 PROCEDURES   ID NOTES 

PIGTAIL THORACENTESIS DENGUE HEMORRHAGIC FEVER

3 way stopcock #1 Sterile gloves s7 #2 Grade I Fever + dec plt + hemoconc + tourniquet test
Macroset #1 50/30cc syringe–Luerlock Grade II w/ Spontaneous Bleeding
Gauge 19 needle #1 Macroset Grade III w/ hypotension, weak pulse
Abocath g 16 #1 Cotton applicator #3 Grade IV w/ Shock (DSS)
Blade 11 with stab knife Sample Specimen bottle #2 SIRS
Gloves sz 7 1 Li bottle #1 T<36 to >38, RR >24, CR >90, WBC <4,000 >12,000/uL
10 cc syringe Lavender top #1 ABSOLUTE NEUTROPHIL COUNT
30 cc syringe 3 way stopcock #1 (bands/stabs + segmenters) x WBC x 100
1 L bottle Gauze ABSOLUTE RETICULOCYTE COUNT
2 specimen bottles Micropore tape % Retic x (hct/45%)
Lavender top 10 ccc syringe #1 Retic Ct: NV 1-2%
Betadine Lidocaine #1
Micropore Betadine #1

 RHEUMA NOTES 
Inter-J drainage bag Abbocath gauge 16 #1
2 % Lidocaine #3 Sterile eye sheet
Sterile gauze #4
Cotton applicator #2
Boston scientific flexima F10 #1
Cook dilator F 10 #1  GASTRO NOTES 
Angiodyne guidewire 0.035 x 150 #1
Leucoplast PEPTIC ULCER DISEASE
BMA H. pylori Regimen: Tx Duration:
ARTHROCENTESIS Clarithro 500 BID, Omep 20 BID, Amox 1g BID 10-14d
Sterile gloves s7
Gauge 19 needle #1 Metro 500 BID, Omep 20 BID, Clarithro 500 BID 10-14d
10 cc syringe #4
Lidocaine polyamp #1
Gauge 19 needle #1
10 cc syringe #5 Labs: CBC, UGIS/ Endoscopy, HBT UTZ panc, Amylase, Na, K, Ca, ECG
Lidocaine polyamp #3
Lavender top #2
Cotton applicator #1
Red top #1 Other Meds: H2 Blockers, PPI, Sucralfate, Antacids
Betadine #1
Kelly forceps #1
Sterile OS 4x4 #5
Cotton applicator #1
Sterile eyesheet #1
Betadine #1
Glass slides #10
 RESIDENCY NOTES 
Band aid
Green top tube #2
Standby blood culture bottles, aerobic
Micropore
and nonaerobic
Specimen cup with formalin #1

 NUTRITION & FEEDING 

TOTAL CALORIE REQUIREMENT
TCR=IBW x % act = kcal/day
% act: 45 heavy, 40 mod, 35 light, sedentary 30, 27.5 bed rest
if obese: subtract 500-1000 kcal/day to lose 1-2 lbs/week
if underweight: add 500-1000 kcal/day to gain 1-2 lbs/week
TCR DISTRIBUTION
60% CHO, 15% CHON, 25% fats
kcal to g: Divided by: 4-4-9
RENAL DIET
1800 kcal/day, 50 g high quality CHON with NPCR (normalized protein
catabolic rate), 50% CHO, 50% fats, 3.5 g Na, 3 g K, < 300 mg cholesterol, div
into 3 meals and 2 snacks
DIABETIC DIET
Full, 2000 kcal/ day 50% CHO, 25% CHON, 25% fats. <7% saturated fat, rest
from MUFA and PUFA, 3 g Na, 20 g fiber to be divided in 3 meals, 2 snacks
OSTEORIZED FEEDING
Start OF 1600 kcal/day, 60% CHO, 20% CHON, 20% fats; 60 g CHON of HBV,
divided into 6 equal feedings with 30 cc flushing q 4 OR 1 cal/cc divided into 6
equal feedings to run as drip for 1 hour per feeding

