reflect fluid status
Look for cause

Always identify cause(s)/trigger factor for current decompensation and if a primary cardiac
cause, refer to cardiology team as in-patient.
Optimise treatment of non-cardiac conditions responsible for, or contributing to, heart
failure
Examples of causes of heart failure presentations
Primary cardiac cause of heart failure
(seek cardiology advice)
Heart failure secondary to comorbidity

(seek cardiology advice only if echocardiogram
confirms left ventricular systolic dysfunction)
Seek cardiology advice in suitable patients if
structural cardiac abnormality on echo or
significant ischaemia precipitated heart failure
secondary to non-cardiac presentation
ACS
Valve disease
Arrhythmia
Cardiomyopathy
Significant pericardial disease
Diastolic dysfunction
Pulmonary hypertension/primary right
heart failure
COPD
Pneumonia
Sepsis
Anaemia
Hypertension
Renal failure
Endocrine abnormalities (e.g. thyroid
disease)
Nutritional deficiencies
Refractory heart failure

If oedema persists despite IV diuretic and optimal dose of ACE inhibitor, consider addition of
metolazone 2.55 mg orally in single doses, repeated as necessary over a short period.
Metolazone can induce massive diuresis. Monitor patients carefully to prevent hypovolaemia
or electrolyte disturbance
If in atrial fibrillation with rapid ventricular rate, add digoxin (see Prescribing regimens and
nomograms)
If resistant to treatment despite these additional measures, seek advice on further
management from cardiology team
Further management
Consider spironolactone only in patients on optimal medical therapy who have ejection
fraction <35%, serum creatinine <220 mol/L, serum potassium <5 mmol/L and heart failure
severity NYHA III IV
If euvolaemic with heart rate >65/min and systolic BP >100 mmHg, consider in-patient
initiation of beta blocker
start with low dose (e.g. bisoprolol 1.25 mg daily)
If ACE inhibitor not tolerated because of cough, substitute angiotensin-II receptor antagonists
such as candesartan
In patients unsuitable for ACEI/ARB or with ongoing symptoms despite optimal ACEI and beta
blocker, consider hydralazine (25 mg 8 hrly) and isosorbide mononitrate/dinitrate
Consider decreasing dosage of furosemide after successful treatment of cause/trigger factor
or introduction of ACE inhibitor
ABG repeat 2 hr after starting O 2

Pulse, BP and respiratory rate 4 hrly until no longer dyspnoeic at rest
if patient unwell or while uptitrating vasoactive drugs (e.g. nitrates, inotropes), measure vital
signs more frequently than 4 hrly
Weight and fluid balance daily
U&E alternate days
more frequent U&Es required when titrating up diuretic or ACEI, and in higher risk patients
Chest X-ray repeat after three or four days to assess response
Mobilise once dyspnoea at rest subsides prolonged bed rest is counterproductive

Encourage patient to exercise as much as possible where symptoms allow
Discharge once:
mobile around ward without dyspnoea
free from central and peripheral congestion (e.g. JVP normal or normalising, third heart
sound resolved, etc) remember persistent peripheral oedema may have a cause other than
fluid overload from heart failure, especially in the elderly
renal function stable and weight stable
Arrange echocardiogram (if not previously performed) as out patient and follow up in clinic
when results available
Ask GP to monitor U&E following discharge
Encourage patients to exercise as much as possible within the limit of symptoms.
if likely to die of pump failure within 612 months, consider to be in end-stage heart failure
Cardiac arrhythmias 2010-11
CARDIAC ARRHYTHMIAS
The mode of presentation dictates the urgency of assessment and treatment.
Treat the patient first and the arrhythmia second.
Accurate diagnosis is not possible without a 12-lead ECG
Symptoms (in order of increasing severity/urgency)
Palpitation
Dyspnoea
Chest pain
Dizziness
Syncope
Cardiac arrest
Signs
Heart rate <60 or >100 beats/min
Hypotension
Hypoperfusion
Jugular venous pressure (JVP) elevated
Cannon waves or flutter waves in internal jugular vein
Variable intensity of first heart sound
Signs of heart failure
Investigations
Always obtain a 12-lead ECG during attack, unless patient unconscious with no pulse, when
resuscitation takes priority see Cardiopulmonary resuscitation life support procedure
guideline. A single-lead rhythm strip is an inferior alternative, but better than no ECG at all
Urgent U&E
Non-cardiac causes of syncope (neurological, metabolic)
IMMEDIATE TREATMENT
Successful management of cardiac arrhythmias often requires specialist experience
Correct any abnormalities of potassium
Indications for seeking urgent advice from cardiology team

Tachycardia or bradycardia with hypotension, cardiac failure, chest pain, shock or requiring
pacing
Atrial fibrillation/flutter (AF) suitable for urgent (present for <12 hr) or elective cardioversion
Wolff-Parkinson-White syndrome
Junctional re-entry or ventricular tachycardia unresponsive to treatment recommended in this
guideline
Ventricular arrhythmias excluding single ectopics
All recurrent arrhythmias
Monitor the effects of all the following treatments by continuous ECG recording
Bradycardias
Sinus bradycardia may need no treatment if symptomatic, give atropine 500 microgram
IV, and repeat once after 5 min if necessary
Sinus pauses and sino-atrial block if episodes prolonged and symptomatic, consider
pacing (contact cardiology team)
Sino-atrial disease manifest as tachycardia-bradycardia seek advice from cardiology team
Atrio-ventricular (AV) conduction block
first degree: no treatment necessary
second and third degree: contact cardiology team with 12-lead ECG
Intraventricular conduction block/bundle branch block consider pacing if:
new appearance of bifascicular block (right bundle branch block and left axis deviation) or
alternating left and right bundle branch block
bifascicular block with otherwise unexplained syncope
trifascicular block (long PR interval and left bundle branch block, not drug-induced)
Tachycardias
If tachycardia associated with hypotension, shock, or cardiac failure, before giving any
anti-arrhythmic drug IV, seek urgent advice from cardiology team to discuss DC
cardioversion (or overdrive pacing for selected tachycardias)
Clinical significance depends upon site of origin. Accurate diagnosis requires 12-lead ECG
(paper speed 25 mm/sec, 40 msec = 1 small square)
Narrow (<110 msec) QRS complexes originate from sinus node, atrium or AV junction (see
below)
Broad (>110 msec) QRS complexes should be considered ventricular in origin unless or
until proved otherwise
If diagnosis in doubt, try carotid sinus massage (CSM) first
recent CVA/TIA, or known established carotid disease are contraindications to CSM
If CSM unsuccessful, unless there is a history of wheezing, give adenosine 3 mg IV over
2 sec via a large bore cannula into antecubital fossa vein with sodium chloride 0.9% flush
note that in patients taking dipyridamole (which decreases adenosine metabolism), initial
dose of adenosine should be 1 mg IV and subsequent doses should be halved
if no response after 12 min, give 6 mg IV over 2 sec. If no response after a further 12 min,
give 12 mg IV over 2 sec
note that in patients taking theophylline (which antagonises the anti-arrhythmic effect of
adenosine), further doses will usually be necessary
obtain rhythm strip
following adenosine, atrial tachycardias should be revealed (P waves with AV block) and
junctional re-entrant tachycardias terminated; ventricular tachycardias will be unaffected,
though retrograde conduction will be blocked
If patient with pathological tachycardia haemodynamically stable with no overt heart failure or
impaired ventricular function, an anti-arrhythmic drug may be given by slow IV injection
provided that full resuscitation facilities are available, preferably on CCU.
Specific rhythms
Sinus tachycardia is usually physiological identify and treat cause (e.g blood loss, heart
failure, thyrotoxicosis, anaemia)
if no obvious underlying cause, cardiac function adequate, and tachycardia inappropriate and
distressing, consider oral B blocker (atenolol 50 mg daily)
Atrial tachycardia arises from atrial myocardium seek urgent cardiology advice about
giving flecainide 2 mg/kg IV (up to 150 mg) over 10 min
flecainide is contraindicated in angina, MI and heart failure
Atrial fibrillation see Atrial fibrillation guideline

Wolff-Parkinson-White syndrome can present as AF QRS complexes will be pre-excited
(i.e. wide and bizarre) and ventricular response very fast with a tendency to degenerate to
ventricular flutter and fibrillation (VF). Never give digoxin or verapamil but seek urgent advice
of cardiology team with a view to restoring sinus rhythm with flecainide or sotalol, or DC
cardioversion
Junctional re-entry tachycardia usually involves AV node in re-entry circuit and is likely to
be terminated by AV nodal blockade give adenosine as above (adjust dose in patients
taking dipyridamole/theophylline); or seek urgent cardiology advice about giving verapamil 5
mg IV over 2 min (3 min if patient >65 yr), repeated if necessary at 510 min intervals to total
10 mg
Do not give verapamil if patient already taking a beta-blocker
Ventricular tachycardia arises from ventricular myocardium. Haemodynamic consequences

are related to ventricular rate and underlying left ventricular function
Amiodarone 150 mg IV over 10 minutes and further amiodarone 150 mg over 10 minutes if
needed
Or if ischemia is suspected give lidocaine 100 mg (50 mg if patient is or estimated to be <50

kg, or whose circulation is severely impaired) IV over 2 min, repeated only once if necessary
after 10 min
seek urgent cardiology advice, with a view to DC cardioversion under general anaesthesia
Torsade de pointes (polymorphic VT) usually self-terminating, but often produces
haemodynamic collapse seek urgent cardiology advice
stop any precipitating drugs
do not give further anti-arrhythmic drugs
+
correct serum K to >4.5. Give sodium chloride 0.9%. 500 mL with potassium chloride
20 mmol IV, over 2 hr, with continuous ECG monitoring
if not given earlier, give magnesium sulphate 2 g (equivalent to 8 mmol) made up to
50 mL with sodium chloride 0.9% by IV infusion over 1015 min
consider beta-blocker/pacing
VF, if sustained, leads to cardiac arrest and must be treated by immediate electrical
defibrillation (when patient unconscious)
General
After any emergency treatment to revert or stabilise a patient's heart rhythm, further
assessment should include:
accurate identification of arrhythmia a 12-lead ECG during the arrhythmia will give the
diagnosis in most cases, sometimes with the addition of specific manoeuvres, such as carotid
sinus massage/adenosine, or by comparison with ECG in sinus rhythm. Electrophysiologic
testing may be required where there is doubt
diagnosis of cause ECGs in sinus rhythm, cardiac enzymes, thyroid function tests, chest Xray
definition of underlying heart disease echocardiography, cardiac catheterisation where
appropriate
2+
2+
identification of precipitating/contributing factors electrolytes (including Ca , Mg ), ECG
monitoring
provocation testing where necessary (e.g. exercise testing, tilt testing, carotid sinus pressure,
drug challenge, invasive electrophysiologic testing)
for most patients with SVT/atrial tachycardia/atrial flutter, radiofrequency ablation refer to
cardiology team
If specialist intervention required for patients with serious or recurrent arrhythmias, seek
advice of cardiology team
Do not use amiodarone as a first-line agent for long-term treatment because of the risk of
serious adverse effects. Reserve for life-threatening arrhythmias not responding to other
agents
Specific
Atrial fibrillation see Atrial fibrillation guideline
VF treat as per ALS guideline and seek urgent cardiology advice
if arrhythmia fails to terminate or recurs, consider and deal with possible trigger factors:
electrolyte abnormalities (hypokalaemia, hypocalcaemia, hypomagnesaemia)
anti-arrhythmic or anti-psychotropic drug toxicity
underlying relative bradycardia (temporary pacing will be necessary)
acute MI consider urgent revascularisation by angioplasty
for recurrent episodes, try lidocaine (with ECG monitoring) by IV infusion 4 mg/min for 30 min,
then 2 mg/min for 2 hr, then 1 mg/min reduce concentration further if continued beyond 24
hr
+
for electrical storm (e.g. recurrent VF), if plasma K >4.5, consider IV magnesium sulphate
++
2 g (8 mmol Mg ) IV over 1015 min, repeated once if necessary AND atenolol 2.5 mg IV at
rate of 1 mg/min, repeated at 5 min intervals to a maximum of 10 mg
in peri-arrest situation, give IV amiodarone 300 mg as bolus injection
in patients with ventricular tachycardia or VF occurring >48 hr after acute MI or with no
obvious reversible factors contact cardiology team as the patient may need implantable
cardioverter defibrillator
24-hour tape for patients with impaired LV function and IHD if non-sustained VT present,
and refer to cardiology team
Refer patients with recurrent arrhythmias requiring prophylactic anti-arrhythmic treatment to a

cardiologist
Make appropriate arrangements for following-up patients with AF who are anticoagulated with
a cardiologist
Atrial fibrillation 2010-11
ATRIAL FIBRILLATION
Symptoms, signs and investigations
See Cardiac arrhythmias guideline
IMMEDIATE TREATMENT
There are 3 strands to effective management of AF, whether presentation acute or chronic:
Rhythm control
Rate control
Thrombo-embolic risk reduction
Acute AF with a rapid ventricular rate
If patient in peri-arrest situation, follow advanced life support see Cardiopulmonary
Rhythm control
Low priority as rate control affords greater clinical benefit than rhythm control. Be certain
that AF started <24 hr previously
If AF present for 24 hr or unsure of duration, follow Rate control below

If AF present for <24 hr, seek urgent cardiology advice aim is to restore sinus rhythm
immediately using anti-arrhythmic drugs (amiodarone, flecainide or propafenone) or DC
cardioversion, unless there is a persistent underlying cause (e.g. thyrotoxicosis, mitral valve
disease, pneumonia)
if unable to cardiovert immediately, give unfractionated heparin IV (1000 iu/hr) and cardiovert
next working day
Rate control
Wolff-Parkinson-White (WPW) syndrome can present as AF. QRS complexes will be preexcited (i.e. wide and bizarre), and ventricular response very fast with a tendency to
degenerate to ventricular flutter and fibrillation (VF). Never give digoxin or verapamil but seek
urgent cardiology advice with a view to restoring sinus rhythm with flecainide or sotalol, or
with DC cardioversion
Once confident not WPW syndrome and if ventricular response to AF rapid during high
sympathetic stress (e.g. pneumonia, myocardial infarction or post-operatively) and systolic BP
>100 mmHg, options include:
either a beta-blocker (atenolol 2.5 mg IV at 1 mg/min, which can be repeated at intervals of
5 min to a maximum of 10 mg, or 50100 mg orally) or a rate-limiting calcium channel blocker
(verapamil 2.5 mg IV over 3 min, which can be repeated at intervals of 5 min to a maximum of
10 mg) but not both
if rate does not fall sufficiently, add digoxin
Where heart failure is a clinical issue, start with digoxin and, if rate does not fall sufficiently
within 48 hr or there is clinical deterioration, contact cardiology team to consider use of
amiodarone
Anticoagulation
Give thromboprophylaxis with warfarin (maintenance INR 2 3). or aspirin 75 mg/day to all
patients with sustained or paroxysmal AF
Choosing for the individual patient

The decision whether to anticoagulate is patient-specific, guided by weighing the risk of
thromboembolic stroke against the adverse risk of bleeding. This is an individual
physician decision. Discuss options with patient and record in medical notes
Assess the risk of stroke, using the CHADS2 score

if patient receiving clopridogel for coronary stent, contact cardiology for advice
CHADS2 score. Add 1 point for each category, except 2 points for previous stroke/TIA
Congestive heart failure (or LVEF <35%)
1
Hypertension (ever, treated/untreated)
1
1
Age 75 yr
Diabetes mellitus
1
Stroke/TIA
2
Score <2
Consider aspirin
Consider warfarin
Score 2
In considering whether to start warfarin or aspirin, discuss with patient and carers the risks
and benefits and the need for regular therapy and, in the case of warfarin, INR checks
Chronic AF
For rate control, digoxin will control resting rate but not exercise rate
prefer atenolol 50100 mg orally daily or (if no LV systolic dysfunction/heart failure) consider
verapamil 4080 mg 8 hrly
For thrombo-embolic risk reduction see Immediate treatment
Other issues
If sinus rhythm restored after recurrent episode of AF with no obvious precipitant (e.g.
pneumonia), consider long-term prophylactic therapy
in patients with evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy,
or hypertensive disease, use a beta-blocker (e.g. atenolol). If contraindicated, seek advice
from cardiologist
in patients with no evidence of ischaemic heart disease/LV systolic dysfunction/LV
hypertrophy, consider Class Ic agent (e.g. propafenone, flecainide) after seeking advice from
cardiology (SpR on call 15142 or mobile 07936 182946)
If DC or chemical cardioversion unsuccessful, consider long-term control of the ventricular
response
if heart failure present, use digoxin +/- beta-blocker or, if beta-blocker contraindicated use
amiodarone
if no heart failure present, use beta-blocker or, if beta-blocker contraindicated, diltiazem or
verapamil
Avoid combinations of anti-arrhythmic drugs (including beta-blockers, diltiazem and
verapamil) except after specific cardiological advice
Avoid combinations of anti-arrhythmic drugs and diuretics if possible as hypokalaemia
worsens pro-arrhythmic potential
For prevention of AF in the bradycardia/tachycardia form of sino-atrial disease, consider
pacing
Consider ablation therapy for patients with:
Wolff-Parkinson-White syndrome
persistent AF in whom ventricular response cannot be satisfactorily controlled with drug
therapy
recurrent AF
DISCHARGE POLICY
Consider cardioversion (request echocardiogram and refer to cardiology clinic) in:
those who are symptomatic
younger patients
those presenting for the first time with lone AF
those with AF secondary to a treated/corrected precipitant
those with congestive heart failure.
INFECTIVE ENDOCARDITIS
Presentation of infective endocarditis (IE) is highly variable; symptoms can be non-specific and of
insidious onset. A high index of suspicion is often required
Symptoms and signs
Systemic symptoms: fever, anaorexia, weight loss, lethargy (especially in the elderly),
nausea, dyspnea, myalgia
Peripheral lesions: mucocutaneous petechiae; Janeway lesions (macular plaques on palms
and soles);Roth spots (small, retinal haemorrhages with pale centres); splinter haemorrhages
Splenomegaly may be present in 15-50% of cases
New onset regurgitant murmur, not an accentuation of pre-existing murmur
Sytemic emboli: Limbs, digits, spenic, renal, splenic, coronary, mesenteric, cranial arteries.
Clinical picture will be defined by the location of the emboli. One of the most common cause
of death is embolic process related in SBE.
Neurologic symptoms: related to mycotic emboli, mycotic aneurysms; cerebritis, very rarely
cerebral abcess
Renal insufficiency: Immune complex glomerulonephritis; embolic renal infarcts; impaired
hemodynamics; drug toxicity
Risk factors
Previous infective endocarditis (IE)

Pre-existing abnormal intra-cardiac flow due to valvular heart disease, or congenital heart
disease such as VSD, PDA, or further complex congenital HD
In situ Prosthetic heart valve
Recent intra-cardiac device implantation such as PPM and ICD
(PCI and coronary stent implantation are not risk factors)
IV drug users
Immunosuppressed patients, especially those with an indwelling IV catheter (Hickmann line)
Investigations
BLOOD CULTURES are the key investigation.
Three set of blood cultures, obtained via three separate venepuncture site and not from an
indwelling catheter, should be obtained immediately via aseptic technique.
Inform microbiologist of suspected IE; cultures then will be incubated for three weeks
Consider fungal cultures for special groups such as those with prosthetic valve; IV drug
users and immunsupressed cases
In an acutely ill patient

Three sets of blood cultures within first 24 hr before starting antibiotic therapy (one aerobic
and one anaerobic bottle per set), without waiting between the three separate venepunctures
START ANTIBIOTIC therapy following 3 sets of blood cultures, without any delay
If IE suspect is not high and patient is not acutely ill

Take three sets of blood cultures within first 48 hr
Consider discontinuing antibiotic therapy and repeating twice daily blood cultures for 3 days
Other investigations
FBC and differential WCC: anaemia, usually normochromic normocytic may be present
ESR and CRP are usually significantly elevated
Complement C3, C4, CH50
ECG, sinus tachycardia, check for progressive AV block seen in aortic valve endocaditis
Urinalysis may reveal proteinuria and microscopic haematuria
Echocardiogram (discuss with cardiology team)
Diagnostic criteria
Modified Duke criteria is currently used for the diagnosis of definite and probable IE. Table 1,
summarises mjor and minor factors for the diagnosis. Further guidance of European Society of
Cardiology (2009) is also accessable via web link on http://www.escardio.org/guidelinessurveys/esc-guidelines/Pages/infective-endocarditis.aspx
Table 1: Modified Duke criteria for the diagnosis of infective endocarditis (adapted from Li et al.)
IMMEDIATE TREATMENT
Do not give antibiotics until at least 3 separate sets of blood cultures have been taken
In endocarditis the valve may be damaged at an early stage. In an ill patient, do not wait for
blood culture report or echocardiographic confirmation
Initial Rx is: Benzylpenicillin 1.2 g IV 4 hrly + Flucloxacillin 2 g IV 6 hrly (4 hrly if >85 kg) +
Gentamicin 1 mg/kg IV 8 hrly.
Allergic to penicillin: Vancomycin (per Vancomycin guideline) + Gentamicin 1 mg/kg IV 8 hrly.
Intra-cardiac prosthetic material in situ, or MRSA is suspected: Vancomycin + Gentamicin as
above + Rifampicin 600 mg orally 12 hrly (IV infusion if unable to swallow or absorb orally)
If diagnosis is confirmed IE, or probable IE, inform the cardiology team and
arrange transfer to cardiology ward
Serum concentrations of vancomycin and gentamicin must be monitored to avoid toxicity
Culture positive
The choice of antibiotics is determined by the results of blood cultures/sensitivity. Following
regimens are recommendable, but frequently updated by the microbiologists whose advice
should be sought as early as possible.
The duration of the antibiotic therapy would be depending on the causative agent; host conditions
such as immune-supression, IV drug use, significant co-morbidities; presence of intra-cardiac
devices/prosthesis; the response rate measured by clinical recovery rate, presence of
complications such as heart failure, peripheral embolisation; response rate measured by
laboratory parameters of CRP/ESR; echocardiographic course: vegetation size (>5 mm), damage
on the valve/ abcess/ dehiscence.
Strep. viridans and Strep. bovis

If strain fully sensitive to penicillin (MIC <0.1 mg/L), treatment is Benzylpenicillin 1.2 g IV 4
hrly + Gentamicin 1 mg/kg IV 8 hrly for two weeks may be sufficient.
However, most cases require 4 weeks Rx with Benzyl-penicillin, depending above mentioned
factors,or penicillin (0.5>MIC >0.1 mg/L), with Gentamicin confined to the first two weeks
If patient penicillin-allergic continue treatment is IV Vancomycin (as per guideline) for at least
four weeks + Gentamicin for two weeks
Staphylococci
If penicillin-sensitive strain, Benzylpenicillin for at least four weeks at above dose +
Gentamicin 1 mg/kg IV 8 hrly for one week
If penicillin-resistant and methicillin-sensitive strain, Flucloxacillin 2 g IV 6 hrly (4 hrly if >85 kg)
for at least + weeks + Gentamicin 1 mg/kg IV 8 hrly for one week
If methicillin-resistant strain, or patient allergic to penicillin, Vancomycin for four weeks plus a
second antibiotic according to sensitivity of infecting organism, as advised by microbiologist
Enterococci
if sensitive to amoxicillin and not highly resistant to gentamicin, give Amoxicillin 2 g IV by
infusion 4 hrly + Gentamicin 1 mg/kg IV 8 hrly for a minimum of four weeks
Culture negative
Failure to culture may be explained by pre-treatment with antibiotics; inadequate
number/poor quality of samples; infection with atypical pathogen (e.g. Chlamydia spp.,
Legionella spp.); infection with a fastidious organism (e.g. members of the HACEK group)
Continue initial antibiotics while seeking further advice from microbiologists: serological
studies for C. Burnetii or Bartonella may be helpful; consider the possibility of fungal agent
Temperature usually settles within days. A subsequent rise may indicate development of a
complication such as abscess formation; may indicate antibiotic resistance
Clinical examination should include assessment of signs of heart failure which may develop
rapidly, as well as checking for signs of peripheral emboli
Inflammatory markers, WBC, CRP, ESR to be repeated at least weekly
Renal function should be monitored closely
In cases of aortic valve endocarditis, repeat ECG regularly; development of AV block,from PR
prolongation to higher degree, may suggest aortic root abscess development behind NCC
Echocardiographic monitoring, with TOE (transoesophageal echocardiography) early during
the treatment and at the end of antibiotic course in all suitable cases; with additional imaging
if a mechanical complications is considered
Gentamicin and Vancomycin require careful monitoring

Pre-dose gentamicin concentration should be <1 mg/L. Peak concentration, taken 1 hr postdose, should be 35 mg/L. Measure serum gentamicin after 24 hr
Pre-dose vancomycin concentration should be 1015 mg/L.
Complications
Heart failure is one of the most common cause of death in such cases, can develop rapidly
as acute valvular regurgitation occurs
Mycotic embolisation to cerebrum may lead a series of presentation from a limited
neurological focal defect to major change in consciousness levels.
Peripheral embolisation may lead to sudden onset flank or abdominal pain with splenic
infarction (listen for friction rub), or mesenteric emboli. Renal infarction may lead to gross
haematuria and flank pain. Multiple lung abscess, especially if it is bilateral should raise the
question of right-sided IE, especially in IV drug users. Coronary arterial emboli may occur,
right coronary artery ostium is more susceptible, hence inferior MI is more likely to develop
Immune complex disease vasculitic rash, arthritis, glomerulonephritis
Early surgical intervention indicated
Decision to undertake valve surgery/ device extraction (such as PPM/ICD) as part of
treatment of infective endocarditis can be extremely challenging and complicated. The
process requires discussion between cardiologists and cardio-thorasic surgeons regarding
timing, nature and feasibility of the operation.
Discharge arrangements would be made by the Cardiology team for clinical review. Repeat
echocardiographic examination and laboratory tests may be required.
References:
Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version
2009):The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of
the European Society of Cardiology (ESC): European Heart Journal doi:10.1093/eurheartj/ehp285
Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr, Ryan T, Bashore T, Corey GR.
Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.
Clin Infect Dis 2000;30:633638.
DVT 2010-11
DEEP VENOUS THROMBOSIS (DVT)

Symptoms and signs
Swelling of limb (arm, calf or leg)
Pain and stiffness of affected limb
Pitting oedema
Increased skin temperature
Erythema
Tenderness
Mild fever
In rare cases, arterial circulation may be severely compromised characterised by severe
pain, swelling, cyanosis and rapid development of tense oedema (phlegmasia caerulea
dolens)
elevate bed foot to 40 and ensure fluid replacement adequate to compensate for
extravasation
refer urgently to on-call general surgical SpR
Risk factors
See Massive pulmonary embolism and Small-to-moderate pulmonary embolism
guidelines
Ruptured Bakers cyst
history of arthritis or trauma to knee
swelling behind knee
examine for arthropathy and effusion
Torn calf muscles/damage to Achilles tendon
sudden pain in calf following twisting of leg
examine for haematoma
disruption of tendon indicates severe rupture
Cellulitis see Cellulitis guideline
INVESTIGATIONS AND DIAGNOSIS

If patient pregnant, contact obstetric team. See Management of a pregnant woman with a
non-obstetric problem guideline
FBC, INR and APTT

D-dimer
note that many clinical states apart from DVT (see Table 1) can raise D-dimer concentration
Table 1: Examples of common conditions/situations in which D-dimer concentration is

raised
Pregnancy
Acute myocardial infarction (MI)
Recent surgery
Chronic subdural haematoma
Renal disease
Disseminated intravascular coagulation
Rheumatoid disease
Gram-negative bacteraemia
Sickle cell crisis
Leukaemia
Subarachnoid haemorrhage
Liver disease
Thrombolytic therapy
Metastatic malignancy
Peripheral vascular disease
Trauma with pathological thrombosis
DVT 2010-11
Whereas a normal D-dimer concentration virtually rules out thrombosis, a raised D-dimer
concentration cannot be used confidently to confirm that thrombosis has occurred
Determine pre-test probability (Table 2)

Refer to algorithm for guidance
Low pre-test probability and normal D-dimer excludes DVT, no further investigations required
In all other cases, request Doppler ultrasound scan
If Doppler ultrasound scan negative, refer to algorithm for guidance

If Doppler ultrasound scan positive and D-dimer raised, DVT confirmed
If Doppler ultrasound scan positive but D-dimer normal, refer to algorithm for guidance
If Doppler ultrasound scan cannot be arranged on day of presentation but patient can
otherwise be discharged:
give suitable single dose of SC dalteparin (see Immediate treatment section for guidance)
if there is a delay of more than 24 hr (e.g. bank holiday), patient to attend SSU between
9.0010.00 a.m. next day for dalteparin
issue information leaflet and inform patient of date of Doppler, before patient leaves
ECC/MRA
Table 2: Clinical model for predicting pre-test probability for DVT

Clinical features (Score 1 point for each of the following features. In patients with
symptoms in both legs, derive measurement from more symptomatic leg)
Previously documented DVT
Active cancer (treatment within six months, ongoing or palliative)
Paralysis, paresis or recent plaster immobilisation of legs
Recent immobilisation (bedridden for >3 days, major surgery under GA within last 4 weeks)
Localised tenderness along distribution of deep venous system
Entire leg swollen
Calf circumference >3 cm greater than asymptomatic leg (measured 10 cm below tibial
tuberosity)
Pitting oedema confined to symptomatic leg
Collateral superficial veins (non-varicose)
Deduct 2 points if an alternative diagnosis is at least as likely as DVT

Score
Pre-test probability
>3
75% (high)
12
17% (moderate)
<0
3% (low)
DVT 2010-11
Algorithm for DVT management

Suspected DVT
Determine pre-test probability

using Table 2
Moderate or high
Low
D-dimer assay
Normal
D-dimer assay
Raised
Doppler scan
Negative
Positive
Manage according
to pre-test
probability
Low or
moderate
Manage according
to D-dimer result
Normal, may be
post-thrombotic
syndrome
High
Manage according
to D-dimer result
DVT excluded
Normal
Raised
Consider contrast venography

discuss with radiologist
Raised
Do not anticoagulate
but repeat Doppler
after 4-7 days
Second
Doppler
negative
Positive
Treat as confirmed
DVT
DVT 2010-11
IMMEDIATE TREATMENT
Unless symptoms severe or patient requires admission to hospital for reasons other than
suspected DVT, treat as out-patient
Encourage ambulation
Elevation of leg when seated
Simple analgesia (e.g. co-codamol)
If out-patient, ensure form authorising daily injections of dalteparin and provision of Class
3 compression hose is completed once diagnosis confirmed
Compression hose
Assess suitability for Class 3 (European standard) graduated compression hose (40 mmHg at
ankle) to reduce risk of post-thrombotic syndrome (chronic oedema). If in doubt about
suitability, do not recommend hose. Document decision in notes
Absolute contraindications:
advanced peripheral arterial disease feel for foot pulses, but note that pulses may be
impalpable because of oedema
heart failure
septic phlebitis
phlegmasia caerulea dolens (see Recognition and assessment)
Relative contraindications:
chronic arthritis of affected leg
leg ulcers
numbness/paralysis of affected leg
suppurative dermatosis
prognosis <6 months
intolerance of elastic stocking fabric
Write a prescription to surgical appliance department to measure, fit and supply two (to wash
or wear) open-toe below-knee stockings to affected leg as an out-patient once tenderness and
swelling have subsided. Advise patient to wear stocking on affected leg during daytime for two
years
Dalteparin
9
If platelet count <100 10 /L, seek advice from on-call haematologist (bleep via call centre)
before starting anticoagulation (see Heparin-induced thrombocytopenia guideline)
If platelet count >100 109/L, or if advised by haematologist, start dalteparin
weigh patient
give a suitable dose of SC dalteparin (see Table 3 if out-patient or, Table 4 if pregnant, or
Table 5 if in-patient)
arrange for out-patient to return daily for further SC injections of dalteparin sodium and check
they have an advice sheet
If anticoagulation contraindicated, consultant physician, staff physician or SpR must make
a decision as to which carries most risk complications of therapy, or the DVT
Table 3: Out-patient administration of SC dalteparin for non-pregnant patients
ALWAYS weigh patient do NOT guess the body
weight or rely on patients own estimate
Body weight
Dose SC dalteparin
<46 kg
7,500 units
4656 kg
10,000 units
5768 kg
12,500 units
6982 kg
15,000 units
DVT 2010-11
>83 kg
18,000 units
Table 4: Dalteparin dosage for pregnant women based on early pregnancy or booking weight
Weight
Dose
<50 kg
5000 units 12 hrly
5069 kg
6000 units 12 hrly
7090 kg
8000 units 12 hrly
>90 kg
10,000 units 12 hrly
Table 5: In-patient administration of SC dalteparin (use designated section on prescription
chart)
Risk of bleeding is increased in patients with severe liver or renal failure (eGFR <20),
thrombocytopenia or defective platelet function, and following surgery, trauma or
haemorrhagic stroke. Adjust dalteparin dose accordingly with advice from appropriate
team e.g. renal, liver or haematology
ALWAYS weigh patient do NOT guess the body weight or rely on patients own estimate
Body Weight
Dose SC dalteparin
Increased risk of bleeding
No increased risk
<46 kg
4,000 units 12 hrly
7,500 units daily
4647 kg
4,500 units 12 hrly
10,000 units daily
4852 kg
5,000 units 12 hrly
10,000 units daily
5356 kg
5,500 units 12 hrly
10,000 units daily
5762 kg
6,000 units 12 hrly
12,500 units daily
63-68 kg
6,500 units 12 hrly
12,500 units daily
6972 kg
7,000 units 12 hrly
15,000 units daily
7377 kg
7,500 units 12 hrly
15,000 units daily
7882 kg
8,000 units 12 hrly
15,000 units daily
>83 kg
8,500 units 12 hrly
18,000 units daily
SUBSEQUENT MANAGEMENT (NON-PREGNANT PATIENTS)
For subsequent management of pregnant woman, go to relevant section below
Dalteparin
Continue dalteparin at a suitable dosage (if out-patient, see Table 3; if in-patient, see
Table 5) until INR established within therapeutic range 23 (34 for recurrent DVT occurring
while INR within the range 23) for two consecutive days
If patient well enough to leave hospital before warfarin initiated, discharge and arrange outpatient dalteparin treatment. Initiate warfarin as out-patient [see Initiating warfarin
(out-patient) below]
on weekdays, dalteparin injections are given at central out-patients department medical clinic
arranged by SSU staff
at weekends, dalteparin injections are given on SSU
Monitoring for heparin-induced thrombocytopenia (HIT) is not required in medical and
obstetric patients who have not been given unfractionated heparin
if patient is being, or has (in last 3 months) been, treated with unfractionated heparin or is a
post-operative surgical patient being treated with LMWH, check platelet count on alternate
days starting from day 4 until day 14 of heparin treatment (from day 2 if patient has been
given heparin in the preceding 100 days). Compare platelet count with pre-treatment result
see Heparin-induced thrombocytopenia guideline
Warfarin (see Warfarin guideline rapid anticoagulation)
Initiating warfarin (out-patient)
DVT 2010-11
Fax completed anticoagulant referral form on hospital intranet: clinical section>referral

forms>haematology>anticoagulant referral forms (ensure all fields completed) requesting
initiation of warfarin to haematology anticoagulant management service (4359), and give
patient yellow anticoagulant treatment record book containing details of all results
Patients discharged from emergency portal on Monday-Wednesday should start warfarin that
evening if counselling and written patient information can be provided by ECC/MRA clinical
pharmacy team
if INR <1.4, give patient single dose of warfarin (10 mg) to be taken at 1800 hr. Record this
dose in yellow anticoagulant book
if INR >1.4, defer initiation of warfarin until clinic attendance
Patients discharged from emergency portal on Thursday-Sunday should start warfarin on
Sunday evening if counselling and written patient information can be provided
if INR <1.4, give single dose of warfarin (10 mg) to be taken at 1800 hr on Sunday evening
before attending pharmacy clinic on Monday morning. Record this dose in yellow
anticoagulant book
if INR >1.4, defer initiation of warfarin until clinic attendance. On presentation to central
pathology laboratory clinic, INR will be checked and warfarin tablets supplied with instructions
on how/when to take them
Initiating warfarin (in-patient)

Start warfarin as soon as diagnosis confirmed, sooner if a long delay in obtaining appropriate
investigation is anticipated see Warfarin guideline rapid anticoagulation
Ensure INR in appropriate range and stable
Give patient a yellow anticoagulation therapy record booklet with the following information
entered: indication for warfarin, target INR, start date and duration of therapy, previous four
INR results and date of next INR
Explain purpose of booklet and need for regular monitoring to patient
Regular monitoring of anticoagulation initially discuss with haematology anticoagulant
management service see anticoagulant referral form on hospital intranet: clinical
section>referral forms>haematology>anticoagulant referral forms (ensure all fields
completed). Call 4630 for further information
out of hours continue to monitor anticoagulation therapy on ward (not necessarily as an in
patient). Call anticoagulation office next working day
Duration of warfarin
If DVT occurred post-operatively in an otherwise healthy patient, continue for six weeks for
calf DVT and for 3 months for proximal DVT
After a first proximal DVT without a clear underlying cause or if permanent risk factors
present, continue for six months
Recurrent DVT and in patients with co-existent active malignant disease, continue indefinitely
If no clear precipitating cause for thrombosis, particularly if this is a recurrent event, consider
occult malignancy or other cause of thrombophilia
if patient aged <45 yr, discuss screening for inherited or acquired thrombophilia with
haematology consultant (ext 4631)
DISCHARGE AND FOLLOW-UP (NON-PREGNANT

PATIENTS)
Ensure INR in appropriate range and stable, unless anticoagulation is being achieved as an
out-patient (see Warfarin guideline slow anticoagulation)
Record last 4 in-patient INR results in yellow anticoagulant book
Arrange follow-up appointment in appropriate medical clinic after 1012 weeks unless a
shorter course of treatment or need for investigation requires earlier follow-up; patients with
DVT 2010-11
confirmed DVT will remain under the care of duty physician for the day on which diagnosis
was confirmed
on receipt of referral form (which must give date on which warfarin to be stopped),
anticoagulation management service contacts referring clinician in writing advising that,
unless notified of any change, warfarin will be stopped on the planned date
copy of letter is sent to patients GP
Advise patient that many drugs (including alcohol) interact with warfarin and to remind their
GP, if additional medication is added, that they are taking warfarin
If hospital supervision planned, ensure discharge letter includes diagnosis, dosage of
warfarin and date of clinic appointment
If anticoagulation to be monitored by GP, supply GP with written information (on separate
sheet, stapled to discharge letter) about:
indication for anticoagulation
proposed duration of treatment
proposed target range for INR
details of anticoagulation in hospital (give dates, INR results and dosage taken)
SUBSEQUENT DRUG MANAGEMENT AND FOLLOW-UP

(PREGNANT PATIENT)
Continue dalteparin until term

Liaise with obstetric team for follow-up
Labour
Once in established labour, stop heparin or other anticoagulant injections
If a planned delivery, stop injections 24 hr before
After delivery
Continue either heparin or warfarin for 6 weeks post partum at least 3 months in total
Recommend wearing of elasticated compression stocking on any affected leg for 2 yr after
delivery to reduce risk of post-thrombotic syndrome
Monitoring treatment
Monitoring for heparin-induced thrombocytopenia (HIT) is not required in obstetric patients
who have not been given unfractionated heparin
If patient is being, or has (in last 3 months) been, treated with unfractionated heparin or is a
post-operative surgical patient being treated with LMWH, check platelet count on alternate
days starting from day 4 until day 14 of heparin treatment (from day 2 if patient has been
given heparin in the preceding 100 days). Compare platelet count with pre-treatment result
If patient underweight or very overweight (<50 kg or >90 kg) either now or during early
pregnancy, or has bleeding problems or renal impairment, discuss need for anti-Xa
monitoring with haematology consultant
PE Massive 2010-11
MASSIVE PULMONARY EMBOLISM

SYMPTOMS AND SIGNS
Massive PE highly likely if there is:
Collapse/hypotension and
Unexplained hypoxia and
Engorged neck veins and
Right ventricular gallop (often)
Cardiac arrest. Blue light patients with out-of-hospital cardiac arrest due to PE rarely
recover
MANAGEMENT
General
O 2 3550% (higher if shocked)
Adequate analgesia for pleuritic pain: indometacin 2550 mg orally 8 hrly; if pregnant,
codeine phosphate 3060 mg orally 8 hrly: if first choice contraindicated or ineffective,
diamorphine 510 mg SC 4 hrly and metoclopramide 10 mg (5 mg in young adults
1519 yr <60 kg) IV 8 hrly (not more frequently)
If right atrial pressure (i.e. JVP) elevated, allow to remain high
AVOID diuretics
PREGNANCY
If pregnant woman has collapse or shock associated with a massive pulmonary
embolism, consider thrombolytic therapy associated with 16% maternal bleeding
complication rate, 1.7% fetal mortality, but no maternal mortality discuss with on-call
obstetric consultant
Assess clinical state

Cardiac arrest
(1) Resuscitation (CPR)

(2) Alteplase 50 mg IV
(3) Reassess after 30 min
Deteriorating
(1) Contact consultant

(2) Alteplase 50 mg IV
(3) Urgent echocardiogram/CTPA
Condition seems stable
(1) Unfractionated heparin

immediately see IV
unfractionated heparin
guideline
(2) Urgent echocardiogram/CTPA
In event of deterioration
D-dimer is not necessary in probable massive PE

Thrombolysis
If life-threatening features (right heart failure, shock) present, give alteplase 50 mg IV as
bolus injection
Failure to respond to alteplase is an indication for emergency direct thrombolysis,
catheter thrombo-embolectomy or pulmonary embolectomy. Contact interventional
department/interventional radiologist and cardiothoracic surgeon to discuss. If it is felt that
right heart catheter monitoring would be helpful, arrange to transfer patient to Acute
Coronary Unit or ITU
If patient stable (with no systemic hypotension), consider thrombolysis if they have:
echocardiographic evidence of right ventricular dysfunction or free-floating right

ventricular thrombus
PE Massive 2010-11
If thrombolysing, give alteplase 10 mg by IV injection over 12 min, followed by 90 mg by

IV infusion over 2 hr (max 1.5 mg/kg in patients weighing <65 kg)
If not thrombolysing, anticoagulate:
if pregnant, go to Small-to-moderate pulmonary embolism guideline Management
of a pregnant patient Immediate treatment
if not pregnant, go to Management of small-to-moderate pulmonary embolism
guideline Management of a non-pregnant patient Immediate treatment
If there are contraindications to giving alteplase or anticoagulation, a consultant
physician, or registrar must make a decision as to which carries most risk possible
complications of therapy, or embolism
Post-thrombolysis
After thrombolytic therapy has ceased, wait until APTT ratio has fallen below 2 before
commencing or recommencing anticoagulation as follows:
in all patients, start with unfractionated heparin with no loading bolus see IV
unfractionated heparin guideline. In pregnant women, monitor anti-Xa concentration as
a guide to dosage adjustment
if pregnant, change unfractionated heparin to dalteparin when APTT stable follow
Management of small-to-moderate embolism guideline Management of a pregnant
patient Immediate treatment
if not pregnant, start warfarin follow Management of small-to-moderate embolism
guideline Management of a non-pregnant patient, from Subsequent management
maintenance anti-coagulation
PE small-to-moderate 2010-11
SMALL-TO-MODERATE PULMONARY
EMBOLISM
RECOGNITION
Pulmonary venous thromboembolism (PE) is often missed clinically

Suspect the diagnosis in any patient who does not respond to initial therapy, or in whose
condition there has been an unexplained deterioration
Most episodes follow popliteal or iliofemoral DVT
PE is easily missed
in severe cardiorespiratory disease
in elderly patients
PE is rare if age <40 with no risk factors
Symptoms and signs (signs may be absent)

Small emboli present with dyspnoea, whereas moderate-sized emboli present with signs of
infarction and pleuritic pain
Dyspnoea (present in 90% of cases) may be of sudden onset
Pleuritic chest pain
Haemoptysis
Syncope
Tachypnoea (>20 breaths/min)
Fever
Pleural rub
Tachycardia
Pneumonia
Myocardial infarction (MI)
Exacerbations of asthma and COPD
ASSESSMENT
Confirming diagnosis
ECG and chest X-ray are often normal and should not be used to confirm/refute the
diagnosis, but are useful for identifying other diseases and explaining symptoms.
ECG may show sinus tachycardia, an S1 Q3 T3 pattern, right bundle branch block, p
pulmonale or right axis deviation.
Chest X-ray may show non-specific shadows or a raised hemidiaphragm, pulmonary
oligaemia, linear atelectasis or small pleural effusion
Determine pre-test probability (Table 1)
Table 1: Clinical scoring system for PE

Are other diagnoses unlikely ?
On clinical grounds
After basic investigations:
white cell count
chest X-ray
ECG
spirometry or peak flow
blood analysis
If YES, score +1
Is at lease one major risk factor present?