 HEMA NOTES 
EPO 50-100 u/kg/BW/wk
Anemia class by who
Vitamin K= 5 mg in 10 ml pNSS/ SIVP
Agrabulocytosis: DOC: Cefepime
Albumin T ½: 21 days
IV IRON (COSMOFER)
Incorporate 50mg into 50ml pnss into a soloset. infuse the above solution for
10 mins.
-refer for any untoward reactions
-if no adverse reaction noted after 30-45mins after the test dose. may give
the remaining 50mg cosmofer iv for 10mins.
  ENDO NOTES 
Insulin Adjustment
- If fasting mean blood glucose is > 140 in the absence of hypoglycemia,
increase insulin glargine by 20% everyday
TERMS
- if patient develops hypoglycemia, decrease glargine by 20%.
Hyperglycemia > 140 mg/dl; A1C > 6.5%
Hypoglycemia < 70 mg/dl
CBG monitoring
Severe hypoglycemia < 40 mg/dl
- CBG TID premeals and HS (q 6 if NPO)
< 50 mg/dl – cognitive impairment
Hba1C x 28.7 – 46.7 = estimated Average Glucose DIABETIC FOOT ULCERS
WAGNER
GLUCOSE TARGETS
Gr 0 – pre or post ulcerative lesions
Critically ill 140-180 mg/dl
1 – partial/ full thickness
Non-critically ill <140 mg/dl (pre-meals)
2 – probing to tendon or capsule
<180 mg/dl (CBG)
3 – deep with osteitis
Higher targets: terminally ill, severe comorbidities, frequent glucose
4 – partial foot gangrene
monitoring, close nursing supervision
5 – whole foot gangrene
DIABETES MELLITUS
DIABETIC KETOACIDOSIS / HYPEROSMOLAR HYPERGLYCEMIC SYNDROME
Diagnostics:
1 Inc RBS
FBS >126mg/dL (>7mmol/L)
2 Plasma Osm > 320 mOsm/L
OGTT / RBS >200 plus Polyphagia, Polydipsia, Polyuria
3 Metab. Acidosis
Goals: HgbA1c <6.5%
4 Ketonemia (+) in DKA
FBS 90-110 mg/dL
Peak Post-prandial <140 mg/dL
Labs: RBS, ABG, U&S Ketone, CBC, HgbA1c, U/A, Na, K, Cl, PO4, BUN, Crea,
Tx:
Amylase, CXR, ECG
Non-pharma: Diet, Exercise
Tx:
OHA
Fluids: IVF PNSS 0.5-5L in 1-7hrs @ 400-1000cc/hr til stable
Sulfonylureas: Glipizide B/TID, Glibenclamide (Older pt) 2.5-5mg OD/ BID,
Then Maintenance D5 0.3NaCl @ 100-200cc/hr
Gliclazide 80mg BID/TID
Insulin: Humulin R 5-15 u IV/IM q1 until CBG <250
Biguanides: Metformin 500 mg TID
Or Insulin Drip 2-10 u/hr til CBG <250, then Sliding scale
Alpha glucosidase Inh: Acarbose 50-100 mg TID w/ meals
Electrolytes: Hypo K <5.3, add 20-40 mEq KCl per Liter IVF
Thiazolidine: Rosiglitazone 4-8 mg OD
pH <7.1 give NaHCO3 IV
Insulin rapid: Lispro, Novolog, Aspart, Novorapid
O2 at 2-5 lpm
shoRt: Humulin-R, Actrapid HM, Humalog
iNtermed: Humulin-N, Monotard HM, Protophane HM, Lente THYROID STORM
Long: Humulin Ultralente, Ultratard HM, Lantus, Glargine Symptoms: Fever, Tachycardia, Sweating, N,V,D, Abd pain, Hypotension,
Insulin 1 U SQ (E.g. Actrapid) = Decrease 10mg/dL Blood glucose Restlessnes, Irritability, Delirium, Seizure, Coma
Labs: TSH, FT4, CBC, U/A, Na, K, Crea, CXR, ECG
DEFER INSULIN IF
Tx: IVF D5NM 8-12h, PTU 50mg/tab 100-200mg Q4-6 (Maint 50BID)
1. short acting insulin for CBG < 100 mg/dl
Propranolol 10-40mg TID-QID, Dexamet 2mg IV or PO Q6,
2. on NPO
KI 2-5 gtts PO Q8 few days only, Paracetamol, Digoxin, Sedatives
3. on HD
Basal insulin keeps sugar below 140
Prandial insulin keeps sugar below 140
Supplemental insulin if > 140
Start insulin drip if in ICU setting; SC insulin if non-ICU
RABBIT-2 TRIAL- INSULIN PROTOCOL
Basal Bolus with Insulin Glargine (Lantus) & Glulisine (Apidra)
- discontinue all OHAs
- total daily insuliln dose as follows if CBG on admission is:
140- 200 mg/dl: 0.4 u/kg/day
201-400 mg/dl: 0.5 u/ kg/day
If with comorbids, elderly, decreased appetite, possible nephropathy,
poor oral intake: 0.3 mg/dl
- give ½ total daily dose as insulin glargine (basal) and ½ as insulin
glulisine (prandial)
- give insulin glargine once daily at the same time of the day
- give insulin glulisine in 3 equally divided doses before each meal
- hold scheduled insulin glulisine if patient is not able to eat
ex#1: 60 kg male, CBG 180 mg.dl
60 x 0.4 = 24
ORDER: Give Lantus (basal) 12 units SQ OD at _____.
Give Apidra (prandial) 4 units SQ TID before meals as follows: (then
make the scale)
ex#2: 80 kg, male, CBG 301
80 x 0.5 = 40
ORDER: Give Lantus 20 units SQ OD at _____.
Give Apidra 6 units SQ TID before meals as follows
110-140 mg/dl 6u
141-180 10 u
181- 220 12 u
221- 260 14 u
261- 300 16 u
>300 18 u