Recent immobilisation or major surgery
Recent lower limb trauma and/or surgery
Clinical deep vein thrombosis
Previous proven DVT or PE
Pregnancy or postpartum
Major medical illness
If YES, score +1
Total score
0
1
2
Pre-test probability
Low
Moderate
High
MANAGEMENT OF A NON-PREGNANT PATIENT

Investigations follow flowchart
If indicated by pre-test probability, request D-dimer assay. Do not request where an
alternative diagnosis is highly likely, clinical probability of PE is high, or in probable
massive PE. Only a negative result is of value
Request CT pulmonary angiogram (CTPA).
In patients with clinical DVT, leg Doppler ultrasound is alternative to lung imaging
FBC, INR, APTT
If pulmonary embolism confirmed, go to Management of a non-pregnant patient
Immediate treatment
Flowchart for diagnosis of non-massive PE
Assess clinical probability see above
High clinical probability
Moderate or low clinical probability
D-dimer unnecessary
D-dimer
D-dimer assay
Positive
Start LMWH
Abnormal CXR, cardiorespiratory disease or previous PE?
Yes
No
Request perfusion scan. Probability of PE reported as:
Abnormal
Very low or
normal
Clinical reassessment
Still no other
diagnosis as
likely as PE
Another
diagnosis now
likely
CT pulmonary angiogram
PE present
Add warfarin
No PE
Another diagnosis
IMMEDIATE TREATMENT
General
O 2 see Oxygen therapy in acutely hypoxaemic patients guidleine
Negative
Adequate analgesia for pleuritic pain: NSAIDS orally 8 hrly; if contraindicated or

ineffective, diamorphine 510 mg SC 4 hrly and metoclopramide 10 mg (5 mg in young
adults 1519 yr <60 kg) IV 8 hrly (not more frequently)
AVOID diuretics
Specific
Before starting Low molecular weight heparin, take blood for FBC, INR, APTT
9
If platelet count <100 10 /L, seek advice from on-call haematologist (bleep via call
centre) before starting anticoagulation see Heparin-induced thrombocytopenia
guideline
If platelet count >100 109/L, weigh patient and prescribe heparin(using designated
section on prescription chart) according to Table
Table: In-patient administration of SC dalteparin (use section on prescription chart)
*Risk of bleeding is increased in patients with severe liver or renal failure (eGFR <20),
thrombocytopenia or defective platelet function, and following surgery, trauma or
haemorrhagic stroke. Adjust dalteparin dose accordingly with advice from appropriate
team e.g. renal, liver or haematology
ALWAYS weigh patient do NOT guess the body weight or rely on patients own
estimate
Body Weight
Dose SC dalteparin
Increased risk of bleeding*
No increased risk
<46 kg
4,000 units 12 hrly
7,500 units daily
4647 kg
4,500 units 12 hrly
10,000 units daily
4852 kg
5,000 units 12 hrly
10,000 units daily
5356 kg
5,500 units 12 hrly
10,000 units daily
5762 kg
6,000 units 12 hrly
12,500 units daily
6368 kg
6,500 units 12 hrly
12,500 units daily
6972 kg
7,000 units 12 hrly
15,000 units daily
7377 kg
7,500 units 12 hrly
15,000 units daily
7882 kg
8,000 units 12 hrly
15,000 units daily
>83 kg
8,500 units 12 hrly
18,000 units daily
If contraindications to anticoagulation, a consultant physician, staff physician or SpR
must make a decision as to which carries most risk possible complications of
therapy, or embolism
Daily clinical examination for signs of further embolisation, right heart failure, and
secondary infection of a pulmonary infarct
Monitoring heparin treatment

In a medical patient who has not been given unfractionated heparin, monitoring for
heparin-induced thrombocytopenia is not required
If patient is being, or has (in last 3 months) been, treated with unfractionated heparin or is
a post-operative surgical patient being treated with LMWH, check platelet count twice
weekly starting from day 4 until day 14. Compare platelet count with pre-treatment result
If patient weighing <50 kg or >90 kg has bleeding problems, renal impairment, or massive
PE, discuss need for anti-Xa monitoring with haematology consultant (ext 4631)
Maintenance anticoagulation
Start warfarin as soon as diagnosis confirmed see Prescribing regimens and
nomograms Warfarin guideline
Patients with PE needs heparin for a minimum of 5 days. Discontinue dalteparin when
INR has, for two consecutive days, been within the therapeutic range: 23 (34 for
recurrent PE occurring while INR within range 23)
INR may be elevated by heparin if APTT ratio exceeds 2.5 in a patient being given
unfractionated heparin, and must not be used as a guide to adjustment of warfarin
dosage

Clinical
Ensure INR in appropriate range and stable
After a first thromboembolic event, continue warfarin for six months. Continue indefinitely
for recurrent or life-threatening PE
If patient aged <45 yr with unprovoked PE, discuss screening for inherited or acquired
thrombophilia with haematology consultant (ext 4631)
Administrative
Advise patient that many drugs (including alcohol) interact with warfarin and to remind
their GP, if additional medication is prescribed, that they are taking warfarin
Give patient a yellow anticoagulation therapy record booklet in which you have entered
the following information: indication for warfarin, target INR, start date and duration of
therapy, the last four INR results and date of next INR
Refer to anticoagulant clinic.
If hospital supervision planned, ensure discharge letter includes diagnosis, dosage of
warfarin and date of clinic appointment
If anticoagulation is to be monitored by GP, supply GP with written information in
discharge letter about:
indication for anticoagulation
proposed duration of treatment
proposed target range for INR
details of anticoagulation in hospital (give dates, INR results and dosage taken)
Document in notes that patient has been given written and verbal information about
warfarin and has been referred to anticoagulation clinic
MANAGEMENT OF A PREGNANT PATIENT

Investigations
Contact obstetric team see Management of a pregnant woman with a non-obstetric
problem guideline
If pre-test probability low or moderate, request D-dimer assay. Remember D-dimer may
be increased in pregnancy. Do not request where an alternative diagnosis is highly likely,
clinical probability of PE is high or probable massive PE. Only a negative result is of
value
Chest X-ray (with fetal shielding)
if another cause for pleuritic chest pain identified, treat appropriately
Start dalteparin go to Immediate treatment
if close to term or bleeding present, consider IV heparin discuss with obstetric team
Bilateral leg Dopplers:
if leg Doppler(s) positive, treat as pulmonary embolism go to Immediate treatment
if leg Dopplers negative, follow flowchart for diagnosis of non-massive PE above
advise patient of very small risk to fetus associated with low-dose perfusion scan or CTPA
(1:280,000) compared with a very high risk of maternal death (1 in 7) associated with
untreated PE during pregnancy
. If possible, speak directly to radiologist for that session to get examination accepted and
expedited urgently
If pulmonary embolism confirmed, go to Immediate treatment below
IMMEDIATE TREATMENT
General
O 2 see Oxygen therapy in acutely hypoxaemic patients guideline
Adequate analgesia for pleuritic pain: codeine phosphate 3060 mg orally 8 hrly: if
ineffective, diamorphine 510 mg SC 4 hrly and metoclopramide 10 mg (5 mg in young
adults 1519 yr <60 kg) IV 8 hrly (not more frequently)
AVOID diuretics
Specific
Before starting dalteparin, take blood for FBC, INR, APTT
If platelet count <100 109/L, seek advice from on-call haematologist (bleep via call
centre) before starting anticoagulation see Heparin-induced thrombocytopenia
guideline
If platelet count >100 109/L, prescribe dalteparin (using appropriate section on
prescription chart) according to Table
Table: Dalteparin dosage for pregnant women based on early pregnancy or booking
weight
Weight
Dose
<50 kg
5000 units 12 hrly
5069 kg
6000 units 12 hrly
7089 kg
8000 units 12 hrly
>90 kg
10,000 units 12 hrly
If contraindications to anticoagulation, a consultant physician, staff physician or SpR
must make a decision as to which carries most risk possible complications of
therapy, or embolism
Daily clinical examination for signs of further embolisation, right heart failure, and
secondary infection of a pulmonary infarct
Monitoring dalteparin treatment

If patient has not been given unfractionated heparin, monitoring for heparin-induced
thrombocytopenia is not required
If patient is being, or has (in last 3 months) been, treated with unfractionated heparin or is
a post-operative surgical patient being given LMWH, check platelet count twice weekly
starting from day 4 until day 14. Compare platelet count with pre-treatment result see
Heparin-induced thrombocytopenia guideline
If early pregnancy weight <50 kg or >90 kg and patient has bleeding problems, renal
impairment, or massive PE, discuss need for anti-Xa monitoring with haematology
consultant (ext 4631)

Arrange follow-up with obstetric team
Maintenance anticoagulation
Continue dalteparin until term. Arrange injections of dalteparin in the community, either by
patient or district nurse
Labour
Once in established labour, stop heparin or other anticoagulant injections
If a planned delivery, stop injections 24 hr before
After delivery
Continue either heparin or warfarin for at least 6 weeks postpartum at least 3 months in
total
Elasticated compression stocking on any affected leg for 2 yr after delivery to reduce risk
of post-thrombotic syndrome
HIT 2010-11
HEPARIN-INDUCED THROMBOCYTOPENIA
Heparin-induced thrombocytopenia (HIT) is a known complication of heparin therapy seen in
patients treated with unfractionated heparin (UFH) or low molecular weight heparin (LMWH).
It is an immune-mediated disorder that can result in life-threatening venous and arterial
thrombosis despite ongoing treatment with heparin. It is extremely important to identify it early
and substitute alternative anticoagulation
MONITORING
In all patients requiring UFH or LMWH, check FBC, INR and APTT before starting
treatment
Medical and obstetric patients who have not been, and are not about to be, given
UFH does not require platelet count monitoring
Inform patients of HIT as a possible complication of heparin therapy
in all other patients, check platelet count on alternate days starting from day 4 until day
14 of heparin treatment (from day 2 if patient has been given heparin in the preceding
100 days)

Clinical features of HIT
A greater than 50% fall in platelet count
Extension of previous thrombus
New arterial/venous thrombosis
Thrombosis in an unusual site (cerebral, renal, skin necrosis)
Anaphylactoid reaction after UFH IV bolus cardio-respiratory, neuralgic or unusual
symptoms within 30 min
DIC
Skin lesions at heparin injection sites
Thrombocytopenia is rarely severe in HIT
Despite low platelet count, bleeding is uncommon
HIT suspected
Perform pre-test probability scoring for HIT
Table 1 Pre-test probability scoring for HIT (four Ts)
Clinical feature
Score
2
1
Thrombocytopenia >50% fall from baseline 3050% fall from
or to nadir of
baseline
or to nadir of
20100 109/L
1019 109/L
Clear onset between
Onset after 10 days
Timing of
or
thrombocytopenia 5 and 10 days
(earlier if recent
Time of onset not
(after heparin
heparin exposure
clear (missing platelet
exposure)
within 100 days)
counts etc)
New thrombosis
Progressive or
Thrombosis or
Skin necrosis
recurrent thrombosis
other sequelae
Post-heparin
Thrombosis not yet
anaphylactoid reaction
proven
No other cause of
Possible other
Other causes of
causes
thrombocytopenia thrombocytopenia
evident
evident
Pre-test probability score
Add score for each clinical category maximum score = 8
68 = High
45 = Intermediate
03 = Low
0
<30% fall from
baseline
or to nadir of
<10 109/L
Onset before 4 days
after recent heparin
(without heparin
exposure within last
100 days)
None
Definite other cause

present
HIT 2010-11
If patient has intermediate or high pre-test probability, suspect HIT and start treatment
without waiting for laboratory confirmation
IMMEDIATE TREATMENT
Obtain blood sample for HIT antibody testing, 4 mL blood in EDTA (purple top) and 4 mL
clotted (red top) tube
Send sample with pre-test probability form to blood bank. If form is to be faxed, notify
blood bank (4628) in advance
Clinical decisions should not be based on HIT antibodies result alone, as it may be false
positive
In patients with intermediate or high pre-test probability of HIT, stop heparin and start
alternative anticoagulant (danaparoid or lepirudin) in treatment doses (listed below).
Remember just stopping heparin is not enough
Do not start warfarin. If warfarin has already been started, omit further doses and give
Vitamin K 1 (phytomenadione) 5 mg by slow IV injection while introducing alternative
anticoagulation
Platelet transfusion is relatively contraindicated. Thrombocytopenia in HIT is rarely severe
and is not associated with bleeding
In patients with low pre-test probability, continue heparin. Contact haematology
consultant for advice about HIT antibody testing
Alternative anticoagulant
Danaparoid
Danaparoid is a low-molecular-weight heparinoid, chemically distinct from heparin, used
for treatment of suspected or proven HIT (with or without thrombosis) and for prevention
of venous thrombosis in patients with a history of HIT
For patients undergoing dialysis, a specific danaparoid dosage guideline is available from
Ward 29 or ITU
Prepare a danaparoid sodium solution by taking 3.6 mL (4500 units) danaparoid sodium
injection to make up to 45 mL in a syringe with sodium chloride 0.9% or glucose 5% to
give a concentration of 100 units/mL. The diluted solution is stable for 24 hr
Table 2 Danaparoid dosing for HIT
Clinical indication
Treatment of HIT (suspected or proven)
whether associated with thrombosis or not
Danaparoid dosing schedule

IV route: By IV injection 2500 units (1250 units
if body weight under 55 kg, 3750 units if over
90 kg) followed by IV infusion 400 units/hour for
2 hours, then 300 units/hour for 2 hours, then
200 units/hour for 5 days
Monitor danaparoid therapy (using anti-Xa
assay) if patient
weighs <55 kg or >90 kg
has renal impairment
has a life- or limb-threatening thrombosis
has a high risk of haemorrhage
Prevention of venous thrombosis in

patients with history of HIT
Lepirudin
Contact coagulation lab (4578) for anti-Xa

assay. Test can be done only during
routine hours after discussion with
take sample between 624 hrs of starting
IV treatment and repeat at 72 hr in patients
with renal failure
target concentration 0.50.8 U/mL
750 units SC every 12 hr
HIT 2010-11
Lepirudin (recombinant hirudin) is a direct thrombin inhibitor used for treatment of

thrombosis in patients with acute HIT
For patients undergoing dialysis, a specific lepirudin dosage guideline is available from
Ward 29 or ITU
in patients with renal failure, the half-life is greatly prolonged see notes on dosage
reduction
renal excretion may also be impaired in patients with cirrhosis
there is no known antidote
rare cases of anaphylaxis have been associated with IV bolus infusion of lepirudin in
patients with or without previous exposure to lepirudin
Table 3 Lepirudin dosing for HIT for adult patients

Clinical indication
Lepirudin dosing schedule
Treatment of life-threatening thrombosis in
0.2 mg/kg*/IV bolus, then
patients with acute HIT
0.10**mg/kg/hr by continuous IV infusion;
monitor APTT*** to adjust infusion rate to
achieve
Target APTT ratio: 1.52.5
Treatment of non-life-threatening
Start at 0.10*mg/kg/hr by continuous IV
thrombosis in patients with acute HIT
infusion; monitor APTT*** to adjust infusion rate
to achieve
Target APTT ratio: 1.52.5
Footnotes
Monitoring
*If body weight >110 kg, use 110 kg in

calculation
**Dose reduction for renal impairment
Serum creatinine
<90 mol/L: 0.10 mg/kg/hr
90139 mol/L: 0.05 mg/kg/hr
140400 mol/L: 0.01 mg/kg/hr
>400 mol/L: 0.005 mg/kg/hr
***Measure APTT 4 hrly after initiation of IV
infusion or any dose adjustment until target
ratio achieved and stable. Measure APTT at
least once daily thereafter
RESTARTING ORAL ANTICOAGULATION
Start warfarin only when:

platelet count has recovered to >150 109/L
patient is fully anticoagulated with alternative anticoagulant
Start warfarin using lower loading dose of 5 mg (see Warfarin guideline) and continue
alternative anticoagulant for a minimum of 5 days (after starting warfarin) and until INR in
target range for 2 consecutive days
Ensure platelet count remains stable
Warn patients that they are at increased risk of thrombosis if they are given UFH or
LMWH during the next 100 days
Document HIT in patient notes and electronic records
If patient requires anticoagulation with heparin after more than 100 days, seek advice
from haematology consultant
Spont Pneumo 2010-11
SPONTANEOUS PNEUMOTHORAX
Symptoms and signs
Sudden onset, occasionally at rest
Chest pain (unilateral)
Dyspnoea
Resonance on percussion, with reduced vocal fremitus and breath sounds (if moderate-large)
If patient in extremis, very dyspnoeic with circulatory compromise, and trachea or mediastinum
(apex beat) displaced, consider TENSION PNEUMOTHORAX (very rare). Give O 2 (10 L/min) through a
high concentration (60100%) mask. Insert a large bore cannula of at least 4.5 cm in length into
second anterior intercostal space, midclavicular line, then insert intercostal tube see Practical
procedures Intercostal tube drainage guideline. Remove emergency cannula when bubbling in
underwater seal system confirms intercostal tube system functioning
BEWARE: suspected basal pneumothorax usually implies a bulla. CT scan and previous chest
X-rays will differentiate bullae from pneumothorax
Investigations
PA chest X-ray
If findings are unclear on PA, lateral (if possible, decubitus) film may help
If findings obscured by surgical emphysema or complex bulla disease, CT scan may help
IMMEDIATE TREATMENT
Chest X-ray
Small collapse
Rim of air <2 cm
Chronic lung disease

+ aged >50 yr
Large collapse
Rim of air >2 cm
No
Yes
Significant dyspnoea
Yes
Intercostal
tube drainage
Aspirate
No
No
Successful?
(asymptomatic)
In-patient
observation
Observe for 4 hr
Follow-up
No
Chronic lung
disease
Yes
Intercostal
tube drainage
Yes
No
Chronic lung disease
Yes
In-patient
observation
1: Degree of collapse on chest X-ray:

Small = rim of air around lung <2 cm
Large = rim of air around lung 2 cm
2: Significant dyspnoea:
Obvious deterioration in usual exercise tolerance
3: Simple aspiration:
See Practical procedures Pleural aspiration of air guideline
If unsuccessful (patient still symptomatic and <2.5 L of air aspirated) on first attempt in patient with no
chronic lung disease, consider repeating
4: Chronic lung disease:
Significant dyspnoea common
Observe all patients overnight
5:
Follow-up:
At clinic in 14 days
Give patient discharge letter and written advice to return immediately if deteriorates
No air travel until chest X-ray resolved
6: Intercostal tube drainage:

See Practical procedures Intercostal tube drainage guideline
7: In-patient observation:
Give O 2 . If patient has chronic lung disease, start with 24% by Venturi mask and watch for signs of CO 2
narcosis see Respiratory failure guideline. Otherwise, give high flow (10 L/min) through 100% mask
SUBSEQUENT MANAGEMENT AND DISCHARGE
Admit to ward 4
Chronic lung disease after aspiration

In-patient care until stable
Recurrent pneumothorax
If second or subsequent pneumothorax in the same side, institute immediate management and refer directly to
respiratory team.
Management of intercostal drains
X-ray next morning

Yes
Still bubbling?
No
Re-expanded?
Yes
Yes
No
Still bubbling or swinging, or

surgical emphysema?
No
Wait 24 hr
Check drain and underwater
seal
If no bubbling remove drain
Repeat X-ray
Collapsed again?
No
Follow-up
Yes
Respiratory opinion
Do not clamp chest tube

1: Chest X-ray (non-portable):
Always keep underwater seal below chest
2:
Removal of chest drain:

Bubbling stopped for at least 24 hr
Cut drain-securing suture
Withdraw tube while patient holds breath in expiration
Close wound with remaining sutures
3: Check drain:
If lung not re-inflated and no bubbling in underwater bottle: Try to remove block or kink
If unsuccessful, remove drain. Insert new drain through new clean incision return to step 6 under
Immediate treatment
4: Follow-up:
At clinic in 710 days
Patient given discharge letter and written advice to return immediately if deteriorates
No air travel until chest X-ray resolved
5: Respiratory physician's opinion:
Why no re-expansion (e.g. air leak, displaced/blocked tube, broncho-pleural fistula, underlying
pulmonary disease)?
Use of high volume/low pressure suction, 1 to 2 kPa/Barr, (equals 8 to 16 mmHg; 8 to 20 cm
H 2 O)
Early thoracic surgery. Refer when pneumothorax fails to resolve after five days of above management
or after three days if patient has chronic lung disease
Asthma 2010-11
ACUTE SEVERE ASTHMA IN ADULTS

Symptoms and signs
Cannot complete sentences in one breath
Respiration 25 breaths/min
Pulse 110 beats/min
Use of accessory muscles
Peak expiratory flow (PEF) <50% of predicted (Figure 1) or best (if known)
PEF <33% of predicted (Figure 1) or best (if known)
SpO 2 <92%
Silent chest, cyanosis, or feeble respiratory effort
Bradycardia or hypotension
Exhaustion, confusion, or coma
Patients with severe or life-threatening attacks may not be distressed and may not have all
these abnormalities. The presence of any one of these should alert the doctor
Investigations
The only investigations needed before immediate treatment are:
PEF
Oximetry
If SpO 2 <92% or patient has any life-threatening features or not responding to treatment,
measure arterial blood gases (ABG)
ABG markers of a life-threatening attack
Normal or high PaCO 2 (>4.6 kPa)
Severe hypoxia: PaO 2 <8 kPa irrespective of treatment with O 2
Low pH (or high H+)
IMMEDIATE TREATMENT
O 2 follow Oxygen therapy in acutely hypoxaemic medical patients guideline (CO 2

retention not usually aggravated by O 2 therapy in asthma)
Salbutamol 5 mg plus ipratropium 500 microgram via O 2 -driven nebuliser 68 L O 2
Prednisolone tablets 40 mg (if taking maintenance prednisolone, increase daily dose by
40 mg) or hydrocortisone 100 mg slow IV bolus, or both if very ill
No sedatives of any kind
If patient has coincident chronic bronchitis (regularly produces sputum), consider antibiotic
treatment see Exacerbation of chronic obstructive pulmonary disease in Medical
guidelines
Chest physiotherapy not indicated
Assess and treat hypovolaemia and electrolyte imbalance see Fluid resuscitation
guideline, Maintenance fluid therapy guideline and Electrolyte disturbances guidelines
Chest X-ray to exclude pneumothorax or consolidation
U&E
FBC
Patients with life-threatening features
Asthma 2010-11
Ask medical registrar, or consultant physician, ideally respiratory, to review urgently
Give magnesium sulphate 2 g made up to 50 mL with sodium chloride 0.9% by IV infusion

over 20 min if not already given earlier (e.g. in ambulance). Never give a second dose of
magnesium without discussion with consultant respiratory physician
Transfer patient to ITU if continues to deteriorate with:
falling PEF, worsening or persisting hypoxia, or hypercapnia
exhaustion, feeble respirations, confusion, or drowsiness
coma or respiratory arrest
En route to ITU, ensure patient is accompanied by a doctor (usually an anaesthetist)
prepared to intubate if patients clinical condition requires it
Admit to a respiratory ward

Correct disturbances in fluid and electrolyte balance, especially potassium (K+)
If patient requires IV fluid with potassium, always use commercially produced pre-mixed
bags of sodium chloride 0.9% and potassium chloride. NEVER add potassium chloride to
infusion bags
If patient improving, continue:
O2
Prednisolone daily at dose in Immediate treatment section, or hydrocortisone 100 mg 6 hrly
as slow IV bolus over 1 min if unable to swallow
Nebulised salbutamol 2.5 mg plus ipratropium 250 microgram 6 hrly
Ask clinical nurse specialist to review patient
Change to discharge medication (check inhaler technique) 24 hr before discharge
If patient not improving after 1530 min:

Continue O 2 and steroids
Give nebulised salbutamol 5 mg more frequently, up to every 1530 min see Monitoring
treatment
Give ipratropium 500 microgram 4 hrly until patient improving
Once patient improving, reduce nebulised salbutamol to 2.5 mg and ipratropium to
250 microgram 6 hrly
If patient still not improving:
Ask medical registrar, or consultant physician, ideally respiratory, to review urgently
Give magnesium sulphate 2 g made up to 50 mL with sodium chloride 0.9% by IV infusion

over 20 min if not already given earlier (e.g. in ambulance). Never give a second dose of
magnesium without discussion with consultant respiratory physician
Senior clinician considers use of aminophylline or salbutamol by infusion see Prescribing
regimens and nomograms for doses. If patient already taking oral theophylline DO NOT
give loading dose IV aminophylline
If any life-threatening features (see above) present, transfer to ITU and refer to
respiratory physician
En route to ITU, ensure patient is accompanied by a doctor (usually an anaesthetist)
prepared to intubate if patients clinical condition requires it
Asthma 2010-11
Repeat measurement of PEF 1530 min after starting treatment

Oximetry: maintain SpO 2 9498%
Repeat blood gas measurements within 2 hr of starting treatment if:
initial PaO 2 <8 kPa (60 mmHg), unless subsequent SpO 2 >92%, OR
initial PaCO 2 normal or raised, OR
patient deteriorates
In patients requiring frequent doses of salbutamol nebuliser, repeat serum potassium within
2 hr of starting treatment and repeat 2 hrly
potentially serious hypokalaemia is especially likely to occur in patients taking corticosteroids,
theophylline and diuretics, and who are hypoxic
Chart PEF before and 1520 min after giving nebulised or inhaled salbutamol, and at least
four times daily until stable; then change to morning and evening before salbutamol dose
When discharged from hospital patients should have:

been taking discharge medication for 24 hr and have had inhaler technique checked and
recorded
PEF >75% of predicted or best and PEF diurnal variability <25% unless discharge agreed
with respiratory physician
treatment with oral and inhaled corticosteroids in addition to bronchodilators
own PEF meter (prescribable) and, if appropriate, a written self-management plan
had reason for exacerbation discussed
details of admission, discharge and potential best PEF sent to GP on discharge
documentation
GP follow-up within 2 days
refer to for follow-up within 4 weeks
Figure 1: Predicted adult PEF chart for use with EU standard peak flow meters marked with
yellow circle around the letters EU
Asthma 2010-11
Peak flow references for male & females
690
670
Males
650
630
610
590
570
550
Height
Peak flow/lmin
530
510
190 m
6 ft 3 ins
183 m
6 ft
175 m
5 ft 8 ins
167 m
5 ft 5 ins
160 m
5 ft 3 ins
175 m
5 ft 8 in
167 m
5 ft 5 in
160 m
5 ft 3 in
290
152 m
5 ft
270
145 m
4 ft 8 in
Females
490
470
450
430
410
390
370
350
330
310
250
20
25
30
35
40
45
50
55
60
65
70
75
80
Age/years
To find predicted PEF value read off from the vertical axis the value corresponding to the point
where a vertical line from patients age intersects with the line on the graph corresponding most
closely with patient's height
COPD 2010-11
EXACERBATION OF CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD)
Symptoms and signs
Worsening of cough
Worsening dyspnoea
Wheezing
Increase in sputum volume, tenacity (difficult expectoration) and purulence
Acute confusion
Pyrexia (often)
Tachypnoea
Tachycardia
Prominent abdominal movement
Pursed lip breathing, tracheal tug, prolonged expiration
Predominant use of accessory muscles
Inspiratory or expiratory wheezes
Look for signs of cor pulmonale (peripheral oedema, raised jugular venous pressure,
hepatomegaly)
Look for signs of type 2 respiratory failure (drowsiness, confusion, cyanosis, flapping tremor,
papilloedema)
Investigations
Arterial blood gases (ABG) when breathing air
Chest X- ray
ECG
Sputum (inspect for purulence and viscosity, and send for culture)
FBC
Blood cultures (if pyrexial) see Collection of blood culture specimens guideline
U&E
Pneumonia (consolidation on chest X-ray) see Community-acquired pneumonia
guideline
Exacerbation of asthma if in doubt treat as such see Acute severe asthma in adults
guideline
Pneumothorax even small can be dangerous (mortality in advanced COPD complicated by
pneumothorax is 50%) see Spontaneous pneumothorax guideline
Left ventricular failure see Cardiac failure guideline
Pulmonary embolism see Massive pulmonary embolism guideline and Small-tomoderate pulmonary embolism guideline
Drug-induced deterioration in respiratory function review medication for sedatives and betablockers
IMMEDIATE TREATMENT
Document in medical record patients functional status before the exacerbation.
A consultant, or registrar must document patients ventilation and resuscitation status
Give O 2 to maintain SpO 2 8892% initially. Then follow Oxygen therapy in acutely
hypoxaemic medical patients guideline
COPD 2010-11
High percentage (>24%) O 2 must NOT be given unless ABG confirm absence of CO 2
retention
Antibiotics
Usual organisms: Strep. pneumoniae, H. influenzae. Consider Staph. aureus if influenza
prevalent
Doxycycline 200 mg orally on first day, then 100 mg orally daily (avoid oral zinc, calcium and
iron, salts and antacids containing magnesium or aluminium within 2 hr of doxycyline)
if patient unable to swallow and absorb oral antibiotic, clarithromycin 500 mg IV by infusion
into larger proximal vein 12 hrly. If phlebitis develops, check if penicillin allergic and if not,
change to co-amoxiclav 1.2 g IV 8 hrly
if patient has symptoms and signs of pneumonia plus new, unexplained chest X-ray
shadowing, follow antibiotic regimen recommended for pneumonia see Communityacquired pneumonia guideline
If Staph. aureus suspected, add flucloxacillin 500 mg orally/IV 6 hrly if no penicillin allergy
advice from a microbiologist
Bronchodilators
Salbutamol (2.5 mg) or terbutaline (5 mg) via air-driven nebulizer 4-6 hrly
Consider adding ipratropium bromide (500 microgram) via nebulizer 6 hrly
If not improving after 4 hr, add aminophylline infusion see Prescribing regimens and
nomograms
Corticosteroid
Prednisolone 30 mg orally daily
If already taking maintenance (long-term) dose of prednisolone, increase daily dose by 30 mg
If severely ill, give hydrocortisone 100 mg by slow IV bolus 6 hrly
Correct dehydration
Physiotherapy
Only aids clearance of sputum
Mechanical ventilation
See Respiratory failure guideline

If improving after 48 hr:
continue with oral antibiotics until sputum mucoid
continue nebulized bronchodilator if already using at home OR check inhaler technique and
substitute appropriate inhaler device for nebulized bronchodilator(s). Involve supported early
discharge team
continue prednisolone at initial dosage (see above)for 714 days before stopping or returning
to maintenance dose (no need to taper withdrawal)
if either PaO 2 >7.3 kPa or SpO 2 >92% while breathing air, stop O 2 but watch for deterioration
If patient conscious and not confused, and has no unstable concurrent clinical conditions,
ring integrated respiratory team for assessment of home care
If not improving:
consider resistant organisms change antibiotic based on sputum culture result, where
known
consider underlying disease (e.g. bronchogenic carcinoma, bronchiectasis)
COPD 2010-11
Peak expiratory flow (PEF) aim to attain patient's best PEF when well (if known)
ABG see Respiratory failure guideline
Sputum volume and conversion from mucopurulent/purulent to mucoid
Subjective improvement of dyspnoea
Objective improvement as reflected by increased exercise tolerance
Check inhaler technique when changing from nebulizer therapy to metered dose inhaler or
spacer devices. Involve integrated respiratory team
Review home medication
Advise to stop smoking
Advise to see own doctor whenever sputum becomes purulent
Advise GP to arrange prophylactic influenza vaccination
If still hypoxic (PaO 2 <7.3 kPa) when clinically stable after recovery, consider referral to
respiratory physician for domiciliary O 2 assessment
If chest X-ray suggests consolidation, repeat as out-patient after six weeks
CAP 2010-11
COMMUNITY ACQUIRED PNEUMONIA

Treat as pneumonia if patient has symptoms and signs below plus new unexplained chest
X-ray shadowing, and the illness is the primary clinical problem
Symptoms
Malaise, fever, rigors
Vomiting, diarrhoea
Confusion (especially in the elderly)
Dyspnoea, cough
Sputum (may be blood-stained, viscid and difficult to expectorate)
Pleuritic pain
Signs
High fever (often absent in the elderly)
Tachycardia
Tachypnoea
Localised crackles
Bronchial breathing (in about one third of hospital admissions)
Chest signs may be absent or masked by other respiratory signs (e.g. COPD, CCF)
Enquire about pet birds (psittacosis, chlamydial infection) and
recent hotel residence away from home (legionellosis)
Investigations
Chest X-ray
Oximetry
If SpO 2 <94% or features of severe pneumonia, measure arterial blood gases
FBC, U&E, LFT, CRP

Microbiology:
sputum inspection, microscopy, culture and sensitivity
blood cultures see Collection of blood culture specimens guideline
in the seriously ill, serology for atypical organisms (influenza A and B, Coxiella burnetii,
Chlamydia psittaci, Mycoplasma pneumoniae, Legionella pneumophila). Date of onset must
be clearly indicated on request form
in the seriously ill (see diagram), OR in patients with travel history/hotel stay during two
weeks before admission, urine for legionella antigen and pneumococcal antigen
Pulmonary thromboembolism
Lung cancer
Left ventricular failure
CAP 2010-11
Severity
Management is based on the CURB 65 assessment of severity. The following diagram
(based on CURB 65 scoring system) is an aid to clinical judgement
Consider core adverse prognostic features:
New mental confusion
mental test score of <8 or new disorientation in
person, place or time
Urea >7 mmol/L
Respiratory rate 30 breaths/min or more
Systolic BP <90 mmHg or diastolic BP <60 mmHg
Age 65 years
Score 1 point for each feature present
01 feature
present
Consider managing
as out-patient, with
outreach support if
necessary
2 features
present
Hospital supervised
treatment
Options include:
short stay inpatient
hospital supervised
outpatient
Treat as non-severe CAP,
but consider additional
adverse prognostic
features:
PaO2 <8 kPa/SpO2 <92%
(any FiO2)
chest X-ray for
bilateral/multilobar
shadowing
3 or more
features present
Manage in hospital as
severe CAP
Early senior doctor
review
4 or 5 consider HDU
or ICU care
IMMEDIATE TREATMENT
Supportive
Give O 2 to maintain SpO 2 between 9498% or, if patient at risk of CO 2 retention, 8892%
see Oxygen therapy in acutely hypoxaemic medical patients
Ensure adequate fluid replacement to compensate for effects of pyrexia and tachypnoea
coupled with inadequate intake See Maintenance fluid therapy guideline
Adequate analgesia for pleuritic pain paracetamol alone is unlikely to be adequate
if well hydrated and eGFR 30 mL/min, indometacin 2550 mg orally 8 hrly
in dehydrated patient or if eGFR <30 mL/min, to prevent renal damage, prefer morphine
sulphate 10 mg orally 4 hrly indometacin may be substituted once adequate fluid
replacement achieved if eGFR 30 mL/min
avoid indometacin if patient taking ACE inhibitor
Prophylactic low molecular weight heparin

Treat any accompanying airflow obstruction or cardiac failure
Physiotherapy only in patients with copious secretions
CAP 2010-11
Antibiotic therapy
Start as soon as diagnosis made give first dose within 4 hr of presentation to hospital
and before leaving assessment area
therapy should always cover Streptococcus pneumoniae
Route of administration depends whether patient able to swallow and absorb oral drugs,
severity of illness and likely pathogens
(NEED OUR ANTIBIOTIC GUIDELINES)
Severity of illness
First line
allergy)
advice from a microbiologist (4666) or a consultant in infectious diseases (2299)
Amoxicillin 500 mg orally
Clarithromycin 500 mg orally
Patient discharged home or
8 hrly
12 hrly
admitted for other reasons
Co-amoxiclav 625 mg orally
Clarithromycin 500 mg orally
Pneumonia of unknown
8 hrly plus clarithromycin
12 hrly. If no NG/PEG tube
aetiology
500 mg orally 12 hrly. If no
and unable to swallow or
Requiring hospital
NG/PEG tube and unable to
absorb oral drugs,
treatment, not severe
swallow or absorb oral drugs,
clarithromycin 500 mg IV by
co-amoxiclav 1.2 g IV 8 hrly
infusion into larger proximal
plus clarithromycin 500 mg IV vein 12 hrly converting to oral
by infusion into larger proximal as soon as oral route available
vein 12 hrly, converting to oral If not responding within
as soon as oral route available 2448 hr, treat as severe
pneumonia
Co-amoxiclav 1.2 g IV 8 hrly
Levofloxacin 500 mg IV by
plus clarithromycin 500 mg IV infusion 12 hrly
aetiology
by infusion into larger proximal or
Requiring hospital
vein 12 hrly
In patients at high risk of C.
treatment, severe and not
If Legionella pneumonia
difficile-associated colitis,
tagged for ESBL
suspected, add rifampicin
discuss use of
600 mg orally/IV by infusion
chloramphenicol 1 g IV 6 hrly
12 hrly (use oral if possible as
for 2 days only plus
it is well absorbed)
vein 12 hrly with
microbiologist, ID or
respiratory consultant
Ertapenem 1 g IV by infusion
Seek advice from a consultant
daily
in infectious diseases (2299)
aetiology
or microbiologist (4666)
Severe and tagged for ESBL If atypical pneumonia
Check that blood, sputum and, suspected, add clarithromycin
if appropriate, urine cultures
500 mg IV by infusion into
have been taken
larger proximal vein 12 hrly
Isolate in single room using
infection control measures
Inform infection control team
(4282) and contact consultant
in infectious diseases (2299)
or microbiologist (4666) for
advice
Amoxicillin 500 mg orally
If pneumococcus sensitive,
Pneumococcal pneumonia
CAP 2010-11
8 hrly. If no NG/PEG tube and

unable to swallow or absorb
oral drugs, benzylpenicillin
1.2 g IV 6 hrly
Staphylococcal pneumonia
(consider if influenza
suspected)
Legionella pneumonia
Mycoplasma pneumonia or
Chlamydia pneumonia
Confirmed Q fever (Coxiella
burnetii), psittacosis
(Chlamydia psittaci)
Aspiration pneumonia
Necrotising pneumonia
Thought to be caused by
Panton-Valentine leukocidin
(PVL) toxin-producing
Staphylococcus aureus
Isolate in single room and
contact microbiologist (via call
centre), infectious diseases
(2299), or respiratory
consultant for advice
clarithromycin 500 mg orally

12 hrly. If no NG/PEG tube
and unable to swallow or
absorb oral drugs,
vein 12 hrly converting to oral
as soon as oral route available
If not sensitive to
clarithromycin, discuss with
Flucloxacillin 1 g IV 6 hrly
MRSA cases or penicillin
If severe/necrotising
allergic:
pneumonia, see Necrotising
Vancomycin IV by infusion
pneumonia below
see Prescribing regimens
and nomograms
If severe/ necrotising
pneumonia, see Necrotising
pneumonia below
Clarithromycin 500 mg orally/IV by infusion into larger proximal
vein 12 hrly, depending on severity
Clarithromycin 500 mg orally/IV by infusion into larger proximal
vein12 hrly
Doxycycline 100 mg orally 12 hrly. For alternative antibiotics,
seek advice from a consultant in infectious diseases (2299) or
Metronidazole 500 mg IV by
Metronidazole 500 mg IV by
infusion 8 hrly plus
infusion 8 hrly plus
benzylpenicillin 1.2 g IV
levofloxacin 500 mg IV by
6 hrly
infusion daily
or
In patients at high risk of C.
difficile-associated colitis,
discuss use of
chloramphenicol 1g IV 6 hrly
for 2 days only plus
infusion 12 hrly in place of
levofloxacin with
Linezolid 600 mg IV 12 hrly
Omit co-amoxiclav
plus clindamycin 1.2 g IV 6
hrly plus rifampicin 600 mg
IV 12 hrly plus co-amoxiclav
1.2 g IV 8 hrly or levofloxacin
500 mg IV 12 hrly
Assessment of requirement for intensive care

Indications for transfer to ITU include:
severe pneumonia on CURB 65 score (4 or 5)
arterial PaO 2 <8 kPa with inspired oxygen >60%
CAP 2010-11
severe acidosis pH <7.25

exhausted, drowsy or unconscious patient
respiratory or cardiac arrest
shock
In severe pneumonia, clinical assessment, including mental state 12 hrly, until improving
Pulse, BP, temperature, respiratory rate and SpO 2 with FiO 2 4 hrly until stable
aim for SpO 2 92%
if type 2 respiratory failure see Respiratory failure guideline
Biochemical screen repeat every 2448 hr while significant abnormalities persist
If patient not improving after 72 hr despite adequate therapy, repeat chest X-ray and CRP
if CRP not falling, consider possibility of empyema, abscess or inappropriate antibiotic
regimen
Nutritional support in prolonged illness
Duration of antibiotics
If IV route used on admission, change to oral when clinical improvement occurs and
temperature normal for 24 hr. Use oral antibiotic to which microbe sensitive. If sensitivity not
known, give amoxicillin 500mg orally 8 hrly plus clarithromycin 500 mg orally 12 hrly. If
allergic to penicillin, clarithromycin 500 mg orally 12 hrly
In uncomplicated pneumonia, give five to seven days treatment
In patients with severe pneumonia, staphylococcal pneumonia, or legionella pneumonia,
continue antibiotics for at least two weeks
Request review by specialist in respiratory medicine and consider:
incorrect diagnosis (e.g. pulmonary embolism, pulmonary oedema, pulmonary eosinophilia,
Wegener's granulomatosis)
resistant organism (e.g. amoxicillin-resistant/penicillin-resistant S. pneumoniae, haemophilus,
mycoplasma, psittacosis, Q fever or staphylococcal pneumonia) discuss with microbiologist
(4666)
unrecognised pulmonary tuberculosis
unrecognised immunodeficiency (e.g. HIV infection leading to pneumocystis pneumonia)
Complications:
parapneumonia effusion or empyema aspirate, culture and drain, and refer to respiratory
physician see Pleural infection and empyema guideline
lung abscess refer to respiratory physician
bronchial obstruction refer to respiratory physician
pulmonary embolism see Pulmonary embolism guideline
fever related to drug therapy omit therapy for 48 hr
Check within 24 hr of planned discharge that patient does not have more than one of the
following:
temperature >37.8C
heart rate >100/min
respiratory rate >24/min
systolic blood pressure <90 mmHg
oxygen saturation <90%
inability to maintain oral intake
abnormal mental status
Clinical review by GP or in hospital clinic after approximately 6 weeks
CAP 2010-11
chest X-ray for all patients who have persistent symptoms or are at high risk of underlying
malignancy (especially smokers and those aged >50 yr) whether or not they have been
admitted. Convalescent serology can be obtained at this visit
HAP 2010-11
HOSPITAL-ACQUIRED PNEUMONIA
This guideline should NOT be used for immunosuppressed patients

Definition
Pneumonia at least 48 hr after hospitalisation and excluding any infection that is incubating at
time of admission
Symptoms and signs
Fever, rigors
Confusion
Cough, dyspnoea
Pleuritic chest pain
Tachycardia
Tachypnoea
Crackles
Bronchial breathing
Effusion
Purulent tracheal secretions, and new and/or persistent infiltrate on chest X-ray otherwise
unexplained
Increased oxygen requirement
Investigations
Chest X-ray (compare with previous chest X-ray if available)
Arterial blood gases (ABG)
FBC, biochemical screen
Sputum: inspection, microbiology, culture and sensitivity
Care: false positive results often occur owing to contaminants in these patients
Two sets of blood cultures from separate sites. Use aseptic technique see Collection of
blood culture specimens guideline
Diagnostic thoracentesis if patient has parapneumonic effusion. See Investigation of pleural
effusion guideline
Urinary legionella and pneumococcal antigens
Congestive cardiac failure
Pulmonary thromboembolism
Drug reactions
Pulmonary haemorrhage
Adult respiratory distress syndrome
IMMEDIATE TREATMENT
If deteriorating, contact ICU early
Supportive
Give O 2 to maintain SpO 2 between 9498% or, if patient at risk of CO 2 retention, 8892%
see Oxygen therapy in acutely hypoxaemic medical patients guideline
HAP 2010-11
check ABG and treat appropriately see Respiratory failure guideline

Ensure adequate fluid replacement to compensate for effects of pyrexia and tachypnoea
coupled with inadequate intake see Maintenance fluid therapy guideline
Adequate analgesia for pleuritic pain paracetamol alone is unlikely to be adequate
if well hydrated and eGFR 30 mL/min, start ibuprofen
in dehydrated patient or if eGFR <30 mL/min, to prevent renal damage, prefer morphine
sulphate 10 mg orally 4 hrly ibuprofen may be substituted once adequate fluid replacement
achieved if eGFR 30 mL/min
avoid indometacin if patient taking ACE inhibitor
Physiotherapy in patients with copious secretions
Antibiotic therapy See Table 1

Start treatment as soon as clinical criteria for diagnosis are met, do not await
microbiological confirmation
Initial therapy may be modified once results of respiratory tract secretions or blood cultures
become available
Route of administration depends on severity of illness
For further advice on antibiotic therapy, contact microbiologist
Severe hospital-acquired pneumonia
Presence of any of the following indicates a severe illness:
Respiratory failure (PaO 2 <8 kPa and/or PaCO 2 >6 kPa)
Respiratory rate >25 breaths/min
Rapid radiographic progression, multilobar pneumonia, or cavitation of lung infiltrate
Diastolic BP <60 mmHg
WBC low (<4 109/L) or very high (>20 109/L)
Poor urine output or rising serum creatinine
Metabolic acidosis
Discuss with senior medical staff whether to refer to ITU
Antibiotic regimens
Many patients with severe hospital-acquired pneumonia will have some renal impairment;
seek advice when selecting antibiotic dosage.
If microbe known, follow advice of consultant microbiologist

If pneumonia of unknown aetiology refer to Table 1
HAP 2010-11
Table 1: Antibiotic regimens for hospital-acquired pneumonia

NEED TO PUT OUR HOSPITAL ANTIBIOTIC GUIDELINES.
<Four days after admission
Severity of illness
First line
allergy)
Co-amoxiclav 625 mg
Clarithromycin 500 mg
Pneumonia of unknown aetiology
orally 8 hrly plus
orally 12 hrly. If no
Non-severe
clarithromycin 500 mg
NG/PEG tube and unable
orally 12 hrly. If no
to swallow or absorb oral
NG/PEG tube and unable
drugs, clarithromycin
to swallow or absorb oral
drugs, co-amoxiclav
larger proximal vein 12 hrly
1.2 g IV 8 hrly plus
converting to oral route as
clarithromycin 500 mg IV
soon as available.
by infusion into larger
If not responding within
proximal vein 12 hrly,
2448 hr, treat as severe
converting to oral route as
pneumonia
soon as available
Co-amoxiclav 1.2 g IV
Levofloxacin 500 mg IV by
8 hrly plus clarithromycin
infusion 12 hrly
Severe and not tagged for ESBL
In patients at high risk of
C. difficile-associated
larger proximal vein
colitis, discuss with
12 hrly. If legionella
pneumonia suspected, add microbiologist, ID or
rifampicin 600 mg orally/IV respiratory consultant
suitability of
by infusion 12 hrly (use
oral route if possible as it is chloramphenicol 1 g IV
6 hrly for 2 days only plus
well absorbed)
by infusion 12 hrly
Meropenem 1 g IV 8 hrly
In view of cross-sensitivity
If atypical pneumonia
between carbapenems and
Severe and tagged for ESBL
Check that blood, sputum and, if
suspected, add
penicillin, seek advice from
appropriate, urine cultures have been clarithromycin 500 mg IV
a consultant in infectious
taken
diseases (2299) or
Isolate in single room using infection
proximal vein 12 hrly
control measures
Inform infection control team (4282)
and contact consultant in infectious
diseases (2299) or microbiologist
(4666) for advice
Metronidazole 500 mg IV
by infusion 8 hrly plus
benzylpenicillin 1.2 g IV
6 hrly
infusion daily
or
colitis, discuss use of
chloramphenicol 1g IV
HAP 2010-11
If history of MRSA or MGNB
> Four days after admission

Severity of illness
by infusion 12 hrly in place
of levofloxacin with
Discuss with consultant microbiologist
First line
allergy)
Piperacillin/tazobactam
Aztreonam 1 g IV 8 hrly
4.5 g IV 8 hrly
plus vancomycin IV by
Non-severe
If Pseudomonas
infusion see
or
suspected, add gentamicin Vancomycin guideline
Severe and not tagged for ESBL
see Gentamicin
guideline
Meropenem 1 g IV 8 hrly
In view of cross-sensitivity
If atypical pneumonia
between carbapenems and
Severe and tagged for ESBL
Check that blood, sputum and, if
suspected, add
penicillin, seek advice from
appropriate, urine cultures taken
consultant in infectious
Isolate in single room using infection
diseases (2299) or
control measures
Inform infection control team (4282)
and contact consultant in infectious
diseases (2299) or microbiologist
(4666) for advice
by infusion 8 hrly
If recent respiratory
sample culture and
infusion daily
sensitivity results available, or
provide additional cover
according to sensitivities.
If sensitivity results not
colitis, discuss use of
available:
chloramphenicol 1g IV
Add benzylpenicillin
1.2 g IV 6 hrly
by infusion 12 hrly in place
of levofloxacin with
As above. In addition:
For patients within ICU
If proven MRSA pneumonia (usually ventilatorassociated, infiltrates on chest X-ray, sputum culture
yields MRSA only) does not respond to IV vancomycin
as expected (within 4872 hr), contact consultant
microbiologist or infectious diseases consultant to
discuss switching to linezolid. Linezolid must be
prescribed only on advice of consultant
microbiologist or consultant in infectious diseases
HAP 2010-11
In hypoxaemic patients, repeat ABG 1 hr after change of inspired O 2 , then assess using
pulse oximeter
Pulse, BP and temperature hrly until patient stable
Repeat biochemical screen every 2448 hr while significant abnormalities persist
If patient not improving despite therapy, repeat chest X-ray after 72 hr
If no improvement, refer to ICU if appropriate.
Duration of antibiotic
If IV route used on admission, change to oral when fever subsides and clinical parameters
stable. Use oral antibiotic to which microbe sensitive. If sensitivity not known, seek advice
from a microbiologist
In uncomplicated pneumonia, continue treatment for 57 days
In patients with severe pneumonia, staphylococcal pneumonia, or legionella pneumonia,
continue antibiotics for at least two weeks
Failure to respond to treatment
Incorrect diagnosis (see Differential diagnosis)
Re-evaluate and consider bronchoscopy to obtain protected specimens brushing and/or
bronchoalveolar lavage specimens for quantitative cultures refer to respiratory physician
Complications: empyema, lung abscess refer to respiratory physician and see Pleural
infection and empyema guideline
Follow up in clinic with chest X-ray about six weeks after discharge to ensure that resolution
of radiological shadowing is occurring
Respiratory failure 2010-11
RESPIRATORY FAILURE
Definition
Respiratory failure is present when lungs unable to maintain normal gas exchange at rest, so that
arterial PaO 2 <8.0 kPa and/or arterial PaCO 2 >6.0 kPa. It has many causes (see below), which
must be identified and treated as part of overall management
Symptoms and signs
Central cyanosis (difficult to detect in anaemic patients)
Drowsiness
Warm peripheries, bounding pulse, tachycardia, flapping tremor
Papilloedema (in patients with hypercapnia)
Investigations
Arterial blood gases (ABG) Always document if patient on air or oxygen including percentage
Chest X-ray
FBC
U&E
ECG
Consider whether:
Type 1 (oxygenation failure)
Low PaO 2 , normal PaCO 2 owing to, for example, asthma, pneumonia, pneumothorax,
pulmonary oedema and embolism, epiglottitis or pulmonary fibrosis
Type 2 (ventilatory failure)
Low PaO 2 , high PaCO 2 owing to, for example, exacerbation of chronic obstructive pulmonary
disease (COPD), neuromuscular disorders, encephalitis, muscular dystrophies or use of
respiratory depressant drugs
IMMEDIATE TREATMENT TYPE 1
Treat underlying cause
Oxygen
See Oxygen therapy in acutely hypoxaemic patients guideline
Aim for SpO 2 9498% (or PaO 2 >8 kPa) but if at risk of hypercapnia, aim for SpO 2 8892%
without increasing pCO 2
For patients not at risk of hypercapnic respiratory failure, commence oxygen via nasal
cannulae 26 L/min (preferably) or simple face mask at 510 L/min or 4060% Venturi mask.
If SpO 2 <85%, commence treatment with reservoir mask at 1015 L/min
monitor SpO 2 continuously and titrate oxygen to keep SpO 2 within oxygen target range
repeat ABG after 3060 min in all patients at risk of type 2 respiratory failure
SUBSEQUENT MANAGEMENT TYPE 1

If improving:
Continue O 2 , adjusting inspired O 2 concentration to achieve SpO 2 of 9498% see flowchart
for oxygen administration on general ward in Oxygen therapy in acutely hypoxaemic
patients guideline
Treat underlying disease
If not improving:
Consider mechanical ventilation
Mechanical ventilation
If PaO 2 >8.0 kPa cannot be maintained despite high concentration O 2 therapy, especially in
acute severe asthma with life-threatening features see Acute severe asthma in adults
guideline, contact ITU (3129, 3134, 2841) and request transfer
IMMEDIATE TREATMENT TYPE 2
Treat underlying cause
Oxygen
Start with 2428% Venturi mask aiming to keep SpO 2 between 8892%
Follow flowchart for non-critical illness requiring moderate amounts of supplemental
oxygen in Oxygen therapy in acutely hypoxaemic patients guideline
treat with lowest dose Venturi mask to maintain SpO 2 between 8892%. Aim to raise
PaO 2 >8 kPa or at least 6.7 kPa in selected patients
if PaCO 2 rises by >1 kPa or pH falls below 7.35 (respiratory acidosis), seek immediate senior
medical advice on NIV in respiratory ward or ICU admission (see below)
repeat ABG again after 3060 min of each inspired oxygen increase
It may be necessary to accept only a modest increase in PaO 2 ;
most patients will survive if PaO 2 >6.7 kPa
Non-invasive ventilation
Patients with pH <7.35. Duty medical registrar or staff grade review patient against following
check list:
Patient must be:
suffering from exacerbation of COPD
on maximal medication see Exacerbation of chronic obstructive pulmonary disease
guideline
Blood gas analysis should fit following criteria:
pH <7.35
PaCO 2 >6 kPa
PaO 2 8 kPa (aim PaO 2 7.38), breathing oxygen using a Venturi mask providing the lowest
concentration of oxygen that achieves this target. Accept lower PaO 2 (but not lower than
6.7 kPa) in selected patients if CO 2 retention appears particularly oxygen sensitive. Call Noninvasive Unit (NIU) (3299) to request admission
If non-invasive ventilation not appropriate, available or possible (e.g. patient distress), and
patient drowsy and/or PaO 2 >6.7 kPa cannot be maintained without rise in PaCO 2 and fall in
pH below 7.26, consider doxapram hydrochloride see Prescribing regimens and
nomograms
SUBSEQUENT MANAGEMENT TYPE 2

If improving
Continue adjusting inspired O 2 concentration to achieve PaO 2 7.38.0 kPa
Consider changing to nasal specs to give O 2
Tail off doxapram therapy, within 2448 hr
If not improving
Consider mechanical ventilation
Intubation and ventilation
Important to consider overall outlook before embarking on this. In general, ventilatory support
is appropriate in a previously active patient with good quality of life over previous six
months, or where history unclear. There is no point in embarking on mechanical ventilation
when patient has end-stage chronic respiratory failure with very poor quality of life and there
is no cure for underlying disease. If you think patient will require ventitalion if NIV fails, inform
critical care team.
Type 1
for patients with Type 1 respiratory failure secondary to asthma see Acute severe asthma
in adults guideline
regular ABG 6 hrly (at least) until patient stabilises
Type 2
remember that CO 2 narcosis can occur several hours after O 2 therapy started or FiO 2
increased. If in doubt, repeat ABG
Ensure that underlying cause has been addressed:
infection adequately treated
collapsed lung in pneumothorax completely expanded see Spontaneous pneumothorax
guideline
anticoagulation stabilised following pulmonary embolism see Pulmonary embolism
guideline
Follow-up at discretion of supervising physician

Advice on life-style appropriate to underlying disease that precipitated admission
Consider referral to respiratory physician for assessment for long-term domiciliary O 2 therapy
or home ventilation
Any patient with neuromuscular disease or kyphoscoliosis presenting with type 2 respiratory
failure, regardless of underlying cause, must be referred to respiratory physician before
discharge
Pleural infection 2010-11
PLEURAL INFECTION AND EMPYEMA

Diagnostic algorithm for management of patients with pleural infection
History, examination and chest X-ray
Pleural effusion and evidence of

infection?
YES
Antibiotics-see below
Diagnostic fluid sampling under ultrasound guidance-See Investigation of a
pleural effusion guideline
Pus?
NO
Review pleural fluid pH and microbiology
NO
Gram stain and/or

culture positive
and/or pH <7.2
YES
Observe unless clinical

indication for chest tube
YES
Involve respiratory physician
Insert chest tube

See Intercostal tube drainage guideline
See Management of chest drain below
YES
Is patient any better
(fluid drained and
sepsis improved)?
NO
1.
2.
3.
4.
5.
Check tube position and chest X-ray

Consider CT scan for residual collection
Consider intrapleural fibrinolytic agent
Consider change to large bore chest tube
Review antibiotics when culture results become available
Is patient any better

at 57 days?
(fluid drained and
sepsis improved)?
NO
1. Review diagnosis
2. Consult with cardiothoracic surgeon
YES
1. Remove tube
2. Review antibiotics
when culture results
available
IMMEDIATE TREATMENT
Management of chest drain
For small bore (1014F) catheters, use the 3-way tap to flush with sodium chloride 0.9%
30 mL every 6 hr
No flushing needed for larger bore drains
Antibiotics
Antibiotics alone are not enough to treat an empyema. Use in addition to removal of infected
fluid. Unless absolutely impossible, send sample of fluid for culture before starting antibiotic
therapy. Start empirical therapy while awaiting results of culture
If microbe known, follow advice of microbiologist

Before microbe known, use empirical treatment in Table 1
Table 1: Antibiotic regimens for empirical treatment of pleural infection

NEED HOSPITAL GUIDELINES
Type of infection
First line
Assume penicillin allergy only if convincing history of either a rash within 72 hr of dose or an
anaphylactic reaction. If any doubt about whether patient truly allergic to penicillin, seek advice
from a consultant in infectious diseases (2299) or microbiologist (4666)
CommunityPiperacillin/tazobactam 4.5 g IV
Levofloxacin 500 mg IV by infusion
acquired pleural
8 hrly
12 hrly
infection
plus
or
in patients at high risk of C. difficileassociated colitis, discuss with
microbiologist, consultant in infectious
diseases or respiratory consultant
Hospital-acquired
Piperacillin/tazobactam 4.5 g IV
Aztreonam 1 g IV 8 hrly
pleural infection
8 hrly
plus vancomycin IV by infusion see
Prescribing regimens and nomograms
vancomycin
Patient tagged for
Start monotherapy with
Seek advice from a consultant in infectious
ESBL or MGNB
meropenem 1 g IV 8 hrly
diseases (2299) or microbiologist (4666)
Check that blood,
sputum and, if
appropriate, urine
cultures have been
taken
Patient tagged for
MRSA
Adjust treatment when relevant culture results become available
Add vancomycin IV by infusion (see Prescribing regimens and nomograms

vancomycin), to above regimens (if not already included). Vancomycin has poor
lung tissue penetration. If MRSA proven (pleural fluid) or likely cause of
empyema (e.g. recent relevant specimen other than pleural fluid positive for
MRSA), discuss use of additional antibiotic (e.g. rifampicin) with microbiologist
(4666) or consultant in infectious diseases (2299). Adjust treatment when
relevant culture results become available
Nutritional support in prolonged illness

Duration of antibiotics
Change to oral route when fever subsides and clinical parameters stable. Use oral
antibiotic to which microbe sensitive with good tissue penetration. If not known or in
doubt, discuss with microbiologist
Continue antibiotic therapy for a prolonged period of time (usually at least until all fluid
has gone and drain has been removed and at least 3 weeks) and monitor patient closely
for recurrence after stopping treatment
Review by respiratory/
Discharge when chest drains removed and clinical variables stable

Continue antibiotics for at least 3 weeks after initiation
Follow all patients up in clinic with chest X-ray about 6 weeks after discharge
2010-11
INVESTIGATION OF A PLEURAL EFFUSION

Diagnostic algorithm for investigation of a pleural effusion
History, clinical examination and chest x-ray
Does clinical picture suggest a

transudate (e.g. LVF,
hypoalbuminaemia, dialysis)?
YES
YES
Treat cause
Resolved?
Stop
NO
Pleural aspiration under ultrasound guidance
Send for: cytology, protein, LDH, glucose, pH
Gram stain, culture and sensitivity, AAFB stains and culture.
Take blood at same time for LDH, protein and glucose
NO
YES
See
Boxes
1 and 2
For technique of
procedures mentioned
in algorithm see
Pleural aspiration of
fluid and Pleural
biopsy guidelines
Do you suspect an
empyema, chylothorax
or haemothorax, rheumatoid disease
or pancreatitis?
NO
YES
Is it a transudate?
See Interpretation of results
overleaf
Treat cause
NO
YES
Have the fluid analysis and
chemical features given a
diagnosis?
Treat
appropriately
Box 1: Additional pleural fluid tests

Suspected disease
Tests
NO
Refer to chest physician
Request contrast-enhanced CT thorax see Prevention of contrast induced nephrotoxicity guideline
Chylothorax
Haemothorax
Empyema
Obtain pleural tissue, either by ultrasound/CT guided biopsy or thoracoscopy; if TB
suspected or patient too frail to undergo thoracoscopy by closed pleural biopsy.
Send these for histology and TB culture together with a repeat pleural aspiration for
cytology, microbiology studies +/ special tests
(see Boxes 1 and 2)
YES
Pancreatitis
Cause found?
NO
Reconsider thoracoscopy
YES
NO
Reconsider PE and TB
Wait for diagnosis to evolve
Haematocrit
Centrifuge
Box 2: Pleural fluid tests which may be

useful in certain circumstances
Suspected disease
Tests
Rheumatoid disease
Cause found?
Cholesterol and
triglyceride
Centrifuge
Treat
appropriately
Glucose
Complement
Amylase
INTERPRETATION OF RESULTS FROM PLEURAL ASPIRATION

Appearance
Appearance of pleural fluid
Fluid
Suspected disease
Putrid odour
Anaerobic empyema
Food particles
Oesophageal rupture
Bile stained
Chylothorax (biliary fistula)
Milky
Chylothorax/pseudochylothorax
If grossly bloody, consider malignancy, pulmonary infarction, trauma, benign asbestos

effusion or post-cardiac injury syndrome
Biochemistry
An exudative effusion is defined by one of the following being present:

pleural fluid protein/serum protein >0.5
pleural fluid LDH/serum LDH >0.6
pleural fluid LDH >2/3 upper limit of normal serum LDH
If serum protein is normal and:

fluid protein >35 g/L, fluid is most likely exudate
fluid protein <25 g/L, fluid is most likely transudate
fluid protein between 25 and 35 g/L, nature of effusion cannot be inferred
Pleural fluid pH
>7.4 suggests transudative effusion, and virtually rules out tuberculous effusion
<7.3 suggests exudative effusion
<7.2 in parapneumonic effusion indicates thick empyema requiring tube thoracostomy for
drainage
<7.1 in malignant pleural effusion is a bad prognostic sign (mean survival <6 weeks)
Pleural fluid glucose <3.3 mmol/L is found in empyema, rheumatoid disease, SLE,
tuberculosis, malignancy or oesophageal rupture
Pleural fluid glucose <2 mmol/L or pleural fluid glucose/serum glucose <0.5 mmol/L
in parapneumonic effusion indicates thick empyema requiring tube thoracostomy drainage
in malignant pleural effusion is a bad prognostic indicator
If pleural fluid glucose >1.6 mmol/L or pleural fluid C4 complement >0.04 g/L, effusion
unlikely to be caused by rheumatoid disease
In acute rupture of oesophagus, pancreatitis, pancreatic pseudocyst, pregnancy or pleural

malignancy, amylase is high (higher than upper limit for normal and pleural fluid/serum ratio
>1)
Cytology
Positive in only 60% of malignant effusions
if first specimen negative, repeat sending a larger amount of fluid.
Pleural lymphocytosis common in malignancy and TB, but not diagnostic
Pleural eosinophilia not diagnostic
Microbiology and histology in case of TB effusion

Smears for AAFB positive in 10-20% only; cultures positive in 25-50%
addition of pleural biopsy for TB culture and histology raises diagnostic rate to 90%
Status epilepticus 2010-11
STATUS EPILEPTICUS
Symptoms and signs
Status epilepticus is defined as a state of seizure activity lasting for 30 min with no
return to consciousness
Refer urgently to registrar on-call, any patient with a seizure
lasting >10 min
Ask about:
previous diagnosis of epilepsy
previous history of status epilepticus
recent withdrawal of anti-convulsant drug/missed medication
respiratory tract or urinary tract infection
vomiting/diarrhoea
Investigations
Capillary blood glucose
Venous blood glucose, calcium, sodium
If patient has history of seizures and is taking carbamazepine or phenytoin, serum
anticonvulsant concentration
If new onset epilepsy, CT scan to exclude space-occupying lesion
Non-epileptic attack disorders (pseudo-seizures)
Important underlying causes
Infection:
meningitis
encephalitis
abscess
Acute head injury
Cerebral tumour
Metabolic disorders:
renal failure
hypoglycaemia
hypercalcaemia
Drug overdosage:
tricyclics
phenothiazines
theophylline
isoniazid
cocaine
Acute cerebral infarction
Alcohol intoxication/withdrawal
Anoxic encephalopathy
IMMEDIATE TREATMENT
Generalised tonic-clonic status is potentially life-threatening and should be treated
without delay
Do not attempt to put anything into patients mouth during a seizure, even if tongue
injured. Intubation, if necessary, requires special care
Avoid rolling patient during a seizure unless absolutely necessary as this can cause
injury to shoulder/hip joints
Flowchart Status epilepticus protocol
Watch and assess (epileptic seizure, syncope, non-epileptic attack)
Assess secondary metabolic factors (hypoglycaemia, electrolyte
imbalance, lactic acidosis, dehydration, hyperpyrexia)
Protect airway and support respiration if possible. If there is any period of
relaxation, try carefully to insert an airway
O2 (high flow mask) 10 L/min
IV access
blood test glucose, U&E, calcium, FBC, serum anticonvulsant
concentration (if patient taking anticonvulsant drug see Therapeutic
drug monitoring guideline)
lorazepam 4 mg IV (diluted 1:1 with sodium chloride 0.9% or water for
injection) as single bolus injection into large vein; if lorazepam
unavailable, give diazepam (Diazemuls) 10 mg IV over 2 min. Monitor O2
saturation carefully for evidence of respiratory depression
poor nutrition/alcoholism, give parenteral thiamine as Pabrinex IV High
potency injection two pairs of ampoules (mixed) by IV infusion in sodium
chloride 0.9% 100 mL over 30 min once daily
if hypoglycaemia suspected, give glucose 20% 50 mL IV over 5 min
repeat if still unconscious after 15 min
0 5 min
Use caution when using Diazemuls because of prolonged sedative effect

Repeat lorazepam 4 mg IV if necessary (diluted 1:1 with sodium
chloride 0.9% or water for injection); as a single bolus injection into a
large vein. Do not exceed total dose of 8 mg of lorazepam
if lorazepam unavailable, give diazepam (Diazemuls) 10 mg IV over 2
min repeated if necessary after a further 5 min. Do not exceed total
dose of 30 mg of diazepam
Monitor O2 saturation carefully for evidence of respiratory depression
If seizures continue after 10 min:
if patient not already taking maintenance phenytoin therapy, give
phenytoin (see Prescribing regimens and nomograms
Phenytoin) with cardiac monitoring
if already taking maintenance phenytoin therapy, contact on call
SpR to discuss reduced dose of IV phenytoin, or use of
phenobarbital or alternative agents
Check blood gases
If, at any stage, respiratory depression or cardiac arrhythmia is
apparent, or pH <7.0, contact ITU
If satisfactory control still not established after 40 min, and contact

registrar or consultant for advice and arrange transfer to ITU
further specialized management on ITU
510 min
Call on call SpR

1040 min
Reasons for failure to respond

Incorrect diagnosis
Underlying cause (e.g. metabolic abnormalities, not recognized and treated)
Delay in intubation and anaesthesia
Inappropriate use of drugs/dosage
Delay in initiating maintenance anticonvulsant therapy
All patients should now be under care of neurology team
If not improving:
reconsider underlying causes
if patient transferred to ITU and anaesthetized, arrange EEG as soon as possible after
intubation to establish state of cerebral ictal activity
if continued sedation necessary, repeat EEG 24 hrly
EEG can be arranged:
If improving:
Once seizure activity has ceased, place patient in recovery position
in patients with previously diagnosed epilepsy, recommence previous AED therapy
in newly diagnosed patients, neurologist to introduce appropriate therapy before
discharge
If on recovery, continued oxygen is required see Oxygen therapy in acutely
hypoxaemic patients guideline
Discharge when patient seizure-free for 48 hr and fit to leave hospital, and anticonvulsant drug therapy established
Review existing follow-up appointments for patients with a previous history of epilepsy
Ensure patients with no previous history have review appointment arranged
Refer all cases to clinical nurse specialist before discharge if not already seen during
admission
Isolated seizures 2010-11
ISOLATED SEIZURE OR UNEXPLAINED EPISODE

OF LOSS OF CONSCIOUSNESS
An episode of loss of consciousness with or without convulsive movement, with spontaneous

recovery and no apparent trigger or cause
Obtain and record description of episode from patient
Obtain and record eyewitness account, if possible
Establish any history of previous episodes of loss of consciousness or altered behaviour
Establish any history of:
early morning jerks
possible absence episodes
previous history of treated epilepsy
Enquire for evidence of vasovagal episodes, cardiac arrhythmias and hypoglycaemia
Investigations
FBC, U&E
ECG
Glucose
If no focal neurological abnormality found, no injury incurred, blood results normal and patient
fully recovered:
discharge patient with appropriate advice see Discharge and follow-up
send for neurology clinic appointment
other necessary investigations to be arranged from neurology department as out-patient
If any focal neurological abnormality found:
urgent CT scan
If CT scan normal, no injury incurred, blood results normal and patient fully recovered:
discharge patient with appropriate advice see Discharge and follow-up
send for neurology clinic appointment
other necessary investigations to be arranged from neurology department as out-patient
If blood results abnormal, arrange appropriate investigations as necessary
IMMEDIATE TREATMENT
None required
Inappropriate use of diazepam can result in unnecessary admission if seizure had already
resolved spontaneously, and can cause respiratory depression
Do not start anticonvulsant therapy before seeking advice from registrar or consultant
If focal neurological abnormalities found or CT scan abnormal, contact registrar on call
while patient in A&E or MAU for advice about further action to be taken
Advise patient to stop driving and to inform DVLA. Record this advice explicitly on casualty
card
Advise patient to return to A&E if a further episode occurs
Issue contact number for clinical nurse specialist to obtain further advice or to query outpatient appointment at First seizure clinic
Cluster 2010-11
CLUSTER SEIZURES AND COMPLEX PARTIAL

AND NON-CONVULSIVE STATUS
Symptoms and signs
Repeated seizures that fluctuate in severity and may last for hours or days
Most common in patients with temporal or frontal lobe epilepsy, or where epilepsy is
associated with a learning disability
Most patients already have an established diagnosis of epilepsy and are taking treatment
Ask about:
previous history of cluster seizures or non-convulsive status
fluctuating conscious level without loss of consciousness
Look for:
confusion, agitation or aggressive behaviour
drowsiness
ataxia
Many of these features are similar to those of drug toxicity or behavioural problems
Important underlying causes
Consider:
recent changes in anti-epileptic drug therapy, dose or brand prescribed
underlying infection
Investigations
FBC, U&E, glucose
If taking carbamazepine or phenytoin, serum anticonvulsant concentrations
IMMEDIATE TREATMENT
Contact SpR on call for advice about need for urgent EEG, admission and management
Avoid alteration in drug treatment before seeking advice
Admission, if indicated, should be under care of consultant neurologist, if possible
If patient admitted to general medical ward, notify clinical nurse specialist in epilepsy or
consultant neurologist already concerned with patients care, as soon as possible
If patient not admitted, send for urgent out-patient review

If patient admitted, arrange out-patient review with neurology service
Stroke 2010-11
STROKE
STROKE SYNDROMES
Infarct subtypes1
(infarcted territory)
Total anterior circulation
syndrome (TACS)
[involving both deep and superficial middle
cerebral artery (MCA) territory]
Partial anterior circulation syndrome

(PACS)
[more restricted cortical infarcts in the
MCA territory, including isolated infarctions
in the anterior cerebral artery (ACA)
territory and striatocapsular infarctions]
Lacunar syndrome (LACS)
(small lacunar infarcts in the basal ganglia
or pons)
Posterior circulation syndrome (POCS)

(infarcts in brainstem, cerebellum and/or
occipital lobes)
1
2
3
Symptoms and signs

New higher cerebral dysfunction (e.g.
dysphasia, dyscalculia, visiospatial disorder)2
and
Homonymous visual field defect2
and
Hemiparesis/hemisensory loss affecting at
least two body areas (2 out of face, arm and
leg)
Patients presenting with only two of the three
components of the TACS
or
Motor/sensory deficit restricted to face or arm
or leg
Pure motor, pure sensory or sensori-motor
deficit
or
Ataxic hemiparesis (with at least faciobrachial
or brachiocrural involvement)3
Ipsilateral cranial nerve palsy with contralateral
motor and/or sensory deficit
Bilateral motor and/or sensory deficit
Disorder of conjugate eye movement
Cerebellar dysfunction without ipsilateral
hemiparesis
Isolated homonymous visual field defect
As defined by Oxfordshire Community Stroke Project

Assume a deficit present if consciousness is impaired and higher cerebral functions or visual
fields cannot be tested formally
Acute focal movement disorders should probably also be included in this group

Definition
For acute management, all patients with symptoms present at time of assessment are
treated as a stroke. A diagnosis of TIA can be made only if symptoms have completely
resolved
Stroke is a neurological deficit of sudden onset:

with focal rather than global dysfunction
with symptoms lasting >24 hr, or resulting in death before 24 hr
in which, after adequate investigation, symptoms are presumed to be of a non-traumatic
vascular origin
The term stroke covers both cerebral infarction and intraparenchymal haemorrhage, which
cannot be differentiated clinically but only by neuroimaging (CT or MR)
Transient ischaemic attack (TIA) is a stroke-like event that resolves within 24 hr; most
resolve within 30 min follow Transient ischaemic attack (TIA) guideline
Stroke 2010-11
Crescendo TIAs (>2 TIAs in one week) follow Transient ischaemic attack (TIA) guideline
treat as high risk even if ABCD2 score <4 and contact stroke team during working hours
(5111)
Subarachnoid haemorrhage, extradural haemorrhage, subdural haemorrhage
Space-occupying lesion
Arterial dissection (look out for Horners syndrome, neck and face pains, whiplash injury, neck
trauma)
Meningitis/encephalitis
Seizures/Todds paralysis
Hypertensive encephalopathy (diastolic BP >120 mmHg, depressed consciousness,
papilloedema)
Metabolic (e.g. hypoglycaemia, hyponatraemia)
Toxic (e.g. overdose)
Anoxic encephalopathy (e.g. shock, arrhythmia)
Trauma
Functional
ACUTE STROKE CARE PATHWAY

Acute stroke is a medical emergency. Screen all patients on arrival and initiate stroke
pathway.
Do not waste time, every minute of delay results in a further loss of 2 million brain cells
Commence Stroke pathway form (forms in A&E or EAU)on arrival

If suitable for thrombolysis (previously independent, time of onset known and <6 hr earlier for
anterior circulation stokes and posterior circulation syndrome), request CT head scan within
15 min or less and discuss immediately with stroke Team( Bleep 5111l only during working
hours
Alert thrombolysis nurse (bleep 5111 between 8:0017:00 working week)
Inform bed manager (Bleep 3011) to arrange a bed at stroke unit
Notify stroke unit (1011/ 3890) as soon as clinical diagnosis made so that a bed can be made
available (this can take a few hours, so do not wait until patient returns from scan). If no bed
available, ask bed manager to move patients to make a bed in accordance with stroke unit
operational policy
Transfer all stroke patients from A&E to acute stroke unit within 4 hours of arrival, and
thrombolysed patients immediately before or after alteplase infusion completed
Urgent investigations
Immediate CT head scan (within 15 min) in patients who:
are potential thrombolysis candidates (clinical diagnosis of stroke, previously independent
and well, onset time known and 4.5 hr or less) write ACUTE STROKE CONSIDERED FOR
THROMBOLYSIS on request form. Inform CT imaging suite and ensure scan carried out
immediately
If onset time known and between 4.5 6 hours consider to enroll into IST-3 trial (Only
working hours)
are anticoagulated or have known bleeding disorder (platelets <100 109/L, INR >1.2)
have depressed level of consciousness (GCS <13)
have unexplained progressive or fluctuating symptoms
have papilloedema, neck stiffness, or fever
have severe headache at onset of stroke
Consider immediate CT angiogram (immediately after CT head) in patients with severe
disabling anterior circulation stroke (National Institute of Health Stroke Scale NIHSS >7) or
Stroke 2010-11
posterior circulation stroke (mild-to-very-severe/coma) who might be candidates for intraarterial thrombolysis (must be fit for general anaesthetic). Do not delay IV thrombolysis while
waiting for angiogram to be performed
Urgent CT head scan (within 1 hr and before transfer out of A&E) in all patients with acute
stroke who do not fulfill criteria for thrombolysis. Write ACUTE stroke priority 1on request
form and give details of neurological deficit. Inform directly to CT imaging suite and negotiate
scan time. Need to phone on call radiologist to gain permission for out of hour
If intracerebral haemorrhage suspected in patient taking warfarin, request immediate INR
(write URGENT on form)
Glucose, U&E, FBC, INR (review results within 4 hr)
Random cholesterol, LFT, CRP, ESR within working hours (review results within 24 hr)
ECG
IMMEDIATE TREATMENT
General
Trained healthcare professional to assess swallowing before giving fluid food/medication
orally. See Fluid and nutrition management below
After CT has excluded haemorrhage, give aspirin 300 mg orally, rectally or via nasogastric
tube immediately
Position to minimise risk of pressure sores and turn 2 hrly
Mobilise all joints through their natural range of movement 4 times-a-day (family members
can be instructed to help with this) to prevent pneumonia
in obese or frail hemiparetic patients, consider pressure-relieving mattress
Do not catheterise unless patient in urinary retention
Fluids
If consciousness impaired or swallowing doubtful, order nil by mouth
In patients who are nil by mouth, dehydrated or at risk of dehydration, give sodium chloride
0.9% (no glucose during first 24 hr) 1 L IV over 6 hr, then 8 hrly
See Maintenance fluid therapy guideline for advice on potassium and after first 24 hr,
standard regimens to follow for maintaining hydration
Pyrexia and infection
Antibiotics for suspected infection (temperature >37.5C)
Treat pyrexia (temperature >37.2C) with paracetamol 1 g orally or rectally 6 hrly
Hyperglycaemia
Maintain blood glucose between 411 mmol/L
Hypoxia
Check airway and clear if necessary
If conscious, sit up and out of bed; if reduced consciousness, recovery position
Do not give oxygen routinely
If oxygen saturation falls to <95%, give supplemental oxygen
Blood pressure
Correct hypotension and try to prevent BP from falling
Recommended target BP within first 24 hr of stroke is 160180/90100 mmHg. Consider
stopping antihypertensive medication and give adequate hydration as first therapeutic
measures
Do not lower BP acutely unless >220/120 mmHg and there is other evidence of hypertensive
encephalopathy seek advice from stroke consultant
Stroke 2010-11
Statins
If patient taking a statin before the stroke, continue
Immediate initiation of statin treatment not recommended in acute stroke
Warfarin
In patients taking warfarin who present with intracerebral haemorrhage, reverse
anticoagulation immediately (within 3 hr or less), aiming for an INR of 1.0 (even in patients
with artificial heart valves). Give phytomenadione (vitamin K 1 ) 5 mg IV immediately as slow
bolus. Contact consultant haematologist on-call to order dried prothrombin complex and
correct INR as soon as possible within 3 hr (including patients with prosthetic valves)
In patients with prosthetic valves and disabling cerebral infarct, stop warfarin for one week
and replace with aspirin 300 mg once daily
Specific syndromes
Acute venous stroke (cerebral sinus venous thrombosis)
In patients with cerebral sinus venous thrombosis (including those with secondary cerebral
haemorrhage) start full dose anticoagulation (initially unfractionated heparin, then warfarin
aiming for target INR 23) unless contraindicated by other concurrent conditions
Stroke secondary to acute arterial dissection
Use either anticoagulants or antiplatelet agents, preferably as part of a clinical trial
Advice
Ask for senior/specialist advice about:
patients in whom unusual cause for stroke suspected (bleep neurology registrar)
intracerebral haematoma (bleep neurosurgical team)
hydrocephalus (bleep neurosurgical team)
Ensure stroke team (5111) aware of all patients with stroke not admitted to stroke unit.
Members of stroke team will assess patient and arrange transfer to stroke unit, if other
concurrent conditions allow
General
Allow patient to sit up as tolerated (bed/chair) as soon as possible
Mobilise conscious patients from day 1
If no haemorrhage on CT, give aspirin 300 mg orally, rectally or via nasogastric tube for two
wks unless contraindicated. In patients with previous dyspepsia, add omeprazole. In patients
genuinely allergic to, or intolerant of aspirin, use clopidogrel 75 mg once daily
Make sure patients who are nil by mouth receive all necessary medication (use rectal, IV or
nasogastric tube)
Treat pyrexia (temperature >37.5C) with paracetamol 1 g orally or rectally 6 hrly
Avoid sedatives (e.g. temazepam, chlorpromazine, haloperidol) if possible
Young patients with intracerebral haemorrhage may have an operable vascular abnormality.
Request neurosurgical assessment
General
Stroke 2010-11
If random glucose >7.5 mmol/L, request fasting glucose

Lipid status (<48 hr after stroke or after six weeks)
Chest X-ray
For specific indications

In patients with cardiac murmurs and/or history of rheumatic fever, consider
echocardiography:
request bubble contrast echocardiogram in young patients (age <50 yr) with stroke to exclude
atrial septal defect(ASD)/patent foramen ovale (PFO)
In patients with no risk factors for atheroma, request echocardiogram, and screen for arteritis
(CRP, ANA, ANCA, Rh Factor) acquired thrombophilia (coagulation screen, lupus
anticoagulant, anticardiolipin antibodies take sample while patient not receiving
anticoagulation (positive results only diagnostic if taken on 2 occasions at least 3 months
apart), fasting homocysteine levels, B 12 and folate
In young patients with PFO/ASD where paradoxical embolism is considered to be cause of
stroke, full thrombophilia screen (coagulation screen, protein C, protein S, antithrombin to
exclude inherited thrombophilia, consider 4 sodium citrate tubes to haematology/Dr Hudson
plus 2 EDTA bottles to haematology inform lab beforehand of samples)
In younger stroke patients (age <50 yr) and those without vascular risk factors, consider MR
angiography to exclude dissection
In patients without vascular risk factors where the diagnosis is in doubt, consider MR scan
including DWI of brain to confirm an infarct, show potential alternative pathology, or
demonstrate normality
If several repeated scans considered necessary to exclude recurrent silent ischaemic events,
consider MR in preference to CT, to reduce radiation exposure
Fluid and nutrition management
Assess swallowing at bedside
Check that patient is:
alert and co-operative
able to sit up for feeding
able to cough on demand
not drooling excessively
Sit patient up, listen to voice and give 5 mL of water on a spoon
Watch and feel swallow with fingers on larynx
Observe for 2 min, looking for:
choking or impaired breathing
delayed swallow
cough
change of voice
If 5 mL swallowed without difficulty, give 50 mL of water before giving soft diet
If there is any doubt about swallowing, recommend nil by mouth, give fluid (2 L/24 hr) IV5 and
ask speech therapist or stroke team to assess swallowing
Tube feeding
In patients with severe strokes and dysphagia, start nasogastric feeding within 24 hr (unless
expected to die within hours)
In mild strokes, where normal swallow expected to return, review after 48 hr and pass
nasogastric tube if dysphagia still present
Where a standard nasogastric tube cannot be kept in place safely and reliably, consider a
nasal bridle
Refer patients with persistent dysphagia after 3 days for dietary advice and consider further
investigation (e.g. video fluoroscopy)
Stroke 2010-11
If NG tube not tolerated and patient unable to take sufficient nasogastric/oral diet for 3 or
more days, refer urgently for PEG (percutaneous endoscopic gastrostomy)
If nasogastric feeding successful but no significant recovery of swallowing occurs within 23
wks, consider referral for PEG
If there is some recovery of swallowing and nasogastric feeding successful, PEG referral may
not be necessary, continue nasogastric feeding until patient able to eat normally
Rehabilitation
Admit all stroke patients to acute stroke unit and start active rehabilitation on day 1
unless consciousness impaired, sit out and mobilise from day 1
Full multidisciplinary assessment; include nurses, occupational therapist, physiotherapist,
doctors, speech and language therapist and clinical psychologist to identify rehabilitation
goals. Involve dietitian, social worker, pharmacist, other medical or surgical specialties, at a
later date, as necessary
Quick recovery
If patient recovers rapidly and is left with no significant residual disability after a few days,
arrange for urgent carotid Doppler (within 1 working day) and make sure secondary
prevention (see below) is in place (12% of patients with minor strokes will extend or have a
further stroke within one week)
Secondary prevention
Manage patients with antiphospholipid syndrome who have an acute ischaemic
stroke in the same way as patients with acute ischaemic stroke without
antiphospholipid syndrome
General
Advise to stop smoking
Give dietary advice
Advise to exercise regularly
Identify and treat diabetes. Keep HbA 1c below 7%
Antiplatelet treatment
Aspirin: once haemorrhage excluded by CT, unless contraindicated, 300 mg/day for 2 weeks
or until discharge. In patients with history of dyspepsia, add omeprazole
after 2 weeks, or at discharge, if this is earlier, reduce dose of aspirin to 150 mg (75 mg in
frail elderly) per day and add dipyridamole MR 200 mg twice daily (for 2 yr)
in patients allergic to, or genuinely intolerant of aspirin, use clopidogrel 75 mg once daily as
single antiplatelet agent
Warfarin: for all patients with atrial fibrillation/flutter (AF) who have no contraindications
two weeks after stroke, start slow induction dose of warfarin (no need to achieve rapid
anticoagulation).For stable patients in good health, see Warfarin guideline: slow
anticoagulation. For frail, malnourished, multimorbid patients or those on multiple other
medications, discuss warfarin starting regime with stroke consultant since lower doses may
be required
once INR >2, stop aspirin, clopidogrel and dipyridamole
In mild non-disabling stroke, discuss with stroke consultant whether warfarin can be started
earlier
Other medication
If total cholesterol >3.5 mmol/L, give simvastatin 40 mg (10 mg if creatinine clearance <30
mL/min) at night starting 48 hr or later after stroke
Stop contraceptive pill/hormone replacement therapy (unless there is an important reason to
continue). In premenopausal women, provide advice on alternative methods of contraception
Stroke 2010-11
12 weeks after stroke/TIA, reduce blood pressure target <140/85 mmHg in most patients,
<130/80 mmHg in diabetics
start treatment slowly use bendroflumethiazide 2.5 mg daily in morning and an ACE
inhibitor as first treatment choices unless patient has specific contraindications
COMPLICATIONS
Pneumonia after starting oral fluids
Reassess swallowing, treat as aspiration pneumonia see Hospital-acquired pneumonia
guideline
Deep venous thrombosis/pulmonary embolism
Treat in usual way if CT head scan has excluded haemorrhage see Deep venous
thrombosis and Pulmonary embolism guidelines
In patients with haemorrhagic stroke and symptomatic DVT/PE, discuss anticoagulation or
placement of a caval filter to prevent (further) pulmonary embolism with consultant
Shoulder pain
Prevent by not pulling on the affected arm and always supporting its weight
Maintain correct position and adequate support, consult physiotherapist, consider
paracetamol
If pain persists, consider addition of NSAIDs, TENS or intra-articular corticosteroids (stroke
specialist nurse 5111)
Depression
High suspicion but consider emotional incontinence/lability, dementia, communication
difficulty
Seizures
Treat conventionally
Pressure sores
Prevent/treat
CAUSES OF DETERIORATION
Malignant MCA syndrome
If deterioration of consciousness within first 48 hr [National Institute of Health Stroke Scale
(NIHSS) item 1a >1 (e.g. drowsy patient) in patients aged <60 yr with large MCA territory
infarcts (NIHSS score >15), consider malignant MCA syndrome
Arrange urgent CT head scan/MRI and discuss with stroke consultant of the day (working
hours) or neurosurgeon at Hope hospital for out of hours
signs on CT of an infarct of at least 50% of the middle cerebral artery territory with or without
additional infarction in the territory of the anterior or posterior cerebral artery on the same
side, or an infarct volume of >145 cm3 on diffusion-weighted MR scan of brain confirm the
diagnosis
Untreated malignant MCA syndrome has 80% mortality but hemicraniectomy within first 48 hr
has been shown to reduce mortality significantly consider urgent referral to neurosurgery
(within 24 hr) to allow surgery within 48 hr
Other brain causes
Stroke progression/further stroke highest risk in minor strokes/TIAs: make sure secondary
prevention is in place from day 1
Progression of intracerebral haemorrhage if deterioration in neurological signs/level of
consciousness after admission, rescan immediately and refer to neurosurgeons for advice
Stroke 2010-11
(unless there are good reasons not to consider surgery). Recheck INR and correct, if
necessary
Cerebral emboli, or vasculitis
Brain oedema (esp. in large parietal strokes)
Hydrocephalus (esp. in cerebellar strokes or in patients with intracerebral haemorrhage, refer
previously fit patients to neurosurgery)
Haemorrhagic conversion (especially in large infarcts)
Action
Review differential diagnosis
Consider: repeat CT/MR, EEG (for possible encephalitis or epilepsy), LP
Non-brain causes
Complications (see previous section)
Coincident medical condition (e.g. hypoxia, hypoglycaemia, hyperglycaemia, pyrexia,
infection, heart failure, fluid/electrolyte disturbance) see relevant guidelines
DISCHARGE POLICY
Acute stroke unit (x 5111) provides information packs for patients and carers, and will
assist in discharge planning and arrangements for continued outpatient rehabilitation.
They will also contact stroke family support worker where needed
Use multidisciplinary stroke checklist