Supplemental Insulin Scale

Sensitive Usual Resistant
110-140 P R A N D I A L D O S E
140-180 2u 4u 6u
181-220 4u 6u 8u
221-260 6u 8u 10u
261-300 8u 10u 12u
301-350 10u 12u 14u
351-400 12u 14u 16u
>400 14u 16u 18u
  DRIPS & IV PUSH 
HEPARIN
5000 units as IV bolus followed by 18 units/kg/h IV infusion via heparin drip as
D5W 19 cc + 1 cc (1:5000 units) at 23-24 cc/hr; (decrease by 3 units if PTT >
Flow= desired dose (mcg/kg/min) x wt (kg) x 60 min/hr
2x-3x)
Concentration (mcg/ml)
CARDIO
Heparin drip
Concn ratio Dopamine(mcg/ml) Dobutamine Levophed- Concn
1.5 – 2.5 = 0.2- 0.4 U/mL
1:1 800 1000 1 16
PTT 50 s = rebolus 5000 units and increase by 100 u/hr
2:1 1600 2000 2 32
50-60 s = increase by 100 u
4:1 3200 4000 4 64
60-85 s = no change
8:1 (central line) 8 128
85- 100 s = decrease by 100 u
ATROPINE 100- 120 s = stop for 30 mins, decrease by 100 units
Atropine 1mg IVP or 2-3mg ETT q3-5 until 0.04mg/kg or 3mg > 120 u = stop for 1 hr, decrease by 100 u
ADENOSINE
Adenosine 6mg rapid IV ff by 20cc NSS, then 12mg q1-2min up to 2 doses D5W 200cc + 10,000u Heparin @ 10-20ugtts/min
AMIODARONE LD 3,000-5,000u SIV
For SVTs, VTs STREPTOKINASE
150 mg/SIVP over 10-30 mins then start drip using 150-300 mg in 250 ml pNSS 1.5M u + D5W 90cc @ 100cc/hr
to run for 24 h PULMO
Prep: 150 mg/3 ml vial
AMINOPHYLLINE
IV loading: 5- 10 mg/kg BW/ 24h
D5W 250 cc + Aminophylline 250 mg/amp at 15-40 ugtts/min; Maintenance
500-1000 mg in 24h
drip of 0.4-0.8 mg/kg/hr is equivalent to 20-40 ugtts/min for a 50 kg person,
shd be reduced to 0.2-0.3 mg/kg/hr for elderly pregnant, CHF, liver dse, or cor
150-300mg IV in 10mins then 1mg/min infusion (300mg)x6hrs then
pulmonale. LD: 5 mg/kg/BW in 30 cc D5W in a soluset
0.5mg/min x18hrs
DOPAMINE D5W 250cc + Amino 250mg/amp, MD: 0.4-0.8mg/kg/hr
Renal dose 3-5 mcg D1 receptor ugtt/min = dose x Wt @ 15-40 ugtts/min LD: 5mg/kg in 30cc
Ino/Chronotropic 5-10 B1 receptor
TERBUTALINE (BRICANYL)
Max/Pressor 10-20 Deactivates A1 receptor
D5NSS 500cc + 10amp @ 15ugtts/min
(vasoconstriction, increase systemic vascular resistance)
SODIUM BICARBONATE
4:1 in 250 ml pNSS to run at 5 mcg/kg/min
Prep: 84 mg/ml x 50 ml = 50 meqs
Ex: 50 kg patient, desired dose at 5 mcg/kg/min = 4.5
Compute for HCO3 deficit
0.4 x BW in kg x (desired – actual HCO3)
D5W 250cc + Dopa 200mg/amp, 2.5-10mcg/kg/min
Give ½ as bolus, then ½ as drip
ugtts/min = (drip mcg x Wt) /13.3 @ 7-60ugtts/min Double dose: 2 amps
DOBUTAMINE
ORDER: Start Sodium Bicarbonate drip as follows: 1 amp in 250 ml D5W to run
4:1 in 250 ml pNSS to run at 5 mcg/kg/min
for 12 -24 hours
Ex: 60 kg patient, desired dose at 5 mcg/kg/min = 4.5
* if will use 3 amps, use 1 Li D5W
Rpt ABGs in 4-6 hours
D5W 250cc + Dobu 250mg/amp, 2.5-20ug/kg/min
If intractable metabolic acidosis – Hemodialysis
ugtts/min = (drip ug x Wt) /16.6 @10-60ugtts/min Double dose: 2 amps
Ex. Wt= 60 kg
NOREPINEPHRINE (LEVOPHED) ABG: pH 7.12/ pCO2 35/ pO2 88/ HCO3 9/ O2 sat 92%
4:1 in 250 ml pNSS to run at 0.2 mcg/kg/min NaHCO3 deficit= 216
Ex: 70 kg patient, desired dose at 0.2 mcg/kg/min = 13
ORDER: Give 100 meqs NaHCO3 IV bolus now, then start drip using 100 meqs
D5W 72cc + Levophed 2mg/2ml 4 amps, @1mg/kg/hr NaHCO3 in 250 ml D5W x 24 hours
1ug/min = 7.5ugtts/min @ 15-60 ugtts/min *Check serum K (hypokalemia)
EPINEPHRINE
1mg IVP or 2-2.5mg ETT Q3-5 mins D5W 250cc + NaHCO3 1 amp 12-24h @ 20-40ugtts/min
ENDO
D5W 250cc + 1 amp (1mg) epi
INSULIN
1ug/min = 15 ugtts/min @ 15-150 ugtts/min
100 cc pNSS + 100 u HR to run at 1-10 units/hr
NICARDIPINE Titrate according to desired blood glucose
10 mg in 90 ml pNSS/D5W x or 20 mg in 80 ml pNSS to run at 6mg/hr, titrate Usually, start at 8u/hr or 8 cc/hr
drip by increments of 2 mg/hr to sustain SBP<160 mmHg CBG q hr while on HR drip
or 1 mg/IV push Prep: 100 u/ml x 10 ml
Prep: 2 mg/ 2ml, 10 mg/10 ml Conc: 100 units/ 100 ml
Conc: 0.1 mg/ml
PNSS 99cc+ 1cc Humulin R, 1u/hr =5ugtts/min @5-50ugtts/min
D5W 90cc+Nicardepine 10mg in Soluset @ 10-50ugtts/min
NEPHRO
Site changed q12h if peripheral
MAGNESIUM SULFATE
METOPROLOL
NV=1.8-2.4
5mg SIV Q5 x 3 doses
2-2.5 g in 250 ml pNSS to run for 12 hours (20 ml/hr)
PROPRANOLOL 2.5 g/10mL amp
0.1mg/kg divided into 3 equal doses IV Q2-3min
ESMOLOL D5W 250cc+ 2g MgSO4 @ 20cc/hr
LD: 500mcg/kg/min SIV MD: 50-200mcg/kg/min over 4mins FUROSEMIDE
HYDRALAZINE D5W250cc+ Furo 250mg/amp, 5-30mg/hr@ 5- 30ugtts/min
D5W 250cc+hydra 2 amps (20mg/amp) @ 5-60ugtts/min GASTRO
VERAPAMIL OCTREOTIDE
2.5-5mg IV over 2 mins, may rpt w/ 5-10mg IV in 15-30mins For variceal bleeding/ pancreatitis
LIDOCAINE Usually given for 5 days or until bleeding stops
1-1.5mg/kg then 0.5-0.75 mg/kg Q5-10mins (max 3mg) then 50 mcg IV bolus then start drip using 1200-1250 mcg Octreotide in 250 ml
infusion of 1-4mg/min (30-50mcg/kg/min D5W to run at 25-50 mcg/hr
ESOMPEPRAZOLE (NEXIUM/LOSEC)
D5W 250cc + Lido 1g @15-60ugtts/min LD: 1mg/kg IV 40mg in 90ml pNSS to run for 5 hours (20 cc/hr)
ISDN (ISOKET) 40mg/10 ml
10 mg in 90 cc pNSS or D5W in a soluset drip to run at 10-50 ugtts/min PANTOPRAZOLE (PANTOLOC)
(equivalent to 1-5 mg/hr) 5 amps in 250 ml D5W to run for 24 hours
20 mg in 80 cc pNSS or D5W in a soluset drip to run at 10-50 ugtts/min 40 mg/amp
(equivalent to 1-5 mg/hr)
CARNITINE + PYRIDOXINE + CYANOCOBALAMIN (GODEX)
D5W 250cc + 2 amps x 12 hrs
D5W 90cc + ISDN 10mg in Soluset @ 10-50ugtts/min
  CARDIO NOTES 
NEURO
NIMODIPINE (NIMOTOP)
10 mg in 50 ml pNSS x 1-2 mg/hr CARDIAC DIAGNOSIS
Max 2 mg/hr Etiology: congenital, infectious, hypertensive, ischemic
OTHERS Anatomic: chambers (hypertrophy, dilated); valves (regurgitation, stenosis),
PULSE STEROID pericardial, MI
D5W 100cc + 1gm SOLUMEDROL infusion x 2hrs OD x 3 days Physiologic: arrhythmia, CHF, MI, functional
MIDAZOLAM (DORMICUM) CONGESTED
20 mg in 100 cc pNSS to run at 1 mg/hr Furosemide challenge: 20. 40, 80 mg/IV, then check UO
Max 5 mg/hr HYPOTENSION
FENTANYL Fast drip 200 cc, x 3 doses
100 ug in 250 cc D5W to run at 1 ug/kg/hr = 13 cc/hr; 1 cc = 4ug Start Levophed at 0.5 mcg/kg/min