Consider referral to the community rehabilitation or outpatient neurorehabilitationTeam
When completing discharge letter, specify diagnosis as cerebral infarct or intra-cerebral
haemorrhage (not CVA)
Ensure all secondary prevention measures are in place and follow-up arranged
Inform GP about secondary prevention needs in discharge letter
Patient and relatives

Advise patient not to drive for one month. Check for hemianopia and hemi-inattention in all
drivers. This is not always obvious to patient and disqualifies from driving until resolved
drivers must inform their insurers before driving again
if back to normal within one month, patient may drive again
if persistent deficit, patient must inform DVLA and await assessment
Ensure patient and relatives are aware of diagnosis, discharge date, follow-up arrangements
and secondary prevention measures
Follow-up at 6 weeks, 6 months, and annually

first follow-up in a specialist hospital clinic. Further follow-ups can carried out by stroketrained teams in the community (if available)
Assess functional status (Rankin), quality of life, mood, and cognition in clinic and refer as
appropriate
Include risk factor assessment and instructions for secondary prevention (refer to stroke
check list) in discharge documentation
If results of investigations outstanding at time of discharge, consider early (12 wk) outpatient clinic follow-up to ensure appropriate secondary prevention
TIA 2010-11
TRANSIENT ISCHAEMIC ATTACK (TIA) AND

MINOR CEREBRAL INFARCTION
Treat patient who still has symptoms at time of assessment as stroke and consider for thrombolysis
(see Stroke guideline) if within <4.5 hr of symptom onset.
TIA can only be diagnosed once all symptoms have resolved
Definition
TIA is a clinical syndrome characterised by an acute loss of focal cerebral or ocular function
with symptoms lasting <24 hr
Minor cerebral Infarction is a clinical syndrome characterised by an acute loss of focal
cerebral or ocular function with no significant residual disability
Crescendo TIAs are >1 TIA within a 24 hr period, or several TIAs over several days. Treat
as high risk, even if ABCD2 score (see below) <3
Frequent TIAs are those occurring at least once per week
Consider any patient presenting acutely with focal neurological signs to have had a stroke
until signs have completely resolved see Stroke guideline
Diagnose a TIA only once symptoms have resolved ( treat according to TIA guideline and
refer to TIA clinic by faxing through a completeTIA referral form)
Diagnosis
TIA is more difficult to diagnose than stroke: try to obtain a witness account
Syncope is unlikely to be a TIA
Vertigo alone is unlikely to be a TIA
Syndromes
Anterior circulation:
dysphasia
visuospatial neglect
usually hemiparesis (face, arm and leg)
usually hemisensory (face, arm and leg)
Posterior circulation (ischaemia in brainstem, cerebellum and/or occipital lobes):
nausea and vomiting
vertigo
diplopia
dystaxia
crossed syndromes (weakness or numbness on side of face and in contralateral limbs)
coma
Assessment of stroke risk
Use ABCD2 score to classify chance of stroke within 7 days as low or high
A
B
C
Age >60 yr
BP >140 mmHg systolic or >90 mmHg
diastolic
Clinical hemiparesis
or
speech problem without hemiparesis
Duration >60 min
or
1059 min
Diabetes
Score
1
1
2
1
2
1
1
TIA 2010-11
ABCD2 score >3 high risk Treat immediately, initiate referral to TIA service immediately using
rapid access TIA referral form from Trust intranet TIA. Specialist appointment target is within 24
hr, carotid endarterectomy (if indicated) within 48 hr
ABCD2 score <3 low risk Treat immediately, initiate referral to TIA service immediately using
rapid access TIA referral form from Trust intranet TIA. Specialist appointment target is within 1
week, carotid endarterectomy (if indicated) within 2 weeks of TIA
IMMEDIATE INVESTIGATIONS
FBC, ESR
Random blood glucose
Biochemical screen
Random cholesterol
ECG
For crescendo or unstable TIAs who need admission, CT scan of head
IMMEDIATE TREATMENT AND ADVICE (before discharge)

It is important to give initial treatment while patient still in hospital and to prescribe follow-on
medication a letter to GP with instructions to prescribe will delay initiation of treatment by days
and leave patients vulnerable at a time when stroke risk is greatest
When
For TIA, begin antiplatelet therapy immediately unless you strongly suspect a hemorrhagic
stroke (severe headache, loss of consciousness) or BP very high (>180/100)
What
Simvastatin 40 mg straightaway and then each night regardless of the cholesterol value
Aspirin 300 mg immediately and daily for 2 weeks, then 75 mg orally daily indefinitely. If
dyspepsia experienced with aspirin, consider adding omeprazole
Dipyridamole 200 mg MR 12 hrly add to aspirin (unless contraindicated) after 2 weeks
(when aspirin dosage reduced to 75 mg daily) and continue for two years (advise patient this
may cause headaches for a few weeks, and to take paracetamol, if needed). Warn patients
with heart failure about tachycardia and hypotension and those with coronary artery disease
about possible worsening of symptoms
In patients who are aspirin or dipyridamole intolerant, substitute clopidogrel 75 mg alone
In patients who develop TIA but are already taking aspirin and dipyridamole, substitute
clopidogrel 75 mg alone (if AF excluded as cause)
do not use proton pump inhibitors in patients taking clopidogrel use ranitidine if gastro
protection required or change to Lansoprazole 30mg
Patient in AF
If in AF, anticoagulate with warfarin see Warfarin guideline: slow anticoagulation unless
there are contraindications, aiming for an INR of 23, and stop antiplatelet agents once
target INR achieved
Patient advice
If smoking advise to stop
Advise patient not to drive until symptom-free for 1 month and to inform insurance company
Advise all patients with definite clinical symptoms of TIA who are otherwise fit to call 999 if
they experience any new TIAs lasting more than a few minutes
TIA 2010-11
For crescendo TIA, frequent TIA or BP unstable, or if symptoms unresolved when

assessment completed) seek advice from stroke team ( Bleep 5111 working hours or Neuro
registrar at Hope hospital for out-of-hours). Otherwise referral to TIA clinic (available from
intranet or in the A&E stroke TIA pathway)
LONG-TERM RISK FACTOR MANAGEMENT (at follow-up)
In addition to the factors addressed in Immediate management, address the following at

follow-up:
smoking cessation advice
hypertension aim for a target BP <140/85 mmHg but do not reduce abruptly
diabetes mellitus aim for HbA 1c <7%
oral contraceptive pill or hormone replacement therapy contraindicated
lifestyle and diet advice
aim for total cholesterol <4 mmol/L and low-density lipoprotein (LDL) <2 mmol/L
SAH 2010-11
SUBARACHNOID HAEMORRHAGE
Symptoms and signs
Severe headache of sudden onset (becoming severe within seconds and no longer than one
minute) implies subarachnoid haemorrhage (SAH) until proved otherwise. It may be
associated with vomiting and loss of consciousness, with subsequent photophobia and neck
stiffness
Symptoms can sometimes resolve within a few hours but should still be investigated with
CT scan of head. Thirty percent of patients with SAH may have minor leaks hours or days
before the major haemorrhage, which are often misdiagnosed as simple headaches or
migraine
Unexplained coma or seizures with subsequent persistent severe headache can indicate
acute SAH
Investigations
CT scan of head within 24 hr of admission, if possible
If initial CT normal (especially if performed more than 2472 hr after initial headache onset)
and clinical suspicion for SAH high, based on appropriate history, exclude SAH completely by
analysis of CSF at least 12 hr after symptom onset (see Practical procedures Lumbar
puncture guideline), measuring:
opening pressure
xanthochromia
MC&S, glucose and protein
Send blood for glucose, protein and bilirubin with CSF sample
Record time from headache onset in hours/days on CSF xanthochromia request card (to
allow best assessment)
When lumbar puncture performed, send sample to clinical biochemistry immediately for
centrifugation to allow CSF spectrophotometry for xanthochromia. This is especially
important if tap was traumatic. You must warn clinical biochemistry before you send
sample
Meningitis
Encephalitis
Cerebral venous sinus thrombosis (with raised opening pressure)
IMMEDIATE TREATMENT
If consciousness impaired, check airway and maintain it

Codeine phosphate 60 mg orally (or IM) 4 hrly as required up to maximum 240 mg in 24 hr
Observe respiratory effort and monitor ECG
If SAH confirmed, and request transfer to Hope Hospital
(After discussion with neurosciences team)
Nimodipine 60 mg orally 4 hrly including throughout night. Commence within 4 hr of SAH or
as soon as diagnosis confirmed. If unconscious, crush tablets and give as soon as possible
via nasogastric tube
Manage blood pressure see Stroke guideline Immediate treatment Blood pressure
SAH 2010-11
If no contraindication, give sodium chloride 0.9% at least 3 L by IV infusion every 24 hr

Arrange for nursing staff to measure patients legs and fit TED stockings
If improving and stable:

In confirmed SAH, consider CT angiography at earliest opportunity
If not improving or deteriorating:
Think about:
metabolic cause (diabetes insipidus, hyponatraemia, hypoxia)
hydrocephalus
acute rebleed
Consider further CT scan of head
Until headache has subsided and patient stable, monitor 4 hrly:

Glasgow coma score
neurological observations
pulse
BP
temperature
When stable, monitor BP twice daily in patients taking nimodipine
As a rule, CT angiography is carried out with a view to operative treatment. If no operative

intervention planned, continue oral nimodipine for a total of 21 days. Discharge after two to
four weeks and review in out-patient clinic
If patient hypertensive, treat BP according to national guidelines e.g. British Hypertension
Society http://www.bhsoc.org
ASPC 2010-11
ACUTE SPINAL CORD COMPRESSION

Symptoms and signs
Acute (usually symmetrical) weakness of arms or legs or both
Sensory level (may be absent in high cervical spine compression)
Hyperreflexia and extensor plantar responses (note that because of spinal shock these may
not be present at outset)
Bowel/bladder dysfunction
Erectile dysfunction in males
Local spinal pain and/or tenderness +/- radicular pain
In patient with diagnosed cancer certain symptoms strongly suggest spinal metastases:
cervical or thoracic pain
progressive or unremitting severe lumbar pain
nocturnal spinal pain preventing sleep
Early diagnosis is imperative, high index of suspicion necessary in patients with mild
weakness and urinary hesitancy especially if history of cancer
Investigations
Acute spinal cord compression is an emergency and such patients should be referred
IMMEDIATELY to a spinal specialist. Do not delay referral; it is better that the spinal
specialist organises emergency MR scan than referral be delayed until a scan has been
done
If cord compression suspected, request immediate MR scan of spinal cord on all occasions,
to include whole neural axis (cervical, thoracic and lumbar)
If MR scan required out-of-hours see On-call radiology service guideline
FBC, U&E, LFT, ESR (and blood cultures if pyrexia) see Collection of blood culture
specimens guideline
Chest X-ray
Differential diagnosis (once cord compression excluded)

Transverse myelitis
Cord ischaemia
Guillain-Barr syndrome
IMMEDIATE TREATMENT
Refer immediately to on-call orthopaedic spinal team (via orthopaedic SpR)

If suspected spinal instability, ensure patient is nursed flat
Once MR scan performed and infective cause excluded, and after discussion with orthopaedic
spinal team on-call, give dexamethasone sodium phosphate 4 mg IV 6 hrly for at least 48 hr
if patient requires surgery +/- radiotherapy, review dose
If surgery not indicated, and patient has cancer, refer immediately to oncology team
SUBSEQUENT MANAGEMENT, DISCHARGE AND FOLLOW-UP
These will be decided by spinal team or oncology team, as patients may receive radiotherapy
after surgery
ARF 2010-11
ACUTE RENAL FAILURE

(acute kidney injury)
RECOGNITION
Acute renal failure (ARF) is a rapid decline in renal excretory function, acid-base balance and
removal of solutes and water
Acute kidney injury (AKI) is defined as an abrupt (within 48 hr) reduction in kidney function
determined by an absolute increase in serum creatinine of either 26.4 mol/L or 50% (1.5 x
baseline), or a reduction in urine output documented as oliguria <0.5 mL/kg for 6 hr
AKI Stage
1
2
3
Clearance
Increase in creatinine 26.4 mol/L
or 1.52 fold increase from baseline
Increase in creatinine >23 fold from
baseline
Increase in creatinine >3-fold or
serum creatinine >350 mol/L or
acute rise of >44 mol/L
Urine output
<0.5 mL/kg
for 6 hr
<0.5 mL/kg
for >12 hr
<0.3 mL/kg
for 24 hr or anuria for 12 hr
Groups at higher risk

Pre-existing chronic kidney disease
Age >60 yr
Sepsis
Cardiac failure
Diabetes
Cirrhosis
Causes
Pre-renal (perfusion)
volume depletion
hypotension, pump failure
sepsis
Renal (organ)
established acute tubular necrosis ischaemic or toxic
glomerulonephritis/vasculitis
tubulointerstitial nephritis
Post-renal (obstructive)
Hospital-acquired renal failure is often multifactorial, with contributions from
hypotension, sepsis and drugs
Risk of ARF resulting from obstruction or renovascular disease is greater if patient has
single kidney
PREVENTION
Be alert to recognise patients at risk (e.g. hypovolaemic states and presentation with sepsis)
Once identified as at risk or has developed AKI, start MEWS scoring to detect further
deterioration at early point. Write appropriate monitoring plan in notes and inform nursing staff
Do not overlook simple interventions (e.g. adequate fluid replacement and discontinuing
nephrotoxic drugs in at-risk individuals)
Minimise risk of acute kidney injury associated with radiographic contrast media see
Prevention of contrast-induced nephrotoxicity guideline
ARF 2010-11
if possible (unless contraindicated), discontinue NSAIDs, diuretics, ACE inhibitors and

angiotensin-II receptor antagonists in at-risk groups
ensure adequate hydration with IV fluids sodium chloride 0.9% 1 mL/kg/hr for 12 hr before
and after procedure unless evidence of fluid overload
consider alternative imaging modality, ultrasound or MR
ASSESSMENT(do not forget to fill AKI proforma)
Detailed history with particular reference to features associated with volume depletion, sepsis
or multi-system disorder
Thorough drug history
Obtain previous U&E for evidence of pre-existing renal dysfunction
Careful assessment of hydration status skin turgor, pulse, jugular venous pressure (JVP),
lying and standing BP, signs of fluid overload
Look for signs of urinary tract obstruction (palpable bladder)
Look for evidence of multiple organ failure
Hypotension (mean arterial pressure <65 mmHg) despite initial fluid resuscitation up to 30
mL/kg, inotrope or vasopressor dependency
Impaired gas transfer: hypoxaemia (PaO 2 <10 kPa) despite 40% O 2
Metabolic acidosis compensated as well as uncompensated
Pulmonary shadowing/oedema on chest X-ray
Patient looks severely ill/exhausted/obtunded
Patients with developing or established multiple organ failure should be identified early
and referred to Intensive Care for further investigation and management
Investigations
Urgent urine dipstick. Presence of haematuria/proteinuria may indicate acute
glomerulonephritis/vasculitis
FBC
Biochemical screen
Blood gases to assess acidosis, hypoxia, lactate
Urgent renal ultrasound to assess renal size/exclude obstruction
Chest X-ray looking for signs of fluid overload, infection
Serum protein and urine electrophoresis
Immunology screen: (ANA/ANCA/C3/C4/Anti-GBM) required only in patients with single organ
failure and urinary sediment
Sepsis screen including blood cultures and urine M C&S
REFERRAL TO RENAL TEAM
Discuss with renal team at MRI any patient with:

creatinine >300 mol/L
ARF without obvious cause (e.g. volume depletion, sepsis)
ARF with haematuria/proteinuria
ARF in the setting of multisystem disorder
ARF 2010-11
IMMEDIATE TREATMENT
Fluid balance
Accurately chart fluid input and urine output (urinary catheter may be required)
If dehydrated, correct with IV crystalloid. Insert CVP line if necessary to maintain pressure
1014 cm H 2 O
once rehydrated, continue IV crystalloid to match urine output + 30 mL/hr
if hypotensive despite rehydration, consider (a) colloid (Volplex, blood) and (b) inotropes.
Discuss with renal team. Do not use dopamine or mannitol
If patient is fluid overloaded, (i.e. pulmonary oedema with oliguria) give furosemide 250 mg (in
25 mL) over 2 hr using infusion pump or syringe driver
If no response, contact renal team urgently
Recheck U&E daily to assess changes in renal function
Drugs
Discontinue/avoid nephrotoxins (e.g. NSAIDs/ACE inhibitors/angiotensin-II receptor
antagonists)
Stop metformin if any evidence of acute kidney injury (e.g. oliguria <0.5 mL/kg/hr for >6 hr, or
acute rise in creatinine >26.4 mol/L, or >1.5 fold increase in baseline creatinine)
Consider need to adjust dosage of any drugs given in renal failure consult BNF (Appendix 3)
or Renal drug handbook
Consider restarting drugs after acute insult resolved
Tumour lysis syndrome
Discuss patients with suspected tumour lysis syndrome (massively increased serum uric acid)
urgently with renal team or oncology
Patients whose renal function continues to decline (even if creatinine <300 mol/L) despite
initial resuscitation should be referred to renal team at MRI within 48 hr of diagnosing ARF
RENAL REPLACEMENT THERAPY
Consider intermittent haemodialysis or continuous renal replacement therapy if evidence of:

fluid overload with oliguria
potassium >6.5 mmol/L
uraemia
severe acidosis
Contact renal team
Often undertaken by renal team
Daily weight and fluid balance

Daily biochemical screen
Monitoring of underlying cause
Arrange out-patient review by renal team (Dr.Mitra) if renal function remains abnormal despite
treatment
Accelerated hypertension 2010-11
ACCELERATED (MALIGNANT) HYPERTENSION

Accelerated hypertension is a specific form of severe hypertension (diastolic pressure usually
>120 mmHg) with evidence of arteriolar damage, evident from retinopathy Grade III/IV. It may
occur in patients with essential or secondary hypertension. Of greatest importance are the
absolute height of the BP and rate of its rise. Recognition of a hypertensive emergency is
essential for effective triage and treatment
Symptoms and signs
Blurring of vision, mental impairment
Headache
Dyspnoea [left ventricular (LV) failure]
Haematuria (usually microscopic)
Cotton wool spots and haemorrhages with or without papilloedema on fundoscopy. Fundi
must be properly examined in patients suspected of having accelerated hypertension.
Evidence of other target-organ damage includes strokes, encephalopathy, LV
failure/enlargement, and renal failure with red cells, casts and protein in the urine
Immediate investigations
Complete history with particular attention to pre-existing hypertension and target-organ
damage (TOD)
FBC, U&E, creatinine, electrolytes
Urine microscopy
ECG
Chest X-ray
IMMEDIATE TREATMENT
If there is any doubt about the need for treatment, seek advice from the renal unit at
Manchester Royal Infirmary
Diastolic BP >120 mmHg and Grade III or Grade IV retinopathy require urgent assessment,
but are not in themselves indications for intravenous treatment. Most patients can be treated
safely with an oral anti-hypertensive drug
Sustained high BP alters cerebral autoregulation; sudden reduction of BP will reduce
cerebral perfusion and can be dangerous.
Aim to reduce blood pressure by no more than 25% in first 2448 hr
Oral therapy
Bisoprolol 5 mg daily or nifedipine SR 10 mg orally 12 hrly increasing to 40 mg orally 12 hrly

as required or amlodipine 5 mg daily increasing to 10 mg daily
Do NOT use sublingual nifedipine
Parenteral therapy
Parenteral therapy indicated only if accelerated hypertension is accompanied by one or more
of the following:
hypertensive encephalopathy
aortic dissection
intracranial haemorrhage
phaeochromocytoma crisis
acute pulmonary oedema
acute renal insufficiency
unstable angina
Accelerated hypertension 2010-11
Give labetalol, glyceryl trinitrate or sodium nitroprusside by IV infusion see Prescribing

regimens and nomograms
if no evidence of pulmonary oedema, and no contraindication (e.g. bronchospasm, heart
block) prefer labetalol, particularly when there is associated aortic dissection. Labetalol can
also be used in patients who have taken cocaine or amphetamine, either of which can induce
transient but significant hypertension leading to stroke and/or serious cardiac damage
in patients with acute pulmonary oedema or acute coronary syndrome, prefer glyceryl
trinitrate as it is a venous as well as, to a lesser degree, an arteriolar dilator
in most other hypertensive emergencies, use sodium nitroprusside as it is a highly effective
short-acting arteriolar and venous dilator. In primary intracerebral haemorrhage, intracranial
pressure may increase and there is a potential antiplatelet effect seek senior advice
In the first instance, diastolic BP should not be reduced below 110115 mmHg, with two
exceptions:
if patient has aortic dissection see Aortic dissection guideline, reduce systolic blood
pressure to <110 mmHg and maintain
if patient has pulmonary oedema, reduce blood pressure until clinical improvement occurs but
not <90/60 mmHg
Hyponatraemic hypertensive syndrome

Hypertension associated with hyponatraemia, hypokalaemia, thirst, polyuria and polydipsia, in
the context of renal arterial disease of recent onset, accelerated hypertension, or
haemodialysis. This syndrome can cause salt and volume depletion associated with
sustained severe hypertension. Consider volume repletion and refer to renal unit
If improving
In patients treated with IV infusion, start oral treatment before IV agent withdrawn
Continue maintenance oral treatment with bisoprolol, labetalol or nifedipine
Add a thiazide diuretic after two to three days if necessary
Assess renal function in more detail (creatinine clearance, ultrasound scan)
Aim to reduce BP to 160/90 mmHg or less over 710 days
Carefully assess all patients for secondary causes of hypertension
If not improving
Seek advice from renal unit
After oral dose, measure BP every 30 min

During parenteral therapy, measure BP every 15 min (ideally by continuous intra-arterial BP
monitoring, nurse on HDU)
Once maintenance therapy has started, measure BP 4 hrly
Monitor urine output and plasma urea, creatinine and electrolytes daily
Address other risk factors for cardiovascular disease (smoking, cholesterol, obesity) and
advise
Discharge home when BP <160/90 mmHg and condition stable
Following discharge provide close follow-up care
Confusion 2010-11
ACUTE CONFUSIONAL STATE (DELIRIUM) IN

OLDER PEOPLE
Recognition
Patients with following conditions are at high risk:
dementia
visual impairment
physical frailty
any severe illness
infection and dehydration
renal impairment
recent surgery (e.g. fractured neck of femur)
alcohol excess
polypharmacy
Identify these patients on admission and incorporate prevention strategies (see Immediate
treatment) into their care plan
Assessment
Assess mental status of all elderly patients on admission. Repeat whenever there are
subsequent changes in mental function
Assessment must include:
history taken from patient and a relative
Confusion Assessment Method (CAM) screening instrument
www.consultgerirn.org/uploads/File/trythis/issue13_cam.pdf
Hodkinson's abbreviated mental test
a full clinical examination, including a neurological and rectal examination
basic investigations as below
Confusion Assessment Method (CAM) screening instrument
To have a positive CAM result, patient must display:
Presence of acute onset and fluctuating course
AND
Inattention (e.g. counting down from 20 to1 with reduced ability to maintain attention or shift
attention)
AND
Either disorganised thinking (disorganised or incoherent speech) or altered level of
consciousness (usually lethargic or stuporous)
Hodkinson's abbreviated mental test
1) Age
2) Time (nearest hr)
3) An address for recall at end of test (this should be repeated by patient to ensure it has been
heard correctly), such as 42 West Street
4) Year
5) Name of hospital
6) Recognition of two persons (doctor, nurse etc)
7) Date of birth
8) Date of World War I
9) Name of present monarch
10) Count backwards (201)
Confusion 2010-11
award one point for each correct answer

a score of seven or less is consistent with impaired brain function
Confusion is a symptom, not a diagnosis. Establish in every case whether you are dealing
with:
delirium (acute confusional state) acute confusion in a previously well patient, which
develops over a short period (hours to days), is always associated with clouding of
consciousness and is usually precipitated by an acute medical or surgical problem
dementia continuing confusion relatively unchanged for a month or more
delirium superimposed on dementia acute confusion in a patient with previous cognitive
impairment who has become suddenly much worse
acute functional psychosis such as schizophrenia, paraphrenia (a variant of schizophrenia
commencing in patients aged >60 yr) or severe depression
any combination of above. See Table 1 for distinguishing features
Investigations
FBC
Full biochemical screen (including calcium)
Blood glucose
CRP
Thyroid function tests
Blood cultures
Urinalysis
Chest X-ray
ECG
Pulse oximetry
Consider need for: lumbar puncture, blood gases, EEG, B 12 , folate
Consider CT scan of head only where a brain lesion suspected (fall, head injury, focal
neurological signs, evidence of raised intracranial pressure)
Table 1: Clinical features of delirium, dementia and acute functional psychosis
Characteristics
Delirium
Dementia
Acute functional
psychosis
Onset
Sudden
Insidious
Sudden
Fluctuating, worse at
Usually stable
Stable
Course over 24 hr
night
Reduced
Clear
Clear
Consciousness
Globally disordered
Usually normal
May be disordered
Attention
Usually impaired
Variable
May be impaired
Orientation
Common
Often absent
Predominantly auditory
Hallucinations
Recent and
Recent and remote
Variable
Memory
immediate memory
memory impaired
impaired
Often asterixis or
Often absent
Usually absent except
Involuntary
coarse tremor
for side effects of drugs
movements
Always present
Often absent
Usually absent
Physical illness
or drug toxicity
(see Table 2)
Confusion 2010-11
Table 2: Underlying conditions commonly associated with delirium

Infections
Chest
Urinary
tract
Metabolic
Hypoxia
Fluid, electrolyte
or acid-base
disturbances
Hypo- or
hyperglycaemia
Uraemia
Endocrinopathies
(hepatic failure)
Drugs/alcohol
Therapeutic use,
abuse of, or
withdrawal from:
Alcohol
Hypnotics
Tranquillizers
Sedatives
Antidepressants
Anticholinergics
Anticonvulsants
Antiparkinsonian
agents
Oral
hypoglycaemics
Digoxin
Cimetidine
NSAIDs
CNS
Post-ictal
Head trauma
Multiple
cerebral
infarcts
Intracerebral
neoplasm
Meningitis
Miscellaneous
Sensory overload
New
environment
Constipation
Faecal
impaction
Pain
Urinary retention
Sensory
deprivation
Visual
impairment
Auditory
impairment
Miscellaneous
Myocardial
infarction
Pyrexia
Hypothermia
IMMEDIATE TREATMENT
Delirium
Environment
Nurse in quiet environment (light in the day, dark at night)
Ensure:
appropriate lighting for time of day
regular and repeated cues to improve personal orientation (at least three times daily)
clocks and calendars to improve orientation
hearing aids and glasses available and in good working order
continuity of care from nursing staff
encouragement of mobility
patient approached and handled gently
elimination of unexpected irritating noise (e.g. pump alarms)
Avoid:
physical restraints (including cot sides, geriatric chairs etc) these have not been shown to
prevent falls and can increase risk of injury it is preferable to nurse patient on a low bed or
with mattress on floor
inter- and intra-ward transfers
Relatives and friends
Family and friends, who may be able to calm patient, are encouraged to visit
Explanation of cause of confusion to relatives; encourage them to bring in familiar objects
and pictures and to participate in rehabilitation (e.g. to help with feeding and drinking)
Clinical treatment
Treat or remove underlying causes (e.g. treat infection, stop all non-essential medication,
correct hypoglycaemia/hypoxia/hypothermia)
Confusion 2010-11
Correct and/or maintain water and electrolyte balance, nutrition and vitamin supply (especially
B complex) in patients with alcohol dependence or malnutrition see Alcohol withdrawal
guideline
For alcohol withdrawal delirium see Alcohol withdrawal guideline
In malnourished patients or those with a history of ethanol abuse, in whom Vitamin B
deficiency is likely, give Strong Compound Vitamin B orally, 2 tablets 8 hrly
Regular analgesia given when needed (e.g. paracetamol)
Adequate fluid intake to avoid dehydration
Good diet, fluid intake, and mobility to avoid constipation
Good sleep pattern (milky drinks at night, exercise during day)
Avoid catheters and constipation
If patient severely disturbed and a danger to self or others see recommendations for
assessment and non-medical management in Aggressive and violent patients guideline
Drug treatment
Keep use of sedatives to a minimum
If absolutely necessary, consider sedation with lorazepam 500 microgram1 mg
(15 microgram/kg) orally/IM (max 2 mg in 24 hr) or (if no heart disease) haloperidol 500
microgram orally/IM up to 2 hrly to a maximum dose of 5 mg in 24 hr:
use one drug only, starting at lowest possible dose
ensure one-to-one nursing while dose of psychotropic medication is titrated upward in a
controlled and safe manner
do not use atypical antipsychotics (risperidone, olanzapine) in patients with dementia or
cerebrovascular disease because of increased risk of stroke
If extrapyramidal symptoms and pyrexia occur, consider neuroleptic malignant syndrome
If underlying cause of confusion has been treated, no further anti-psychotic treatment may be
necessary
If maintenance treatment required, consider haloperidol 500 microgram orally daily or 12 hrly.
Review all medication at least every 24 hr. No long-term treatment should be required in
patients with delirium
Acute functional psychosis
Neuroleptics or sedatives may be of use in patients with delusions, hallucinations or paranoia
but should not be used for insomnia, restlessness, wandering or difficult behaviour
Delirium
Further investigation:
if confusion slow to resolve, consider vitamin B 12 and folate assays, and syphilis serology,
and review diagnosis (Table 2)
Reconditioning of patient:
encourage good food, adequate fluids, bowel regulation, pain control, sufficient sleep,
avoidance of sedation and attention to appearance (clothes, shoes, teeth, spectacles, hearing
aids, hair and shaving)
Rehabilitation:
start early and be comprehensive to avoid permanent immobility, pressure sores, infections
and thromboembolic disease. Always liaise with physiotherapist, occupational therapist and
nursing staff. Where rehabilitation likely to be prolonged, refer to department of geriatric
medicine where all the resources of the multidisciplinary team are available
Dementia
For insomnia, restlessness, wandering or difficult behaviour, avoid medication
Confusion 2010-11
For psychotic symptoms (e.g. delusions, hallucinations or paranoia), use haloperidol up to a

maximum maintenance dose of 500 microgram 8 hrly
review response within two weeks with a view to reducing dose or stopping treatment
for patients requiring longer term treatment, review treatment every six months and try to
reduce or stop it
MONITORING
If change occurs, repeat assessment of mental status (see Recognition and assessment)
If sedation given, monitor respiratory rate, pulse and blood pressure
Many elderly patients will make a full recovery and can be discharged without referral to
another agency
Offer reassurance and support delirium is very unpleasant and can leave patients with
unpleasant half recollections of events and delusions
Refer to social services if community care package required or full community care
assessment needed
Consider referral to a community psychiatric nurse or a psychogeriatrician
If in patient psychiatric assessment is required, refer to the Liaison Psychiatry team.
In patients with pure delirium, stop all sedatives before discharge
For patients with established dementia, give relatives or carers contact number of
Alzheimers Disease Society ( 01625 503302) for support and leaflets
In patients with dementia and/or psychotic symptoms, keep sedation to a minimum. Ask
GP (in discharge letter) to review sedative medication two weeks after discharge and then at
least 6-monthly (aiming to reduce and eventually discontinue treatment)
For patients with a Hodkinson's abbreviated mental test score less than eight but not
previously known to have dementia, arrange review by GP to confirm or exclude a diagnosis
of dementia
If patient has history of memory problems, consider referral to Old age psychiatry or memory
clinic
Hypothermia 2010-11
HYPOTHERMIA IN OLDER PEOPLE

An older person's ability to recognise and to respond both physiologically and practically to cold
may be impaired. Hypothermia (core temperature: mild 3532C; moderate <3230C; severe
<30C) usually occurs in the presence of other acute or chronic illness, which can obscure its
diagnosis. A high level of suspicion is required. Although much more common in winter,
hypothermia can occur at any time of year
Symptoms and signs
In mild cases, patient may complain of being cold but this is not reliable
Symptoms of a precipitating condition (e.g. stroke, infection, Parkinson's disease)

Shivering may be present in mild cases but is usually absent in severe cases
Skin (abdomen, inner thigh, axilla) cold, mottled and feels like marble
Face may appear puffy and myxoedematous
Muscle rigidity, absent deep reflexes and extensor plantars may be found
Depressed respiration
Bradycardia with underlying sinus rhythm or atrial fibrillation
Hypotension
Confusional state (delirium)
Apathy
Coma when temperature <32C
Investigations
Measure core body temperature with tympanic thermometer
FBC, U&E, INR
Enzymes (CK, AST, ALT)
Serum amylase
NB: venous blood pools and may give erroneous results for the above laboratory
measurements
Blood glucose (may be high but falls during rewarming see Monitoring)
Urinalysis
Thyroid function tests
Blood culture see Collection of blood culture specimens guideline
Arterial blood gases remember to enter core temperature into analyser
ECG (may show characteristic J wave between QRS complex and ST segment, best seen in
leads II and V6, or QT c prolongation)
Chest X-ray (looking for pneumonia, aspiration, pulmonary oedema)
Consider associated/causative conditions
Hypothyroidism
Hypopituitarism
Hypoadrenalism
Stroke
Epilepsy
Parkinson's disease
Fractures
Drug overdose
Dementia
Pneumonia
Myocardial infarction
Over-sedation
Hypothermia 2010-11
Drug-induced (alcohol, barbiturates, phenothiazines, lithium, tricyclics, opioids)

Heart failure
Head injury
IMMEDIATE TREATMENT
Supportive treatment:
Special mattress (to prevent pressure sores)
If hypoxaemic, give controlled O 2 therapy see Oxygen therapy in the acutely
hypoxaemic medical patient guideline
Warming:
Nurse at room temperature of 2530C
Warm with blankets (remember to cover head and neck)
If pneumonia suspected see Community-acquired pneumonia guideline
ITU
Transfer to ITU is probably not appropriate for most older people with hypothermia unless
there are other clinical indications for this, as outcome is unlikely to be affected
Most patients will improve spontaneously without further active treatment

Avoid unnecessary interventions and movement (these can precipitate cardiac arrhythmia)
If temperature rises by >1C/hr, cool by removing blankets to maintain peripheral
vasoconstriction
Identify and treat other predisposing factors
Prognosis poor if patient fails to warm. High risk of death if temperature <30C
If re-warming fails in moderate-severe hypothermia (<32C), consultant may consider active
re-warming with forced air re-warming blanket (Bair hugger) and warm IV fluids IV fluid
warmer in A&E, or given via a heated infusion pump. Never warm IV fluids in microwave.
Observe (temperature, pulse, BP) every 15 min and with continuous cardiac monitoring
Hypothermia protects against cerebral hypoxia so continue cardiac arrest procedures for
longer than usual, if necessary until core temperature reaches 37C
Hrly (if patient requires active re-warming, every 15 min)
Core temperature with tympanic thermometer. Aim to raise by 0.51C/hr, for mild
hypothermia
For moderate to severe hypothermia aim to re-warm at 1C/hr
pyrexia after re-warming does not necessarily indicate infection
Heart rate and rhythm (continuous cardiac monitoring)
bradycardia and AV block can occur and may require temporary pacing
ventricular ectopics are suppressed by cold and may appear during warming
BP
Respiration
Glucose
treat hypoglycaemia with glucose infusion see Acute hypoglycaemia guideline
do not treat hyperglycaemia with insulin unless blood glucose persistently >30 mmol/L
insulin is ineffective in the hypothermic state and should not be used unless re-warming is
very slow
2 hrly
pH (until core temperature >35C)
If hypoxaemic or acidotic, PaCO 2
Hypothermia 2010-11
COMPLICATIONS
Paralytic ileus
Gastric dilatation
Respiratory failure
Cardiovascular collapse
Oliguria
Gastric ulceration
Pancreatitis
Consider need for elderly care or intermediate care referral for full multi-disciplinary team
assessment
Assess cognitive state immediately before discharge if cognitive impairment, advise referral
to memory clinic
If patient lives alone, ensure they can summon help by telephone or Care Line
Ensure home is adequately heated
Ensure patient and family are aware of risks of hypothermia
Constipation 2010-11
MANAGEMENT OF CONSTIPATION IN
HOSPITALISED ELDERLY PATIENTS
Enquire about usual bowel habit

If patient from nursing/residential home and unable to provide information, ensure
detailed information is obtained by requesting the Home-to-Hospital form (4 page
document)
Enquire about laxatives prescribed by GP or bought over the counter
Enquire about adverse effects from laxatives in the past
Risk factors
Constipation likely in patients who are:
immobile/less mobile than usual
drinking less fluid than usual
eating less cereal, fruit and vegetables than usual
taking prescribed codeine or iron post-operatively (e.g. orthopaedic patients)
Patients taking opioid analgesics should have laxatives prescribed routinely
IMMEDIATE MANAGEMENT
Routine nursing care
Complete bowels section on nursing sheets daily
Encourage fluids (1 L/day)
If patient usually takes prescribed laxatives, ensure these are prescribed in hospital
Toileting
Ensure toileting facilities provided safeguard privacy and dignity
Transfer to toilet, if possible
Avoid commode
Prevent inhibition
Ensure privacy
Control noise (try to locate toilets in quieter part of ward)
Ensure patient can easily summon help
make bell or button accessible and respond promptly
Control odours (use air freshener if necessary)
Bowels not open (BNO)
Follow flowchart 1
if bowels not opened for >3 days, perform digital rectal examination
if this reveals impaction, follow flowchart (evacuation disorder)
if rectum empty, follow flowchart (bowel transit disorder)
Before prescribing laxatives, carry out digital rectal examination in all patients and
document findings
Take care when using laxatives of any kind in patients with suspected intestinal
obstruction (ask for senior advice in these patients)
If haemorrhoids or anal fissure, avoid rectal preparations
In patients with inflammatory bowel disease, colitis or Crohns disease, avoid
macrogols (Movicol)
Flowchart 1 Bowels not opened for 3 days

Digital rectal
examination
Patient able to swallow
Faecal impaction
No faecal impaction
Patient unable to swallow
Stool high in rectum
Address correctable factors e.g.:

diet and fluid intake
fibre
mobility
toilet facilities
medication
Stool in rectum
Symptoms persist (over next 24 hr)

Phosphate
enema (using
long rectal tube)
and osmotic
laxative
Evacuation disorder
(patient cannot push to empty rectum)
Repeat digital rectal examination
Hard stool
Soft stool
Rectum empty
See Flowchart 2 Bowel transit

disorder
Phosphate enema
Glycerol suppository
`
No response
No response
Arachis oil
enema
Do not use
in patients
with nut
allergy
Bisacodyl suppository 10 mg
No response
Sodium citrate enema
(Micolette/Micralax/Relaxit)
No response
Phosphate enema
Not successful
Manual evacuation or washout
Oral route is preferred

Use macrogols (movicol) 8 sachets/day
dissolved in 1 L water taken over 6 hr to
treat faecal impaction
in patients with cardiovascular impairment,
2 sachets is maximum in any one hour
Can use for 3 days maximum
Once faecal impaction is resolved,

follow flowchart 2
Flowchart 2 Bowel transit disorder
Bowel transit disorder

(patient constipated but rectum
empty)
Patient not taking opioids or does

not have Parkinsons disease or
multiple sclerosis
Patient taking opioids or with

Parkinsons disease or multiple
sclerosis
Macrogols (Movicol) 1-3 sachets in

divided doses adjusted according to
response. Maximum duration of
treatment 2 weeks
Symptoms relieved no
further treatment
necessary
Symptoms continue
after taking macrogols
for 2 weeks
Prescribe other laxatives singly or, if no response, in

pairs e.g.
Sodium picosulphate liquid 510 mg at night or
Ispaghula 1 sachet 12 hrly, or
Senna 24 tablets at night, or
Bisacodyl 510 mg at night, or
Lactulose 15 mL 12 hrly (this may take up to 2448
hr to take effect), or
Docusate sodium 100 mg (up to 500 mg daily in
divided doses)
Symptoms
relieved-further
treatment is
individual to each
patient
Or in terminally ill patients ONLY*
Use dantron either as

co-danthramer 25/200 1-2 caps at night OR
co-danthramer strong 37.5/500
1-2 caps at night OR
with docusate (faecal softener) as codanthrusate 50/60 1-3 capsules at night
If patient does not respond to

the above medications or 2
of them in combination,
consider macrogols again
*To be used only in a palliative care setting
Macrogols (Movicol) 1-3 sachets in

divided doses adjusted according to
response. Can be taken >2 weeks
duration
Symptoms relieved
maintenance dose of
macrogols of 1-2
sachets daily indefinitely
Still constipated after

3 days
Prescribe other laxatives singly or, if no response,

in pairs e.g.
Sodium picosulphate liquid 510 mg at night, or
Ispaghula 1 sache12 hrly, or
Senna 24 tablets at night, or
Bisacodyl 510 mg at night, or
Lactulose 15 mL 12 hrly (this may take up to
2448 hours to take effect), or
Docusate sodium 100 mg (up to 500 mg daily in
divided doses)
Or in terminally ill patients ONLY*
Use dantron either as

co-danthramer 25/200 12 caps at night OR
co-danthramer strong 37.5/500 12 caps at
night OR
with docusate (faecal softener) as
co-danthrusate 50/60 13 capsules at night
Symptoms relieved
maintenance dose of
the effective treatment
daily indefinitely
Falls 2010-11
MANAGEMENT OF FALLS IN A&E AND WARDS

Falls are common in the elderly and may be the presenting symptom of an acute illness
Causes are generally multifactorial with a considerable overlap between falls and
syncope
It is difficult to rule out syncope because patient may have no memory of the event and
there may be no eye witness accounts
Risk factors
Gait and balance impairment
Reduced muscle strength
Reduced visual acuity
Cognitive impairment
Drugs polypharmacy, sedatives/hypnotics, antidepressants, neuroleptics, diuretics,
class 1 anti-arrhythmics, alcohol, anti-cholinergics
falls are more likely to occur in patients taking any of these agents alone, in combination,
or because of interactions with other drugs
Predisposing conditions Alzheimers disease, stroke, parkinsonism, peripheral
neuropathy, arthropathy, depression, visual impairment, cardiac failure
Environmental hazards poor lighting, loose carpets, lack of safety equipment, poorly
fitting shoes or clothes
History
Circumstances of fall
Obtain an eye witness account if possible
Ask for information that may suggest:
syncope
vertigo
dizziness
unsteadiness
seizures
Consequences of the fall
Time spent on floor
Injuries sustained
Document any risk factors
History of falls, including previous fractures
Impaired mobility
Fear of falling
Poor vision
Incontinent of urine
Confirmed dementia
Social history
Carer support
? Lives alone
Environmental hazards
Examination
Cardiovascular:
Check for postural drop (after standing for 3 min) of 20 mmHg in systolic BP or 10 mmHg
in diastolic BP. If drop confirmed, review diuretic therapy, antihypertensive medications
and major tranquillizers
Presence of arrhythmias
Structural heart disease
Heart failure
Neurological:
Evidence of head injury
Glasgow Coma Score
Vision
Muscle strength
Tone
Lower extremity peripheral nerves
Proprioception
Extrapyramidal and cerebellar function
Cognitive assessment
Hodkinsons abbreviated mental test score. See Acute confusional state in older
people
Locomotor
Evidence of hip fracture or other bony injury
Presence of muscle wasting
Leg ulcers
Deformities
INVESTIGATIONS
FBC, U&E
ECG
Urinalysis
Imaging to identify injuries or acute illness
IMMEDIATE TREATMENT (IN A&E)
Treat injuries
Acute medical problems

Commence treatment and refer to appropriate medical team (e.g. cardiology for acute MI
or stroke team for new stroke)
If patient meets Bournemouth criteria for frail elderly and requires admission, request
elderly care bed
If syncope suspected, see Syncope guideline
If no acute medical problem and patient not independently ambulant, refer to
physiotherapy. Consider referral to intermediate care team for supervision at home or, if
necessary, in an intermediate care bed
SUBSEQUENT MANAGEMENT AFTER ADMISSION

Investigations
Cardiovascular
If aortic stenosis or hypertrophic obstructive cardiomyopathy (HOCM) suspected,
echocardiogram
24 hr tape if:
bradycardia
first degree atrioventricular block
right bundle branch block (RBBB) and left axis deviation
second or third degree atrioventricular block
recurrent episode of loss of consciousness, with no features of epilepsy
Osteoporosis
History of fragility fractures or frequent falls:
bone biochemistry
TFT
if serum corrected calcium low or high, plasma parathyroid hormone (PTH)
if osteomalacia suspected, check serum vitamin D 3 (to request, consultant must
contact consultant biochemist)
Women >75 yr and men of any age with suspected osteoporosis but no history of fragility
fracture:
DEXA (bone density) scan
Perform full multifactorial assessment
Drugs
Polypharmacy, especially if patient taking one or more of the following:
cardiovascular drugs
insulin or oral hypoglycaemic agents
hypnotics
psychotropic drugs
Alcohol can increase risk of falls in elderly patients
Environment
Refer to occupational therapy
Neurovascular problems
Gait and balance refer to physiotherapy
Living arrangements
Social work referral
Specialist referral
Depending on clinical findings, refer to appropriate specialist
Recurrent falls (and fit for discharge)
Unless patient has moderate-severe dementia, refer to Elderly care OPD explaining the
results of investigations already carried out
Syncope CP 22.04.10
SYNCOPE
Definition
Transient self-limiting loss of consciousness
Usually of rapid onset and with spontaneous, complete and prompt recovery
Underlying pathology is global hypoperfusion
May be preceded by a feeling of faintness, light-headedness or muscular weakness
(presyncope); presyncope should be evaluated in the same way as true syncope
Evaluate presyncope as true syncope
Aim of assessment
Majority of patients will have made a full recovery at point of assessment with low risk of
serious adverse outcomes. Aim to identify the small proportion with a significant underlying
cause at risk of serious outcome
Principal causes
Reflex (neurally mediated) syncope
Vasovagal (simple faint)
Situational: micturation, cough, defaecation, pain, swallowing
Carotid sinus syndrome
Syncope resulting from orthostatic hypotension (>20 mmHg fall in systolic BP after 3 min
standing)
Autonomic failure
Drug-induced
Volume depletion (e.g. haemorrhage, diarrhoea, vomiting)
Cardiac syncope
Arrhythmias: bradycardia, tachycardia, implanted device failure
Structural cardiac or cardiopulmonary disease (e.g. valvular heart disease, LV outflow
obstruction, cardiac tamponade, pulmonary embolism)
Disorders with impairment or loss of consciousness
Epilepsy
Metabolic (hypoglycaemia, hypoxia, hyperventilation with hypocarbia)
Intoxication
TIAs of vertebrobasilar origin. See Transient Ischaemic attack guideline
Disorders resembling syncope without loss of consciousness
Falls. See Management of falls in A&E and wards guideline
Cataplexy
Functional: pseudosyncope, somatisation disorders
TIAs of carotid origin. See Transient Ischaemic attack guideline
History
Circumstances
Before episode (position, activity, predisposing factors or precipitating events)
Symptoms at onset of episode (nausea, aura, visual, cardiac symptoms)
Details of episode (eye-witness account, collateral history from paramedics): skin colour,
duration of loss of consciousness, breathing pattern, movements, tongue biting, etc
End of episode: confusion, muscle aches, skin colour, injury, incontinence
Syncope CP 22.04.10
Brief non-specific symptoms/signs (e.g. nausea, and diaphoresis) and brief myoclonic
jerking are common in syncope
Syncope may present as true seizure, owing to cerebral hypoperfusion
Risk factors
Previous presyncopal or syncopal episodes
Previous cardiac and medical history, family history (e.g. sudden cardiac death, epilepsy)
Medication
Occupation and driving status
Physical examination
Clinical assessment to identify serious underlying conditions (e.g. abdominal aortic aneurysm,
gastrointestinal bleed)
Vital signs at rest
Evidence of orthostatic hypotension (lying and standing BP)
Evidence of injury
MANAGEMENT IN A&E
Screening investigations
12-lead ECG
Blood tests useful only if clinically indicated (e.g. haemoglobin for suspected haemorrhage)
Blood glucose
Pregnancy test in women of childbearing age (consider ectopic pregnancy)
High-risk clinical features
Accumulation of comorbidities and age >65 yr
Admit patients with any of the following features for further evaluation:
cardiac disease: congestive cardiac failure, ischaemic or structural heart disease
haematocrit <30%
abnormal ECG (e.g. evidence of ischaemia, conduction defects or dysrhythmia)
persistently abnormal vital signs (e.g. hypotension, hypoxia)
family history of sudden cardiac death
Advise patient to:

avoid precipitating situations
maintain hydration
avoid becoming overheated
take avoiding action if warning symptoms occur
Adjust cardiovascular medication, especially in elderly patients experiencing giddy spells with
postural change and occasional syncope. Discuss with senior clinician and ensure patient
and GP receive written instructions of any adjustments
If underlying cause identified, discharge as indicated in Table
If patient not admitted, refer to appropriate clinic or back to GP
Syncope CP 22.04.10
Identified cause
Simple faint (vasovagal
episode)
Definite provocational factors
with associated prodromal
symptoms unlikely to occur
whilst sitting or lying. Benign in
nature
Loss of consciousness/loss
or altered awareness likely to
be unexplained syncope
Low risk of recurrence:
No relevant abnormality on
CVS and neurological
examination and normal ECG
High risk of recurrence:

Abnormal ECG
Clinical evidence of
structural heart disease,
sudden syncope occurring
whilst driving, sitting, lying,
on exertion or resulting in
injury >1 episode in
previous six months
Discharge and follow-up

If social circumstances
favourable, discharge
Advice on driving restrictions

as per DVLA guidelines **
Group I and II No driving
restrictions
If social circumstances
If events frequent and patient
sustained injuries, consider
referral to elderly care
team(elderly patients) or refer
to GP for follow-up
Group I can drive 4 weeks

after event
Group II can drive 3 months
after event
If high-risk clinical features

present, admit
If cardiac cause suspected,
discuss with cardiologist
Group I:
If cause identified and
treated, can drive 4 weeks
after event
If no cause identified cannot
drive for 6 months
Unwitnessed (presumed) loss Refer to first seizure clinic

of consciousness/loss or
(complete referral forms and
altered awareness with
arrange imaging as indicated)
seizure markers:
and, if social circumstances
Strong clinical suspicion of
epilepsy but no definite
evidence (see First seizure
guideline)
**Group I: cars, motorcycles, Group II: LGV, HGV etc
Group II:
If cause identified and
treated, can drive after 3
months
If no cause found, licence
revoked for one year
Group I one year revocation
Group II five year revocation
Chronic 2010-11
CHRONIC ANAEMIA
Do not use this guideline in patients presenting with acute bleeding
Definition
Haemoglobin (Hb) <13 g/dL (male) <11.3 g/dL (female)
Symptoms and signs
Shortness of breath (especially on exertion)
Weakness, lethargy
Palpitation
Headaches
Pallor of mucous membranes
Tachycardia
Features of cardiac failure
Koilonychia (suggests iron deficiency)
Jaundice (alerts to possibility of haemolytic or megaloblastic anaemia)
Evidence of infection or spontaneous bruising (alerts to possibility of marrow failure)
Abdominal or rectal mass (alerts to possibility of GI malignancy)
Patients with severe anaemia may have no symptoms or signs
Previous history
Ask about:
recent bleeds
menstrual loss
melaena
altered bowel habit
diet
family history of anaemia
Investigations
FBC and film
U&E
Liver function (non-urgent unless jaundiced)
Group and save serum
Serum ferritin ( non-urgent, but if transfusion required, take before blood transfusion)
Serum B 12 and folate (non-urgent, but if transfusion required, take before blood transfusion)
Patients admitted with chronic anaemia have often had blood tests requested via their GP.
Check with laboratory as diagnosis may have been made already
Interpretation of laboratory findings
Microcytic/hypochromic (MCV <78 fl; MCH <26 pg)
iron deficiency
anaemia of chronic disorders
Normocytic/normochromic (MCV 78100 fl; MCH >26 pg)
anaemia of chronic disorders
acute blood loss
haemolytic anaemia
bone marrow failure (e.g. leukaemia, myeloma, infiltration by carcinoma)
Chronic 2010-11
Macrocytic (MCV >100 fl)

megaloblastic (B 12 or folate deficiency)
alcohol
liver disease
IMMEDIATE TREATMENT
None required unless evidence of GI bleed (see Acute upper gastrointestinal

haemorrhage guideline), or cardiac failure (see Acute cardiac failure guideline)
Urgent transfusion is not required unless there is active bleeding
EXCESSIVE OR RAPID TRANSFUSION CAN BE HARMFUL
If blood film indicates leukaemia, discuss with on-call haematologist
Severe anaemia resulting from haematinic deficiency will have developed very slowly and
respond to oral replacement therapy, appropriate to type of anaemia
Ensure haematinic assays have been taken and received by the lab before commencing
therapy
iron deficiency ferrous sulphate 200 mg orally 8 hrly ALWAYS look for cause of blood
loss (e.g. menstrual/GI bleed)
macrocytic anaemia hydroxocobalamin 1 mg IM 3 times a week plus folic acid 5 mg daily
(until results of vitamin assays available, then omit B 12 or folate as appropriate); once need
for each vitamin confirmed, continue hydroxocobalamin 3 times weekly for total of 2 weeks
(then 1 mg every 3 months) and folic acid 5 mg daily for total of 4 months (up to 15 mg daily
in malabsorption states)
autoimmune haemolytic anaemia (AIHA) laboratory will perform direct Coombs test
(DCT) if indicated. Positive DCT indicates AIHA. Discuss with on-call haematologist give
prednisolone 60 mg orally daily
other anaemias ask for haematology opinion
If symptomatic, consider blood transfusion see flowchart
FURTHER INVESTIGATIONS
B 12 deficiency: intrinsic factor antibody, Schilling test

Folate deficiency: dietary assessment and advice
If coeliac disease a possibility, request anti-endomysial IgA
If macrocytic anaemia, discuss with consultant in charge before any transfusion
Reticulocyte count after three days

Hb weekly (should rise by 1 g/week if treatment successful)
If iron deficiency anaemia (<10 g/dL) of recent onset in males and postmenopausal females,
request GP refers on a 2 week cancer proforma, to upper GI team (if patient has dyspepsia)
or to colorectal team
In premenopausal females, refer to gastroenterology for investigation
Other anaemias: consider follow-up in haematology clinic
Chronic 2010-11
Transfusion flowchart for chronic anaemia

Hb <10 g/dL
Symptomatic acute angina?
Yes
No
Crossmatch 2 units of
bank blood
Symptoms of anaemia
Transfuse 1 unit
packed cells
and reassess see algorithm for
ordering blood
Transfuse to maximum 10 g/dL
Remains
symptomatic?
No
No transfusion
indicated at
present
No
Hb >5 g/dL?*
No
Yes
Transfuse 1 unit
packed cells and
reassess see
algorithm for ordering
blood
Transfuse to a
maximum
10 g/dL
Yes
Transfuse 1 unit
and reassess
see algorithm
for ordering
blood
Minimal
acceptable Hb
is 8 g/dL*
Yes
Transfuse 1 unit
packed cells and
reassess see
algorithm for
ordering blood
Transfuse to
maximum 10 g/dL
No transfusion
indicated at
present
Algorithm for ordering blood

Crossmatch 2 units
of bank blood
Transfuse 1 unit
Reassess symptoms
Check for signs of
pulmonary congestion
Symptoms/signs resolved
Symptoms/signs persist
Transfuse 2nd unit
Reassess
No
Yes
Stop
Clinically stable
Sickle cell 2010-11
MANAGEMENT OF SICKLE CELL DISEASE

Most common presentation of patients with sickle cell disease (SCD) is pain due to vasoocclusion (VOC). This guideline offers advice on management of VOC and some of the
complications of SCD, especially acute chest syndrome
VASO-OCCLUSIVE CRISIS
Symptoms and signs
Severe pain (usually in extremities, back or abdomen)
Dehydration
Enlarged liver or spleen
Bone pain
Low grade fever (<38C) even in absence of infection
History
Is pain similar to that of a sickle cell crisis, or is it different in any way?
Analgesia used before coming in to hospital?
Any precipitating factors infections, dehydration, stress?
Any complicating factors:
shortness of breath/cough/chest pain
headache/neurological symptoms
abdominal pain/priapism
features to indicate infection
relevant specialty to assess features of other non sickle related presentations
Previous episodes and complications
Examination
Look for:
Fever
Dehydration
SpO 2 on air and on oxygen
Chest signs
Hepatosplenomegaly
if neurological symptoms, full neurological findings
Investigations
Presence of sickle cells in blood film does not correlate with clinical events
FBC and reticulocyte count

check whether Hb and reticulocyte count similar to patients baseline. Worsening anaemia
and low reticulocyte count may indicate erythrovirus (parvovirus) -induced bone marrow
aplasia
Group and save (new patients obtain full red cell phenotype)
Biochemical screen
If fever or relevant symptoms or signs, septic screen
Only if infection or acute chest syndrome (see below) suspected, chest X-ray
Painful bones need not normally be X-rayed
IMMEDIATE TREATMENT
Analgesia
Administer first dose of analgesia within 30 min of presentation to emergency department
Sickle cell 2010-11
Non-opioid analgesia
Not all patients require opioid analgesia although many do. If no contraindications, offer the
following:
paracetamol 1 g orally 6 hrly
if well hydrated and eGFR 30 ml/min, diclofenac 50 mg orally 8 hrly or ibuprofen 400 mg
orally 8 hrly
dihydrocodeine 3060 mg orally 46 hrly (max 240 mg in 24 hr)
Review doses in presence of renal impairment
Opioids in opioid nave patients
If weight 50 kg, morphine 2.5 mg SC up to every 2 hr
If weight >50 kg, morphine 5 mg SC up to every 2 hr
Opioids in patients using opiates/opioids regularly
May require higher doses (e.g. morphine 510 mg SC up to every 2 hr or equivalent dose of
diamorphine or other alternatives)
pethidine no longer recommended for sickle vaso-occlusive pain
Monitoring
Reassess response in 1 hr and consider repeating/increasing dosage according to efficacy
Monitor patients receiving opioid analgesia at least hrly
Fluid replacement
Replace fluid orally if possible. Venous access often difficult in patients with SCD: reserve for
situations where oral intake inadequate or inappropriate (e.g. vomiting)
if unable to give orally, glucose (4%) and sodium chloride (0.18%) 1 L by IV infusion over 3
hr; then glucose (4%) and sodium chloride (0.18%) with potassium chloride 20 mmol/L 1L by
IV infusion every 6 hr
Always use commercially produced pre-mixed bags of infusion fluid and potassium
chloride. NEVER add potassium chloride to infusion bags
Avoid using veins in ankles/feet for venous access; cannulation carries high risk of leg
ulceration. Avoid central lines as carry high complication rate
Blood transfusion
Indications for blood transfusion in sickle cell disease are very specific (see below) discuss
all cases with haematologist
Oxygen therapy
If SpO 2 <95%, give O 2 see Oxygen therapy in acutely hypoxaemic patients guideline
Antibiotics
Continue prophylactic antibiotics; penicillin V 250 mg orally 12 hrly. If penicillin allergy,
erythromycin 250 mg orally 12 hrly
For patients with evidence of infection antibiotics as per trust policy. See appropriate
guideline for type of infection
Other
Thromboprophylaxis unless contraindicated. See Prophylaxis against venous
thromboembolism
Sickle cell 2010-11
Painful crises usually last about one week

Once pain controlled, reassess analgesic regimen daily and taper dosage gradually,
changing to oral morphine as dosage reduced (1 mg SC diamorphine = 3 mg oral morphine)
If Hb falls below 5 g/dL, especially if reticulocyte count also decreased, blood transfusion is
likely to be indicated discuss with haematologist
Respiratory rate hrly after opioid started for evidence of respiratory suppression
Pulse oximetry
Fluid balance
U&E for dilutional hyponatraemia
Consider visual analogue scale to record pain intensity and response to analgesia
ACUTE CHEST SYNDROME

Definition
Commonest severe/life-threatening acute illness and main cause of mortality characterised
by fever, respiratory symptoms and new pulmonary infiltrates on chest X-ray
Discuss patients with suspected acute chest syndrome urgently with consultant
haematologist
Clinical features
Pain in chest wall, upper abdomen, and/or thoracic spine
Signs of lung consolidation, usually bilateral and generally starting at bases. Upper and
middle lobe consolidation without basal changes is suggestive of chest infection rather than
sickle acute chest syndrome
Fever
Tachypnoea
Tachycardia
Cough may be a late symptom (dry or fluorescent yellow sputum)
Physical signs may precede X-ray findings
Special investigations
Arterial blood gases on air
Chest X-ray
Blood cultures, sputum cultures, respiratory acute serology, BAL/NPA/nose-throat swab in
viral transport medium for respiratory pathogens PCR
Monitor saturations on and off inhaled oxygen
Group and save
Management
IV fluids
Always use IV fluids. See Fluid resuscitation and Maintenance fluid therapy guidelines for
regimen dependent on patients clinical condition
Avoid fluid overload
Broad spectrum antibiotics
Sickle cell 2010-11
First line
Assume penicillin allergy only if convincing history of either rash within
72 hr of dose or anaphylactic reaction. If any doubt about whether patient truly allergic to
penicillin, seek advice from a microbiologist (4666) or a consultant in infectious diseases
(2299)
Amoxicillin 500 mg IV 8 hrly
Clarithromycin 500 mg IV by infusion into large
plus
clarithromycin 500 mg IV by infusion into
plus
large proximal vein
gentamicin see Prescribing regimens and
12 hrly
nomograms
As soon as oral route available:
amoxicillin 500 mg orally or via NG/PEG
tube 8 hrly
plus
clarithromycin 500 mg orally or via NG/PEG
tube 12 hrly
Clarithromycin 500 mg orally or via NG/PEG

tube 12 hrly
Respiratory support
In patients with rib/thoracic spine pain, incentive spirometry may reduce incidence of acute
chest syndrome by encouraging maximal inspiration discuss with physiotherapist
(alternatively, encourage patient to take 10 maximal inspirations every hr)
Nebulised salbutamol 2.5 mg 6 hrly
If significant hypoxia, monitor patient closely and consider CPAP. In severe cases ventilation
may be required
Blood transfusion
If worsening hypoxia and respiratory distress, urgent exchange or top-up transfusion may be
needed. Discuss early with consultant haematologist
Target Hb 10 g/dL, HbS <30%
Cross-match required amount of blood as packed cells
Establish venous access if not already available
If Hb <5 g/dL, transfuse packed cells until Hb 910 g/dL
If Hb 5 g/dL, organise an exchange transfusion see Exchange transfusion below.
Discuss with haematologist
Cross-match blood for transfusion for ABO, Rh and Kell antigens, sickle negative
OTHER COMPLICATIONS
(Discuss with consultant haematologist)
Priapism
Painful prolonged reaction with/without prior sexual stimulus. This is an emergency, involve
urologist early as penile aspiration/irrigation may be necessary. In some instances shunt
procedures are needed
Stroke
A major complication of SCD more common in children
Ischaemic stroke is more common in children, whereas haemorrhagic stroke is more common
in adults
Investigations:
CT scan of head to confirm whether ischaemic or haemorrhagic
MR scan of brain to delineate area of ischaemia/haemorrhage
Carotid Doppler ultrasound scan
Urgent review by neurologist and exchange transfusion to reduce HbS <30%
Sickle cell 2010-11
Splenic sequestration
More common in infants and children and often associated with sepsis
Clinical features:
rapidly enlarging, painful spleen
anaemia may present with shock
fall in Hb of 2 g/dL from baseline
Management
Resuscitate and treat shock
Emergency (top-up) transfusion: to baseline Hb
Broad spectrum antibiotics (e.g. benzylpenicillin) to cover pneumococcus and haemophilus
Hepatic sequestration
Acute tender hepatomegaly and anaemia. Manage with a top-up transfusion to baseline Hb
Gallstone complications
Common in this patient population. Manage as any other patient
BLOOD TRANSFUSION
May be simple top-up or exchange transfusion
Top-up transfusion
Indications
Severe anaemia (Hb <4.5 g/dL) owing to:
hepatic or splenic sequestration
red cell aplasia or haemolysis
severe anaemia when decrease in Hb >20% from baseline in a symptomatic patient (heart
failure, dyspnoea, hypotension and marked fatigue)
transfuse to baseline Hb
Consider when exchange transfusion indicated and starting Hb <5 g/dL. Discuss with
Exchange transfusion
Indications
Severe chest syndrome
New ischaemic stroke
Multi-organ failure
Consider in priapism
Do not initiate exchange transfusion before discussing with on-call consultant
haematologist
Targets
To reduce HbS to <30%
To maintain Hb <13.0 g/dL Note: haematocrit of donor blood is approximately double that
of patient
To maintain steady blood volume throughout procedure
Venous access
Ideally, identify two ports for venous access; one for venesection, the other for transfusion. In
emergency, it is often advisable to use a central line, or arterial line (e.g. on ITU)
Exchange transfusion must be performed isovolaemically (equal quantities in and out)
Ensure patient well hydrated before exchange
Sickle cell 2010-11
prehydrate with sodium chloride 0.9% 500 mL as first 500 mL of blood is being removed, then
give sodium chloride 0.9% 500 mL concurrently
do not remove blood until venous access for transfusion is secure
continue to administer IV fluids between transfusions at standard rate of 3 L/m2/24 hr
See Administration of blood and blood components guideline
Method
Usually requires at least 2 exchanges, each of 4 units venesected and 4 units transfused
Venesect 500 mL of blood and simultaneously infuse 500 mL sodium chloride 0.9% (at same
speed as the bleeding)
As second 500 mL (and subsequent units) venesected, transfuse first unit of blood over
12 hr
Venesect 500 mL and replace with blood and sodium chloride 0.9% five more times (discuss
in advance with consultant)
Check interim Hct and Hb
A simple top-up transfusion may be required following isovolaemic exchange transfusion
Post-RBC exchange FBC and Hct
Discharge home when pain controlled by oral medication

Provide three to four days supply of analgesia
Do not prescribe parenteral opioids TTO
Bleeding disorders 2010-11
BLEEDING DISORDERS IN ADULTS

All patients with inherited bleeding disorders possess a medical card identifying their
condition and severity. To confirm diagnosis, severity and treatment, contact main
blood bank Contact haematology medical staff for advice regarding management even
if no treatment deemed necessary
Definition
Inherited bleeding disorders occur because of:
Factor VIII deficiency (Haemophilia A)
Factor IX deficiency (Haemophilia B)
von Willebrand factor deficiency (vW disease)
Hereditary intrinsic platelet defects (rare)
Deficiency of other coagulation factors (rare)
Haemophilia A and B; severity depends on baseline plasma concentration of Factor

VIII/IX expressed as a percentage of normal:
mild (640%) muscle and joint bleeds, usually following trauma
moderate (15%) muscle and joint bleeds, usually following trauma
severe (<1%) spontaneous joint and muscle bleeds
Presentation
Haemophilia A or B
Haemophilia A and B display X-linked inheritance and occur almost exclusively in men.
Most patients with haemophilia A or B present as muscle or joint bleeds:
minor bleeds usually present with pain and slight restriction of movement with minimal or
no joint swelling
major bleeds present with severe pain/tenderness with marked swelling and restriction of
movements of the joint
in the event of head injury or suspected intracranial bleed, administer appropriate factor
concentrate immediately and arrange urgent CT of head. Do not wait for scan before
starting treatment
be alert for a major bleed into psoas muscle
von Willebrands disease
Affects men and women, and presents with:
gum/mucosal bleeds
frequent and prolonged epistaxis
menorrhagia
easy bruising
IMMEDIATE TREATMENT
Treat all bleeds without delay delayed treatment results in increased need for treatment
and risk of irreversible complications
Treatment of significant bleeds usually involves administration of clotting
factors/desmopressin:
in Haemophilia A: recombinant Factor VIII, (Advate, Refacto, Kogenate) or desmopressin
in Haemophilia B: recombinant Factor IX, (Benefix)
in von Willebrands disease: plasma-derived vW factor (Haemate P) or desmopressin
Haemophilia A
Minor muscle or joint bleed
In mild/moderate haemophilia A, consider IV desmopressin
if patient has baseline Factor VIII >10% and is aged 260 yr with no history of
hypertension or ischaemic heart disease, give desmopressin 0.3 microgram/kg IV in
50 mL sodium chloride 0.9% over 20 min (warn patient that flushing and headache may
occur and advise to restrict fluid intake to 1 L during next 24 hr)
if patient does not meet these criteria, give Factor VIII concentrate to raise Factor VIII to
3050%
In severe haemophilia A, give Factor VIII concentrate to raise factor percentage to 30
50%, usually by single injection
Major muscle/joint bleed or head injuries

Admit patient and inform on-call haematology medical staff
In haemophilia A of any severity, give Factor VIII concentrate to raise percentage to
50100%
rest joint for at least one day, prescribe appropriate analgesia
check for neurological deficit (femoral nerve in a psoas bleed, median nerve compression
in carpal tunnel with a forearm bleed)
In event of head injury or suspected intracranial bleed, administer Factor VIII concentrate
immediately and arrange urgent CT scan of head. Do not wait for scan before starting
treatment
Further therapy requires monitoring of factor percentage with advice from haematology
team
repeated doses of Factor VIII concentrate usually given at 12 hrly intervals
Haemophilia B
Desmopressin has no role in treating haemophilia B
Minor muscle or joint bleeds
Give Factor IX concentrate to raise percentage to 3050%
Major muscle/joint bleeds or head injuries
Admit patient and inform on-call haematology medical staff
In haemophilia B of any severity, give Factor IX concentrate to raise percentage to
5080%
rest joint for at least one day and prescribe appropriate analgesia
check for neurological deficit (femoral nerve in a psoas bleed, median nerve compression
in carpal tunnel with a forearm bleed)
In event of head injury or suspected intracranial bleed, administer Factor IX concentrate
immediately and arrange urgent CT scan of head. Do not wait for scan before starting
treatment
Further therapy requires monitoring of factor percentage with advice from haematology
team
repeated doses of Factor IX concentrate usually given once daily
Patients with von Willebrands disease or hereditary platelet disorders
Discuss with on-call haematology medical staff
Patients with Type 1 disease usually respond well to desmopressin but non-responders
will require treatment with Haemate-P
Patients with Type 2 and 3 disease require vW factor concentrate
Use local measures to stop bleeding (e.g. nasal packing, etc)
Give tranexamic acid 1 g orally 8 hrly
Consider desmopressin
if patient aged 260 yr with no history of hypertension or ischaemic heart disease, give
desmopressin 0.3 microgram/kg IV in 50 mL sodium chloride 0.9% over 20 min (warn
patient that flushing and headache may occur and advise to restrict fluid intake to 1 L
during next 24 hr)
Patients with other coagulation factor deficiencies or other bleeding manifestations
Contact on-call haematology consultant/SpR
USE OF COAGULATION FACTOR CONCENTRATES
Coagulation factor concentrates are available from hospital blood bank

Before initiating treatment, discuss management with Dr Hudson (during working hours;)
or on-call haematology medical staff to decide:
factor concentrate required, dose, frequency and duration of treatment
monitoring of pre- and post-infusion percentages (if required)
Document use of any factor concentrate (including dose and time given) on treatment
chart
If admitted, all patients need careful monitoring to ensure bleeding has stopped
Calculation of factor dose

Give individual patients same brand of concentrate each time treatment is required
(information in medical notes or in blood bank)
Step 1: calculate factor (%)

increase required = desired factor percentage baseline factor percentage of
patient
Step 2: calculate dose of specific factor required

a) For Factor VIII concentrates (Advate, Kogenate, Refacto)
dose required (in units) = body weight (kg) factor (%) increase required
2
b) For Factor IX concentrate (Benefix)
dose required (in units) = body weight (kg) factor (%) increase required 1.2
c) For vW Factor concentrate (Haemate P)

dose required (in units) = weight (kg) RIC* (%) increase required
3
* Ristocetin co-factor activity
Reconstitution of factor concentrate
Always wear gloves
Check dosage of factor to be given and select number of bottles of appropriate

concentrate required
Most factor concentrates are provided in packs with:
concentrate powder
diluent in syringe
vial adapter for transfer of diluent
infusion set
Read instructions carefully before reconstituting factor incorrect reconstitution may
result in wastage of expensive concentrate. If in doubt, seek advice from haematology
Transfer diluent in dried concentrate vial via a needleless adapter
Ensure no concentrate remains undissolved
Draw up concentrate into a syringe
Administer concentrate via butterfly needle over 25 min
Allergic reactions are uncommon. If reaction occurs, treat with chlorphenamine +/hydrocortisone
Discard all bottles and needles into sharps bin
Record dose administered and date and time in patient notes and treatment chart
Return any unused concentrate (even if pack opened) to hospital blood bank
SUBSEQUENT MANAGEMENT, DISCHARGE AND FOLLOWUP
All haemophilia patients admitted with a bleed must be reviewed by haematology team on
following working day
2010-11
ACID-BASE DIAGRAM
Aminophylline 2010-11
AMINOPHYLLINE
INDICATIONS
Acute severe asthma

Reversible airways obstruction
DOSAGE
Loading
In order to avoid risk of fatal overdose, give loading dose only if patient has NOT received
oral theophylline/aminophylline within last 24 hr
250500 mg (5 mg/kg lean body weight) IV by infusion over 2030 min

calculate lean body weight using formula for ideal body weight in Gentamicin guideline
Dilute in 100 mL bag of diluent (see Diluents)
Monitor heart rate continuously during infusion
Maintenance
Appropriate drug concentration and infusion rate are determined by body weight, concurrent
medical problems, drug therapy and smoking history
For obese patients (actual body weight >120% ideal body weight), use ideal body weight
(IBW). To calculate IBW see Prescribing regimens and nomograms Gentamicin
guideline
For patients with markedly reduced clearance* (disregard smoking status) give 0.25
mg/kg/hr
*Patients with liver failure, heart failure or those taking ciprofloxacin, cimetidine or fluvoxamine
Add 250 mg (10 mL) to 500 mL of diluent after first removing 10 mL from the bag
Concentration = 250 mg in 500 mL = 0.5 mg/mL
Table 1: Infusion rate (mL/hr) for a range of body weights (dosage 0.25 mg/kg/hr)
Dosage
Weight (kg)
mg/kg
40
45
50
55
60
65
70
75
80
85
90
95
per hr
20
23
25
28
30
33
35
38
40
43
45
48
0.25
For adult non-smokers and ex-smokers >3 months give 0.5 mg/kg/hr
Concentration = 250 mg in 500 mL = 0.5 mg/mL
Dosage
Weight (kg)
mg/kg
40
45
50
55
60
65
70
75
80
85
90
95
per hr
40
45
50
55
60
65
70
75
80
85
90
95
0.5
For adult smokers give 0.9 mg/kg/hr
Concentration = 500 mg in 500 mL = 1 mg/mL
Aminophylline 2010-11
Dosage
Weight (kg)
mg/kg
40
45
50
55
60
65
70
75
80
85
90
95
per hr
36
41
45
50
54
59
63
68
72
77
81
86
0.9
MONITORING
If loading dose given, monitor heart rate continuously throughout infusion and check serum
potassium 12 hr after dose
Monitor serum theophylline 46 hr after starting maintenance infusion (to anticipate toxicity)
and again after 24 hr (to check steady-state concentration)
Draw samples from opposite arm to that receiving infusion. Target range = 1020 mg/L.
Adjust maintenance dosage of aminophylline according to plasma theophylline concentration
(relationship is linear, so doubling dosage will double steady-state concentration)
Monitor serum potassium daily while infusion continues
There are several medications that may increase or decrease theophylline concentration.
Always check in current BNF, Appendix 1 for full list of interactions. Clearance of
theophylline may be reduced (e.g. serum concentration increased) in the elderly, and in
patients with cirrhosis, viral infection or prolonged fever
PREPARATIONS
Aminophylline injection = 25 mg/mL, 10 mL ampoules
DILUENTS
Sodium chloride 0.9%, glucose 5% or compound sodium lactate (Hartmanns) solution
ACE 2010-11
INTRODUCTION OF AN ANGIOTENSINCONVERTING ENZYME (ACE) INHIBITOR

INDICATIONS
Congestive heart failure

Post Myocardial Infarction
Hypertension
CONTRAINDICATIONS
Known or suspected bilateral renal artery stenosis

History of hypersensitivity to ACE inhibitors
Pregnancy
CAUTIONS
Severe aortic stenosis

Renal impairment
Concomitant use of potassium sparing diuretics
Concurrent use of NSAID
IN-PATIENT PROCEDURE
Initiate ACE inhibitor therapy under close clinical supervision in patients who are taking high
doses of diuretics or a low sodium diet, or who are dehydrated
Check renal function and electrolytes before starting therapy. It is unwise to introduce an ACE
inhibitor if serum creatinine is >300 mol/L. If serum creatinine 150300 mol/L, a lower
dosage may be appropriate
In order to avoid dangerous hyperkalaemia, review need for any potassium-sparing agent or
potassium supplement, and stop if possible
Congestive heart failure

Profound first-dose hypotension may occur in patients with heart failure who are already
taking a high dose of a loop diuretic (e.g. furosemide 80 mg daily or higher). To help prevent
this, omit or reduce morning dose of diuretic before first dose of ramipril (but watch for
rebound pulmonary oedema)
Ensure patient is supine. Give first dose of ramipril, 1.25 mg orally
Monitor BP every 15 min for first hr, then every 30 min for a further 2 hr
On following day, if first dose of ramipril tolerated (no symptomatic fall in BP and systolic BP
not less than 90 mmHg) and serum creatinine <150 mol/L, start maintenance dosage of
ramipril 2.5 mg orally daily. Restart/continue diuretic
Monitor BP every 4 hr (during the day) for 24 hr, then daily if stable
Recheck renal function 48 hr after starting therapy. If no deterioration and BP stable, increase
dose of ramipril to 5 mg orally daily (continue 2.5 mg orally daily if serum creatinine >150
mol/L)
Recheck renal function 48 hr after increasing dosage
Myocardial infarction
In normotensive/hypertensive patients, start treatment within 24 hr of infarction if there are no
contraindications
Give ramipril 2.5 mg orally 12 hrly for two days. If serum creatinine >150 mol/L, start with
1.25 mg orally 12 hrly for two days and recheck renal function
If renal function satisfactory, double dose to 5 mg orally 12 hrly or 2.5 mg orally 12 hrly
ACE 2010-11
If treatment not tolerated (symptomatic fall in BP or BP <90 mmHg), reduce dose by half.
Continue only if patient tolerates a maintenance dose of at least 2.5 mg orally 12 hrly (1.25
mg in elderly or in patients with serum creatinine >150 mol/L)
Recheck renal function 48 hr after starting therapy
Digoxin 2010-11
DIGOXIN
INSTRUCTIONS FOR USING NOMOGRAM
The nomogram for digoxin dosage provides a loading (L) and maintenance dose (M) for an adult
patient whose plasma creatinine (A), age (B), and body weight (D) are known. To use, join A to B
with a line that crosses C; then join this intercept on C to D with a line that crosses M and L. Note
that M indicates the number of tablets to be prescribed as a single daily dose from day 2, and L
indicates the total number of tablets to be taken on day 1 (if the loading recommendation is 3
tablets 250 microgram, it is usual to give two immediately followed by the third 6 hours later)
Do not give loading dose if patient currently taking digoxin, and consider reducing recommended
loading dose if digoxin (or other cardiac glycoside) given in preceding 2 weeks
Specific circumstances
In elderly patients with reduced muscle mass, serum creatinine may be artificially low and will
not reflect renal function. Assume a value of 100 mol/L for A in such patients
In obese patients, body weight will not reflect distribution volume of digoxin. Use ideal body
weight calculated from height (see Prescribing regimens and nomograms Gentamicin
guideline) for D in such patients
Nomogram reproduced from the original devised by Prof George Mawer, with permission
MONITORING
Indications for measurement
To question need for continued treatment in patients with sinus rhythm
To monitor effect of concurrent disease or drug treatment
To confirm diagnosis of suspected toxicity, and to aid dose reduction
To investigate suspected treatment failure or non-compliance
Sampling
Steady state is not achieved until one to three weeks after starting therapy or changing the
dosage, depending on patient's renal function
Digoxin 2010-11
Take samples at least 6 hr post-dose. It is often easier to sample immediately before a dose
is due
Target range
0.82.0 microgram/L
concentrations <0.8 microgram/L have no useful inotropic effect
Sensitivity to digoxin is affected by thyroid function, oxygen saturation, and serum
concentrations of potassium and calcium. Sensitivity is increased by hypothyroidism, hypoxia,
hypokalaemia and hypercalcaemia, and decreased by hyperthyroidism and hyperkalaemia.
This should be taken into account when interpreting individual serum digoxin concentrations
in relation to the target range. Decisions about dosage adjustment should always consider
the clinical effect of the drug as well as the serum concentration
In atrial fibrillation, once treatment is established, ventricular rate is the best guide to the
appropriate dosage for patients taking digoxin alone for rate control
Dobutamine 2010-11
DOBUTAMINE HYDROCHLORIDE
INDICATIONS
Inotropic support in low output cardiac failure associated with myocardial infarction,
cardiogenic shock
Administer dobutamine via a central venous cannula wherever possible. If it must be given
peripherally, use a large vein, preferably in the arm
DOSAGE
By continuous IV infusion 2.510 microgram/kg per min, adjusted according to response.