DIAZEPAM ENOXAPARIN DOSE BASED ON GFR
D5W 100cc + Diaz 10mg Q6 (Max 60mg/d) GFR(ml/min) SC DOSE (mg/kg q12h)
DICLOFENAC ≥ 80 1
D5W500cc+ 2amps @ 25ugtts/min 70-79 0.9
KETOPROFEN (ORUDIS) 60-69 0.8
D5W 250cc + 1 vial @ 20 ugtts/min 50-59 0.7
MORPHINE SULFATE 40-49 0.6
PNSS50cc+1amp Morph (16mg/amp) @ 6 ugtts/min 30-39 0.5
20-29 0.4
10-19 0.3
HYPERTENSION
Stages:
Pre >120/80
I >140/90
II >160/100
a) HTN URGENCY : Dias >120-130, No target organ damage, Dec BP in 2-3
days
Tx Oral: Nifedipine 5, 10mg/cap chew, SL or PO Q30, Captopril 25mg ½-
1 tab SL or PO Q30, Clonidine 75mcg 1 tab SL or PO Q1
b) HTN EMERGENCY: Sys >210, Dias >130 w/ HA, BOV, Stroke, Angina, MI,
HF, CKD, Retinopathy, Dec BP in 24 h
Tx IV AntiHpn: Nicardipine 5mg/hr, Inc by 1-2.5 mg/hr Q15 upto 15
mg/hr, Hydralazine, Enalaprilat, ISDN
Labs: CBC, U/A, FBS, Na, K, BUN, Crea, SGPT, Lipids, CXR, ECG
Tx: Stage I Thiazide, ACEI, ARB, BB, CCB
II 2 or more Drugs e.g ACEI + Thiazide
w/ CHF Diur, ACEI, ARB, AA w/ CKD ACEI, ARB
w/ MI BB, ACEI, Aldo Ant w/ ESRD Diuretic, CCB
w/ CAD Diur,, BB, ACEI, CCB w/ Stroke Diuretic, ACEI
w/ DM Diuretic, ACEI, ARB, w/ Dyslipid CCB, ACEI
Cheap Meds: Captopril 25, 50 BID, Imidapril (Norten/Vascor) 5, 10mg OD,
Losartan (Lifezaar) 50mg 1-2tabs OD, Metop (Neobloc) 50, 100 BID, Nifedipine
(Calcibloc) 30mg OD, Spirono + Butizide (Aldazide) 25/2.5 mg ½ - 1 tab OD
ACUTE MYOCARDIAL INFARCTION
Types: 1 Spontaneous (coronary)
2 Secondary (htn, embolism, arrhythmia)
3 Sudden Cardiac Death
4 MI w/ PCI (a) or Stent (b)
5 MI w/ CABG
Criteria:
Trop or CKMB >99th Percentile (>3x PCI) (>5x CABG)
With Symptoms
ECG: ST Elev V2-V3 0.2 or 0.15mV, Others 0.1, LBBB, Q V2-V3 0.02 secs, Others
0.03 secs
Cardiac Imaging
Killip: I No Cong
II Bibasal rales, S3, JVP, Hepatomeg
III Rales >50%, Pulmo Edema
IV Shock
Tx: O2, Nitrates, B/Ca Blocker, ASA160-325mg QID or Clopid 75mg/d,
Heparin/LMWH, Morphine2-4mg IV, ACEI, Diazepam, Statin, Duphalac
Absolute Contraindication Fibrinolytic: Active Bleed, Trauma, Surgery <2w,
CVA <3m, CNS Tumor, BP >180/110, Aortic Dissection
CONGESTIVE HEART FAILURE
Framingham’s Criteria: 2 Major or 1 Major + 2 minor
Major: Minor:
PND S3 Gallop Ext Edema Pl eff
Neck V D Inc JVP >16 Night Cough Tachyc >120
Rales HepatoJR Dysp on E VC dec 1/3
Cardiomeg Acute P. Edema Hepatomeg Wt loss 4.5kg in 5d
Tx: B blocker/Ca Blocker, Dilators: ACE/ARB/Nitrates/Hydra, Diuretics,
Digitalis, Dopa/Dobu/Nore
FC: I No limitation, II Slight, III Marked, IV Symptoms at rest
 REVISED GOLDMAN CARDIAC RISK INDEX (RCRI)
Six independent predictors of major cardiac complications*
CP CLEARANCE  High-risk type of surgery (includes any intraperitoneal, intrathoracic, or
Clinical Predictors suprainguinal vascular procedures)
Major  History of ischemic heart disease (history of MI or a positive exercise
 Unstable coronary syndromes (acute MI) test, current complaint of chest pain considered to be secondary to
 Unstable or severe angina (Canadian class III or IV) myocardial ischemia, use of nitrate therapy, or ECG with pathological Q
 Decompensated heart failure waves; do not count prior coronary revascularization procedure unless
 Significant arrhythmias, high-grade AV block, symptomatic ventricular one of the other criteria for ischemic heart disease is present)
arrhthymias with uncontrolled ventricular rate  History of HF
 Severe valvular disease  History of cerebrovascular disease
Intermediate  Diabetes mellitus requiring treatment with insulin
 Mild angina pectoris (Canadian Class I or II)  Preoperative serum creatinine >2.0 mg/dL (177 mol/L)
 Previous MI by history or pathologic Q waves Rate of cardiac death, nonfatal MI, and nonfatal cardiac arrest according to
 Compensated or prior heart failure the number of predictors
 DM (particularly insulin-dependent) No risk factors - 0.4 % (95% CI 0.1-0.8 %)
 Renal insufficiency 1 risk factor - 1.0 % (95% CI 0.5-1.4 %)
Minor 2 risk factors - 2.4 % (95% CI 1.3-3.5 %)
 Advanced age ≥ 3 risk factors - 5.4 % (95% CI 2.8-7.9 %)
 Abnormal ECG (LVH, LBBB, ST-T abnormalities) Rate of cardiac death and nonfatal MI, cardiac arrest or ventricular
 Rhythms other than sinus (a-fib) fibrillation, pulmonary edema, and complete heart block according to the
 Low functional capacity number of predictors and the nonuse or use of beta blockers
 History of stroke, uncontrolled systemic hypertension No risk factors - 0.4 to 1.0 % vs <1 % with beta blockers
Surgical Predictors 1-2 risk factors - 2.2 to 6.6 % vs 0.8 to 1.6 % with beta blockers
High (>5%) ≥ 3 risk factors - >9 % vs >3 % with beta blockers
 Emergent major operation, particularly in the elderly
 Aortic and other major vascular operations
 Peripheral vascular surgery AHA/ACC 2007
 Anticipated prolonged surgical procedures w/ large fluid/blood loss High risk (reported risk of cardiac death or nonfatal MI often)
Intermediate (<5%) Aortic and other major vascular surgery
 Carotid endarterectomy Peripheral arterial surgery
 Head and neck surgery Intermediate risk (reported risk of cardiac death or nonfatal MI 1-5%)
Carotid endarterectomy
 Intraperitoneal and intrathoracic surgery
Head and neck surgery
 Orthopedic surgery
Intraperitoneal and intrathoracic surgery
 Prostate surgery
Orthopedic surgery
Low (<1%)
Prostate surgery
 Endoscopic procedures
Low risk* (reported risk of cardiac death or nonfatal MI < 1%)
 Superficial procedure
Ambulatory surgery
 Cataract surgery
Endoscopic procedures
 Breast surgery Superficial procedure
Functional Predictors (Metabolic Equivalents/METs) Cataract surgery
 Poor (<4 METs): vacuuming, ADLs, walking 2mph, writing Breast surgery
 Moderate (4-7 METs): Cycling, flight of stairs, golf, walking 4mph, yard * Do not generally require further preoperative cardiac testing
work
 Excellent (>7 METs): jogging, scrubbing floors, tennis
ORDER
Stratified as ______ risk in developing perioperative complications
Still for final risk stratification (if still awaiting labs, or awaiting consultant’s
approval)