Monitor heart rate and rhythm, BP, cardiac output (if possible), and urine output. If no
response, seek advice of cardiology team before increasing dose further
NOTES
IV solutions prepared as below are stable for 24 hr at room temperature. The solutions may
turn pink and the colour may intensify with time, owing to slight oxidation of the drug, but
there is no significant potency loss over 24 hr
The 2 mg/mL solution is preferable where dobutamine is being infused via a peripheral vein
When withdrawing treatment, decrease dosage gradually by small decrements according to
response, rather than discontinuing therapy abruptly
PREPARATIONS
Dobutamine hydrochloride 250 mg in 20 mL vials
DILUENTS
Sodium chloride 0.9% or glucose 5%

Dobutamine hydrochloride is incompatible with sodium bicarbonate and other strongly
alkaline solutions
Infusion via syringe pump

See Table 1 for dosage and corresponding pump rate
Using a 50 mL syringe make up 250 mg dobutamine (20 mL) to 50 mL with diluent (see
Diluents) = 5 mg/mL = 5000 microgram/mL
Table 1: Infusion via syringe pump (flow rate mL/hr)
Dosage
microgram/
kg per min
2
3
4
5
6
7
8
9
10
12
14
16
18
20
25
30
35
40
Weight (kg)
45
1.1
1.6
2.2
2.7
3.2
3.8
4.3
4.9
5.4
6.5
7.6
8.6
9.7
10.8
13.5
16.2
18.9
21.6
50
1.2
1.8
2.4
3
3.6
4.2
4.8
5.4
6
7.2
8.4
9.6
10.8
12
15
18
21
24
55
1.3
2
2.6
3.3
4
4.6
5.3
5.9
6.6
7.9
9.2
10.6
11.9
13.2
16.5
19.8
23.1
26.4
60
1.4
2.2
2.9
3.6
4.3
5
5.8
6.5
7.2
8.6
10.1
11.5
13
14.4
18
21.6
25.2
28.8
65
1.6
2.3
3.1
3.9
4.7
5.5
6.2
7
7.8
9.4
10.9
12.5
14
15.6
19.5
23.4
27.3
31.2
70
1.7
2.5
3.4
4.2
5
5.9
6.7
7.6
8.4
10.1
11.8
13.4
15.1
16.8
21
25.2
29.4
33.6
75
1.8
2.7
3.6
4.5
5.4
6.3
7.2
8.1
9
10.8
12.6
14.4
16.2
18
22.5
27
31.5
36
80
1.9
2.9
3.8
4.8
5.8
6.7
7.7
8.6
9.6
11.5
13.4
15.4
17.3
19.2
24
28.8
33.6
38.4
85
2
3.1
4.1
5.1
6.1
7.1
8.2
9.2
10.2
12.2
14.3
16.3
18.4
20.4
25.5
30.6
35.7
40.8
90
2.2
3.2
4.3
5.4
6.5
7.6
8.6
9.7
10.8
13
15.1
17.3
19.4
21.6
27
32.4
37.8
43.2
95
2.3
3.4
4.6
5.7
6.8
8
9.1
10.3
11.4
13.7
16
18.2
20.5
22.8
28.5
34.2
39.9
45.6
100
2.4
3.6
4.8
6
7.2
8.4
9.6
10.8
12
14.4
16.8
19.2
21.6
24
30
36
42
48
105
2.5
3.8
5
6.3
7.6
8.8
10.1
11.3
12.6
15.1
17.6
20.2
22.7
25.2
31.5
37.8
44.1
50.4
110
2.6
4
5.3
6.6
7.9
9.2
10.6
11.9
13.2
15.8
18.5
21.1
23.8
26.4
33
39.6
46.2
52.8
Dobutamine 2010-11
Minibag infusion via controlled-infusion device

See Table 2 for dosage and corresponding infusion rate
Withdraw 40 mL from a 250 mL bag of diluent (see Diluents). Add two 250 mg vials of
dobutamine (40 mL) to the bag and mix well.
500 mg in 250 mL = 2 mg/mL = 2000 microgram/mL
Table 2: Minibag infusion via controlled-infusion device (flow rate mL/hr)
Dosage
microgram/
kg per min
2
3
4
5
6
7
8
9
10
12
14
16
18
20
25
30
35
40
Weight (kg)
45
50
55
60
65
70
75
80
85
90
95
100
105
110
3
4
5
7
8
9
11
12
14
16
19
22
24
27
34
41
47
54
3
5
6
8
9
11
12
14
15
18
21
24
27
30
38
45
53
60
3
5
7
8
10
12
13
15
17
20
23
26
30
33
41
50
58
66
4
5
7
9
11
13
14
16
18
22
25
29
32
36
45
54
63
72
4
6
8
10
12
14
16
18
20
23
27
31
35
39
49
59
68
78
4
6
8
11
13
15
17
19
21
25
29
34
38
42
53
63
74
84
5
7
9
11
14
16
18
20
23
27
32
36
41
45
56
68
79
90
5
7
10
12
14
17
19
22
24
29
34
38
43
48
60
72
84
96
5
8
10
13
15
18
20
23
26
31
36
41
46
51
64
77
89
102
5
8
11
14
16
19
22
24
27
32
38
43
49
54
68
81
95
108
6
9
11
14
17
20
23
26
29
34
40
46
51
57
71
86
100
114
6
9
12
15
18
21
24
27
30
36
42
48
54
60
75
90
105
120
6
9
13
16
19
22
25
28
32
38
44
50
57
63
79
95
110
126
7
10
13
17
20
23
26
30
33
40
46
53
59
66
83
99
116
132
Dopamine 2010-11
DOPAMINE HYDROCHLORIDE
INDICATIONS
Management of cardiac failure after acute myocardial infarction (MI)
Administer dopamine through a central line, if available. If dopamine has to be given

through a peripheral line, use a large vein high up in a limb, preferably the arm, in order to
reduce risk of tissue necrosis. Watch I.V. site closely
DOSAGE
Management of cardiac failure after acute MI

start with 2 microgram/kg per min by continuous IV infusion via as large a vein as possible
increase following Table 1 or 2 up to 5 microgram/kg per min if required. An IV infusion pump
is essential for controlling infusion rate
Monoamine oxidase inhibitors (MAOIs) potentiate effects of dopamine and its duration of
action. Patients who have been treated with an MAOI (phenelzine, isocarboxazid,
tranylcypromine, moclobemide) within the last two weeks should be given one-tenth of the
usual starting dose.
Dopamine given at rates above 5 microgram/kg per min causes vasoconstriction, which
can reduce renal perfusion and worsen heart failure
NOTES
The 2 mg/mL solution is preferable where dopamine is being infused via a peripheral vein.
Reserve 4 mg/mL solution for infusion via a central line
Extravasation of dopamine at the infusion site can cause local vasoconstriction, which may
lead to tissue necrosis and sloughing. Inspect infusion site regularly for signs of irritation or
vasoconstriction. Ischaemia can be reversed by infiltrating phentolamine mesylate 510 mg in
1015 mL of sodium chloride 0.9%. Use a syringe with a fine hypodermic needle to infiltrate
the area liberally as soon as extravasation is noted
Do not use ampoules of dopamine if solution is darker than slightly yellow, or discoloured in
any other way
PREPARATIONS
Dopamine hydrochloride 40 mg/mL in 5 mL ampoules (200 mg)
DILUENTS
Sodium chloride 0.9% or glucose 5% (higher risk of tissue necrosis)

Dopamine is inactivated by sodium bicarbonate 5% and alkaline solutions
ADMINISTRATION VIA SYRINGE PUMP

For 2 mg/mL solution (preferable for infusion via a peripheral vein)
Take 2.5 mL (100 mg) of dopamine hydrochloride solution and make up to 50 mL with diluent
(see Diluents) in a 50 mL syringe. The diluted solution is stable for 24 hr
Concentration = 100 mg in 50 mL = 2 mg/mL (2000 microgram/mL)
Dopamine 2010-11
Table 1: Flow rate (mL/hr) for dopamine hydrochloride infusion (2 mg/mL)

Dosage
microgram/
kg per min
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Weight (kg)
45
0.7
1.4
2
2.7
3.4
4.1
4.7
5.4
6.1
6.8
50
0.8
1.5
2.3
3
3.8
4.5
5.3
6
6.8
7.5
55
0.8
1.7
2.5
3.3
4.1
5
5.8
6.6
7.4
8.3
60
0.9
1.8
2.7
3.6
4.5
5.4
6.3
7.2
8.1
9
65
1
2
2.9
3.9
4.9
5.9
6.8
7.8
8.8
9.8
70
1.1
2.1
3.2
4.2
5.3
6.3
7.4
8.4
9.5
10.5
75
1.1
2.3
3.4
4.5
5.6
6.8
7.9
9
10.1
11.3
80
1.2
2.4
3.6
4.8
6
7.2
8.4
9.6
10.8
12
85
1.3
2.6
3.8
5.1
6.4
7.7
8.9
10.2
11.5
12.8
90
1.4
2.7
4.1
5.4
6.8
8.1
9.5
10.8
12.2
13.5
95
1.4
2.9
4.3
5.7
7.1
8.6
10
11.4
12.8
14.3
100
1.5
3
4.5
6
7.5
9
10.5
12
13.5
15
For 4 mg/mL solution (infuse via a central line only)

Take 5 mL (200 mg) of dopamine hydrochloride solution and make up to 50 mL with diluent
(see Diluents) in a 50 mL syringe. The diluted solution is stable for 24 hr
Concentration = 200 mg in 50 mL = 4 mg/mL (4000 microgram/mL)
Table 2: Flow rate (mL/hr) for dopamine hydrochloride infusion (4 mg/mL)
Dosage
microgram/
kg per min
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Weight (kg)
45
0.3
0.7
1
1.4
1.7
2
2.4
2.7
3
3.4
50
0.4
0.8
1.1
1.5
1.9
2.3
2.6
3
3.4
3.8
55
0.4
0.8
1.2
1.7
2.1
2.5
2.9
3.3
3.7
4.1
60
0.5
0.9
1.4
1.8
2.3
2.7
3.2
3.6
4.1
4.5
65
0.5
1
1.5
2
2.4
2.9
3.4
3.9
4.4
4.9
70
0.5
1.1
1.6
2.1
2.6
3.2
3.7
4.2
4.7
5.3
75
0.6
1.1
1.7
2.3
2.8
3.4
3.9
4.5
5.1
5.6
80
0.6
1.2
1.8
2.4
3
3.6
4.2
4.8
5.4
6
85
0.6
1.3
1.9
2.6
3.2
3.8
4.5
5.1
5.7
6.4
90
0.7
1.4
2
2.7
3.4
4.1
4.7
5.4
6.1
6.8
Withdraw dopamine gradually, monitoring for hypotension
95
0.7
1.4
2.1
2.9
3.6
4.3
5
5.7
6.4
7.1
100
0.8
1.5
2.3
3
3.8
4.5
5.3
6
6.8
7.5
Doxapram 2010-11
DOXAPRAM
INDICATIONS
Ventilatory failure see Respiratory failure guideline for consideration of non-invasive

ventilation
DOSAGE
Supervise patients carefully during administration of doxapram

Give doxapram by continuous IV infusion
Ensure oxygen is given concurrently
NOTES
Doxapram increases heart rate and BP, which should be monitored. It can also cause CNS
stimulation and tremor, which can become intolerable and prevent increase of dosage to the
optimal level
Doxapram is incompatible with drugs in alkaline solution such as furosemide and
aminophylline
PREPARATIONS
IV infusion doxapram hydrochloride 2 mg/mL in glucose 5% 500 mL

The regimen in Table 1 rapidly produces a steady-state plasma concentration of doxapram
Table 1: Regimen to attain steady-state plasma concentration of doxapram

Time from start
015 min
1630 min
3160 min
thereafter
Dose
4 mg/min
3 mg/min
2 mg/min
1.5 mg/min*
Pump rate
120 mL/hr
90 mL/hr
60 mL/hr
45 mL/hr
* Check arterial blood gases (ABG) 90 min after starting infusion. If no improvement, increase
infusion rate in increments of up to 1 mg/min (to a maximum of 4 mg/min) monitoring ABG hrly
until PaO 2 >7.3 kPa (on O 2 ) and PaCO 2 falling
Gentamicin 2010-11
GENTAMICIN
Do not start or continue gentamicin treatment for >3 days unless advised in a guideline or
by) or microbiologist
In all patients being treated with gentamicin, measure serum creatinine daily and serum
gentamicin where recommended
ONCE-DAILY DOSING
This protocol should NOT be used for patients in the following categories:
Ascites
Pregnant women
Endocarditis see Infective endocarditis guideline
Cystic fibrosis (CF) see Exacerbation of bronchiectasis in adults with cystic
fibrosis guideline
Major burns
Creatinine clearance (CrCl) <20 mL/min
In these situations, unless a specific protocol exists, use gentamicin nomogram for
multiple daily dose regimens to select an initial dosage and regimen, then adjust on
the basis of serum gentamicin concentration (see Monitoring multiple daily dose
regimens)
If there are no contraindications to its use, once-daily dosing with gentamicin is safer, more
convenient, and cheaper than multiple daily dose regimens
PROCEDURE
Initial dose
Weigh patient
if unfit to be weighed or obese (i.e. 20% over IBW), calculate ideal body weight (IBW) from
height/length, using formula below:
males:
IBW (kg) = 50 + [2.3 (height in inches 60)]
(1 cm = 0.394 inch and 1 foot = 12 inches)
females:
IBW (kg) = 45 + [2.3 (height in inches 60)]
If patient emaciated AND unfit to be weighed, estimate actual weight rather than
calculating ideal body weight
Use lowest weight (estimated, actual or ideal) to select dose from table 1. Dilute gentamicin
dose in 100 mL glucose 5% or sodium chloride 0.9% and administer by IV infusion over 1 hr
Table 1: Dose banding for gentamicin 7 mg/kg (maximum dose 560 mg daily) IV by
infusion over 60 min
Lowest weight (actual or ideal) (kg)
Dose of gentamicin (mg)
4448
320
4954
360
5560
400
6165
440
6671
480
7277
520
78
560
Gentamicin 2010-11
Prescribe first dose in once only section of current drug chart. Subsequent doses are
prescribed in the antimicrobial section 2448 hr after first dose, following measurement of
gentamicin concentration or calculation of creatinine clearance. See next section.
During 2010/11, a new drug chart containing a separate gentamicin (once daily) IV section
will be issued
Further doses
Measure concentration after 614 hr
Take blood samples for gentamicin (10 mL clotted blood) and creatinine 614 hr after start of
infusion. Do not sample via cannula used for infusion
Request measurement of gentamicin concentration and document in patient record. It is
imperative that time when infusion began and time when sample was taken are
accurately documented on the microbiology request card; this will appear on the
report
Complete blue microbiology request form as follows:
antibiotic assay type tick gentamicin box
dose frequency tick once daily box
enter dose and date and time of last dose
sample(s) taken tick random box for samples taken after 614 hr
enter date and time of random sample taken
enter date taken and time taken again at bottom of form
Dose interval
Use Figure 1 to select dose interval. Use serum gentamicin concentration and time interval
between start of infusion and sample to plot intercept (see example given on Figure 1). See
table 2 for additional information on gentamicin dose intervals and subsequent monitoring
Give next dose (7 mg/kg by infusion see table 1) at time after interval in figure 1
Table 2: Additional information on gentamicin dose intervals and subsequent monitoring
Serum gentamicin concentration result at
Action and interval
614 hr
Falls on the line dividing time intervals
Select the longer time interval
Above upper limit for Q48
Abandon once daily regimen. Stop gentamicin
and discuss indication and adjustment of dose
and time interval with microbiologist
Falls in Q36h or Q48h area
Patient is likely to have impaired renal function.
Continue with once-daily regimen at indicated
dose interval of 36 hr or 48 hr. Monitor
gentamicin concentration 614 hr after every
subsequent dose
Falls in Q24h sector or is <2 mg/L
Continue with once-daily regimen at dose
interval of 24 hr. Check gentamicin
concentration in three days, or earlier if
patients condition suggests renal function may
have deteriorated
Gentamicin 2010-11
Figure 1:
Use values of plasma concentration and time interval to find intercept

(Example: a concentration of 6 mg/L after 10 hr yields a dose interval of 36 hr)
Antimicrob Agents Chemother 1995;39(3):650-655

If serum gentamicin concentration taken between 614 hr from first dose not available
within 24 hr of first dose
Calculate provisional dosing interval according to patients renal function as follows:
Measure serum creatinine and calculate CrCl from one of the following equations:
males:
(140 age) weight (kg)
CrCl = 1.23
serum creatinine (mol/L)
females:
(140 age) weight (kg)
CrCl = 1.03
serum creatinine (mol/L)
Use Table 3 to select dose interval according to CrCl
Table 3: Gentamicin dose interval according to CrCl

CrCl
Dosing interval
(mL/min)
(hr)
>60
24
4059
36
2039
48
<20
Do not use this protocol
Prescribe gentamicin according to calculated starting dose and interval. Cross off sections of
drug chart to ensure correct dosing interval is followed
Note time infusion commenced
Gentamicin 2010-11
give next dose (7 mg/kg by infusion as above see table 1) after interval indicated by Table
3 above
After measuring gentamicin concentration, do not give more than one dose to any patient
without knowing the assay result
Monitoring
Check serum creatinine daily. Calculate CrCl from serum creatinine to check dose interval
has not changed
If dose interval has to be changed, check gentamicin concentration 614 hr after start of next
infusion (note time of start of infusion and time of sampling) and use Figure 1 to verify correct
dose interval
Do not send pre-dose (to measure trough concentration) or 1 hr post-dose (to measure
peak concentration) sample unless treatment is following multiple daily dose regimen
MULTIPLE DAILY DOSING

Gentamicin nomogram for multiple daily dose regimens
This nomogram is NOT to be used for children or patients with cystic fibrosis (CF)
Nomogram for gentamicin dosage

(devised by Prof. G. Mawer), which
provides a loading dose (L), a
maintenance dose (M), and a suitable
interval between doses for an adult
patient whose serum creatinine
concentration (A), age (B) and body
weight (D) are known
To use, join A to B with a line that
crosses C; then join this intercept on
C to D with a line that crosses M and
L
Monitoring multiple daily dose regimens

For patients with CF, refer to Exacerbation of bronchiectasis in adults with cystic
fibrosis guideline available
For patients with infective endocarditis, refer to Infective endocarditis guideline as target
concentrations differ in this indication
Measure serum gentamicin after 24 hr. A trough sample should be taken immediately before
third dose, and a peak sample 1 hr after dose (doses are given by IV injection NOT infusion)
Target peak concentration is 510 mg/L
Trough concentration should be maintained <2 mg/L
Gentamicin 2010-11
The relationship between maintenance dose and steady state concentration is linear.
Doubling the dose will double peak and trough serum concentrations, assuming renal
function stable
Measurement of trough and peak concentrations

Take blood samples for gentamicin (10 mL clotted blood) just before IV injection for pre-dose
trough concentration and 1 hr after IV injection for post-dose peak concentration. Do not
sample via cannula used for IV injection
Request measurement of gentamicin concentration and document in patient record. It is
imperative that time when IV injection given and time when sample was taken are
accurately documented on the microbiology request card; this will appear on the
report
Complete blue microbiology request form as follows:
antibiotic assay type tick gentamicin box
dose frequency tick 8 hrly or 12 hrly box. If dosing interval longer than this (e.g. 24 hrly or
36 hrly), tick .. hrly box and complete frequency
enter dose, date and time of the dose around which trough and peak are to be measured
sample(s) taken tick pre-dose or post-dose box as applicable
enter date and time of sample taken
enter date taken and time taken again at bottom of form
Glasgow coma 2010-11
GLASGOW COMA SCALE

Eye opening
Spontaneous
To speech
To pain
Nil
Score
4
3
2
1
Best motor response

Obeys command
Localises pain
Flexion - withdrawal to pain
Flexion - abnormal (decorticate rigidity)
Extension to pain (decerebrate rigidity)
Nil
Score
6
5
4
3
2
1
Best verbal response

Orientated
Confused conversation
Inappropriate words
Incomprehensible sounds
Nil
Score
5
4
3
2
1
Normal aggregate score: 15

It is good practice to record score
in each domain (e.g. eye opening 4,
motor response 6, verbal response 5)
GTN 2010-11
ISOSORBIDE DINITRATE
0.05% (25mg/50ml)
INDICATIONS
Unresponsive Left Ventricular Failure

Uncontrolled pain of cardiac origin
Accelerated hypertension with pulmonary oedema or acute coronary syndrome
PREPARATIONS
Isosorbide Dinitrate 25mg/50ml
ADMINISTRATION
Isosorbide Dinitrate 0.05% can be administered undiluted by slow intravenous infusion
using a syringe pump.
DOSAGE
Isosorbide Dinitrate is given by continuous IV infusion, initially 1 mg/hour (2ml/hour)
increasing to 12 mg/hour (24ml/hour), increasing in increments of 2ml at 1530 min
intervals until desired response or a maximum of 24 ml/hour is achieved, provided BP
remains >90/60 mmHg
In order to maintain the appropriate infusion rate, clinical assessment and blood
pressure monitoring are essential.
Table : Isosorbide dinitrate via syringe pump (flow rate mL/hr)

Dosage
(mg/hour)
Flow rate
(mL/hr)
10
12
10
12
14
16
18
20
24
NOTES
Isosorbide Dinitrate should not be administered as a bolus injection.

Monitor BP (usually keeping systolic > 90mm/Hg) and pulse. These should be taken
at 5,10,15,30 and 60 minute intervals following commencement and each increment.
Renew the infusion every 24 hours, to reduce the risk of any degradation
IVUH 2010-11
IV UNFRACTIONATED HEPARIN
Before prescribing, check indication for use of IV unfractionated heparin in relevant
guideline. Is this correct regime?
The anticoagulant response to IV unfractionated heparin varies widely among patients with
thromboembolic disease, possibly because of variations in the plasma concentration of
heparin-binding proteins. Thus, unfractionated heparin treatment is monitored to maintain the
ratio of patient's Activated Partial Thromboplastin Time (APTT) to the mean control APTT
within a defined target range of approximately 2.03.0. Dose adjustment is complicated
because unfractionated heparin displays saturation kinetics
Before treatment, all patients requiring unfractionated heparin should have:
FBC (especially to check baseline platelets)
International Normalised Ratio (INR)
APTT ratio
U&E (to check baseline serum potassium)
If starting a pregnant woman on IV unfractionated heparin, contact consultant
haematologist (ext 1801) to arrange anti-Xa monitoring
INITIATION OF TREATMENT LOADING DOSE
Weigh patient
give bolus dose of unfractionated heparin (1000 units/mL) 75 units/kg IV over 5 min (Table 1)
if patient unfit to be weighed, give bolus dose of unfractionated heparin 5000 units IV over
5 min
Do you need loading dose? Check indication for use of IV unfractionated heparin in
relevant guideline
Table 1
Volume of 1000 units/mL solution required to give loading dose of 75 units/kg
45
50
55
60
65
70
75
80
85
90
95
kg kg kg kg kg kg kg kg kg kg kg
Volume (mL) of heparin
3.4 3.8 4.1 4.5 4.9 5.3 5.6 6.0 6.4 6.8 7.1
diluted up to 10 mL with
sodium chloride 0.9% to be
administered IV over 5 min
Weight
MAINTENANCE OF TREATMENT INFUSION
Prepare an infusion using ready prepared ampoules of 20,000 units in 20mls

IV unfractionated heparin is supplied in various concentrations. Check concentration
carefully to avoid risk of overdose and death due to extreme anticoagulation
Start infusion dose at 18 units/kg/hr which is equivalent to 0.018 mL/kg/hr (see Table 2)
Check APTT ratio 4 hr (6 hr if no loading dose) after starting infusion and then 4 hr after any
dose change (Table 2)
Adjust rate as dictated by APTT ratio (Table 3)
Patients with renal impairment may have delayed clearance of heparin
Once APTT ratio lies within target range of 2.03.0, check APTT only once daily
100
kg
7.5
IVUH 2010-11
Table 2:
Infusion rate of IV heparin 1,000 units/mL required for a range of body weights to
give 18 units/kg/hr
Weight
45
50
55
60
65
70
75
80
85
90
95
100
kg
kg
kg
kg
kg
kg
kg
kg
kg
kg
kg
kg
Rate in
0.8 0.9
1
1.1 1.2 1.3 1.3
1.4 1.5
1.6 1.7
1.8
mL/hr
Table 3: APTT ratio and corresponding change in infusion rate
APTT ratio
Change in infusion rate
>5.00
Stop infusion for 1 hr, then reduce by 1 mL/hr.

If infusion rate is <1 mL/hr, stop infusion for 1 hr then
restart after reducing rate by one-third
Reduce by 0.6 mL/hr
Reduce by 0.2 mL/hr
Reduce by 0.1 mL/hr
No change
Increase by 0.2 mL/hr
4.15.0
3.64.0
3.13.5
2.03.0
1.51.9
1.21.4
<1.20
Adapted from Fennerty A.G., Renowden S., Scolding N. et al. BMJ 1986; 292: 579-80
MONITORING
Platelet count before starting heparin and then on alternate days from day 5 (day 2 if
unfractionated heparin or low-molecular-weight heparin given within last 100 days). If platelet
count falls by >50% during heparin therapy, suspect heparin-induced thrombocytopenia see
Heparin-induced thrombocytopenia guideline
Monitor for hyperkalaemia see Electrolyte disturbances Hyperkalaemia guideline
U&E before starting heparin and then twice weekly if IV unfractionated heparin likely to
continue for >7 days or patient has raised baseline serum potassium, diabetes mellitus,
chronic kidney disease or acidosis, or is taking a potassium-sparing agent
If starting a pregnant woman on IV unfractionated heparin, contact consultant haematologist
(ext 1801) to arrange anti-Xa monitoring
Labetalol 2010-11
LABETALOL
INDICATIONS
Accelerated hypertension
DOSAGE
Aim to reduce diastolic BP to 110115 mmHg over several hours. Labetalol can be given by
either IV injection or IV infusion
IV bolus injection
Initially 50 mg (10 mL) of labetalol hydrochloride over at least 1 min
After bolus injection, maximum effect usually occurs within 5 min and the effective duration of
action is usually about 6 hr, but can be as long as 18 hr
If necessary, repeat after 5 min and, if still no response, again 10 and 15 min after initial dose
Total dose should not exceed 200 mg
IV infusion via a syringe pump
Using a 50 mL syringe make up 100 mg (20 mL) of labetalol hydrochloride to 50 mL with
glucose 5%. Diluted solution is stable for 24 hr
Start with 0.5 mg/min by IV infusion, increasing according to response to 2 mg/min
Continue infusion until a satisfactory response is achieved, then stop
In most patients, the effective cumulative dose is usually 50200 mg depending on initial
blood pressure, but occasionally higher doses may be required. Table 1 gives corresponding
flow rate for a range of doses
Table 1: Labetalol IV infusion and flow rates
Dose (mg/min)
Flow rate (mL/hr)
0.5
15
1
30
1.5
45
2
60
NOTES
Ensure patient remains supine during and for 3 hr after end of administration to avoid
excessive postural hypotension. Monitor heart rate after injection and during infusion. In most
patients, there will be a small decrease in heart rate: severe bradycardia is unusual but can
be controlled by giving atropine sulphate 600 microgram by IV injection, repeated if
necessary at 5-min intervals. Total dose of atropine sulphate should not exceed 2.4 mg.
Watch for signs of bronchospasm, especially in patients with any known impairment in
respiratory function
PREPARATIONS
Labetalol hydrochloride injection 100 mg in 20 mL ampoule (5 mg/mL)
DILUENTS
Glucose 5%
Labetalol hydrochloride is incompatible with sodium bicarbonate 4.2%
Oxygen therapy O2 2010-11
OXYGEN THERAPY IN ACUTELY HYPOXAEMIC

PATIENTS
INDICATIONS
Critically ill patient (see list of possible critical illnesses below)

this includes acute localised tissue ischaemia (e.g. acute peripheral vascular disease,
reduced bowel perfusion)
Documented hypoxaemia (PaO 2 <8 kPa or SpO 2 <94%)
Acute hypoxaemia suspected on clinical grounds
Risk of intermittent hypoxaemia in surgical post-operative patient
Goal
To deliver O 2 at the minimum concentration required to achieve adequate tissue
oxygenation and minimise complications of hyperoxia
OXYGEN PRESCRIPTION
Include
Oxygen saturation target:
SpO 2 8892% for non-critical patients at risk of type 2 (hypercapnic) respiratory
failure
Target not used for post-operative surgical patients at risk of intermittent
hypoxaemia
SpO 2 9498% for all other patients
Oxygen flow rate
Delivery device (e.g. simple face mask, Venturi mask, nasal cannulae, reservoir mask)
Frequency (continuous or PRN use)
CRITICAL ILLNESS
Indications for example
Cardiac/respiratory arrest or resuscitation
Shock/severe hypovolaemia/haemorrhage
Severe sepsis
Major trauma
Near-drowning
Anaphylaxis
Major pulmonary haemorrhage
Major head injury
Carbon monoxide poisoning
Acute neurological or respiratory compromise caused by drugs (e.g. opioids), injury or
suspected intracerebral pathology
Acute localised tissue ischaemia
Management
Follow ABC approach and address underlying cause
Initial oxygen therapy is via reservoir mask at 15 L/min (use bag-valve mask for
active resuscitation during cardiac/respiratory arrest)
Once stable, reduce oxygen dose and aim for target saturation range of 9498%
Patients with COPD and other risk factors for hypercapnia who develop critical illness
should have the same initial target oxygen saturation as other critically ill patients
pending the results of blood gas results after which these patients may need
controlled oxygen therapy or supported ventilation if there is severe hypoxia and/or
hypercapnia. See Flowchart
SURGICAL HIGH-RISK POST-OPERATIVE PATIENTS

Who
Patients who have had general anaesthetic within previous 72 hr and one of the following:
Ischaemic heart disease, known or suspected
Obstructive sleep apnoea
Receiving drugs known to reduce respiratory drive, especially patients using PCA or
epidural for analgesia or other systemic opioids
Risks of surgery
Hypoventilation and consequent significant desaturation during sleep despite normal
SpO 2 when awake
Management (even if SpO 2 normal)
No risk of hypercapnic respiratory failure
Give oxygen 2 L/min via nasal cannulae or 5 L/min via simple face mask. If SpO 2 falls
below 94%, follow Flowchart for oxygen administraton on general ward
If patient tachynoeic, seek advice in accordance with MEWS escalation strategy
Risk of hypercapnic respiratory failure
These are high risk surgical patients follow specific advice regarding oxygen therapy
and ABG monitoring given by anaesthetist (or critical care if involved). Document this
advice on the anaesthetic chart, in patient notes and/or on prescription chart. If unsure,
contact anaesthetist who cared for patient, duty anaesthetist or critical care team
Length of oxygen therapy
Continue oxygen therapy until systemic opioids discontinued or, for IHD/OSA groups,
72 hours have elapsed since anaesthesia
NON-CRITICAL ILLNESS
All other patients with documented hypoxaemia (PaO 2 <8 kPa or SpO 2 <94%) other than
those with critical illnesses, follow Flowchart for non-critical illness requiring moderate
amounts of supplemental oxygen below
MONITORING
Monitor SpO 2 continuously. Follow Flowchart for oxygen administration on general

ward below
If oxygen requirement increases, seek senior advice
Closely observe patients at risk of CO 2 retention for signs of CO 2 retention, reduced
respiratory effort, and conscious level, (GCS <14 or V on the AVPU scale)
if patient at risk of CO 2 retention, repeat ABGs in 3060 min after adjusting inspired O 2 or
if conscious level deteriorates
Discuss any deteriorating patient with consultant responsible for management of comorbidity and critical care team
Do not withhold oxygen therapy, unless patient's unsuitability for intubation and
ventilation has been agreed.
Patients with obstruction or pseudo-obstruction of bowel and reduced conscious level
may not be suitable for NIPPV (non-invasive positive pressure ventilation)
WEANING FROM OXYGEN
When oxygen therapy is no longer indicated, Step down oxygen to room air as soon as
possible monitoring SpO 2 see Flowchart for oxygen administration on general ward
Flowchart for non-critical illness requiring moderate amounts of supplemental oxygen

(See separate advice in guideline for high risk post-operative surgical patients)
Is the patient critically ill or
in a peri-arrest condition?
Follow Critical Illness section above

Yes
No
Is this patient at risk of hypercapnic respiratory failure (type 2 respiratory failure)?
Main risk factor is severe or moderate COPD (especially patients with previous respiratory failure or requiring long-term oxygen).Other
patients at risk include those with severe chronic chest wall or spinal disease (e.g. kyphoscoliosis), neuromuscular disease, severe
obesity, cystic fibrosis, bronchiectasis or previously unrecognised COPD
No
Yes
Aim for SpO2 9498%
Target saturation is 8892% while

awaiting blood gas results
Start 28% or 24% O2 via Venturi

mask and obtain ABGs
(reduce FiO2 if SpO2 >92%)
pH <7.35*
and PaCO2 >6.0 kPa
(respiratory acidosis
or patient tiring)
pH 7.35
and PaCO2 >6.0 kPa
(hypercapnia)
Seek immediate
senior review
Consider NIV or
invasive ventilation
Treat with lowest

dose Venturi mask
that will keep SpO2
between 8892%
Treat with lowest

FiO2 to keep SpO2
8892% via
Venturi mask
pending senior
medical advice or
NIV or ICU
admission
Repeat ABGs at 3060

min
If respiratory acidosis (pH
<7.35 and PaCO2 >6.0)
seek immediate senior
review, consider NIV/ICU
Consider reducing FiO2
if PaO2 8.0 kPa
SpO2 <94% on air or oxygen or if requiring

oxygen to achieve above targets
Yes
No
Commence or continue oxygen via nasal

cannulae 26 L/min (preferably) or simple
face mask at 510 L/min or Venturi mask
2460% and check ABG
PaCO2 6.0 kPa

(normal or low)
PaCO2 6.0 kPa

or respiratory
deterioration
Seek immediate
senior review
Consider invasive
ventilation
Treat appropriately
aiming to keep SpO2
between 94% and
98%**
Repeat ABG in
3060 min for all
patients at risk of
type 2 respiratory
failure
Monitor SpO2
Oxygen not required
unless saturation
falls below target
range
Treat appropriately
(see flow chart for
oxygen
administration on
general ward) aim to
keep
SpO2 9498%
Treat urgently
Aim for SpO2
9498% pending senior
review
Also consider COPD or
other undiagnosed
chronic hypercapnic
respiratory failure
If likely, aim for
SpO2 of 8892%
An increase in FiO2 requires a medical review. Patients at risk of carbon dioxide retention must be monitored by repeat ABGs in
1 hr (or sooner if conscious level deteriorates)
* If pH is <7.35 with normal or low PaCO2, investigate and treat for metabolic acidosis and keep SpO2 9498%
** Patients previously requiring NIV or IPPV should have a target range of 8892%, even if the initial PaCO2 is normal
Key:
ABG = arterial blood gas

COPD = chronic obstructive pulmonary disease
FiO2 = fraction of inspired oxygen
SpO2 = arterial oxygen saturation measured by pulse oximetry
ICU = intensive care unit

NIV = non-invasive ventilation
PaCO2 = carbon dioxide tension
PaO2 = oxygen tension
Flowchart for oxygen administration on general ward

Choose most suitable delivery system and flow rate
Titrate oxygen up or down to maintain target oxygen saturation
Table below shows available options for stepping dosage up or down. Chart does not
imply any equivalence of dose between Venturi* masks and nasal cannulae
Except in major and sudden fall in saturation, allow at least 5 min at each dose before
adjusting further upwards or downwards
Once patient has adequate and stable saturation on minimal oxygen dosage, consider
discontinuation
If patient requires
increasing oxygen
therapy or if MEWS
score rising, seek
medical advice
Take ABG or earlobe

blood gases (ELBG)
within 1 hr of
requiring increased
oxygen dose
Venturi* mask 24%

24 L/min*
Nasal cannulae
1 L/min
Venturi* mask 28%

46 L/min
Nasal cannulae
2 L/min
Venturi* mask 35%

810 L/min
Nasal cannulae
46 L/min
Signs of respiratory
deterioration seek
medical advice
Increased respiratory rate
(especially if >30/min)
Reduced SpO2
Increased oxygen dose
required to maintain SpO2
in target range
Increased MEWS score
CO2 retention
Drowsiness
Headache
Flushed face
Tremor
Venturi* mask 40% 1012 L/min

or simple face mask 56 L/min
Venturi* mask 60% 1215 L/min

or simple face mask 710 L/min
Reservoir mask 15 L/min O2 flow
If reservoir mask required, seek senior medical input immediately
For Venturi* masks, if respiratory rate >30, higher flow rate required. Colour of box matches
colour of appropriate Venturi mask
Critically ill patients and those in peri-arrest situation give maximal oxygen therapy
via reservoir mask or bag-valve whilst awaiting arrival of medical help.
Patients with COPD and other risk factors for hypercapnia who develop critical illness
should have the same initial target saturations as other critically ill patients pending
the results of blood gas measurements, after which these patients may need controlled
oxygen therapy or supported ventilation if there is severe hypoxaemia and/or
hypercapnia with respiratory acidosis
Pain control in palliative care 2010-11
PAIN CONTROL IN PALLIATIVE CARE

PRINCIPLES
Obtain detailed pain history to identify cause as clearly as possible

Select treatment and dosage appropriate to individual patients needs
Keep it simple: most cancer pain is controlled with oral drug therapy
Pain relief should be
by the clock (regularly)
by the mouth (orally)
by the ladder
Follow (WHO) analgesic ladder:

morphine
diamorphine
STRONG OPIOID
dihydrocodeine
codeine phosphate
WEAK OPIOID
paracetamol
NON-OPIOID
Add adjuvant analgesia if required (e.g. NSAID/anticonvulsant/antidepressant)
(See West Midlands guidelines for the use of drugs in symptom control 2007)
STARTING PATIENT ON MORPHINE

Conventional regimen
If regular weak opioid not controlling pain, initiate immediate release morphine (e.g. morphine
sulphate solution 10 mg in 5 mL). Usual starting dose is 510 mg every FOUR hr.
(Remember, oral codeine 10 mg is equivalent to 1 mg oral morphine. Therefore, 60 mg
codeine four times daily is equivalent to 24 mg morphine in 24 hr)
in patients with moderate/severe renal failure, consider alternative strong opioid seek
advice from hospital specialist palliative care team via call centre, or via Douglas Macmillan
Hospice out-of-hours
At the same time, prescribe same dose for as required use, to treat breakthrough pain, this
dose can be repeated as often as necessary
Review after 2448 hr, and convert to modified-release morphine (e.g. Zomorph , MST ).
Add up total daily dose of morphine given. For modified release morphine, divide by two and
give this dose 12 hrly (see example 1 below)
Overlap at changeover, giving last dose of morphine sulphate solution and first dose of
modified release morphine together
Continue to treat breakthrough pain with morphine sulphate solution as required at onesixth of current total daily dose of modified release morphine (see example 1 below)
repeated every 4 hr (review pain management if analgesia required more frequently)
Example 1
Patient started taking morphine sulphate solution 10 mg 4 hrly 2 days ago
Over previous 24 hr, patient has required 3 extra doses of morphine sulphate solution 10 mg for
breakthrough pain
Total morphine dose in 24 hr = 9 x 10 mg morphine sulphate solution = 90 mg
Modified release morphine dosage is 90 mg divided by 2 = 45 mg 12 hrly
New dosage morphine sulphate solution for breakthrough pain is 90 mg divided by 6 = 15 mg as
required
initiate regular softener-stimulant laxative (e.g. codanthramer capsules or solution at night)

if nausea develops as a result of starting morphine, use regular haloperidol 1.5 mg orally or
SC daily
Alternative regimen
In patients with less severe pain, if administration of 4-hrly morphine is difficult, or on the
advice of palliative care team, morphine may be initiated as a modified release preparation
If regular weak opioid not controlling pain, initiate modified release morphine (e.g. Zomorph,
MST) Usual starting dose 1020 mg orally 12 hrly. (Remember, oral codeine 10 mg is
equivalent to 1 mg oral morphine. Therefore, 60 mg codeine four times daily is equivalent to
24 mg in 24 hr)
At the same time prescribe as required oral morphine sulphate solution (immediate release
morphine) 2.55 mg (see example 2 below)
Review after 2448 hr, add up total daily dose of morphine given, divide by two and rewrite
modified release morphine prescription to reflect increased daily requirement
At the same time:
increase dose of immediate release oral morphine solution to one sixth of new total daily
dose
Example 2
Patient started taking modified release morphine 15 mg 12 hrly 2 days ago
Over previous 24 hr, patient has used 6 extra doses of morphine sulphate solution 5 mg for
breakthrough pain
Total morphine dose in 24 hr = 15 mg modified release morphine + 15 mg modified release
morphine + (6 x 5 mg morphine sulphate solution) = 60 mg
New dosage modified release morphine is 60 mg divided by 2 = 30 mg 12 hrly
New dosage morphine sulphate solution for breakthrough pain is 60 mg divided by 6 = 10 mg as
required
initiate regular softener-stimulant laxative (e.g. codanthramer capsules or solution at night)

If nausea develops as a result of starting morphine, use regular haloperidol 1.5 mg orally or
SC daily
REVIEW
Review at least 4 hrly whenever patient reviewed (e.g. drug rounds, observations). If pain
severe, increase to 12 hrly until control achieved
If patient continuing to experience pain, and pain opioid sensitive, consider increasing opioid
dosage by one third
Alternatively, summate doses required for breakthrough pain and increase regular dose
accordingly as described above
If necessary, increase dose of laxative as dose of morphine increases
Anti-emetic requirement should diminish consider withdrawal after five days
If drowsiness increases or pupils become pin-point, consider reducing dosage of opioid if
patient still in pain, seek advice from specialist palliative care team (bleep via call centre)
if drowsiness profound or cognitive function impaired despite reducing dosage, consider
alternative opioid and refer to specialist palliative care team (bleep via call centre)
ALTERNATIVE OPIOIDS
Preferred second-line opioid is oxycodone

Fentanyl patches can be useful if pain well controlled with morphine and patient struggling to
swallow or there are problems with compliance after discharge
uncontrolled pain is difficult to manage with fentanyl owing to its long half life
Starting dose of alternative opioids is determined by calculating approximate equivalent dose

to the current 24 hr dose of analgesic. This dose will then need to be titrated according to
response
Approximate relative potencies of oral morphine, oral oxycodone, transdermal fentanyl

and subcutaneous diamorphine and oxycodone
4 hrly
24 hrly
24 hrly
Fentanyl patch
24 hrly SC
oral
oral morphine
oral
(microgram/hr)
diamorphine (mg) or
morphine
(mg)
oxycodone
24 hrly SC oxycodone
(mg)
(mg)
(mg)
1020
60120
3060
25
2040
2535
150210
75105
50
5070
4050
240300
120150
75
80100
5565
330390
165195
100
110130
If considering alternative opioid preparations, seek advice from hospital specialist
palliative care team via call centre, Douglas Macmillan Hospice out-of-hours or medicines
information (2905) or on-call pharmacist out-of-hours
INDICATIONS FOR SYRINGE DRIVERS
Inability to swallow
Persistent nausea and vomiting
Unconscious patient
Malabsorption
Opioids via syringe driver will not give better analgesia than the oral route unless there is
a problem with absorption or administration
Dosage
To convert oral morphine to SC diamorphine
3 mg oral morphine equivalent to 1 mg diamorphine SC
Administer at a fixed rate, not variable over 24 hr
Prescribe additional single doses of SC diamorphine as required for breakthrough pain,
equivalent to one-sixth of 24 hr syringe pump dose
if necessary for pain, dose can be repeated as often as hrly. If frequent administration
required, seek advice from specialist palliative care service
Example
Patient using modified release morphine 40 mg 12 hrly required 1 additional dose of morphine
sulphate solution
10 mg for breakthrough pain in last 24 hr
Total morphine dosage in 24 hr = 40 mg modified release morphine + 40 mg modified release
morphine + 10 mg morphine sulphate solution
= 90 mg
Diamorphine dosage in syringe driver = 90 mg divided by 3 = 30 mg SC over 24 hr in syringe
driver
Dose of diamorphine for breakthrough pain = 30 mg divided by 6 = 5 mg SC as required
Reassess pain, and increase diamorphine dosage to take account of need for as required
doses of SC diamorphine
If not nauseated while taking regular morphine, anti-emetic unnecessary when converting to
SC infusion
If unsure of compatibility when two or more drugs are required in a syringe driver, seek
specialist advice from medicines information (2905) or specialist palliative care team (via call
centre), or via Douglas Macmillan Hospice out-of-hours

Other medications that can be useful in syringe driver
Anti-emetics for nausea and vomiting (e.g. haloperidol, metoclopramide, levomepromazine)
Midazolam for agitation
Hyoscine for respiratory secretions
See:
BNF: Prescribing in palliative care
Palliative Care Formulary (PCF3) Twycross et al (2007), available online at
http//www.palliativedrugs.com (registration free). A copy of PCF2 (2003) is available on each
ward at UHNS
Palliative care guidelines for the use of drugs in symptom control (2007) West Midlands
Palliative Physicians: available on each ward at UHNS
Phenytoin 2010-11
ADJUSTMENT OF ORAL PHENYTOIN DOSAGE

If the steady-state concentration at a given dose is known, the dose increment required to raise
the concentration to a target level can be estimated using the nomogram (see below). The higher
the concentration, the smaller will be the difference between the old dose and the new. The
nomogram will be equally helpful in the selection of dose decrement if there is a need to reduce
dosage. If URGENT advice about phenytoin dosage required out-of-hours in patients with
suspected phenytoin toxicity, consult on-call pharmacist
It may take three to four weeks for steady state to be achieved after a change in phenytoin dose.
The nomogram will give misleading prediction if:
Serum concentration measurement is inaccurate because patients compliance is in doubt,
Change in concurrent treatment has been made since measurement of serum concentration,
Where binding of phenytoin to plasma albumin is reduced (in renal failure or when serum
albumin is low). If creatinine clearance is <25 mL/min, seek advice from your ward clinical
pharmacist or medicines information (1268). If serum albumin <40 g/L, use following equation
to correct serum phenytoin concentration, which can then be used in nomogram:
Corrected serum phenytoin =
Measured serum phenytoin (mg/L)

[0.0225 measured serum albumin (g/L)] + 0.1
Use the following nomogram only if serum phenytoin is reported in units of mg/L
Given a single reliable serum
concentration on a given daily dose of
phenytoin, the dose required to achieve a
desired concentration can be predicted
Draw a line connecting the observed
concentration (left-hand scale) with the
dose administered (centre scale) and
extend to intersect the right-hand
vertical line
From this point of intersection, draw
another line back to the desired
concentration (left-hand scale)
Read the dose to produce the desired
concentration off the centre scale
Nomogram devised by Prof. A. Richens and
Dr B. Rambeck
Phenytoin 2010-11
INTRAVENOUS PHENYTOIN
INDICATIONS
Status epilepticus for patients not taking maintenance phenytoin therapy

If phenytoin is given too rapidly, hypotension, cardiac arrhythmias, impaired cardiac
conduction, CNS depression or respiratory arrest can occur. All patients should have
continuous ECG and BP monitoring throughout the infusion
DOSAGE
Phenytoin 18 mg/kg by slow IV infusion into a large vein no faster than 50 mg/min
administer via a syringe pump (Table 1) over 30 min
if a syringe pump is not available, phenytoin sodium injection can be diluted in 100 mL
sodium chloride 0.9% to a maximum concentration of 10 mg/mL (i.e. max 1000 mg in
100 mL). If dose exceeds 1 g, (see first two lines of table) add the required dose to a 250ml
bag of sodium chloride 0.9%.. Check that solution is free of haziness or precipitation. Use
an in-line filter (0.220.50 m). Start administration immediately after dilution and ensure
infusion is completed within 1 hr of preparation
NOTES
Phenytoin sodium parenteral solution is highly alkaline and should be administered slowly
(maximum rate 50 mg/min) into a large vein. To reduce local venous irritation, flush cannula
with sodium chloride 0.9% before and after infusion. It is important to ensure that
extravasation does not occur check infusion site regularly. Soft tissue irritation and
inflammation (varying from slight tenderness to extensive necrosis and sloughing, requiring
amputation in rare instances) can occur with or without extravasation
PREPARATIONS
Phenytoin sodium injection 50 mg/mL in 5 mL (250 mg) ampoules
DILUENTS
Sodium chloride 0.9% only (see Dosage)
Table 1: Administration of undiluted phenytoin via syringe pump

Weight (kg)
Dose (mg)
mL of
phenytoin
(50 mg/mL)
Syringe
pump rate
(mL/hr)
45
810
16
50
900
18
55
990
20
60
1080
21.5
65
1170
23.5
70
1260
25
75
1350
27
80
1440
29
85
1530
30.5
90
1620
32.5
95
1710
34
100
1800
36
32
36
40
43
47
50
54
58
61
65
68
72
MONITORING
In patients requiring rapid achievement and maintenance of therapeutic phenytoin concentrations,
who have been given an intravenous loading dose, it is usually wise to monitor phenytoin
concentrations within 2 to 3 days of initiating therapy. A second phenytoin concentration would
normally be obtained in another 35 days; subsequent doses of phenytoin can then be adjusted.
If the plasma phenytoin concentrations have not changed over a 3 to 5-day period, the monitoring
interval can usually be increased to once weekly in the acute clinical setting. In stable patients
requiring long-term therapy, phenytoin plasma concentrations are generally monitored at
3 to 12-month intervals
Salbutamol 2010-11
SALBUTAMOL
INDICATIONS
Severe bronchospasm
DOSAGE
IV injection
This is a slow bolus for immediate treatment see Acute severe asthma in adults guideline
patients with life-threatening features
250 microgram over 10 min

if using 500 microgram in 1 mL preparation, take 0.5 mL and make up to 20 mL with diluent in
a 50 mL syringe (see Diluents) this gives concentration of 12.5 micrograms/mL
Administer via a syringe driver at a rate of 120 mL/hr (= 2 mL/min)
IV infusion
Initial rate = 5 microgram/min, adjusted according to response and heart rate, usual range
320 micrograms/min or more if necessary (Table 1)
Use preparation for IV infusion (5 mg in 5 mL). Remove 5 mL from a 500 mL bag of diluent
(see Diluents), then add 5 mL (5 mg) of salbutamol to the bag (5 mg in 500 mL = 10
micrograms/mL)
NOTES
Salbutamol increases heart rate, which can lead to palpitation, and this may preclude further
dosage increases. Cardiac monitoring is advised in patients with ischaemic heart disease
Salbutamol also causes rapid cellular uptake of potassium, which can lead to serious
hypokalaemia. Check plasma potassium 12 hr after starting IV salbutamol and after each
dosage increase
PREPARATIONS
Salbutamol injection 500 micrograms in 1 mL ampoule

Salbutamol solution for IV infusion 5 mg in 5 mL ampoule (1 mg/mL)
DILUENTS
Sodium chloride 0.9% or glucose 5%
Table 1: IV infusion (5 mg in 500 mL)

Dose
(microgram/min)
Infusion rate
(mL/min)
Pump rate
(mL/hr)
10
11
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.1
18
24
30
36
42
48
54
60
66
Dose
(microgram /min)
Infusion rate
(mL/min)
Pump rate
(mL/hr)
12
13
14
15
16
17
18
19
20
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
72
78
84
90
96
102
108
114
120
Sodium nitro JM 16.04.10 Ready
SODIUM NITROPRUSSIDE
Sodium nitroprusside is a very potent agent and should be used only on wards (e.g. ITU)
where continuous monitoring of BP (preferably via arterial line) is possible
INDICATIONS
Accelerated hypertension
DOSAGE
Aim to reduce diastolic BP to 110115 mmHg over several hours

Initially 0.3 microgram/kg per min by IV infusion, then increase in increments of 0.5
microgram/kg per min according to response (Tables 13), allowing 510 min between each
increment
Maximum dose = 8 microgram/kg per min
Patients already taking antihypertensive drugs and the elderly will be more sensitive to
sodium nitroprusside
If BP not adequately reduced within 10 min at maximum dosage, discontinue infusion see
Accelerated (malignant) hypertension guideline for alternative
ADMINISTRATION
Administer sodium nitroprusside using a controlled infusion device, drip regulator or microdrip regulator, or similar device that will allow precise control of flow rate
Sodium nitroprusside may be administered in a 50 mL syringe via a syringe pump, or in
250 mL or 500 mL bags. Choice of bag size or use of syringe pump will depend on dosage,
patient weight and fluid status, and availability of equipment
Infusion via syringe pump

Table 1 gives dosage and corresponding flow rates
Reconstitute sodium nitroprusside with 2 mL of glucose 5%. Withdraw resulting solution and
make up to 50 mL with glucose 5%. Mix thoroughly. Infusion solution has a faint orangebrownish tint. If it is highly coloured do not use
Sodium nitroprusside must be protected from light. Immediately wrap syringe and tubing
with foil provided. Infusion solution is then stable for up to 24 hr from time of preparation
Table 1: Administration of sodium nitroprusside (1 mg/mL) via syringe pump (rate mL/hr)
Concentration = 50 mg in 50 mL = 1000 microgram/mL (1 mg/mL)
Dosage
Weight (kg)
(microgram
45
50
55
60
65
70
75
80
85
90
95
100
/kg per min)
0.3
0.8
0.9
1
1.1
1.2
1.3
1.4
1.4
1.5
1.6
1.7
1.8
0.5
1.4
1.5
1.7
1.8
2
2.1
2.3
2.4
2.6
2.7
2.9
3
1
2.7
3
3.3
3.6
3.9
4.2
4.5
4.8
5.1
5.4
5.7
6
1.5
4.1
4.5
5
5.4
5.9
6.3
6.8
7.2
7.7
8.1
8.6
9
2
5.4
6
6.6
7.2
7.8
8.4
9
9.6 10.2 10.8 11.4 12
2.5
6.8
7.5
8.3
9
9.8 10.5 11.3
12
12.8 13.5 14.3 15
3
8.1
9
9.9 10.8 11.7 12.6 13.5 14.4 15.3 16.2 17.1 18
3.5
9.5
10.5 11.6 12.6 13.7 14.7 15.8 16.8 17.9 18.9
20
21
4
10.8
12
13.2 14.4 15.6 16.8
18
19.2 20.4 21.6 22.8 24
4.5
12.2
13.5 14.9 16.2 17.6 18.9 20.3 21.6
23
24.3 25.7 27
5
13.5
15
16.5
18
19.5
21
22.5
24
25.5
27
28.5 30
5.5
14.9
16.5 18.2 19.8 21.5 23.1 24.8 26.4 28.1 29.7 31.4 33
6
16.2
18
19.8 21.6 23.4 25.2
27
28.8 30.6 32.4 34.2 36
6.5
17.6
19.5 21.5 23.4 25.4 27.3 29.3 31.2 33.2 35.1 37.1 39
7
18.9
21
23.1 25.2 27.3 29.4 31.5 33.6 35.7 37.8 39.9 42
7.5
20.3
22.5 24.8
27
29.3 31.5 33.8
36
38.3 40.5 42.8 45
8
21.6
24
26.4 28.8 31.2 33.6
36
38.4 40.8 43.2 45.6 48
Infusion in a bag via a controlled-infusion device

Tables 2 and 3 give dosage and corresponding flow rates. If flow rate corresponding to
required dosage and patient's weight is in shaded area of Table, a more concentrated
solution may be more appropriate/practical
Select most appropriately sized bag of glucose 5%. Withdraw 2 mL from bag and use to
reconstitute sodium nitroprusside. Add resulting solution to infusion bag and mix thoroughly
Infusion solution has a faint orange-brownish tint. If it is highly coloured, do not use
Sodium nitroprusside must be protected from light. Immediately wrap infusion bag and all
parts of administration set with foil provided. Infusion solution is then stable for up to 24 hr
from time of preparation
Table 2: Administration of sodium nitroprusside (100 microgram/mL) via infusion bag
(rate mL/hr)
Concentration = 50 mg in 500 mL = 100 microgram/mL
Dosage
Weight (kg)
(microgram
45
50
55
60
65
70
75
80
85
90
95
/kg per min)
0.3
8
9
10
11
12
13
14
14
15
16
17
0.5
14
15
17
18
20
21
23
24
26
27
29
1
27
30
33
36
39
42
45
48
51
54
57
1.5
41
45
50
54
59
63
68
72
77
81
86
2
54
60
66
72
78
84
90
96
102 108 114
2.5
68
75
83
90
98
105 113 120 128 135 143
3
81
90
99
108 117 126 135 144 153 162 171
3.5
95
105 116 126 137 147 158 168 179 189 200
4
108
120 132 144 156 168 180 192 204 216 228
4.5
122
135 149 162 176 189 203 216 230 243 257
5
135
150 165 180 195 210 225 240 255 270 285
5.5
149
165 182 198 215 231 248 264 281 297 314
6
162
180 198 216 234 252 270 288 306 324 342
6.5
176
195 215 234 254 273 293 312 332 351 371
7
189
210 231 252 273 294 315 336 357 378 399
7.5
203
225 248 270 293 315 338 360 383 405 428
8
216
240 264 288 312 336 360 384 408 432 456
Table 3: Administration of sodium nitroprusside (200 microgram/mL) via infusion bag
(rate mL/hr)
Concentration = 50 mg in 250 mL = 200 microgram/mL
Dosage
Weight (kg)
(microgram
45
50
55
60
65
70
75
80
85
90
95
/kg per min)
0.3
4
5
5
5
6
6
7
7
8
8
9
0.5
7
8
8
9
10
11
11
12
13
14
14
1
14
15
17
18
20
21
23
24
26
27
29
1.5
20
23
25
27
29
32
34
36
38
41
43
2
27
30
33
36
39
42
45
48
51
54
57
2.5
34
38
41
45
49
53
56
60
64
68
71
3
41
45
50
54
59
63
68
72
77
81
86
3.5
47
53
58
63
68
74
79
84
89
95
100
4
54
60
66
72
78
84
90
96
102 108 114
4.5
61
68
74
81
88
95
101 108 115 122 128
5
68
75
83
90
98
105 113 120 128 135 143
5.5
74
83
91
99
107 116 124 132 140 149 157
6
81
90
99
108 117 126 135 144 153 162 171
6.5
88
98
107 117 127 137 146 156 166 176 185
7
95
105 116 126 137 147 158 168 179 189 200
7.5
101
113 124 135 146 158 169 180 191 203 214
8
108
120 132 144 156 168 180 192 204 216 228
100
18
30
60
90
120
150
180
210
240
270
300
330
360
390
420
450
480
100
9
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
240
NOTES
Take care to avoid extravasation check infusion site regularly to ensure this has not
occurred
Nitroprusside is metabolised to free cyanide, which is converted in the liver to thiocyanate. If
response obtained, continue therapy only for a few hours to avoid risk of toxicity
Start oral antihypertensive therapy while BP is being controlled by sodium nitroprusside
Over-rapid reduction in BP may produce the following symptoms: headache, dizziness,
nausea, retching, abdominal pain, perspiration, palpitations, apprehension, retrosternal
discomfort if these occur, reduce infusion rate in decrements of 0.5 microgram/kg per min,
monitoring BP and symptoms carefully
When finally withdrawing sodium nitroprusside, to prevent rebound increase in BP, reduce
infusion rate gradually reduce by 2530% every 5 min, rechecking BP before each
decrement
If therapy required for >24 hr, consult manufacturer's literature on monitoring and
management of potential toxicity. Signs of toxicity include tachycardia, sweating,
hyperventilation, arrhythmias, marked metabolic acidosis
PREPARATIONS
Sodium nitroprusside 50 mg ampoules/vials for reconstitution
DILUENTS
Glucose 5%
Therapeutic drug monitoring 2010-11
THERAPEUTIC DRUG MONITORING

INDICATIONS FOR MONITORING
Undertake therapeutic drug monitoring only if the result is likely to affect patient management.
Appropriate indications are to:
assist dose adjustment for optimal serum concentrations
confirm suspected toxicity
monitor effect of drug/drug or drug/disease interactions
investigate treatment failure
investigate suspected non-compliance
ASSAYS AVAILABLE
Clinical biochemistry
Carbamazepine
Sodium valproate [discuss the indication and need for monitoring with clinical biochemistry before
making a request]
Phenobarbital
Phenytoin
Digoxin
Theophylline
Lithium
Microbiology
Gentamicin
Tobramycin
Vancomycin
All other drugs discuss directly with the laboratory concerned
Timing the sample
Unless toxicity is suspected, assays are unlikely to be of value until regular dosing has produced a
steady state, usually 45 half-lives after treatment began or dose was last altered. See Table 1 for
further details
Note that half-lives of anticonvulsants can vary in patients taking more than one
anticonvulsant
Sending a sample
Send all samples in clotted blood bottles
Requests sent to clinical biochemistry should be made using a Therapeutic Drug Monitoring form
Requests sent to microbiology should be made using a microbiology form and must reach the
laboratory by 1530 hr
Ensure the following details are provided:
dose, frequency and duration of treatment with drug
time of last dose
any impaired organ function (e.g. renal impairment, liver disease, cardiac failure)
potentially interacting drugs (see individual drugs and BNF Appendix 1) including dose, frequency
and duration of co-prescription
Unless these data are recorded, correct interpretation of assay result may not be possible
For further advice on therapeutic drug monitoring, or assistance when selecting a dose
adjustment contact your wards clinical pharmacist or medicines information (2905/2906).
Please ensure you have details of the dose regimen, sample time and assay result to hand, as
well as patients clinical details and other drug treatment. For advice on optimal use of
antimicrobial agents, contact a microbiologist
Therapeutic drug monitoring 2010-11
Table 1: Guidance on blood sampling and interpretation

Drug
Assay day
Time from start
Sample
or change of
dosage
Carbamazepine
Weekdays
From start:
Pre-dose
23 weeks
Adjust dose:
34 days
Digoxin
Weekdays
13 weeks*
At least 6 hr
post-dose
Gentamicin
Lithium
Tues/Fri
1 week*
At least 12 hr
post-dose
Half-life
Target range
35 hr (single
dose)
1020 hr
(regular dosing)
40 hr
412 mg/L
Phenobarbital
Phenytoin
Fri
Weekdays
24 weeks*
34 weeks*
Anytime
Anytime
26 days
35 hr
1540 mg/L
1020 mg/L
Theophylline
(as MR tablets)
Weekdays
5 days
68 hr
1020 mg/L
Tobramycin
(8 hrly dosing)
Daily
12 hr
Vancomycin
Daily
2030 hr
IV: anytime
Oral: at least 6 hr
post-dose
Trough:
Immediately predose
Peak:
1 hr post-dose
Trough:
immediately
pre-dose
Peak: peak levels
have no clear
significance and will
be measured only
after prior
agreement with
consultant
microbiologist
511 hr
Induces own metabolism
0.82 microgram/L
See Prescribing Regimens and Nomograms

845 hr
0.61.2 mmol/L
2.5 hr
Notes
Trough: <2 mg/L

Peak: 510 mg/L
(810 mg/L for enterobacterial
pneumonia and cystic fibrosis
patients)
Trough: 1015 mg/L
If lithium toxicity suspected, stop lithium.

Contact patients consultant psychiatrist
Dose-concentration relationship non-linear

see Phenytoin nomogram
Tobramycin range based on 8 hrly dosing
*These particular time intervals apply to patients taking oral maintenance doses of these drugs, and not to patients who have been given a loading dose
Warfarin 2010-11
WARFARIN
Before starting treatment with warfarin, all patients must be given an anticoagulation pack,
and encouraged to read this and discuss any issues with the prescribing doctor. This
information must be supported by counselling on warfarin treatment by a healthcare
professional before discharge from hospital on warfarin
PREPARATION
Sensitivity to warfarin is increased in frail, sick patients, those aged >80 yr or who are
significantly underweight, those who have congestive cardiac failure or abnormal liver
function, and those who are having parenteral nutrition or drugs that potentiate warfarin
significantly (see appendix 1 BNF)
for patients with increased sensitivity to warfarin, halve the doses expressed within these
algorithms
Once decision is made to give warfarin, review patients medication history, including any
herbal remedies, to determine if any interact significantly with warfarin
consider whether alternatives could be substituted or medications discontinued. This is
particularly important for medications taken on an as required basis e.g. NSAIDs, where the
interaction may be inconsistent
seek further information from medicines information (2905) where necessary
RAPID ANTICOAGULATION
However rapidly treatment with warfarin is initiated, coagulation will not be inhibited for 72 hr
because warfarin does not affect the action of synthesised clotting factors. The following method
allows the maintenance dose of warfarin to be predicted over 4 days, by optimal interpretation of
timed daily INR measurements. The INR is used to guide the selection of daily warfarin dose,
even during concurrent anticoagulant treatment with unfractionated heparin, dalteparin or any
other low-molecular-weight heparin
DOSE PREDICTION
Proceed as follows:
Day 1
Take blood for measurement of INR
If INR >1.4, this predictive method cannot be used and the choice of dose must rely on
clinical judgement alone
If INR <1.4 and there is no reason to believe that the patient will be more than usually
sensitive to warfarin, give warfarin 10 mg before evening meal between 1700 and 1800 hr
Have you checked if patient sensitive to warfarin? See PREPARATION above
Day 2, 3 and 4
Take blood between 0900 and 1000 hr (16 hr after previous dose of warfarin)
Measure INR and use the result to select next dose from Table 1
Give the dose before evening meal between 1700 hr and 1800 hr. The dose selected on day
4 is the predicted maintenance dose necessary to achieve a stable INR in the range 24
Further adjustment may be necessary as INR stabilises depending on target range desired
NOTES
Notify the laboratory if unfractionated heparin is being infused at the time a blood sample is
drawn
INR may be increased in the presence of sufficient unfractionated heparin to raise the APTT
ratio to >2.5 and should not be used as a basis for a decision on warfarin dose in this
Warfarin 2010-11
circumstance, unless laboratory staff can confirm that unfractionated heparin is not affecting
INR value
The prediction will become less reliable if interval between dose and blood sample deviates
significantly from 16 hr
Inaccuracies may also occur if drugs known to interact with warfarin (see BNF Appendix 1)
are started, altered in dose or stopped during this induction period
All warfarin tablets are scored and any doses recommended in the Table can be administered
by appropriate use of 1 mg, 3 mg and 5 mg tablets
Table 1 has no predictive value beyond day 4 and should not be used
Dose adjustments from day 5 onward must be made intuitively
On discharge, refer patients stabilised on warfarin to haematology anticoagulant management
service for ongoing monitoring using DAWN computerised dosing system
Table 1: Dosage adjustment for rapid anticoagulation based on INR measurements (days
2, 3 and 4). Remember to halve doses in sensitive patients
INR
<1.8
1.8
>1.8
INR
<2.0
2.02.1
2.22.3
2.42.5
2.62.7
2.82.9
3.03.1
3.23.3
3.4
3.5
3.64.0
>4.0
INR
<1.4
1.4
1.5
1.61.7
1.8
1.9
2.02.1
2.22.3
2.42.6
2.73.0
3.13.5
3.64.0
4.14.5
>4.5
Day 2 (16 hr after first 10 mg dose)

Warfarin dose (mg)
10.0
1.0
0.5
Day 3 (16 hr after second dose)
Warfarin dose (mg)
10.0
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
Day 4 (16 hr after third dose)
Warfarin dose (mg)
>8.0
8.0
7.5
7.0
6.5
6.0
5.5
5.0
4.5
4.0
3.5
3.0
0 give 2 mg from day 5
0 give 1 mg from day 6
Warfarin 2010-11
SLOW ANTICOAGULATION
Where anticoagulation can be achieved more gradually (e.g. to prevent thrombo-embolism in
patients with atrial fibrillation), heparin is unnecessary and warfarin can be initiated on an
outpatient basis, using the method described below
This method can be used to allow patients to be discharged before their dosage of
warfarin is stable, providing first dose is given on Monday, Thursday or Friday and patient
is referred to haematology anticoagulant management service for ongoing monitoring
Once decision made to administer warfarin
Take blood for measurement of INR
providing INR <1.5, and no patient factors likely to cause increased sensitivity to warfarin (see
PREPARATION above) start warfarin treatment 5 mg daily on Monday, Thursday or Friday
but not on other days of the week
Complete referral form for haematology anticoagulant management service including a
decision whether any current prescribed antiplatelet treatment is to be continued once target
INR achieved
Measure INR on days 5 and 8, and adjust daily dosage according to algorithm (see Table 2)
do not measure INR or adjust warfarin dosage on any other day as this will obviate use of the
algorithm
Warfarin 2010-11
Table 2: Algorithm for dosage adjustment in slow anticoagulation

Day 5
Dosage (mg)
Day 8
Dosage (mg)
INR
for days 57
INR
from day 8
1.7
5
1.7
6
1.8 2.4
5
2.5 3.0
4
>3.0<5
3 for 4 days
>5
Omit until INR<5
1.8 2.2
4
1.7
5
1.8 2.4
4
2.5 3.0
3.5
3.1 3.5
3 for 4 days
>3.5<5
2.5 for 4 days
>5
Omit until INR<5
2.3 2.7
3
1.7
4
1.82.4
3.5
2.53.0
3
3.13.5
2.5 for 4 days
>3.5<5
2 for 4 days
>5
Omit until INR<5
2.8 3.2
2
1.7
3
1.82.4
2.5
2.53.0
2
3.13.5
1.5 for 4 days
>3.5<5
1 for 4 days
>5
Omit until INR
<5
3.3 3.7
1
1.7
2
1.82.4
1.5
2.53.0
1
3.13.5
0.5 for 4 days
>3.5
omit for 4 days
>3.7
0
<2.0
1.5 for 4 days
2.02.9
1 for 4 days
3.03.5
0.5 for 4 days
At day 15 (or day 12) check INR and make fine dose adjustment as appropriate
OVERANTICOAGULATION WITH WARFARIN

Causes
Causes of overanticoagulation include:
Concurrent disease/illness affecting clotting factor synthesis, vitamin K availability, or warfarin
handling
cardiac failure
liver disease
cholestasis
diarrhoea
gastrocolic fistula
hypoalbuminaemia
malnutrition
abrupt weight reduction
renal impairment
thyrotoxicosis
fever
Warfarin 2010-11
Interaction with drugs that inhibit warfarin elimination and enhance its effect (see BNF
Appendix 1)
Withdrawal of concurrent treatment with a drug that hastens warfarin elimination and
reduces its effect (see BNF Appendix 1)
Overdosage (accidental or deliberate)
Management
Management of overanticoagulation depends on the INR and the degree of any haemorrhage
occurring (table 3)
Table 3 Management of overcoagulation
INR >8
High INR without
bleeding
INR more than 0.5 units

above target range but not >8
Minor haemorrhage
(non-life threatening)
INR >8
INR more than 0.5 units

above target range but not >8
INR in target range
Major haemorrhage
(life threatening)
Unless a patient has a prosthetic heart valve

(see box below), withhold warfarin and give
phytomenadione (Konakion MM) 1 mg orally
(draw up 0.1 mL from ampoule using 1 mL
syringe provided, and expel contents into
patients mouth). Monitor INR daily and give
further phytomenadione (Konakion MM)
12 mg orally if necessary. Restart warfarin
when INR <5.0 and adjust dose until result
within target range and stable
If INR >5.0, omit warfarin until
INR <5.0. Then restart warfarin, monitoring
INR daily. Adjust dose until result within target
range and stable
Unless patient has a prosthetic heart valve
(see box below), omit warfarin and give
phytomenadione (Konakion MM) 2 mg orally
(draw up 0.2 mL from ampoule using 1 mL
syringe provided, and expel contents into
patients mouth). Monitor INR daily until within
target range, giving further doses of
phytomenadione (Konakion MM) as
necessary
Omit warfarin until haemorrhage controlled
and monitor daily until INR within target range
before restarting
Check for occult malignancy
Treat symptomatically
Obtain venous access. Take blood for INR,
and cross-matching. Transfuse to replace
estimated blood loss. Withhold warfarin and,
unless patient has a prosthetic heart valve
(see box below), consider full reversal of
anticoagulation with dried prothrombin
complex 50 units/kg (if available discuss
with haematologist) or fresh frozen plasma
15 mL/kg. If continued anticoagulation
contraindicated or unnecessary, give
phytomenadione 5 mg slowly IV
In patients with prosthetic heart valves, reversal of anticoagulation can increase risk of
valve thrombosis. Discuss management with cardiothoracic unit. Full reversal is
inadvisable in such patients except after acute intracranial haemorrhage (discuss with
neurosurgical unit)
Admin fluid 2010-11
ADMINISTRATION OF FLUID AND INSULIN

INFUSIONS
Administer insulin and fluid (e.g. glucose 5% or sodium chloride 0.9%) infusions via same
cannula using an anti-syphon valve (Vygon Protect-A-Line 2 extension set); the purpose
of this is to prevent:
inadvertant and dangerous administration of either insulin or fluid alone
an overdose of insulin, which could occur if insulin were to be siphoned up into the fluid
giving set and accidentally administered as a bolus
See Figure 1 for appropriate set up of Vygon Protect-A-Line 2 extension set
Formatted: Font color: Auto

Figure 1: Anti-syphon valve connection

Fluid infusion connected
via giving set and
volumetric pump
to anti-syphon valve of
Vygon Protect-A-Line 2
extension set
Connect to
IV cannula
Insulin infusion in syringe pump

connected to
Vygon Protect-A-Line 2
extension set

Flushing IV lines 2010-11
FLUSHING INTRAVENOUS LINES

Ensure aseptic technique used Follow Trust standard operating procedures for
infection control
FLUSHING SOLUTIONS
All flushing solutions must be prescribed by an authorised prescriber and administration

recorded using the intravenous prescription chart
sodium chloride 0.9%
heparin 10 units/mL in sodium chloride 0.9% (e.g. Hepsal)
When prescribing flushing solutions take into account patients fluid and sodium
allowance particularly for neonates, multilumen catheters and when flushing is required
several times daily
Heparin is potentially a dangerous drug. Higher strengths of heparin given

inadvertently can lead to full anticoagulation. Ensure that correct strength of heparin is
prescribed and administered.
Do not use heparin in any strength as a flush without a valid prescription. Do not use
heparin if there is any history of an adverse reaction to it, e.g. HIT (Heparin induced
thrombocytopenia)
PERIPHERAL IV CANNULAE
Continuous infusion in progress
No flush required
Intermittent administration of drugs
Flush with sodium chloride 0.9% 5 mL after drug administration (and between drugs if
more than one administered)
Not in use (preferable to remove cannula, unless IV access genuinely required for
emergency access)
Flush every 8 hrs with sodium chloride 0.9% 5 mL
PERIPHERALLY INSERTED LONG VENOUS CATHETER (long

line)
No flush required
Intermittent administration of drugs within a 24 hr period
Flush with sodium chloride 0.9% 5 mL before and after drug administration
Not in use
Flush daily with sodium chloride 0.9% 5 mL followed by heparin 10 units/mL in sodium
chloride 0.9% (e.g. Hepsal) 5 mL
Draw up 5 mL heparin 10 units/mL in sodium chloride 0.9% (e.g. Hepsal ) and inject
4.5 mL. This ensures flushing completed on the downstroke of syringe plunger. If
plunger allowed to reach end of barrel, it can bounce back and draw blood into
catheter tip
SHORT TERM CENTRAL VENOUS CATHETERS

Acute care setting single, double and triple lumen configurations
No flush required
Intermittent administration of drugs within a 24 hr period

Flush with sodium chloride 0.9% 5 mL before the drug, and sodium chloride 0.9% 5 mL
after drug administration
Intermittent blood sampling
Flush with sodium chloride 0.9% 5 mL after blood sampling and then administer heparin
10 units/mL in sodium chloride 0.9% (e.g. Hepsal) 5 mL
Not in use
Flush daily via appropriate injection membrane or needle-free device with sodium chloride
0.9% 5 mL followed by heparin 10 units/mL in sodium chloride 0.9% injection (e.g.
Hepsal) 5 mL
Draw up 5 mL heparin 10 units/mL in sodium chloride 0.9% (e.g. Hepsal ) solution and
inject 4.5 mL. This ensures flushing completed on the downstroke of syringe plunger.
If plunger allowed to reach end of barrel it can bounce back and draw blood into
catheter tip
BROVIAC AND HICKMAN TYPE CENTRAL VENOUS

CATHETERS
No flush required
Intermittent administration of drugs within a 24 hr period in hospital
Flush with sodium chloride 0.9% 5 mL before and after drug administration via lumen,
appropriate injection membrane or needle-free device
for patients with pro-coagulant condition, e.g. nephrotic syndrome, flush with sodium
chloride 0.9% 5 mL before and after drug administration and then flush with heparin 10
units/mL in sodium chloride 0.9% injection (e.g. Hepsal) 5 mL
Insertion flush
Flush with sodium chloride 0.9% 5 mL during procedure. At end of procedure, lock with
heparin 10 units/mL in sodium chloride 0.9% 5 mL
Intermittent administration of drugs within a 24 hr period in the community
Flush with sodium chloride 0.9% 10 mL before and after drug administration and then
flush with heparin 10 units/mL in sodium chloride 0.9% injection (e.g. Hepsal) 5 mL via
lumen, appropriate injection membrane or needle-free device
Intermittent blood sampling
Flush with sodium chloride 0.9% 5 mL after blood sampling and then flush with heparin 10
units/mL in sodium chloride 0.9% injection (e.g. Hepsal) 5 mL
Not in use
Flush once weekly with heparin 10 units/mL in sodium chloride 0.9% injection (e.g.
Hepsal) 5 mL
Volume of heparin flushing solution used must be 0.5 mL greater than the volume of
the catheter and any other equipment attached to it (e.g. one-way tap, short extension).
Draw up 0.5 mL more heparin solution than is required. This ensures flushing
completed on the downstroke of syringe plunger. If plunger allowed to reach end of
barrel it can bounce back and draw blood into catheter tip
IMPLANTABLE PORT (e.g. Portacath)
Follow local unit procedure
GROSHONG CENTRAL VENOUS CATHETER
This special catheter has a slit valve at the tip to prevent backflow of blood into catheter.
Heparin is not required to maintain patency. Use sodium chloride 0.9% for flushing (follow
manufacturers instructions for amount and frequency of flush)
CENTRAL VENOUS HAEMODIALYSIS CATHETERS
Follow local unit procedure
Perc CVC 2010-11
PERCUTANEOUS CENTRAL VENOUS

CANNULATION
Central venous cannulation can cause serious morbidity and must not be performed by
unsupervised inexperienced operators. Failure to use full sterile technique can lead to lifethreatening infection. Always seek help from your SpR or consultant.
When inserting CVC into internal jugular vein in an elective situation, use 2-dimensional
(2-D) imaging ultrasound guidance. 2-D imaging ultrasound should be available in areas
where central line cannulation is carried out on a regular basis. If not available and only in
an emergency, use landmark technique as described below.
Expertise and equipment to place line under 2-D imaging ultrasound guidance is present
in theatres and ICU for those trained in its use
INDICATIONS
Monitoring rapid changes in blood volume, especially if right heart function impaired
Infusions of drugs irritant to veins
Long term IV feeding
Insertion of Swan-Ganz catheter or intracardiac pacing device
CONTRAINDICATIONS
Sepsis at cannulation site

Atypical emphysema or bullae (avoid infraclavicular or supraclavicular approaches to
subclavian vein)
Carotid artery aneurysm (precludes use of internal jugular vein on same side)
Hypocoagulation and hypercoagulation states
EQUIPMENT
Perform procedure using full sterile technique, considering the environment in which line
is placed
Sterile gloves, mask, gown and towels

Dressing pack with cotton balls, gauze swabs, galley pots
Scalpel holder with blade size 11
Skin antiseptic. If not allergic to alcoholic chlorhexidine gluconate use 2% solution. If allergic
(but not to iodine) use povidoneiodine solution
Lidocaine 1% plain in a 5 mL syringe fitted with an orange (25 G) needle
Sodium chloride 0.9% in a 20 mL syringe
Heparinised saline 10 units/mL in a 5 mL syringe
Adhesive tape (1-cm-wide)
0 or 1 silk or nylon stitch suture
Tourniquet
Manometer
Sodium chloride 0.9% (500 mL bag)
Central venous catheter
Bionector (vygon) hubs for three-way taps prevent repeated unscrewing of ports for access
to line and, if cleaned with each use, reduce infection
Selection of catheter type

Use single-lumen catheter unless multiple ports are essential for patient management
If administering total parenteral nutrition, use single-lumen catheter or designate one port
exclusively for this purpose
Perc CVC 2010-11
For patients in whom long-term (>34 weeks) vascular access is anticipated, use tunnelled
catheter or implantable vascular device
For adult inpatients who require short-term (13 weeks) central venous catheterisation and
who are at high risk of catheter-related bloodstream infection, use antimicrobial impregnated
central venous access device (CVAD)
Selection of catheter insertion site

Before assessing site for catheter insertion, determine mechanical risk:
patient-specific factors (e.g. pre-existing catheters, anatomic deformity, bleeding diathesis,
some types of positive pressure ventilation)
relative risk of mechanical complications (e.g. bleeding, pneumothorax, thrombosis)
To reduce risk of infection, prefer subclavian vein to jugular or femoral. Remember that
bleeding diathesis is a relative contraindication to subclavian line insertion. Alternatively,
consider peripherally inserted (arm) catheter
Choice of vein and appropriate catheter
Table 1 lists approaches and catheters in order according to safety and effectiveness, the
safest appearing first, the most effective last. In selecting appropriate insertion site, compare
risks of infection against risks of mechanical complications
Table 1: Selection of cannula and catheter
Route of insertion
Infection risk
Gauge of cannula
needle
Low
14 G
Arm vein
Medium
16 or 14 G
External jugular vein
High
16 or 14 G
Internal jugular vein
Lower than jugular
16 or 14 G
Subclavian vein
* Long cannulae are available (120150 mm long, 1418 G)
Minimum length of
catheter (mm)
600
200
150*
150*
PROCEDURE
Consent
Explain procedure and reassure patient
check patient not allergic to skin antiseptic
Obtain and record consent
Position of patient and site of insertion
Place patient into correct position for chosen approach see Position and technique
Check site of introduction
Aseptic technique and local anaesthetic
Scrub up using full sterile technique
Put on gown, gloves, mask and face and eye protection
Prepare skin with antiseptic
Drape operative field
If patient conscious, after drawing back to check not in blood vessel, infiltrate local
anaesthetic
Insertion of CVC
Check fit and function of equipment
Proceed with chosen approach see Position and technique
Aspirate blood to check catheter position before injecting fluid
On connection to CVP fluid column, column should show slow oscillations with respiration
and quicker oscillations with every heartbeat
Ensure cannula insertion site is covered by a clear sterile dressing
Perc CVC 2010-11
Chest X-ray to look for pneumothorax and confirm tip of catheter lies above pericardial
reflection by checking tip at or above the level of the carina
POSITION AND TECHNIQUE

Whichever vein used, avoid air embolism by maintaining venous pressure above
atmospheric by correct position or tourniquet on limb
Antecubital fossa median (basilic) or cephalic veins
Distend veins by tourniquet
Turn head to same side to compress neck veins
Abduct arm
Insert catheter >600 mm length
Before releasing tourniquet, position proximal end of catheter below level of patient's elbow to
avoid air embolus
Catheter passage through cephalic vein may be impeded by fascia deep to axillary vein
External jugular vein
Place patient at 20 head down
Vein runs from angle of mandible to behind middle of clavicle
Choose most prominent of the right or left veins
STOP if no vein visible or palpable
Turn patient's head to opposite side
Insert catheter >200 mm length
In 50% of patients, catheter cannot be threaded into an intrathoracic vein. If so, try finger
pressure above clavicle, depressing shoulder, or flushing catheter. Use of Seldinger or a
spiral J-shaped wire may help. DO NOT use excessive force
Internal jugular vein routine insertion (Figure 1)
All practitioners involved in elective placement of CVCs into internal jugular vein must be
trained in using 2-D imaging ultrasound
Place patient at 20 head down with head turned to left

Use right (not left to avoid injury to thoracic duct) jugular vein running behind sternomastoid
close to lateral border of carotid artery
Use 2-D imaging ultrasound guidance to identify vein
Insert cannula
Internal jugular vein emergency landmark insertion (Figure 1)

Attach needle to syringe filled with sodium chloride 0.9%
Use right (not left to avoid injury to thoracic duct) jugular vein running behind sternomastoid
close to lateral border of carotid artery
Identify sternomastoid, cricoid cartilage and carotid artery
With left hand, protect carotid artery at level of cricoid cartilage
Insert needle lateral to carotid artery midway between mastoid process and suprasternal
notch
Direct needle towards patient's feet, parallel to midline, with syringe raised 30 above skin
Gently aspirate as needle is advanced until a flush of blood signifies entry into vein
Remove needle
Perc CVC 2010-11
Insert cannula along identified entry point
Operators of limited experience can try cannulation with small (21 G) needle to locate vein
first and then use small needle as guide. If artery is punctured, compress firmly for 5 min
Figure 1: Internal jugular vein
30
30
Perc CVC 2010-11
Infraclavicular subclavian vein (Figure 2)

Often only patent route in circulatory collapse.
Blind procedure risks major hazards (e.g. pneumothorax, death from uncontrollable
haemorrhage).
To be performed or supervised ONLY by experienced operators
Place patient at 20 head down with head turned away

Identify midpoint of clavicle and suprasternal notch
Attach long needle and cannula to syringe filled with sodium chloride 0.9%
Insert needle below lower border of mid-point of clavicle
Advance needle tip close to undersurface of clavicle
Aim at suprasternal notch, to enter vein lying in angle formed by middle one-third of clavicle
and first rib
Aspirate gently as needle is advanced until a flush of blood signifies entry into vein
If unsuccessful, withdraw needle to just beneath skin before trying in a new direction
Figure 2: Infraclavicular subclavian vein puncture
Perc CVC 2010-11
AFTERCARE
Strict asepsis at all times to avoid infection
Fix catheter with adhesive tape (1 cm wide) crossed over distal to venepuncture site to grip it
firmly (antecubital fossa), OR affix with suture (other approaches)
Change IV giving set as per hospital protocols using aseptic technique
Do not inject drugs into venous catheter or take blood samples through stopcocks if possible
Monitor venepuncture site for infection daily
Watch out for catheter-related infections. If an infection occurs remove catheter immediately
and send tip for culture
Maintain continuous flow through catheter to prevent clotting; if clotting occurs, try to clear by
injecting 25 mL heparinised sodium chloride 0.9% 10 units/mL under pressure
COMPLICATIONS
Injury to vital structure, pneumo- or haemothorax, arterial puncture, damage to thoracic duct
or phrenic nerve
Infection, local or systemic sepsis
Catheter or air embolus
Cardiac arrhythmias usually stop spontaneously
if persistent, withdraw catheter into IVC
if severe, treat
Perforation of myocardium, mediastinum or pericardium withdraw catheter and stop infusion
Figure 3: Measuring central venous pressure
Tapping 2010-11
TAPPING ASCITES AND PARACENTESIS

INDICATIONS
To investigate cause (Table 1)

To examine ascitic fluid for bacterial infection
To treat, by removing fluid to relieve abdominal discomfort or severe dyspnoea, or by
introducing chemotherapeutic agents
RELATIVE CONTRAINDICATIONS
Paracentesis only
Bleeding disorder suggested by unexpected bleeding (spontaneous or from venepuncture
sites)
Coagulopathy
Platelets <50 109/L
Infected ascites <48 hr after starting treatment with antibiotics
Previous abdominal surgery
Table 1: Causes of ascites
Common
Rare
Cirrhosis
Abdominal cancer, especially ovarian and
lymphoma
Heart disease (esp. constrictive pericarditis)
Tuberculous peritonitis
Non-cirrhotic portal hypertension
Hepatic vein occlusion
Severe hepatitis
Chronic pancreatic disease
Myxoedema
Chronic renal disease
Polyserositis (e.g. SLE)
Severe hypoproteinaemia of any cause
Benign ovarian disease
EQUIPMENT
Diagnostic sample:
syringe (20 mL) with green (21 G) needle
Aspiration of 50 mL:
dressing pack
skin antiseptic
selection of needles: 1923 G
selection of syringes: 5 mL for local anaesthetic; 50100 mL for aspiration
lidocaine 1% plain 5 mL
If paracentesis planned:
peritoneal type catheter or large IV cannula and fluid collection system for catheter
Specimen containers:
for ascitic WBC, either 4 mL EDTA tube to haematology or 10 mL sterile pot to microbiology
for biochemistry, 10 mL in plain container
for cytology, 1020 mL in universal container with 3.8% citrate anticoagulant (if unavailable,
use clotting studies bottle)
for microbiology, 10 mL in sterile universal container and blood culture bottles (aerobic and
anaerobic)
Tapping 2010-11
PROCEDURE

Ensure patients bladder is empty
Tapping ascites
Lie patient supine
Re-examine abdomen and select site where there is shifting dullness but no solid organs:
preferred sites are iliac fossae, away from inferior epigastric blood vessels and scars, or
suprapubic area
Don mask and sterile gloves
Cleanse skin and infiltrate 36 mL of lidocaine into anterior abdominal wall down to parietal
peritoneum
Attach long, fine needle (1923 G) to large syringe and introduce needle into abdominal
cavity. Keep puncture in abdominal wall as small as possible
Aspirate gently if tip of needle correctly placed, fluid will flow easily into syringe; if no fluid
obtained, reposition either patient or needle
Remove up to 50 mL of fluid, withdraw needle, and apply simple dressing (in patients with
suspected TB, take much larger quantities of fluid and use centrifuged deposit to isolate
causative organism)
Paracentesis
Follow tapping ascites procedure then:
introduce catheter
allow free drainage in sterile collecting system
drain to dryness or remove catheter after 8 hr free drainage
infuse albumin 20% 100 mL IV immediately, and give further doses for every 3 L of fluid
drained
Troubleshooting
If no fluid aspirated (failure to enter peritoneal cavity, perforation of a viscus, or occlusion of
the end of the needle by a piece of omentum), reposition tip of needle and continue to
aspirate while withdrawing needle slowly. It is reasonable to make two attempts on each side
of the abdomen
If no fluid obtained after these manoeuvres, request ultrasound scan to confirm presence of
ascites, and to indicate best approach to small quantity of loculated fluid, or ask radiologist to
aspirate sample under direct scan guidance
SPECIMENS
Note appearance of fluid. Cloudy fluid often signifies peritonitis; uniform bloodstaining is most
often found in patients who have a cancer or who have suffered trauma to abdomen; milky
fluid indicates chylous ascites
Send samples for cytology, cell count, protein concentration, and, in selected cases (if clinical
suspicion of infection), enzyme estimations and bacteriological culture
AFTERCARE
If several litres of fluid have been removed, record pulse and BP hrly for 4 hr
Stop diuretics for 24 hr
Persistent leakage through puncture wounds is sometimes a problem. A stitch may be
needed. Keep puncture in abdominal wall as small as possible and remove sufficient fluid to
reduce pressure in abdominal cavity
SB Tube 2010-11
INSERTION OF SENGSTAKEN-BLAKEMORE
TUBE
Insertion of a Sengstaken-Blakemore (S-B) tube can cause serious morbidity
Not to be performed by inexperienced operators
The S-B tube has a gastric balloon and, in one model, an oesophageal balloon and channels that
allow irrigation and suction of stomach and oesophagus. Depth markings appear on body of tube;
total tube length is 110 cm and distance from distal tip to centre of oesophageal balloon is 23 cm.
There is a tip-to-tip radiopaque line and a radiopaque marker in distal tip that assists in
radiological evaluation of placement
INDICATIONS
Control of massive haemorrhage from oesophageal and gastric varices not controlled by
drugs see Acute upper gastrointestinal haemorrhage guideline
CONTRAINDICATIONS
Known oesophageal disease, such as tumours and oesophageal diverticula
EQUIPMENT
Non-sterile gloves, plastic apron