LEE CARDIAC RISK INDEX

Risk Factors Points
High risk surgery (intra-peritoneal, intra-thoracic, 1
suprainguinal vascular procedures)
Ischemic heart disease 1
History of congestive heart failure 1
History of cerebrovascular disease 1
Insulin treatment for DM 1
Pre-op scr > 176.8 mol/L 1
Class Risk factors CV Complications (%)
I 0 0
II 1 8.89
III 2 21.05
IV 3–6 45.45
  NEPHRO NOTES 
INTRAVENOUS FLUID
Glucose Na Cl K Lactate Others
D5W 50g/L MI, HTN
CHRONIC KIDNEY DISEASE
D10W 100g/L
1: >90 4: 15-29
PNSS (0.9) 154 154 CVA
2: 60-89 5: <15
D5 0.3NaCl 50 51 51 CKD
3: 30-59
PLR 130 109 4 28 Ca 3
NM 40 40 13 Mg 3 Acetate 26
CKD w/o Atrophy: DM, PKD, MM, Amyloidosis, Sarcoidosis
D5NMK 50 40 40 30 Mg 3 Acetate 26
NR 140 98 5 Mg 3 Acetate 27
Dx: Dec GFR or Inc Crea for 3 mos; Renal atrophy; Anemia; Uremic Sx: Fluid &
D5 IMB 50 25 22 20 23 Mg 3 PO4 3
Elec; Endo/Metabolic: osteodystrophy, amenorrhea; Neuro: fatigue, HA, sleep
disorder, seizures, altered ment; CV, Pulmo: HTN, CHF, Pericarditis, WATER DEFICIT
Cardiomyopathy; GI: anorexia, vomiting, fetor, bleed; Derma: pigment, [(Serum Na -140)/140 x TBW ] *TBW=wt x 0.6 or 0.5
pruritus; Hema: normo anemia, lymphocytopenia, splenomeg; Elec: Hyper Na, Correction: ½ Given in 12-24h, ½ next 24 h OR 10mEq/L/h
K, P, Hypo Ca use IVF D5W
ACUTE RENAL FAILURE HYPERNATREMIA
Sudden Inc Crea, Dec UO [(Na-140)/140] x k x wt in kg
24
*Fractional Excretion of Sodium (FENa) K
*Renal Failure Index (RFI) Male 0.6 elderly M 0.5
FENa: U Na x P Cr x 100 FENa or RFI < 1 = Pre Renal Female 0.5 elderly F 0.45
U Cr x P Na FENa or RFI >1 = Renal HYPONATREMIA
RFI: U Na + (U Cr / P Cr) BUN/Crea: >20 = Pre, <15 = Renal NV: 135-145 mEq/L
Tx: Fluid, Elec, HD B/C Ratio: BUN x 2.8 / Crea x 0.011 Na Deficit = 0.6 x Wt x 10 or (Desired – Actual) x wt x k
BUN-CREA RATIO 24
lnc urea reabsorption—prerenal azotemia, hypovolemia Na deficit x 1000 cc
lnc urea production—hyperalimentation, hyprproteinemia, gluco tx, GI bleed Na infusate

plasma osmalality-275-290mosml/kg Na Deficit/2/154 (per bottle of PNSS)

pOsm-2Na+Glu+BUN Correction: 1/2 Given in 8-12h, ½ next 16-24 h
0.5-1 mEq/L/hr or 15-20 mEq/L/day
lnc=15-20 mosml/kg OR NaCl tabs 1-2 tabs TID-QID
=serum na is low
=serum osmolyte in plasma-Na,Glu NaCl tab = 17 meqs
If using hypertonic solution (3%): repeat serum Na after 6 hours
pre-renal>20:1 If using pNSS: repeat serum Na after 24 hours
intrinsic<10-15:1 HYPERKALEMIA
post renal>20 Check if with ECG changes: dec P wave amplitude, widened QRS, tenting of T
DIALYSIS wave
Indications: a) If < 5.5: restrict K in diet
Acidosis b) 5.5-6.5: Kalimate 1 sachet TID x 3 doses
Electrolyte Imbalance (Intractable HyperK) c) >6.5: with or without ECG changes, as follows:
Intoxication D5050 + 10 units HR/ SIVP for 3 doses, 4 hrs apart
Overload (Fluid) Ca gluc 500 mg SIVP x 3 doses, 4 hours apart
Uremia [BUN > 100-150; Crea > 8-10 mg/dL] MgSO4 500 mg SIVP x 2 doses, 4 hours apart
NaHCO3 1amp SIVP in 10min
Short Term Complications: Septicemia, Arrhythmia, Dysequilibrium, Hypo, Salbutamol neb 20mg
HBV/HCV, Air Emboli, Anaphulaxis, Heparin complications,Cramps Furosemide 40-80mg stat
Long Term Complications: MI, CVA 2 to Uremia, Dialysis dementia, Repeat serum K, after 6-8 hours
Osteomalacia HYPOKALEMIA
RENAL TUBULAR ACIDOSIS NV: 3.5-5.3 mEq/L
Type I Distal Tubule—H 0.3 x Wt x (Desired – Actual K) or (4 – actual deficit) x 150
Type II Proximal Tubule—HCO3 K durule = 10 meqs = Inc 0.1 mEq/L Serum K
Type III (combined I & II) KCL syrup 1 ml= 1meq
Type IV Hypo Aldo ↑K KCL drip: 40 meqs + pNSS to make 250cc to run at 5 meqs/ hr for 2 cycles
HYPERMAGNESEMIA
PLASMA OSM (mOsm/L): Hydrate
2 Na + BUN (mmol/L) + RBS (mmol/L) HYPOMAGNESEMIA
*BUN mg/dL / 2.8; RBS mg/dL /18 = mmol/L MgSO4 500 mg/IV in 200 cc; 1 g/IV in 250 cc; 2 g/IV in 200 cc
*NV: 280-300 To run for 8h/12h/24h for ____ cycles (usually 2 cycles)

HCO3 DEFICIT: MILD

0.4 x Wt x (Desired HCO3 (16) – Actual HCO3) OR [(BE x Wt x 0.3)/2]
Note: Give only 1/2 of computed deficit as bolus
½ can be thru drip in 24 h in D5W (1 amp = 44 mEq)
Central Venous Pressure (CVP): Normal 8-12, on mech vent 12-15
1. 1g MgSO4 has 8meqs (4mmol) of elemental Mg
2. Assume a total Mg deficit of 1-2 meq/kg
3. Bec. 50% of infused Mg can be lost in the urine, assume that the total Mg
required is 2x the Mg deficit
4. Replace 1 meq/kg for the first 24 hrs and 0.5 meq/kg daily for 3-5 days

Poisoning: Activated Charcoal 100mg in 300cc water via NGT MODERATE

MAINTENANCE FLUID 1. Add 6g of MgSO4 (48 meq) to 250 or 500 ml PNSS and infuse over the next
Total fluid/day: 35 cc/kg/day 6 hrs
BM: 1 bm = 100 cc 2. Follow 5g MgSO4 (40 meq) + 250 or 500 cc PNSS x 6 hrs
Fever: for each 1 degree rise above 37+ 100-150 cc/day 3. Continue 5g of MgSO4 every 12 hrs by continous infusion for the next 5
Diarrhea: 1 cc/kg hydration days
Febrile: 2 cc/kg
SEVERE
1. Infuse 2g MgSO4 (16 meq) iv over 2 mins
2. Follow with 5g (40 meq) in 250 ml or 500 ml PNSS, infuse over the next 6
hrs
3. Continue 5mg MgSO4 every 12 hrs by continous infusion for the next 5 days
HYPERCALCEMIA
Bisphosphonate: Pamidronate 30-90 mg/day, single dose x 3 days
Calcitonin: 4-8 IU/kg/min SQ q 6
HYPOCALCEMIA Simplified Renal Index (SRI) Scoring
Corrected Ca: (4 – alb) x 0.8 + serum Ca for Estimating Risk of Post-cardiac surgery Renal Replacement Therapy (RRT)
Ca gluc 1 g in 100 cc pNSS to run for 2 hours x 1 dose followed by MgSO4 drip Variable Points
4 g in 250 cc pNSS to run over 12h x 1 dose eGFR 31-60 ml/min 1
Ca gluc 500 mg/SIVP q 4-6 h under CM eGFR < 30 ml/min 2
Ca gluc 1 g + 250 cc pNSS x 4 hours under CM (usually for 2-3 cycles) DM requiring medication 1
Ca gluc = 45 mg Ca (?) LVEF < 40% 1
Ca carbonate = 27 mg Ca Previous cardiac surgery 1
HYPOALBUMINEMIA ALBUMIN-FUROSEMIDE (LASIX) INFUSION Procedures other than CABG or isolated ASD repair 1
Albumin 25% (50 ml) + 20 mg Furosemide to run for 1 hr. q 12 for 4 doses or Non-elective procedure 1
Albumin 25% to run for 1 hr followed by Furosemide 20 mg IV q 12 for 3 doses
Pre-operative intra-aortic balloon pump 1
SODIUM BICARBONATE
Points Risk of RRT
Weight x 0.4 x (desired – actual) Risk
(%)
If HCO3 < 12 or pH < 7.2 – correct deficit
Low risk 0-1 0.4
Give ½ deficit in bolus, then ½ in drip:
D5W 1li x 1 amp or 250 cc D5W + 100 meqs NaHCO3 to run for 24h Intermediate risk 2-3 3
High risk ≥4 10
RCIN (Radiocontrast-Induced Nephropathy) PROPHYLAXIS
1. Maintain TFR: 80 cc/hr (ideally pNSS = isotonic)
2. Fluimucil (antioxidant) 600mg/tab 2 tabs q12h dissolved in 50 cc water Risk factor Points
(1 day before and day of the procedure) Female Gender 1
3. NaHCO3 150 megs NaHCO3 in 850cc D5W to run at 1cc/kg/hr (start 3 Congestive Heart Failure 1
hours prior until 6 hours post procedure) LV EF <35% 1
4. d/c pNSS once NaHCO3 started COPD 2
5. Ascorbic Acid 500 mg/tab TID Pre-operative use of IABP 1
6. Monitor I/O Insulin requiring DM 1
CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) Previous cardiac surgery 1
 Priming: PNSS 1L + heparin 5000u/L, then PNSS 1L Emergency surgery 2
 Modality: SCUF/ CVVH/ CVVHD/ CVVHDF Valve surgery (reference to CABG) 1
 Blood flow: start at 80 to 100cc/min .....and increase to ___ cc/min (4- CABG + valve surgery (reference to CABG) 2
5cc/kg/min) as tolerated....(max 180ml/min) Other cardiac surgeries 2
 Dialysate: ___ cc/hr (35 cc/kg/hr or 2000cc/hr/1.73m2)...1000ml/min Pre-operative Scr 1.2 to 2 mg/dl 2
PNSS 1L at 0cc/hr/ Dianeal 1.5% 5L/HEMOSOL 5L at 1000ml/hr Pre-operative Scr > 2.1 mg/dl 5
Additive:
None/ KCl (___meq/L)/ Ca-gluconate (___amps/5L bag)/Other: Pre-operative Risk
___ n ARF-HD (%) 95% CI
Score/ Class
 Replacement fluid: ___ cc/hr (35 cc/kg/hr or 2000cc/hr/1.73m2) 1 (0-2) 8,416 0.4 0.28 to 0.56
PNSS 1L at 0cc/hr/ HEMOSOL 5L
2 (3-5) 6,097 1.8 1.5 to 2.2
Additive:
3 (6-8) 1,181 7.8 6.3 to 9.5
None/ KCl (___meq/L)/ Ca-gluconate (___amps/5L bag)/ Other:
4 (9-13) 144 21.5 15.1 to 29.1
___
 Target net UF: ___ cc/hr (1-2 cc/kg/hr)
 Anticoagulation:
GENERAL SURGERY ACUTE KIDNEY INJURY (AKI) RISK INDEX
o No heparin: flush with 200-300cc NS every q hr, and prn TMP >
150, blood streaking in filter Age >56 yrs
o Heparin with target ACT = _____ (170-210) Male sex
Prepare heparin 5000 units in 500cc PNSS (10u/hr) for drip Active congestive heart failure
Check baseline ACT: Ascites