Two 50 mL bladder catheter tipped syringes appropriate to tube
S-B tube
Lubricant gel
4 non-toothed clamps
Endoscopy mouthpiece
Adhesive tape
Sphygmomanometer
Ice to aid swallowing
Lidocaine spray 2%
SB Tube 2010-11
Midazolam (low-strength) 1 mg/mL in 2 mL or 5 mL ampoules (optional in agitated patient

see below)
PROCEDURE
Consent
Explain procedure to patient
Premedication
Spray throat with lidocaine 2% spray
Midazolam 12 mg by slow IV injection over 1 min may be used in agitated patient to produce
light sedation for period of intubation
Preparation and position of patient
Remove tube from sterile packaging
Identify oesophageal (if present) inflation and aspiration lumina, and gastric inflation and
aspiration lumina, as identified on nipples at the proximal end of the S-B tube
Test inflate oesophageal (if present) and stomach balloons, using 50 mL syringe filled with
air. After test inflation, aspirate all air from both balloons
Lubricate distal 10 cm of tube with lubricant gel
If patient lucid and conscious, pass tube with patient seated; if unconscious, prefer left lateral
position
Use either nasogastric or orogastric (OG) routes. If OG route chosen, use endoscopy
mouthpiece to ensure patient does not chew on tube, thereby perforating it
Insertion of tube
Advance tube slowly, either through nostril or over tongue through mouthpiece, until
approximately 10 cm has been passed. At this stage, encourage conscious patient to take
small sips of water and to swallow while tube is advanced slowly. This technique encourages
tip to pass into oesophagus
Graduated markings are evident on outer surface of tube. Once 50 cm of tube has been
passed through mouth, check it is in stomach by injecting 20 mL of air into gastric lumen and
listen for air entering stomach, or check for aspiration of gastric contents
Once position confirmed, inflate gastric balloon with 250 mL of air, or X-ray contrast and
glucose 5% (half and half), using 50 mL syringes. Clamp gastric lumen tube
Apply firm traction at mouth or nostril and fix tube in position taping it to face, so that gastric
balloon snuggles firmly against diaphragm. An option is to apply traction to tube over head of
bed, using weight of no greater than 500 g (e.g. 500 mL bag of IV fluid). Vigorous traction is
not necessary
Check position with chest X-ray
Further bleeding
If bleeding continues and S-B tube has oesophageal balloon, inflate oesophageal balloon
with air to pressure of 40 mmHg, using sphygmomanometer. The inflated oesophageal
balloon is now in optimal position to produce oesophageal tamponade. Deflate oesophageal
balloon for 5 min/hr
Leaving gastric aspiration channel on free drainage, apply intermittent suction to oesophageal
aspiration lumen to remove oral secretions that accumulate above oesophageal balloon in
oesophagus
If bleeding continues (red blood in gastric aspirate) check that:
oesophageal balloon is inflated
gastric balloon is pulled firmly against diaphragm
an alternative lesion has not been overlooked
SB Tube 2010-11
AFTERCARE
Check traction or position of tape on face every hour

Maintain free gastric aspiration or low pressure continuous aspiration using a pump
Apply intermittent aspiration to oesophageal aspiration channel to minimise accumulation of
secretions in oesophagus
After approximately 24 hr, deflate oesophageal balloon (if used) to avoid mucosal injury and
oesophageal ulceration. If there is no evidence of re-bleeding, deflate gastric balloon after a
further 2 hr and disconnect traction. Wherever possible, leave tube in position for a further 24
hr to allow re-inflation if rebleeding occurs
Medication or liquid nutrients can be instilled via gastric aspiration channel
EXTUBATION
Disconnect tube from all suction sources

Clamp gastric and oesophageal aspiration lumina to prevent liquid within tube from escaping
and being inhaled at time of extubation
Deflate both balloons by inserting 50 mL syringe into self-sealing connectors, and evacuating
completely all air in balloons with syringes
During extubation, encourage patient to take deep breath and exhale slowly
Withdraw tube with one continuous motion
COMPLICATIONS
Perforation of the gastric balloon may allow proximal migration of oesophageal balloon into
pharynx, causing respiratory embarrassment
keep a pair of scissors near patient at all times. Should respiratory obstruction become
apparent, cut through entire tube immediately and remove it, remembering to grasp tube
between the patient and scissors at the time of transaction
Oesophageal rupture or ulceration
Balloon migration
Arterial puncture 2010-11
ARTERIAL PUNCTURE
INDICATIONS
Moderate or severe respiratory failure

Patients with severe respiratory or cardiac disease scheduled for major abdominal or thoracic
surgery
Suspected acid-base disturbance
Suspected carbon monoxide poisoning
Emergency blood sampling when venepuncture impossible
CONTRAINDICATIONS
See Table 1
Consider risks and benefits in patients with bleeding diathesis
EQUIPMENT
Non-sterile disposable gloves

Alcohol swabs or other antiseptic solution
Lidocaine plain 2 mL 1% and 25 or 27 G needle
Blood gas syringe (Pulsator) with 23 G needle
Plastic syringe cap
Cotton wool balls to press over site after arterial puncture
PROCEDURE
You must be supervised by an experienced doctor until you are familiar with, and
competent to perform, procedure
Consent
Preparation
If blood gas analysis not going to be performed within a few minutes, have an ice bag ready
to cool sample
Check concentration of O 2 patient is breathing at time arterial sample is taken and that it
remains constant for 15 min before sampling; note it on request form, in patient notes and on
results printout
Note patients temperature on request form
Aseptic technique and position of patient
Select site of puncture see Table 1 and Figure 1 and position patient
Wear gloves, cleanse skin
Local anaesthetic
Palpate artery and infiltrate skin on each side of artery with lidocaine plain 1% 0.51.0 mL
Always aspirate before injection of local anaesthetic to prevent injection of lidocaine into
the artery
Sampling
Hold blood gas syringe with 23 G needle, bevel up; for radial (Figure 1) and brachial arteries
at about 30 to skin surface; for femoral artery at 60
Advance needle towards artery; with special blood gas syringe, blood pulsates into syringe
If shooting pain felt, nerve may have been entered. Remove needle and redirect
If no blood obtained, withdraw needle slowly, observing for pulsation at base of needle;
arterial blood often enters during withdrawal
If necessary, try once more. If unsuccessful, seek help
Obtain 1.52 mL blood a smaller volume may suffice for immediate analysis
Withdraw needle
Apply pressure to site for 5 min, or longer if site bleeds
Dispose of needle in sharps bin
Remove bubbles in syringe by holding bevel up and gently tapping side and pushing plunger
up
Cap syringe
If source of blood (arterial/venous) uncertain, take heparinised venous sample for comparison
Figure 1: Needle positioning for radial artery puncture
Table 1: Differences in technique, advantages, disadvantages and contraindications

among puncture sites
Artery
Positioning of
patient
Angle of
needle to
skin
()
Puncture site
Radial
Arm extended
and supported
on pillow with
wrist extended
20
30
Proximal to
proximal
transverse
crease and on
lateral aspect of
wrist
Brachial
Arm extended
and supported
on pillow
30
Medial to biceps
tendon in
antecubital
fossa
Important
anatomical
structures in
proximity
to puncture
site
Median nerve
medial
Advantages
Disadvantages
Contraindications
Easily
accessible
Easily
compressible,
therefore useful
if there is
known bleeding
tendency
Venous
sample may
be obtained
Easily
accessible
Theoretical
risk of
ischaemia.
Venous
sample
easily
obtained
Buerger's
disease
Raynaud's
disease
Arteriovenous
dialysis shunt
present or
imminent
Absent ulnar
collateral
circulation
Arteriovenous
fistula in arm
Elbow fractures
Femoral
Supine
60
Mid-inguinal
point 2 cm
below inguinal
ligament
Femoral
nerve lateral
Femoral vein
medial
May be only
quickly
accessible
artery in
shocked
patient
Venous
sample
more likely
than at other
sites
Severe
peripheral
vascular disease
Aortofemoral
bypass surgery
SPECIMEN
Take sample to nearest blood gas analyser, enter appropriate data (e.g. patients
temperature) and inject directly from syringe
If blood gas analysis can be performed within 10 min of removing sample from patient, do not
cool sample during this period
If a greater delay inevitable or sample is to be sent to the laboratory, cool syringe and its
contents with ice, but re-warm to body temperature before analysis, to minimise errors
caused by continued metabolism of white cells within blood sample
Ensure printed record displays patients name, unit number and inspired O 2 concentration
Pleural aspiration air 2010-11
PLEURAL ASPIRATION OF AIR

INDICATIONS
Treatment of pneumothorax see Spontaneous pneumothorax guideline for when to use

technique
EQUIPMENT
Pneumothorax simple aspiration pack plus:

cleansing pack
gloves
gown
lidocaine 1% plain maximum 10 mL
PROCEDURE
Consent
Obtain and record writtenconsent
Site of insertion and position of patient
Check site of entry on chest X-ray
Use safe triangle approach or alternatively 2nd intercostal space mid-clavicular line.
Support patient with head of bed elevated to about 30 (arm behind head if axillary approach
chosen) or sitting edge of the bed
Aseptic technique and local anaesthesia
Scrub up and prepare patient's skin
Infiltrate local anaesthetic down to pleura
Aspiration of air confirms pneumothorax
Insertion of cannula
Enter pleural cavity with cannula attached to a 10 mL syringe
Withdraw needle from cannula when air is freely aspirated
Connect cannula via plastic tube to 3-way tap and a 50 or 60 mL syringe
Withdraw air until no more can be aspirated or to a maximum of 2.5 L (50 mL 50) whichever
is achieved first
STOP if resistance is felt or patient coughs excessively
If resistance is felt when only a small amount of air has been aspirated, cannula may be
kinked: remove it and repeat procedure
AFTERCARE
Apply small adhesive dressing over puncture site

Repeat chest X-ray aspiration successful if pneumothorax smaller or resolved
If unsuccessful and <2.5 L of air aspirated, consider repeating if patient has no chronic lung
disease
Pleural biopsy 2010-11
PLEURAL BIOPSY
INDICATIONS
Diagnosis of a pleural effusion

Reserve this procedure for pleural effusions where tuberculosis is suspected or patient
too frail to undergo thoracoscopy
CONTRAINDICATIONS
(All relative discuss with consultant)
Severe bullous emphysema or chronic obstructive pulmonary disease (COPD)
Impaired blood clotting
Suspected mesothelioma
EQUIPMENT
Pleural biopsy pack plus:

gloves
gown
lidocaine 1% plain maximum 10 mL
SPECIMEN BOTTLES
Saline bottle for tubercular culture

Formalin 10% for histology
PROCEDURE
Review chest X-ray (PA and lateral)
Consent
Seat patient on bed or chair leaning slightly forward with arms folded and resting on a pillow,
placed on a support such as a bed table
Examine patient and mark site. Easiest site, when fluid not loculated, is posterior chest wall
medial to angle of scapula, one interspace below upper limit of dullness to percussion
Avoid site where pyoderma or herpes zoster present
Scrub up and prepare patient's skin
Infiltrate skin with lidocaine using orange needle
Palpate intercostal space, infiltrate (using green needle) 1020 mL of lidocaine to parietal
pleura and periosteum of lower rib, and into pleural space once fluid aspirated
Avoid inferior border of upper rib
Blunt dissection
Note thickness of chest wall to pleura
Make 1 cm horizontal incision in skin
Careful blunt dissection with forceps through intercostal muscles
Pleural biopsy 2010-11
Introduce closed needle (either Abrams or Raja depending on local Pleural biopsy pack)
through parietal pleura with a slight rotary movement
When notch is closed, needle is airtight. To prevent air entering pleural space, make sure
that a syringe or closed 3-way tap is attached before notch is opened
Taking samples
Abrams needle
Attach fresh syringe to needle. Notch on Abrams needle faces same way as spherical
marker on tube. Face marker along line of intercostal space (to the left if operator right
handed) NEVER UPWARDS
apply lateral pressure towards marker with forefinger. Slowly withdraw needle until resistance
is first felt. Hold needle firmly and sharply twist grip of inner tube clockwise to take specimen.
Withdraw needle with slight rotary action as patient exhales
Raja needle
Point flat surface upwards to ceiling. Attach fresh syringe to needle. Turn needle 180
clockwise in closed position. Keeping proximal hub fixed, move distal hub over it
anticlockwise. This will open latch in downward direction
withdraw needle towards chest wall until resistance felt. Aspirate pleural fluid with syringe to
make sure that needle is in pleural space. Turn distal hub clockwise to close needle and
secure specimen. Withdraw needle with slight rotatory action as patient exhales
For both needles
Open needle and retrieve specimen with harvester provided (Raja) or needle (Abrams)
Cover entry site with gauze swabs as needle emerges
Place specimen from inner tube or tip of needle in appropriate bottle
Repeat biopsy four-times for histology
COMPLICATIONS
Pain at site of biopsy

Pneumothorax
Faint
Haemothorax
Haematoma
Transient fever
SPECIMENS
Send to laboratory as soon as possible:

Histopathology:
biopsy in formalin 10% for histology
Microbiology:
biopsy in saline bottle for tubercular culture
AFTERCARE
A small adhesive dressing over puncture site

Chest X-ray check for pneumothorax. If present see Spontaneous pneumothorax
guideline
Intercostal Pharmacist 2010-11
INTERCOSTAL TUBE DRAINAGE

(FAMILIRISE YOURSELF WITH LOCAL CHEST DRAIN POLICY)
If ultrasound machine and ultrasound trained personnel available, perform procedure
under ultrasound guidance
Intercostal tube drain insertion should not be performed by unsupervised inexperienced
operators
INDICATIONS
Drainage of pneumothorax see Spontaneous pneumothorax guideline for when to use

technique
Therapeutic drainage of fluid from pleural space
CONTRAINDICATIONS
(All relative discuss with consultant)
Impaired blood clotting
Suspected mesothelioma
Post-pneumonectomy space
SELDINGER CHEST DRAINS

Equipment
Chest drain pack
Sterile gloves,
Lidocaine 1% plain 10 mL with another 10 mL on standby in case needed
Morphine 10 mg in 1 mL and naloxone 400 mcg in 1 mL
Underwater seal drainage bottle and tubing
Skin antiseptic.
PROCEDURE
Consent
Obtain and record written consent
Premedication
Consider premedication morphine 510 mg IM
If respiratory depression occurs, give naloxone 100 microgram IV. If response unsatisfactory
or unsustained, repeat naloxone 100 microgram IV every 2 min
Check correct site on chest X-ray for simple pneumothorax, usual site fourth or fifth
intercostal space (ICS), mid-axillary line which is within safe triangle, bordered by anterior
border of latissimus dorsi, lateral border of the pectoralis major, a line superior to the
horizontal level of the nipple and apex below axilla
site must be just above rib
Support patient with head of bed elevated to about 30 , arm behind head or sitting at edge of
the bed leaning on a table
Mark site

Scrub up and clean patient's skin over a wide area with skin antiseptic
Intercostal Pharmacist 2010-11
Check all equipment fits adequately

Palpate intercostal space, infiltrate with 1020 mL of lidocaine to parietal pleura and
periosteum of lower rib, and into pleural space once fluid/air can be aspirated (see box
above)
Insertion of drain
Small and medium bore drains (1026 F)
Prefer Seldinger technique, which avoids need for blunt dissection
use a needle and syringe to localise position by identification of air or fluid. Pass guidewire
down hub of needle, remove needle and enlarge track with a dilator. Pass drain into thoracic
cavity along the wire
never use a trocar to dissect tissues during chest drain insertion
tie securing suture
AFTERCARE
Prescribe adequate analgesia indometacin 50 mg orally 8 hrly or co-codamol 8/500 2 tab

orally 6 hrly for first 2448 hr, then as needed
Repeat chest X-ray within 2 hr
For care of intercostal tube and underwater seal see Spontaneous pneumothorax
guideline
Remove only 11.5 L of fluid at any one time due to danger of re-expansion pulmonary
oedema
REMOVAL OF DRAIN
Once bubbling from pneumothorax (see Spontaneous pneumothorax guideline) or drainage

of fluid has stopped for at least 24 hr, cut drain-securing suture, withdraw tube while patient
holds breath in expiration, and close wound with remaining sutures
if malignant effusion, attempt talc pleurodesis before removal, to reduce rate of recurrence
see Pleurodesis guideline
Long lines John 2010-11
INSERTION OF LONG LINES

INDICATIONS
>5 day IV access required (e.g. antibiotics for CF in hospital or at home)

if less than <10 days required, use 8 cm Leaderflex
If risk of phlebitis or infection (e.g. parenteral nutrition) unacceptable, use long line with tip of
line in central vein
CONTRAINDICATIONS
No suitable veins for insertion of catheter
EQUIPMENT
Assistant
Long line. There are several types in common use: choose widest bore possible
Vygon PICC 3, 4 or 4.5 F, 60 cm Lifecath (Expert silver coated)
Vygon Nutriline 2, 3 or 4 F, 30 cm
Leaderflex 22G (2.5 F) line 8 cm or 20 cm
Vygon Neocath or Epicutaneo-cave catheter 2 F (23G) 50, 30 or 15 cm has different
insertion technique, not recommended for adults
DO NOT ATTEMPT INSERTION UNLESS YOU ARE FULLY TRAINED
Use whichever line you have been trained to use
Flush solution: 5 mL sodium chloride 0.9%

Single dressing pack
Sterile gloves
Sterile scissors
Two extra sterile towels
5 mL syringe/green needle
Tape measure
Sterile semi-permeable transparent dressing (e.g. Opsite/Tegaderm)
Incontinence pad
Two extra packs gauze swabs
Alcoholic chlorhexidine (or other skin antiseptic)
One injectable bung
Three wide Steristrips (optional to secure line)
Sterile untoothed forceps (to feed line through butterfly)
PROCEDURE
Preparation
Check patients notes for comments about previous line insertions. Some veins can be
particularly difficult and patient can often provide guidance
Comment [J1]: In this diagram, the line

identifying the median basilic vein does not
seem to end oa vein.
The correct line is in printed
guideline MK
Assess whether patient will need sedation and arrange appropriate person to administer.
Rarely, patients with needle phobia will need general anaesthetic
Arrange for EMLA cream to be applied to specified veins at three different sites at least 1
hr before starting procedure the median basilic vein (see figure) is usually best (avoid
femoral if possible because of higher infection risk)
If necessary, shave patients arm to avoid hair plucking when dressing is removed
Check whether blood samples are required
Gather all necessary equipment including a spare line (unopened)
BP cuff inflated to 80 mmHg is more reliable tourniquet than either an elastic strip or an
assistants squeeze
Consent
Premedication and position of patient
Position patient seated in chair or lying with his/her arm stretched out and supported by
table or bed (on utility drape)
ensure patient in position and comfortable, and lighting optimal
Measure distance from site of insertion to sternal notch (if inserting in arm) or xiphisternum
(if inserting in leg) so catheter tip is placed outside heart
Aseptic technique
Wash hands, and put on sterile gown and sterile gloves
Clean patients skin thoroughly with alcoholic chlorhexidine in area of planned insertion for
at least 30 seconds and allow to dry
Drape sterile sheet to expose only chosen vein, and cover surrounding areas to provide
working room and a flat surface on which to rest your line, forceps and flush
Vygon Nutriline PIC line
Assemble line fully and flush with 1 mL sodium chloride 0.9% to ensure patency
Place everything you will need onto sterile sheet within reach
Ask assistant to apply tourniquet (or squeeze patients arm), but remain ready to release
Check patient ready for you to start
Be careful introducer for this line is much stiffer than standard cannula and more likely
to perforate entire vein
Insert peelable cannula until blood flowing freely. It is not necessary to thread needle into
vein. In some patients, this will come quite quickly so have catheter ready
Ask assistant to release tourniquet to reduce blood flow
Taking PIC line in forceps, pass it up through cannula. At about 5 cm, you will reach tip of
the cannula. If line passes easily beyond 6 cm, you have probably succeeded. Resistance
at any point usually indicates failure to thread vein, or curling of line. If butterfly needle will
not thread more than 5 cm, rotation so that bevel faces downwards may help to introduce
line into vein
Insert line to previously measured distance from site of insertion
When tip of line judged to be in correct position, carefully withdraw sheath and remove
from around line by pulling two blue wings apart
Pressing firmly on insertion site with piece of gauze, remove cannula
Without releasing pressure on entry site (it may bleed for a few minutes), reassemble line
and flush with 4 mL sodium chloride 0.9%
With sterile scissors, cut rectangle of gauze (1 2 cm) to prevent hub of line rubbing skin
Check all connections firmly tightened. Coil any unused line next to insertion site and
secure with Steristrips
Cover entry site, connections and all exposed line with one piece of clear dressing (e.g.
Opsite)
If patient has no history of allergy to iodine, arrange X-ray to check tip position
if patient fit enough to be moved, transfer to Imaging department, otherwise request
portable X-ray on ward
immediately before taking X-ray, inject 0.5 mL of contrast (e.g. Omnapaque 240) into line
see Prevention of contrast-induced nephrotoxicity guideline
if tip near heart or if no blood flushes back up line, do not draw blood back up line this
increases risk of line blockage
Flush once more and line is then ready to use
Leaderflex lines
Inserted by Seldinger technique:
Cannulate target vein with either needle provided or blue cannula
Feed guidewire into vein through cannula sheath and remove sheath leaving wire in situ
Feed line over guidewire but before line enters skin ensure wire can be grasped at hub. A
gentle twisting action may help line into vein
Remove guidewire and secure line in place
It is not necessary to verify position of 8 cm lines radiologically
LONG LINE CARE
Keep dressing clean and intact

Maintain aseptic technique for accessing system and dressing changes. Before accessing
system, disinfect hub and ports with disinfectant compatible with catheter (e.g. alcohol or
povidone iodine)
Assess site at least daily for any signs of infection and if signs of infection are present. If
short term CVCs, remove; if long term CVC, discuss with consultant
Replace administration sets every 24 hr and after administration of blood, blood products
and lipids. Routine catheter replacement is unnecessary
Assess need for device daily and remove as soon as possible
Document insertion and all interventions in patient notes
Catheterisation 2010-11
URETHRAL CATHETERISATION
Patients who have previously undergone a radical prostatectomy should be catheterised
only by a urologist as urethral damage can easily occur
INDICATIONS
Temporary catheterisation:
to relieve acute retention of urine
to improve pelvic access during surgery
to measure urine output after major surgery and during major illnesses
Long-term catheterisation:
male patients with urinary retention and prostatic hypertrophy who are unfit for prostatectomy
some patients with neurological problems (e.g. multiple sclerosis, myelodysplasia, or spinal
trauma, where intermittent self-catheterisation not feasible)
in elderly or severely incapacitated incontinent patients as a last resort
CONTRAINDICATIONS
Suspected urethral injury after pelvic trauma (refer to urologist)

Urinary tract infection (avoid catheter if possible)
EQUIPMENT
Sterile gloves, and sheet of water-repellent paper with hole cut in centre
Dressing pack with cotton balls, gauze swabs, galley pots
Skin antiseptic
Tube of anaesthetic gel or syringe of Instillagel (lidocaine 2%, chlorhexidine 0.25%)
Appropriate urethral catheter (see Choice of catheter)
10 mL syringe filled with sterile water
Kidney dish
Measuring jug
Drainage bag
Choice of catheter
Use catheter appropriate to task for which it is required.
NB female catheters exist that are shorter than standard catheters. They must not be used
in men as balloon will damage urethra
Short term (up to 14 days) use Foley

Longer term use silicone (Silastic) with inflatable balloon
12F or 14F is usually suitable for women
14F or 16F is usually suitable for men
Use silver-coated catheters for:

ICU patients
renal patients
surgical patients who require catheters for 57 days post-op
patients colonised with multi-resistant organism
patients for whom infection control team has recommended this choice
PROCEDURE
Consent
Male catheterisation
Preparation
Lie patient supine
Open sterile pack
Don sterile gloves
Assistant should open catheter, syringe, antiseptic/sodium chloride 0.9% onto pack. Operator
then draws up water into syringe and keeps sterile
Place sterile towel to protect area
Use left hand to hold penis and right hand to insert catheter
Clean penis with swab soaked in sodium chloride 0.9% or antiseptic. Retract prepuce as
necessary and clean glans
Insert syringe with Instillagel into urethra
Massage gel carefully down urethra to sphincter. Gently compress distal urethra to prevent
gel escaping
Allow at least 5 min to elapse before proceeding to catheterisation
Procedure
Hold penis vertically at commencement of catheterisation
As catheter advanced into bladder, gradually pull penis downwards to straighten urethra and
to align catheter with prostatic urethra. Urine will begin to drain if present
If procedure difficult or painful, or bleeding occurs, abandon procedure
Advance catheter another 4 cm after urine starts to drain
Inflate catheter balloon with 510 mL water. This should not cause any pain or bleeding
Connect catheter bag
Gently withdraw catheter until there is resistance
Replace prepuce to avoid danger of paraphimosis
Female catheterisation
Preparation
Lie patient supine
Place patients thighs apart, knees flexed and feet together
Open sterile pack
Don sterile gloves
Assistant should open catheter, syringe, antiseptic/sodium chloride 0.9% onto pack. Operator
draws up water into syringe and keeps sterile
Place sterile towel to protect area
Disinfect urethral meatus with an antiseptic swab
As female urethra is short, expect to use one third as much anaesthetic gel as would be
required in a male patient
Insert nozzle or syringe tip (Instillagel) into meatus and instil 45 mL of gel
Allow at least 5 min to elapse before proceeding to catheterisation
Procedure
Part labia to reveal meatus and insert catheter until urine clearly draining. Catheter will
usually pass without difficulty
Inflate balloon with 510 mL water
Connect catheter bag
COMPLICATIONS
Urethral
Failure of catheter to reach bladder obtain specialist help. Do not make further attempts
Bacteraemia or septicaemia, which may be caused by overmanipulation. As soon as
suspected, give broad spectrum antibiotic and fluids IV see Antibiotic Policy on Trust
intranet. Remove the catheter, if feasible.
Bleeding can occur, particularly if catheter inflated in urethra. Remove catheter, obtain
specialist help
SPECIMENS
Record volume of urine that drains after catheter inserted. Send aliquot for culture
AFTERCARE
Connect catheter to a closed drainage bag that is emptied as necessary

If system has to be opened (e.g. to change bag or to wash out clots occluding catheter), full
sterile precautions essential
Patients who have had chronic retention of urine sometimes have obstructive renal failure.
Catheterisation can be followed by a spectacular postobstructive diuresis with profound
metabolic consequences. Be prepared to start an IV infusion in these patients, who may
not be able to drink enough to replace their fluid losses. They are best managed by
urology team as inpatients
Remove catheter as soon as possible to minimise risk of infection, especially with
extended spectrum beta-lactamase producing Gram-negative bacilli (ESBL)
An indwelling catheter almost always leads to bacteriuria within two weeks. When bacteriuria
established, even the most intensive antibiotic treatment is unlikely to make urine sterile until
catheter removed or replaced
Bacteriuria associated with an indwelling catheter without clinical evidence of infection
does not require antibiotic treatment
Bladder irritation can produce severe and painful bladder spasms, and can cause bypassing
of urine alongside the catheter. Try reducing amount of fluid in balloon, or use smaller or less
rigid catheter
If there is leakage around catheter it is futile to replace with a larger one. This simply commits
patient to spiral of increasing catheter size. Urethra becomes steadily more dilated until it can
retain no catheter
Effective bladder washout for blood clots or debris is a specialised technique. Refer to
urology team
Removal of catheter
If catheter balloon fails to deflate when the time comes to remove it, do not try to burst it by
overdistension, as bladder may burst first. Refer to urology team
Do not cut catheter
Lumbar puncture 2010-11
LUMBAR PUNCTURE
INDICATIONS
Diagnosis (Table 1)
in suspected subarachnoid haemorrhage (SAH), perform lumbar puncture (LP) only if scan
negative in face of reasonable clinical suspicion, and at least 12 hr after onset of symptoms
(e.g. headache)
Introduction of contrast media see Prevention of contrast-induced nephrotoxicity
guideline
Introduction of chemotherapeutic agents (e.g. in leukaemia)
CONTRAINDICATIONS
Raised intracranial pressure (indicated by morning or postural headache, vomiting, and

papilloedema) request CT scan
danger is of fatal transtentorial or cerebellar coning
Suspected cord compression diagnostic LP does not distinguish intrinsic lesion (e.g.
multiple sclerosis) from extrinsic compression by disc or tumour; MR scan is investigation of
choice
Local sepsis puncture through infected skin carries risk of meningitis
Coagulopathy
Table 1: Indications for diagnostic LP

Indications
Suspected SAH
Myelopathies and suspected multiple
sclerosis
(but not if cord compression suspected)
Acute or demyelinating peripheral
neuropathies (e.g. Guillain-Barr syndrome)
Infections of CNS (e.g. bacterial meningitis,
tuberculosis, acute and subacute
encephalitides, neurosyphilis, viral, fungal,
and protozoal meningitis)
Meningeal infiltration
Suspected idiopathic (formerly benign)
intracranial hypertension
Tests
Blood, xanthochromia, protein, glucose
Protein, IgG or gammaglobulin,
oligoclonal bands (N.B. take paired blood sample)
Cells, protein
Gram stain, cells, protein, treponemal
haemagglutinating antibody (or other specific tests),
glucose, culture, special stains, and antibodies
Cytology
Opening CSF pressure
EQUIPMENT
Sterile gloves
Green sterile towel and drapes
Dressing pack with cotton balls, gauze swabs, galley pot
Skin antiseptic
Lidocaine 2% plain in 5 mL syringe with orange (25 G) and green (21 G) needles
LP needles (22 G): 3 and 3.5 inches long
Manometer
Specimen containers (three clear glass, one grey top plastic) for microscopy/culture, protein,
other tests (if indicated), and glucose, respectively
Adhesive dressing
PROCEDURE
Preparation
Appoint and brief assistant
Number the three clear glass bottles (1, 2, 3)

Consent
Explain procedure, inform patient of symptoms that may follow procedure, and reassure
Obtain and record written consent
Position of patient and puncture
Place patient on left side with back against edge of bed, neck slightly flexed, and both legs
drawn up towards chest. Consider placing pillow between patients legs to ensure that back is
perpendicular to bed, and raise bed to comfortable height
Palpate anterior superior iliac crest. L34 interspace is apparent as a palpable gap lying
perpendicularly beneath it, but L23 or L45 are equally acceptable sites. Mark skin over
chosen interspace about 1 cm inferior to tip of adjacent spinous process
Aseptic technique
Wash hands
Don gloves, cleanse skin and position sterile drapes
Assistant opens all packs including syringes and needle, shaking sterile contents on to sterile
towel
Check all equipment fits
Draw up lidocaine while assistant holds lidocaine bottle
Stretch skin evenly over interspace, infiltrate skin and deeper tissues with lidocaine (orange
needle for skin and green needle for deeper tissues), and allow at least 1 min for lidocaine to
work
Introduce LP needle at 90 to back, with bevel in sagittal plane (to minimise size of hole) and
pointing slightly towards head. Push through resistance of superficial supraspinous ligament
and negotiate interspinous ligament to meet firmer resistance of ligamentum flavum at about
47 cm, when an extra push results in a popping sensation as dura is breached and needle
enters subarachnoid space. Withdraw stylet and clear colourless fluid should drip out
Measure CSF pressure, then collect CSF specimens (see below) with assistant holding CSF
bottles
After CSF collected and while still sterile, replace LP stylet into introducer and withdraw LP
needle
Dry tap
If no fluid emerges or fluid does not flow easily, rotate needle a flap of dura may be lying
against bevel. If there is still no fluid, reinsert stylet and cautiously advance, withdrawing
stylet after each movement. Pain radiating down either leg indicates that needle is too lateral
and has hit nerve roots. Withdraw needle almost completely, check patient's position, and
reinsert in midline
If needle meets total obstruction, do not force it: it may be lying against an intervertebral disc
and could damage it. Again, withdraw, check position, and reinsert. If there is complete
failure, move one space up or down depending upon original position. Procedure may be
easier if patient is sitting up, although this would preclude measurement of CSF pressure
Dry tap usually results from faulty technique. After two or three attempts ask someone more
experienced for help. Rare causes of genuine dry tap are arachnoiditis, meningeal infiltration
and true low CSF pressure
Manometry
When CSF flows freely, measure pressure. Connect manometer to needle hub. Ask assistant
to hold top and record pressure (normal 80180 mm CSF). Height of meniscus should
change with respiration. Most common cause of low pressure is poor needle placement, but if
genuine do not try to aspirate as CSF flow may be obstructed by cerebellar tonsil herniation
or spinal block. In either case, seek a neurological opinion
slightly raised CSF pressure in very anxious or obese patient may be ignored. Pressures
>250 mm are abnormal and should be investigated. If greatly raised pressure is discovered in
clear fluid, collect CSF from the manometer to provide specimens. Ask patient to 'uncurl' to
see if pressure falls once abdominal compression relieved
if still raised despite this manoeuvre, withdraw needle immediately and seek neurological
opinion
Bloodstained tap
Collect bloodstained fluid in three tubes. In traumatic tap, blood forms streams in otherwise
clear CSF; the first three consecutive specimens show clearing of blood and usually become
less obviously coloured, with a corresponding fall of the red cell count. In subarachnoid
bleeding, CSF is usually diffusely bloodstained in all three tubes, but the three-tube test
should not be relied upon to exclude SAH
SPECIMENS
Requests depend on clinical problem (Table 1)
If taking CSF samples for both diagnostic microbiology and suspected SAH, take samples
for microbiology first
For diagnostic microbiology
For routine bacterial culture, always obtain 1 mL in sterile container
if TB meningitis suspected, obtain additional 1 mL for TB culture
if pre-treated with antibiotics and meningococcal meningitis suspected, obtain additional
1 mL in separate sterile container for meningococcal PCR
if herpes simplex virus meningo-encephalitis suspected, obtain additional 1 mL in separate
sterile container for HSV PCR
request other CSF PCR tests according to suspected pathogen(s)
send samples to microbiology lab
Suspected SAH
For diagnosis of SAH:
CSF into fluoride oxalate bottle for glucose and send to clinical biochemistry
CSF into plain bottle for xanthochromia and protein determination (minimum volume 1 mL).
Place last of three plain bottles to be filled in dark container and send to clinical
biochemistry
Provide following information with sample:
time between onset of symptoms and LP
results of CT scan xanthochromia screening will normally be performed only where CT scan
is negative
date of any previous LP xanthochromia screening misleading after recent LP
contact clinical biochemistry (4645), ask for senior member of staff or bleep duty biochemist
(143) and explain that CSF sample is being sent for xanthochromia screening
When taking samples of CSF for suspected SAH, also obtain a blood sample 57 mL in
serum separator tube (gold top) for determination of total protein and bilirubin
concentrations send to clinical biochemistry
AFTERCARE
Lying down after LP does not reduce the incidence of headache, which is best prevented by
careful technique, use of a small gauge needle and ensuring adequate fluid intake for
first 24 hr
postural headache (significantly worsened by sitting +/or standing from supine position and
improved by lying) occurs in about 2030% of patients, may be accompanied by vomiting,
and may not occur for three to four days manage by laying patient flat, bed tilted head
down, and liberal use of analgesics (paracetamol or codeine phosphate) with anti-emetics
(metoclopramide or domperidone). It usually lasts 3672 hr, but can occasionally persist for a
week
Knee aspiration 2010-11
KNEE ASPIRATION
For other joints see comments at end of this document
Knowledge of knee anatomy is essential
INDICATIONS
Diagnosis:
an acute hot joint of uncertain
origin must be aspirated
(before starting any
antibiotics)
often used in diagnosis of
chronic and subacute
articular pathologies
Treatments:
recurrent aspiration in
management of septic
arthritis
aspiration of tense effusions
of any cause
before therapeutic intraarticular corticosteroid
injection
Figure 1: Arthrocentesis of the knee. Medial approach
CONTRAINDICATIONS
No absolute contraindications to joint aspiration

Caution in patient with clotting disorder/taking anticoagulants (discuss with consultant)
Caution in patient with prosthetic joint (discuss with orthopaedic surgeon)
Avoid passing needle into joint through skin lesion (e.g. psoriasis), as this can lead to joint
sepsis
EQUIPMENT
Sterile dressing pack

Gloves
Skin antiseptic
20, 10 and 2 mL syringes, green and orange needles
Lidocaine 1% plain
SPECIMEN BOTTLES
Blood culture bottle for aerobic and anaerobic culture of synovial fluid
Plain sterile universal containers for Gram staining
orange top Lithium Heparin tube for white cell count for crystals (NB tube type: push on
orange top not screw on and no beads the tube for synovial fluid differs from the
paediatric biochemistry tube. Synovial cytology tubes are usually available in : A&E, ETU,
OPD)
PROCEDURE
Consent
Knee aspiration 2010-11
Position of patient and site of insertion

Ask patient to lie supine
Make sure muscles around joint are relaxed to minimise any discomfort from procedure.
Putting pillow under knee may help to relax it (but if the effusion is only small then try to
ensure knee fully extended as this will facilitate aspiration)
Identify margins of knee joint and patella
Mark a point (e.g. with thumbnail) 1 cm deep to mid-point of medial aspect of patella
Aseptic technique and premedication
Wash your hands, don gloves, prepare skin around knee
Infiltrate skin with lidocaine 1% using an orange needle (optional)
Sampling
Use no-touch technique. Insert green needle with 10 or 20 mL syringe horizontally at
previously marked point into gap between patella and femur and slightly upward towards
suprapatellar pouch. If there is only a small effusion, it can help to displace patella medially to
increase gap between patella and femur (Figure 1)
Aspirate while advancing needle and stop advancing if synovial fluid aspirated. Once fluid
begins to appear, it can be milked down by pressure with one hand over suprapatellar pouch
Once syringe full, detach from needle, leaving needle in joint. Empty syringe into specimen
bottles
Re-attach syringe to needle and re-aspirate. Aspirate joint to dryness
When aspiration complete, withdraw needle
A sticking plaster or Micropore dressing to skin is sufficient
Documentation
Record procedure in notes. Take care to document exact joint aspirated, and volume,
macroscopic appearance (frank pus, turbid straw-coloured fluid, frank blood, bloodstained synovial fluid, etc) and viscosity (viscous or thin) of fluid
SPECIMENS
Send synovial fluid URGENTLY in blood culture bottle and one plain sterile universal
container to microbiology
request urgent Gram stain
Send synovial fluid in lithium heparin tube (see above) container via Pathology to Dept
Osteoarticular Pathology, University of Manchester (tel / fax 0161 275 5266)
NB If uncertain re competency to perform this procedure seek advice from

Orthopaedic or Rheumatology team before proceeding
In the case of a small joint seek advice from Orthopaedic or Rheumatology
team before proceeding in general it will be necessary for someone
experienced in joint aspirations to perform aspirations of smaller joints
In the case of suspected septic arthritis of the hip joint contact Orthopaedic
team aspiration will need to be done under imaging guidance either by
Orthopaedic team or by Consultant Radiologist
Blood cultures 2010-11
COLLECTION OF BLOOD CULTURE

SPECIMENS
Blood culture specimens are essential in managing patients with serious infection
INDICATIONS
If systemic signs indicate blood stream invasion (e.g. systemic inflammatory response
syndrome, severe sepsis or septic shock, rigors or new confusion with or without
evidence of localised infection), obtain blood culture specimens
do not restrict blood culture specimens to patients who spike a fever (>38 C); patients
with sepsis, especially the elderly, may not have fever
If secondary infection with a new pathogen suspected or if antibiotics seem ineffective,
repeat blood cultures
How many sets?

Sepsis take two sets of blood culture specimens in first hour before starting antibiotics
Suspected endocarditis collect three sets of blood culture specimens at different times
in 24 hr
Collect blood culture specimens before starting antimicrobial drugs
EQUIPMENT
Blood culture bottles

each set of blood cultures comprises two bottles one aerobic and one anaerobic
If available, use vacuum-assisted blood collection system as it reduces risk of
needle stick injury
One sterile needle or butterfly to draw blood directly into blood culture bottles
20 mL sterile syringe
if venous access difficult or sampling from a central line, use a syringe for drawing blood
and two sterile needles for inoculating blood into culture bottles
ChloraPrep Frepp skin antisepsis
2 x Sanicloth 2% for cleaning blood culture bottles
Sterile examination gloves
Disposable plastic apron
Disposable tourniquet
Sterile gauze
Alcohol hand gel
Sticking plaster
Sharps bin
PREPARATION
Consent
Identify patient
Explain procedure
Collect equipment
See Equipment above
Phlebotomist
Use aseptic, non-touch technique at all stages of procedure
See www.clean-safe-care.nhs.uk
Blood cultures 2010-11
Wash hands (if hands already clean, alcohol gel may be used). Allow to air dry
Put on apron
Preparing culture bottles

Flip off plastic lid
Use a Sanicloth 2% to clean septum of each bottle and allow to dry before inoculation of
blood
to avoid false positive results, if using winged butterfly system mark bottles to ensure 10
mL of blood not exceeded
Select site
Apply disposable tourniquet
Select venepuncture site
percutaneous peripheral vein (non-cannula) blood samples are the best source of
contamination-free cultures
use femoral vein only if venepuncture not possible at other sites
Use cannula (e.g. arterial line, central line) samples for blood culture ONLY
when no other option or for evaluation of line sepsis
Prepping skin
Gently rub ChloraPrep Frepp applicator up, down and across intended puncture site for
30 sec and allow to dry for 30 sec
While skin disinfectants dry, put on sterile examination gloves (gloves must be worn to
protect phlebotomist. If there is need to re-palpate injection site after disinfecting skin,
sterile examination gloves allow asepsis to be maintained)
DRAWING/TRANSFER OF BLOOD CULTURES

Fill blood culture bottles before collecting samples for other tests (e.g. FBC). This
reduces risk of contamination from non-sterile containers
Perform venepuncture without re-palpating puncture site. Use either 20 mL syringe or

collect blood directly into culture bottles using vacuum device
If blood is being collected for other tests, always collect blood culture first
Collect 810 mL of blood into each bottle
If using a safety needle (regular straight or butterfly)

Inoculate aerobic culture first; draw blood directly into bottle (or syringe if venepuncture
difficult or sampling from a central line); hold bottle upright and use bottle graduation lines
to accurately gauge sample volume and collect sample
If using syringe
Inoculate aerobic culture first; do not change needle between sample collection and
inoculation
Post collection
Remove tourniquet
Apply sterile gauze to puncture site
Remove and dispose of old needle using sharps bin
Apply sticking plaster
Label blood culture bottles with patient name, date of birth, date and time sample taken
remove barcode label from culture bottles and place on path lab form
Remove gloves, clean hands and arrange transport of sample to microbiology laboratory
Document in medical notes that blood cultures have been taken include:
time and date of sample
name of person who took sample

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The Bedside Clinical Guidelines Partnership

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ACUTE POISONING/DRUG OVERDOSAGE

FLUIDS AND ELECTROLYTES

PRESCRIBING REGIMENS AND NOMOGRAMS

Compiled by : Dr. Phyu Wai

1. GUIDELINES ON THE MANAGEMENT OF COMMON MEDICAL CONDITIONS

2. PRESCRIBING REGIMENS AND NOMOGRAMS

New guidelines and major changes

Strong evidence from at least one systematic review of multiple well-designed

Extremely important as contrast-medium induced nephrotoxicity associated with:

If eGFR <60 mL/min

Daily monitoring of renal function for 4872 hr after procedure

Aggressive patient 2010-11

AGGRESSIVE AND VIOLENT PATIENTS

Spontaneous self-reporting of angry or violent feelings or fluctuating levels of consciousness

Carers warn of imminent violence:

increased restlessness, bodily tension, pacing, arousal

increased volume of speech, erratic movements

facial expression tense and angry, discontented

refusal to communicate, withdrawal

unclear thought processes, poor concentration

delusions or hallucinations with violent content

audible threats, or aggressive gestures

recognition of signs apparent in earlier episodes

PERSONAL (OWN) BEHAVIOUR

Maintain adequate distance

Do not attempt to deal with a violent patient on your own

Aggressive patient 2010-11

Assess using verbal de-escalation

retain that information long enough to be able to make a decision

use or weigh that information as part of decision-making process

Aggressive patient 2010-11

agitation, excitement, overt hostility or suspiciousness

Aggressive patient 2010-11

In cases of substance misuse, treat any symptoms suggestive of withdrawal see

Monitor vital signs

Pregnant woman 2010-11

MANAGEMENT OF A PREGNANT WOMAN WITH A

Anatomical and physiological changes in pregnancy result in altered:

PRACTICE AND ETHICS OF

Consider each patient on their own merits

Obtain advice from ward dietitian

If patient not eating sufficiently, consider tube feeding

Refer to ward dietitian and/or nutrition team

Indications for PEG insertion

neurological (e.g. stroke)

mechanical (e.g. oesophageal cancer)

To supplement inadequate intake where alternative measures have failed:

Contraindications to PEG insertion

oesophageal or gastric varices

ETHICS AND CONSENT

Admin of blood 2010-11

ADMINISTRATION OF BLOOD AND BLOOD

Jehovah's witnesses: Transfusion without consent is a gross physical violation. Discuss

Check patient identification details these must include:

REQUESTING BLOOD PRODUCTS

Admin of blood 2010-11

Each patients identification wristband must display their:

Do not use addressograph stickers for sample labelling

Send samples to blood transfusion laboratory

Admin of blood 2010-11

The units are received by a doctor/registered practitioner who:

Admin of blood 2010-11