Hypertension
 If ACT < 150, give heparin IV bolus (20u/kg), then start
Emergency Surgery
heparin drip at ___ u/hr (10u/kg/hr). Repeat ACT in 4
Intra-peritoneal surgery
hours.
Renal insufficiency – mild or moderate (Pre-operative Screa >1.2 mg/dl)
 If ACT 150-200, no bolus, start heparin drip at ___ u/hr
Diabetes mellitus – oral or insulin therapy
(10u/kg/hr). Repeat ACT in 4 hours.
 If ACT > 200 -- no heparin and repeat ACT in 2 hours.
Acute Kidney
 When CRRT ongoing, draw post-filter ACT from blue port Pre-operative Total Patients Hazard ratio
Injury Incidence
on R side of system. Risk Class n (%) (95% CI)
(%)
 If ACT < 170 -- give heparin IV bolus (10u/kg) then increase
heparin drip at ___ u/hr (10%) MORE than previous rate, Class I
31, 500 (55) 0.2
(0-2 risk factors)
Repeat ACT in 4 hours.
 If ACT 170-210 -- keep drip rate same, repeat ACT in 6 Class II 4.0
12,576 (22) 0.8
hours. (3 risk factors) (2.9 to 5.4)
 If ACT > 210 -- hold heparin x 1 hour, the restart drip at ___ Class III 8.8
7,933 (14) 1.8
u/hr (10%) LESS than previous rate. Repeat ACT in 4 hours. (4 risk factors) (6.6 to 11.8)
 Flush with 200-300 cc NSS every 2-3 hours prn TMP > 150, Class IV 16.1
3,615 (6) 3.3
blood streaking in filter. (5 risk factors) (11.9 to 21.8)
 Labs: Class V 46.3
1,456 (3) 8.9
o When CRRT on-going, may draw chemistries and CBC from red (6+ factors) (34.2 to 62.6)
port at bottom of system, or from central line, unless otherwise
ordered RADIO CONTRAST-INDUCED NEPHROPATHY (RCIN) RISK SCORE
 Other orders Variable Points
o Refer all alarms to NFOD Hypotension 5
o May use remaining dialysate/ replacement fluid with next system IABP 5
o Prime back-up machine when filter clotting is imminent CHF 5
>75y/o 4
Anemia 3
DM 3
Contrast Vol 1 /100cc
Crea >1.5 or 4
Crea Cl MDRD
40-60 2
20-40 4
<20 6
 Risk score Risk of RCIN Risk of dialysis Na level 2% NaCl 1L 3% NaCl 1L Totilac 250 ml
0-5 7.5 % 0.04 % Increase by 10
Increase by 20 Increase by 5
6-10 14 % 0.12 % Na <135 ml/hr to max 50
ml/hr ml/hr
11-16 26.1 % 1.09 % ml/hr
>16 57.3 % 12.6 % Increase by 10 Increase by 5 ml/hr Increase by 2.5
135-144
RCIN RISK ASSESSMENT ml/hr to max 50 ml/hr ml/hr
Dx: Maintain current Maintain current Maintain current
145-150
ECC: rate rate rate
Contemplated procedure: Decrease by 10 Decrease by 2.5
151-153 Decease by 5 ml/hr
Approx vol of contrast: ml/hr ml/hr
Risk Stratification Decrease by 20 Decrease by 10 Decrease by 5
risk of RCIN: 154-157 ml/hr then q4hr ml/hr then q4hr ml/hr then q4hr
risk of RCIN requiring HD: renals renals renals
Hold 2% for 1 hr Hold 3% for 1 hr Hold Totilac for 1
The risk stratification has been explained to the pt. The patient is aware & 158-159 then resume ½ of then resume ½ of hr then resume ½
fully understands the above risk & consequences of RCIN. Final disposition for prev rate prev rate of prev rate
procedure c/o AMD. Shift 2% HS to Shift 3% HS to Plain Shift Totilac to
160-162
Plain 0.45% NaCl 0.45% NaCl Plain 0.45% NaCl
In order to reduce the risk of RCIN, the following prophylaxis measures are >163 Refer Refer Refer
recommended:
1. FLUIMUCIL Totilac
o Fluimucil 600mg/tab dissolved in 100cc H2O 12 hours and 6 2% NaCl 1L 3% NaCl 1L
250 ml
hours before contrast administration, then 6 hours and 12 hours Content 20 g 30g 56.5g
after procedure or Amount of Na in
o Flumucil 150 mg/kg dilute in 500cc PNSS, give 30 mins before 7.866g 11.799g 11.5g
solution
procedure then another 50 mg/kg during and til 4 hours after
Milliequivalents 342 513 504
procedure (preparation: 25mg/vial, 200mg/ml, 1 vial = 5 gram)
% Sodium 0.8% 1.18% 1.15%
o Hydration 1 cc/kg/hr
o Repeat Crea 24-48 hours after procedure 1020
Osmolality 684 mosm/L 1027 mosm/L
mosm/L
2. NaHCO3 BASED HYDRATION
o Plain LR or D5W 1 L + 150 meq NaHCO3 to run at 3 cc/kg/hr 1
hour before procedure, then decreased to 1 cc/kg/hr during
procedure till 6 hours thereafter

CKD IN RADIO CONTRAST-INDUCED NEPHROPATHY (RCIN)

CreaCl (mL/min) DM Non-DM
50 0.2 0.04
40 2.1 0.3
30 10 2
20 43 12
10 84 48
 PULMO NOTES 
RIFLE CRITERIA
WHEN TO INTUBATE
RISK: sCr x 1.5; < 0.5 ml/kg/hr x 6 hours
RR > 35cpm Apnea >20s
INJURY: sCr x 2; < 0.5 ml/kg/hr 12 hrs
PaO2 <50mmHg PaCO2 >60
FAILURE: sCr x 3 or sCr ≥ 4 mg/dl with an acute rise; > 0.5 mg/dl; < 0.3
GCS <7 Arrythmia
ml/kg/hr x 24 hours, or anuria x 12 hrs
Shock
LOSS: persistent ARF = complete loss of kidney function; > 4 weeks
MECHANICAL VENTILATOR
ESRD: ESRD > 3 months
Hook to MV on AC mode with the following settings:
TV= 6-10 ml/kg
RENAL PANEL
BUR= 12-18
2 – BUN Crea Na K Cl HCO3
FiO2= see formula
3 – Ca P Mg Na K Cl HCO3
Repeat CXR, ABG 30 minutes post intubation
4 – BUN Crea Uric acid Mg P Ca Na K Cl HCO3
RESPIRATORY FAILURE TYPES HYPOXEMIA (pO2)
I Hypoxemic 60-79 Mild
WORK-UP FOR GN II Hypercarbic /vent 40-59 Mod
CBC, BUN, crea, electrolytes III Post-op atelec <40 Severe
o ASO, ANA, C3, HepB, HepC, VDRL, IV Shock
o albumin, 24hr urine CHON,
ABGs NORMAL VALUES
o 24hr crea cl, UTZ of KUB
pH 7.35-7.45 HCO3 22-26
pCo2 35-45 BE -2 to +2
HYPERTONIC SALINE PROTOCOL pO2 80-100 O2 Sat >90%
For 2% HS start at 60 ml/hr9ie total fluid rate of 120 ml/hr= 60 ml 2% HS and DESIRED FiO2 P/F RATIO
60 ml/hr NSS A = pCO2 / 0.8 pO2/ FiO2
For 3% HS, always to be infused thru central line B = 713 x FiO2 – A
Start at 30 ml/hr and run PNSS to equal desired fluid intake/day C = pO2 / B
D = ({[105-(Age/2)]/C} + A ) / 713
HYPERTONIC SODIUM LACTATE (Totilac)( premixed solution) FLOW RATE CONVERSION
Always to be infused thru central line (DFiO2 – 20) / 4
Start at 15 ml/he and run with PNSS to equal desired TFR FiO2
Repeat Na, K q6hrs, BUN crea, serum osm as desired Room Air = 0.21
Per nasal cannula (LPM x 4) + 20
Goal Na 145-155 Per face mask (LPM – 1) x 10
NaCl 1 vial: 2.5 meqs/mL, 20 mL= 50 meqs/vial EXPECTED pO2
< 60 y/o: 104 – (Age x 0.43)
0.9% NaCl: 154 meqs > 60 y/o: 80 – Yrs >60
2% NaCl: NSS 920 ml + NaCl 80 ml (2.5 meqs/mL=200meqs)
OXYGENATION
3% NaCl:NSS
TV = 6-8 ml x wt in kg
≤ 60 yo = 400-500
>60 yo =
ABGs: Acidemic or Alkalemic? COMMUNITY ACQUIRED PNEUMONIA
Respiratory or Metabolic? Stable VS Macrolide or Doxy
If respiratory, acute or chronic? CAP RR <30, CR <125, BP >90/60 or Co-Amox 2g BID or
If metabolic, anion gap normal or abnormal? LR No or Stable Comorbid 2nd G Ceph (Ceftri, Cefu,
If metabolic, is respiratory compensating? No Sepsis nor Aspiration Cefpo 500 BID)
CXR: Localized, no pl. eff or Fluoroquinolone (LGM)
ACIDOSIS ALKALOSIS abscess B lac + Macro
pH<7.4 pH >7.4 Not progressive in 24 h
Metabolic: HCO3 <24 Metabolic: HCO3 >24
Respiratory: pCO2 >40 Respiratory: pCO2 <40 CAP Unstable VS: RR>30, CR>125 Antipneumo
MR T<35or >40 Floroquinolone (LGM)
ANION GAP: Na – (Cl + HCO3) ; (NV 8-16) Unstable Comorbid
Unmeasured cations: K, Ca, Mg, Globulinn, lithium Sepsis or Aspiration IV B lac (Ceftri, Cefu,
Unmeasured anions: lactate, ketones, uremic anion, toxic anion, albumin CXR: Multilobar, w/ pl eff or Ampi), +/- B lact inh
abscess, + Macro (C,A)
RESPIRATORY ACIDOSIS Progression >50% in 24 h
pH: 7.4 – ( 0.008 (actual pCO2 – 40)
pH: 7.4 – ( 0.003 (actual pCO2 – 40) chronic CAP Clinical Feature of MR plus No Pseudo:
HR SHOCK: BP <90/60, UO <30cc/hr, B lac (ceftri, cefo, ampi)
RESPIRATORY ALKALOSIS altered mental state/ confusion + Azithro or Fluoro IV
pH: 7.4 + (0.008 (40- actual pCO2)) Hypoxia PaO2 <60 W/ P: B lactam (piper-tazo
pH: 7.4 + (0.003 (40- actual pCO2)) Hypercapnia PaCO2 >50 cefi, imip or merop)+ Levo
* If actual pH is less than the expected: Respiratory acidosis with concomitant CXR same as MR or Cipro or AG + Azith
metabolic acidosis CAP HIGH RISK
* If actual pH is more than the expected: Respiratory acidosis with BTS Criteria: CURB 65 ATS Criteria ICU:
concomitant metabolic alkalosis Confusion Major: Need for Mech. vent
* Acute: for every 10 mmHg dec in pCO2, pH inc by 0.08 Urea Nitrogen >20mg/dl Septic Shock/ Vasopressors
* Chronic: for every 10 mmHg dec in pCO2, pH inc by 0.03 RR >30 Minor: CURB
BP <90/60 PaO2/FiO2 <250
METABOLIC ACIDOSIS Multi-lobar infiltrates,
Expected pCO2: (1.5 x actual HCO3) + 8 +/- 2 Hypothermia<36
Leukopenia<4,
METABOLIC ALKALOSIS Thrombocytopenia<100
Expected pCO2: (0.75 x actual HCO3) + 20 +/- 5 HEALTH CARE ASSOCIATED PNEUMONIA
* If actual pCO2 is greater than expected, there is concomitant Respiratory >48h after admission
acidosis Early <5d
* If actual pCO2 is lesser than expected, there is concomitant respiratory Late >5d
alkalosis ASTHMA (GINA 2006) PEFV: >20% (Post – Pre) / ½ (Post +Pre) x 100
PLEURAL EFFUSION LIGHT’S CRITERIA CONTROLLED Daytime Sx <2x/wk Short B2 agonists
Pleural/Serum CHON>0.5 (M Int) No Nocturnal sx
Pleural/Serum LDH >0.6 Relievers <2x/wk
Pleural LDH >2/3 Serum PARTLY Daytime sx >2x/wk B2 + Inh Corticosteroid
CONTROLLED w/ Nocturnal sx + anticholi
Thoracentesis Specimen (Mild P) Relievers >2x/wk (>1 attack/s per yr)
Bottle 1: Cell ct, diff ct PEF / FEV1 <80%
Bottle 2: TP, LDH, glu UNCONTROLLED >3 features in any week B2 + inh + anti + oral
Bottle 3: AFB, GS, CS (Mod-Sev P) (1 attack in any wk) steroid + LTM
Bottle 4: Cytology and Cell block
PTB ATS CLASS Acute attack: B2 q20 x 3, O2, Medrol 16mg BID or Pred 60mg OD or Hydrocort
0 No Exposure 3 Disease 250mgIV taper, Aminophylline IV bolus 5-6 mg/kg, Epinephrine
1 Exposure 4 Treated WHEEZING
2 Infxn (+PPD) 5 Suspect Check O2 sat, nebulize with salbutamol/ combivent x 3 doses q 20 min
PTB WHO CATEGORIES: COPD (GOLD2006) FEV1/FVC <70%
I New Smear +/- Extensive D’se 2HRZE 4HR Stage I Mild FEV1 >80% Short B2 Agonist + Anticholi
New Severe Extrapulmo D’se II Mod 50-80% Long B2 + Anticholi + theo
II Smear + After Tx Failure 2HRZES 1HRZE 5HRE III Severe 30-50% Long B2 + Anti + Inh Steroid + theo
Relapse / Interruption IV Very Severe <30% Same as severe + O2
III New Smear – Less Extensive 2HRZ(E) 4HR
Less Severe Extrapulmo Acute attack: Combivent neb, Amino, PO/IV steroid (Prednisolone 30-
40mg/d), Antibiotics, O2 (MV if RR>35, pH<7.25, PCO2 >60mmHg)

PTB SPUTUM
Pus >25, Epith <10, Bacteria 10-100/lpf
MYRIN
<55kg 3 tabs
55-70kg 4 tabs
>70kg 5 tabs